Fig. 22.1
George Crile Sr. who was of one of the founders of Cleveland Clinic. (Courtesy of the American Association of Nurse Anesthetists Archives.)
Fig. 22.2
Agatha Hodgins. (Courtesy of the American Association of Nurse Anesthetists Archives.)
Hodgins described her work as a nurse anesthetist in the early war years (Bankert, pp. 44–5): [7]
“The unit…in the charge of Dr Crile, left in December, 1914, for service in the American Ambulance in Neuilly, Paris, France. Attached to this unit were three anesthetists’the writer and two members of her staff. The assignment of this anesthesia unit was to introduce gas-oxygen in war surgery, from that base hospital. The fortunate result was that of being able to successfully accomplish this assignment both on this special unit, and later, on the French surgical division of the American Ambulance Hospital.”
Nitrous Oxide/Oxygen for Trauma Victims
In 1915, Hodgins returned to the US to direct one of the earliest formal nurse anesthesia educational programs. Other American nurse anesthetists continued to provide nitrous-oxide/oxygen anesthesia until the armistice in 1918. Crile and Hodgins added pre-operative injections of scopolamine or atropine and morphine prior to nitrous-oxide and oxygen administration. The combination produced a “dissociated” mental state that Crile termed anoci-association, a state in which patients did not perceive pain. This was a forerunner of balanced anesthesia. Anoci-association, but particularly the administration of nitrous oxide with limited concentrations of oxygen and no oxygen monitor, required special skills.
Alice Hunt, a nurse anesthetist on the Yale faculty, described her approach.
“The technique calls for careful attention to detail in several ways, as follows: (1) an endeavor to gain the patient’s confidence and cooperation and to allay apprehension; (2) adequate narcotic premedication for relief of pain; (3) rinsing out of all diluting air from the lungs and tissues of the body; (4) avoidance of painful manipulation during the induction period; and (5) gentle surgical handling of the body tissues throughout the operation-a strong plea for this anesthesia, for it is a well-recognized fact that an important contributing cause of surgical shock is trauma to the tissues.” [15]
Crile also knew that the technique demanded observant care.
“Oxygen is a pilot light to keep the flame of life burning safely. If the light burns too high, the patient immediately comes out from the anesthesia, if too low, the patient is too deeply submerged; if it is turned out, the patient dies. Yet with a steady flow of gas under constant pressure, the patient is carried easily through the narrow zone of anesthesia. Miss Hodgins made an outstanding anesthetist for she had to a marked degree both the intelligence and the gift.” [16]
Personal accounts reveal some unusual stresses of wartime experiences. Sophie Winton (1887–1989), who worked with James Gwathmey wrote that she averaged twenty-five to thirty anesthetics a day. “As soon as they were through operating on one patient, I would have the next patient anesthetized….Many a night I had to pour ether or chloroform on my finger to determine the amount I was giving, because we had no lights except the surgeon had a searchlight for his work, so the only sign I had to go by was respiration” [17].
From “The History of the Pennsylvania Hospital Unit”:
“Throughout the British Army, anesthetics had hitherto only been administered by doctors and when shortly after our arrival our women began their work they (the British) were greatly astonished. The skill and care which was displayed soon caused their amazement to yield to admiration. The idea was soon adopted by the British authorities, and in the early spring of 1918, classes were formed of British nurses who received instruction at our hospital and at several others, and before the end of the war a number of British nursing sisters were performing the duties of anesthetists in various hospitals throughout the British Expeditionary Forces….” [18]. In 1936, Crile reflected that: “if the Great War had gone on another year, the British army would have adopted the nurse anesthetists right in the middle of the war.” [19]
Accolades accrued to Winton and her colleagues: “All the nurses in Winton’s unit were awarded the Croix de Guerre. Bankert reported (p. 48) [7] that Winton herself was also awarded six overseas service bars as well as honors from the Overseas Nurses Association, the American Legion, and the Veterans of Foreign Wars.” They were paid $ 60 per month. But as they were associated with the Red Cross nurses, they “did not receive full military rank, nor the pay and allowances equal to male military personnel. Veterans’ compensation was also denied them” [20].
