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History of anaesthesia: Nurse anaesthesia practice in the G7 countries (Canada, France, Germany, Italy, Japan, the United Kingdom and the United States of America)

Tenedios, Christina; O’Leary, Sian; Capocci, Mauro; Desai, Sukumar, P.

European Journal of Anaesthesiology: March 2018 - Volume 35 - Issue 3 - p 158–164
doi: 10.1097/EJA.0000000000000774
Review
Free

Many factors determine whether nurses, physicians or both administer anaesthesia in any country. We examined the status of nurse-administered anaesthesia in the Group of Seven (G7) countries (Canada, France, Germany, Italy, Japan, the United Kingdom and the United States of America) and explored how historical factors, mixing global and local contexts (such as professional relations, medical and nursing education, social status of nurses, demographics and World Wars in the 20th century), help explain observed differences. Nearly equal numbers of physicians and nurses are currently engaged in the delivery of anaesthesia care in the United States but, remarkably, although the introduction or re-introduction of nurse anaesthesia in the 20th century was attempted in all the other G7 countries (except Japan), it has been successful only in France because of the cooperation with the United States during World War II.

From the Department of Anaesthesia, Harvard Medical School (CT, SO, SPD), Brigham and Women's Hospital, Boston, Massachusetts, USA (CT, SO, SPD) and Unit of History of Medicine, Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University, Rome, Italy (MC)

Correspondence to Sukumar P. Desai, MD, Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA; Brigham and Women's Hospital, Boston, Massachusetts, USA E-mail: sdesai@bwh.harvard.edu

Published online 2 January 2018

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Introduction

The discovery of anaesthetic agents in the mid-19th century has variously been attributed to general practitioner Crawford Williamson Long (1815 to 1878),1,2 dentist Horace Wells (1815 to 1848),3–5 medical student and dentist William T.G. Morton (1819 to 1868),6–8 physician Charles T. Jackson (1805 to 1880)9,10 and obstetrician James Y. Simpson (1811 to 1870).11,12 In 1863, during the Civil War, Catherine Lawrence became the first nurse to administer anaesthesia in the United States.13 Since then, both physicians and nurses have administered anaesthetics in the United States, but practices vary in other nations, ranging from a physician-only model to situations in which individuals with little training provide such care. To bypass the effects of economic factors, we will attempt to explain the variation among a narrowly defined set of wealthy countries – the Group of 7 nations.14 Listed alphabetically, these nations are Canada, France, Germany, Italy, Japan, the United Kingdom and the United States of America. We describe the delivery model for anaesthesia care in these seven nations and provide historical and cultural explanations for observed differences (Table 1).

Table 1

Table 1

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United States

Anaesthesia care in the United States is provided by physicians and nurses who have obtained advanced training in anaesthesia. As of 2016, there were 38 225 anaesthesiologists and 37 376 certified registered nurse anaesthetists (CRNAs) providing anaesthesia in hospital-based surgeries: over 27 million procedures since 2014.15 Physician graduates from medical schools complete state licensing requirements, obtain at least 4 years of residency training and take the certifying examinations of the American Board of Anesthesiology. Minimum qualifications for nurses who wish to train as anaesthetists are a bachelor's degree in nursing or the equivalent, a valid state nursing licence and 1-year experience in critical care nursing.16 As of August 2015, there were 115 training programmes for nurse anaesthetists in the United States.16 The length of the training programme is 24 to 36 months, and students administer an average of 850 anaesthetics while training. In 2014, the National Board of Certification and Recertification of Nurse Anesthetists (NBCRNA) reported 2445 first-time candidates for its Certification Examination. Since 2016, CRNAs are required to participate in a newly established recertification programme verifying maintenance of educational standards. Since 1980, nurse anaesthetist training programmes migrated from a hospital-based to a university-based Master's programme. In 2025, a doctoral degree programme will be fully implemented.17 The scope of clinical practice for CRNAs is defined by the state in which they practise, with at least 16 states allowing independent practice without physician supervision.18,19 Nurse anaesthetists administer all anaesthetic agents and utilise all techniques entailed in general and regional anaesthesia. The United States was the first country in which a professional organisation such as the American Association of Nurse Anesthetists (AANA) clearly issued a ‘Scope of Practice’ document – in 1980.18 The AANA controlled the education and certification process for nurse anaesthetists until 2007, when the NBCRNA was created from the former AANA's council to supervise education and recertification.20

