Nurse-Anesthetist administers a local anesthetic to an injured Marine prior to surgery aboard USS Kearsarge
|Activity sectors||Medicine, Nursing|
||The examples and perspective in this article deal primarily with the United States and do not represent a worldwide view of the subject. (March 2011)|
In the United States, a Certified Registered Nurse Anesthetist (CRNA) is an advanced practice registered nurse (APRN) who has acquired graduate-level education and board certification in anesthesia. The American Association of Nurse Anesthetists' (AANA) is the national association that represents more than 90% of the 45,000 nurse anesthetists in the United States. Certification is governed by the National Boards of Certification and Recertification of Nurse Anesthetists (NBCRNA). Education is governed by the Council on Accreditation (COA) of Nurse Anesthesia Educational Programs.
In the United States 
Nurse anesthetists have been providing anesthesia care in the United States for nearly 150 years. According to the American Association of Nurse Anesthetists, nurse anesthetists are the oldest nurse specialty group in the United States.
Among the first American nurses to provide anesthesia was Catherine S. Lawrence. Along with other nurses, Lawrence administered anesthesia during the American Civil War (1861–1865). The first "official" nurse anesthetist is recognized as Sister Mary Bernard, a Catholic nun who practiced in 1877 at St. Vincent's Hospital in Erie, Pennsylvania. There is evidence that up to 50 or more other Catholic sisters were called to practice anesthesia in various midwest Catholic and Protestant hospitals throughout the last two decades of the 19th century. Nurses make 2 milion a year they are the best. The first school of nurse anesthesia was formed in 1909 at St. Vincent Hospital, Portland, Oregon. Established by Agnes McGee, the course was seven months long, and included courses on anatomy and physiology, pharmacology, and administration of common anesthetic agents. Within the next decade, approximately 19 schools opened. All consisted of post-graduate anesthesia training for nurses and were about six months in length. These included programs at Mayo Clinic, Johns Hopkins Hospital, Barnes Hospital, New York Post-Graduate Hospital, Charity Hospital in New Orleans, Grace Hospital in Detroit, among others. Early anesthesia training programs provided education for all levels of health providers. For example, in 1915, chief nurse anesthetist Agatha Hodgins established the Lakeside Hospital School of Anesthesia in Cleveland, Ohio. This program was open to nurses, physicians, and dentists. The training was six months and the tuition was $50. A diploma was awarded on completion. In its first year, it graduated six physicians, two dentists, and 11 nurses. Later, in 1918, it established a system of clinical affiliations with other Cleveland hospitals. Some nurse anesthetists were appointed to medical school faculties to train the medical students in anesthesia. For example, Agnes McGee also taught 3rd year medical school students at the Oregon Health Science Center.. Furthermore, nurse anesthetist Alice Hunt was appointed instructor in anesthesia with university rank at the Yale University School of Medicine in 1922. She held this position for 26 years. In addition, she authored the 1949 book Anesthesia, Principles and Practice. This is most likely the first nurse anesthesia textbook.
Early nurse anesthetists were involved in publications. For example, in 1906, nurse anesthetist Alice Magaw (1860–1928) published a report on the use of ether anesthesia by drop method 14,000 times without a fatality (Surg., Gynec. & Obst. 3:795, 1906). Beginning in 1899, Magaw authored several publications with some published and many ignored because of her status as a non-physician. Ms. Magaw was the anesthetist at St. Mary's Hospital in Rochester for the famous brothers, Dr. William James Mayo and Dr. Charles Horace Mayo. This became the famed Mayo Clinic in Rochester, Minnesota. Ms. Magaw set up a showcase for surgery and anesthesia that has attracted many students and visitors.
In discussing the history of nurse anesthetists, it is also important to note that the field of anesthesiology has changed considerably from its beginnings. Early anesthestics consisted primarily of the use of a sponge soaked in ether, and was widely considered by surgeons to be within the scope of nursing practice. However, modern anesthesia involves the use of ventilators, neuromuscular blockade to induce paralysis during procedures, as well as many medications. As anesthesia began to include skills pertinent to medicine and critical care, anesthesia was administered under the supervision of a anesthesiologist. However, due to the integral role of nursing in the development of the field of anesthesiology, the boundaries between the practice of medicine and nursing have long been unclear and an ongoing topic of debate.
