Certified Registered Nurse Anesthetists

Nurse anesthesia practice traces its origins to the inception of surgical anesthesia, a major innovation that allowed for the development of surgery as a means of treatment for disease. Anesthesia in the late 1800s was hazardous and crude. There was not a good understanding of the pharmacologic and physiologic effects of anesthetic drugs, primarily diethyl ether and chloroform. These anesthetics were often delivered in a "careless manner" by a surgical resident fresh out of medical school who had little or no training in the effects of the anesthetic (Bankert, 1989, p. 22). This led to disastrous results for patients. Thus, some surgeons turned to religious Hospital Sisters who would devote their entire attention to the well-being of the patient during the delivery of the anesthetic. One of the Hospital Sisters, Sister Mary Bernard, was the first identified nurse that delivered anesthesia at St. Vincent's Hospital in Erie Pennsylvania in 1877 (Bankert, 1989).

The practice of utilizing nurses to deliver anesthesia spread rapidly through the Catholic and secular hospitals of the late 1800s and early 1900s. In 1912, a formal program of training in the delivery of anesthesia for nurses was developed in Springfield, Illinois, by Mother Magdalene Wiedlocher of the Third Order of the Hospital Sisters of St. Frances. This order of Hospital Sisters went on to establish St. Mary's Hospital in Rochester, Minnesota, that we now know as the origin of the Mayo Hospitals. These nurse anesthetists at St. Mary's Hospital became known as experts in the delivery of anesthesia who devoted their full attention and skill to the well-being of the patient receiving anesthesia. One nurse anesthetist in particular, Alice Magaw, stood out as an example of the diligent care delivered by nurse anesthetists. In addition to skillfully delivering anesthetics, Magaw recorded her work and published it in respected medical journals of the time. One such paper published in 1906 documented 14,000 anesthetics at St. Mary's Hospital "without a death directly attributable to anesthesia" (Bankert, 1989, p. 31). Magaw's legacy is honored in the motto of the American Association of Nurse Anesthetists (AANA): Safe and effective anesthesia care (AANA, n.d.-b).

Certified Registered Nurse Anesthetists (CRNAs) are registered nurses who have become anesthesia specialists by taking a graduate curriculum which focuses on the development of clinical judgment and critical thinking. They are qualified to make independent judgments concerning all aspects of anesthesia care based on their education, licensure, and certification. CRNAs are legally responsible for the anesthesia care they provide and are recognized in state law in all 50 states, the District of Columbia, Puerto Rico, and the Virgin Islands. (AANA, 2010)

Anesthesia care is delivered in collaboration with surgeons, podiatrists, dentists, radiologists, psychiatrists, cardiologists, and anesthesiologists in outpatient, inpatient, and office-based settings.

The CRNA scope of practice includes comprehensive anesthesia and pain care across the lifespan in many different settings. The scope includes:

1. Performing and documenting a preanesthetic assessment and evaluation of the patient, including requesting consultations and diagnostic studies; selecting, obtaining, ordering, and administering preanesthetic medications and fluids; and obtaining informed consent for anesthesia.

2. Developing and implementing an anesthetic plan.

3. Initiating the anesthetic technique which may include: general, regional, local, and sedation.

4. Selecting, applying, and inserting appropriate noninvasive and invasive monitoring modalities for continuous evaluation of the patient's physical status.

5. Selecting, obtaining, and administering the anesthetics, adjuvant and accessory drugs, and fluids necessary to manage the anesthetic.

6. Managing a patient's airway and pulmonary status using current practice modalities.

7. Facilitating emergence and recovery from anesthesia by selecting, obtaining, ordering, and administering medications, fluids, and ventilatory support.

8. Discharging the patient from a postanesthesia care area and providing postanesthesia follow-up evaluation and care.

9. Implementing acute and chronic pain management modalities.

10. Responding to emergency situations by providing airway management, administration of emergency fluids and drugs, and using basic or advanced cardiac life support techniques. (AANA, 2010b)

The CRNA may also have other responsibilities that could include administration and management activities, education, research, quality improvement, interdepartmental liaison, committee appointments, and oversight of other non-anesthesia departments.

Nurse anesthesia educational programs are offered at both the master's level and the clinical doctoral level. The Council on Accreditation of Nurse Anesthesia Educational Programs (COA) is the entity that accredits all nurse anesthesia educational programs regardless of the degree offered. This formal process of accreditation began in 1952 (Bankert, 1989). At this time, nurse anesthesia programs at the master's degree level are a minimum of 24 months in length and at the doctoral level, a minimum of 36 months. All nurse anesthesia educational programs must provide a minimum number of cases and a minimum curriculum that includes pharmacology of anesthetic agents and adjuvant drugs including concepts in chemistry and biochemistry (105 hours); anatomy, physiology, and pathophysiology (135 hours); professional aspects of nurse anesthesia practice (45 hours); basic and advanced principles of anesthesia practice including physics, equipment, technology and pain management (105 hours); research (30 hours); and clinical correlation conferences (45 hours); radiology; and ultrasound. In addition, the curriculum must include three (3) separate comprehensive graduate level courses in advanced physiology/ pathophysiology, advanced health assessment, and advanced pharmacology. Students must administer a minimum of 550 clinical cases that prepare them for the full scope of practice in a variety of clinical settings (COA, 2014). Completion of the nurse anesthesia educational program and the required cases qualifies the student to sit for the national certification examination (NCE).