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United Kingdom

British tradition limits the administration of anaesthesia to surgeons and physicians, excluding nurses. As of 2015, there were more than 14 000 physician anaesthetists in the United Kingdom, half of whom were fully trained consultants.21 Currently, the anaesthesia care team includes another three roles: physicians’ assistant (anaesthesia) [PA(A)], operating department practitioner (ODP) and anaesthesia/recovery room nurses. However, the PA(A) is the only category of other provider who administers anaesthesia in the United Kingdom. According to the Royal College of Anaesthetists, PA(A)s are practitioners providing general, regional and local anaesthesia under the direction and supervision of an anaesthetist. Physician anaesthetists supervise PA(A)s in two rooms, or a PA(A) in one room and an anaesthetist in training in the other room in a 2 : 1 model. This team approach has been in use since 2004 to offset a predicted shortage of anaesthetists. Development and competencies of PA(A)s are the responsibility of the Royal College of Anaesthetists. To enter PA(A) training, one must be a healthcare practitioner (nurse or ODP etc.) or have a health sciences or biomedical science degree. As of 2015, approximately 165 PA(A)s practise in the United Kingdom.22

ODPs are assistants across all phases of the peri-operative period from the pre-anaesthetic phase, through the surgical phase and into the recovery phase. They have either a 2-year diploma or a 3-year degree in operating department practice from a university.

Although their duties include setting up machines, IV lines and monitoring patients, they do not perform pre-operative assessments or administer medications. ODPs may also assist the surgeon in setting up instruments and equipment, act as liaisons between the surgical team and the rest of the hospital, and undertake the role of a scrub nurse. During the recovery phase, ODPs may monitor the patient and provide support through recovery from anaesthesia until discharge from the recovery ward.23

In the third role, there are 5400 recovery/anaesthesia nurses currently working with physician anaesthetists.24 Registered nurses (RNs) may qualify after 9 months of work with a mentor. Depending on the institution, individual experience and expertise, their duties may include tracheal intubation, intravenous cannulation, administration of medications and tracheal extubation. Typically, these anaesthesia nurses monitor and provide care for patients in the recovery room (some patients may still be mechanically ventilated), sometimes without physician supervision. They may also manage the airway during cardiac arrest. Other duties include conducting preoperative and postoperative rounds on surgical patients. The British Anaesthetic and Recovery Nurses’ Association is their professional association and practice is regulated by the United Kingdom's Nursing and Midwifery Council.24

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France

At the outbreak of World War II, training of nonphysicians was established to provide anaesthetists for the army.25 The first nurse anaesthetists were pioneers in the anaesthesia specialty, purchasing their own equipment and medications, studying anaesthesia abroad and were unsupervised. French surgeons were in favour of nurse anaesthetists and helped them to obtain the right to practise from the Ministry of Health.25 Since 1948, training schools for nurse anaesthetists have been established. However, this situation created competition and some conflict with physicians, some of which persists to this day.25,26

Currently, the model of anaesthesia delivery in France bears many similarities to that in the US. Nurse anaesthetists are known as Infirmier Anesthésiste Diplômé d’État (IADE). In 2014, there were 8500 nurse anaesthetists and 8800 physician anaesthesiologists, and they provided care for 8.5 million procedures.27 RNs with 2 years of experience, preferably one of which was in critical care nursing, may apply for an entrance examination prior to commencing anaesthesia training. There are currently 27 training programmes whose duration is 2 years, after which candidates sit for a national examination to obtain the National Diploma of Nurse Anaesthetist. IADEs work in a supervised role (a physician anaesthetist must establish the anaesthetic, and she/he must be able to intervene at any time), but administer general and regional anaesthesia (reinject local anaesthetic through a device placed by anaesthesiologist) and participate in peri-operative resuscitation. The French union of nurse anaesthetists is called Syndicat National des Infirmiers Anesthesistes,28 and their role is defined within the Code de la Santé Publique (National Law of Public Health, 1978), last amended in 2017 (Decree number 2017-316, dated 10 March 2017).

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Germany

Anaesthesia became a medical specialty in Germany long after it did in other countries. Surgeons usually controlled the administration of anaesthesia by junior colleagues or nurses. The shortage of trained medical officers during both World Wars entailed the practice of unspecialised nonmedical individuals administering anaesthesia, including nurses. This practice was ‘expressly considered a compromise of the fine art of anaesthesia under the pressure of war circumstances’, although the high war casualties meant that nurses continued to administer anaesthesia under the authority of the surgical team.29 In the 1950s, the German Nurses Association decided that the administration of anaesthesia could not be the responsibility of nurses and should be performed only by physicians. However, German nurses were still providing anaesthesia care in small and rural hospitals until the 1970s.29 A 1996 report indicated that there were at least 290 nurse anaesthetists in the former West Germany (among over 6000 anaesthesia providers).30,31 Currently, anaesthetics in Germany are administered almost entirely by physician anaesthesiologists.