Thatcher (p. 97) [3] traced two other changes to World War I. The Army and Navy both began to formally train nurses for duty as anesthetists for war service, a practice that continues to this day. The other change stemmed from the increased popularity of nitrous oxide: a “booming demand” after the war for trained nurse anesthetists” familiar with the technique of nitrous oxide anesthesia.
Success Triggers Opposition
The success of nurse anesthetists during World War I and afterwards, triggered opposition among the growing number of physicians entering anesthesia. According to Thatcher (p. 108) [3]. “The rapid growth of postgraduate schools of anesthesia in which nurses were trained, as well as the increasing enthusiasm for the trained nurse anesthetist during and after World War I, did not escape the attention of physician specialists in anesthesia, and during the 1920s resentment against the nurse anesthetist culminated in attempts to legislate her out of existence.”
The movement began in New York as early as 1912 with an article by attorney Lawrence Irwell entitled “The Case Against the Nurse-Anaesthetist”. “The moment that a nurse of her own volition, in consequence of symptoms observed by her, increases or decreases the amount of an anesthetic, which is being given to man, woman or child, she unquestionably and beyond doubt practices medicine in the legal sense of the words and violates the law of New York, Ohio, or Illinois, as the case may be.” He snidely concluded his article urging: “self respecting nurses to turn their attention to other matters’perhaps urinalysis” [21].
Bankert considered that Frank McMechan, the founder of the Interstate Association of Anesthetists, was “probably the most virulent” opponent to nurse anesthetists. In an editorial in the American Journal of Surgery, [22] he inveighed: “The nurse anesthetist must go, because she is unlicensed, and because her employment is as much an economic crime against the profession and public asfee splitting (emphasis original).” McMechan threatened: “to bring an end to the administration of anesthetics by unlicensed persons in every state in the middle West in which such can be secured” [22].
In 1916, McMechan attempted to close the Lakeside School, a high profile source of nurse anesthetists. Through the Interstate Association of Anesthetists, McMechan petitioned the Ohio Medical Board to adopt a resolution that stated in part, “it has been charged by many well-known and reputable physicians, that the law regarding the administration of anesthetics by others (sic) than licensed physicians has been systematically violated by Lakeside Hospital, Cleveland, Ohio, and that courses in anesthetics are given nurses in Lakeside Hospital.” Thatcher wrote (p. 113) [3] that together with physicians Albert Freiberg and J Baldwin, McMechan: “denounced in no uncertain terms the administration of anesthetics by nurses.”
More subtle opposition came from giants in anesthesia. Ralph Waters, the father of academic anesthesiology, held nurse anesthetists in low esteem:
“I hear that some surgeon in this state is using a nurse or an office girl’I’m not sure which’to administer anesthetics to his patients. Do you know why? The only honorable reason he could give is because he believes that she can give an anesthetic better than any practitioner of medicine available in his community. Surgeons with this handicap can be found in many communities in the United States today.” He believed that: “A nurse’s training is not sufficient foundation for becoming an anesthetist of value to both patient and surgeon.”(Bankert, p. 56). [7]
Program closures occurred or were threatened. A program had been established at the Johns Hopkins Hospital in 1917. In 1931, Olive Berger became its director, and in 1941 the pioneer thoracic surgeon Alfred Blalock, became the Chief of Surgery. According to Bankert (p. 199), [7] Berger:
“managed the anesthesia department, administered anesthesia, and trained at least four nurse anesthesia students a year. She administered the anesthesia for the first total pneumonectomy at John Hopkins and, with Helen Lamb, developed an endotracheal technique for intrathoracic surgery. She was the first nurse anesthetist to administer anesthesia to infants for tetralogy of Fallot.”
