Interaction Between Nurse Anesthetists and
Patients in a Highly Technological
Karin Aagaard, MScN, Birgitte Schantz Laursen, PhD, MScN,
Bodil Steen Rasmussen, PhD, MD, Erik Elgaard Sørensen, PhD, MScN

Purpose: To explore the specific interactions between patients and nurse
anesthetists in the highly technological environment of anesthesia
nursing, focusing on the time interval between patient entrance into
the operating room and induction of general anesthesia.
Design: Focused ethnography was used for data collection.
Methods: Participant observation and interview of 13 hospitalized pa-
tients being admitted for major or minor surgical procedures and 13
nurse anesthetists in charge of their patients and anesthetic procedures.
Photographs were taken of specific situations and technological objects
in the observation context. The analysis was inspired by grounded theory.
Finding: A core variable of creating emotional energy is presented, and two
subcore variables are delineated: instilling trust and performing embodied
Conclusion: Creating emotional energy has an important impact on the
interaction between patients and nurse anesthetists. Furthermore, the
motives underpinning nurse anesthetists’ interactions with patients are
a central constituent in developing anesthesia care.
Keywords: anesthesia care, patient-nurse interaction, general anes-
thesia, focused ethnography.
Ó 2016 by American Society of PeriAnesthesia Nurses

anesthesia can be stressful for patients, and they
Karin Aagaard, MScN, is a PhD Student, Department of may feel vulnerable.1 When engaging with pa-
Anesthesiology and Intensive Care Medicine, Aalborg Univer- tients in the operating room (OR), nurse anesthe-
sity Hospital, Aalborg, Denmark; Birgitte Schantz Laursen, tists (certified registered nurse anesthetists
PhD, MScN, is a Senior Lecturer, Aalborg University Hospital [CRNAs]) prepare patients for the procedures
and Aalborg University, Aalborg, Denmark; Bodil Steen Ras-
and actions related to the anesthetic induction.
mussen, MD, PhD, is a Professor, Department of Anesthesi-
ology and Intensive Care Medicine, Aalborg University Many patients are frightened of the anesthetic, be-
Hospital and Clinical Lecturer, Clinical Institute of Medicine, ing unconscious, the surgical outcome and poten-
Aalborg University, Aalborg, Denmark; and Erik Elgaard tial for postoperative pain.2 Thus, a significant
Sørensen, PhD, MScN, is a Professor in Clinical Nursing, Aalborg challenge for CRNAs in this highly technological
University, Head of Clinical Nursing Research Unit, Aalborg
environment is to maintain balance between pa-
University Hospital, Aalborg, Denmark.
Conflict of interest: None to report. tient safety and control of the technical aspects
Address correspondence to Karin Aagaard, Department of of the procedure, while caring for the emotional
Anesthesiology and Intensive Care Medicine, Aalborg Univer- needs of the patient.3 Time constraints impinge
sity Hospital, Borger Alle 10, 9210 Aalborg SØ, Denmark; on the interval from patients entering the OR
e-mail address: kaag@hst.aau.dk.
and induction. During this short period, a complex
Ó 2016 by American Society of PeriAnesthesia Nurses
1089-9472/$36.00 interaction involving the patient, CRNA, and high-
http://dx.doi.org/10.1016/j.jopan.2016.02.010 ly technological procedures takes place.4 Here,

