Anesthesiologists are charged with monitoring the vital life functions, such as heart rate, blood pressure, temperature, and breathing as well as pain control for surgery patients. Additionally, they assist patience with pain relief after surgery, during child birth, or in response to illness that present chronic pain. Nurse anesthetists, the longest standing nurse specialty group in the United States, have delivered anesthesia care for nearly 150 years. The development of nurse anesthesiology was a major factor in the advancement of the field of surgery in the United States. In the late 1800's the high rate of morbidity due to poor anesthetic practices increased the demand for clinicians who specialized in anesthesiology. Prior to the formal development of this field, little training was given to the person administering the anesthesia, who was more or less an extra pair of hands for the physician whose attention was thus divided between the care of the patient and the surgery at hand (Postotnik, 1984). This paper shall offer a brief history and development of nurse anesthesiology, including an introduction of the field's pioneers as well as modern day outlooks and challenges.
Many extraordinary women were instrumental in advancing the field of nurse anesthetist. Some advanced the profession through field work and others through academic and professional settings. For example, historical records name Catherine S. Lawrence, along with many unnamed nurses, administered anesthesia to wounded soldiers in the field during the American Civil War in the 1860's (AANA, 2007). In contrast, the earliest named specialized nurse anesthetist on record is Sister Mary Bernard, a Catholic nun who worked at St. Vincent's Hospital in Eerie Pennsylvania in1887. Additionally, records indicate that more than 50 other Catholic sisters administered anesthesia in various mid-western U.S. hospitals in the late 19th century. (Bankert, 1989)
Following these early forerunners in this field, came Alice Magraw, working at St. Mary's Hospital in Rochester Minnesota and later in the Mayo Clinic with brothers Dr. Charles Mayo and Dr. James Mayo. History deems her the "mother of anesthesia" for her advanced knowledge and proficiency in the field, noting most significantly her ability in the use of open drop technique for inhalation anesthesia. This method involves administering drops of a liquid anesthetic to a gauze mask or cone, worn over the mouth and nose of the patient, so that the patient inhales the anesthetic at a rate sufficient to keep them sedated. Not only was Magraw an accomplished nurse but she made significant contributions to her field through publication including the documentation of 14,000 anesthetics procedures achieved without complication (Magraw, 1906).
Following these early, and somewhat primitive, days of anesthesiology, many significant advances in improvement have occurred including two most notable: the founding of the first official education training programs in anesthesia in 1909 by Agnes McGee, and the creation of the American Association of Nurse Anesthetists, AANA, in 1931 by Agatha Hodgins.
The first formal school for nurse anesthesia was established in 1at St. Vincent Hospital, Portland, Oregon in 1909 by Agnes McGee. The school consisted of a six-month course incorporating pharmacology, anatomy and physiology, and the administration of common anesthetic agents (Thatcher, 1953). Graduates of the program received a diploma. Within 10 years of this pioneer program, 20 post-graduate schools for training in anesthesia opened. Training began is various hospitals throughout America, including the prestigious hospitals known today such as The Mayo Clinic and Johns Hopkins Hospital. Furthermore, nurse anesthetist Alice Hunt, who was a teacher of anesthesia at the Yale University School of Medicine in 1922, authored the probably first textbook of anesthesia in 1949 entitled, "Anesthesia, Principles and Practice."
Agatha Hodgins began her work as an anesthetist for Dr. George W. Criles in 1908. With his direction and guidance, she mastered the method of administering nitrous oxide anesthesia, a preferred method of Dr. Crile due to the ill effect of surgical shock attributed to ether or chloroform. Within the first two years chief nurse anesthetist Agatha Hodgins successfully administered anesthesia to over 575 patients (Bankert, 1989). Her skill in this field led her to train other nurses and formalize Ohio's Lakeside Hospital School of Anesthesia in 1915, at which she remained director until 1933. This program was made available to various levels of medical professionals. 19 Graduates completed the program the first year, including six physicians, two dentists, and 11 nurses (Thatcher, 1953). Nurse anesthetists faced harsh criticism from those who believed that anesthesia ought to be administered by physicians alone. The debate temporarily limited the nurses' ability to practice in their field of expertise, but soon the ban was lifted and the advances in this area proceeded.