In 1941, Blalock invited Austin Lamont, an alumnus of Ralph Waters, to open a residency at Hopkins. “Lamont’s concept of an anesthesia department that included physician anesthesia, residency training and a resident research program was forged by the model presented in both Wisconsin and New York” [23]. But Lamont and Blalock “came to a parting of the ways”. Lamont wrote that his resignation was “due to Blalock’s opposition to my wish to increase the number of physician anesthetists and decrease the number of anesthetic nurses” [23]. The Johns Hopkins program survived until 1985, a time when numerous programs closed (see below).
Attempts to Outlaw Nurse Anesthesia
During the first half of the twentieth century, two lawsuits unsuccessfully argued that nurse anesthesia practice was illegal. In Frank v. South (Kentucky, 1917), surgeon Louis Frank, together with nurse anesthetist Margaret Hatfield, sued the Kentucky State Board of Health to test the contention that Hatfield was practicing medicine. The court ruled that both nurses and physicians could practice anesthesia without breaking the law (Bankert, p. 116) [3].
In Chalmers-Francis v. Nelson (California, 1936), the Los Angeles County Medical Association and its Anesthesia Section sued nurse anesthetist Dagmar Nelson for allegedly practicing medicine. Nelson however, with support from surgeon Verne Hunt, convinced the court:
“(1) (that) the giving of drugs upon the direct or understood instruction of a physician was a recognized practice and within the limits of the definition of nursing, (2) that the recognition and the reporting of changes in a patient’s condition and acting accordingly under the direct or understood supervision of a physician was within the province of nursing, (3) that nursing education as accepted by law gave instruction in the administration of anesthetics and the recognition of the signs and stages of anesthesia and (4) that it was an established practice within the law for registered nurses to give anesthetics as a nursing duty” (Bankert, p. 146). [3]
Acting with the backing of these two rulings, nurse anesthetists sought legislation in some state legislatures to legalize their work. “A number of states adopted statutes recognizing the practice of nurse anesthetists. Typically, these statutes followed the formulation in Frank v. South, and provided that nurse anesthetists were to work under the ‘supervision’ or ‘direction’ of a physician” [24]. Stoll wrote (p. 86) [25] that “Any nurse anesthetist would have been convicted of practicing medicine without such direction and supervision.” Ultimately, twenty-three states enacted a supervision requirement either in their medical practice act, nursing practice act, or hospital licensing requirements [26].
Attempts to Control Nurse Anesthesia
Decades later, the concept of required supervision would be turned against nurse anesthetists. In 1985, H Ketcham Morrell, president of the American Society of Anesthesiologists (ASA) wrote: “…the operating surgeon or obstetrician who purports to provide medical direction of the nurse, in the absence of an anesthesiologist, carries a high risk of exposure, on a variety of legal theories, for the acts of the nurse” [24].
Additionally, two federal (Medicare) payment schemes, the Tax Equity and Fiscal Responsibility Act (TEFRA-1982), and the Prospective Payment System (PPS-1983), disadvantaged Certified Registered Nurse Anesthetists (CRNAs). TEFRA and PPS were accountability measures meant to ensure that an anesthesiologist oversaw no more than 4 CRNAs at once, and personally performed certain services as part of a given anesthetic, to qualify for payment. However, the PPS inadequately compensated the physician/nurse team. Rita Rupp, a policy expert who was Special Assistant to the Executive Director at the AANA, concluded that: “Simply put CRNA services were, for all practical purposes, non-reimbursable” [11] The PPS and TEFRA rules were misconstrued as a standard of care, despite the government’s caution that they were not (Bruton-Maree and Rupp, pp. 361–3) [27].
