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Nurse anesthetist

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A nurse anesthetist is a nurse who specializes in the administration of anesthesia.

In the United States, a Certified Registered Nurse Anesthetist (CRNA) is an advanced practice registered nurse (APRN), a registered nurse (RN) who has acquired graduate-level education in anesthesia overseen by the American Association of Nurse Anesthetists's (AANA), Council on Accreditation of Nurse Anesthesia Educational Programs.

In the United States

History

Nurse anesthetists have been providing anesthesia care in the United States for nearly 150 years. The American Association of Nurse Anesthetists claims that nurse anesthetists are the oldest nurse specialty group in the United States.[1]

Among the first American nurses to provide anesthesia was Catherine S. Lawrence, who, probably along with other nurses, administered anesthesia during the American Civil War (1861-1865).[2] 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.[3] 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.[4][5]

The first school of nurse anesthesia was formed in 1909 at St. Vincent Hospital, Portland, Oregon. Established by Agnes McGee, the course was six months long, and included courses on anatomy and physiology, pharmacology, and administration of common anesthetic agents.[6] 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.[7] 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.[8] Later, in 1918, it established a system of clinical affiliations with other Cleveland hospitals.[8] 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.[6] 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.[9] 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.[10] 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.[11] 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.[12]


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.[13] 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.[14] This is now the current point of entry into the CRNA profession and nearly 60% of practicing CRNAs have completed this level of education.[15] As CRNAs trained under the older certificate or baccalaureate programs retire, the percentage of advanced degree prepared CRNA steadily rises.

Training & Education

Nurse anesthetists must first complete a four-year bachelor's degree, usually a Bachelor of Science in Nursing but it can be a Bachelor of Science in another science-related subject in some instances. They must be a licensed registered nurse. In addition, candidates are required to have 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.[16] Following appropriate experience, applicants apply to a Council on Accreditation (COA) accredited program of anesthesia education for an additional 24 to 36 months, 6 to 9 contiguous semesters (only 2 out of the existing 107 programs are 2 years).[16] Realistically, it takes a CRNA 8 - 10 years of education, clinical training, and experience to attain this goal.

Although all nurse anesthetists currently graduate with a master's degree, one may continue their education to the terminal degree level, either earning a Ph.D. or similar research doctorate (DNS, DNSc), or a clinical/practice doctorate such as a DNAP (Doctor of Nurse Anesthesia Practice), or DNP/DrNP (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/DrNP) or Doctor of Nurse Anesthesia Practice (DNAP).[17] This move will affect all advance practice nurses, with a mandatory implementation by the year 2015.[18] 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.[17]

The didactic curricula of nurse anesthesia programs are governed by the Council on Acceditation (COA) standards and provide students the scientific, clinical, and professional foundation upon which to build sound and safe clinical practice. The basic nurse anesthesia academic curriculum and prerequisite courses focus on coursework in anesthesia practice: pharmacology of anesthetic agents and adjuvant drugs including concepts in chemistry and biochemistry (105 contact hours); anatomy, physiology, and pathophysiology (135 contact hours); professional aspects of nurse anesthesia practice (45 contact hours); basic and advanced prinicples of anesthesia practice including physics, equipment, tehcnology and pain management (105 contact hours); research (30 contact hours); and clinical correlation conferences (45 contact hours).[16] Because all programs will be converting to a doctorate level education, the length of the programs, in most cases, will need to increase to 36 months (9 semesters) per the recommendation of the COA of Nurse Anesthesia Programs.[16]

Most programs exceed these minimum requirements. In addition, many require study in methods of scientific inquiry and statistics, as well as active participation in student-generated and faculty-sponsored research.[16]

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. The results of a 1998 survey of program directors show that nurse anesthesia programs provide an average of 1,595 hours of clinical experience for each student.[16]Depending upon academic requirements, and all are at the master's degree level or higher.

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.[16]

Legal challenges

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.[19][20] 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.[21] 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.[22][23] For example, endotracheal intubation (placing a breathing tube into the windpipe) is performed by physicians, nurse anesthetists, anesthesiologist assistants, 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.

Scope of practice

Today, nurse anesthetists practice in all 50 states and administer approximately 32 million anesthetics given to patients in the United States each year (AANA 2006 Practice Profile Survey). The Park Ridge, Illinois-based American Association of Nurse Anesthetists (AANA) is the professional association representing greater than 90 percent of the nation's CRNAs are 39,000 members in the AANA. This includes certified, recertified, and student members. The AANA has state nurse anesthetist associations under the national association.

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).[24]

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.[25] To date, 15 states have opted out of the federal requirement, instituting their own individual requirements instead.[26]

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. Contrary to popular belief, CRNAs are not required to work with an anesthesiologists in the United States. CRNAs are vital part of the patient care team that may work with podiatrists, dentists, anesthesiologists, surgeons, obstetricians and other healthcare professionals requiring their services in various settings and situations.[24]

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.[27] 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.[28]

But frequently CRNAs will provide care alongside an anesthesiologist in what is termed the "Anesthesia Care Team." This formula adds the expertise of an anesthesiologist to perioperative and intraoperative 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.[29] 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 have a list of delineated clinical privileges for nurse anesthetists. Clinical privileges are based on the scope and complexity of the expected clinical practice, qualifications and experiences, actual requested and granted privileges, and serve to allow the CRNA to provide core services and activities under defined conditions, with or without supervision.[30] Rather than varying significantly from place to place due to state nurse practice acts, institutional variation in clinical privileges is most common.

