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The unbreakable bonds of nursing.

Two thousand ten is a precarious time to be a nurse. Health care reform is imminent. We can pretend it won't happen, but it will despite our best efforts to prevent it. All I can say is, it's about time ... Time to fix a health care system that I love, but realize needs to change in order to suit the needs of the patients and their families. I was taught the focus must always be on the patient and the patient's family.

Our current health care system is too expensive for the value it provides. Now is the time to brainstorm on how to provide quality with getting the best "bang for our buck" or in economist terms, to be cost effective without sacrificing the quality of care. This is where we need to tread lightly. A pure economist might tell us the most cost effective way to take care of a patient is to kill him humanely and I have actually heard an economist say that in jest. These kinds of comments have people fearing "death camps," euthanasia and all kinds of morally repugnant ideas that keep people fearing ANY kind of change in health care. Change will occur whether we like it or not. The cost of health care continues to sky rocket, while the cost of living wages dwindle, as unemployment continues to rise. Money is running out, so where will the money come from? I do not pretend to know all of the answers. All I do know is that nursing must be sitting at the table to discuss the big changes with our legislators and leaders, probably more so than any other group, because we are the proclaimed patient advocates. Our valuable history will attest to that fact.

Nurses have existed in some form for centuries, as have physicians, and pharmacists. Florence Nightingale is lauded as our famous nurse leader, the pioneer of modern nursing. She was a feminist, statistician, hospital administrator, and a woman ahead of her time. 2010 is a great time to be a nurse. It happens to be the International Year of the Nurse, commemorating the centennial of Nightingale's death. The United Nations Decade for a Healthy World is 2010 to 2020. Nightingale focused on prevention and holistic care, which is the cornerstone of nursing today. How appropriate that her centennial coincides with the Decade for a Healthy World.

Nightingale was inspired by what she took as a Christian divine calling to become a nurse in 1837, at the tender age of 17. She made the decision to enter nursing in 1845, despite the anger and distress of her family, her mother in particular. She rebelled against the expected role for a woman of her high economic status to become a wife and mother. Instead, Nightingale cared for people in poverty, and was active in the reform of the Poor Laws in Great Britain.

Florence Nightingale's most famous contribution came during the Crimean War. In 1854, she and a staff of 38 women volunteer nurses, who were trained by Nightingale, tended to British troops in what is now modern day Istanbul. She and her nurses found wounded soldier being poorly cared for by overworked medical staff in the face of official indifference. Medicines were in short supply, hygiene was neglected, and mass infections were common. Most of the soldiers died from typhus, typhoid, cholera and dysentery rather than from battle wounds. Conditions were fatal because of overcrowding, defective sewer systems, and lack of ventilation in the military hospitals. Within six months of Nightingale's arrival, death rates were reduced from 42% to 2% by simple improvements of hygiene and sanitation. Initially she thought the high death rates were due to poor nutrition, limited supplies, and overworking of the soldiers. The statistician in her led to her later conclusion that the sanitary conditions were what made the critical difference in survival rates.

Remember that Florence was a nurse, so the human touch and connection were also of great importance in the healing process. "The Lady with the Lamp" was the phrase that a report in THE TIMES stated: She is a "ministering angel" without any exaggeration in these hospitals, and as her slender form glides quietly along each corridor, every poor fellow's face softens with gratitude at the sight of her. When all the medical officers have retired for the night and silence and darkness have settled down upon those miles of prostrate sick, she may be observed alone, with a little lamp in her hand, making her solitary rounds.

"Nightingale's achievements are all the more impressive when they are gauged against the background of social restraints on women in Victorian England. Her father, William Edward Nightingale, was an extremely wealthy landowner, and the family moved in the highest circles of English society. In those days, women of Nightingale's class did not attend universities and did not pursue professional careers; their purpose in life was to marry and bear children. Nightingale was fortunate. Her father believed that women should be educated, and he personally taught her Italian, Latin, Greek, philosophy, history, and more unusual of all for women of the time, writing and mathematics." Nightingale wrote Notes on Nursing, published in 1859. Every day sanitary knowledge, or the knowledge of nursing, of how to put the constitution in such a state as that it will have no disease, or that it can recover from disease, takes a higher place. It is recognized as the knowledge which every one ought to have distinct from medical knowledge, which only a profession can have. That profession is nursing, one that focuses on the well-being of patients, not merely the absence of disease, the holistic aspects of nursing. In my opinion, any nurse who focuses merely on the physical aspects of patient care is missing a critical piece in the healing equation. Nurses need to harness whatever power lies within a patient and his or her family to help in the healing process. Whatever you wish to call it, it does exist and begs to be used by all of our patients. Most patients wish to be healed and much of that power lies within them. Nurse just need to analyze how to best channel that power, or have the patient "heal himself." Nurses support patients on their journey of healing.