CRNAs sought legislative and then regulatory relief. Medicare rules were the logical place to request removal of the supervision requirement, because they impacted all the states wherestate laws did not impose supervision (p. 408) [24]. Efforts by the AANA and the ASA to renegotiate TEFRA ended after “the ASA had second thoughts” about agreed upon revisions (Bruton-Maree and Rupp, p. 363) [27]. The Clinton administration removed the other supervision requirement. This was overturned by the GW Bush administration, with a proviso that states could “opt out” of supervision if the governor so chose. To date, Governors in 17 of the 31 eligible states have done so (Table 22.1).
Table 22.1
States in which the governor has opted out of the federal CRNA supervision requirement, and the date
State | Date of opting out |
|---|---|
Iowa | 2001 |
Nebraska | 2002 |
Idaho | 2002 |
Minnesota | 2002 |
New Hampshire | 2002 |
New Mexico | 2002 |
Kansas | 2003 |
North Dakota | 2003 |
Washington | 2003 |
Alaska | 2003 |
Oregon | 2003 |
Montana | 2004 |
South Dakota | 2005 |
Wisconsin | 2005 |
California | 2009 |
Colorado | 2010 |
Kentucky | 2012 |
Other activities pertinent to education included ostracism of anesthesiologists participating in training programs, (see for example, John Adriani below; Bankert, p. 154) [7] and an attempt to control school accreditation (also discussed below) [28]. Like the preceding lawsuits and attempts to legislate restrictions, both of these efforts failed.
What prompted the opposition to nurse anesthesia? Bankert argued (p. 57) [7] that economic factors were key. She cited C McCauley, a colleague of Ralph Waters: “I think the main reason that we are having nurses give anesthetics, at least up in this country, is the question of money.” Thatcher wrote (p. 135): [3] “Undoubtedly, it was the economic pinch of the depression that led the California physician anesthetists to renew their attack against nurse anesthesia in October, 1933, leading to the trial of Dagmar Nelson…” Stoll, citing (p. 200) [25] Hodgins (1935) wrote that opposition was greatest against nurse anesthetists who worked on a fee for service basis, at a lesser price than anesthesiologists.
Bankert added (p. 62 and p. 95) [7] that surgeons like Louis Frank and Verne Hunt, recognized the limited resources of nurse anesthetists, and financially supported the pursuit of their claims or defense. Attempts to control the activities of nurse anesthetists prompted them to form state associations for self protection (e.g., Ohio in 1931, New York in 1933, and California in 1935 and others) (Thatcher p. 162) [3] Closer ties developed between the AANA and other nursing organizations (Stoll, p. 200) [25]. Finally, efforts to improve education, which lagged between the mid 1950s and the 1970s, were reignited when anesthesiologists moved to control the accreditation of nurse anesthesia schools (Stoll, pp. 128–38) [25].
Nurse Anesthesia Education
Teaching the Art of Anesthesia
Surgeons taught nurses to administer anesthesia in the 1870s and 1880s. By the mid to late 1890s, nurses began to train other nurses. As noted earlier, the first formal training in anesthesia took place in the 1890s at St. Mary’s Hospital (the Mayo Clinic) with Magaw and Henderson doing most of the teaching. Initially they learned from surgeons, adding education by trial and error, supplemented with keen observation. They knew little pharmacology or physiology, and offered no theories, but they understood how to deliver chloroform and ether effectively and safely. They gave their students guidance, plenty of time, and individual oversight. Thatcher wrote (p. 62) [3] that “Sometimes the nurses (students) stayed for 2 or 3 months and learned to give ether under supervision.” Education was tailored to the learning style of each student, and respectful of the need for oversight for patient protection. Such early nurse education in anesthesia differed from most education of anesthetists, which historian AJ Wright described (p. 15) [5] as: “on the spot training of any person available.”
From Technical Training to Professional Education
As the twentieth century began, Thatcher described (p. 93) [3] the training of nurses in anesthesia as taking three forms:
“(1) that given by graduate nurses in a hospital in which they were to be employed as anesthetists;
(2) that provided gratuitously to visitors-physicians and nurses- who went to a hospital to observe and sometimes give anesthetics under supervision; and
(3) that given by the manufacturers and the demonstrators of gas machines, who often traveled round the country to sell and teach the operation of machines to anyone who would buy.”
