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Research News: Nurse Anesthesia

Mary W. Stewart, PhD, RN

IS THE PRACTICE of nurse anesthetists nursing? Canadian Anesthesia Society is part of a movement
The American Association of Nurse Anesthetists to widely adopt CRNAs in Canada. However, lim-
(AANA), representing more than 42,000 Certified ited understanding of the role contributes to the
Registered Nurse Anesthetists (CRNAs), clearly de- belief by many Canadian nurses that nurse anesthe-
fines the role as advanced practice nursing. The his- sia is not nursing. The authors planned and con-
tory of nurse anesthetists is long and impressive. As ducted a rigorous qualitative study of nurse
early as the Civil War (1861-1865), nurses were pro- anesthesia practice in the United States (US). The
viding anesthesia care. In 1877, Sister Mary Bernard purpose of the study was to develop a grounded
of Pennsylvania was recognized as the first nurse to theory of CRNA practice with the hope of gaining
specialize in anesthesia. Today, few in the United an understanding of whether and how nursing is
States would argue against their legitimacy. an integral part of that practice.
CRNAs practice in every setting where anesthesia
is available and in some states are the sole anesthe- Methods: Because of the lack of theory regarding
sia professionals in nearly 100% of rural hospitals.1 nurse anesthesia practice, the authors decision
to use Grounded Theory was appropriate. Data col-
The question of nursing as the foundation for nurse lection and analysis occur at the same time in this
anesthesia is less certain in countries where the research design. As the experiences of participants
role is yet to be adopted. Confessing their own hes- are revealed, concept and themes are identified.
itation of accepting CRNAs into the Canadian
health care system, the authors of this original re- Multiple sources were used for gathering informa-
search explored the role and practice of CRNAs. tion over a period of 16 months. Specifically, the
They gave particular attention to how nurse anes- researchers used the following to uncover data:
thesia practice is nursing.
 interviews with 18 informants (practitioners,
Keeping Vigil Over the Patient: A Grounded leaders, students) from the 2006 AANA An-
Theory of Nurse Anaesthesia Practice by nual Meeting;
Schreiber R, MacDonald M. J Adv Nurs. 2010;66;  AANA archives (documents, historical re-
552-561. cords, and memorabilia);
 observation of scientific sessions, convention
Background and Purpose: The oldest recognized procedures, relationships among attendees;
nursing specialty, nurse anesthesia, is practiced in  interviews with four experts on regulatory,
more than 100 countries. Acknowledging the legal, practice, and financial issues, followed
need for alternate anesthesia care providers, the by 11 telephone interviews with informants
identified through previous contacts;
 visits to two hospitals, an outpatient surgery
Mary W. Stewart, PhD, RN, is Professor, Special Assistant to
clinic, and a school of anesthesia;
the Dean, and Director of PhD Program at the University of
Mississippi Medical Center School of Nursing, Jackson, MS.  interviews with CRNAs, RNs, educators, stu-
Conflict of interest: None to report. dents, physicians, and a director of anesthe-
Address correspondence to Mary W. Stewart, University of sia; and
Mississippi Medical Center, School of Nursing, 2500 North  field notes.
State Street, Jackson MS 39216-4505; e-mail address:
2011 by American Society of PeriAnesthesia Nurses Interviews were recorded, transcribed verbatim,
1089-9472/$36.00 and compared with notes to ensure accuracy. Par-
doi:10.1016/j.jopan.2011.03.005 ticipants represented 10 states comprising rural

