Nurse anesthetist
Encyclopedia
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 92% of the 40,000 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.
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 midwest 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 six 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, physician
s, and dentist
s. 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 3rd 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 famed Mayo Clinic
in Rochester, Minnesota
. Ms. Magaw set up a showcase for surgery and anesthesia that has attracted many students and visitors.
in a science related field or a Bachelor of Science in Nursing
. 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. Following the acute care experience, applicants apply to a Council on Accreditation (COA) accredited program of nurse-anesthesia. Education is offered on a masters degree or doctor degree. Program length varies from 24 to 36 months. Many programs require entrance prerequisites similar to medical schools (pre-med courses) and up to two years of acute care experience. 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 sound and safe clinical practice. 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. In addition, many require study in methods of scientific inquiry and statistics, as well as active participation in student-generated and faculty-sponsored research.
, diploma or certificate. As early as 1976, the Council on Accreditation was developing requirements for degree
programs. In 1981, the Council on Accreditation developed guidelines for master's degree
s. In 1982, it was the official position of the AANA board of directors' 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. 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. 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 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. 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. Several nurse anesthesia programs have already upgraded to the DNP or DNAP entry level format. Because all programs will be converting to a doctorate level education, the length of the programs, in most cases, will need to increase or exceed 36 months per the recommendation of the COA of Nurse Anesthesia Programs.
requirements and recertification every two years thereafter, plus any additional requirements of the state in which they practice.
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 17 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, 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.
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, CRNAs, or in independent practice. They 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, peripheral nerve block, sedation, or local. Scope of CRNA practice is commonly further defined by the practice location's clinical privelge 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, 16 states have opted out of the federal requirement, instituting their own individual requirements instead.
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).
Because many less-developed countries
have few anesthesiologists, they rely mainly on nurse anesthetists. 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.
, 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 nurse
s, 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 in 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.
Anesthesia
Anesthesia, or anaesthesia , traditionally meant the condition of having sensation blocked or temporarily taken away...
.
In the United States
United States
The United States of America is a federal constitutional republic comprising fifty states and a federal district...
, a Certified Registered Nurse Anesthetist (CRNA) is an advanced practice registered nurse
Advanced practice nurse
An advanced practice registered nurse is a nurse with advanced didactic and clinical education, knowledge, skills, and scope of practice in nursing....
(APRN) who has acquired graduate-level education and board certification in anesthesia. The American Association of Nurse Anesthetists'
American Association of Nurse Anesthetists
The American Association of Nurse Anesthetists is the professional association of nurse anesthetists in the United States. The organization states that it has a membership of 39,000, includes certified , recertified, and student members. The organization represents around 90 percent of nurse...
(AANA) is the national association that represents more than 92% of the 40,000 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.
History
Nurse anesthetists have been providing anesthesia care in the United States for nearly 150 years. According to the American Association of Nurse Anesthetists, nurse anesthetists are the oldest nurse specialty group in the United States.Among the first American nurses to provide anesthesia was Catherine S. Lawrence. Along with other nurses, Lawrence administered anesthesia during the American Civil War
American Civil War
The American Civil War was a civil war fought in the United States of America. In response to the election of Abraham Lincoln as President of the United States, 11 southern slave states declared their secession from the United States and formed the Confederate States of America ; the other 25...
(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
Erie, Pennsylvania
Erie is a city located in northwestern Pennsylvania in the United States. Named for the lake and the Native American tribe that resided along its southern shore, Erie is the state's fourth-largest city , with a population of 102,000...
. There is evidence that up to 50 or more other Catholic sisters were called to practice anesthesia in various midwest 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
Portland, Oregon
Portland is a city located in the Pacific Northwest, near the confluence of the Willamette and Columbia rivers in the U.S. state of Oregon. As of the 2010 Census, it had a population of 583,776, making it the 29th most populous city in the United States...
. Established by Agnes McGee, the course was six months long, and included courses on anatomy
Anatomy
Anatomy is a branch of biology and medicine that is the consideration of the structure of living things. It is a general term that includes human anatomy, animal anatomy , and plant anatomy...
and physiology
Physiology
Physiology is the science of the function of living systems. This includes how organisms, organ systems, organs, cells, and bio-molecules carry out the chemical or physical functions that exist in a living system. The highest honor awarded in physiology is the Nobel Prize in Physiology or...
, pharmacology
Pharmacology
Pharmacology is the branch of medicine and biology concerned with the study of drug action. More specifically, it is the study of the interactions that occur between a living organism and chemicals that affect normal or abnormal biochemical function...