Although better than training by trial and error, these methods lacked uniformity or a didactic component. They were technical and only addressed the need to cover service requirements.
The recognition of the importance of asepsis in the 1890s, underlay the expansion of surgery, and this, in turn increased the need for safer, better, more consistent anesthesia. According to Thatcher (p. 48) [3] “The new (aseptic) surgery, combined with the new knowledge of other practical aspects of bacteriology, stimulated organized efforts to set standards of education and service in all phases of medical care.”
In 1910, Medical Education Changed, and Nurse Education Followed
Publication of the Flexner Report in 1910, contributed to the closure of many inadequate medical schools. Medical education became university based, science-driven and research oriented [29]. Nursing education needed to change to keep pace.
“Early on, before anesthesia education was regulated, there were a lot of substandard schools. They needed to be improved or closed to ensuresafe patient care. Our profession took on that responsibility.” (April 2011 personal communication, Betty Horton, AANA Education Director from 1990–2002,)
The First Schools of Nurse Anesthesia
Agnes McGee graduated in 1907, from St. Joseph’s Hospital School of Nursing in Chicago, and received anesthesia training in Heidelberg, Germany, before settling in Portland, Oregon. In 1908–09, Good Samaritan and St. Vincent’s hospitals in Portland used interns to deliver anesthesia, but the interns rebelled, resolving that ‘they were not going to spend their internship giving anesthetics.’ Their revolt opened the way for McGee, and in 1909, at St. Vincent’s Hospital; she opened the first school of nurse anesthesia in the US. [30–31]
According to Brown, the school “expanded and flourished under McGee’s leadership” [31]. The initial course occupied four months. It was extended to one year in 1939. The students studied the “anatomy and physiology of the respiratory tract, pharmacology of anesthetic agents and techniques of administration of anesthesia” [31]. St. Vincent’s curriculum was the first to contain both didactic and clinical components. The program continued until 1956, training 142 students over its life span. Other programs followed at St John’s Hospital, Springfield, Illinois (1912); the New York Post-Graduate Hospital, New York City (1912); and the Long Island College Hospital, Brooklyn (1914). For her pioneering work, McGee received the AANA Award of Appreciation in 1953.
A second pivotal event for nurse anesthesia education took place in 1909: the twelfth annual convention of the Nurse’s Associated Alumni of the US, in Minneapolis. The meeting was to feature a presentation on the nurse as anesthetist by Henderson, and a response by Hodgins. Instead, nurses in attendance took over the agenda, and expressed their desire for formal specialty training programs in anesthesia. Thatcher wrote (p. 91) [3] that Hodgins was said to have gone home: “with a bee in her bonnet”, perhaps remembering J Baldy’s declaration the year before, that: “At present there is no place to my knowledge where a nurse or anyone else could apply for a training in anesthesia.” Hodgins and Crile began their school at the Lakeside Hospital in Cleveland, thinking their program was the first. Regardless, the meeting in Minneapolis produced the Lakeside program, a program from which 54 other institutions developed six-month-long postgraduate training programs’modeled on the one at Lakeside. Hodgins and Crile trained nurses, doctors, and dentists in the administration of nitrous-oxide-oxygen anesthesia. Founded in 1915, the school became known for this anesthetic approach, just as the Mayo Clinic had evolved as a center for teaching ether anesthesia. In 1916, 11 nurses, 6 physicians, and 2 dentists graduated. In 1917, the Lakeside school was closed by the challenge from the Ohio Medical Board described above. Thatcher reported (p. 106) [3] that it reopened in 1918, and by 1919, 54 nurses and 2 physicians had graduated.
