Nurse-Anesthetist administers a local anesthetic to an injured Marine prior to surgery aboard USS Kearsarge
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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) 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 150 years. According to the American Association of Nurse Anesthetists, nurse anesthetists are the oldest nurse specialty group in the United States. Additionally, in testament to the profession’s roots, today’s nurse anesthetists remain the primary anesthesia providers to U.S. service men and women at home and abroad.
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 mid-west Catholic and Protestant hospitals throughout the last two decades of the 19th century. 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 third 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 Mayo Clinic in Rochester, Minnesota. Ms. Magaw set up a showcase for surgery and anesthesia that has attracted many students and visitors.
Nurse Anesthesiology is a graduate prepared profession. In the United States of America, nurse anesthetists must be licensed registered nurse and complete a master's degree in anesthesia and/or nursing with a post-masters certification in anesthesia. In addition, candidates are required to have a minimum of one year of full-time nursing experience in a medical or surgical intensive care unit. Following this experience, applicants apply to a Council on Accreditation (COA) accredited program of nurse-anesthesia. Education is offered on a master's degree or doctoral degree (in Nurse Anesthesia Practice). Program length is typically 28 months in duration, but can vary from 24 to 36 months. 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 a sound and safe clinical practice. Accredited programs afford and ensure 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. Among the oldest schools in the U.S., Ravenswood Hospital in Chicago, opened in 1925 by Mae Cameron, which in 2001 became the NorthShore University HealthSystem School of Nurse Anesthesia, was the first school to be accredited by the Council on Accreditation of Nurse Anesthesia Educational Programs in 1952.
History of education
CRNAs in the United States receive Master's or Doctoral degrees in nurse anesthesia. The Council on Accreditation develops 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 applying for a school of anesthesia shall be, at minimum, baccalaureate prepared and then complete 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 evolved 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 and education of 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. In August 2007, the AANA announced its support of this advanced clinical degree as an entry level for practice of all nurse anesthetists with a target compliance date of 2025. In accordance with traditional grandfathering rules, all those in current practice will not be affected. Several nurse anesthesia programs have already transitioned to the DNP or DNAP entry level format. Because all programs will be converting to a doctorate level education, the length of the programs will continue to expand. Nurse anesthetists have always embraced the responsibility of helping meet America’s growing healthcare needs. As healthcare technologies continue to advance and the knowledge base of the human body continues to expand, the 2025 requirement of a doctoral level education for entry into nurse anesthesia practice will ensure that patients have continued access to the highest quality anesthesia care that is possible.
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. Currently in revision, recertification in the future will included NBCRNA mandated course subjects in addition to board retesting, similar to physician requirements.
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. There were limited anesthetic drug choices and less was known about the physiologic effects of anesthesia and surgery. In 1942, there were 17 nurse anesthetists for every one anesthesiologist. As knowledge grew and surgery became more complex, the numbers of physicians in this specialty expanded in 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 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 34 million anesthetics each year (AANA). CRNA practice varies from state to state, and is also dependent on the institution in which CRNAs 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, other CRNAs, or in independent practice. When practicing within the Anesthesia Care Team model, CRNAs most often fall under the medical direction, or supervision, of an anesthesiologist. CRNAs also 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, 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.
More than 40 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 for anesthesia services. 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 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 en 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.
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