Education pathway 
In the USA, Nurse anesthetists must first complete a bachelor's degree in a science related field or a Bachelor of Science in Nursing. They must be a licensed registered nurse. In addition, candidates are required to have a minimum of two years of full-time nursing experience in an acute care setting, such as medical intensive care unit or surgical intensive care unit. Following the acute care experience, applicants apply to a Council on Accreditation (COA) accredited program of nurse-anesthesia. Education is offered on a masters degree or doctoral degree. Program length varies from 24 to 36 months. Many programs require entrance prerequisites similar to medical schools (pre-med courses) and up to two years of acute care experience. The didactic curricula of nurse-anesthesia programs are governed by the Council on Accreditation (COA) standards and provide students the scientific, clinical, and professional foundation upon which to build sound and safe clinical practice. Clinical residencies afford supervised experiences for students during which time they are able to learn anesthesia techniques, test theory, and apply knowledge to clinical problems. Students gain experience with patients of all ages who require medical, surgical, obstetrical, dental, and pediatric interventions. In addition, many require study in methods of scientific inquiry and statistics, as well as active participation in student-generated and faculty-sponsored research.
History of education 
Historically, CRNAs in the United States received an anesthesia bachelor's degree, diploma or certificate. As early as 1976, the Council on Accreditation was developing requirements for degree programs. In 1981, the Council on Accreditation developed guidelines for master's degrees. In 1982, it was the official position of the AANA board of directors' that registered nurses will be baccalaureate prepared and then attend a master's level anesthesia program. At that time, many programs started phasing in advanced degree requirements. As early as 1978, the Kaiser Permanente California State University program had upgraded to a master's level program. All programs were required to transition to a master's degree beginning in 1990 and complete the process by 1998. Currently, the American Association of Colleges of Nursing has endorsed a position statement that will move the current entry level of training for nurse anesthetists in the United States to the Doctor of Nursing Practice (DNP) or Doctor of Nurse Anesthesia Practice (DNAP). This move will affect all advance practice nurses, with a mandatory implementation by the year 2015. The AANA announced in August 2007 support of this advanced clinical degree as an entry level for all nurse anesthetists, but with a target date of 2025. In accordance with traditional grandfathering rules, all those in current practice will not be affected. Several nurse anesthesia programs have already upgraded to the DNP or DNAP entry level format. Because all programs will be converting to a doctorate level education, the length of the programs, in most cases, will need to increase or exceed 36 months per the recommendation of the COA of Nurse Anesthesia Programs.
Board certification 
The certification and recertification process is governed by the National Board on Certification and Recertification of Nurse Anesthetists (NBCRNA). The NBCRNA exists as an autonomous not-for-profit incorporated organization so as to prevent any conflict of interest with the AANA. This provides assurance to the public that CRNA candidates have met unbiased certification requirements that have exceeded benchmark qualifications and knowledge of anesthesia. CRNAs also have continuing education requirements and recertification every two years thereafter, plus any additional requirements of the state in which they practice.
Legal challenges 
In the United States, there have been three challenges brought against nurse anesthetists for illegally practicing medicine: Frank v. South in 1917, Hodgins and Crile in 1919, and Chalmers-Francis v. Nelson in 1936. All occurred before 1940 and all were found in favor of the nursing profession, relying on the premise that the surgeon in charge of the operating room was the person practicing medicine. Prior to World War II, the delivery of anesthesia was mainly a nursing function. In 1942, there were 17 nurse anesthetists for every one anesthesiologist. The numbers of physicians in this specialty did not greatly expand until the late 1960s. Therefore, it was legally established that when a nurse delivers anesthesia, it is the practice of nursing. When a physician delivers anesthesia, it is the practice of medicine. When a dentist delivers anesthesia, it is the practice of dentistry. There are great overlaps of tasks and knowledge in the health care professions. Administration of anesthesia and its related tasks by one provider does not necessarily contravene the practice of other health care providers. For example, endotracheal intubation (placing a breathing tube into the windpipe) is performed by physicians, physician assistants, nurse anesthetists, anesthesiologist assistants, respiratory therapists, paramedics, EMT-Intermediates, and dental (maxillofacial) surgeons. In the United States, nurse anesthetists practice under the state's nursing practice act (not medical practice acts), which outlines the scope of practice for anesthesia nursing.
