In Europe, anaesthesia services are mainly provided by trained physician anaesthesiologists, though many countries also have nonphysician anaesthesia team members. Currently, there is risk of a significant shortage of human resources in medicine, especially in anaesthesia, and the anaesthesia workforce may be inadequate to meet the growing demands of surgery and other areas where anaesthesia expertise is required. A shortfall of anaesthesia team members in one country provides an opportunity for members of the anaesthesia workforce, both physician and nonphysician groups, from other countries. Migration occurs despite1 anaesthesiologists and other anaesthesia team members in Europe having differing roles specific to their individual countries.
Although nonphysician anaesthesia team members have traditionally played an important role in Europe and in North America, to date there has been no study of the demographic and practical characteristics of their work. To address the quality or scope of the working domain of anaesthesia team members, an examination of the validity of their training and supervision, and the diploma or degree awarded, is essential. In this study, we examined the profiles of nonphysician anaesthesia team members and their tasks within different European countries. We also sought to establish whether the international exchange of nonphysician anaesthesia team members within the European Union is feasible in its present form. Finally, information was collected on the national organisations representing nonphysician and physician anaesthesia team members throughout Europe to determine their level of organisation.
Following approval by the Medical Ethics Committee of the Catharina Hospital in Eindhoven, The Netherlands, 31 European countries were surveyed. A questionnaire was sent to all the respective representatives of the Union of European Medical Specialists (UEMS) Anaesthesiology section and the International Federation of Nurse Anesthetists (IFNA) to gather information regarding the position on 1 January 2008. After 1 month, reminders were sent to those who had not responded with further e-mail and telephone contacts as required. We also crosschecked the numbers of anaesthesiologists and anaesthesia team members against the national anaesthesia societies and the official government institution of each country (Ministry of Health, National Institute of Health, Medical Council). The latter represent the only source of data that is used by the European Union (Eurostat).
The survey (Appendix I, http://links.lww.com/EJA/A16) compared the job descriptions of the nonphysician anaesthesia team members and asked questions regarding categories of nonphysician anaesthesia team members available; total number of physician and nonphysician anaesthesia team members in the country; whether and for how long the anaesthesia team members are trained in basic nursing and also training specific to anaesthesia; the scope of nonphysicians' involvement in preoperative, perioperative and postoperative care; additional duties nonphysician anaesthesia team members are allowed to perform (preparing the operating room, checking anaesthesia monitors, equipment and materials; monitoring patients); and the anaesthesia tasks they are allowed to perform under direct or indirect supervision. ‘Direct supervision’ was defined as the continuous presence of the anaesthesiologist in the operating room, whereas ‘indirect supervision’ was when the anaesthesiologist was not physically in the operating room but readily available to help. We also asked physician and nonphysician anaesthesia team members whether they were affiliated to a national society, the date of the society's establishment, their website URL and whether they had a national anaesthesia journal.
All relative workforce figures are given per 100 000 people. The group averages for the relative workforce figures were calculated in order to reflect the situation in the more populated countries. Population statistics of European countries were provided by the World Health Organisation (1 January 2008; Fig. 1).
Sufficient data regarding anaesthesia team members were obtained from all 31 countries surveyed to permit international comparisons. Two different categories of nonphysician anaesthesia team members were identified: nurse anaesthetists and circulation nurses (Table 1).
Nurse anaesthetists have a nursing degree (not essential in The Netherlands), have acquired additional education and training in anaesthesia and administer anaesthesia under the direct or indirect supervision of a physician anaesthesiologist to patients undergoing surgical or diagnostic procedures, according to a plan defined by the supervising anaesthesiologist. They are allowed to administer drugs to patients according to a written protocol or in accordance with the anaesthesiologist's agreement/order, and they may perform intubations and extubations and insert intravenous and arterial lines, depending on locally agreed protocols and terms and conditions of service. The number of formal study years (theory and practice) to become a nurse anaesthetist varies widely across Europe, from 1 year up to 4 years (Table 2). All courses of study result in a diploma provided by the local school of nursing, Ministry of Health, government or University School of Medicine.
Nurse anaesthetists are currently working in the following countries: Bulgaria, the Czech Republic, Denmark, Estonia, France, Hungary, Iceland, Lithuania, Luxembourg, The Netherlands, Norway, Poland, the Slovak Republic, Sweden and Switzerland. In Poland, nurse anaesthetists were introduced in 2003, though they still have only limited responsibilities (Table 2).