Journal of PeriAnesthesia Nursing, Vol -, No - (-), 2016: pp 1-11 1

CRNAs can meet patients’ specific concerns, mini- Setting and Informants
mize their discomfort during instrumental proced-
ures while, concurrently, facilitating patient The study was carried out in the Department of
cooperation with the instrumental and anesthetic Anesthesiology at a university hospital in
procedures.5 Denmark. The Department of Anesthesiology
was represented by several medical subspecialties,
In many countries, anesthesia falls within the for example, gastrointestinal anesthesia and
domain of medicine and uses highly technological cardiothoracic anesthesia. Two wards represent-
procedures.4 Although anesthesia nursing practice ing these subspecialties were chosen. Gastrointes-
is well established in Denmark, CRNAs are chal- tinal cancer surgery represented major cancer
lenged by working in environments in which there surgery, and breast cancer surgery represented mi-
is limited time for establishing a relationship with nor cancer surgery.
their patients.6 Furthermore, working in a high tech-
nological area being incorporated in the care of the The criteria for selecting patients for this study
patient, nurses often find themselves delicately were 18 years of age or older and admitted for elec-
balancing between approaching the patient’s body tive cancer surgery. Patients received premedica-
as an object of medical care while also perceiving tion, excluding benzodiazepines, according to
the patient as a subject with whom a relationship local hospital guidelines. The patients’ ages ranged
needs to be established.3 Thus, the challenge facing from mid 50s to late 70s.
CRNA is to be conscious of and deliver humane and
dignified care in a highly technological environ- The CRNAs in charge of the patients agreed to be
ment.7 In this specific preoperative environment, observed and to participate in subsequent inter-
CRNAs work to establish a relationship with pa- views. The CRNAs were all females, registered
tients and assess their implicit and explicit needs nurses with 2 years of special anesthesia training,
for physical and psychosocial care within the compromising both theoretical and practical edu-
limited time available. Given the paucity of research cation.10 The CRNAs’ practical experience ranged
in this field, the purpose of this study was to identify from 1 to 40 years.
and explore the interaction between patients and
CRNAs in a highly technological environment of Ethics
nursing, focusing on the time interval from patients
entering the OR and until induction. The project was reported to the Danish Data Pro-
tection Agency (journal no. 2008-58-0028). Partic-
ipants were informed verbally and in writing,
Methods regarding the purpose of the study. All participants
gave written consent. The study met ethical guide-
Focused ethnography is chosen as the methodology lines for nursing research in Scandinavia.11 Head
for data collection as the purpose of this study is to nurses at the Department of Anesthesiology and
explore the interaction between patients and CRNAs Department of Surgery were appointed gate-
in a specific environment. Furthermore, the research keepers, granting physical access for making field
design encompasses both patients and CRNAs ex- observations and in contacting potential partici-
plaining and elaborating on selected observations pants.12 Head nurses and CRNAs were met with
of their interactions. Knoblauch8 emphasizes that beforehand, with the intention of information
the entities studied in focused ethnography are situ- sharing and expectations of each professional out-
ations, interactions, and activities. Focused ethnog- lined. Anesthesiologists and OR nurses were
raphy in health care research can be applied when informed in writing about the study taking place.
the research concerns a context-specific and
problem-focused framework. The research motive Data Collection
of this method is to develop nursing knowledge
and practice.9 Focused ethnography8 allowed focus Data were collected in three phases, each during
on everyday social interactions between patients which episodic data were collated (Figure 1).13
and CRNAs from the time interval between patient While collecting phase 1 data, patient familiarity al-
entrance into the OR and induction of anesthesia. lowed subject separation into differing groupings.

Phase 1 Phase 2
Phase 3
May, June and August October 2013 – February
January - October 2014
2013 2014, April 2014
• Observed and • Ten field observations • Photographs taken of
participated in practice and postoperative the observation
for a total of ten days interviews with ten context: January and
at two surgical wards nurse anesthetists and March 2014
• Observed the practice ten patients • Postoperative
of different nurse • A total of 73 hours of interviews with three
anesthetists for six data collection nurse anesthetists and
days three patients:
• A total of 96 hours of September- October
data collection 2014
• A total of 19 hours of
data collection

Figure 1. Phases in the episodic data collection with a specification of the total number of hours spent.

Observations were made of the daily routines in on field notes observed during CRNAs-patients’ in-
the nursing environments of the two surgical teractions. Furthermore, the individual patient and
wards and the work domains of the CRNA. The CRNA reflections on the situation were a focus
first author accompanied the nurses on the surgi- point. Phase 2 data collection extended from
cal ward when making daily rounds on patients October 2013 to February 2014. Duration of
preoperatively and postoperatively. In addition, each interview was between 20 and 60 minutes,
direct observation of the CRNAs in their primary which were audio recorded and then transcribed
caregiving role enhanced the appreciation of a verbatim.
nonanesthetist professional for their particular
specialty. This can be seen as both a strength and Data in phase 3 were collected to show how mean-
a limitation in relation to being objective in ing of the context of the OR affected the CRNA-
connection to anesthesia and being subjective as patient relation. Thus, symbols in interaction and
a nurse. Knowledge of the specific nursing field CRNAs’ routines in performing highly technolog-
made it possible to focus and understand their ical procedures were explored. Photographs
perspective perioperatively.8 Phase 1 extended were taken of the observation context and instru-
from May to August 2013. mental setup in the OR by a hospital photogra-
pher.14 These photographs were used during
In phase 2, patients were observed on the day of interviews as a method for mapping patterns in
surgery up until anesthesia induction. The first the observations and interviews of the CRNAs
author attended the surgical report during the and patients.15 Three CRNAs and three patients
nurses’ morning shift and sat by the patients who were interviewed, each group being presented
were being prepared for surgery. The observation with the same photographs. Duration of the inter-
focus was patients’ verbal and nonverbal interac- views was from 20 to 60 minutes, which were
tions with health care professionals on the ward. audio recorded and later transcribed verbatim.
Ten CRNAs’ interactions with different patients Phase 3 extended from January to October 2014.
were observed during preparation for the anes-
thetic procedure. Field notes were written after Data Analysis
each observation. Both patients and CRNAs were
interviewed separately after the anesthetic and The data set was analyzed across the three phases
surgical procedures. CRNAs were interviewed of the study and informed by the analytical tools of
the day of observation, but patients were inter- grounded theory.16 The analytical tools used were
viewed on either the first postoperative day or open, selective and theoretical coding, and con-
the second postoperative day, dependent on their stant comparison. In the process of coding,
stated level of postsurgical discomfort. A semi- memos were written as ideas emerged. Memos
structured interview guide was prepared based encapsulated written ideas about the codes and

