Nurse anesthetist

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Nurse anesthetist
A United States Army nurse anesthetist providing independent anesthesia on a forward surgical team
Occupation
Activity sectors
Anesthesia, nursing
Description
CompetenciesAdministration of anesthetics and the elimination of pain
Education required
Varies by country
Fields of
employment

A nurse anesthetist is an advanced practice nurse who administers anesthesia for surgery or other medical procedures. They are involved in the administration of anesthesia in a majority of countries, with varying levels of autonomy.

A survey published in 1996 reported that there were 107 countries where nurses administer anesthesia in some form, and a further nine countries where nurses act as assistants in the administration of anesthesia.[1] Depending on the country or locality, their role may be limited to intraoperative care during anesthesia itself or may also extend before and after (for preanesthetic assessment and immediate postoperative management).[2] The United States is one of the only countries in which nurses provide anesthesia without supervision from a medical doctor trained in anesthesia, also known as a physician anesthesiologist.[2]

The International Federation of Nurse Anesthetists was established in 1989 as a forum for developing standards of education, practice, and a code of ethics.[3]

History

American Civil War and the 19th Century

Among the first nurses to provide anesthetics was Catherine S. Lawrence during the American Civil War. It was during the Second Battle of Bull Run in 1863 that she administered chloroform to wounded soldiers who needed emergency operations in the battlefield.[4] Nevertheless, it still took several years for nurses to step forward and formally answer the call to provide anesthesia. Reasons for this delay included lack of training, the non-emergency nature of civilian surgical practice after the war was over, and the paucity of role models and sponsors. However, the wartime concept of nurses providing anesthesia care gradually took root as surgeons trained and encouraged nurses to take on this important role.[5]

Catholic nuns played an important role in the training of nurses and also in anesthesia. The earliest recorded nurse to specialize in anesthesia was Sister Mary Bernard Sheridan, a Catholic nun who practiced in 1877 at St. Vincent's Hospital in Erie, Pennsylvania.[11] Her influence spread throughout the Midwest, and many other Catholic nuns who were also nurses began training to administer anesthesia. Nuns of the Third Order of the Hospital Sisters of St Francis from Münster established a community in Springfield, Illinois, and on June 22, 1879, they founded St John's Hospital.[6] At St John's, the administration of chloroform and ether was taught to the nurses by surgeons, and many of the Franciscan Sisters were assigned as anesthetists throughout the Midwest. Nurse anesthesia became “undoubtedly a prevailing practice in many Catholic hospitals”.[7][8]

Catherine Lawrence (1820-1904) in a photograph taken during the American Civil War

In 1883, Minnesota was devastated by a tornado. Mother Alfred Moes and the Sisters of Saint Francis proposed building a hospital to aid the sick and injured in Southern Minnesota. However, they stipulated that William Worrall Mayo (1819-1911) and his sons work at the hospital. The Mayos agreed, and in 1889, St Mary's Hospital opened with 27 beds.[9] Although Catholic nuns seemed to be the most influential force in teaching nurses to administer anesthesia in the late 1800s, it was William W. Mayo who should be credited for promoting the popularity of nurse anesthesia practice.[10] Mayo and his sons William J. Mayo and Charles H. Mayo were well known for their surgical skills. Surgeons traveled from across the country to their clinic in Minnesota to observe operations and learn their surgical techniques. However, the visiting surgeons also took note of the nurses administering anesthesia at the head of the operating table.[11]

One of the most well-known nurse anesthesia pioneers was Alice Magaw, who came to St Mary's Hospital in Rochester, Minnesota, in 1893. She was trained by the Graham sisters, Edith and Dinah, and began working as a nurse anesthetist for Charles H. Mayo, who bestowed on her the title of “Mother of Anesthesia” due to her natural aptitude and mastery of safe administration of open-drop ether.[12] In addition to being skilled at anesthesia administration, Magaw documented and evaluated all her anesthesia procedures, culminating with a landmark article in nurse-anesthesia history.[13] An even larger work (A Review of Over Fourteen Thousand Surgical Anesthesias) was published in 1906, reporting huge number of open-drop ether anesthetics, incredibly without a single fatality.[14] Magaw's work highlighted the benefits of the trained anesthetist, allowing great advances in the practice of medicine. As the reputation and success of the Mayo Clinic spread, so did the renown of the Mayo Clinic nurse anesthetists.[15]

The sustainability and historical longevity of the practice of nurse anesthesia can be attributed to excellent working relationships between nurse anesthetists and surgeons in these early years of the practice. Impressed by the provision of superior anesthesia by nurses at St Mary's, and following the example of the Mayo Clinic, prominent Cleveland surgeon George Washington Crile recruited Agatha Cobourg Hodgins as his personal anesthetist in 1908.[16]

