1 Introduction

Technological and scientific advances in surgical treatment and postoperative care reduce the risk of surgical treatments, improve the treatment and care of patients, and increase the quality of life. An estimated 234 million surgeries are performed around the world each year, making surgical care an integral part of healthcare [1, 2]. The role of the nurse in the care and treatment of patients at different stages of the surgical process is significant. The surgical process includes preoperative preparation, intraoperative care, and treatment and care interventions for the patient's recovery after surgery. Intraoperative care is a process that begins with the patients being taken to the operating room and continues until they leave the operating room [2]. In the postoperative period, patients are first admitted to PACU. Since the passing effect of anesthesia is a great source of stress in patients, the PACU environment should be comfortable and safe. PACU is a vital part of hospitals designed to provide post-anesthesia care to patients, connected to operating rooms and staffed by anesthesiologists, nurses, technicians, and surgeons [2, 3]. Most of the surgical morbidity and mortality are seen in the postoperative period. Patients come to the recovery unit from the operating room with risks such as airway obstruction, vomiting, tremor, agitation, delirium, pain, and hypothermia. The fact that the most important period in the treatment process of patients is the early and late postoperative period reveals the importance of care in PACU [2, 4].

The post-anesthesia care process covers all levels of care in most institutions, but some institutions offer Phase-I and Phase-II services. In Phase-I, treatment and care are continued until the patient is transferred to another unit in the postoperative period. At this stage, the nurse monitors the airway, oxygen therapy, vital signs, complications, and symptoms [2]. Phase II requires less follow-up, treatment, and observation than Phase I. This stage is generally intended for patients undergoing day surgery [2, 3]. Nursing care in PACU aims to take into account the patient's condition after surgical intervention. This allows healthcare professionals, especially nurses, to identify and repair the needs of patients whose condition is worsening [5]. However, many barriers to nursing care in the PACU have been identified [6,7,8,9]. This review elucidates the significance and methodology of nursing care in the PACU, complications that manifest in the PACU's early phase, challenges inherent to nursing care therein, and potential strategies to surmount these challenges.

2 Nursing Care at PACU

PACU nurses provide care to patients in the postoperative period when they are at greatest risk for respiratory and cardiovascular complications during recovery from surgery and anesthesia [10]. The first evaluation begins by evaluating the patient's neurological, airway, respiratory and circulatory status. The initial neurological assessment should focus on the level of consciousness, such as orientation, sensory and motor status, pupillary size, equivalence, and responsiveness. The patient may be awake, drowsy, or asleep. Since hearing is the first returning sense in the unconscious patient, all activities should be explained to the patient from the moment of admission to PACU. If the patient has received regional anesthesia (e.g. spinal, epidural), sensory and motor blockade may still occur, dermatome levels should be evaluated. Patient characteristics such as residual neuromuscular blockade, opioid use, and sleep breathing impairment (e.g., obstructive sleep apnea) affect oxygenation and ventilation. The nurse must be alert for signs of inadequate oxygenation and ventilation. Any signs of respiratory distress require immediate intervention. Pulse oximetry monitoring is a noninvasive way to assess oxygenation and can provide early warning for hypoxemia. Subcutaneous carbon dioxide (PtcCO2) and end-tidal CO2 (PetCO2) (capnography) monitoring is used to detect respiratory depression in high-risk patients. Volumetric capnography and acoustic respiratory rate monitoring can help detect respiratory distress early. Changes in the initial ECG findings should be noted and evaluated before surgery. Blood pressure should be measured and compared with the previous value. Body temperature, peripheral pulses, capillary vessel filling and skin condition (eg, color, humidity) are evaluated. Any signs of inadequate tissue perfusion require immediate intervention. The urinary system should be evaluated by measuring fluid intake and output and determining fluid balance. Intraoperative fluid totals are part of the report of the physician in charge of anesthesia. Attention should be paid to the presence of all IV lines; all irrigation solutions and infusions; and all outlet devices, including catheters and wound drains. The operation site should be evaluated, and the condition of the dressing, and the type and amount of drainage should be noted. Instructions on incision care should be followed [11].

