Evolution of Nurse Anesthesia 1

Running Head: Evolution of Nurse Anesthesia

The Evolution of Nurse Anesthesia

Alexandra N. Milton

Glen Allen High School

 Evolution of Nurse Anesthesia 2

Abstract

This paper discusses the changes in technology and education that have been made to the

nurse anesthesia field, also including the role nurse anesthetists play in providing anesthesia to

their patients. Since nurse anesthesia started as early as the 1800s, a lot has changed regarding

the practice. It was a practice that was feared long ago and still frightens many people today, but

it is nearly 50 times safer than it was during the 1980s due to the technological advancements

and stricter education (Wilson, 2012). One way certified registered nurse anesthetists (CRNAs)

differ from anesthesiologists is their nursing background which allows them to gain an emotional

bond with their patient. This bond allows their patient to instill trust with their nurse anesthetist,

therefore they feel calmer already. These three aspects of the paper will highlight the evolution

of nurse anesthesia from its past, present, and future outlook. The conclusion of this paper

discusses the future of nurse anesthetists, suggesting that the future is always changing and if

CRNAs continue to do what they are taught, they will always thrive.
 Evolution of Nurse Anesthesia 3

Introduction

The practice of nurse anesthesia has dated all the way back to the 1800s. Two hundred

years later, it is a practice still known and widely accepted. From the earliest known nurse

anesthetist, Sister Mary Bernard, to a nurse anesthetist providing anesthesia tomorrow, there

have been setbacks and successes of the field (Wilson, 2012). While many may understand that

anesthesia has been implemented for centuries, many fail to recognize how much the practice has

evolved. There have been multiple improvements and changes made to the education path, the

technology, and the practice itself such as the development of new programs and techniques.

The American Association of Nurse Anesthetists established the foundation for nurse

anesthetists years ago and today. They have created the educational requirements of certified

registered nurse anesthetists (CRNAs) and other helpful sources of information for current and

future CRNAs. There are many who fear the administration of anesthesia today, especially by a

nurse anesthetist, yet they know little as to how the practice has evolved and how much safer it is

today.

Educational Changes

When the practice was first introduced, nurses were sent all over the country by their

surgeons to learn how to provide anesthesia. The Mayo Clinic in Rochester, Minnesota

eventually became the hotspot for surgeons to send their nurses to learn from Alice Magaw, the

Mother of Anesthesia. Surgeons also sent their nurses to Agatha Hodgins at the Lakeside

Hospital in Cleveland, Ohio to observe and learn how to administer nitrous-oxide anesthesia

(Stewart, 2012). Instead of being sent across the country to learn different techniques, nurse
 Evolution of Nurse Anesthesia 4

anesthetists are currently taught in many schools and programs in different states to learn the

same technique of intubation.

The American Association of Nurse Anesthetists (AANA) was established in 1931 by

Agatha Hodgins and has set the foundation for nurse anesthetists today. They have designed the

education requirements for nurse anesthetists over the years. Before the AANA, there were not

any set requirements for nurse anesthetists. There was an increasing demand of education due to

a lack of nurse anesthetists. During the students education experience, the American

Association of Nurse Anesthetists produced its first 38-page certification examination, consisting

of true-false, fill-in, essay, and multiple choice questions. Ninety women in thirty-nine in

twenty-eight states completed this exam (American Association of Nurse Anesthetists). Those

who fear anesthesia, should not because the CRNAs take a rigorous test and classes prior to

receiving their degree. Because of the increased demand, the AANA began its work of

accrediting anesthesia schools in 1950 (2005). As of January 2012, the requirements are as

follows:

a Bachelor of Science in Nursing (BSN) or other appropriate

baccalaureate degree, a current license as a registered nurse, at
least one year of experience as a registered nurse in an acute care
setting, graduation with a minimum of a masters degrees from an
accredited nurse anesthesia educational program, [the] national
certification examination [is passed] following graduation, [must
obtain a minimum of forty 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.]
Before 1998, when these requirements were set in stone, the education differed in every area.

Although many people would feel more comfortable having anesthesia administered by an
 Evolution of Nurse Anesthesia 5

anesthesiologist, studies have shown no difference in safety between anesthesiologists and

CRNAs (Schultz, 2015). Now the AANA has announced its support for nurse anesthetists to

gain doctorate degrees by 2025 (Wilson, 2012). Once nurse anesthetists begin to earn their

doctorate degree, they will obtain a higher education like anesthesiologists. However, both

anesthesiologists and CRNAs take the same test to provide anesthesia (L. Cryster, personal

communication, April 9, 2017). The sole difference between nurse anesthetists and CRNAs is,

When anesthesia is administered by a CRNA, it is considered the practice of nursing. When

administered by an anesthesiologist, it is considered the practice of medicine. (Schultz, 2015).

Either way, both are utilizing the same techniques for administration of anesthesia, so one should

not worry about who is administering it. Every few years the field is always changing and

improving, the education changes in order to promote better performing nurse anesthetists.