In addition, anaesthesiologists collaborate with practitioners called ‘anaesthesia nurses’ whose duties include preparing the anaesthesia machine and medications, and assisting in critical situations. State law does restrict anaesthetic responsibility to physicians, and nurses may assist anaesthesiologists and maintain anaesthesia in uncomplicated cases, without special training or any involvement in clinical decision-making.30 Programmes for the education of Anaesthesia Technical Assistant were introduced in 2004, creating new anaesthesia professionals without nursing training.

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Italy

Until the end of World War II, anaesthesia was not known as a medical specialty in Italy (though a Society of Anaesthesia and Analgesia was founded in 1934, gathering interested physicians and surgeons) and was usually provided by nurses and junior surgeons. It evolved into a speciality (finally established in 1948) when surgeons sought to improve their techniques, and enlisted junior residents to learn more about anaesthesia through studying in the United States and the United Kingdom.32 Professional specialisations for nurses were introduced in 1940, with 1-year courses after obtaining a nursing diploma. Nurse specialisation in anaesthesia was introduced in 1969, although, a decade later, new rules cancelled the role of nurse anaesthetist.33 Today, a few master courses (12 to 14 months) are available for nurse training in anaesthesia and resuscitation, though there is no formal recognition for nurse anaesthetists. Anaesthesia is still administered by physicians, assisted by nurses (with no mandatory training, though field experience may be recognised to coordinate rotations in hospital duties). Participation by nurses is limited to monitoring vital signs and reporting clinical progress to the anaesthesiologist, before, during and after surgery.

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Japan

In the 1950s, after meetings with medical educators from the US, anaesthesia became a specialty in Japan. Before that, surgeons had administered their own anaesthesia, following the influence of the German medical education system (adopted in Japan in the second half of the 19th century).34–36 However, it was realised that trained anaesthetists were essential for more complicated operations.37 Although nurse-administered anaesthesia has been suggested, some oppose it, citing ‘medicolegal issues’, or the need to ‘maintain high medical standards’.37 As a result, anaesthesia is administered only by physicians and there are no training programmes for nurse anaesthetists. However, shortage of trained anaesthetists in rural areas is a concern for Japan's Ministry of Health, Labour and Welfare. The ministry has proposed the introduction of nurse anaesthetists, but both the Japanese Society of Anaesthesiologists (JSA) and the Japanese Association of Nursing were against the proposal. Moreover, the government lacks resources to establish a training programme for nurse anaesthetists.38 In small rural hospitals, in the absence of anaesthesiologists, surgeons have developed considerable expertise and experience in the administration of anaesthetics. In such settings, it is possible that nurses may be participating in anaesthetic care, under the supervision of the surgeon.

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Canada

The first anaesthetic was administered in Canada in New Brunswick on 18 January 1847.39 As Canada was a British colonial province at the time, Canadian anaesthesiology was linked to the physician-based practice in the United Kingdom.40 In the early 20th century, due to the shortage of anaesthetists and the flexibility and skill of available nurses, nurses administered anaesthetics in rural settings in this vast and sparsely populated nation.41 No formal training programmes for nurse anaesthetists appeared in Canada, and it is believed that nurses have been excluded from anaesthesia practice for medico-legal reasons.41 In a recent attempt to decrease surgical waiting times, the role of the nurse anaesthetist was re-evaluated: the University of Toronto developed a ‘Nurse Practitioner in Anesthesia’ (NP-A) pilot programme. There were four students in the first class in 2009. A formal curriculum was implemented, and after the intense 600 clinical hour year−1 training programme, three students graduated in 2012.42 The programme has been discontinued due to insufficient student interest.

Another anaesthesia provider exists: the anaesthesia assistant. Anaesthesia assistants have been utilised in Quebec since 2005 in an attempt to meet the shortage of anaesthesia providers.42,43 This role functions under the direct supervision of an anaesthetist, and practitioners undertake preoperative and postoperative assessment, as well as anaesthesia (i.e. induction, maintenance and emergence from anaesthesia). Training is 2 years long, resulting in a graduate certificate. For admission into the programme, one must have 2 years of critical care experience as a registered nurse, or be a respiratory therapist, the latter category making up the majority among graduate anaesthesia assistants.

Although it is theoretically possible that nurses might once again administer anaesthetics in the NP-A role in Canada, anaesthetics are currently administered only by physicians and anaesthesia assistants (who may or may not be RNs).44

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Discussion

The Group of 7 – created in 1976 – represents the world's seven largest industrialised economies.14 For our present aim, this group of nations can be considered as homogeneous in regard to macroscopic medical development (though with striking differences in regard to access to healthcare), and increasingly integrated with respect to medical professionals. However, anaesthesia administration exhibits sharp differences. Historical and geopolitical factors help explain some of these differences.