The life-long pioneering efforts of Nurse Hodgins are accredited with the universal compliance standards in education and professional norms that the world of anesthesiology enjoys today.It was in 1926, at the Alumnae Association of The Lakeside Hospital School of Anesthesia, that Hodgins first presented the proposal of establishing a national organization for nurse anesthetists. It took seven more years of meetings and discussion for Agatha to fulfill her vision of a national organization. The National Association of Nurse Anesthetists (NANA) was formally incorporated in Ohio on March 12, 1932 and renamed the American Association of Nurse Anesthetists (AANA) in 1939. This organization remains in full operation today.
In recent U.S. history, nurse anesthetists had a wide variety of options for certification including a certificate or diploma of completion, or bachelor's degree. Beginning in 1976, however, higher standards were being formed by the Council on Accreditation toward degree programs. By 1981 the Council established formidable guidelines for master's degrees in anesthetics and in 1982 the AANA followed with a formal adoption of an academic standard for anesthetists. The standard remains that registered nurses receive the foundational degree of a Bachelor's in Nursing followed by a Master's degree in anesthesia. By that time, however, advanced degrees were already taking hold as academic programs began to offer more options. The Kaiser Permanente at California State University, for example, was offering a master's program in 1978.
As technology and medical knowledge advances the need for greater expertise in the field of anesthesiology also advances. As a result professional organizations have begun to require even greater academic requirements. For example, the American Association of Colleges of Nursing is currently proposing that nurse anesthetists hold a Doctor of Nurse Anesthesia Practice (DNAP) or a Doctor of Nursing Practice (DNP) to enter the field in the United States. In 2007 the AANA concurred with this proposal, suggesting its complete implementation by the year 2025. DNAPs and DNP are involved in practice, research, teaching, and administration. In 2010 there were over 200 nursing schools nationwide that offer or plan to offer a doctorate in nursing with a current enrollment of nearly 2000 students. This figure has more than doubled since 2006.
Program directors assert that these programs offer nurses medical skills and expertise that are equivalent to primary care physicians. With a DNP or DNAP these nurses have the authority to write prescriptions and apply for hospital privileges. With specialty medicine on the rise, primary care doctors are in short supply and the new "Dr. Nurse" is proposed as a viable alternative. As the educational requirements, demand, and salary increases for nurse anesthesiologists so do the demographics. Over 40% of nurse anesthetists are men; whereas, in general nursing population 90% are women.
The outlook for the profession in the United States is positive. Not only does this field of expertise offer one of the highest paying average salaries among nurses, but there are currently over 30,000 practicing Certified Registered Nurse Anesthetists (CRNA) practicing in 50 states and the demand is on the rise. Colleges and Universities continue to improve and add training programs to meet the rising demands. The changing landscape of healthcare in general presents some key issues that impact the specialty area of nurse anesthesiology. Acceleration in the cost of healthcare, exemplified in the increase of managed healthcare services, and a growth in specialization are but two current events that will greatly impact the future of anesthesiology.
Managed healthcare system, such as a Health Maintenance Organizations (HMO) or a Preferred Provider Organizations (PPO), control the way healthcare services are financed and delivered to enrolled members. Management services have the difficult task of balancing high-quality healthcare with rising costs. This reality has an impact on nurse anesthesiologists. Healthcare providers are challenged to do more with less. CRNAs, as opposed to physician anesthesiologists, provide a lower cost, high quality patient care alternative. The trend to lower healthcare costs serves to keeps the demand for CRNAs high.
The demand for and the presence of highly trained nurses in the operating room has raised the question of autonomy of the Nurse Anesthetists in the operating room. Federal law maintains that nurses must be supervised by a physician but allows states to opt out of the supervision rule. California was one of sixteen states to opted-out of this rule. This option seemed to contradict a prior state law that stated CRNAs…