Nightingale started her own nursing program, now called the Florence Nightingale School of Nursing and Midwifery in 1860. She trained Linda Richards, "America's first trained nurse" in the 1870s. Linda Richards went on to become a great nursing pioneer in the United States and Japan. What a splendid history nursing has!

Numerous studies in our profession have proven that when nurse to patient ratios are too great, morbidity, mortality, and infection rates increase. Can many other professions make that claim? Nurses have been the "whistleblowers" of health care corruption and report those who do harm to patients. Nurses are consistently voted among the most trusted of health care professionals in survey after survey.

Nurses historically were the ones who cleaned the patient rooms and linens, stoked the fires, fed the sick from meals the nurses had prepared, gave the patients medications, helped with patient exercise, and performed respiratory percussion to loosen secretions. Before the specialties of dietary, nutritionists, physical therapists, occupational therapists, music therapists, and respiratory therapists, came into being, there were nurses. We are the profession that treats every aspect of the entire patient, the one body with many parts and a soul, a soul that can often soar when the body has already shut down. We as nurses witness those born into this world and those who exit it. We help regardless of where our patients are on their journey. It is our great honor to witness all of this, or at least as much as we can handle.

So the rich history of nursing blends with that of nurse anesthesia. Nurses were the first professional group to provide anesthesia services in the US. Established in the late 1800s as the first clinical nursing specialty, nurse anesthesia was developed in response to the growing need surgeons had for specially trained anesthetists. The profession continued developing in the early 1900s through the efforts of Dr. William Mayo and the mother of anesthesia, Alice Magaw, at the facility later known as the Mayo Clinic.


World War I increased the demand for nurse anesthetists and as a result, the training of nurses for this field escalated. Existing nurse anesthetists trained both physicians and nurses to provide anesthesia services at home and abroad. The formalization of physician education in the field of anesthesia did not become prevalent until after World War II. Only seven anesthesiology residencies for physicians of at least one year of specialty training were in existence at the outbreak of World War II.

Since World War I, nurse anesthetists have been the principal anesthesia providers in combat areas in every war in which the United States has been engaged. During World War II, there were seventeen nurse anesthetists to every one physician anesthetist. In Vietnam, the ratio of CRNAs to physician anesthetists was approximately 3:1. During the Panama strike authorized in 1989, only CRNAs were sent with the fighting forces.

Nurse anesthetists have been pioneers in anesthesia for specialty surgery, particularly lung and heart surgery. They are also involved in the development of anesthesia equipment for utilizing certain anesthesia techniques.

CRNAs were the first specialty nursing group to receive direct Medicare Part B reimbursement under the Omnibus Budget Reconciliation Act of 1986.

Missouri's Unique Contributions to AANA and CRNA History

The Missouri Association of Nurse Anesthetists (MoANA) was founded in 1935 by fifteen charter members, including Helen Lamb, of St. Louis. Helen Lamb was the first president of the Missouri Association of Nurse Anesthetists (MoANA) and later served as president of the American Association of Nurse Anesthetists (AANA). Helen was the director of one of the first schools of nurse anesthesia, begun in 1929 at Barnes Hospital in St. Louis. The Barnes/Washington University Nurse Anesthesia Program graduated its last official class in August of 1994. The program is now called the Goldfarb School Nursing Anesthesia Program at Barnes-Jewish College in St. Louis. The college reopened its door again in 2005, and is directed by Bernadette Henrichs, CRNA, PhD, and Vicki Coopmans, CRNA, PhD.

Who Are Nurse Anesthetists?

A Certified Registered Nurse Anesthetist (CRNA) is an advanced practice nurse who administers anesthesia. CRNAs are anesthesia professionals who safely administer approximately 32 million anesthetics to patients each year in the United States, according to the American Association of Nurse Anesthetists (AANA) 2008 Practice Profile Survey.


CRNAs are the sole anesthesia providers in nearly 70 percent of all rural hospitals, affording these medical facilities obstetrical, surgical, and trauma stabilization capabilities. They work in every setting in which anesthesia is delivered, including hospital surgical suites and obstetrical delivery rooms, ambulatory surgical centers, and the offices of dentists, podiatrists, and plastic surgeons.

Scope of Practice

All 50 states and the District of Columbia recognize CRNAs as qualified anesthesia providers who administer all types of anesthesia (local, regional and general) at the request of surgeons, dentists, ophthalmologists and podiatrists.

