Nurse anesthetist

A nurse anesthetist (AE) is a registered nurse and advanced practice nurse who has acquired additional education and training to administer anesthesia. The title, Certified Registered Nurse Anesthetist (CRNA), reflects the nurse's qualifications and abilities.

Education
In the United States, education is overseen by the American Association of Nurse Anesthetists (AANA) Council on Accreditation of Nurse Anesthesia Educational Programs (COA). The nurse anesthetist's education, training, and official title vary in different nations.

Historically, American CRNAs received an anesthesia bachelors 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 official position of the AANA board of directors 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 advance degree requirements. As early as 1978, the Kaiser Permanente California State University program had upgraded to a master's level program. All programs were required to transition to a master's degree beginning in 1990 and complete the process by 1998. This is now the current point of entry into the CRNA profession and a majority of practicing CRNAs have completed this level of education. 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. However, many programs require greater than one year experience. Because most programs have far more qualified applicants than available spaces, successful candidates usually have several years of experience in nursing in addition to specialized education in nursing or other health disciplines. Following appropriate experience, applicants enroll in an accredited program of anesthesia education for an additional two to three years. Programs are highly competitive. These college or university based programs combine intensive 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.

The certification and recertification process is governed by the National Board on Certification and Recertification of Nurse Anesthetists (NBCRNA). The NBCRNA exist as an autonomous not-for-profit incorporated organization 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.

Nurse anesthetists may continue their education to the terminal degree level, either earning a Ph.D., DNSc (Doctor of Nursing Science) or DNP (Doctor of Nursing Practice). At the terminal degree level, nurse anesthetists have a wider variety of professional choices available to them, and may teach, participate in administration or pursue research. Currently, the American Association of Colleges of Nursing (AACN) 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). This move will affect all advance practice nurses, with the proposed implementation by the year 2015. The AANA announced in August 2007 support of this advanced clinical degree as an entry level for all nurse anesthetists, but with a target date of 2025. This will increase the time in training, but refine clinical decision-making through research utilization and science-based practice. In accordance with traditional grandfathering rules, all those in current practice will not be affected.

Scope of practice
Nurse anesthetists practice in all 50 of the United States and administer approximately 27 million anesthetics given to patients in the United States each year (AANA 2005 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 36,000 members in the AANA. This includes certified, recertified, and student members. Approximately 46% of the CRNAs are men, versus approximately 8% in the nursing profession as a whole. 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 require some degree of supervision from the operating physician or surgeon. The degree of independence or supervision varies with state law. Some states use the term collaboration to define a relationship of independence between the two parties yet mutual agreement and open communication on the anesthetic techniques. Other states require the consent of a physician to administer the anesthetic. No state requires supervision by an anesthesiologist.

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. To date, 14 states have opted out of the federal requirement.

CRNAs practice in a wide variety of settings including public and private sectors, traditional hospital settings, pain clinics, physician's offices, or in solo practice. They have a substantial role in the military, Veterans Administration (VA), and public health. They may work with podiatrists, dentists, anesthesiologists, surgeons, obstetricians and other professionals requiring their services. Frequently, CRNAs will provide care along side an anesthesiologist, in what is termed the Anesthesia Care Team. This combines the expertise of both a physician and nurse anesthetist to provide excellent peri-operative care. CRNAs can administer anesthesia in all types of surgical cases, and are able to apply all the accepted anesthetic techniques - general, regional, local, or sedation. Any restrictions on CRNA practice are dependent on the hospital's credentialing process and the anesthesia department's guidelines. Each health care facility will have a list of allowed privileges for allied health practitioners. Like physicians, these privileges are based on prior training, certifications and experience. State law does not define this aspect of practice; it defines the extent of collaboration (or supervision) with the surgeon or anesthesiologist.

Most lay people and health professionals don't have knowledge of the world wide extent of nurse anesthesia practice. Anesthesiologists (physicians who have completed four additional specialty years of residency training beyond medical school) usually practice in developed and modern countries. This leaves many undeveloped nations with few anesthesiologists, and therefore they rely mainly on nurse anesthetists. In 1989, an international organization of nurse anesthetists was established. The International Federation of Nurse Anesthetists (IFNA) has flourished in membership and has become an authoritative 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. Recent studies by the IFNA found anesthesia care worldwide is both a medical and nursing function. Researchers identified 107 countries where nurse anesthetists train and practice and 9 countries where nurses assist in the administration of anesthesia.

Compensation
According to numerous salary reports throughout the years, CRNAs remain the highest compensated of all nursing specialties. Their average reported annual salary range in 2006, reported by the AMGA Medical Group Compensation and Financial Survey, was $140,396.