176 Journal of PeriAnesthesia Nursing, Vol 26, No 3 (June), 2011: pp 176-178


and urban settings and ranged from 0 to 40 years of anxiety-free environment, which is helpful to
experience in anesthesia nursing. A majority (23/ everyone in the room.
41) of interviewees were female.
Foregrounding nursing is the foundation of the
Researchers used the classic constant-comparative previous three strategies. Participants legitimized
method of grounded theory to code concepts and the CRNA role through nursings long history in
explore relationships among them. Theoretical sat- anesthesia care and focused educational prepara-
uration, the point where no new theoretical codes/ tion to practice in the advanced nursing role. In
relationships are found, was reached in December response to how nursing is integral to anesthesia
2007. The researchers used a peer debriefing care, one participant in the article responded,
group to challenge data interpretations and ensure What part of it is medicine? Wheres the diagno-
their understandings were grounded in the data. In sis and treatment of illness? This is supportive
addition, study participants reviewed the results to care . the entire time. Nurses distinguish their
confirm that the findings were consistent with care from physicians in how anesthesia is pro-
their own practice and understanding. vided. For nurses, it is about supporting the patient
through surgery, relieving pain and anxiety, and de-
Results: Schreiber and MacDonald described their livering them safely to a point where they can care
findings using a spherical figure. The participants for themselves or other nurses can care for them.
defined the basic social problem as keeping the pa-
tient safe throughout surgery. The resolution to Conclusions: This study is the first grounded the-
this problem was labeled Keeping Vigil over the ory work on the enactment of nurse anesthesia
Patient. The role of the CRNA is to keep a state practice in the US. Researchers concluded that
of watchfulness against dangers to the patient un- the findings resonated with their personal under-
dergoing surgical procedures. standing of nursing. Nursing is integral to the
role of the CRNA and offers great promise for ex-
CRNAs use four strategies in being vigilant: panding and enhancing anesthesia care in Canada.
What many see as a role that is split between med-
1. Engaging with the patient icine and nursing, the CRNAs in the US seamlessly
2. Finessing the human-technology interface operate with a firm foundation of nursing. More-
3. Massaging the message over, the participants in this study were passionate
4. Foregrounding nursing and positive about their contributions to patient
care. These findings and understandings should fa-
Engaging with the patient includes building inti- cilitate adoption of the CRNA role in Canada and
macy and a relationship, keeping in touchliter- other countries where nurse anesthesia has
allywith the patient; and engaging spiritually much room for growth.
with the patient. The spiritual connection emerged
in various ways, eg, the CRNA sees their role as PeriAnesthesia Nursing Implications: The first re-
a guide through a frightening experience and often sponsibility we have as perianesthesia nurses is to
used positive imagery to facilitate a sense of calm question assumptions that nurse anesthesia pro-
and trust. Finessing the human-technology inter- viders are not practicing nursing. Addressing the
face takes into account the intimidating atmo- ignorance of advanced practice nursing roles,
sphere of the OR and the need to educate and CRNA contributions in particular, is a duty
patients about the environment and routines. Mas- we all share. The Institute of Medicines report
saging the message refers to how the CRNA man- on the Future of Nursing: Leading Change, Ad-
ages interactions among the OR team, including vancing Health2 urged policy makers to remove
controversies between the surgeon and CRNA or barriers that hinder advanced practice registered
the CRNA and the anesthesiologist. If the patients nurses, including CRNAs, from practicing to their
safety is in jeopardy, the CRNA will advocate firmly. fullest extent. Bettin3 also cited recent studies
At the same time, if the conflict is one of mere pref- that revealed the efficacy and financial feasibility
erence, the CRNA will acquiesce to the physician. of CRNA care. These findings compel us to support
This is one way the CRNA strives to maintain an the role of the CRNA.

Further, we can learn from the CRNA example of Finally, as part of sustaining the passion of nurses
loving our work that was articulated in this study. working in anesthesia care, perianesthesia nurses
Because we work closely with CRNAs, anesthesiol- need to share our stories of CRNA providers and
ogists, surgeons, and other OR personnel, peri- patient care with health care policy makers glob-
anesthesia nurses can influence the patterns of ally. To be a worldwide leader in health care en-
appropriate, respectful communication in anesthe- compasses more than complicated technology
sia settings. Placating others by dismissing the value and political agendas. US nurses can set the stage
of our own informed perspectives is not healthy for international understanding of the contribu-
and could strip the joy of nursing from us. Nurses tions of CRNAs; it is in everyones best interest to
can help nurses overcome this negative pattern. do so.

1. American Association of Nurse Anesthetists. A brief look Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-
at nurse anesthesia history. 2011. Available at: http://www Health/Report-Brief.aspx. Accessed March 20, 2011.
.aana.com/brieflookhistory.aspx. Accessed March 20, 2011. 3. Bettin C. IOMs future of nursing report reinforces find-
2. National Academy of Sciences. The future of nursing: ings of anesthesia studies in Health Affairs and Health Eco-
Leading change, advancing health. Institute of Medicine of the nomic$. 2010. Available at: http://www.aana.com/news.aspx?
National Academies. 2010. Available at: http://iom.edu/ id528106. Accessed March 20, 2011.