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The first nurse to provide anesthesia was Catherine S. Lawrence, and probably along with other nurses, administered anesthesia for [[American Civil War|Civil War]] surgeons circa 1861 to 1865.<ref name="timeline">American Association of Nurse Anesthetists (2007). ''AANA History: Hand in Hand with Nurse Anesthesia.'' Retrieved May 26, 2007 from http://www.aana.com/75th/timeline1844.aspx</ref> 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]].<ref name="ThatcherBernard">Thatcher, V.S. (1953) ''History of Anesthesia, With Emphasis on the Nurse Specialist.'' Philadelphia: J.B. Lippincott Company, p. 54.</ref> There is evidence that up to 50 or more other Sisters were called to practice anesthesia in various midwest Catholic and Protestant hospitals throughout the last two decades of the 19th century.<ref name="Thatchersisters">Thatcher, V.S. (1953) ''History of Anesthesia, With Emphasis on the Nurse Specialist.'' Philadelphia: J.B. Lippincott Company, p. 54-67.</ref><ref name="bankertsysters">Bankert, M. (1989) ''Watchful Care; A History of America's Nurse Anesthetists.'' New York: The Continuum Publishing Company. p. 25-26.</ref> The first school of nurse anesthesia was formed in 1909 at St. Vincent Hospital, [[Portland, Oregon]]. Established by Agnes McGee, the course was 6 months long, and included courses on anatomy and physiology, pharmacology, and administration of common anesthetic agents.<ref name="Thatcherfirstschool">Thatcher, V.S. (1953) ''History of Anesthesia, With Emphasis on the Nurse Specialist.'' Philadelphia: J.B. Lippincott Company, p. 95.</ref> Within the next decade, approximately 19 schools opened. All consisted of post-graduate anesthesia training for nurses and were about 6 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.<ref name="Thatcherschools">Thatcher, V.S. (1953) ''History of Anesthesia, With Emphasis on the Nurse Specialist.'' Philadelphia: J.B. Lippincott Company, p. 90-109.</ref> 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 6 months, and the tuition was $50.00. A diploma was awarded on completion. In its first year, it graduated 6 physicians, 2 dentists, and 11 nurses.<ref name="Thatcherhodgins">Thatcher, V.S. (1953) ''History of Anesthesia, With Emphasis on the Nurse Specialist.'' Philadelphia: J.B. Lippincott Company, p. 105.</ref> Later, in 1918, it established a system of clinical affiliations with other Cleveland hospitals.<ref name="Thatcheraffiliations">Thatcher, V.S. (1953) ''History of Anesthesia, With Emphasis on the Nurse Specialist.'' Philadelphia: J.B. Lippincott Company, p. 105.</ref> 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 [[University of Oregon]].<ref name="Thatchermcgee">Thatcher, V.S. (1953) ''History of Anesthesia, With Emphasis on the Nurse Specialist.'' Philadelphia: J.B. Lippincott Company, p. 95.</ref> 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.<ref name="Thatcherhunt">Thatcher, V.S. (1953) ''History of Anesthesia, With Emphasis on the Nurse Specialist.'' Philadelphia: J.B. Lippincott Company, p. 101-102.</ref> In addition, she authored the 1949 book ''Anesthesia, Principles and Practice''. This is most likely the first nurse anesthesia textbook.
The first nurse to provide anesthesia was Catherine S. Lawrence, and probably along with other nurses, administered anesthesia for [[American Civil War|Civil War]] surgeons circa 1861 to 1865.<ref name="timeline">American Association of Nurse Anesthetists (2007). ''AANA History: Hand in Hand with Nurse Anesthesia.'' Retrieved May 26, 2007 from http://www.aana.com/75th/timeline1844.aspx</ref> 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]].<ref name="ThatcherBernard">Thatcher, V.S. (1953) ''History of Anesthesia, With Emphasis on the Nurse Specialist.'' Philadelphia: J.B. Lippincott Company, p. 54.