History
Nurse anesthetists have been providing anesthesia care in the United States for over 125 years. Nurse anesthetists were the first "nursing specialty group" in the United States.

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. 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 Sisters were called to practice anesthesia in various midwest Catholic and Protestant hospitals throughout the last two decades of the 19th century. By the early 1900s, the influence of nurse anesthetisa had moved east. 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. Following this many schools formed. Between 1912 and 1920, 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, Presbyterian Hospital in Chicago, Charity Hospital in New Orleans, Grace Hospital in Detroit, among others. In contrast, nearly 20 years later, only seven physician anesthesia residencies existed.

Since physician residences in anesthesia did not exist very early on, doctors attended these programs to learn anesthesia. For example, in 1915, chief nurse anesthetist Agatha Hodgins established the Lakeside Hospital School of Anesthesia in Cleveland, Ohio. This program was open to graduate 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. Later, in 1918, it established a system of clinical affiliations with other Cleveland hospitals. Ms. Hodgins was originally appointed as anesthetist in 1908 by Dr. George W. Crile. Under Dr. Crile's direction, she became an expert in the administration of anesthesia, and had administered 575 anesthetics by 1909.

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. 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 also 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 many other publications, beginning in 1899, with some published and many ignored because of her status as a nurse. Ms. Magaw was the anesthetist at St. Mary’s Hospital in Rochester for the famous Drs. William J. Mayo and Charles H. Mayo. This became the famed Mayo Clinic in Rochester, Minnesota. She is often referred to as "the Mother of Anesthesia." She set up a showcase for surgery and anesthesia and attracted students from across the United States and the world. Recently, the city of Corunna, Michigan, discovered that Alice Magaw and family are interred in Corunna's Pine Tree Cemetery.

After much growth, the nurse anesthesia specialty was formally organized on June 17, 1931, when the National Association of Nurse Anesthetist (AANA) held their first meeting. It was Agatha Hodgins who organized the event, inviting members from the Alumnae Association of the Lakeside School of Anesthesia and also nurse anesthetists from across the United States. As a new organization, it had two main objectives: establish a national qualifying exam, and establish an accreditation program for nurse anesthesia schools. The first national certification exam was held on June 4, 1945, with 92 candidates sitting for the exam. After many years of preparation, on January 19, 1952, a program for the accreditation of nurse anesthesia schools when into effect. This has been recognized by the U.S. Department of Education since 1955.

Legal Challenges
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). All occurred before 1940 and all were found in favor of the nursing profession. 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. The numbers of physicians in this specialty did not greatly expand until the late 1960s. Therefore, it was legally established that when a nurse delivers anesthesia, it is the practice of nursing. When a physician delivers anesthesia, it is the practice of medicine. When a dentist delivers anesthesia, it is the practice of dentistry. There are great overlaps of tasks and knowledge in the health care professions. Administration of anesthesia and its related tasks by one provider does not necessarily contravene the practice of other health care providers. For example, endotracheal intubation (placing a breathing tube into the windpipe) is performed by physicians, nurse anesthetists, respiratory therapists, paramedics, and dental (oral) 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, CRNAs 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. CRNAs 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.

CRNAs have made a significant contribution in the provision of anesthesia services in every U.S. war during the 20th century. During World War I, America's nurse anesthetists played a vital role in the care of combat troops in France. From 1914 to 1915, two 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. They even 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, with American participation in the war, for the first time the U.S. Military started 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. Nurse anesthetist Sophie Gran Winton served at an army hospital in Chateau-Thierry, France, and earned the French Croix de Guerre medal, along with other awards, for her anesthesia service. Anne Penland was the first nurse anesthetist on the British Front, and was blinded in one eye from a shrapnel wound. American nurse anesthetists also served in World War II and Korea, receiving numerous citations and awards. They are represented by such heroes Second Lieutenant Mildred Irene Clark, who provided anesthesia in the heat of battle for casualties from the Japanese bombing of Pearl Harbor. During the Vietnam war, nurse anesthetists served as both CRNAs and flight nurses, and outnumbered physician anesthesiologist by 3:1. CRNAs have been casualties of war. Lieutenants Kenneth R. Shoemaker, Jr. and Jerome E. Olmsted, where killed in an air evac mission in route to Qui Nhon, Vietnam. A CRNA 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. For Operation Iraqi Freedom and Operation Enduring Freedom, CRNAs comprise the largest group of anesthesia providers at forward positioned medical treatment facilities. In addition, they play a key role in the continuing education and training of Department of Defense nurses and technicians in the care of wartime trauma patients.