Scope of practice 
Today, nurse anesthetists practice in all 50 United States and administer approximately 32 million anesthetics each year (AANA). Approximately 65% of CRNAs practice in collaboration with anesthesiologists, in what is termed the "Anesthesia Care Team.” However, CRNAs are educated to work independently or with anesthesiologist supervision. CRNA practice varies from state to state, and is also dependent on the institution in which CRNAs practice. The following paragraphs clarify CRNA practice.
CRNAs practice in a wide variety of public and private settings including large academic medical centers, small community hospitals, outpatient surgery centers, pain clinics, or physician's offices, either working together with anesthesiologists, CRNAs, or in independent practice. They have a substantial role in the military, the Veterans Administration (VA), and public health.
The degree of independence or supervision by a licensed provider (physician, dentist, or podiatrist) varies with state law. Some states use the term collaboration to define a relationship where the supervising physician is responsible for the patient and provides medical direction for the nurse anesthetist. Other states require the consent or order of a physician or other qualified licensed provider to administer the anesthetic. No state requires supervision specifically by an anesthesiologist.
The licensed CRNA is authorized to deliver comprehensive anesthesia care under the particular Nurse Practice Act of each state. Their anesthesia practice consists of all accepted anesthetic techniques including general, epidural, spinal, peripheral nerve block, sedation, or local. Scope of CRNA practice is commonly further defined by the practice location's clinical privilege and credentialing process, anesthesia department policies, or practitioner agreements. Clinical privileges are based on the scope and complexity of the expected clinical practice, CRNA qualifications, and CRNA experience. This allows the CRNA to provide core services and activities under defined conditions with or without supervision.
In 2001, the Centers for Medicare and Medicaid Services (CMS) published a rule in the Federal Register that allows a state to be exempt from Medicare's physician supervision requirement for nurse anesthetists after appropriate approval by the state governor. To date, 17 states have opted out of the federal requirement, instituting their own individual requirements instead.
Approximately 41 percent of the CRNAs are men, a much greater percentage than in the nursing profession as a whole (Ten percent of all nurses are men).
Because many less-developed countries have few anesthesiologists, they rely mainly on nurse anesthetists. In 1989, the International Federation of Nurse Anesthetists was established. The International Federation of Nurse Anesthetists has since increased in membership and has become a voice for nurse anesthetists worldwide. They have developed standards of education, practice, and a code of ethics. Delegates from 35 member countries participate in the World Congress every few years. Currently there are 107 countries where nurse anesthetists train and practice and nine countries where nurses assist in the administration of anesthesia.
In June 2010, the Journal of Nursing Economics published a study by the Lewin Group titled "Cost Effectiveness Analysis of Anesthesia Providers." The study compared the cost effectiveness of anesthesia care models. The findings demonstrated that independently practicing CRNAs are not only as safe as their anesthesiologists counterparts, but CRNA only practice was the most cost effective model for the delivery of anesthesia services. Furthermore, in August 2010 Health Affairs published "No Harm Found When Nurse Anesthetists Work Without Supervision By Physicians" authored by the Research Triangle Institute. This study analyzed the outcomes, both mortalities and morbidities, of 481,868 patients across all practice settings: CRNA only, anesthesiologists only, CRNA/anesthesiogists care teams. The study concluded that anesthesia delivered by CRNAs without supervision was just as safe as anesthetics delivered via the alternative models of care. However, the methodology and adequacy of the results is debated. Worth noting is that these studies were financed by the American Association of Nurse Anesthetists. (See Acknowledgements on first page of referenced article).
