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Nurse Anesthesia:

A Historical Timeline

By: Tyler Vizier

1861

The Beginning

In the height of the Civil War, chloroform anesthesia was discovered to treat wounded soldiers. Since few professional nurses were in circulation at the time, the easily administered anesthetic was found to be able to be appropriately provided by anyone willing to hold the soaked rag to a soldiers nose/mouth.

The Aide of Nurses

The Aide of Nurses

During the war, in attempt to provide more direct patient care, Catholic Sisters were awarded more freedom to interact and assist in procedures. In surgery, the sisters were to hold chloroform soaked rags over patients nose/mouth to induce anesthesia, a role normally delegated to medical students.

Following the war, acceptance of this new aid to surgeons began an upswing when doctors realized the benefit of the nurse compared to the medical student, who was the acting reponsible party for anesthesia.

While the medical student's focus was to watch and learn about the surgery itself, the nurse's concern during the procedure was the patient.

1889

Dr. W. W. Mayo was one of the first medical doctors to formally recognize and train a nurse anesthetist (NA) with the help of "The Mother of Anesthesia", Alice Magaw.

By 1900, Magaw published her records and results of 1,092 anesthesia cases in the St. Paul's Medical Journal, where she described, in detail, the absence of mishaps when the nurse anesthetist provided anesthesia.

1911-1912

As with most new medical advances, by 1911 oppostition arose and the New York State Medical Society attempted to argue that the administration of an anesthetic by a nurse violated the state law, but was unsucessful.

In 1912, as a resolution to the New York controversy, the Ohio State Medical Board passed law which allowed only physicians to administer anesthesia.

Advancement among Controversy

Advancement among Controversy

Despite all odds being against nurses providing anesthesia, in 1915 Agatha Hodgins establised the first Certified Registered Nurse Anesthetist (CRNA) program. Lakeside Hospital School of Anesthesia's doors opened in Cleveland, Ohio despite the newly passed state board law.

1917

As anticipated, the first legalities and court case regarding nurse administered anesthesia was introduced. With opposition to nurse anesthetist practice evolving in Ohio, the South was also in favor of ruling out the practice as whole. Frank v. South in Kentucky, fortunately, ruled in favor of nurse Margaret Hatfield, establishing that anesthesia administered under provision of a doctor did not constiute practicing medicine outside of the nursing scope.

This court ruling declared nurse anesthesia legal, but "subordinate" to the medical profession.

Opposition at Home; Need in the Field

Opposition at Home; Need in the Field

While NA's were fighting to practice on home ground, World War I broke and the United States entered combat. With soldier's wounds becoming more severe in battle, the need for NA's and higher skill levels were increasing.

During the increase in need for anesthesia professionals at war, learning environments in the States began to evolve as well. Research increased and the Lakeside program developed new anesthesia methods, including administration of nitrous oxide and oxygen and administration of morphine and scopolamine together.

After War Ramifications

In 1922, as quickly as employment opportunities for NA's increased at the start of the war, at the end, the opportunities decreased at the same rate. Medicine became increasingly complex and the need for medical specialties grew creating controversy among practicing doctors and nurse anesthetists.

1931

After an attempt to affiliate with the American Nursing Association (ANA) was denied by vote, Agatha Hodgins established the American Association of Nurse Anesthetists (AANA).

Denial of affiliation with the ANA was directly related to the lingering fear that the nurse anesthestist could face legal challenges due to "practicing medicine without a medical license." The potential legalities were not a responsibility the ANA was willing to take on resulting in the establishment of a separate association (Thatcher, 1953).

1934

For a second time, the court challenged the practice of nurse anesthetists. L.A. County Medical Association presented a case against NA Dagmer Nelson insisting that nurse anesthesia was, again, practicing medcine without a license.

The court ruled that Nelson was, in fact, practicing within their scope and that administration of anesthesia under proper supervision of a licensed medical doctor was appropriate.

1936

Despite Nelson winning against L.A. County, Dr. William Chalmers-Frances felt it necessary to respond to Nelson's victory in the courtroom with another case.

Again, the courts ruled that Nelson was acting within the nursing scope of practice, chalking up another win for the nurse anesthetist.

1936

1938

Unhappy with the results of his presented case, Dr. Chalmers-Frances appealed the ruling to the California Supreme Court in hopes of overturning the descision in favor of Nelson.

And again, the courts deemed that Nelson appropriatly practiced nursing anesthesia.