20th Century and legal challenges in the United States

Several notable nurse anesthetist from the early 20th century are revered by their modern counterparts. Agnes McGee taught at the Oregon Health Science Center.[17] Alice Hunt was appointed instructor in anesthesia with university rank at the Yale University School of Medicine beginning in 1922 and continuing for 26 years. She authored the 1949 book Anesthesia, Principles and Practice, likely the first nurse anesthesia textbook.[18]

The first challenge to the nurse's right to administer anesthesia came in 1911 from Francis Hoeffer McMechan, a native Cincinnati physician, who felt that the field of anesthesia should belong solely to physicians. McMechen challenged the practice of nurse anesthesia with the Ohio Medical Board, which along with Ohio State Attorney General ruled in 1916 that only a registered physician could administer anesthesia.[19] Surgeons at the Lakeside Hospital in Cleveland, such as Crile, initially obeyed the ruling; however, in 1917, Crile and his supporters successfully lobbied the Ohio legislature to create an exemption within the Medical Practice Act for nurses who were educated appropriately to administer anesthesia under the supervision of a physician.[20]

Alice Magaw (bottom right) administering anesthesia during a surgery at the Mayo Clinic.

Perhaps the most noteworthy challenge occurred in 1934, when nurse anesthetist Dagmar Nelson was charged by an anesthesiologist, William VaneChalmer-Francis, with practicing medicine and violating California Medical Practice by administering anesthesia without a license. The case went all the way to the California Supreme court, but Nelson was given a favorable ruling at each level of the case.[21] The Dagmar Nelson case was won via precedents set by early nurse anesthetists. The California Supreme Court reasoned that Nelson's practice of anesthesia was in “accordance with the uniform practice in operating rooms” not only in Los Angeles but also throughout the country including the Mayo Clinic, where Nelson had trained and “where...one hundred thousand surgical operations had been performed” with anesthetic administered by nurses.[22]

Despite the rapid growth of the nurse anesthetist profession following the Great War, World War II again precipitated a shortage of anesthetists. A recruitment campaign was begun, but this was quickly followed by concern about the emergence of “ill advised and unjustified schools”.[23] Helen Lamb in turn stressed the importance of maintaining educational standards even in times of shortages. By the end of WWII, the military had trained more than 2000 nurses to provide anesthesia using a program patterned by the NANA. The quality of nurse anesthesia education was again upgraded following WWII, and although university affiliation was advised, most programs were still hospital based. In 1933, the NANA established an Education Committee to develop educational standards, and by 1952, formal accreditation standards were in place.[24]

Legal cases

Under US law, Frank v. South,[25] Chalmers-Francis v. Nelson[26] and other court decisions established that anesthesia was the practice of nursing as well as medicine.[31] As such, the practice of anesthesia in the US may be delivered by either a nurse anesthetist or an anesthesiologist. The decisions have not been challenged since the Dagmar Nelson case.[32]

United States

Main article: Certified Registered Nurse Anesthetist

In the United States, nurse anesthetists have the protected title of Certified Registered Nurse Anesthetist (CRNA); they account for approximately half of the anesthesia providers in the United States and are the main providers of anesthesia in rural America.[27]

Nurses have been providing anesthesia care to patients since the American Civil War.[28] Nurse anesthetists are considered an essential role to the health care workforce. They provide pain management and emergency services to the airway management, which was very important to patients in the Civil War.[29]

The National Association of Nurse Anesthetists professional association was established by Agatha Hodgkins in 1931.[30] Depending on the local system of healthcare, they participate only during the operation itself or may also be involved before and after (for preanesthetic assessment and immediate postoperative management). It was renamed the American Association of Nurse Anesthetists in 1939.[30] The group established educational institutions for nurse anesthetists in 1952 and established the CRNA certification in 1957.[30] AANA continuing education was established in 1977.[30] As of 2011, some 92% of CRNAs in the U.S. were represented by the AANA.[30]

Scope of practice rules vary between healthcare facility and state. Before 2001, Medicare required that physicians supervise CRNAs in the administration of anesthesia.[30] In 2001, Medicare's rules changed, allowing individual states to decide whether CRNAs may administer anesthesia without physician supervision.[30] In the absence of a state requirement that anesthesiologists supervise CRNAs, individual healthcare facilities decide.[30] CRNA organizations have lobbied in many states for the ability to practice without anesthesiologist supervision; these efforts are opposed by physician groups.[30] In 2011, sixteen states granted CRNAs autonomy, allowing them to practice without anesthesiologist oversight.[30] In 2017, there were 27 states in which CRNAs could independently practice (that is, "without a written collaborative agreement, supervision or conditions for practice").[31] In 2020, there was no physician supervision requirement for nurse anesthetists in ambulatory surgical facilities in 31 states[32] In states that have opted out of supervision, the Joint Commission and CMS recognize CRNAs as licensed independent practitioners.[33] In states requiring supervision, CRNAs have liability separate from supervising practitioners and are able to administer anesthesia independently of anesthesiologists.[34][35][36][37]