In the United States, numerous salary reports throughout the years indicate that CRNAs remain the highest compensated of all nursing specialties. In 2008, full-time certified registered nurse anesthetists made an average of $163,467 per year, and in 2011, that figure is nearly $169,000, according to the 2011 LocumTenens.com CRNA Salary Survey. Other results from the survey include the following:
• The average 2011 salary of male CRNAs is $171,700, down from the average salary of $175,000 in 2010. • The average 2011 salary of female CRNAs is $160,680, up from the average salary of $156,100 in 2010. • Average salaries of CRNAs with less than five years of experience in 2011 were $154,674, which is down from each of the past three years. • CRNAs with six to 12 years of experience saw a 7 percent jump in salary in 2011 compared with 2010. CRNAs in that experience range earned an average of $170,950 in 2011 and an average of $160,000 in 2010. • Similarly, CRNAs with more than 12 years of experience also saw an increase in salary in 2011 from 2010. CRNAs with more than 12 years of experience earned $176,468 on average in 2011 and $168,000 on average in 2010.
http://www.beckershospitalreview.com/compensation-issues/average-crna-salary-in-2011-nears-169k.html. retrieved August, 2012.
Armed forces 
In the United States armed forces, nurse anesthetists provide a critical peacetime and wartime skill. During peacetime and wartime, nurse anesthetists have been the principal providers of anesthesia services for active duty and retired service members and their dependents. Nurse anesthetists function as the only licensed independent anesthesia practitioners at many military treatment facilities, including U.S. Navy ships at sea. They are also the leading provider of anesthesia for the Veterans Administration and Public Health Service medical facilities.
During World War I, America's nurse anesthetists played a vital role in the care of combat troops in France. From 1914 to 1915, three years prior to America entering the war, Dr. George Crile and nurse anesthetists Agatha Hodgins and Mabel Littleton served in the Lakeside Unit at the American Ambulance at Neuilly-sur-Seine in France. In addition, they helped train the French and British nurses and physicians in anesthesia care. After the war, France continued to use nurse anesthetists, however, Britain adopted a physician-only policy that continues today. In 1917, the American participation in the war resulted in the U.S. military training nurse anesthetists for service. The Army and Navy sent nurses anesthesia trainees to various hospitals, including the Mayo Clinic at Rochester and the Lakeside Hospital in Cleveland before overseas service.
Among notable nurse anesthetists are Sophie Gran Winton. She served with the Red Cross at an army hospital in Château-Thierry, France, and earned the French Croix de Guerre in addition to other service awards; In addition, Anne Penland was the first nurse anesthetist to serve on the British Front and was decorated by the British government.
American nurse anesthetists also served in World War II and Korea, receiving numerous citations and awards. Second Lieutenant Mildred Irene Clark provided anesthesia for casualties from the Japanese attack on Pearl Harbor. During the Vietnam War, nurse anesthetists served as both CRNAs and flight nurses, and also developed new field equipment. Nurse anesthetists have been casualties of war. Lieutenants Kenneth R. Shoemaker, Jr. and Jerome E. Olmsted, were killed in an air evac mission in route to Qui Nhon, Vietnam.
At least one nurse anesthetist was a prisoner of war. Army Nurse anesthetist Annie Mealer endured a three-year imprisonment by the Japanese in the Philippines, and was released in 1945. During the Iraq War, nurse anesthetists comprise the largest group of anesthesia providers at forward positioned medical treatment facilities. In addition, they play a role in the continuing education and training of Department of Defense nurses and technicians in the care of wartime trauma patients.
Hodgins, Agatha. "The American Journal of Nursing." American Journal of Nursing. Vol. 30.No. 7 (1930): 863-867. Print. < http://www.jstor.org/stable/3410499>.