</ref> There is evidence that up to 50 or more other Sisters were called to practice anesthesia in various midwest Catholic and Protestant hospitals throughout the last two decades of the 19th century.<ref name="Thatchersisters">Thatcher, V.S. (1953) ''History of Anesthesia, With Emphasis on the Nurse Specialist.'' Philadelphia: J.B. Lippincott Company, p. 54-67.</ref><ref name="bankertsysters">Bankert, M. (1989) ''Watchful Care; A History of America's Nurse Anesthetists.'' New York: The Continuum Publishing Company. p. 25-26.</ref> The first school of nurse anesthesia was formed in 1909 at St. Vincent Hospital, [[Portland, Oregon]]. Established by Agnes McGee, the course was 6 months long, and included courses on anatomy and physiology, pharmacology, and administration of common anesthetic agents.<ref name="Thatcherfirstschool">Thatcher, V.S. (1953) ''History of Anesthesia, With Emphasis on the Nurse Specialist.'' Philadelphia: J.B. Lippincott Company, p. 95.</ref> Within the next decade, approximately 19 schools opened. All consisted of post-graduate anesthesia training for nurses and were about 6 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.<ref name="Thatcherschools">Thatcher, V.S. (1953) ''History of Anesthesia, With Emphasis on the Nurse Specialist.'' Philadelphia: J.B. Lippincott Company, p. 90-109.</ref> 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 6 months, and the tuition was $50.00. A diploma was awarded on completion. In its first year, it graduated 6 physicians, 2 dentists, and 11 nurses.<ref name="Thatcherhodgins">Thatcher, V.S. (1953) ''History of Anesthesia, With Emphasis on the Nurse Specialist.'' Philadelphia: J.B. Lippincott Company, p. 105.</ref> Later, in 1918, it established a system of clinical affiliations with other Cleveland hospitals.<ref name="Thatcheraffiliations">Thatcher, V.S. (1953) ''History of Anesthesia, With Emphasis on the Nurse Specialist.'' Philadelphia: J.B. Lippincott Company, p. 105.</ref> 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 [[University of Oregon]].<ref name="Thatchermcgee">Thatcher, V.S. (1953) ''History of Anesthesia, With Emphasis on the Nurse Specialist.'' Philadelphia: J.B. Lippincott Company, p. 95.</ref> 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.<ref name="Thatcherhunt">Thatcher, V.S. (1953) ''History of Anesthesia, With Emphasis on the Nurse Specialist.'' Philadelphia: J.B. Lippincott Company, p. 101-102.</ref> 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).'' She had several other publications, beginning in 1899, with some published and many ignored because of her status as a nonphysician.<ref name="LivingHeritage">Bankert, M. (1990). "A Living Heritage." CRNA Forum. Vol. 6 No. 1, p. 5-9.</ref> Ms. Magaw was the anesthetist at St. Mary’s Hospital in Rochester for the famous Drs. [[William J. Mayo]] and [[Charles H. Mayo]].<ref name="Thatcher"/> This became the famed [[Mayo Clinic]] in [[Rochester, Minnesota]]. She set up a showcase for surgery and anesthesia that has attracted many students and visitors.
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).'' She had several other publications, beginning in 1899, with some published and many ignored because of her status as a nonphysician.<ref name="LivingHeritage">Bankert, M. (1990). "A Living Heritage." CRNA Forum. Vol. 6 No. 1, p. 5-9.</ref> Ms. Magaw was the anesthetist at St. Mary’s Hospital in Rochester for the famous Drs. [[William J. Mayo]] and [[Charles H. Mayo]].<ref name="Thatchermagaw">Thatcher, V.S. (1953) ''History of Anesthesia, With Emphasis on the Nurse Specialist.'' Philadelphia: J.B. Lippincott Company, p. 60.</ref> 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.<ref name="Thatchershowcase">Thatcher, V.S. (1953) ''History of Anesthesia, With Emphasis on the Nurse Specialist.'' Philadelphia: J.B. Lippincott Company, p. 62.</ref>