Professional work domain
No European country allows nurse anaesthetists to provide anaesthetic services independently, without the anaesthesiologist's preevaluation and agreement. In Denmark, France, Norway and Sweden, nurse anaesthetists are allowed to induce general anaesthesia for the American Society of Anesthesiologists (ASA) I and II patients independently, according to specified protocols and agreements, but with indirect supervision from an anaesthesiologist. Although they are not allowed to start anaesthesia independently, in The Netherlands and Norway, nurse anaesthetists with additional training are allowed to give sedation under Monitored Anaesthesia Care (MAC) for procedures like diagnostic endoscopies, under the indirect supervision of an anaesthesiologist. According to national guidelines in Denmark, France, Hungary, The Netherlands and Poland, four hands are always required during the induction of anaesthesia: an anaesthesiologist together with a nurse anaesthetist, or two nurse anaesthetists (Denmark and France). In Europe, nurse anaesthetists do not work without an anaesthesiologist's supervision, in the manner of Certified Registered Nurse Anesthetists (CRNA) in USA. Specifically trained nurse anaesthetists may participate in the preoperative assessment of patients ASA I and II only in The Netherlands, Norway,2 Slovenia and Sweden.
Legal and professional terms
Although all the above countries employ nurse anaesthetists, differences exist between the national groups. In The Netherlands, a basic nursing diploma is not an absolute prerequisite to become a nurse anaesthetist. In France, by law, practicing nurse anaesthetists must be registered with the National France State Diploma.3 Although the responsibilities of Hungarian nurse anaesthetists are rather limited, similar to those of circulation nurses, Hungarian law requires that each anaesthetic must be provided simultaneously by an anaesthesiologist and a nurse anaesthetist.
Circulation nurses (also called anaesthetic nurses)
Circulation nurses are employed in the operating theatre and can be asked to help the anaesthesiologist during the induction, maintenance or emergence of anaesthesia. Following basic nursing training, they can proceed to training in operating theatre practice in schemes that vary significantly according to local circumstances. Circulation nurses are never allowed to take any responsibility for the anaesthetic care of patients or to have direct patient-related roles during the induction and maintenance of anaesthesia. Because they are still nurses, they retain their nursing qualifications and can prepare medication, administer intramuscular injections and intravenous solutions, except in Ireland, Malta and Romania where they only assist the anaesthesiologist.
Circulation nurses are currently working in the following countries: Austria, Belgium, Cyprus, Finland, Germany, Greece, Ireland, Italy, Latvia, Malta, Portugal, Romania, Spain and the United Kingdom. In Austria, Germany, Latvia and Spain, circulation nurses are specifically certified, which is not the case in the other countries.
Responsibilities and qualifications
Although circulation nurses have little influence on how anaesthesia is actually performed, they have important roles within the anaesthesia team that differ from country to country. Not only do their roles differ, but also their scope of responsibility and qualifications. In Belgium, anaesthesia circulation nurses generally have an ICU and/or an emergency nursing diploma, and are allowed, under the direct supervision of an anaesthesiologist, to perform certain tasks within anaesthesia such as the insertion of intravenous lines, intubation and the injection of medication. Until 1994, there were nurse anaesthetists in Finland (n = 1700), but with very limited working responsibilities; since 1994, only circulation nurses have been trained. Latvia started with a new system in 2009 in which nurses are trained in anaesthesia and receive university diplomas under the regulation of Riga Stradins University. Currently, Latvian nurses (n = 400) are working in the ICU and the anaesthesia department under the direct supervision of an anaesthesiologist. Greece has circulation nurses as well as anaesthesia technicians. Both groups are trained in the theatre to assist the anaesthesiologist, and their roles are similar, though anaesthesia technicians have 3 years of education in a polytechnic rather than a nursing degree. Italy is similar to Greece, with theatre nurses and anaesthesia technicians who, in some regions, do not require nursing training.
Other work domains of nonphysician anaesthesia team members
In many European countries, nurse anaesthetists participate in the acute pain service (Denmark, Finland, Germany, Italy, Luxembourg, The Netherlands, Norway, Portugal, Romania, Slovak Republic and Switzerland), or work in the recovery room (Denmark, Belgium, Estonia, Finland, France, Germany, Greece, Hungary, Italy, Latvia, Luxembourg, Malta, The Netherlands, Poland, Portugal, Romania, Slovak Republic, Spain, Sweden, Switzerland and the United Kingdom). These functions may differ within each country and again at local level.