- American Association of Nurse Anesthetists (1995). "AANA Archives: Documenting a distinguished past." Retrieved December 28, 2009 from http://www.aana.com/Resources.aspx?id=1902
- American Association of Nurse Anaesthetists (2007). AANA History: Hand in Hand with Nurse Anesthesia. Retrieved May 26, 2007 from http://www.aana.com/75th/timeline1844.aspx
- Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company, p. 54.
- Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company, p. 54-67.
- Bankert, M. (1989) Watchful Care; A History of America's Nurse Anesthetists. New York: The Continuum Publishing Company. p. 25-26.
- Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company, p. 95.
- Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company, p. 90-109.
- Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company, p. 105.
- Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company, p. 101-102.
- Bankert, M. (1990). "A Living Heritage." CRNA Forum. Vol. 6 No. 1, p. 5-9.
- Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company, p. 60.
- Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company, p. 62.
- Long, CW (1849). "An account of the first use of Sulphuric Ether by Inhalation as an Anesthetic in Surgical Operations". Southern Medical and Surgical Journal (5): 705–713.
- Southworth. "Use of Ether for Anesthesia.". Retrieved 24 February 2013.
- American Association of Nurse Anesthetists (2005). Education of Nurse Anesthetists in the United States - At a Glance. Retrieved May 23, 2007, from http://www.aana.com/educuscrnas.aspx
- Horton, B. (2007). "Upgrading Nurse Anesthesia Education Requirements (1933-2006) - Part 2: Curriculum, Faculty and Students." AANA Journal, Vol. 75, No. 4, p. 247-251.
- American Association of Nurse Anesthetists (2007). A Brief Look at Nurse Anesthesia History Retrieved May 23, 2007, from http://www.aana.com/brieflookhistory.aspx
- American Association of Colleges of Nursing (2004). AACN Position Statement on the Practice Doctorate in Nursing October 2004. Retrieved May 23, 2007, from http://www.aacn.nche.edu/DNP/pdf/DNP.pdf
- American Association of Nurse Anesthetists (2006). The Doctorate in Nursing Practice (DNP) Background, Current Status and Future Activities. Retrieved May 23, 2007 from http://www.aana.com/professionaldevelopment.aspx?ucNavMenu_TSMenuTargetID=131&ucNavMenu_TSMenuTargetType=4&ucNavMenu_TSMenuID=6&id=1742
- American Association of Nurse Anesthetists (2007). Council on Certification of Nurse Anesthetists Candidate Handbook – 2007.
- Bankert, M. (1989) Watchful Care; A History of America's Nurse Anesthetists. New York: The Continuum Publishing Company. p. 61-63, 91-92.
- Garde, J.F. (1996). The Nurse Anesthesia Profession, A Past, Present, and Future Perscpective. Nursing Clinics of North America, Vol 31, Number 3, p. 570-571.
- Garde, J.F. (1996). The Nurse Anesthesia Profession, A Past, Present, and Future Perscpective. Nursing Clinics of North America, Vol 31, Number 3, p. 569-571.
