Role analysis of certified nurse anesthetists in modern healthcare

Role Analysis of Certified Nurse Anesthetists

If one considers the historical development of nursing and particularly advanced nursing practices, it becomes evident that until fairly recently nursing was considered more as an adjunct to the medical profession and an extension of the healthcare environment than an independent profession. However the concept and reality of the nursing profession has undergone radical change in the last century. In the first instance nursing has become more holistic in nature and has also entered into more technologically orientated areas of medical expertise that were previously reserved for specialists. In brief, from being seen as an aid or assistant the modern nurse has developed into a fully-fledged professional with extensive and far-reaching responsibilities and functions.

These facts, which will be explored in this paper with particular reference to the nurse anesthetist, emphasize that there has been a wide-ranging and dramatic change in the role and responsibly of the nurse, which extends to and influences the entire range of the medical health care environment.

Changes in the nursing profession are often the result of social and medical needs. There is also a correlation between advanced nursing practices and the development of the social welfare system. (Donahue, 1996, p. 459) Another aspect is the growth of nursing in terms of its professionalization. "Its history documents a detailed account of the growth of an occupation in its quest for professionalization... " (Donahue, 1996, p. 459) in other words, the development of advanced nursing is related both to the demands of the society and to the growth of the profession. This also applies to the certified nurse anesthetist.

The recent history of the nursing profession has been characterized by a greater degree of responsibility and increasingly important roles in the hospital and medical environment. As Donahue (1996) states, "During the past decade nursing practice has been shaped by rapidly increasing responsibility, accountability, autonomy, and authority in patient care." (Donahue, 1996, p. 459) in essence the boundaries between the nursing and other medical professions is ' collapsing'; or rather there is a new synergy within the profession which means that nurses are taking on roles that were previously reserved for other specialists. This has resulted in a relatively new era of collaboration and sharing of roles in the profession. This will even result in a further differentiation and specialization of roles.

Potentially, further differentiation of roles will occur as relationships between nurses and physicians are transformed and new patterns of governance within the nursing hierarchy are established. Collaboration will be the byword as health professionals can no longer practice independently; boundaries are collapsing. The need for highly technically skilled nurses in hospitals will continue, but they will, in all probability, be accountable for their practice to a nurse with advanced preparation who will serve as the case manager for a group of patients. (Donahue, 1996, p. 459)

These advances in the nursing profession are related to the collaborative model of specialization. This model "...builds on acquired nursing skills with advanced knowledge of medicine and the behavioral and biological sciences. Nurse practitioners, nurse anesthetists, and nurse midwives..." (Donahue, 1996, p. 459)

All of these advances are evidenced by that fact that there are an increasing number of nurses working in medical - surgical units and being involved in the care of medical - surgical patients. A National Sample Survey of Registered Nurses in 2000 found that, "More than 32% of nurses working in hospitals primarily care for medical/surgical patients...this translates to more than 230,000 full-time and part-time med/surg nurses nationwide. " (Hauser, 2003, p.26)

2. Brief history of advanced nursing and nurse anesthetists

The history of the specialization and advancement in the nursing profession has its roots in the struggle that began in the early 1900s for nursing to be accepted as a full profession. "Nursing has struggled since the early 1900's to achieve popular acceptance as a profession." (the Role of Collective Bargaining and Unions in Advancing the Profession of Nursing) Nursing as profession has also had to battle against prejudice and the often-mentioned bias of a male-dominated society. (the Role of Collective Bargaining and Unions in Advancing the Profession of Nursing)

One of the earliest examples of specialization is the nurse as midwife in the 16th century. However the real specialization and advancement in nursing begins in the 19th century with industrialization and, more importantly, the movement of people from the rural environment to the city. This was of course the beginning of the modern hospital and medial institution. These events were to result in innovations by pioneers such as Florence Nightingale. Nightingale upgraded the staff in these hospitals and increased the training of all nurses. She was also largely responsible for the creation of the unique identity for the nursing profession, which not only emphasized care and functional ability, but also high moral character. "Nightingale's reforms sought to train nurses with a focus on both character and ability. "(Engebretson, Joan)

With the increase in industrialization there was a consequent increase in the emphasis on technical aspects of medical care.

The values of industrialization, efficiency, and cost control dominated the workplace. Hospitals were also not immune to this trend as they expanded, and more sick people sought care in hospitals instead of in their homes. Increasing numbers of patients needed skilled care as medical technologies provided the means to perform more invasive and dangerous procedures.

Engebretson, Joan) greater technical knowledge of process and procedures was required in medicine and this also impacted on the nursing profession. Consequently the duties and responsibilities of nursing staff were extended and nurses became involved in the technical side of medical care. As Engebretson states "Nursing had become clearly defined as skilled work by 1920." (Engebretson, 2002, p.20) There were obvious consequences for the role of the nurse and the advance of the profession. Nurses therefore required "...increasing theoretical and scientific knowledge to provide nursing care. "(Engebretson, 2002, p.20) Nursing training shifted to academic institutions which is seen as the beginning of the movement towards a professional status and acceptance of nursing; as well as a change in the responsibilities and duties of the nurse

As burgeoning technologic and scientific discoveries increasingly dominated health care, nurses were compelled to develop continuing expertise to care for patients in hospitals. Nurses needed advanced education to make appropriate decisions, as they had been given more responsibilities and decision making powers, particularly for advanced practice roles (Engebretson, 2002, p.21)

This was to result in the involvement of nurses in dealing with complex technical instrumentation, such as dialysis machines, cardiac monitors, and fetal monitors. All of the above factors act as a preamble to the discussion of the modern nurse anesthetists. However, as will be shown, nurse anesthetists have a history which in fact predates contemporary technical advances.