The Lakeside School was housed within the anesthesia department. From 1915–1933, Hodgins directed and was the driving force behind both. As reported by Thatcher (p. 76) [3] “One now famous surgeon, who as a student went to Cleveland to learn the technic (nitrous oxide-oxygen anesthesia), was admonished by his chief: ‘George (Crile, the surgeon) will talk a lot, but you watch Agatha’.” The curriculum lasted six months, tuition was charged, and a diploma was granted. Hodgins gave the classroom instruction (added in 1918), and she had up to three assistants to help supervise the students. To widen clinical experience, students rotated to operating rooms in hospitals around Cleveland (Thatcher, p. 106) [3].
The Lakeside School had considerable influence. In her 1948 presentation of a posthumous award to George Crile, for his support of nurse anesthesia education, AANA President Lucy Richards noted: “Living memorials to him are the 54 formal schools for the training of nurse anesthetists in registered hospitals in this country. Because of his vision and his confidence, the anesthesia service in over 75 per cent of the nation’s registered hospitals is being conducted by nurse anesthetists educated in schools patterned after the one of which he was the founder” [32]. Three-quarters of the 54 schools established by 1948 were centered in the mid-west (39%) and Northeast (35%) (Fig. 22.3).
Fig. 22.3
Distribution of the 54 schools of nurse anesthesia listed by the AANA, that produced graduates qualified to take the certifying examination in 1948
Anesthesia education improved during this era. Classroom instruction began to supplement on-the-job training. But as Thatcher described (p. 96), [3] “while these pioneer educational ventures started a shift of emphasis from service to education, the service requirements of hospitals remained paramount in the majority of the training programs that sprang up during World War I and the postwar period. All other considerations were secondary to that of turning out anesthetists who had technical proficiency.”
Assuring Quality in Anesthesia Education
Between 1931 and 1955, Hodgins, Helen Lamb, and Gertrude Fife changed anesthesia education by organizing a national nurse anesthetists’ association, promulgating educational standards and agitating for their acceptance. These pioneers fought to accredit schools, determine curriculum standards, certify graduates by examination, educate educators, and initiate continuing education for practicing nurse anesthetists.
In 1931, many programs were deficient. Requirements for opening a school were lax, consisting “merely of obtaining the consent of the hospital and the surgeons and a willingness on the part of the instructor to impart knowledge and techniques to the student apprentice.”(p. 103) Some schools did not keep pace with scientific and technical advances. Thatcher reported (p. 96) [3] that “the courses represented all shades of adequacy depending on the native intelligence and the teaching ability, experience and education of the instructor.” Certification was needed to ensure that graduate nurse anesthetists met an acceptable standard. Hodgins appreciated that achieving this goal required a coordinated nationwide effort.
Birth of the American Association of Nurse Anesthetists (AANA) and Education Standards
The National Association of Nurse Anesthetists (NANA’changing its name to the American Association of Nurse Anesthetists, or AANA, in 1939) was born in 1931, at a meeting convened by Hodgins, of members of the Lakeside Alumnae Association. The organization was the culmination of her life’s work, and became a singular force for bettering anesthesia education [3,33] Membership was to be contingent upon certifying that the applicant’s practice and capabilities met set standards. Applicants for membership either had to have practiced anesthesia more than 3 years, or graduated from a program of nurse anesthesia that met standards set by the AANA. Certification of a nurse anesthetist or a school by the AANA would signify quality in education. Thatcher wrote (p. 209) [3] that the accomplishment of these intended goals would “place the association in the position of a pioneer among nurse specialty groups.”
An Education Committee was formed to define and achieve these goals. Its work became “the main plot development in the story of the national organization,” and Lamb chaired the Education Committee. After training at the Lakeside School under Hodgins, Lamb had been recruited by Evarts Graham to the Barnes Hospital in St. Louis. There, she founded a program of nurse anesthesia in 1929, remaining as its director until retiring in 1951. With Graham, Lamb pioneered endotracheal anesthesia, and collaborated with the engineer Richard von Foregger on the design of anesthesia equipment. She administered anesthesia for the world’s first pneumonectomy (Thatcher, p. 158, and Bankart, p. 202) [7]. She was an exacting teacher, and is today remembered annually by an award in her name, bestowed by the AANA upon an outstanding nurse anesthesia educator.