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In the United States military, nurse anesthetists provide a critical peacetime and wartime skill. During peacetime, they provide the majority of anesthesia services for retired service members, active duty military, and their dependents. Nurse anesthetists function as the only licensed independent anesthesia practitioners at many military treatment facilities, including Navy ships at sea. They are also the leading provider of anesthesia for the Veterans Administration and Public Health medical facilities.
In the United States military, nurse anesthetists provide a critical peacetime and wartime skill. During peacetime, they provide the majority of anesthesia services for retired service members, active duty military, and their dependents. Nurse anesthetists function as the only licensed independent anesthesia practitioners at many military treatment facilities, including Navy ships at sea. They are also the leading provider of anesthesia for the Veterans Administration and Public Health medical facilities.


Nurse anesthetists have made contributions in the provision of anesthesia services in every U.S. war during the 20th century. Furthermore, nurse anesthetists have and continue to be the principal providers of anesthesia services during military conflicts.<ref name="militaryconflicts">American Association of Nurse Anesthetists (2010). "History of Nurse Anesthesia Practice." Retrieved January 1, 2010 from http://www.aana.com/crnahistory.aspx</ref> 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, France.<ref name="lakesideunit">Milestones in Anesthesia (1993) Nurse Anesthetists: The Dawn of a Specialty, Part II. Vol. 3, No. 2, p. 10-11.</ref><ref name="Thatcherlikesideunit">Thatcher, V.S. (1953) ''History of Anesthesia, With Emphasis on the Nurse Specialist.'' Philadelphia: J.B. Lippincott Company, p. 97.</ref> 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 to various hospitals (e.g. Mayo clinic in Rochester, Lakeside hospital in Cleveland) for anesthesia training and then overseas service.<ref name="Thatcher1917">Thatcher, V.S. (1953) ''History of Anesthesia, With Emphasis on the Nurse Specialist.'' Philadelphia: J.B. Lippincott Company, p. 96-99.</ref> For example, nurse anesthetist Sophie Gran Winton served with the Red Cross at an army hospital in Chateau-Thierry, France, and earned the French Croix de Guerre medal in addition to other service awards.<ref name="Winton">Bankert, M. (1990). "A Living Heritage." CRNA Forum. Vol. 6 No. 1, p. 9-10.</ref> Anne Penland was the first nurse anesthetist to serve on the British Front and was decorated by the British government.<ref name="Penland">Bankert, M. (1990). "A Living Heritage." CRNA Forum. Vol. 6 No. 1, p. 13.</ref> American nurse anesthetists also served in World War II and Korea, receiving numerous citations and awards.<ref name="ww2korea">Bankert, M. (1989) ''Watchful Care; A History of America's Nurse Anesthetists.'' New York: The Continuum Publishing Company, p. 107-123, 137-139.</ref> They are represented by such heroes Second Lieutenant Mildred Irene Clark, who provided anesthesia for casualties from the Japanese bombing of [[Pearl Harbor]].<ref name="clark">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</ref> During the Vietnam war, nurse anesthetists served as both CRNAs and flight nurses, and also developed new field equipment.<ref name="vietnam">Bankert, M. (1989) ''Watchful Care; A History of America's Nurse Anesthetists.'' New York: The Continuum Publishing Company, p. 144-148.</ref> 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..<ref name="kia">Bankert, M. (1989) ''Watchful Care; A History of America's Nurse Anesthetists.'' New York: The Continuum Publishing Company, p. 148.</ref> A nurse anesthetist was also 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..<ref name="pow">Bankert, M. (1989) ''Watchful Care; A History of America's Nurse Anesthetists.'' New York: The Continuum Publishing Company, p. 119-142.</ref> For Operation Iraqi Freedom and Operation Enduring Freedom, nurse anesthetists comprise the largest group of anesthesia providers at forward positioned medical treatment facilities.<ref name="crnawar">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</ref> 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.
Nurse anesthetists have made contributions in the provision of anesthesia services in every U.S. war during the 20th century. Furthermore, nurse anesthetists have and continue to be the principal providers of anesthesia services during military conflicts.<ref name="militaryconflicts">American Association of Nurse Anesthetists (2010). "History of Nurse Anesthesia Practice." Retrieved January 1, 2010 from http://www.aana.com/crnahistory.aspx</ref> 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, France.<ref name="lakesideunit">Milestones in Anesthesia (1993) Nurse Anesthetists: The Dawn of a Specialty, Part II. Vol. 3, No. 2, p. 10-11.</ref><ref name="Thatcherlikesideunit">Thatcher, V.S. (1953) ''History of Anesthesia, With Emphasis on the Nurse Specialist.'' Philadelphia: J.B. Lippincott Company, p. 97.</ref> 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 to various hospitals (e.g. Mayo clinic in Rochester, Lakeside hospital in Cleveland) for anesthesia training and then overseas service.<ref name="Thatcher1917">Thatcher, V.S. (1953) ''History of Anesthesia, With Emphasis on the Nurse Specialist.'' Philadelphia: J.B. Lippincott Company, p. 96-99.</ref> For example, nurse anesthetist Sophie Gran Winton served with the Red Cross at an army hospital in Chateau-Thierry, France, and earned the French Croix de Guerre medal in addition to other service awards.<ref name="Winton">Bankert, M. (1990). "A Living Heritage." CRNA Forum. Vol. 6 No. 1, p. 9-10.</ref> Anne Penland was the first nurse anesthetist to serve on the British Front and was decorated by the British government.<ref name="Penland">Bankert, M. (1990). "A Living Heritage." CRNA Forum. Vol. 6 No. 1, p. 13.</ref> American nurse anesthetists also served in World War II and Korea, receiving numerous citations and awards.<ref name="ww2korea">Bankert, M. (1989) ''Watchful Care; A History of America's Nurse Anesthetists.'' New York: The Continuum Publishing Company, p. 107-123, 137-139.</ref> They are represented by such heroes Second Lieutenant Mildred Irene Clark, who provided anesthesia for casualties from the Japanese bombing of [[Pearl Harbor]].<ref name="clark">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</ref> During the Vietnam war, nurse anesthetists served as both CRNAs and flight nurses, and also developed new field equipment.<ref name="vietnam">Bankert, M. (1989) ''Watchful Care; A History of America's Nurse Anesthetists.'' New York: The Continuum Publishing Company, p. 144-148.</ref> 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.<ref name="kia">Bankert, M. (1989) ''Watchful Care; A History of America's Nurse Anesthetists.'' New York: The Continuum Publishing Company, p. 148.</ref> A nurse anesthetist was also 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.<ref name="pow">Bankert, M. (1989) ''Watchful Care; A History of America's Nurse Anesthetists.'' New York: The Continuum Publishing Company, p. 119-142.</ref> For Operation Iraqi Freedom and Operation Enduring Freedom, nurse anesthetists comprise the largest group of anesthesia providers at forward positioned medical treatment facilities.<ref name="crnawar">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</ref> 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.


