Who Controls the Power over Pain? A Comparative History of Nurse Anaesthesia.

From the advent of the use of anaesthesia during surgery through the Second World War, confusion and competition over who should administer the technology - doctors or nurses - dominated gendered discussions of professional boundaries. Using information about practice in the United States, the United Kingdom, and France in this period, we find vastly different outcomes for nurse-administered anaesthesia. Differences in perceptions regarding the gendered nature of this technology and its related level of prestige largely determined who could practice it. When administering anaesthesia carried low prestige and was viewed as non-technical, it fell under the purview of women's work in medicine, that is, nursing. When the same technology gained prestige and became perceived as a technical, medical skill, doctors associated it with their masculine professional identity and worked to exclude nurses from administering anaesthesia.

Surgeon-nurse anesthetist collaboration advanced surgery between 1889 and 1950.

To meet the need for qualified anesthetists, American surgeons recruited nurses to practice anesthesia during the Civil War and in the latter half of the 19th century. The success of this decision led them to collaborate with nurses more formally at the Mayo Clinic in Minnesota. During the 1890s, Alice Magaw refined the safe administration of ether. Florence Henderson continued her work improving the safety of ether administration during the first decade of the 20th century. Safe anesthesia enabled the Mayo surgeons to turn the St. Mary's Hospital into a surgical powerhouse. The prominent surgeon George Crile collaborated with Agatha Hodgins at the Lakeside Hospital in Cleveland to introduce nitrous oxide/oxygen anesthesia. Nitrous oxide/oxygen caused less cardiovascular depression than ether and thus saved the lives of countless trauma victims during World War I. Crile devised "anoci-association," an outgrowth of nitrous oxide/oxygen anesthesia. Hodgins' use of anoci-association made Crile's thyroid operations safer. Pioneering East Coast surgeons followed the lead of the surgeons at Mayo. William Halsted worked closely with Margaret Boise, and Harvey Cushing worked closely with Gertrude Gerard. As medicine became more complex, collaboration between surgeons and nurse anesthetists became routine and necessary. Teams of surgeons and nurse anesthetists advanced thoracic, cardiovascular, and pediatric surgery. The team of Evarts Graham and Helen Lamb performed the world's first pneumonectomy. Surgeon-nurse anesthetist collaboration seems to have been a uniquely American phenomenon. This collaboration facilitated both the "Golden Age of Surgery" and the profession we know today as nurse anesthesia.

Goldie Brangman Remembers the Operation to Save Dr King.

In September 1958 the Rev Dr Martin Luther King Jr was stabbed and nearly assassinated. Surgeons at Harlem Hospital in New York City removed a 17.8-cm (7-in)-long letter opener from Dr King's chest. Certified Registered Nurse Anesthetist Goldie Brangman remembers this event because she participated in Dr King's anesthetic. This article correlates Brangman's memories with published accounts of the event. It also places the event within the context of the modern civil rights movement that Dr King led.

Alice Magaw: a model for evidence-based practice.

The model of evidence-based practice (EBP) of Alice Magaw places the practice of nurse anesthesia as an early pioneer in patient safety and is prophetic to the aims of the Institute of Medicine (IOM). In its 2001 report, Crossing the Quality Chasm, the IOM identified 6 aims essential to improving the delivery of care. These aims include safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. Magaw used her vast expertise in anesthetic administration to develop protocols and a body of knowledge that could be used as a template for practitioners near and far. This early use of EBP principles places nurse anesthesia at the forefront of the model and the movement to provide high-quality care. Practitioners sought her practice model out as she demonstrated her techniques to visiting providers as well as through her published ideal anesthetics in the literature. She wrote, "Pioneers are noted for building upon a body of knowledge, establishing a model for continuous improvement, and exemplifying notable methods of research with subsequent documentation of their findings." Magaw exemplified the EBP model.

Imagining in Time: The Legacy of Olive Berger (1898-1981).

Olive Berger was a true nurse anesthesia pioneer for our profession. She dedicated her life to the advancement of nurse anesthesia through her leadership, advocacy, scholarly writing, clinical achievements and innovation. She blazed the trail by forming and establishing education requirements for nurse anesthesia programs, established a state nurse anesthesia organization, and led the American Association of Nurse Anesthetists as its 14th president in 1958. She was the Chief Certified Registered Nurse Anesthetist and Program Director at the Johns Hopkins Hospital and is best known for her collaboration with surgeons Dr. Alfred Blalock and Dr. Helen Taussig, providing anesthesia care during the groundbreaking repair of tetralogy of Fallot on infants.