, 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
Mayo Clinic
Mayo Clinic is a not-for-profit medical practice and medical research group specializing in treating difficult patients . Patients are referred to Mayo Clinic from across the U.S. and the world, and it is known for innovative and effective treatments. Mayo Clinic is known for being at the top of...
, Johns Hopkins Hospital
Johns Hopkins Hospital
The Johns Hopkins Hospital is the teaching hospital and biomedical research facility of Johns Hopkins University School of Medicine, located in Baltimore, Maryland . It was founded using money from a bequest by philanthropist Johns Hopkins...
, Barnes Hospital, New York Post-Graduate Hospital, Charity Hospital in New Orleans, Grace Hospital
Grace Hospital
Grace Hospital is an independent, not-for-profit hospital located in Morganton, Burke County, NC.As of July, 2011 Grace Hospital had 184 patient beds....
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
Cleveland, Ohio
Cleveland is a city in the U.S. state of Ohio and is the county seat of Cuyahoga County, the most populous county in the state. The city is located in northeastern Ohio on the southern shore of Lake Erie, approximately west of the Pennsylvania border...
. This program was open to nurses, physician
Physician
A physician is a health care provider who practices the profession of medicine, which is concerned with promoting, maintaining or restoring human health through the study, diagnosis, and treatment of disease, injury and other physical and mental impairments...
s, and dentist
Dentist
A dentist, also known as a 'dental surgeon', is a doctor that specializes in the diagnosis, prevention, and treatment of diseases and conditions of the oral cavity. The dentist's supporting team aides in providing oral health services...
s. 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 3rd 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
Alice Magaw
-References:...
(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
William James Mayo
William James Mayo, M.D. was a physician in the United States and one of the seven founders of the Mayo Clinic. He and his brother, Charles Horace Mayo, both joined their father's private medical practice in Rochester, Minnesota, USA, after graduating from medical school in the 1880s...
and Dr. Charles Horace Mayo
Charles Horace Mayo
-External links:*...
. This became the famed Mayo Clinic
Mayo Clinic
Mayo Clinic is a not-for-profit medical practice and medical research group specializing in treating difficult patients . Patients are referred to Mayo Clinic from across the U.S. and the world, and it is known for innovative and effective treatments. Mayo Clinic is known for being at the top of...
in Rochester, Minnesota
Rochester, Minnesota
Rochester is a city in the U.S. state of Minnesota and is the county seat of Olmsted County. Located on both banks of the Zumbro River, The city has a population of 106,769 according to the 2010 United States Census, making it Minnesota's third-largest city and the largest outside of the...
. Ms. Magaw set up a showcase for surgery and anesthesia that has attracted many students and visitors.
Education pathway
In the USA, Nurse anesthetists must first complete a bachelor's degreeBachelor's degree
A bachelor's degree is usually an academic degree awarded for an undergraduate course or major that generally lasts for three or four years, but can range anywhere from two to six years depending on the region of the world...
in a science related field or a Bachelor of Science in Nursing
Bachelor of Science in Nursing
The Bachelor of Science in Nursing is an American four year academic degree in the science and principles of nursing, granted by a tertiary education university or similarly accredited school...
. They must be a licensed registered nurse
Registered nurse
A registered nurse is a nurse who has graduated from a nursing program at a university or college and has passed a national licensing exam. A registered nurse helps individuals, families, and groups to achieve health and prevent disease...
. 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. Following the acute care experience, applicants apply to a Council on Accreditation (COA) accredited program of nurse-anesthesia. Education is offered on a masters degree or doctor degree. Program length varies from 24 to 36 months. Many programs require entrance prerequisites similar to medical schools (pre-med courses) and up to two years of acute care experience. 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 sound and safe clinical practice. 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. In addition, many require study in methods of scientific inquiry and statistics, as well as active participation in student-generated and faculty-sponsored research.
History of education
Historically, CRNAs in the United States received an anesthesia bachelor's degreeBachelor's degree
A bachelor's degree is usually an academic degree awarded for an undergraduate course or major that generally lasts for three or four years, but can range anywhere from two to six years depending on the region of the world...
, diploma or certificate. As early as 1976, the Council on Accreditation was developing requirements for degree
Academic degree
An academic degree is a position and title within a college or university that is usually awarded in recognition of the recipient having either satisfactorily completed a prescribed course of study or having conducted a scholarly endeavour deemed worthy of his or her admission to the degree...
programs. In 1981, the Council on Accreditation developed guidelines for master's degree
Master's degree
A master's is an academic degree granted to individuals who have undergone study demonstrating a mastery or high-order overview of a specific field of study or area of professional practice...
s. In 1982, it was the official position of the AANA board of directors' 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. 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
Master's degree
A master's is an academic degree granted to individuals who have undergone study demonstrating a mastery or high-order overview of a specific field of study or area of professional practice...