History of Nurse Anesthesia Practice)

Another import at aspect of this Association is that it furthers the profession in terms of certification of CRNA credentials and these credential are today recognized and accepted by the medical community.

However, in closing this section it should also be noted that there are still instances within the medical profession of prejudice against the nurse anesthetist.

Opposition to the training and clinical practice of nurse midwives and nurse anesthetists continues to be an issue... The nurse midwifery and nurse anesthetist conflicts have resulted in underutilization and inappropriate use of these highly skilled nurse specialists. Debate and ambivalence regarding their role continues to confuse the American public. (Donahue, 1996, p. 431)

Despite this, the employment nurse anesthetists are widespread and accepted and many hospitals "...employ nurse anesthetists in addition to regular anesthesiologists..." (Postotnik, 1984) in fact, as will be referred to in the following section, there is a shortage of these professionals in many areas.

3. Situation and status of CRNAs

There are many reports which indicate that there is a shortage of CRNAs in many parts of the country. As the president of the AANA, Deborah Chambers has stated: "The shortage of nurse anesthetists is delaying surgeries and making healthcare less accessible to Americans," (America's Nurse Anesthetists Commend Bush Administration...)

Chambers has also reiterated the importance of these nursing professionals. She states that "Certified Registered Nurse Anesthetists (CRNAs) provide two-thirds of all anesthetics given in the United States each year, and are the predominant anesthesia providers to rural America and the military, said Chambers." She also notes that the certification requirements are extremely stringent.

The shortage of these nursing professional is also acutely experienced in New Mexico. There are numerous reports which describe the effects of this shortage. For example; "A lack of nurses has caused 72% of hospitals to reduce services, 38% of home care agencies to refuse referrals, and 15% of long-term care facilities to refuse admissions; and public health offices are cutting vital services." (Is There a Nurse Available? The Nursing Shortage in New Mexico)

The same report also states that many emergency room patients have been turned away at New Mexico hosptals. Furthermore,."..clinic hours have been shortened, and some intensive care units have closed... "(Is There a Nurse Available? The Nursing Shortage in New Mexico)

It is also generally reported that New Mexico has "... major problems in the supply and distribution of its health care workforce. "(Reports: The Health Care Workforce in Eight States: Education, Practice & Policy: New Mexico) the general situation is described as follows.

The ratio of National Health Service Corps personnel per 10,000 population living in HPSAs is over twice the U.S. average. New Mexico's overall ratios of physicians, nurses, dentists and pharmacists per 100,000 population each are significantly below the national average. The state has one medical school and one pharmacy school, and no dental school. There are just 15 schools of nursing in New Mexico.

Reports: The Health Care Workforce in Eight States: Education, Practice & Policy: New Mexico)

These figures also relate to the situation with regard to CRNAs. The number of active CRNAs in New Mexico was ascertained at 120 in 1997. New Mexico has 5.9 nurse anesthetists per 100,000 population, which is lower than the national rate of 9.3. (Nursing Jobs in New Mexico) This situation is exacerbated by the fact that "...nurse anesthetists are the sole anesthesia providers in more than half of New Mexico hospitals..." (47TH LEGISLATURE - STATE of NEW MEXICO - SECOND SESSION)

4. Licensure and legal requirements.

The following basic requirements are needed according to the New Mexico Board of Nursing website.

1. Current RN license.

2. Graduate of a Nurse Anesthetist education program accredited by the American Association of Nurse Anesthetists' Council on Accreditation.

CRNAs who are initially licensed by the board or a board in another jurisdiction after January 1, 2001, and must be educated in a nurse anesthetist program at a master's level or higher level.

3. Certified by the American Association of Nurse Anesthetist's Council on Certification.

REQUIREMENTS and INSTRUCTIONS for CRNA LICENSURE)

Furthermore the legal requirements include that fact that "...Certified Registered Nurse Anesthetist with lapsed AANA certification are not eligible for a permit to practice." (REQUIREMENTS and INSTRUCTIONS for CRNA LICENSURE) it is also emphasized that any failure of the applicant to write the scheduled qualifying examination or if the exam, will "render the applicant

Ineligible to practice anesthesia in NM and the employer must immediately return the permit-to-practice to the board..." (REQUIREMENTS and INSTRUCTIONS for CRNA LICENSURE)

The New Mexico statutory authority also states that;

certified registered nurse anesthetist may provide pre-operative, intra-operative and post-operative anesthesia care and related services, including ordering of diagnostic tests, in accordance with the current American association of nurse anesthetists' guidelines for nurse anesthesia practice.

And certified registered nurse anesthetist who has met the requirements for prescriptive authority in the area of anesthesia practice is authorized to prescribe and administer therapeutic measures, including dangerous drugs and controlled substances included in Schedules II through V of the Controlled Substances Act [30-31-1 NMSA 1978] within the emergency procedures, perioperative care or perinatal care environments.

Health Care Practitioner Scope of Practice Guide)

Conclusion

There is by all accounts a bright outlook for this professional specialization in the nursing profession. As one article states: "Faster-than-average growth is expected for anesthesia nurses through 2012 as the American population ages, according to the U.S. Bureau of Labor Statistics. While anesthesia nursing is certainly nothing new to surgery and patient care, it continues to be a promising, challenging career for those who heed its call." (Hyman G. 2006)

The situation in New Mexico as discussed above certainly warrants a greater number of nurse anesthetists. There is also little doubt, given the relatively long history of this specialization in nursing, that this is an area where nurses can excel and contribute to the health care environment. The changing status of nurses and their greater acceptance as professionals in hospitals and other medical institutions is also a positive sign for the advancement of nurse anesthetists.