Certified Registered Nurse Anesthetist

Certified Registered Nurse Anesthetist (CRNA) is a qualification in the United States for nurse anesthetists with a Doctorate or Master's degree.[1] CRNAs account for approximately half of the anesthesia providers in the United States and are the main providers of anesthesia in rural America, administering approximately 43 million anesthetics to patients each year.[2] Historically, nurse anesthetists have been providing anesthesia care to patients since the American Civil War more than 150 years ago. The CRNA credential came into existence in 1956 and approximately 40% of nurse anesthetists are male.[3]

"CRNA" redirects here. For other uses, see CRNA (disambiguation).
CRNA
A nurse anesthetist administers a local anesthetic.
Occupation
Activity sectors
Anesthesia, Nursing
Description
Education required
Fields of
employment

Scope of practice safeguards and practitioner oversight requirements vary between healthcare facility and state, with 20 states and Guam granting complete autonomy as of 2016. In states that have opted out of supervision, the Joint Commission and CMS recognize CRNAs as licensed independent practitioners.[4] In states requiring supervision, CRNAs have liability separate from any supervising practitioner and are able to administer anesthesia independently of anesthesiologists.[5][6][7]

In the United States

History

Among the first American nurses to provide anesthetics was Catherine S. Lawrence during the American Civil War (1861–1865).[8] The first "official" nurse anesthetist was Sister Mary Bernard, a Catholic nun who practiced in 1877 at St. Vincent's Hospital in Erie, Pennsylvania.[9] There is evidence that up to 50 or more other Catholic sisters were called to practice anesthesia in various midwest Catholic and Protestant hospitals throughout the last two decades of the 19th century.[10][11] The first school of nurse anesthesia was formed in 1909 at St. Vincent Hospital, Portland, Oregon. Established by Agnes McGee, the course was seven months long, and included courses on anatomy and physiology, pharmacology, and administration of the few common anesthetic agents available at the time.[12] Within the next decade, approximately 19 schools opened. All consisted of post-graduate anesthesia training for nurses and were about six months in length. These included programs at Mayo Clinic, Johns Hopkins Hospital, Barnes Hospital, New York Post-Graduate Hospital, Charity Hospital in New Orleans, Grace Hospital in Detroit, among others.[13] During those early days of administering anesthetics, knowledge and available anesthetic options were extremely limited and programs provided what little education they could for all levels of health providers. For example, in 1915, chief nurse anesthetist Agatha Hodgins established the Lakeside Hospital School of Anesthesia in Cleveland, Ohio. This program was open to nurses, physicians, and dentists. The training was only six months and the tuition was $50. In its first year, it graduated six physicians, eleven nurses, and two dentists.[14]

Several notable nurse anesthetist from the early 20th century are revered by their modern counterparts. Agnes McGee taught at the Oregon Health Science Center.[12] Alice Hunt was appointed instructor in anesthesia with university rank at the Yale University School of Medicine beginning in 1922 and continuing for 26 years.[15] She authored the 1949 book Anesthesia, Principles and Practice, likely the first nurse anesthesia textbook.

Beginning in 1899, nurse anesthetist Alice Magaw (1860–1928) authored several papers, her most notable, published in 1906, reported on the use of ether anesthesia by drop method 14,000 times without a fatality (Surg., Gynec. & Obst. 3:795, 1906). [16] Ms. Magaw was the anesthetist at St. Mary's Hospital in Rochester for the famous brothers, Dr. William James Mayo and Dr. Charles Horace Mayo.[17] which became the Mayo Clinic in Rochester, Minnesota. Ms. Magaw set up a showcase for surgery and anesthesia that has attracted many students and visitors.[18]

The didactic curricula of nurse-anesthesia programs is governed by the COA standards. Accredited programs provide supervised experiences for students with patients of all ages who require medical, surgical, obstetrical, dental, and pediatric interventions.[19] Programs require study in methods of scientific inquiry and statistics, as well as active participation in a student-generated and faculty-sponsored research project. Among the oldest schools in the U.S., Ravenswood Hospital in Chicago, opened in 1925 by Mae Cameron, which in 2001 became the NorthShore University HealthSystem School of Nurse Anesthesia, was the first school to be accredited by the Council on Accreditation of Nurse Anesthesia Educational Programs in 1952.[20][21]