Anaesthesia physician assistants
Apart from nurse anaesthetists and circulation nurses, in some countries other personnel also can participate in anaesthesia care. In Switzerland and the United Kingdom, (nonphysicians) anaesthesia physician assistants (APAs) participate in the preoperative assessment of ASA I and II patients (www.ifna-int.org).4 They can also start general anaesthesia for ASA I and II patients with indirect supervision by an anaesthesiologist according to specific protocols and agreements, comparable to nurse anaesthetists in Denmark, France, Norway and Sweden. The Swiss APA is even allowed to perform spinal and epidural anaesthesia under indirect supervision. In Exeter (UK), on a trial basis only, the APA provides sub-Tenon's blocks for cataract surgery, as well as Bier's blocks.5 In the UK, the APAs do not need to be a nurse, nor do they need to have attained a nurse anaesthetist diploma. They are allowed to provide sedation under MAC for procedures such as diagnostic endoscopies, under the indirect supervision of an anaesthesiologist (www.ifna-int.org).4
In Ireland, Sweden, Turkey and the UK, anaesthesia technicians are responsible for preparing the operating room, checking the anaesthetic machine, monitors and equipment and transporting the patient. These technicians have no involvement in monitoring patients, administering drugs or resuscitation and have no direct patient-related role during the induction and maintenance of anaesthesia. Only in Turkey (n = 3950) an official training is given and a state diploma is required. In several other countries, anaesthesia departments have dedicated technically trained staff who are only responsible for the technical support/repair of theatre equipment in general. In addition to the above, several countries have personnel who are responsible for the logistics of the anaesthetic supply.
Several countries (Sweden, Switzerland and the UK) employ one or more of these types of nonphysician anaesthesia roles in combination.
Anaesthesia workforce in Europe
Where national registration does not exist, the exact number of the anaesthesia workforce (physician and nonphysician) in European countries is often unknown, especially the number of circulation nurses. In the Scandinavian countries, the relative number of anaesthesia team members is high (e.g. Sweden has 24 anaesthesiologists, four residents and 44 nurse anaesthetists per 100 000 population), whereas Turkey has the lowest ratio of anaesthesia manpower per population (four anaesthesiologists, two residents and no nurse anaesthetists or circulation nurses per 100 000 population).
The establishment of national anaesthesia societies for both groups and the institution of anaesthesiology as an independent specialty are fairly recent developments. In most European countries, these milestones were not reached until after World War II. Supplement Tables 1 and 2, http://links.lww.com/EJA/A17 contain information regarding national associations of nurse anaesthetists and anaesthesiologists, and their websites and journals. Nurse anaesthetists are generally represented by national societies, but not circulation nurses. In some countries, the national associations of nurse anaesthetists have websites and even journals of their own. However, anaesthesiologists are usually much better organised. In all the European countries, anaesthesiologists have their own associations, and in most, they have their own websites (except Cyprus, Iceland and Luxembourg) and anaesthesia journals (except Cyprus, Estonia, Iceland, Latvia, Lithuania, Luxembourg and Switzerland).
The present study demonstrates the heterogeneity and variety of anaesthesia practices throughout Europe, with a large diversity among nonphysician anaesthesia team members. Generally two European models can be defined: the nurse anaesthetists who are allowed to maintain anaesthesia without direct supervision of the anaesthesiologist; and circulation nurses who can assist for a specific procedure under direct supervision of the anaesthesiologist and cannot monitor patients and maintain anaesthesia alone. Their diversity is apparent not only in terms of job titles, but also in the required education, the responsibilities of their roles, the tasks performed and their work domain. A specific diploma is not always awarded after the study or training period.
In Europe, in general, the anaesthesia team consists of an anaesthesiologist and a nurse anaesthetist or a circulation nurse. The importance of anaesthesiologists and nonphysician anaesthesia personnel working together was demonstrated by Kluger and Bryant,6 who found that the most reported factor in reducing job stress among anaesthesiologists was the presence of trained anaesthesia personnel. Some countries, such as Poland, have only recently come to appreciate the value of well trained nurse anaesthetists after the training of circulation nurses was found to be inadequate.
A recent study7 estimated the current shortage of anaesthesiologists in USA to be 4655 (2009), a figure that is likely to be considerably higher by 2020. Expectations are that a similar situation will prevail in Europe. However, as the financial and workforce pressures of healthcare systems increase, support for the appointment of more physicians to work as anaesthesiologists can be expected to decrease. This should create an incentive for European anaesthesiologists to consider the different models of organisation that currently exist. These models may offer solutions for other countries experiencing shortages in anaesthesiologists, prompting an examination of those that currently work with less physicians and more nurse anaesthetists (e.g. the two-table system with nurse anaesthetists in The Netherlands).