1938

1939

Although medical doctors continued to fight the role of the nurse anethetist, it was not until 1939 that the medical profession itself had a designated written examination for anesthesia as a specialized medicine practice.

While the doctors did not agree with the nurse anesthetist as a whole, this specialization solidified the need for trained professionals in anesthesia.

World War II

(1941-1944)

As with the first World War, at the start of the second, the need for nurse anethestists grew at an alarming rate. With battles raging in Europe, the need for the specialty allowed young nurses in the foreign country to study the skills needed to administer anesthesia. WWII also precipitated advancements such as the use of sodium pentathal, endotracheal intubations, and regional blocks for wounded soldiers.

1945

Of the times, the biggest step in advancement for nurse anesthesia as a profession was the institution of mandatory certifications dictated by the AANA. This regulation ensured that practicing nurses were up to date and safe to administer and provide anesthesia.

1945

The Korean War (1950)

Keeping with the war trend, the Korean War, again, called for an increased need for nurse anethetists. Bringing the same increase in learning and job opportunities in the field, it was time, on the home front, to evolve the standards of education to provide establishment for the nurse anethetist.

Vietnam War

(1955-1975)

With similarity to the previous wars being an increase in need for NA's, a key difference during the Vietnam War was the now purposeful use of the nurse anethetist on the front line. While the NA previously worked in hospitals in the general war area, it was not until the Vietnam War that the NA acted as a part of a "med-vac" team to provide direct patient care and anesthesia prior to a soldier's hospital arrival.

1961

Finally, the United States acknowledged the need for proper and official education for the nurse anesthetist. The U.S. Army established a nurse anesthesia program at Walter Reed General Hospital and graduated the first all male class.

This was a substantial change from the usual female nurse role and the shift was largely due to war needs.

1972

With anesthesia evolving, support was necessary from the AANA and the newly formed American Society of Anesthesiology (ASA). In 1972, the associations released a joint statment promoting the anesthesia team versus the singular use of an anesthesiologist.

1976

Feelings of the ASA quickly changed and a vote of directors recanted the associations prior statment with the AANA and fully supported and endorsed physician control over the nurse anesthetist's practice.

1977

With another fight against doctors in front of them, the AANA initiated and led a detailed effort to ensure that medicare reimbursed facilities allowing the NA to bill for their specific services. The undertaking of establishing the Certified Registered Nurst Anethetist (CRNA) as a autonomous practice was continued and thriving.

1985-1986

Still the opposition from physicians led to further court cases challenging the practice of nurse anesthesia.

In 1985 and 1986, court cases Bhan v. NME Hospitals, Inc. and Oltz v. St. Peter's Community Hospital prohibited contracts to be signed between hospitals and anesthesiologists limiting CRNA practice privileges. This set the precident that CRNAs could be awarded damages if said contracts were made.

1990s

By 1990, there were 17 master's programs in nurse anesthesia and by 1998, it was required that all accredited CRNA programs provide a master's level education. Soon after in 1999, the number of accredited programs significantly grew from 17 to 82 causing the nurse anethetist to have a true presence in medicine.

2000s

As medicine evolved, so did education to train professionals to practice. In 2007, the AANA announced that by 2025 the master's trained CRNA would be of the past. It's support was fully focused on the Doctor of Nurse Anethesia Practice (DNAP). Pushing nurse anesthesia further into an autonomous role from the physician.

2018

The Now

On top of education evolving towards the DNAP, the American Association of Colleges of Nursing is fervently pushing towards the Doctor of Nursing Practice (DNP) degree integration. Programs are continually striving to design their curricula to meet both the needs of the CRNA and that of the DNP.

The Future of the CRNA

Problems facing the future of the the profession are similar to those faced by founding members. Combating lobbying by the ASA to limit nurse anesthesia practice rights has been and will always be an obstacle. The push for every CRNA to be involved with the AANA is crucial to the promotion of autonomous nurse anesthesia practice, which will propel the profession as a whole to the forefront of advanced practice nursing.

References

Foster, S. D., & Faut-Callahan, M. (2011). A

professional study and resource guide for the CRNA (2nd ed.). Park Ridge, IL: American Associaton of Nurse Anesthetists.

Hameric, A. B., Hanson, C. M., Tracy, M. F., &

OGrady, E. T. (2014). Advanced practice nursing: An integrative approach (5th ed.). St. Louis: Elsevier.

References

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