relationships between the codes, which led to sub- that collecting more data would contribute neither
sequent theorizing.17 to further development of emerging categories
and variables nor to development of further the-
The audio recordings were transcribed consecu- ory.16
tively, then iteratively went from data to analysis,
coding the data inductively. Each phase of data Findings
collection was coded before further collection
continued. Codes, known as in vivo codes, were Analysis led to development of creating emotional
developed from the data itself, whereas other co- energy as the core variable. The core variable was
des were developed from the meanings embedded discerned through two subcore variables:
in the transcribed interview texts.18 Constant com- instilling trust and performing embodied actions
parison allowed exploration of similarities and dif- and their associated categories and properties.
ferences in the collected data.18 Photographs Findings are illustrated in Figure 2. When photo-
facilitated understanding of patterns and routines graphs are presented as evidence, the reference
during the interaction between CRNA and patient. point is Figure 3. To illustrate dynamics of the find-
Showing photographs of anesthetic-specific situa- ings and their relation to the photographs, findings
tions and instruments in the OR was used to sup- are illustrated in Figure 3, which shows the linear
port and illustrate codes and patterns emerging process of preparing the patient for a surgical pro-
from the observations and interviews.19 cedure, ending with the patient being anesthe-
tized. This linear process, a dynamic interaction,
Development of the study in phase 3 led to identi- takes place between CRNAs and patients. This
fication of the core variable creating emotional interaction is embedded in CRNAs’ ability to instill
energy, which was grounded in the data and trust in patients while performing embodied ac-
captured the characteristics of the interactions be- tions during routine procedures (Figure 3).
tween CRNAs and patients in a highly technolog-
ical environment. Two subcore variables were In this section, each citation of observations and
also delineated: instilling trust and performing interviews has a specific reference number as-
embodied actions. The characteristics of the two signed for each of the 13 patients and 13 CRNAs.
subcore variables are further elucidated by two Participants from phase 2 (Figure 1) have a number
categories (Figure 2). from 1 to 10. Participants from phase 3 (Figure 1)
are numbered 11, 12, and 13.
Different combinations of sampling, that is, col-
lecting data through the three aforementioned
phases, coding and memoing, resulted in a satura-
tion of emerging categories and variables, meaning


Instilling trust embodied

Depending on
Offering a
routines in

technology and
interaction Figure 3. Dynamic patterns of creating emotional
humane care
energy when preparing patients for general anes-
Figure 2. Presentation of findings: the core vari- thesia. This figure is available in color online at
able, two subcore variables, and their categories. www.jopan.org.

Creating Emotional Energy Instilling Trust

Creating emotional energy emerged as the core The first subcore variable was designated
variable and was further conceptualized through instilling trust, characterized by CRNAs’ interac-
two subcore variables: instilling trust and per- tions with each patient. The key process in
forming embodied actions (Figure 2). Creating instilling trust was the patient’s and CRNA’s mutual
emotional energy encompasses CRNAs’ ability focus on the procedure, which was affected by
to perceive patients’ physical and psychosocial each other’s emotional state. The CRNA was
needs during induction for the purpose of estab- affected by the patient’s signals of physical and
lishing a relationship with each patient while psychosocial needs in a vulnerable situation.
maintaining their necessary professional dis- Communicating this awareness verbally or nonver-
tance. The intended outcome of creating bally to the patient resulted in the patient feeling
emotional energy is to instill trust and confi- trust and confidence in the situation. CRNAs and
dence in patients. By focusing first and foremost patients’ mutual focus of attention, and their
on safety procedures, CRNAs were emotionally mutual response to each other’s signals and ac-
prepared to respond to patients’ physical and tions, feed on one another and resulted in
psychosocial needs. This sensitivity results in emotional energy that led to a feeling of trust and
CRNA consciously organizing and performing confidence in the patient. CRNAs and patients
technical procedures, while taking patient needs were dependent on being able to sense each
into account. The six photographs in Figure 3 other’s signals and, at the same time, focus on
illustrate how creating emotional energy was re- the mutual trajectory of preparing for the anes-
flected in preparation and interaction between thetic and/or operative procedure. To instill trust
CRNAs and patients. Creating is important for es- in the patient, one CRNA used touch while prepar-
tablishing relationships with patients. Embedded ing for the instrumental procedure, saying:
in the construction of creating is a conscious Touching the patient on his/her shoulder or arm
way of acting that may well challenge the CRNA’s is my way of being human while remaining a pro-
routines when performing technical procedures. fessional, in other words, ‘‘You can total count
The authors found different levels of emotional on me; I’ll take care of you’’ (CRNA 4). The fourth
energy in CRNAs during interaction with pa- picture in Figure 3 illustrates this quotation. The
tients. Moreover, the findings showed that CRNA placing her hand on the patient’s shoulder
emotional energy was embedded in instrumental while placing the face mask over the patient’s
actions and routines, perhaps at the expense of mouth and nose imparted trust.
being sensitive toward patients’ psychosocial
needs, when some CRNAs would ordinarily Two distinct categories emerged in unfolding the
interact with patients. This, in turn, affected subcore variable instilling trust: offering a lifeline
the way CRNAs instilled trust in patients while and controlling interaction (Figure 2).
performing embodied actions. A CRNA in the
following citation expressed the core variable Offering a Lifeline
creating emotional energy: The CRNA is
describing a specific sensibility and mutual focus A CRNA, reflecting on a key issue for the interdisci-
of attention in an OR environment among the plinary team members, expressed offering a life-
CRNA, the patient, OR nurses, and anesthesiolo- line: how was the contact and care of the patient
gists. Emotional energy was embedded in this organized? ‘‘I think that some CRNAs say that it is
sensibility, thus affecting the way actions were the CRNA who is entitled to this contact. But it
performed. ‘‘And in fact you can sense if there doesn’t matter, as long as the patients feel that
is someone in the room who does not have this they have a lifeline. In this context, a lifeline means
specific sensibility. There is a sort of situational a health care professional who takes the responsi-
awareness. Either you walk in and pick up on bility of staying in contact with the patient during
this sensibility right away, or you just walk in, the procedure; someone who comforts and guides
perform a task and leave’’ (CRNA 11). the patient through the entire procedure. Too

