Nurse anesthetist

A nurse anesthetist is an advanced practice nurse who administers anesthesia for surgery or other medical procedures. Nurse anesthetists (NA's) administer or participate in administration of anesthesia services in 107 countries, working with or without anesthesiologists. Because of different historical backgrounds, anesthetist responsibilities and roles vary widely between countries. Depending on the locality, their role may be limited to intraoperative care during anesthesia itself or may also extend before and after (for preanesthetic assessment and immediate postoperative management). The International Federation of Nurse Anesthetists was established in 1989 as a forum for developing standards of education, practice, and a code of ethics.

A survey of hospital-based practice conducted in 1996 reported that, worldwide, nurse anesthetists provided 85% of all anesthesia for Caesarean sections; administered drugs to induce anaesthesia (77%); performed tracheal intubation (74%); administered spinal anaesthesia (57%); administered epidural anaesthesia (44%); managed anaesthetised patients intraoperatively (79%); performed tracheal extubation (77%); and managed patients in the immediate postoperative period (54%). Fifty-seven per cent of respondents at that time reported that they were required to have a physician anesthesiologist supervise their work, while 43% reported no such requirement.

History
Before the first public demonstration of successful ether anesthesia in 1846 by William T.G. Morton, a dentist at Massachusetts General Hospital, pain associated with surgery dissuaded patients and surgeons from most forms of elective surgery. From 1850 until about 1875, most surgical morbidity and mortality was blamed on either infection or anesthesia. After 1875, anesthesia was cited as the cause of the greatest incidence of morbidity and mortality. In addition to high risks, the job of anesthetist was also very low paying, which dissuaded bright students to take up anesthesia as a profession. An acute shortage of anesthetists compelled most surgeons to recruit medical students or low-ranking physicians from marginal medical specialties. After several incidents following this model, some surgeons felt that training a dedicated anesthetist might improve matters. Surgeons turned to religious hospital sisters, who devoted complete attention to the well-being of the patient and who accepted the gravest responsibilities without any economic reward. Among the first American nurses to provide anesthetics was Catherine S. Lawrence during the American Civil War. It was during the Second Battle of Bull Run in 1863 that she administered chloroform to wounded soldiers who needed emergency operations in the battlefield. The earliest recorded nurse to specialize in anesthesia was Sister Mary Bernard Sheridan, a Catholic nun who practiced in 1877 at St. Vincent's Hospital in Erie, Pennsylvania. Her influence spread throughout the Midwest, and many other Catholic nuns who were also nurses began training to administer anesthesia. Nuns of the Third Order of the Hospital Sisters of St Francis from Münster established a community in Springfield, Illinois, and on June 22, 1879, they founded St John's Hospital. At St John's, the administration of chloroform and ether was taught to the nurses by surgeons, and many of the Franciscan Sisters were assigned as anesthetists throughout the Midwest. Nurse anesthesia became “undoubtedly a prevailing practice in many Catholic hospitals”.

Although Catholic nuns seemed to be the most influential force in teaching nurses to administer anesthesia in the late 1800s, it was William W. Mayo who should be credited for promoting the popularity of nurse anesthesia practice. Mayo and his sons William J. Mayo and Charles H. Mayo were well known for their surgical skills. Surgeons traveled from across the country to their clinic in Minnesota to observe operations and learn their surgical techniques. However, the visiting surgeons also took note of the nurses administering anesthesia at the head of the operating table.

United States
A Certified Registered Nurse Anesthetist (CRNA) is a nurse anesthetist who is licensed to administer anesthesia in the United States. CRNAs account for approximately half of the anesthesia providers in the United States and are the main providers of anesthesia in rural America. Historically, nurse anesthetists have been providing anesthesia care to patients since the American Civil War and the CRNA credential came into existence in 1956. CRNA schools issue a master's or doctorate degree to nurses who have completed a program in anesthesia, which ranges from two to three years in length. Scope of practice and practitioner oversight requirements vary between healthcare facility and state, with 25 states and Guam granting complete autonomy as of 2024. In states that have opted out of supervision, the Joint Commission and CMS recognize CRNAs as licensed independent practitioners. In states requiring supervision, CRNAs have liability separate from supervising practitioners and are able to administer anesthesia independently of physicians, such as anesthesiologists.