History of education

CRNAs in the United States receive Master's or Doctoral degrees in nurse anesthesia. The nursing Council on Accreditation develops requirements for degree programs. In 1981, the Council on Accreditation developed guidelines for master's degrees. In 1982, it was the official position of the AANA board of directors that registered nurses applying for a school of anesthesia shall be, at minimum, baccalaureate prepared and then complete a master's level anesthesia program.[22] As early as 1978, the Kaiser Permanente California State University program had evolved to a master's level program. All programs were required to transition to a master's degree beginning in 1990 and complete the process by 1998.[23] Currently, the American Association of Colleges of Nursing has endorsed a position statement that will move the current entry level of training and education of nurse anesthetists in the United States to the Doctor of Nursing Practice (DNP) or Doctor of Nurse Anesthesia Practice (DNAP).[24] This move will affect all advance practice nurses, with a mandatory implementation by the year 2015.[25] In August 2007, the AANA announced its support of this advanced clinical degree as an entry level for practice of all nurse anesthetists with a target compliance date of 2025. In accordance with traditional grandfathering rules, all those in current practice will not be affected and neither will the training provided to those now receiving the DNP or DNAP designation.[24] Currently, more than 50% of the 120 nurse anesthesia programs have already transitioned to the DNP or DNAP entry level format.[26]

Certification

Board certification and recertification process is governed by the National Board on Certification and Recertification of Nurse Anesthetists (NBCRNA). The NBCRNA exists as an autonomous not-for-profit incorporated organization. CRNAs also have continuing education requirements and recertification check-ins every two years thereafter, plus any additional requirements of the state in which they practice. The new recertification pathway focuses on: maintenance of certification, lifelong learning, and continued competence. The Continued Professional Certification (CPC) Program consists of 8-year periods, and each period comprises two four-year cycles.[27]

Under US law, Frank v. South,[28] Chalmers-Francis v. Nelson[29] and other court decisions established that anesthesia was the practice of nursing as well as medicine.[30] As such, the practice of anesthesia in the US may be delivered by either a nurse anesthetist or physician anesthesiologist. The decisions have not been challenged since the Dagmar Nelson case.[31] In addition to legal decisions, individual hospital and surgical facility policies also regulate the granting of anesthesia clinical privileges and are often based on contractual agreements with provider groups.

All challenges to the CRNA scope of practice 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. 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

The degree of independence or supervision by a licensed provider (physician, dentist, or podiatrist) varies with state law.[32] Some states use the term collaboration to define a relationship where the supervising physician and the CRNA work together to provide the anesthetic. Other states require the consent or order of a physician or other qualified licensed provider to administer the anesthetic.[33]

The licensed CRNA is legally authorized to deliver care under the particular Nurse Practice Act of each state. Scope of CRNA practice is commonly further defined by the practice location's clinical privilege 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.[34]

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.[35] To date, 17 states have opted out of the federal requirement, instituting their own individual requirements instead.[36]

Armed forces

Nurse anesthetists serve in the United States armed forces. In some military treatment facilities, nurse anesthetists function as the only licensed independent anesthesia practitioners, including U.S. Navy ships at sea. They also provide anesthesia for the Veterans Administration and Public Health Service medical facilities.

During World War I, America's nurse anesthetists cared for 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.[37][38] In addition, they helped train the French and British nurses and physicians in anesthesia care. 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.[39]

Among notable nurse anesthetists are Sophie Gran Winton. She served with the Red Cross at an army hospital in Château-Thierry, France, and earned the French Croix de Guerre in addition to other service awards.[40] In addition, Anne Penland was the first nurse anesthetist to serve on the British Front and was decorated by the British government.[41]

American nurse anesthetists also served in World War II and Korea.[42] Second Lieutenant Mildred Irene Clark provided anesthesia for casualties from the Japanese attack on Pearl Harbor.[43] During the Vietnam War, nurse anesthetists served as both CRNAs and flight nurses, and also developed new field equipment.[44] Nurse anesthetists have been casualties of war. Lieutenants Kenneth R. Shoemaker, Jr. and Jerome E. Olmsted, were killed in an air evac mission en route to Qui Nhon, Vietnam.[45]

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.[46] During the Iraq War, nurse anesthetists provide care at forward positioned medical treatment facilities.[47] 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.

References
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  2. Daughettry, Lindsay (2010). "Is There a Shortage of Anesthesia Providers in the United States?". Rand Health. Retrieved September 30, 2018.
  3. "CRNA Fact Sheet". www.aana.com.
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