Because many less-developed countries have few anesthesiologists, they rely mainly on nurse anesthetists.[31] In 1989, the International Federation of Nurse Anesthetists was established.[32] 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 nine countries where nurses assist in the administration of anesthesia.[31]

Compensation

In the United States, numerous salary reports throughout the years indicate that CRNAs remain the highest compensated of all nursing specialties as well as other non-physician healthcare providers. In 2009, the median annual salary for nurse anesthetists was $157,724 annually (not including call-pay, bonuses, pension, or benefits) as reported by the AMGA Medical Group Compensation and Financial Survey. [33]

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.[34] 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.[35][36] 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, including the Mayo Clinic at Rochester and the Lakeside Hospital in Cleveland, for anesthesia training, before overseas service.[37]

Among notable nurse anesthetists are Sophie Gran Winton, who 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;[38] Anne Penland, who was the first nurse anesthetist to serve on the British Front and was decorated by the British government and [39]

American nurse anesthetists also served in World War II and Korea, receiving numerous citations and awards.[40] Second Lieutenant Mildred Irene Clark provided anesthesia for casualties from the Japanese attack on Pearl Harbor.[41] During the Vietnam War, nurse anesthetists served as both CRNAs and flight nurses, and also developed new field equipment.[42] 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.[43]

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.[44] During the Iraq War, nurse anesthetists comprise the largest group of anesthesia providers at forward positioned medical treatment facilities.[45] 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. ^ 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
  2. ^ 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
  3. ^ Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company, p. 54.
  4. ^ Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company, p. 54-67.
  5. ^ Bankert, M. (1989) Watchful Care; A History of America's Nurse Anesthetists. New York: The Continuum Publishing Company. p. 25-26.
  6. ^ a b Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company, p. 95.
  7. ^ Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company, p. 90-109.
  8. ^ a b Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company, p. 105.
  9. ^ Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company, p. 101-102.
  10. ^ Bankert, M. (1990). "A Living Heritage." CRNA Forum. Vol. 6 No. 1, p. 5-9.
  11. ^ Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company, p. 60.
  12. ^ Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company, p. 62.
  13. ^ 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.
  14. ^ American Association of Nurse Anesthetists (2007). A Brief Look at Nurse Anesthesia History Retrieved May 23, 2007, from http://www.aana.com/brieflookhistory.aspx
  15. ^ 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.
  16. ^ a b c d e f g 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
  17. ^ 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
  18. ^ 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
  19. ^ Bankert, M. (1989) Watchful Care; A History of America's Nurse Anesthetists. New York: The Continuum Publishing Company. p. 61-63, 91-92.
  20. ^ 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.
  21. ^ 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.
  22. ^ 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
  23. ^ 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
  24. ^ a b American Association of Nurse Anesthetists (2007). Certified Registered Nurse Anesthetists at a Glance. Retrieved November 19, 2009 from http://www.aana.com/ataglance.aspx
  25. ^ 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
  26. ^ 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
  27. ^ 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
  28. ^ 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
  29. ^ American Association of Nurse Anesthetists (2007), medically directed by a physician. Scope and Standards for Nurse Anesthesia Practice. Retrieved May 24, 2007 from http://www.aana.com/scope.aspx
  30. ^ American Association of Nurse Anesthetists (2007). Guidelines for Clinical Privileges. Retrieved May 24, 2007 from http://www.aana.com/clinicalprivileges.aspx
  31. ^ a b 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
  32. ^ International Federation of Nurse Anesthetists (2007). About IFNA... Retrieved May 23, 2007, from http://ifna-int.org/ifna/page.php?16
  33. ^ AMGA Medical Group Compensation and Financial Survey (2009). 2009 AMGA MID-LEVEL COMPENSATION. Retrieved March 7, 2009 from http://www.cejkasearch.com/compensation/amga_midlevel_compensation_survey.htm
  34. ^ American Association of Nurse Anesthetists (2010). "History of Nurse Anesthesia Practice." Retrieved January 1, 2010 from http://www.aana.com/crnahistory.aspx
  35. ^ Milestones in Anesthesia (1993) Nurse Anesthetists: The Dawn of a Specialty, Part II. Vol. 3, No. 2, p. 10-11.
  36. ^ Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company, p. 97.
  37. ^ Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company, p. 96-99.
  38. ^ Bankert, M. (1990). "A Living Heritage." CRNA Forum. Vol. 6 No. 1, p. 9-10.
  39. ^ Bankert, M. (1990). "A Living Heritage." CRNA Forum. Vol. 6 No. 1, p. 13.
  40. ^ Bankert, M. (1989) Watchful Care; A History of America's Nurse Anesthetists. New York: The Continuum Publishing Company, p. 107-123, 137-139.
  41. ^ 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
  42. ^ Bankert, M. (1989) Watchful Care; A History of America's Nurse Anesthetists. New York: The Continuum Publishing Company, p. 144-148.
  43. ^ Bankert, M. (1989) Watchful Care; A History of America's Nurse Anesthetists. New York: The Continuum Publishing Company, p. 148.
  44. ^ Bankert, M. (1989) Watchful Care; A History of America's Nurse Anesthetists. New York: The Continuum Publishing Company, p. 119-142.
  45. ^ 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

External links

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