See also

References

  1. ^ McAuliffe, M. S; Henry, B (1996). "Countries where anesthesia is administered by nurses". AANA Journal. 64 (5): 469–79. PMID 9124030.
  2. ^ a b McAuliffe, M. S; Henry, B (1998). "Survey of nurse anesthesia practice, education, and regulation in 96 countries". AANA Journal. 66 (3): 273–86. PMID 9830854.
  3. ^ International Federation of Nurse Anesthetists (2007). About IFNA... Retrieved May 23, 2007, from http://ifna-int.org/ifna/page.php?16
  4. ^ Lyon, James (1896). Autobiography. Sketch of life and labors of Miss Catherine S. Lawrence, who in early life distinguished herself as a bitter opponent of slavery and intemperance, and in later life as a nurse in late war, and for other patriotic and philanthropic services. Albany, New York: J.B. Lyon.
  5. ^ 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 Archived 2007-06-04 at the Wayback Machine
  6. ^ Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company, p. 54.
  7. ^ Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company, p. 54-67.
  8. ^ Bankert, M. (1989) Watchful Care; A History of America's Nurse Anesthetists. New York: The Continuum Publishing Company. p. 25-26.
  9. ^ Clapesattle, H. (1969). The Doctors Mayo. Minneapolis: University of Minnesota Press.
  10. ^ Dickenson-Berry, F.M. (1912). [30] Notes on the administration of anaesthetics in America, with special reference to the practice at the Mayo Clinic. Proc R Soc Med. pp. 1912–1913.
  11. ^ Clapesattle, H. (1969). The Doctors Mayo. Minneapolis: University of Minnesota Press.
  12. ^ Bankert, Marianne (1989). Watchful care: a history of America's nurse anesthetists. New York: The Continuum Publishing Company.
  13. ^ Magaw, Alice (1900). "Observations on 1092 cases of anesthesia from January 1, 1899 to January 1, 1900". St Paul Med J. 2: 306–311.
  14. ^ Magaw, Alice (1906). "A review of over fourteen thousand surgical anaesthesias". SG&O. 3: 795–799.
  15. ^ Ray, William (2016). "The history of the nurse anesthesiaprofession". Journal of Clinical Anesthesia. 30: 51–58. doi:10.1016/j.jclinane.2015.11.005. PMID 27041264.
  16. ^ Crile, G.W. (1947). George Crile: an autobiography. Philadelphia: Lippincott.
  17. ^ Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company, p. 95.
  18. ^ Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company, p. 101-102.
  19. ^ McMechan, F. H. (1916). "The Ohio State Medical Board and the nurse anesthetist". Am J Surg. 30: 130.
  20. ^ Bankert, M. (1989) Watchful Care; A History of America's Nurse Anesthetists. New York: The Continuum Publishing Company, p. 107-123, 137-139.
  21. ^ Van-Nest, R.L. (2006). "The life and trial of Dagmar Nelson, Part 2". AANA J (74): 261–265.
  22. ^ Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company.
  23. ^ Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company.
  24. ^ "Standards for Accreditation of Nurse Anesthesia Educational Programs, Revised January 2013". Council on Accreditation of Nurse Anesthesia Educational Programs. 2013. Retrieved 20 July 2021.
  25. ^ 175 Ky 416, 194 SW 375 (1917)
  26. ^ 6 Cal 2d 402 (1936)
  27. ^ [citation needed]
  28. ^ "CRA Fact Sheet".
  29. ^ "What is a Nurse Anesthetist?". www.kumc.edu. Retrieved March 29, 2022.
  30. ^ a b c d e f g h i j Matsusaki T, Sakai T (2011). "The role of certified registered nurse anesthetists in the United States". Journal of Anesthesia. 25 (5): 734–740. doi:10.1007/s00540-011-1193-5. PMID 21717163. S2CID 7991965.
  31. ^ Laura Dyrda, 27 states where CRNAs can practice independently, Becker's ASC Review (January 18, 2017).
  32. ^ Angie Stewart, 31 states with no CRNA supervision requirement in ASCs, Becker's ASC Review (October 14, 2020).
  33. ^ "Archived copy" (PDF). Archived from the original (PDF) on August 4, 2018. Retrieved August 3, 2018.{{cite web}}: CS1 maint: archived copy as title (link)
  34. ^ Joint Commission on Accreditation of Healthcare Organizations. "Standards Revisions Related to the Centers for Medicare & Medicaid Services (CMS)" (PDF). Archived from the original (PDF) on August 4, 2018. Retrieved August 3, 2018.
  35. ^ Gene Blumenreich. "A Surgeons Responsibility for CRNAs" (PDF). www.aana.com. Archived from the original (PDF) on August 4, 2018. Retrieved August 3, 2018.
  36. ^ American Association of Nurse Anesthetists (2013). "Scope of Nurse Anesthesia Practice" (PDF). www.aana.com. Archived from the original (PDF) on August 4, 2018. Retrieved August 3, 2018.
  37. ^ Gene Blumenreich. "Legal Briefs: Captain of the Ship Doctrine" (PDF). www.aana.com. Retrieved August 3, 2018.
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