many health care professionals offering a lifeline talk to and having the emotional energy to small
make the situation confusing and insecure [the pa- talk with the entire interdisciplinary team. This
tient]. I think that the most important thing is to misled the CRNA into not following the patient’s
signal to the patient that we are working together appeal for a comforting handhold during the pro-
in taking care of you. The atmosphere among col- cedure. Furthermore, time constraints and priori-
leagues is very important’’ (CRNA 1). Embedded tizing the performance of technical procedures
within offering a lifeline was partly a concern were important factors in the equation. The
for patients’ needs for trust and confidence, partly CRNA’s wish to have primary contact with the pa-
CRNAs and OR nurses being able to take the role of tient was not coordinated with the interdisci-
comforting and guiding the patient through the plinary team beforehand. ‘‘I’m the one to have
procedure, which, in turn, may challenge the pro- the main contact with the patient and then I do
fessional identity of each group of health care pro- want it. I’m not the one to stand back. It is the
fessionals. Offering a lifeline was also an outcome OR nurse who must stand back. I’m dependent
of CRNAs’ professional training in maintaining on the fact that the OR nurses sense the same as
control of the situation. I in connection with the patient’’ (CRNA 3).
Thus, the primary challenge in offering patients a
Also involved in offering a lifeline was a tacit lifeline was the coordination between interdisci-
commitment by the CRNA and secondary CRNA, plinary team members in the OR of who would
who was assisting during the preanesthetic pro- take responsibility to be the patient’s lifeline.
cedure, to coordinate among themselves who is
going to be the patient’s lifeline during the anes- Controlling Interaction
thetic procedure. The following situation illus-
trates the ambiguities of this particular CRNAs control interactions with patients when
interaction. A patient is lying in a hospital bed, preparing and guiding them through the anes-
outside the OR. The CRNA responsible for the thetic induction. Guiding patients with words
anesthetic procedure walks by and greets the pa- and voice tone were specific ways of giving pa-
tient. Immediately, the patient takes hold of the tients back some control in this vulnerable situa-
CRNA’s hand while staring intently. The CRNA tion. A CRNA explained how she guided patients
and patient continue to hold hands while they while positioning the face mask: ‘‘I know that the
are talking (observation 3). This situation mani- patients are about to surrender control of their vi-
fests an obvious appeal for a lifeline by the patient, tal functions to me, so I feel that I need to give
which is illustrated in the third photograph in them back some control. The patient is not able
Figure 3. Later, the patient verbally expressed a to ask questions, so I’m thinking, ‘What would
need for hand holding during the anesthetic pro- the next possible question from the patient be?
cedure: The patient asks the CRNA: ‘‘would you How may the patient experience these proced-
hold my hand while I’m sleeping?’’ The CRNA an- ures? And then I explain that’’’ (CRNA 11).
swers: ‘‘I would like to, because I’m sitting here Embedded in these guiding and controlling actions
anyway’’ (observation 3). The patient’s appeal for was also the CRNAs’ way of relying on routines,
a holding hand was not taken into account before- while performing instrumental procedures and in-
hand by the CRNA or coordinated with the inter- teracting with their patients. Patients were uncon-
disciplinary team: The CRNA stands by the ditionally leaving responsibility for their lives in
patient’s headboard holding the face mask. The the hands of the CRNA. Their decision to entrust
secondary CRNA gives the patient intravenous CRNAs with this, and the specific treatment, was
medicine. The patient is lifting the right hand. further supported by intradisciplinary and inter-
The secondary CRNA, who is busy infusing the disciplinary team members being physically pre-
medicine, leans over and puts the hand down sent when they guided and informed patients
again. The patient lifts the hand again, and the during the procedure.
anesthesiologist, who has been standing in the
rear of the OR, walks to the opposite side of the Maintaining OR turnover and limited time be-
operating table and takes the patient’s hand (obser- tween preparation for the next anesthetic proced-
vation 3). The challenge in this situation was the ure and surgery motivated CRNAs in using
CRNA’s impression of the patient being easy to different levels of controlling interaction. For

