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.
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 education requirements and recertification every two years thereafter, plus any additional requirements of the state in which they practice.
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 (placing abreathing 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.
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.
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.
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.
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 $189,000 according to a Merritt Hawkins & Associates study from 2009. The AMGA Medical Group Compensation and Financial Survey reported the annual salary as $150,724.
In the United States armed forces, 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 inChâteau-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 nurses, 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.