Leslies education experience was a twenty-seven month program, with the first semester

being in the classroom and the second semester participating in clinicals. Clinicals enable

nursing and other medical students to practice on patients. They are supervised by a professor or

other medical professional, allowing students to learn and observe in a real environment. She

described the program as very challenging --- she was on call, would sleep at the hospital, and

was there for twenty-four hours sometimes. While she was in the program her and other students

spent most of their time learning on real patients and taking a mannequin head home in order to

practice intubating (L. Cryster, personal communication, April 9, 2017). She has only been a

CRNA for eighteen years and they have already changed a lot about the practice. Today

simulation technology is being used for students to learn. Simulation technology allows students

to learn in a
 Evolution of Nurse Anesthesia 6

clinical setting [that] can be realistically stimulated. There is not

threat to patient safety. Active learning can occur. Specific and
unique patient situations can be presented. Errors can be corrected
and discussed immediately. Consistent and comparable
experiences can occur for all students.
Simulation technology encourages safety among students and patients, before simulations were

used, students were forced to practice on real patients. Practicing on real patients, put them in

danger even with a nurse anesthetist or anesthesiologist observing than does simulation

technology. Nurse anesthesia is always changing and evolving as new discoveries are being

made. More programs are created as more students join the field, for example In 2011, 111

programs in 38 states exist for students. Over 2,000 students were admitted in 2009. It is a

competitive program and because 2011 only had 111 programs, top students from all over the

country were selected (Marsusaki & Sakai, 2011). Those in the field are always learning and

adapting to their surrounding and since the 1800s, most of the field as changed.

Technology Changes

The first recorded technique was called the open-drop inhalation technique which used

chloroform and ether anesthesia. This technique allowed nurse anesthetists to place a mask

made of gauze over the patients mouth and nose and inhale drops of chloroform or ether. In

1847, Sir James Young Simpson, a physician utilized chloroform in the open-drop inhalation

technique. Although chloroform was used as an anesthetic, it needed to be administered by the

top physicians because there were many fatalities. In 1942, another physician, Crawford

Williamson, was the first to use ether, a liquid that causes pain to subside, but keeps the patient

conscious throughout a procedure (History.com Staff, 2010). The demand for nurses increased

in the start of World War I when Agatha Hodgins was sent with a surgeon, George Crile to
 Evolution of Nurse Anesthesia 7

France in 1914. In France Hodgins trained both physicians and nurses how to administer

anesthesia. Soon the United States Army and Navy began to send some of their nurses to St.

Marys Hospital in Rochester, Minnesota and Pennsylvania Hospital in Philadelphia,

Pennsylvania for six weeks (Ira, 1991). Many years later, Agatha Hodgins perfected

administering nitrous-oxide anesthesia, also known as laughing gas (Wilson, 2012). From the

1840s to the early 1900s, there were already three different drugs administering anesthesia by

CRNAs, one can only imagine how the future looks for anesthesia.

Today an Operation Room is filled with technology for each position, the surgeon,

surgical nurse, registered nurse, and nurse anesthetist. Today a nurse anesthetist has an

anesthesia machine and cart. The machine contains the patients vitals which are the heart rate,

oxygen intake, and the carbon dioxide outtake. The cart contains the materials needed to put the

patient to sleep, such as different sizes of laryngoscopes, laryngoscopy endotracheal tubes, IVs,

drugs, etc. Laryngoscopy endotracheal tubes are one of the tools nurse anesthetists use to put

patients to sleep. This tube goes into the patients trachea with the assistance of a laryngoscope.

The laryngoscope is the metal tool placed in the patients mouth and the laryngoscopy

endotracheal tube follows the laryngoscope to the trachea. The process of putting a patient to

sleep begins when the nurse anesthetist brings the patient to the Operating Room and connects

the patient to monitors which consist of a blood pressure cuff, pulse oximeter which measures

Oxygen saturation, and an ECG/EKG, otherwise known as electrocardiogram. The

electrocardiogram records the activity of the heart by using the electrodes that are stuck to the

patients skin. The patient is given Oxygen prior to induction through a mask, lasting about five

minutes in order to fill the lungs with one hundred percent Oxygen. The patient is then given a
 Evolution of Nurse Anesthesia 8

mixture of drugs through the IV to put them to sleep, the CRNA takes control of their

ventilation. In some cases, the airway that needed to be secure was accomplished through

intubation or a direct laryngoscopy endotracheal tube. The tube is placed in the trachea and is

secured to the lip with tape.

Secondly, a mixture of anesthetic gases is turned on to keep the patient asleep during

surgery, so they do not feel any pain or discomfort during the procedure. There are two common

types of anesthetic gases, Sevoflurane and Desflurane, both putting the patient to sleep

differently (Encyclopedia of Surgery). Sevoflurane is commonly used for the induction of

pediatric anesthesia because patients do not have an IV. Desflurane is less soluble than

Sevoflurane, so the patient will breathe the gas faster and fall asleep quicker. There are more

gases used for putting a patient under anesthesia, but Sevoflurane and Desflurane are the most

common. Along with anesthetic gases, there are also intravenous anesthetics (anesthetics that

are released through the patients IV), such as Propofol, also called Diprivan, which puts patients

to sleep (Encyclopedia of Surgery). With the strict education of nurse anesthetists, they are able

to decide which drugs to use depending on the type of procedure and patient.

