Nurse Anesthetists: the Often-Overlooked CRNA

Most people outside the medical field – and a good deal of those within it – are not sure exactly what a nurse anesthetist does; some may have never even heard of it, or think of them as “assistants” to anesthesiologists. Nurse anesthetists have a long and storied history spanning over 150 years, and today perform an important and increasing role in patient care.

The first nurse to provide anesthesia was Catherine S. Lawrence, who administered anesthesia for Civil War surgeons circa 1861 to 1865. However, anesthesia was used infrequently, because it was considered too dangerous.The first “official” nurse recognized as a nurse anesthetist was Sister Mary Bernard, a Catholic nun who practiced in the 1870s at St. Vincent’s Hospital in Erie, Pennsylvania. The first school of nurse anesthesia formed in 1909 at St. Vincent Hospital, Portland, Oregon. The course of study was 6 months long, and included classes on anatomy and physiology, pharmacology, and administration of common anesthetic agents. Soon, many schools offering similar programs were formed. Between 1912 and 1920, approximately 19 schools opened in the United States. All consisted of post-graduate anesthesia training for nurses, and were about 6 months in length. These included programs at Mayo Clinic, Johns Hopkins Hospital, Barnes Hospital, New York Post-Graduate Hospital and Presbyterian Hospital in Chicago.

At the time, physician residences in anesthesia did not exist, so doctors attended these programs to learn anesthesia. The nurse anesthesia specialty was formally organized on June 17, 1931, when the American Association of Nurse Anesthetists (AANA) held its first meeting. The new organization had two main objectives: establish a national qualifying exam, and establish an accreditation program for nurse anesthesia schools. The first national certification exam was held on June 4, 1945, with 92 candidates sitting for the exam.

Prior to World War II, anesthesia was considered more a nursing specialty. In 1942, there were 17 nurse anesthetists for every one anesthesiologist. Even as late as 1971, 48.5% of anesthesia was given by certified registered nurse anesthetists (CRNAs), while 38.34% was provided by American Society of Anesthesiology members. The numbers of physicians in this specialty did not greatly expand until the late 1960s and 1970s, which parallels a time in surgical history when operations became much more complex.

After many years of preparation, on January 19, 1952, a program for the accreditation of nurse anesthesia schools went into effect. The credential CRNA (Certified Registered Nurse Anesthetist) came into existence in 1956. CRNAs are anesthesia professionals who safely administer approximately 30 million anesthetics to patients each year in the United States, according to the American Association of Nurse Anesthetists’ (AANA) 2007 Practice Profile Survey.

Nurse anesthetist programs are offered by 109 educational institutions in the United States today. The programs are between 24 to 36 months in length (average 28) and provided on a Masters degree level. All programs include clinical training in university-based or large community hospitals. In addition, there are Doctorate programs (Nursing Doctorate or Doctor of Nursing Practice) at several universities in the United States. All programs require you to be a registered nurse, and have a four year college degree in science or nursing (BSN), and at least one year of acute care nursing experience before entry. Acute care is usually defined as intensive care, coronary care, emergency/trauma, etc. In addition, applicants must meet the qualifications of the graduate school (GRE, GPA, required course work). Because most programs have far more qualified applicants than available spaces, successful candidates usually have several years of experience in nursing in addition to specialized education in nursing or other health disciplines. Graduate college requirements may include a minimum score on GRE exams (e.g. 1000+), and possibly a 400 or graduate level statistics course. Anesthesia school requirements usually include recent college level math, physics, chemistry and anatomy.

There is a varied scope of practice for nurse anesthetists. They can work for a hospital, outpatient surgery center (surgery, dental, podiatrist), in a group practice or they can practice independently. CRNAs will work in collaboration with surgeons, dentists or podiatrists, or on an anesthesia team with an anesthesiologist, to provide anesthesia care. Laws governing the degree of physician collaboration or supervision will vary state to state. Most often, the patient can expect to receive their anesthetic from an anesthesia care team, with the CRNA and anesthesiologist working together. CRNAs can administer anesthesia in all types of surgical cases, applying all the accepted anesthetic techniques – general, regional, local, or sedation. The exception is “pain medicine,” which is usually practiced by anesthesiologists. Others become clinical instructors, school directors, or department supervisors. Working hours vary according to practice, but in many cases, exceed 40 hours per week. Salaries exceed most nursing specialties, depending on location and experience.

CRNAs are the primary anesthesia providers in rural America, enabling healthcare facilities in these medically underserved areas to offer obstetrical, surgical and trauma stabilization services. In some states, CRNAs are the sole providers in nearly 100 percent of the rural hospitals. Nurse anesthetists have been the main providers of anesthesia care to U.S. military men and women on the front lines since WWI, including the current conflicts in Iraq and Afghanistan.

Managed care plans recognize CRNAs for providing high-quality anesthesia care with reduced expense to patients and insurance companies. Approximately 44 percent of the nation’s 39,000 nurse anesthetists and student nurse anesthetists are men, compared with less than 10 percent in the nursing profession as a whole. More than 90 percent of U.S. nurse anesthetists are members of the AANA.

As advanced practice nurses, CRNAs practice with a high degree of autonomy and professional respect. They carry a heavy load of responsibility and are compensated accordingly. There is also a stringent recertification/continuing education requirement, as CRNAs must obtain a minimum of 40 hours of approved continuing education every two years, document substantial anesthesia practice, maintain current state licensure and certify that they have not developed any conditions that could adversely affect their ability to practice anesthesia.

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“Pain medicine” is not exclusively practiced by physician Anesthesiologists. There are CRNAs who do the majority of pain management in rural America. The AANA now offers pain management fellowships and CRNAs can Bill for pain management just the same as physician anesthesiologists. in fact the ASA attempted to sue a CRNA in Colorado who had been providing pain management services to patients and had really good outcomes in an attempt to stop her practice and limit her scope. They lost the lawsuit and she had back pay from insurance companies for 2yrs worth of pay. So pain management is not exclusive to physician anesthesiologists. Also the Majority of care is provided by CRNAs in a “care team model” because a physician anesthesiologist know nothing more than being experts in the stock market and drinking coffee in the lounge. The only care team models are those in major metropolitan areas but the majority of hospitals do not practice “care team” if they do I would like to see where you found these statistics. Other than that great article