==References==
==References==

Revision as of 17:45, 1 January 2010

A Certified Registered Nurse Anesthetist, or CRNA, (AE) is an Advanced Practice Registered Nurse (APRN) who has acquired graduate level education and who specializes in the administration of anesthesia.

Education

In the United States, education is overseen by the American Association of Nurse Anesthetists (AANA), specifically, the Council on Accreditation of Nurse Anesthesia Educational Programs. A nurse anesthetist's education and official title vary in different nations. In the United States, the official credential is Certified Registered Nurse Anesthetist or CRNA.

Historically, CRNAs in the United States received an anesthesia bachelor's degree, diploma or certificate. As early as 1976, the COA was developing requirements for degree programs. In 1981, guidelines for master’s degrees were developed by the COA. In 1982, the AANA board of directors' official position was 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.[1] 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.[2] This is now the current point of entry into the CRNA profession and nearly 60% of practicing CRNAs have completed this level of education.[3] As CRNAs trained under the older certificate or baccalaureate programs retire, the percentage of advanced degree prepared CRNA steadily rises.

Nurse anesthetists must first complete a four-year baccalaureate degree in nursing or a science related subject. They must be a licensed registered nurse. Then, the AANA requires a minimum of one year of full-time nursing experience in an acute care setting, such as medical intensive care unit or surgical intensive care unit.[4] Following appropriate experience, applicants enroll in an accredited program of anesthesia education for an additional two to three years.[4] These college or university based programs combine theory, didactic education, and clinical practice. Most CRNAs graduate with a master's degree in either anesthesia or nursing. Upon completion of their education, they must pass a mandatory national certification examination.[4]

The certification and recertification process is governed by the National Board on Certification and Recertification of Nurse Anesthetists (NBCRNA). CRNAs also have continuing education requirements and recertification every two years thereafter, plus any additional requirements of the state in which they practice.[4]

Nurse anesthetists may continue their education to the terminal degree level, either earning a Ph.D., DNAP (Doctor of Nurse Anesthesia Practice), or DNP (Doctor of Nursing Practice). At the terminal degree level, nurse anesthetists have available a wider variety of professional opportunities. They may teach, participate in administration, or pursue research. 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 in Nursing Practice (DNP) or Doctor of Nurse Anesthesia Practice (DNAP).[5] This move will affect all advance practice nurses, with the proposed implementation by the year 2015.[6] 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.[5]