example, CRNAs would fend off patients’ ques- embodied actions being integrated parts of a
tions by letting them know that this was neither routine. This subcore variable was expressed by
the time nor the place to discuss their thoughts a CRNA: ‘‘It is not a conscious act of reflection
on the specific situation. This is illustrated by the every time, but earlier on in my career I decided
following CRNA’s interview response: ‘‘I don’t what it is I’m going to do in various phases and
think it is appropriate for patients to be asking a what I’m going to say’’ (CRNA 11). This statement
lot of questions at the last minute - some have a ten- also illustrates the importance of technical and
dency to do that. Then, I think, it is time to move interactional routines. The fifth photograph in
on. Of course that’s my assessment of the situa- Figure 3 shows the mutual effect of these two
tion’’ (CRNA 9). types of routines used to perform embodied ac-
tions. ‘‘I deliberately hold the hand of the patient’s
Case observations also brought to light how arm I’ve chosen for venous cannulation. I think
CRNAs took control by overhearing patients finish- that I’m able to signal professional competency
ing their answers to the CRNAs’ questions. This by using touch as I perform the task’’ (CRNA 11).
was because the CRNA was professionally engaged The categories for describing this subcore variable
with moving on to the next task and changing her are depending on routines in interaction and
place in the OR, as in the next example. The CRNA integrating technology and humane care.
asks the patient if he has slept well and is ready for
today’s hardship. The patient tells the CRNA that Depending on Routines in Interaction
he has slept for 5 hours. The CRNA asks if the pa-
tient took a sleeping pill. The patient explains The depending on routines in interaction cate-
that he didn’t, but he used some pills prescribed gory contains both routines in technical proced-
by his general practitioner. he is not able to finish ures and routines in performing embodied
his sentence because the CRNA turns away from actions. Embodied actions are part of CRNAs’ rou-
the patient to read her journal (observation 2). tines when performing technical procedures,
CRNAs’ verbal communication and physical posi- while simultaneously interacting with patients.
tion in the room in relation to the patients indi- These routines support CRNAs’ feelings of confi-
cated great nuances in their thoughts and dence and control during their interaction with pa-
priorities when interacting with patients. There tients and help them remain alert and prepared.
appeared to be a conflict between prioritizing One CRNA points out the symbolic importance
and thinking about the meaning of this particular of the first photograph in Figure 3. ‘‘This is such
interaction, on the one hand, and the instrumental an illustrative picture for me. It indicates how
and practical tasks overriding CRNAs being you go through everything once again before the
consciously present in their interaction with pa- patient arrives and confirm to yourself that you’re
tients, on the other. The second photograph in confident about the procedure you’re about to
Figure 3 illustrates how patient safety procedures perform. This is prerequisite for being sufficiently
are a central task. The aforementioned excerpt receptive towards the patient’’ (CRNA 11). CRNAs
from an interview and an observation shows two depend on familiar routines in their daily work to
different ways of controlling the interaction. be able to deal with time constraints, patient
safety, and effective performance in preparing for
Performing Embodied Actions the anesthetic procedure. ‘‘You are under this
time pressure, and then you need your rhythm,
The second subcore variable, performing and, at the same time, I also believe that the
embodied actions, was evident from observations rhythm lies in the things you say to the patient’’
that CRNAs had specific embodied and tacit ways (CRNA 8). In this work, routine is embedded an im-
of acting while preparing patients for the anes- plicit challenge, namely that CRNAs risk mini-
thetic induction. CRNAs’ descriptions of embodied mizing their emotional energy and sensitivity
actions were characterized by being tacit and toward patients’ individual physical and psychoso-
dependent on clinical experience and routines. cial needs. The risk was to use small talk and a min-
Use of the word performing captures a prereflex- imum of embodied actions without reflection and
ive way of acting and performing instrumental pro- sensibility toward the patient, thus adversely
cedures. Hence, clinical experience contributed to affecting the possibility of establishing a