While the bed is in a flat position in patients with a tendency to hypotension during transport to the PACU, the head-up position should be placed in patients with airway problems. When there is a risk of aspiration, oral bleeding, and vomiting, the patient should be transported in the side-lying position [12]. The patient admitted to PACU should be taken to a stretcher or bed. The patient's dirty operating room apron should be removed and the patient should be dressed in a clean and dry gown. Bed edges should be lifted for patient safety. The PACU nurse should provide individualized nursing care to the patient by taking into account the preoperative patient information according to the type of anesthesia and surgery [2, 13]. (PACU Initial Assessment is given in Table 1) [11, 14].

Table 1 Initial PACU Assessment
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After the nurse's initial evaluation of the patient and comprehensive body systems examination, it is of great importance in PACU to provide care for possible complications. This is because after general anesthesia and surgery, physiological changes can occur that can affect all body systems, and the general condition of the patient can change rapidly [2, 4]. The resulting physiological changes may cause hemodynamic, respiratory, and thermoregulatory problems. In addition, discontinuation of anesthetic agents, return of the effects of muscle relaxants, and complications due to tracheal extubation may occur. The most common complications include acute pain, nausea, vomiting, delirium, tremors, hypothermia, dry mouth, and hunger [2]. In the study conducted by Koraş-Sözen [15] to evaluate the early complications seen in the postoperative recovery unit (n = 265), 49.4% of the patients developed various complications, followed by pain with a rate of 31.3%, followed by nausea-vomiting with 29%, tremor with 11.5%, hypotension with 8.4%, headache with 7.6%, bradycardia with 3.8%, hypertension with 2.3%, dyspnea with 2.3%, oliguria with 2.3% and hypothermia with 1.5%. In addition, it is stated that taking the necessary precautions in advance according to the type of surgery and the condition of the patient can reduce complications. In the observational study of Abebe et al. [7], in which the incidence of complications in PACU and related factors were examined, it was stated that the incidence of complications was 54.8% in surgical patients admitted to PACU, and respiratory complications and nausea/vomiting were the most common complications. It was found that female gender, duration of anesthesia > 4 h, and duration of stay in PACU > 4 h were associated with postoperative complications. It is suggested that field-specific institutional guidelines and protocols should be developed to improve PACU outcomes.

It is stated that half of the complications after anesthesia are seen in the first 1 h and 75% in the first 5 h. Complications in patients during the recovery period are worse than complications during anesthesia. High American Society of Anesthesiologists (ASA) value, emergency procedures, anesthesia lasting 2–4 h, and abdominal and orthopedic surgical procedures have the highest incidence of complications. Complications and side effects can be detected early thanks to nursing observation, care, and treatment in PACU, and the incidence of complications, mortality rates, and length of hospital stay can be reduced with timely intervention. Complications seen in PACU are respiratory problems, circulation problems, neurological problems, pain, change in body temperature, and nausea and vomiting probl.ems [2] (Table 2 includes complications seen in the early period and nursing approach at PACU) [11, 16].

Table 2 Early Complications in PACU and nursing approach
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3 Barriers to Nursing Care at PACU

In transforming PACU into a safe and quality care service for the surgical patient, some obstacles in front of nursing care need to be eliminated. These barriers identified by the literature review are given below.

3.1 The Handover at PACU

The handover report is the interprofessional transfer of critical and essential patient information, professional responsibility, and accountability from one healthcare provider to another [11]. An integral part of the continuity of quality care is the effective transfer of clinical information [17]. The anesthesiologist examines the patient's allergies and related health and medication history, including medications taken or not taken that day. The report also includes specific concerns and/or recommendations regarding the surgery, procedure, or diagnostic test performed, the antibiotic(s) administered, anesthesia and analgesia, any complications or concerns, fluids and volume status given, and the post-anesthesia care plan. The American Association of Nurse Anesthesiology (AANA) Implementation Considerations emphasize that the transition in this process is based on a two-way interaction, preferably face-to-face and that both healthcare professionals should be actively involved in communication [6]. During the transition period, the environment should be free of distractions and interruptions and allow for an open communication platform, including the opportunity to ask and answer questions. In addition, handover reports should be standardized and interactive, enabling one to ask questions and clarify information. The physician in charge of anesthesia should remain at PACU until responsibility for the patient's care is accepted [11].