Scope of practice

Nurse anesthetists practice in all 50 of the United States and administer approximately 32 million anesthetics given to patients in the United States each year (AANA 2006 Practice Profile Survey). The American Association of Nurse Anesthetists (AANA) is the professional organization representing greater than 90 percent of the nation's CRNAs. There are 39,000 members in the AANA. This includes certified, recertified, and student members. Approximately 41% of the CRNAs are men, versus approximately 10% in the nursing profession as a whole.[7] The AANA headquarters is currently located in Park Ridge, Illinois, USA.

Each state's board of nursing has its own regulations for professional nursing practice and establishes practice guidelines for nurse anesthetists. All states have nurse anesthetist associations (tied with the lead organization, the AANA), which govern nurse anesthesia practice.

Nurse anesthetists work as licensed independent practitioners or work with some degree of supervision by a physician. The degree of independence or supervision varies with state law.[8] Some states use the term collaboration to define a relationship where each party is responsible for their field of expertise while maintaining open communication on anesthetic techniques. 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.[9]

In 2001, the Centers for Medicare & 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.[10] To date, 15 states have opted out of the federal requirement, instituting their own individual requirements instead.[11]

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, whether working together with anesthesiologist, other CRNAs alone, or in solo practice. They have a substantial role in the military, the Veterans Administration (VA), and public health. They may work with podiatrists, dentists, anesthesiologists, surgeons, obstetricians and other professionals requiring their services.[7] Frequently, CRNAs will provide care alongside an anesthesiologist, in what is termed the Anesthesia Care Team. This combines the expertise of an anesthesiologist with that of the CRNA in a collaborative approach to perioperative care. 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.[12] Scope of CRNA practice is commonly further defined by the practice location's clinical privelge and credentialing process, anesthesia department policies, or practitioner agreements. Each health care facility will most commonly have a list of delineated clinical privileges for physicians and nurse anesthetists alike. Clinical privileges are based on the scope and complexity of the expected clinical practice, qualifications and experiencs, actual requested and granted privileges, and serve to allow the CRNA to provide core services and activities under defined conditions, with or without supervision.[13] Rather than varying significantly from place to place due to state nurse practice acts, institutional variation in clinical privileges is most common.

Anesthesiologists (physician anesthesia specialists) usually practice in developed countries. This leaves many undeveloped nations with few anesthesiologists, and therefore they rely mainly on nurse anesthetists.[14] In 1989, an international organization of nurse anesthetists was established.[15] 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 and practice, and a code of ethics. Delegates from member countries participate in the World Congress every few years. Currently there are 107 countries where nurse anesthetists train and practice and 9 countries where nurses assist in the administration of anesthesia.[14]

Compensation

In the United States, numerous salary reports throughout the years report that CRNAs remain the highest compensated of all nursing specialties. Their average reported annual salary range in 2007, reported by the AMGA Medical Group Compensation and Financial Survey, was $140,013.[16]

History in the United States

Nurse anesthetists have been providing anesthesia care in the United States for nearly 150 years, and therefore the oldest nurse specialty group in the United States.[17]

The first nurse to provide anesthesia was Catherine S. Lawrence, and probably along with other nurses, administered anesthesia for Civil War surgeons circa 1861 to 1865.[18] 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.[19] There is evidence that up to 50 or more other Sisters were called to practice anesthesia in various midwest Catholic and Protestant hospitals throughout the last two decades of the 19th century.[20][21] The first school of nurse anesthesia was formed in 1909 at St. Vincent Hospital, Portland, Oregon. Established by Agnes McGee, the course was 6 months long, and included courses on anatomy and physiology, pharmacology, and administration of common anesthetic agents.[22] Within the next decade, approximately 19 schools opened. All consisted of post-graduate anesthesia training for nurses and were about 6 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.[23] 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 6 months, and the tuition was $50.00. A diploma was awarded on completion. In its first year, it graduated 6 physicians, 2 dentists, and 11 nurses.[24] Later, in 1918, it established a system of clinical affiliations with other Cleveland hospitals.[25] 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 University of Oregon.[26] 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.[27] 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). She had several other publications, beginning in 1899, with some published and many ignored because of her status as a nonphysician.[28] Ms. Magaw was the anesthetist at St. Mary’s Hospital in Rochester for the famous Drs. William J. Mayo and Charles H. Mayo.[29] 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.[30]