Education and Experience

For those applying to a nurse anesthesia program, the minimum requirements include:

* Bachelor of Science in Nursing or other appropriate baccalaureate degree.

* License as a registered nurse.

* Minimum of one year of experience in an acute care nursing setting

* Graduation from an accredited school of nurse anesthesia program at least two years in length. These programs offer a graduate degree and include clinical training in university based or large community hospitals.

* Passing a national certification exam following graduation, and completing a continuing education and recertification program every two years thereafter.

Due to the American Association of Colleges of Nursing (AACN) changes, all Master Degrees awarded in Nursing Schools will be lengthened to doctoral degrees (DNP or PhD or both) by the year 2015.

By 2025, the Council on Accreditation (accredits nurse anesthesia programs) is requesting that all programs be converted to a doctoral program. This means all CRNAs will graduate with a DNP or PhD or similar doctoral degree. Many programs are making that change, starting in 2010. All programs are currently transitioning their educational programs to grant doctoral degrees with the deadline of 2025.

Accredited Nurse Anesthesia Programs in Missouri

Goldfarb School of Nursing at Barnes-Jewish College--Nurse Anesthesia Program

Provides an MSN in Nursing with a specialization in Nurse Anesthesia. Program is 28 months in length.

St. John's School of Nurse Anesthesia at Missouri State University

Provides a MS in Nurse Anesthesia. Program is 30 months in length.

Truman Medical Center School of Nurse Anesthesia

Provides an MA in Biology. Program is 36 months in length.

Webster University

Provides an MS in Nurse Anesthesia. Program is 30 months in length.

Missouri Association of Nurse Anesthetists (MoANA)

The Missouri Association of Nurse Anesthetists (MoANA) is the professional association of Missouri Anesthetists. MoANA strives to ensure patient safety in anesthesia and access to excellent anesthesia care for all Missouri citizens--rural and urban. MoANA represents over 900 CRNAs in our state.

MoANA is currently in legal arbitration with the Board of Healing Arts regarding the ability and rights of nurse anesthetists to perform pain management on patients with chronic pain. Blocks such as lumbar epidural, thoracic epidural and cervical facet blocks, are often performed with the use of fluoroscopy. The Board of Healing Arts has now stated this is outside of the scope of practice of nurse anesthetists and the practice of medicine. As of yet, there has not been a decision made. MoANA still has a case before the Administrative Hearing Commission on whether MoANA can join a suit before the Board of Healing Arts regarding one CRNA in the state of Missouri who was practicing with an anesthesiologist in a chronic pain setting.

The chronic pain issue and issues regarding supervision requirements by physicians in the Missouri Nurse Practice Act continue to be an ongoing stressor between MoANA and the Missouri Society of Anesthesiologists. Advanced practice nurses in Missouri practice in collaborative practice agreements with physicians and nurse anesthetists practice differently.

CRNAs practice under the supervision of a surgeon, dentist, ophthalmologist, or podiatrist. CRNAs in Missouri are licensed registered nurses and hold a Certificate of Recognition for Advanced Practice under the Board of Nursing. Anesthesia given by a CRNA is the practice of nursing. In fact, over 53% of Missouri's counties with hospitals providing anesthesia services are covered solely by CRNAs. These CRNAs provide anesthesia to many patients who would have to drive an inordinate number of miles to receive anesthesia services if sole provider CRNAs did not exist in Missouri. Less than 47% of Missouri's counties with hospitals providing surgical services have anesthesiologists, whereas 100% of Missouri's counties with hospitals providing surgical services have CRNAs.

Managed care plans recognize CRNAs for providing high-quality anesthesia care with reduced expense to patients and insurance companies. The cost-efficiency of CRNAs help to control escalating health care costs. Studies that compare morbidity, mortality and infection rates between CRNAs and anesthesiologists have found no statistically significant differences. One of these studies was done by a cardiologist, Dr. Pine, who probably provided the least biased study of the many performed.

In May, we celebrate Nurses Week 2010. I hope this year is our banner year. I consider myself fortunate to be a nurse, to have a job in this trying economy, and to serve my patients and their families, and my fellow nurses. Nightingale had it right. We are here to serve, educate, and protect, our patients and each other. It is our calling as it was hers. It is an honor to be a nurse in 2010, the International Year of the Nurse. We should never forget our unbreakable bonds.

Georgene Bosaw, CCRN, CRNA, MS in Nurse Anesthesia

References available upon request.
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Author:Bosaw, Georgene
Publication:Missouri Nurse
Geographic Code:1USA
Date:Apr 1, 2010
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