Following publication of the America Association of Colleges of Nursing's initiative to move education of advanced practice nursing into doctoral frameworks by 2015, the AANA established a task force on doctoral education for nurse anesthetists in 2005. The task force recommended to the Board of Directors of the AANA that all nurse anesthesia educational programs be offered in a clinical doctoral framework by the year 2025 (AANA, 2007). The COA will not consider any new master's degree programs for accreditation beyond 2015. Students accepted into an accredited program on January 1, 2022, and thereafter must graduate with doctoral degrees (COA, 2014). Unlike other nursing advanced practice specialties, nurse anesthesia programs are not necessarily housed in schools of nursing. Of the 113 programs of nurse anesthesia accredited in the United States, 47 (42%) are in a variety of non-nursing academic units (COA Annual Report, 2013). These programs may offer the Doctorate of Nurse Anesthesia Practice (DNAP) degree. Wherever the educational program is housed, all nurse anesthesia educational programs must be accredited through the COA and the graduates must pass the national certification examination. Thus the public is assured that every nurse anesthetist has met a set of predetermined qualifications for entry into practice.

In 1986, the passage of the Omnibus Budget Reconciliation Act marked nurse anesthetists as the first group of advanced practice nursing professionals to be granted direct reimbursement for anesthesia and pain management services to Medicare enrollees. This paved the way for entrepreneurship and innovative practice settings for nurse anesthetists. In the 2013 AANA Practice Survey, 23.4% of respondents identified themselves as "independent contractors" (AANA, 2013). Furthermore, in 2001 the Center for Medicare and Medicaid Services (CMS) published its anesthesia care rule granting state governors the ability to opt out of the federal physician supervision requirement, thus allowing nurse anesthetists to work in collaboration with other healthcare providers without physician supervision (AANA, 2001). To date, 17 states have opted out of the CMS requirement for physician supervision of nurse anesthetists. In a recent study in the journal Health Affairs compared outcomes in states with physician supervision and those opt-out states. No harm was found when CRNAs delivered anesthesia without physician supervision (Dulisse & Cromwell, 2010).

Nurse anesthesia practice is remarkably varied and flexible. Nurse anesthetists function in fast paced trauma team settings in urban areas and in highly independent rural settings. Nurse anesthetists provide critically needed surgical and obstetric anesthesia, acute pain management, trauma stabilization, and, in some instances, chronic pain management for the rural communities they live in. Without the services of nurse anesthetists, many of these small rural hospitals would close (Siebert, Alexander, & Lupien, 2003). Nurse anesthetists have served in the military in peace and on the battlefield in every armed conflict since the World War I, including the most recent conflicts in Iraq and Afghanistan (AANA, 2010a). Nurse anesthetists are a crucial part of the modern health care system today both in terms of quality of care and access to highly skilled affordable care. The education and training of nurse anesthetists position these advanced practice nurses to lead healthcare into the future.

INTERNATIONAL

Although the content in this chapter has focused on APNs in the United States, it is encouraging to see the continuing development of these roles in other countries. Midwifery, a profession often distinct from nursing, has a longer history internationally than in the United States. The International Confederation of Midwives, so named in 1954, has more than 116 midwifery organization members representing 102 countries (see internationalmidwives.org). The recent Lancet Series on Midwifery (2014) highlighted midwifery as " a vital solution to the challenges of providing high-quality maternal and newborn care for all women and newborn infants, in all countries" (Renfrew, 2014). Clinical specialization in nursing has existed in many countries for a very long time. For example, in the United Kingdom the NP role developed dramatically during the 1990s once the National Health Services recognized its legitimacy (Reverly, Walsh, & Crumbie, 2001). However, in other countries APNs are only beginning to develop programs and practices (Wang, Yen, & Snyder, 1995).

CONCLUSION

APRNs have made significant contributions to quality health care, particularly for vulnerable populations. If all Americans are to receive quality, cost-effective health care, it is critical that greater use be made of APRNs. Their advanced knowledge and skills, both in nursing and related fields make valuable contributions to the current and future health care system, especially in the task of meaningful health care reform. As the United States becomes more diverse, APRNs play key roles in providing culturally competent care. They assume leadership in developing new practice sites and innovative systems of care to enhance health care outcomes. A bright future awaits nursing and APRNs.

Acknowledgment

The author acknowledges the contributions of Mary Zwygart-Stauffacher, who contributed to this chapter in a previous edition.