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 for 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. 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. Several nurse anesthesia programs have already upgraded to the DNP or DNAP entry level format. Because all programs will be converting to a doctorate level education, the length of the programs, in most cases, will need to increase or exceed 36 months per the recommendation of the COA of Nurse Anesthesia Programs.
Board certification
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 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 educationContinuing education
Continuing education is an all-encompassing term within a broad spectrum of post-secondary learning activities and programs. The term is used mainly in the United States and Canada...
requirements and recertification every two years thereafter, plus any additional requirements of the state in which they practice.
Legal challenges
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. In 1942, there were 17 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
Intubation
Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic or rubber tube into the trachea to maintain an open airway or to serve as a conduit through which to administer certain drugs...
(placing a breathing tube
Tracheal tube
A tracheal tube is a catheter that is inserted into the trachea in order for the primary purpose of establishing and maintaining a patent airway and to ensure the adequate exchange of oxygen and carbon dioxide. Many different types of tracheal tubes are available, suited for different specific...
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 32 million anesthetics each year (AANA). Approximately 65% of CRNAs practice in collaboration with anesthesiologists, in what is termed the "Anesthesia Care Team.” However, CRNAs are educated to work independently or with anesthesiologist supervision. CRNA practice varies from state to state, and is also dependent on the institution in which CRNAs practice. The following paragraphs clarify CRNA 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, CRNAs, or in independent practice. They 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
Anesthesiologist
An anesthesiologist or anaesthetist is a physician trained in anesthesia and peri-operative medicine....
.
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. Scope of CRNA practice is commonly further defined by the practice location's clinical privelge 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
Centers for Medicare and Medicaid Services
The Centers for Medicare & Medicaid Services , previously known as the Health Care Financing Administration , is a federal agency within the United States Department of Health and Human Services that administers the Medicare program and works in partnership with state governments to administer...
(CMS) published a rule in the Federal Register
Federal Register
The Federal Register , abbreviated FR, or sometimes Fed. Reg.) is the official journal of the federal government of the United States that contains most routine publications and public notices of government agencies...
that allows a state to be exempt from Medicare's physician supervision requirement for nurse anesthetists after appropriate approval by the state governor
Governor (United States)
In the United States, the title governor refers to the chief executive of each state or insular territory, not directly subordinate to the federal authorities, but the political and ceremonial head of the state.-Role and powers:...
. To date, 16 states have opted out of the federal requirement, instituting their own individual requirements instead.
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).
Because many less-developed countries
Developing country
A developing country, also known as a less-developed country, is a nation with a low level of material well-being. Since no single definition of the term developing country is recognized internationally, the levels of development may vary widely within so-called developing countries...
have few anesthesiologists, they rely mainly on nurse anesthetists. 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.
Research
In June 2010, the Journal of Nursing Economics published a study by the Lewin Group titled "Cost Effectiveness Analysis of Anesthesia Providers." The study compared the cost effectiveness of anesthesia care models. The findings demonstrated that independently practicing CRNAs are not only as safe as their anesthesiologists counterparts, but CRNA only practice was the most cost effective model for the delivery of anesthesia services. Furthermore, in August 2010 Health Affairs published "No Harm Found When Nurse Anesthetists Work Without Supervision By Physicians" authored by the Research Triangle Institute. This study analyzed the outcomes, both mortalities and morbidities, of 481,868 patients across all practice settings: CRNA only, anesthesiologists only, CRNA/anesthesiogists care teams. The study concluded that anesthesia delivered by CRNAs without supervision was just as safe as anesthetics delivered via the alternative models of care.Compensation
In the United States, numerous salary reports throughout the years indicate that CRNAs remain the highest compensated of all nursing specialties. In 2009, the median annual salary for nurse anesthetists was $150,724 annually as reported by the AMGA Medical Group Compensation and Financial Survey.Armed forces
In the United States armed forcesUnited States armed forces
The United States Armed Forces are the military forces of the United States. They consist of the Army, Navy, Marine Corps, Air Force, and Coast Guard.The United States has a strong tradition of civilian control of the military...
, 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
Active duty
Active duty refers to a full-time occupation as part of a military force, as opposed to reserve duty.-Pakistan:The Pakistan Armed Forces are one of the largest active service forces in the world with almost 610,000 full time personnel due to the complex and volatile nature of Pakistan's...
and retired service members and their dependents
Dependant
This article is related to law. For the personality trait, see Dependent Personality DisorderA dependant or dependent is a person who relies on another as a primary source of income...