In the United States, there have been three challenges brought against nurse anesthetists for illegally practicing medicine (Hodgins and Crile, 1919; Frank v. South, 1917; and Chalmers-Francis v. Nelson, 1936).[31][32] 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 seventeen nurse anesthetists for every one anesthesiologist.[33] 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.[34][35] For example, endotracheal intubation (placing a breathing tube into the windpipe) is performed by physicians, nurse anesthetists, respiratory therapists, paramedics, 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.

Military service

In the United States military, nurse anesthetists provide a critical peacetime and wartime skill. During peacetime, they provide the majority of anesthesia services for retired service members, active duty military, and their dependents. Nurse anesthetists function as the only licensed independent anesthesia practitioners at many military treatment facilities, including Navy ships at sea. They are also the leading provider of anesthesia for the Veterans Administration and Public Health medical facilities.

Nurse anesthetists have made contributions in the provision of anesthesia services in every U.S. war during the 20th century. Furthermore, nurse anesthetists have and continue to be the principal providers of anesthesia services during military conflicts.[36] 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, France.[37][38] 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 to various hospitals (e.g. Mayo clinic in Rochester, Lakeside hospital in Cleveland) for anesthesia training and then overseas service.[39] For example, nurse anesthetist Sophie Gran Winton served with the Red Cross at an army hospital in Chateau-Thierry, France, and earned the French Croix de Guerre medal in addition to other service awards.[40] Anne Penland was the first nurse anesthetist to serve on the British Front and was decorated by the British government.[41] American nurse anesthetists also served in World War II and Korea, receiving numerous citations and awards.[42] They are represented by such heroes Second Lieutenant Mildred Irene Clark, who provided anesthesia for casualties from the Japanese bombing of Pearl Harbor.[43] During the Vietnam war, nurse anesthetists served as both CRNAs and flight nurses, and also developed new field equipment.[44] 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.[45] A nurse anesthetist was also 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.[46] For Operation Iraqi Freedom and Operation Enduring Freedom, nurse anesthetists comprise the largest group of anesthesia providers at forward positioned medical treatment facilities.[47] 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.

References

  1. ^ 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.
  2. ^ American Association of Nurse Anesthetists (2007). A Brief Look at Nurse Anesthesia History Retrieved May 23, 2007, from http://www.aana.com/brieflookhistory.aspx
  3. ^ Muckle, T. J., Apatov N. M., & Plaus, K (2009). "A Report on the CCNA 2007 Professional Practice Analysis." AANA Journal Vol. 77, No. 3, p. 181-189.
  4. ^ a b c d 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
  5. ^ a b 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
  6. ^ 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
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  9. ^ 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
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  16. ^ AMGA Medical Group Compensation and Financial Survey (2007). 2007 AMGA MID-LEVEL COMPENSATION. Retrieved April 14, 2008 from http://www.cejkasearch.com/compensation/amga_midlevel_compensation_survey.htm
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  28. ^ Bankert, M. (1990). "A Living Heritage." CRNA Forum. Vol. 6 No. 1, p. 5-9.
  29. ^ Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company, p. 60.
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  31. ^ Bankert, M. (1989) Watchful Care; A History of America's Nurse Anesthetists. New York: The Continuum Publishing Company. p. 61-63, 91-92.
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  34. ^ 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
  35. ^ 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
  36. ^ American Association of Nurse Anesthetists (2010). "History of Nurse Anesthesia Practice." Retrieved January 1, 2010 from http://www.aana.com/crnahistory.aspx
  37. ^ Milestones in Anesthesia (1993) Nurse Anesthetists: The Dawn of a Specialty, Part II. Vol. 3, No. 2, p. 10-11.
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  41. ^ Bankert, M. (1990). "A Living Heritage." CRNA Forum. Vol. 6 No. 1, p. 13.
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  43. ^ 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
  44. ^ Bankert, M. (1989) Watchful Care; A History of America's Nurse Anesthetists. New York: The Continuum Publishing Company, p. 144-148.
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  47. ^ 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
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