Status of the anesthesia workforce in 2011: evolution during the last decade and future outlook.

The purpose of this review is to present a comprehensive assessment of the anesthesia workforce during the past decade and attempt forecasting the future based on present knowledge. The supply of anesthesiologists has gradually recovered from a deficit in the mid to late 1990 s. Current entry rates into our specialty are the highest in more than a decade, but are still below the level they were in 1993. These factors along with slower surgical growth and less capital available for expanding anesthetizing locations have resulted in greater availability of anesthesiologists in the labor market. Despite these recent events, the intermediate-term outlook of a rapidly aging population and greater access of previously uninsured patients portends the need to accommodate increasing medical and surgical procedures requiring anesthesia, barring disruptive industry innovations. Late in the decade, nationwide surveys found shortages of anesthesiologists and certified registered nurse anesthetists to persist. In response to increasing training program output with stagnant surgical growth, compensation increases for these allied health professionals have moderated in the present. Future projections anticipate increased personnel availability and, possibly, less compensation for this group. It is important to understand that many of the factors constraining current demand for anesthesia personnel are temporary. Anesthesiologist supply constrained by small graduation growth combined with generation- and gender-based decrements in workforce contribution is unlikely to keep pace with the substantial population and public policy-generated growth in demand for service, even in the face of productivity improvements and innovation.

The role of Certified Registered Nurse Anesthetists in the United States.

Certified Registered Nurse Anesthetists (CRNAs) have been providing anesthesia care in the United States (US) for nearly 150 years. Historically, anesthesia care for surgical patients was mainly provided by trained nurses under the supervision of surgeons until the establishment of anesthesiology as a medical specialty in the US. Currently, all 50 US states utilize CRNAs to perform various kinds of anesthesia care, either under the medical supervision of anesthesiologists in most states, or independently without medical supervision in 16 states; the latter has become an on-going source of conflict between anesthesiologists and CRNAs. Understanding the history and current conditions of anesthesia practice in the US is crucial for countries in which the shortage of anesthesia care providers has become a national issue.

Ira P. Gunn: educator, advocate, legend.

This column examines the contributions of nurse anesthetist Ira P. Gunn, CRNA, MLN, FAAN (1927-2011), widely recognized as a visionary and tireless advocate for the profession of nurse anesthesia. Her contributions to nurse anesthesia practice, research, education, publication, consultation, credentialing, and government relations have significantly contributed to the preservation and advancement of nursing and nurse anesthesia.

A Commitment to Quality: The History of Nurse Anesthesia Accreditation Part Two: 1983-2019.

In 1934, Gertrude Fife, President of the National Association of Nurse Anesthetists (NANA) sought to elevate the standards of anesthesia practice and standardize the education of nurse anesthetists. NANA members located schools, developed education standards and a school approval process, that eventually led to creation of the Council on Accreditation of Nurse Anesthesia Educational Programs (COA) in 1975. Examination of historical documents demonstrated that COA developed into a well-known accreditation agency recognized by both governmental and non-governmental organizations, enhancing the standards of anesthesia education and promoting high-quality educational programs. Note: See the April 2020 issue of AANA Journal for Part One of this article.

The hunt for 1LT Kenneth R. Shoemaker Jr., CRNA.

Little was known about 1LT Kenneth R. Shoemaker Jr, 1 of 2 nurse anesthetists killed during the Vietnam War, outside of his family and friends. This column examines the life, death, and legacy of Shoemaker as seen through the eyes of his family, former classmates, and fellow nurse anesthetists who served in Vietnam.

Imagining in Time.

In 1934, Gertrude Fife, president of the National Association of Nurse Anesthetists (NANA), recognized a need to elevate the standards of anesthesia practice and standardize the education of nurse anesthetists. Early members of the association responded by working to locate schools, setting education standards, and developing a school approval process, which eventually led to creation of the Council on Accreditation of Nurse Anesthesia Educational Programs (COA) in 1975. Examination of historical documents demonstrates that COA developed into a well-known accreditation agency that is recognized by both governmental and non-governmental organizations, meeting the goal of elevating the standards of anesthesia education and continuing this process through its commitment to promoting high-quality educational programs.

Alice Magaw (Kessel): her life in and out of the operating room.

Alice Magaw (Kessel) was a pioneer in nursing research and the practice of nurse anesthesia through the publication of her clinical findings. This historical review will consolidate and preserve existing information and document new findings pertaining to this outstanding anesthetist. Primary historical sources, newspapers, legal documents, and other forms of information will be utilized, as well as correspondence with individuals who had some relative association with Magaw.