According to AANA (2019)'s report, studies have shown that an unstructured PACU handover process threatens patient safety, leads to reduced satisfaction among PACU nurses, and reduces the amount of information transferred. It is stated that 80% of serious medical errors are caused by inadequate handover reports. Known causes of incomplete transfers are reported as too many tasks, insufficient time, incomplete patient information, informal handover structure, and a chaotic environment. However, it is stated that clear and complete transfer-based communication supports the PACU team in maintaining care and achieving the results sought by the patient and family/caregiver [6]. Abebe (2022) stated that according to the review reports of the Anesthesia Closed Claims Project (CCP) database, the leading cause of anesthesia-related malpractice errors is communication breakdowns. Communication problems between clinicians are frequently experienced in operating rooms, PACU, and intensive care units. It is stated that this ineffective communication in PACU affects health care expenses, length of hospital stay, unplanned intensive care unit admissions, mortality, and morbidity [7].

It is noted that a standard PACU transfer checklist focuses on the critical points that need to be addressed for a full transfer and can shorten the duration of the oral report. It is reported that with the use of a standardized form, the skipping of critical points is significantly reduced. Therefore, it is emphasized that a standard tool (Such as SBAR: Situation, Background, Assessment, Recommendation or PATIENT: Patient, Airway, Temperature, Intravenous and Intake/output, End-tidal carbon dioxide, Narcotics, Twitches) should be used in the transition process [6]. A systematic review published in 2013 shows that the implementation of structured handover protocols and interventions to improve communication skills improves patient handover in PACU [18]. Arias-Botero and Padrón-Mercado (2017) determined that while 57% of nurses thought that handover information was of good quality, 26% thought it was incomplete [8]. According to Abebe et al. (2022), the use of a standard checklist is indicated to reduce overall medical errors and the rate of adverse events in PACU [7]. Another study shows that the use of post-anesthesia care tools provides early detection of patients at risk of worsening the condition, improves delivery to surgical ward nurses, and reduces healthcare costs [1].

PACU is an important place for surgery patients to recover. Health professionals working here are required to provide PACU nurses with complete and comprehensive postoperative handover information. A standardized handover model is needed for clinical nurses to improve patient safety management and work efficiency [19].

3.2 Forms used in PACU and Lack of Documentation

According to the results of the studies, record keeping is significant in PACU but the lack of time and training in this regard creates obstacles in record keeping. It is reported that manual records take time and these records are sometimes unreadable, while digital forms are filled out faster, albeit complex, but there are delays in making records due to the lack of computers, and the practice of "cut-and-paste" limits the quality of recorded information. Generally, there is a lack of documentation of information about the intraoperative period, nausea and vomiting, pain assessment, and physician instructions. According to the report of Arias-Botero and Padrón-Mercad (2017), 51% of the nurses did not use the recovery scale in patients who came to PACU, the Modified Aldrete Scoring System Scale was the most popular, but 16% of the nurses who applied the scale did not record the scale scores. In addition, it was noted that when the patient is discharged from PACU, some forms cannot be filled out due to time-consuming, such as the surgeon's postoperative recommendations and proof that the recipient understands the care recommendations [8]. In the study of Bowyer and Royse (2016), it is emphasized that to identify patients who may benefit from the timely intervention in the postoperative period, real-time evaluation of patient recovery should be performed, therefore the quality of postoperative recovery should be measured [20]. Niyungeko et al. (2021), in their study (n = 82) in which they examined nursing practices in the recovery room, reported that only 47.5% of the nurses knew the nursing protocols used for post-operative patients, and they did not have sufficient information about the different tools used to evaluate the patient's post-anesthesia discharge [5]. Pazar and Yava (2013) examined the effect of the nursing guide application, which was developed for this study and followed up according to the early warning score system (EWSS) in PACU, and found that the use of EWSS and nursing guidelines enabled early detection of complications and earlier interventions. In line with these results, EWSS and nursing guidelines were recommended to be used in the post-anesthesia care unit [21]. Street et al. (2018) examined the use of a post-anesthesia care tool and its effect on nursing assessment, communication, and management regarding patients in PACU and reported that the post-anesthesia care tool provides an increase in the frequency of nursing evaluation, nurses show significant improvement in responding to complications such as pain, nausea-vomiting, hypothermia, and contribute to the recognition of clinical deterioration and transition from PACU to the service. In addition, it was noted that the use of standardized assessment, documentation, and communication procedures at PACU can improve patient safety and quality of care, especially in high-stress clinical areas [22].