Lamb “could size people up very quickly (Kelly JW: personal communication, 2011),” “and looked into the future with sharper vision than had anyone else up to that point” (Thatcher, p. 189) [3]. Her career overlapped those of McMechan who opposed nurse anesthesia, [23] and Waters who resisted the presence of nurse anesthetists in academic centers [34]. Observing these men and their actions, Lamb probably suspected that nurse anesthesia would be threatened if it failed to keep up with the progress made by physicians.
The Education Committee first surveyed existing schools to determine the current state of anesthesia education. From the survey results, the Committee published minimum curriculum standards for schools in 1933, making these increasingly stringent in 1935, 1936 and 1948 (Fig. 22.4). The Committee then established and maintained a list of “accredited” schools that met those standards. These were the first universal standards in nurse anesthesia education.
Fig. 22.4
Course requirements for nurse anesthesia programs markedly increased between 1931 and 1948. (Data from Stoll DA: The emerging role of the nurse anesthetist in medical practice (dissertation). Evanston, IL, Northwestern University, 1988)
Defining adequate schools was only one of the AANA’s educational goals. Beginning in 1933, the Association published a journal; it has subsequently been in print continuously. The Education Committee also established a certifying examination that all graduates would have to pass to obtain AANA membership (see also Chapter 36). World War II delayed implementation of the examination by several years. In the interim, the AANA established an Education Department in 1935, with Lamb as its first director.
In her 1934 address at the annual meeting in Memphis, Fife articulated the AANA’s intention to become the sole authority on nurse anesthesia education: “The Association will serve as a pace-maker for the better schools and will influence the poorer schools to meet the required standards. The Association will secure for (accredited) schools on its list a recognition throughout the United States such as could not be secured in any other way, and will make possible the acceptance of guiding principles in matters pertaining to the education of the nurse anesthetist” (Thatcher, p. 210) [3].
Hodgins vs. Fife: How Should Certification Be Achieved?
To accomplish these goals, the Association had to arbitrate a dispute between Hodgins and Fife over how certification should be achieved. Hodgins favored state registration. Bankert wrote (p. 97) [3,7] that “her reasons for doing so may have been the result of her conviction that the work fell under neither the category of medicine nor of nursing, and that nurse anesthetists needed the protection of a separate legal status. She may also have been affected by years of listening to the charge leveled by physician-anesthetists hostile to the existence of nurses in the field, that they were ‘unlicensed’ practitioners.”
Fife took the position that national certification would be more practical.
“Furthermore, every anesthetist should be required to pass a National Board examinations (sic). I do not believe that state board registration for nurse anesthetists is either practical or possible. Quicker and more direct action can be obtained through a National Board, and more uniform methods of teaching will result from the establishment of universal rather than sectional standards” (Bankert, p. 211) [7].
This “contest of wills” ended only after Hodgins’ death, with the eventual implementation of national certification.
Strengthening the AANA by Affiliation with Other Organizations
Other matters diverted attention from the move to establish standards. Organized physician groups filed law suits’the two discussed above and several in other states’challenging the right of nurses to practice anesthesia. To confront the lawsuits of organized physicians, maintain standards in the face of the government’s wartime needs, and keep up with expanding marketplace needs was daunting. And the AANA was weak, having fewer than 1,000 members, each paying only $ 5 in annual dues. However, the AANA persevered.
Hodgins, Lamb, and Fife, and their fellow organizers affiliated the AANA with the American Hospital Association. Philosophical differences hindered attempts to work with other associations. Hodgins had written to the American Nurses Association (ANA) seeking affiliation as a subsection, prior to establishing the NANA: “Our reason for asking affiliation with the ANA, is simply recognition of the primary fact that we are registered, graduate nurses, qualified for and pursuing a special work” (Bankert, p. 70) [7]. The ANA stalled and finally rejected the request, creating a rift that would not be healed until the 1970s.