In Europe, the certification required to practise as a nonphysician anaesthesia team member lacks a recognised standard. The duration of training and education varies widely, not only between European nurse anaesthetists and circulation nurses, but also within these two groups. Before starting anaesthesia training, a nursing degree is compulsory in every European country, except in The Netherlands. However, the level of basic nursing training, and the diploma awarded, lack consistency, though they meet European standards (Table 2).8 In 2010, IFNA will launch its accreditation system for educational institutes (www.ifna-int.org) This system may lead to a more standardised educational system and practice for nurse anaesthetists. Ideally, this will result in similar certification criteria for nurse anaesthetists, producing healthcare professionals who are able to transpose their training and skills from one country to another.
When dealing with a shortage of anaesthesiologists, there may be two choices: changing the model or training a greater number of nurse anaesthetists. One advantage of the latter is the short duration of training of nurse anaesthetists (on average 3 years). Unfortunately, if anaesthesiologists are in short supply, so also are nurse anaesthetists. That moves the emphasis from training to retaining these healthcare workers in their jobs by promoting high levels of job satisfaction, something that involves offering career perspectives, personal development or opportunities to work in foreign countries.9
Although APAs working under the supervision of anaesthesiologists are allowed to give anaesthesia under MAC, they should not be confused with nurses, nurse practitioners or physician assistants who are working under supervision of surgeons, cardiologists and other medical personnel. The existence of APAs in the UK and Switzerland is relatively new. Their higher level of education, in comparison to the nurse anaesthetists and circulation nurses, allows them to practise with a degree of independence, but only with an anaesthesiologist as supervisor. In both countries, the introduction of the APA could be seen as an answer to the increased demand on the service. In line with the use of nonphysicians in cardiology, endoscopy and surgery, the introduction of the APA may allow a reallocation of anaesthesia tasks, which are now solely performed by the anaesthesiologist. This, of course, is a question of priority.
We suggest that it is in the best interest of patients to introduce a European standard for education, training and competencies, which outlines the specific tasks to be undertaken by specific groups and defines the job titles of the different types of anaesthesia team members according to the level of responsibility appropriate to each group. Currently, there is no body with this remit, but the IFNA and the European Board of Anaesthesiology are possible organisations that might recognise the benefits. As well as being required for exchange programmes, uniformity will also contribute to the legal status of nurse anaesthetists, furthering their professionalism, increasing patient safety10 and enhancing anaesthesia as a speciality.
The availability of reliable, systematic, country-based workforce statistics is generally poor throughout Europe. The accuracy of the data presented should be interpreted cautiously and may not necessarily reflect the true number of active anaesthesiologists in a particular country. Differences between the sources (UEMS, National Anaesthesia Societies, Ministry of Health, IFNA, Eurostat) do exist. The number provided by national government authorities may be higher than the actual number of practising anaesthesiologists in any country because some of these anaesthesiologists may be working abroad. The number provided by the National Anaesthesia Societies may not reflect the actual number of practising anaesthesiologists because the list might include honorary and retired members, and not all anaesthesiologists are obliged to join their national society. The data provided in Table 2 is the most reliable data available. The numbers of residents are well regulated and sources are reliable.
This survey has several limitations: the figures given in Table 2 are not ‘full-time equivalents' and, therefore, influence the total number of anaesthesia team members per 100 000 inhabitants of a country; in several countries, some nurse anaesthetists or circulation nurses may be involved in recovery room duties and some may also partly cover the acute pain service and intensive care and consequently, the actual number of these anaesthesia team members working in the operating theatre may not be comparable between countries; similarly, some anaesthesiologists may work in intensive care; due to the recent split of the former USSR and Yugoslavian countries, accurate information from some regions could not be obtained and these were omitted from further analysis; this study was only a questionnaire survey and not an observation or on-site reporting of the actual situation and, therefore, it cannot reflect the skills and knowledge of a specific anaesthesia team member; the theory and practical training of specific anaesthesia team members was outside the scope of this study; the information obtained might differ between the national society, a university hospital and a local hospital within a particular country; and because this area is subject to perpetual evolution, the numbers of personnel will vary according to the timing of the questionnaire.
In conclusion, our survey has revealed that at present, the anaesthesia workforce in Europe is very diverse in name, education, training, certification, and with regard to tasks allocated within the anaesthesia team. Uniformity in training and certification of nurse anaesthetists and circulation nurses in Europe is essential and needs urgent attention, especially where workforce migration occurs. Institutions and hospitals should be given the freedom to work with nurse anaesthetists or circulation nurses, as long as the role and responsibilities of team member are clear and based on strict criteria. These recommendations may become increasingly relevant in view of the imminent shortage of anaesthesiologists in Europe.