3.3 Training Requirement of Nurses at PACU

Nurses need competence in postoperative care to ensure the safe and successful recovery of patients who have undergone surgery. However, there is no consensus on the competence or training required to provide safe, high-quality patient care in PACU [9]. To promote a safe and successful recovery after surgery, the nurse working at PACU must have received special training in postoperative care [23]. Post-anesthesia care should be performed by trained and professional nurses [24]. In a qualitative study conducted with nurses working at PACU, nurses stated that it is important to always be “one step ahead” after surgery and to be prepared for any eventuality. They stated that they needed to be vigilant, anticipate complications, and be prepared for anything that might happen, meaning “you have to be able to anticipate something before it happens.” In addition, it was stated that nurses should understand the surgeries performed and have advanced knowledge of pharmacology, know the hemodynamic parameters related to the patient, and know that all these affect each other [9]. Similarly, Dejarkom et al. (2014) stated that PACU staff should have excellent skills in detecting postoperative complications for the safety of patients [25]. It was reported that nurses working in PACU have high knowledge and skills in subjects such as follow-up, venous access, and medication management but have deficiencies in cardiovascular and respiratory problems and management of emergencies [8]. In a qualitative study by Dahlberg et al. (2022) based on nurses' perspectives on the competencies of nurses working in PACU in Sweden, it was reported that transferring critically ill patients who need to be treated in the intensive care unit to PACU because there is no room may put the health of patients at risk, since PACU nurses do not have the knowledge or experience to care for such patients. In the same study, it was emphasized that the competence of specialist nurses can be utilized in promoting safe and high-quality care in PACU, supervising recruits, and creating a knowledge base for graduate education [9].

3.4 The Workload of Nurses at PACU

Due to the number of duties and working hours, nurses often mention their workload. According to the surveys, the number of patients per licensed practice nurse per shift is four, and the number of patients per professional nurse is eight. Administrative duties such as document management, drug entries into the system, coordination of admission and discharge of patients, supervision of licensed practice nurses, diet lists, reaching the anesthesiologist when necessary, and liaison between the anesthesiologist and nurse assistants are reported among the reasons for the workload experienced by nurses. Professional nurses report that they do not have enough time to focus on patient care tasks due to heavy administrative duties. Although it has been stated that this situation causes a feeling of disappointment in the professional motivation of nurses, the fact that nurses with senior care responsibilities in PACU have less contact with patients was expressed as contradictory [8].

Kiekkas et al. (2021) examined the skipped nursing care in PACU and its causes and determined that the three nursing care activities most frequently reported by nurses were drug preparation, administration and evaluation of efficacy, patient surveillance and evaluation, and pain-related care. It is reported that these activities are performed significantly higher in patients coming from the intensive care unit due to their density, the prevalence of skipped nursing care activities was 78.1%, and the three most reported reasons for missed nursing care were the insufficient number of nurses, unexpected increase in patient volume or acuity, and heavy hospitalization or discharge activity. In addition, it was recommended that skipped nursing care should be identified and minimized, and the number of critically ill patients admitted to PACU and the length of stay should be limited [26]. Similar to the study of Kiekkas et al. (2021), Lalani et al. (2013) stated that although the patients are ready for transfer from PACU, the lack of beds in the wards causes congestion in the PACU, which leads to dissatisfaction among surgeons, nurses, patients, and their families, and that the long stay of patients in PACU increases the workload of nurses and affects the quality of postoperative nursing care [27]. There are other studies in the literature with similar results [10, 28]. In the study of Dahlberg et al. (2022), it is reported that nurses in PACU are stressed due to high patient flow and fast tempo, which threatens patient safety. It is noted that nurses do not have time to do written instructions or evidence-based practices and deviate from established routines [9].