When the procedure is over, the nurse anesthetist begins emergence, also known as the

process of waking the patient up. The anesthetic gases are turned off and the flow of Oxygen is

increased. The patient must be able to swallow after being suctioned, responds to commands,

and has their airway reflexes back in order for the tube to be taken out. The patient then receives

Oxygen through the face mask, additional pain medications are given, and the patient is taken to

PACU or Post Anesthesia Care Unit (L. Cryster, personal communication, 2016).
 Evolution of Nurse Anesthesia 9

With these new technologies, nurse anesthetists have become better equipped over the

years. They utilize technology for assistance with the patient, but are also trained to figure out

what is happening when the machine is off. During Leslie Crysters educational career, her

professors would turn off the machines while a patient was on the operating table in order to

figure out what was occurring without it (L. Cryster, personal communication, 2016). They are

trained for various circumstances with and without technology. CRNAs in the past would not

have been able to do this without the technological advancements provided today.

A Nurse Anesthetists Role

A nurse anesthetists role is not only to provide anesthesia to their patient, but to create

an emotional bond with each patient. The nurse anesthetist is with the patient the entire time,

before, during, and after the procedure, allowing for the patient to trust someone. Mary Stewart

(2011), claims that a nurse anesthetist sees their role as a guide through a frightening

experience. Nurses care about the patients feelings and needs, so nursing is integral to the

role of the CRNA, and without it an emotional bond would not likely form.

The bond begins during the interview with the patient, prior to the operation and is the

first time the patient meets the CRNA, including a history and a physical. The history includes

prior surgeries, any types of diseases, NPO or nothing by mouth, drug allergies, and then the

consent is signed (Encyclopedia of Surgery). A nurse anesthetist asks the patient about their

prior surgeries, because the patient may have felt nervous or uncomfortable the last time. During

this interview Leslie Cryster, a nurse anesthetist asks questions about the patients, for example

where are they from and how many children? Before the nurse anesthetist begins this physical
 Evolution of Nurse Anesthesia 10

with the patient, the anesthesiologist has already met with the patient, but they rarely make a

connection with them if the CRNA will be administering the anesthesia. She believes it is good

to find a connection on some level with the patient. It is important for CRNAs to recognize

someones anxiety, instead of ignoring it.

The physical incorporates the CRNA listening to the patients heart and lungs and

evaluating the airway based on the Mallampati Score. This rates the patients mouth in four

different classes, Class I, Class II, Class III, and Class IV. A patient who has a Class I mouth

will be the easiest to intubate and Class IV is almost impossible for a nurse anesthetist and

anesthesiologist to intubate. Patients with a Class I mouth have all of the structures visible,

including the soft palate, uvula, fauces, and pillars, however patients with a Class IV mouth have

structures that are less visible, making it dangerous to intubate. Throughout this interview,

patients may begin to feel anxious, so the CRNA provides them with a mild sedative (L. Cryster,

personal communication, 2016). Because of this interview, nurse anesthetists take into account

the patient's physical and psychosocial needs., in return emotional energy is created

between the patient and CRNA (Aagaard et al., 2016). This enables nurse anesthetists to instill

trust with their patients, therefore the patients must put their life in their anesthesia providers

hands.

Patients hear all over the news, from their friends and family about people who wake up

from anesthesia, die, or have a bad experience, but fail to look at how far the field has come in a

short amount of time. The outcome of anesthesia cannot always be predicted, but it is far safer

than it was centuries ago.

 Evolution of Nurse Anesthesia 11

Conclusion

Nurse anesthesia has evolved into a difficult, yet rewarding career for many. The fear of

anesthesia still grows in many, but as Wanda Wilson (2012), argues, anesthesia is nearly 50

times safer than it was during the 1980s. The evolution of the practice has led to successful

findings and different techniques of administering anesthesia, but no one can predict what the

future holds for CRNAs. The world is always changing, different jobs stumble across different

problems, but nurse anesthetists will always be able to thrive because of their vigilance,

preparation, determination, knowledge, experience, and ability that serve them so well caring for

their patients every day. (Wilson, 2012). With these important characteristics, CRNAs are

trained in various scenarios with and without real patients, enabling them to overcome challenges

in the future.

What is known, is the new education requirement instilled by the American Association

of Nurse Anesthetists for a doctoral degree by 2025 in order to be a nurse anesthetist (Stewart,

2012). The AANA makes changes and improvements to the nurse anesthetist education in order

to better prepare students for real life experience. Without the AANA, the field of nurse

anesthesia might be absent today, consequently there would not be an anesthesia provider for

patients to instill trust with. Each year the practice becomes safer and safer due to new

discoveries. It is unpredictable what might happen next, but as each day progresses it becomes

more safe.
 Evolution of Nurse Anesthesia 12

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