France
The specialty of a non-medical anesthesia professional did not exist before WWII in France. After WWII, the Hôpital de Saint-Germain-en-Laye offered practical training for paramedics and nurses. Until the 1970s, many general hospitals had no appointed physician anesthesiologists. In 1960, the Ministry of Health commissioned a certificate of competence as infirmier aide anesthésiste (IAA) for nurse anesthetists. From then onward, only specialized nurses were allowed to administer anesthesia independent of the surgeon. Similar to the situation in the US, anesthesiologists tried to distance themselves from anesthetists. In 1974, the Professional Association of Physician Anesthesiologists submitted a Bill in order to extinguish the profession, but the bill was withdrawn and a campaign was started for the legal recognition oh the nurse anesthetist profession. In the 1980s, the profession of nurse anesthetist was nationally recognized and given the new title infirmier spécialisé en anesthésie-réanimation (ISAR). This was accompanied by an official training program and state diploma. Training to become an NA requires at least two years’ experience as a general nurse, followed by success at an examination at the end of two years’ special training in an anaesthetic nurse school teaching the acquisition of the national certification.

United Kingdom
The British Army had only ever experienced anaesthesia delivered by doctors and the arrival at the “front” of USA NAs astonished them. The great skill and care that was displayed by these NAs soon caused amazement to yield to admiration and, in 1918, classes were formed for British nursing sisters and these nurses started performing duties in various hospitals. Between the First and Second World Wars, operating theatre attendants (OTAs) or theatre porters/orderlies were helping the surgeons and anesthesiologists. After WWII, the OTA changed their names to operating theatre technician (OTT) and extended their role following the model used in the military. OTTs became the assistant to the anesthesiologist and were responsible for the anaesthesia equipment and assisted the anesthesiologist during complex tasks including transfusion, resuscitation and endotracheal intubation. Besides the OTTs, an anaesthetic nursing service was established during the eighties. These relatively few registered anaesthetic nurses could take more responsibility in comparison to the OTT and were, for example, allowed to administer drugs and to set up intravenous infusions. The prospect of training non-medical anaesthesia professionals to administer anaesthesia had been suggested, intermittently, for several years, but has been resisted strongly by the Association of Anaesthetists of Great Britain and Ireland In Europe, only Belgium and the UK have relied entirely on physician-based anaesthesia but, in recent years, experimental training schemes for non-medical graduates have been introduced to address the staffing crisis problem

Germany
Until after WWII, the surgeons were responsible for both operating and supervising the nurse who administered anesthesia. Anesthesia was a subspeciality of the surgical department. Because surgery became increasingly more complex, the Facharzt für Anästhesie (anaesthesia physician) was introduced and the German Society for Anesthesiology and Intensive Care was founded in 1953. In the 1960s, nurse anesthetists were utilized as a rescue solution due to a severe shortage of anaesthesiologists. NAs administered anesthesia under supervision of the surgeon and filled in for the shortage of anesthesiologists. Almost from the beginning, the German anesthesiologists worked together with an anesthesia assistant. After completing their nursing program, to become a nurse anesthetist (NA), the nurses were trained for two more years within anesthesia and intensive care. It was not until 1992 that enough anesthesiologists were trained to abandon the NA concept. In 2004, the German private HELIOS hospitals started, once again, to train nurses to become Medizinische Assistant fur Anästhesie (MAfA) comparable to the NA. To become a MAfA, nurses first had to work for at least two years in an anesthesia or intensive care department, followed by one year of practical training in anesthesia (400 hours). The training involved 200 hours of theoretical training and three days of training in an anesthesia simulator. The HELIOS hospitals initiated this MAfA training so that they could introduce parallel anesthesia, that is, one anesthesiologist giving anesthesia in two different theatres. In every OR, a MAfA would administer the anesthesia and receive supervision from the anesthesiologist. Sadly, three weeks after certification of one of the first MAfAs, a fatal complication occurred in a healthy 18-year-old male while a MAfA was giving anesthesia. After this incident, much criticism was levelled by the National Physicians’ Board in Germany and MAfA training was stopped immediately.