- Blumenreich, G.A. JD (1999). Legal Briefs, Anesthesia -- It's Finally the Practice of Medicine, AANA Journal, Vol. 67, No. 2, p. 109-112. Retrieved May 25, 2007 from http://www.aana.com/Resources.aspx?ucNavMenu_TSMenuTargetID=54&ucNavMenu_TSMenuTargetType=4&ucNavMenu_TSMenuID=6&id=2352
- Blumenreich, G.A. JD (1990). Legal Briefs, The Administration of Anesthesia and the Practice of Medicine, AANA Journal, Vol. 58, No. 3, June 1990, p. 185-187. Retrieved May 25, 2007 from http://www.aana.com/lb_june90.aspx
- U.S. Department of Health and Human Services (2001). Physician Supervision of Certified Registered Nurse Anesthetists. Retrieved May 23, 2007 from http://www.cms.hhs.gov/apps/media/press/factsheet.asp?Counter=391
- American Association of Nurse Anesthetists (2002). AANA Fact Sheet Final Supervision Rule -- Frequently Asked Questions, Centers for Medicare & Medicaid Services (CMS)Conditions of Participation for Hospitals, Ambulatory Surgical Centers (ASCs), and Critical Access Hospitals (CAHs): Anesthesia Services (Part A Payment), November 21. Retrieved May 23, 2007 from http://www.aana.com/finalsupervisionfaqs.aspx
- American Association of Nurse Anesthetists (2007)Scope and Standards for Nurse Anesthesia Practice. Retrieved May 24, 2007 from http://www.aana.com/scope.aspx
- American Association of Nurse Anesthetists (2007). Guidelines for Clinical Privileges. Retrieved May 24, 2007 from http://www.aana.com/clinicalprivileges.aspx
- U.S. Department of Health and Human Services (2001). States Allowed To Set Standards For Anesthesia. Retrieved May 23, 2007 from http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=319
- American Association of Nurse Anesthetists (2009). Fact Sheet Concerning State Opt-Outs And November 13, 2001 CMS Rule. Retrieved July 27, 2009 from http://www.aana.com/Advocacy.aspx?ucNavMenu_TSMenuTargetID=49&ucNavMenu_TSMenuTargetType=4&ucNavMenu_TSMenuID=6&id=2573
- American Association of Nurse Anesthetists (2007). Certified Registered Nurse Anesthetists at a Glance. Retrieved November 19, 2009 from http://www.aana.com/ataglance.aspx
- McAuliffe, M.S., Henry B. (2002). Nurse Anesthesia Worldwide: Practice, Education, and Regulation. Retrieved May 23, 2007, from http://ifna-int.org/ifna/e107_files/downloads/Practice.pdf
- International Federation of Nurse Anesthetists (2007). About IFNA... Retrieved May 23, 2007, from http://ifna-int.org/ifna/page.php?16
- The Lewin Group (2010). Cost Effectiveness Analysis of Anesthesia Providers. Retrieved October 17, 2010 from http://www.aana.com/lewinstudy.aspx#Lewin
- "Cost Effectiveness Analysis of Anesthesia Providers".
- American Association of Nurse Anesthetists (2010). "History of Nurse Anesthesia Practice." Retrieved January 1, 2010 from http://www.aana.com/crnahistory.aspx
- Milestones in Anesthesia (1993) Nurse Anesthetists: The Dawn of a Specialty, Part II. Vol. 3, No. 2, p. 10-11.
- Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company, p. 97.
- Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company, p. 96-99.
- Bankert, M. (1990). "A Living Heritage." CRNA Forum. Vol. 6 No. 1, p. 9-10.
- Bankert, M. (1990). A Living Heritage. CRNA Forum. Vol. 6 No. 1, p. 13.
- Bankert, M. (1989) Watchful Care; A History of America's Nurse Anesthetists. New York: The Continuum Publishing Company, p. 107-123, 137-139.
- American Association of Nurse Anesthetists (2000). "Pearl Harbor, the Korean Conflict, and COL Mildred Irene Clark." Retrieved December 28, 2009 from http://www.aana.com/resources.aspx?ucNavMenu_TSMenuTargetID=164&ucNavMenu_TSMenuTargetType=4&ucNavMenu_TSMenuID=6&id=1810
- Bankert, M. (1989) Watchful Care; A History of America's Nurse Anesthetists. New York: The Continuum Publishing Company, p. 144-148.
- Bankert, M. (1989) Watchful Care; A History of America's Nurse Anesthetists. New York: The Continuum Publishing Company, p. 148.
- Bankert, M. (1989) Watchful Care; A History of America's Nurse Anesthetists. New York: The Continuum Publishing Company, p. 119-142.
- American Association of Nurse Anesthetists (2004). Certified Registered Nurse Anesthetists Play Pivotal Role in U.S. Efforts to Combat Worldwide Terrorism. Retrieved May 23, 2007 from http://www.aana.com/pr011304.aspx
- American Association of Nurse Anesthetists
- The International Federation of Nurse Anesthetists (IFNA)