relationship embodying trust and confidence with technical tasks. A patient expresses this in the
the patient. CRNAs’ interaction strategy may then following: ‘‘It is a bit like a factory when there
be characterized as a production-centered action, are three [health professionals] standing here.
in contrast to a patient-centered interaction, as in you do this, and you do that, and then, next patient
the following interview excerpt: ‘‘It is not only [laughter]’’ (patient 2).
time that controls us [laughter], but today there
are 12 acute patients waiting for surgery, and I Discussion
am on duty tomorrow, so I have told my colleagues
to work efficiently to minimize the number of pa- This study delineates the complexity of CRNAs’
tients by tomorrow’’ (CRNA 2). interaction with patients in a highly technological
environment. The core variable of the findings is
Integrating Technology and Humane Care conceptualized as creating emotional energy
and is further elaborated through two subcore vari-
Integrating technology and humane care is a core ables: instilling trust and performing embodied
element of CRNAs’ daily clinical practice. This inte- actions.
grating practice demands that CRNAs’ attention be
divided between the technological procedures Different domains of activity and performing
and their interaction with patients, before and dur- instrumental and technical procedures are inter-
ing these procedures. Furthermore, patients’ woven during CRNAs’ interaction with patients.
cooperation during the procedures and CRNAs’ This study’s findings point to the critical impor-
cooperation with the interdisciplinary team are tance of analyzing embodied actions. By doing
two salient components in the integrating tech- so, CRNAs are able to create emotional energy as
nology and humane care category. CRNAs’ atten- an outcome of the specific interaction with pa-
tion before and during a specific technological tients before induction of general anesthesia.
procedure focuses on juggling multiple tasks to This emotional energy may then result in instilling
ensure patient safety while being vigilant and guid- trust in patients. Previous researches on communi-
ing them through anesthetic induction. This is ex- cation between patients and health care profes-
pressed by a newly CRNA: ‘‘I think it comes with sionals in the anesthetizing area20 and the
time and it depends on the experience you have. embodiment and ephemeral teamwork in anes-
In the beginning, and even now, I need to check thesia21 stress the importance of analyzing
the values on the screen. I do not have that intui- embodied conduct and embodiment in the work-
tive feeling yet. I need to turn my head away place. In line with this research is a study on pro-
from the patient, and I’m a person who wants to fessional activity in the OR,22 which focuses on
see what my assistant is doing. For that reason, how surgical work is accompanied by talk and
the patient gets about a third of my attention, bodily conduct. Hindmarsh and Pilnick21
and, I think, with growing experience you focus concluded in one study that the body is a central
more on the patient. As a newly CRNA you are site for organizing work and recognizing how par-
more technically oriented’’ (CRNA 8). In this state- ticipants in a social interaction see bodies with re-
ment, the CRNA expresses a conscious way of gard to the material contexts of tools and
working with technology when being newly certi- technologies. In light of these three studies, it is
fied, which may be at the expense of interacting therefore extremely relevant for CRNAs to reflect
with patients. This is expected to change with on the importance of using embodied actions
growing experience in clinical practice. Thus, when performing technical procedures. Touch,
the aforementioned example indicates that there physical placement in the room, eye contact, and
is a specific way of working with technological in- tone of voice are thus ways to create emotional en-
struments, which was characterized by CRNAs’ ergy and trust during the necessary technical steps
performance of embodied actions when interact- in preparing patients for induction of the anes-
ing with patients and cooperating with interdisci- thetic.
plinary team members. A latent risk here is to
objectify the patient, if CRNAs do not succeed in Trust in professionals is characterized as an im-
consciously reflecting and sensing patients’ phys- plicit contract between professional and
ical and psychosocial needs when performing layperson, in this case between a CRNA and a

patient. Professionals have an ethical and legal concerned with skills and clinical competencies
obligation of instructing patients on their best in- but also with the external expectations for effi-
terests. Trust is supported by patients’ feeling of ciency in the daily clinical setting. Varying ways
confidence in CRNAs’ future tasks. Furthermore, of using time optimally when interacting with pa-
patients have confidence in their own way of tients and concerns for keeping production
judging CRNA’ professional actions. Thus, there running may affect CRNAs’ emotional involvement
is a double confidence in building trust between in patients, thereby adversely affecting patients’
patients and CRNA.23 In addition, Engdahl and Lid- feeling of trust.
skrog24 have argued that trust does not develop
through information but through emotional Similar to our study, Karlsson et al3 found that pa-
involvement. This means that patients are tients were not always the center of CRNAs’ atten-
emotionally involved by taking an active part in tion during regional anesthesia because of nurse
and having a say during their preparation for gen- anesthetists’ attention to the more technical as-
eral anesthesia. According to this study, an pects of the procedure or their focus on a specific
emotional understanding of trust implies the area of the patients’ bodies. This resulted in an
importance of the CRNA being aware of an implicit asymmetric interaction between patients and
trusteeship when interacting with each patient. In CRNAs. Our study also indicates an asymmetric
connection to the presented articles on trust, this motive for this interaction. CRNAs were motivated
study supports the emotional understanding of by patient-centered interaction and production-
trust by emphasizing the importance of CRNAs’ centered interaction; the interaction was influ-
emotional involvement through touch, eye con- enced by which profession offered the patient a
tact, physical placement in the room, and verbal lifeline and instilled trust. CRNAs’ level of sensi-
guidance of each patient. tivity while performing the clinical practice rou-
tines of their practices is affected by their
CRNAs’ instrumental and verbal routines during different motivations for interacting. This, in
the preparation of patients for general anesthesia turn, affects the emotional energy in their relation-
are characterized as formal rituals. Formal rituals ship with the individual patient. Karlsson et al3
are defined as rituals that build up mutual focus describe a similar situation where physical and
and emotional entrainment initiated by a emotional distance between patients and CRNAs
commonly recognized apparatus of ceremonial resulted in a lack of interaction, thereby making
procedures.25 These types of rituals generate feel- it difficult for CRNAs to respond to patients’ phys-
ings of membership and clear group boundaries. ical and psychosocial needs.
Emotional entrainment may be challenged, howev-
er, depending on CRNAs’ reflections on and use of A study aiming to describe the interaction be-
verbal and embodied actions when performing rit- tween CRNAs and patients immediately before cor-
uals related to the instrumental procedures. For onary artery bypass grafting surgery revealed the
instance, in the examination of emotional labor concept of reassurance as a major finding. Reassur-
in nursing by Theodosius,5 she studied the instru- ance was achieved through performance of well-
mental character of nursing. Theodosius5 found structured nursing and continually informing
that this kind of nursing facilitates the clinical pro- patients throughout the procedure.6 In contrast,
cedure in a way that minimizes discomfort and our study emphasizes the ambiguities and devia-
maximizes the healing process in the patient’s tions that are embedded in CRNAs’ interactions
body. The patients are concerned with the poten- with patients, thereby offering a more nuanced un-
tial threat to their bodies and, therefore, con- derstanding of this specific type of nursing per-
cerned with their personal safety. The nurse, formed in a highly technological environment.
meanwhile, is concerned with her performative
achievement, reflected in her skill and clinical During the presentation of the categories depend-
competency, which is directly linked to her iden- ing on routines and offering a lifeline, three mo-
tity as a nurse.5 Thus, CRNAs’ motives for interac- tives for CRNAs’ interactions with patients
tion and performing highly technological nursing emerged: Time and operating turnover times,
are affected by the CRNA’s professional identity. CRNAs being the primary lifeline, and focusing
To this, our study adds that CRNAs are not only on the patient and not on which health care

