A survey about education and the role of postanesthesia care unit (PACU) nurses in 11 countries revealed a wide variation in how the profession was viewed and treated. There was little international standardization in education and professional guidelines.1

“We believe anesthesia nursing training is very important and something we need to highlight and discuss,” says Karuna Dahlberg, PhD, RN, CCN, study co-author and associate senior lecturer at the Örebro University School of Health Sciences in Sweden.

International discussions between nurse educators, leaders, and others led to questions about PACU nursing challenges and about requirements and practices in different countries for educating people entering this nursing specialty area. The survey went to PACU nurses in places with membership in the International Collaboration of PeriAnaesthesia Nurses, Inc. (ICPAN). Dahlberg and colleagues observed respondents saw the same issues with patients, but believed their training and educational experiences to be diverse.

The authors grew curious about international diversity in training and education of PACU nurses and set out on a strategic plan involving creating collaborative, global advanced practice, says Joni M. Brady, BNP, PMGT-BC, CAPA, study co-author and chair of the ICPAN board of directors. “Where education was concerned, only one country [in the study] has a certification for perianesthesia nursing, and that is the United States,” Brady says. “Three countries have a formal education process to become a perianesthesia nurse and to be called a PACU nurse.”

The three countries with a formal education process are Ireland, the Netherlands, and Australia. Their programs range from six months to 15 months after the person becomes a registered nurse (RN), Dahlberg says. Certification in the United States occurs through the American Board of Perianesthesia Nursing Certification. There are certificates for post-surgery nurses and ambulatory post-surgery nurses.

“You can be a nurse and work in the PACU, and certification is not required,” says Jan Odom-Forren, PhD, RN, CPAN, FASPAN, FAAN, study co-author and associate professor at the University of Kentucky College of Nursing. “I have a CPAN [certification], and I’d want someone with a CPAN working in an ambulatory unit because it shows they’re interested in staying up to date on important pieces of education and requirements.”

Another difference involves the work setting and who works in the PACU. “In the United States, whether in a freestanding surgery center or a hospital, you have perianesthesia nurses working in the PACU, and they may or may not have assistants to help them,” Odom-Forren says.

Nurse anesthetists and intensive care nurses in Sweden, most of whom have earned some sort of higher education, work in the PACU, says Ulrica Nilsson, PhD, RNA, study co-author and professor of nursing at the Karolinska Institutet.

“In Sweden, we struggle to have a specific education to become a PACU nurse, so this is an important paper for us,” says Nilsson, a professor of perioperative medicine and intensive care at Karolinska University Hospital in Stockholm. “There is not a specific education you need to work in the PACU. We want to have this education as you have in the U.S. and as they have in Australia.”

Perianesthesia nursing is not recognized as a specific specialty in Sweden and some other countries, Dahlberg says, “but we’re working on it.”

“Ulrica, Karuna, and I want to emphasize the specific competence a nurse needs to work in the PACU,” says Maria Jaensson, PhD, RNA, study co-author and associate professor at the Örebro University School of Health Sciences. “You may be skilled to work as a nurse, but not in high-quality PACU care.”

At international forums, before this study, Brady and other nurse leaders would hear that PACU nurses’ work was not recognized as a specialized practice. “Some organizations had perianesthesia lumped under critical care,” Brady explains. “A big piece of the goal of this study was advocacy for nurses to be recognized as a specialized group with specialized knowledge.”

Perianesthesia nurses offer critical skills for patient safety. “We’re an important part of the room,” Brady says. “A big piece is to say we’re very important for outcomes, safety, and professional [goals], and we’re a vital part of the team.”

Regardless of education or certification, it is important for a PACU nurse to know about anesthetic agents and how that medication works with other medication patients are taking.

“PACU nurses should know how the patient was preoperatively, which anesthetic medications they had, how that impacts their care, and [how that] affects the PACU,” Odom-Forren says.

It also is important for PACU nurses to know about specific surgical procedures and their risks of complication and mobilization.

“They need knowledge about anesthesia and surgery and knowledge about other problems patients can have,” Nilsson says. “The care is quite complex, and the care is very short. When the patient comes to the care unit, you must think about the next level of care.”

PACU nurses must be alert to potential severe complications. “The PACU nursing curriculum should have education on how to follow up these patients and implement this in clinical practice,” Nilsson offers.

In the ambulatory surgery setting especially, PACU nurses need to be considerate of patients’ social determinants of health.

“Who will help the patient at home after surgery? Is the patient homeless?” Brady asks. “We face, in the United States, many challenges now with food insecurity, and nurses have to think about these, in addition to all of the clinical pieces.”

Although it was not part of the study, the researchers and global nursing leaders also have discussed how PACU nurses are coping with the toll of the COVID-19 pandemic.

“In meeting with both my board and the 11 members of the Global Advisory Council, everyone is really struggling with this pandemic, except New Zealand, where they have a strong female leader,” Brady says. “What I’m hearing is a lot of exhaustion and leadership issues.”

For instance, many PACU nurses have been moved to different units during pandemic surges, creating stress and moral distress.

“They are seen as an easy grab for bringing into COVID intensive care units,” Brady explains. “We have a crucial care skill base, and it’s seen as appropriate to send us over to the critical care unit.”

PACU nurses often are moved to new units and offered no support. “One colleague in London told me he was pulled to the critical care unit, and no one helped him or even showed him where the supplies were,” Brady says. “We worry about their mental health and stress levels. When you’re put in a situation that is unfamiliar and in crisis mode, where does that leave you in your own practice?”

It also is a stressful time for nursing students and nurse educators. “We want to educate skilled nurses with different competencies, and we had to turn education to a digital mode,” Jaensson explains. “It’s stressful to put nurses [in healthcare facilities] because they are concerned for their own safety and for their families at home, and they need to study and educate themselves.”

There are plenty of students applying to nursing school internationally, but it is a challenge to give them a clinical practice with quality, and the clinical teachers are strained and working too much. The same trend is happening in the United States.

“We have more students applying to nursing school than we can take,” Odom-Forren says. “All of us in education are trying to figure out the best way to educate students.”

For instance, clinical setting simulation can help provide experience without too much stress on a healthcare system that is already too stressed because of the pandemic.

“Organizational support is imperative right now, and organizations need to think about everything they can do to support their nurses,” Odom-Forren says.

One example is to help nursing staff with child care support, which became critically scarce during the pandemic’s surges and shutdowns. Another tactic is to give nurses a day off to prevent exhaustion. 


  1. Dahlberg K, Brady JM, Jaensson M, et al. Education, competence, and the role of the nurse working in the PACU: An international survey. J Perianesth Nurs 2021 Jan 29;S1089-9472(20)30248-3. doi: 10.1016/j.jopan.2020.08.002. [Online ahead of print].