3.5 Situations that Prevent the Independence of Nurses in PACU

Independence is defined as a sense of freedom in how patient care is planned and the ability to act quickly to meet patient needs. This sense of freedom brings with it a great deal of responsibility to nurses to have sufficient knowledge and to question situations that have the potential to harm the patient. However, several conditions that prevent nurses from working independently are described. One is that nurses only have access to a few common prescription medications, which prevents nurses from meeting patient needs quickly and limits their ability to work independently. Another obstacle is that the shortage of physicians in PACU complicates the work of nurses. That's because nurses have to contact physicians by phone to get prescriptions for medication, which can make a simple task very time-consuming. Nurses complain of medication prescriptions given orally, in addition to the time lost when consulting a physician. Nurses have noted that oral prescriptions are risky, can lead to misinformation or loss of information, and endanger patient safety [9].

3.6 Notification of Adverse Events and Perception of Teamwork at PACU

It has been shown that adverse events that develop in PACU are associated with patient complications. It is noted that low-severity adverse events (phlebitis, pressure ulcers) may result in social punishment if the event is reported, but often it is not taken into account. It is stated that the more severe the adverse events, the more pronounced the need to report the event [8]. Based on these results, it is recommended that a risk management model focused on patient safety should be implemented and strengthened in PACU, especially from the perspective of the nursing role. In addition, it is emphasized that the conditions of the institution (number of staff, training programs, shift distribution, improved adverse event management, patient handover process, recording of medical information, etc.) should be improved to minimize the occurrence of adverse events and ensure comprehensive and proactive management of the patient. Arias-Botero and Padrón-Mercado (2017) reported that another point emphasized by the people interviewed at PACU is teamwork and that the healthcare professionals here stated that "nothing can be done alone". However, in the definitions made, it is stated that PACU is not associated with teamwork, this concept is not internalized in PACU, and a common action related to PACU is not defined by the employees [8]. Dejarkom et al. (2014), reported that cooperation between surgeons, anesthesiologists, and PACU employees is essential in patient care at PACU [25]. (Barriers to nursing care at PACU and recommendations for these barriers are summarized in Table 3) [29, 30].

Table 3 Nursing care barriers in PACU and recommendations
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4 Conclusion

PACU is an environment where there is continuous circulation of various patients with individual needs in the postoperative period. Nursing proficiency at PACU requires specialized knowledge and proactively working with patients and staff at a fast pace to accept the patient and provide safe, high-quality care. The PACU nurse must have sufficient knowledge and skills in improving nursing care. Based on the results of the studies on the subject, it can be stated that to provide safe and high-quality nursing care in PACU, the training needs of nurses should be met, the newly recruited nurses should be supervised by specialist nurses, standardized handover tools, documentation, and communication procedures should be used. Measurement tools should be used to measure patient care in PACU, to recognize complications that may develop, and to respond quickly. The number of nurses should be increased to reduce the workload of nurses, and measures should be taken to reduce the number of patients admitted to the PACU and the length of stay in the PACU. In addition, situations that prevent nurse independence should be eliminated, a risk management model focused on patient safety should be implemented in PACU, institutional conditions should be improved, and field-specific institutional guidelines and protocols should be developed to improve patient outcomes in PACU. In addition, due to the limited number of studies in the literature on nursing care and situations that hinder care in PACU, it may be suggested that nurses contribute to the literature by conducting research on this subject.