professional offers a lifeline. Thus, different types tion context. The combination of observations, in-
of motivation affect CRNAs’ level of emotional en- terviews, and photographs facilitated multisite
ergy during interaction with patients. Emotional comparison and an in-depth understanding of the
energy gives CRNAs and patients energy to initiate variables and categories. Thus, it was possible to
actions and interact socially.25 By focusing on the go beyond the merely descriptive to theory gener-
patient during interaction, CRNAs are able to instill ation, which is seen as strength of the study.
feelings of trust, confidence, and safety in patients
in a vulnerable situation. However, when working Gathering data from only one hospital in Denmark
in a highly technological environment, there is a may be a limitation with regard to external validity.
great risk of failure during interaction if instru- A more comprehensive study of the different orga-
mental procedures and care are not well integrated nizations and cultures of Departments of Anesthe-
in nurse anesthetists’ routines. Bolton26 empha- siology in other regions of Denmark might have
sizes that motivations are embedded in social situ- influenced our findings and provided the study
ations and relationships, which are wedded to with further nuances. A distinguishing organiza-
actions that acknowledge institutionalized prac- tional structure for Scandinavian CRNAs is that
tices and hierarchical power relationships. Thus, they work under delegated responsibility from
CRNAs’ motivation for preparing patients for the the anesthesiologist, which means CRNAs are
anesthetic procedure is embedded in professional themselves inducting patients in many situations.
competencies in performing instrumental proced- Consequently, a limitation is that the responsible
ures, patients’ safety, patients’ feeling of trust, the anesthesiologist is not included in the study.
CRNAs’ professional position in the interdisci-
plinary team, and the culture and ethical standards Another limitation may be that the patients
of the Department of Anesthesiology. included in the study were in their late 50s to early
70s, which excluded younger patients’ perspec-
Strengths and Limitations tives. The decision to focus solely on cancer pa-
tients was another limitation. Research shows that
Focused ethnography was found to be an appro- patients undergoing surgery for benign and malig-
priate method for exploring the interaction be- nant cancers expressed themselves differently in
tween CRNAs and patients in highly relation to the outcome of their surgery.28 However,
technological environments. Focused ethnog- because of this study’s intense data collection, the
raphy is often used in applied research fields, theorizing on creating emotional energy is useful
such as nursing.13 Conventional ethnography and in explaining the complexity of nursing care in
focused ethnography differ in the amount of time highly technological nursing and how different
used to collect data. Focused ethnography uses work cultures in the Department of Anesthesiology
short-termed field visits, a methodology that is may influence nurses’ professional identity.
compensated for by an intensity in data collec-
tion.8 The data intensity of this project reflects a Conclusion and Implications for Practice
combination of observations, interviews, and pho-
tographs. Furthermore, the participants in the Creating emotional energy and the motives behind
study have an in-depth knowledge of the area be- CRNAs’ interactions with patients are central ingre-
ing studied,27 which allows a better understanding dients in developing anesthesia care. Furthermore,
of the complexities surrounding the interaction CRNAs’ conscious reflections on creating
between patients and CRNAs. By focusing on the emotional energy associated with their motivations
participants’ emic view on the interaction through have an impact on how CRNAs establish a relation-
the etic lens of the first author, it is possible to ship with patients and show us how it is possible to
develop knowledge relevant for nursing.13 integrate technical procedures and care during
preparation of patients for general anesthesia.
Using grounded theory tools in the analysis and in
the development of theoretical ideas was found to Emotional energy is an integral component of
be very appropriate. Observations were confirmed instrumental and highly technological nursing. Be-
through interviews of CRNAs and photographic ing linked to tacit emotions and embedded in clin-
evidence illustrating central objects in the observa- ical procedure, it is a challenge for CRNAs to even

think to mention it. Because of these factors, the These findings can be used to further educate
development of the core variable creating nurses about interaction with patients in the
emotional energy may be useful in other nursing context of highly technological nursing and create
settings when performing instrumental a self-awareness of the motives behind different
procedures. interaction patterns.