Betty Lank: a kind and gentle anesthetist devoted to children.

Many noted clinicians and educators led the development of nurse anesthesia as a profession during the first half of the 20th century. Betty E. Lank, CRNA, a nurse anesthetist at Children's Hospital Boston, Massachusetts, for 34 years, devoted her professional life to the delivery and advancement of pediatric anesthesia. She is credited with many contributions including the first use of cyclopropane for infant anesthesia, developing pediatric-sized anesthesia masks and ventilation bags, and instituting standards for specialized postanesthesia recovery areas. Lank recorded her anesthesia experiences in various nursing publications and shared her knowledge with colleagues at professional meetings. Her accomplishments make her a notable figure in the early history of pediatric anesthesia, and her dedication helped forge the foundation for anesthesia at Children's Hospital Boston.

Nursing and anaesthesia: historical developments in Canada.

There is little historical knowledge available about nurses' role in anaesthesia in Canada. It appears, from the few sources available, that nurses did administer anaesthesia in the early 20th century in Canada. The limited historiography reveals that nurses who worked in small rural hospitals across Canada were, due to the lack of physician specialty and coverage, involved in the administration of anaesthesia. To learn more about nurses' role in this area the authors explored the oral history collection from the British Columbia's History of Nursing group at the College of Registered Nurses of British Columbia Library. Several stories indicated that between 1917 and 1953 there were opportunities for Canadian nurses to administer anaesthesia. The oral histories identified that there was a need for the administration of anaesthesia, that nurses had the skill to provide it, and that flexibility in their nursing practice enabled them to fulfill this role. There was an increasing need for anaesthesia service that was not being filled by physicians. To further explore nurses' role the authors also examined nursing and medical journals from that time period. There is limited understanding of how this role ceased to exist in Canada while it became well established in the United States. Various legal cases from that time period, and the substantially different results between Canadian and America cases, provide some insight into the reasons why nurse anaesthetists were excluded from anaesthesia practice in Canada. As the Canadian healthcare environment continues to change, and the need for anaesthesia services increases, new questions have begun to arise about the potential for an advanced practice role in anaesthesia for Canadian nurses. The demand for anaesthesia services is increasing in-line with the aging Canadian population and the shortage of available services is most dramatic in small, rural hospitals. This article provides important historical background on the development of the role of nurse anaesthetists in Canada.

AANA's first annual meeting: the first-fruit of an adventure.

The75th Annuual Meeting of the American Association of Nurse Anesthetists will take place this year in Minneapolis, Minnesota. This column looks back at the Association's first Annual Meeting, held September 13-75, 1933, in Milwaukee, Wisconsin. Discussion includes Gertrude Fife's and Helen Lamb's work in organizing the meeting and the program, a day-by-day look at the meeting events and speakers, and the response to first Annual Meeting.

The life and trial of Dagmar Nelson--Part 1.

During the more desperate years of the Great Depression, a group of physicians brought an injunction proceeding against Dagmar Nelson and her employing hospital for illegally practicing medicine without a license. She administered general anesthesia and her employer knew it and supported her. It was a bizarre trial in that the arguments presented by both sides seem incongruous to our way of thinking today. The evidence presented at the trial echoed the predominant view at the time--the undisputed dominance of the male physician over the female nurse, who was portrayed, even by the defense, as only an extension of the surgeon who "has the power and therefore the responsibility" to control the surgery. Had she lost, anesthesia as a specialty of nursing would not exist. The method by which she won, however, has haunted us to this day. Part 2 of this 2-part column on "The life and trial of Dagmar Nelson" is scheduled for publication in the August 2006 AANA Journal.

The life and trial of Dagmar Nelson--part 2.

During the more desperate years of the Great Depression a group of physicians brought an injunction proceeding against Dagmar Nelson and her employing hospital for illegally practicing medicine without a license. She administered general anesthesia and her employer knew it and supported her. It was a bizarre trial in that the arguments presented by both sides seem incongruous to our way of thinking today. The evidence presented at the trial echoed the predominant view at the time--the undisputed dominance of the male physician over the female nurse, who was portrayed, even by the defense, as only an extension of the surgeon who "has the power and therefore the responsibility" to control the surgery. Had she lost, anesthesia as a specialty of nursing would not exist. The method by which she won, however, has haunted us to this day. Part 1 of this 2-part column was published in the June 2006 AANA Journal.