Role Analysis of Certified Nurse

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.

2.1. Nurse anesthetists

Involvement of nurses in anesthesia was in fact established in the latter part 1800s and has "... become recognized as the first clinical nursing specialty. " (History of Nurse Anesthesia Practice) the reason for the development of this nursing specialization was that the surgeons saw the experienced professional nursing staff as a solution to the severe problem of high mortality at the time. Nurse soon became professionally advanced in this area. "Serving as pioneers in anesthesia, nurse anesthetists became involved in the full range of specialty surgical procedures, as well as in the refinement of anesthesia techniques and equipment. "(History of Nurse Anesthesia Practice)

One of the earliest records of anesthetic care of patients by nurses are documents attesting to the services of Sister Mary Bernard, a Catholic nun who assumed her duties at St. Vincent's Hospital in Erie, Pennsylvania in 1887. (History of Nurse Anesthesia Practice)

The most famous nurse anesthetist of the nineteenth century was Alice Magaw, who worked at St. Mary's Hospital (1889), in Rochester, Minnesota. This hospital was later to be known as the Mayo Clinic. Magaw become well-known for her mastery of techniques and achievements in the field of anesthesiology. In fact, "Hundreds of physicians and nurses from the United States and throughout the world came to observe and learn... anesthesia techniques." (History of Nurse Anesthesia Practice) Magaw also published various papers in medical journals on anesthesiology.

The first formal programs for nurse anesthetists were started in 1909. An important historical aspect during this period was the work of Dr. George Crile and his nurse anesthetist, Agatha Hodgins. Hodgins was instrumental in teaching physicians and nurses from England and France how to administer anesthesia. She was also the founder of the American Association of Nurse Anesthetists (AANA),

The services of nurse anesthetists have been important in various combat areas of the world since the First World War. Their services have often been recognized and been commemorated. "The names of two CRNAs killed in the Vietnam War are engraved on the Vietnam Memorial Wall in Washington, DC. Military nurse anesthetists have been honored and decorated by the United States and foreign governments for outstanding achievements, dedication to duty, and competence in treating the seriously wounded. "(History of Nurse Anesthesia Practice)

Among the earlier formal programs for nurse anesthesia were those established at Johns Hopkins Hospital in Baltimore, the University Hospital of the University of Michigan in Ann Arbor, Charity Hospital in New Orleans, Barnes Hospital in St. Louis, and Presbyterian Hospital in Chicago. (History of Nurse Anesthesia Practice) Another important historical event which shows the acceptance and advancement of nurse anesthetists was the invitation of Alice Hunt, a nurse anesthetist, to join the Yale Medical School faculty as an instructor of anesthesia in 1922.

The American Association of Nurse Anesthetists was founded in 1931 and today is a professional organization which represents more than 35,000 Certified Registered Nurse Anesthetists (CRNAs) and student nurse anesthetists. (AANA Overview)

Furthermore the AANA, promulgates education, and practice standards and guidelines, and affords consultation to both private and governmental entities regarding nurse anesthetists and their practice. The AANA Foundation supports the profession through award of education and research grants to students, faculty, and practicing CRNAs."

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.