. Nurse anesthetists function as the only licensed independent anesthesia practitioners at many military treatment facilities, including U.S. Navy
United States Navy
The United States Navy is the naval warfare service branch of the United States Armed Forces and one of the seven uniformed services of the United States. The U.S. Navy is the largest in the world; its battle fleet tonnage is greater than that of the next 13 largest navies combined. The U.S...
ships at sea. They are also the leading provider of anesthesia for the Veterans Administration
United States Department of Veterans Affairs
The United States Department of Veterans Affairs is a government-run military veteran benefit system with Cabinet-level status. It is the United States government’s second largest department, after the United States Department of Defense...
and Public Health Service
United States Public Health Service
The Public Health Service Act of 1944 structured the United States Public Health Service as the primary division of the Department of Health, Education and Welfare , which later became the United States Department of Health and Human Services. The PHS comprises all Agency Divisions of Health and...
medical facilities.
During World War I
World War I
World War I , which was predominantly called the World War or the Great War from its occurrence until 1939, and the First World War or World War I thereafter, was a major war centred in Europe that began on 28 July 1914 and lasted until 11 November 1918...
, America's nurse anesthetists played a vital role in the care of combat troops in France
France
The French Republic , The French Republic , The French Republic , (commonly known as France , is a unitary semi-presidential republic in Western Europe with several overseas territories and islands located on other continents and in the Indian, Pacific, and Atlantic oceans. Metropolitan 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
Neuilly-sur-Seine
Neuilly-sur-Seine is a commune in the western suburbs of Paris, France. It is located from the center of Paris.Although Neuilly is technically a suburb of Paris, it is immediately adjacent to the city and directly extends it. The area is composed of mostly wealthy, select residential...
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
Château-Thierry
Château-Thierry is a commune in northern France about east-northeast of Paris. It is a sub-prefecture of the Aisne department in Picardy.-History:...
, France, and earned the French Croix de Guerre
Croix de guerre
The Croix de guerre is a military decoration of France. It was first created in 1915 and consists of a square-cross medal on two crossed swords, hanging from a ribbon with various degree pins. The decoration was awarded during World War I, again in World War II, and in other conflicts...
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
World War II
World War II, or the Second World War , was a global conflict lasting from 1939 to 1945, involving most of the world's nations—including all of the great powers—eventually forming two opposing military alliances: the Allies and the Axis...
and Korea
Korean War
The Korean War was a conventional war between South Korea, supported by the United Nations, and North Korea, supported by the People's Republic of China , with military material aid from the Soviet Union...
, receiving numerous citations and awards. Second Lieutenant
Second Lieutenant
Second lieutenant is a junior commissioned officer military rank in many armed forces.- United Kingdom and Commonwealth :The rank second lieutenant was introduced throughout the British Army in 1871 to replace the rank of ensign , although it had long been used in the Royal Artillery, Royal...
Mildred Irene Clark provided anesthesia for casualties from the Japanese attack on Pearl Harbor
Attack on Pearl Harbor
The attack on Pearl Harbor was a surprise military strike conducted by the Imperial Japanese Navy against the United States naval base at Pearl Harbor, Hawaii, on the morning of December 7, 1941...
. During the Vietnam War
Vietnam War
The Vietnam War was a Cold War-era military conflict that occurred in Vietnam, Laos, and Cambodia from 1 November 1955 to the fall of Saigon on 30 April 1975. This war followed the First Indochina War and was fought between North Vietnam, supported by its communist allies, and the government of...
, nurse anesthetists served as both CRNAs and flight nurse
Flight nurse
A Flight Nurse is traditionally a specialty where highly trained Registered Nurses provide comprehensive prehospital and emergency and critical care to all types of patients during aeromedical evacuation or rescue operations aboard helicopter and propeller aircraft or jet aircraft.Flight Nurses are...
s, 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 in route to Qui Nhon, Vietnam.
At least one nurse anesthetist was a prisoner of war
Prisoner of war
A prisoner of war or enemy prisoner of war is a person, whether civilian or combatant, who is held in custody by an enemy power during or immediately after an armed conflict...
. Army
United States Army
The United States Army is the main branch of the United States Armed Forces responsible for land-based military operations. It is the largest and oldest established branch of the U.S. military, and is one of seven U.S. uniformed services...
Nurse anesthetist Annie Mealer endured a three-year imprisonment by the Japanese in the Philippines
Philippines
The Philippines , officially known as the Republic of the Philippines , is a country in Southeast Asia in the western Pacific Ocean. To its north across the Luzon Strait lies Taiwan. West across the South China Sea sits Vietnam...
, 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.