1. Smith AF, Mishra K. Interaction between anaesthetists, 13. Higginbottom G. The use of focused ethnography in
their patients, and the anaesthesia team. Br J Anaesth. 2010; nursing research. Nurse Res. 2013;20:36-43.
105:60-68. 14. Riley R, Manias E. The uses of photography in clinical
2. Mitchell M. Patient anxiety and modern elective surgery: A nursing practice and research: A literature review. J Adv Nurs.
literature review. J Clin Nurs. 2003;12:806-815. 2004;48:397-405.
3. Karlsson A-C, Ekebergh M, Larsson Mauleon A, Almerud 15. Magilvy J, Congdon J, Nelson J, Craig C. Visions of rural

Osterberg S. Patient-nurse anesthetist interaction during aging: Use of photographic method in gerontological research.
regional anesthesia and surgery based on video recordings. J Gerontologist. 1992;32:253-257.
Perianesth Nurs. 2013;28:260-270. 16. Gibson B, Hartman J. Rediscovering Grounded Theory,
4. Schreiber R, Macdonald M. Keeping vigil over the patient: 1st ed. London, UK; Thousand Oaks, CA: Sage Publications,
A grounded theory of nurse anaesthesia practice. J Adv Nurs. Ltd; 2014.
2010;66:552-561. 17. Glaser BG. Theoretical Sensitivity, 5th ed. Mill Valley, CA:
5. Theodosius C. Emotional Labour in Health Care. The Un- Sociology Press; 1978.
managed Heart of Nursing, 1st ed. Oxon, UK: Routledge; 2008. 18. Glaser B. Basics of Grounded Theory, 1st ed. Mill Valley,
6. Berg K, Kaspersen R, Unby C, Hollman Frisman G. The CA: Sociology Press; 1992.
interaction between the patient and nurse anesthetist immedi- 19. Pink S. Doing Visual Ethnography, 3rd ed. London, UK;
ately before elective coronary artery bypass surgery. J Peria- Thousand Oaks, CA: Sage Publications, Ltd; 2013.
nesth Nurs. 2013;28:283-290. 20. Pilnick A, Hindmarsh J. ‘‘When you wake up it’ll all be
7. Barnard A, Sandelowski M. Technology and humane over’’: Communication in the anaesthetic room. Symb Interact.
nursing care: (Ir)reconcilable or invented difference? J Adv 1999;22:345-360.
Nurs. 2001;34:367-375. 21. Hindmarsh J, Pilnick A. Knowing bodies at work:
8. Knoblauch H. Focused ethnography. Forum Qual Soc Res. Embodiment and ephemeral teamwork in anaesthesia. Organ
2005;6. Stud. 2007;28:1395-1416.
9. Muecke M. On the evaluation of ethnographies. In: 22. Bezemer J, Cope A, Kress G, Kneebone R. ‘‘Scissors,
Morse J, ed. Critical Issues in Qualitative Research Methods. please’’: The practical accomplishment of surgical work in the
Thousand Oaks, CA: Sage Publications; 1994:187-209. operating theater. Symb Interact. 2011;34:398-414.
10. Curriculum description, education in anesthesia nursing 23. Barbalet J. A characterization of trust, and its conse-
for registered nurses.; 2012. quences. Theor Soc. 2009;38:367-382.
11. Sygepleiernes Samarbeid i Norden, [Northern Nurses’ 24. Engdahl E, Lidskog R. Risk, communication and trust: To-
Federation]. Ethical guidelines for nursing research in the wards an emotional understanding of trust. Public Underst Sci
Nordic countries [Etiske retningslinier for sygeplejeforskning i 2012;1-15.
Norden Etiske retningslinjer for sykepleieforskning i Norden 25. Collins R. Interaction Ritual Chains. Princeton, NJ:
Etiska riktlinjer f€
or omvardnadsforskning i Norden Hoitoty€ on Princeton University Press; 2005.
tutkimuksen eettiset. 2003. Available at: http://old.sykepleien. 26. Bolton SC. Emotion Management in the Workplace, 1st
no/ikbViewer/Content/337889/SSNs etiske retningslinjer.pdf. ed. Hampshire, UK: Palgrave Macmillan; 2005.
Last accessed 2003. 27. Higginbottom GMA, Pillay JJ, Boadu NY. Guidance on
12. Hammersley M, Atkinson P. Ethnography: Principles performing focused ethnographies with an emphasis on health-
and Practice, 3rd ed. London, UK: Routledge. 2007. Available care research. Qual Rep. 2013;18:1-16.
at: http://www.worldcat.org/title/ethnography-principles-and- 28. Moene M, Bergbom I, Skott C. Patients’ existential sit-
practice/oclc/804544520&referer5brief_results. Accessed uation prior to colorectal surgery. J Adv Nurs. 2006;54:
March 18, 2013. 199-207.