At the sixth annual meeting of the NANA, Lamb spoke of efforts to enlist support from the American Hospital Association: “The (Education) Committee’s most important activity centers around the movement now under way to enlist the endorsement of the American Hospital Association…for the inspection of schools of anesthesia for nurse anesthetists; and upon the basis of inspection to eventually approve those schools whose curriculum proves to be the equivalent of the standard already adopted by our Association” [35].
Before settling on the American Hospital Association, the NANA held “numerous conferences” with other organizations. Thatcher listed (p. 233): [3] “a talk by Miss Lamb on the association’s educational aims before the American Board of Surgery in St. Louis…a meeting of the entire Board of Trustees with members of the American Board of Surgery and the newly organized American Board of Anesthesiology in New York City on November 27, 1938, and subsequent conferences with representatives of the American Hospital Association and the American Board of Anesthesiology.”
The specifics of those meetings are unknown. For the American Hospital Association (AHA) to contemplate imposing new standards on a school must have been politically delicate. Thatcher would conclude (p. 233): [3] “The conferences pointed to the facts that the AHA would be the most desirable sponsoring body, but that a more detailed plan should be prepared for formal submission to that organization and that the association could effect a raising of standards in schools of anesthesia by having definite rather than nonspecific requirements for admission to membership.”
Liaison with the AHA was instrumental in this formative stage. As John Garde observed: “By 1933, the NANA had still not held its first national meeting, and suffered from general disarray organizationally” [36]. The AHA, recognizing the value of nurse anesthetists to their hospitals, invited the NANA to hold its first national meeting in conjunction with them [36]. The relationship was a success, and the AANA (renamed from the NANA in 1939) and the AHA held their annual conventions together for 43 years, from 1933 to 1976.
Other imperatives trumped the educational aims of the association. Stoll wrote (p. 6) [25] that “While it may be rationalized that the primary reason for the support from administrators and surgeons was based on the proven capabilities of nurse anesthetists, the reality of this support was the need for an inexpensive provider of anesthesia services. It is important to state that when serious challenges to nurse anesthetists’ right to work began, these organizations and individuals provided the necessary peer and professional support required to ensure that nurse anesthetists remained in practice.”
World War II Delays Educational Advancement
The demands for trained anesthesia personnel posed by World War II were a challenge. The need for nurse anesthetists was so great that the Army pressed them into service after as little as three months training, some within “earshot of battle.” This compounded a severe shortage of civilian nurse anesthetists. The AANA wisely (it would turn out) did not resist the accelerated training programs, although these emergencies delayed implementing the leaders’ plans for a national certifying examination and a school accreditation program. Fife articulated the AANA’s position, including its attempt to maintain minimum standards of competence, in a recruiting brochure published in 1942:
“The need for nurse anesthetists both in civilian and Army hospitals is becoming increasingly urgent. In order to meet the situation many Schools of Anesthesia have increased the student body. The degree of expansion is limited, however, because in order to qualify for membership in the AANA, each anesthetist must have administered a certain number of anesthetics during her training. The AANA has been opposed to lowering the standards by allowing the student to be graduated with less clinical experience than necessary to prepare her properly for work in active surgical clinics” [37]. Instead of resisting the accelerated training, Bankert wrote (p. 124) [7] that the AANA: “encouraged the establishment of schools in hospitals equipped to offer training in this field.”Related posts:
History Reflected in the Evolving Approaches to Anesthesia for a Patient Undergoing Cholecystectomy
Major Anesthesia-Related Events in the 2000s and Beyond
1846–1860: Following the Discovery of Anesthesia
A History of Research in Anesthesia
The Evolution of Premedication
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