Scandinavia
Initially, nurses took a great deal of responsibility for the practice of Anaesthesia in Scandinavia and worked in a fashion similar to that pertaining many other countries, under the leadership of a surgeon. Some prominent surgeons, in the mid-19th century, realised that developments in surgery required a parallel, appropriate development in anaesthesia. Scandinavian nurses developed general anaesthesia into a craft that required high levels of qualification characterised by expert knowledge, observational expertise and skills. Formal education of NAs has taken place since 1962 in Sweden, 1963 in Finland and 1965 in Norway. National societies of NAs were founded in 1960 in Sweden, 1965 in Norway and 1966 in Finland.

The Netherlands
Despite a gradual increase in the number of anaesthesiologists responsible for anaesthesia, in the first half of the 20th century, nurses and religious nuns largely took care of the anaesthetic aspects of an operation under supervision of a surgeon. Since 1966, NAs were officially trained by the Nationale Vereniging van Ziekenhuizen (National Society of Hospitals). According to a survey held in 1969, a shortage of 80–100 anaesthesiologists existed in the Netherlands. This deficit was solved by allowing NAs to administer anaesthesia but only under direct supervision of the surgeon. In 1970, the Dutch National Health Council stated that every anaesthesiologist needed the help of a qualified NA. The flexible, two-table system was henceforth only allowed if an NA stayed with the patient throughout the operation. During the end of the 1960s and early 1970s NAs were exclusively supervised by anaesthesiologists and no longer by surgeons. It was not until 1984 when the training of NAs received approval from the Ministry of Health.

Africa
The majority of people living in African countries do not have access to safe and affordable anesthesia, analgesia, and surgical care. There are 30 distinct pathways to train as an anesthesia provider in Africa, defined as the unique combination of entry qualification, duration, and qualification awarded. A majority (73%) of countries in Africa rely on non-physician anesthesia providers (NPAP) or some form of non-physician qualification in order to practice anesthesia. Most countries had both physician and non-physician training routes. Of all the NPAP training pathways, 60% required a nursing background for entry, 14% required either nursing or other clinical experience, 12% specifically required clinical experience other than nursing, and 14% required no prior clinical experience. Physicians provided clinical supervision and curriculum teaching for NPAP programs less than half the time. Liberia, Niger, Togo, Congo, Central African Republic, South Sudan, and Eritrea currently only train nurse anesthetists in the administration of anesthesia.

Asia
After 1869, Japanese medicine came under German influence such that regional anaesthesia was dominant over general anaesthesia. It was not until 1950, when Meyer Sakland from USA conveyed modern knowledge of anaesthesia to the Japanese, that general anaesthesia became popular and developed rapidly. Until now, there have been no non-medical anaesthesia professionals in Japan; however, recently, the debate has started regarding its potential introduction into Japanese operating theatres. In 2010, a first, important step was taken by starting an exchange education programme with the USA. In China, the history is not much different. Some early pioneer anaesthesiologists came back from the USA bringing with them the message of anaesthesia, but it was not till the early 1950s that modern anaesthesia was introduced only to come to an abrupt halt during the Cultural Revolution when only acupuncture and Chinese herbal medicine were encouraged. After 1979, anaesthesia developed rapidly and achieved independence from surgery by 1989. The role of non-medical anaesthesia professionals is very limited in China.

Australia
In outback Australia, anaesthesia was frequently administered by non-medical assistants, attracting strong criticism by the medical establishment. The standard pattern of anaesthesia administration in the early 1900s in Australian cities was that the general practitioner (GP) referring the patient to the surgeon would administer the anaesthetic. In 1934, anaesthesia physicians became organised industrially and educationally very early as the Australian Society of Anaesthetists (ASA), and an early principle was that, whenever possible, one anaesthetist (and not an assistant) would care for and supervise one patient and that the anaesthetised patient would receive priority over all other activities. As nursing shortages were widespread, there was little scope for branching out into anaesthesia administration; nurses gravitated towards operating theatre scout and scrub duties. While the concept of non-medical nurse practitioners surfaced and was successful in the different states of Australia and in New Zealand, the non-medical anaesthesia professional has been more prevalent within the sub- branches of the anaesthesia services. Physicians became the sole administrators of anaesthesia in other parts of the former British Empire – in Singapore, Malaya, Hong Kong, India, Malta, Aden and Gibraltar.