Until the advent of antisepsis, anaesthesia in surgery was limited.45,46 However, major military events such as the Crimean War (1853 to 1856) in Europe47–49 and the Civil War (1861 to 1865) in the United States50–53 provided an important testing ground and generally saw the expansion of anaesthesia in military as well as in civilian operations.54 It is not clear whether nurses administered anaesthesia during the Crimean War, but in the United States, nurses were involved in the administration of anaesthesia during the Civil War.55 In Europe, during the Franco–Prussian war (1870 to 1871), nurses were taught to administer anaesthesia.55

A major factor supporting the development of the nurse anaesthesia profession was the reluctance on the part of physicians in the late 19th century to engage in the practice of anaesthesia. At the turn of the 20th century anaesthesia did not seem challenging, interesting or financially lucrative and, especially in the United States, few medical practitioners could make a living practising anaesthesia exclusively (particularly outside large cities).56–63 A letter from the Dean of Harvard Medical School to the President of Harvard University in 1906 reads: ‘The practice of anaesthesia is so narrow a subject that a good man would not want to tie himself down to that and would hardly be willing to do so’.62,64 The administration of anaesthesia was usually delegated to a junior member of the surgical team, a medical student, or nonmedical personnel.55,65,66 Formal training in anaesthesia started at the turn of the century, though certification was introduced later.

According to Thatcher's reconstruction, such problems paved the way for nurse anaesthesia in the United States, as nurses – and especially Catholic nurses – were willing to accept a subordinate role and comparatively low wages.55 As a result, since the 1880s, several Catholic Hospital sisters were trained to administer anaesthesia (among other nursing duties) and imparted informal training to other nuns and nurses, establishing a tradition in nurse anaesthesia.55,67–72 Only in 1909 did the first school for nurse anaesthesia open in Portland, Oregon and three more institutions trained nurse anaesthetists before the beginning of World War I.64

By the time World War I began, nurses as well as physicians were administering anaesthesia in most parts of the United States.73 The World Wars brought a tremendous demand for anaesthetists73–76 and members of both professions worked together – a practice that continues today. However, over the past decade, some states have allowed the independent practice of anaesthesia by nurse anaesthetists. After World War II, the number of physician anaesthesiologists increased rapidly, due to changes in the Medicare and Medicaid billing system: in 1949, CRNA numbers were twice those of physician anaesthesiologists, but by the late 1980s, physicians outnumbered nurses.77

In Europe, research and debate over the science of anaesthesia had been lively since its inception, especially about the frequent undesired side-effects experienced with chloroform, including the sudden death of the patient.78–80 Thanks to a favourable cultural context, chloroform anaesthesia gained popularity among the medical community and the lay public.81,82

In England (but not in Scotland), the early adoption of chloroform and regulations about death reporting may have been the main reasons behind the need for physician anaesthetists.81 Already in 1853, a jury investigating the death of a 28-year-old woman in University College Hospital (London) due to chloroform anaesthesia administered by the house surgeon, recommended ‘more precaution ought to be used when chloroform is administered, by a person of experience being present during its administration’.83 This approach favoured medical specialism, though outside large city hospitals underqualified individuals often administered anaesthesia under the surgeon's supervision.

In Britain, the development of anaesthetic techniques and the shortage of qualified medical personnel during both World Wars led to the integration of nurses into the specialty. During World War I, some hospitals started to train nurses in all anaesthetic procedures, including emergency anaesthesia ‘in case a professional administrator should be unprocurable’.84 Although nurses’ work freed medical officers for duties on the front line, physician anaesthetists protested believing anaesthesia ‘administration should be done by a doctor with proper training’. After the end of World War I, a physician even warned his colleagues about ‘the danger…in perpetuating this system’.85 Due to the lack of support from physicians and governing authorities, the contribution made by nurses received little recognition.29

Although some of the nurse anaesthetists remained in service until the early 1950s,86 there is no evidence that British nurses continued to be trained in anaesthesiology after the end of World War I. The General Nursing Council believed such training impossible, as they would need supervisors from the medical profession (physician anaesthetists), which strongly opposed such participation. The matter has been revisited during subsequent times of shortages, but policy makers always presumed that patients preferred to receive anaesthesia care from a specialist physician.29 In 1935, the Diploma in Anaesthetics was introduced, so that general practitioners could prove their competence – and could raise their medical status.87

World War II challenged once more usual peace time practices. The US Army employed ‘A good many medical officers who had had little, if any, special preparation in anaesthesia. In general, this was not a satisfactory plan’.88 The employment of nurses – after adequate training – was thus mandatory.64,75,89 This approach was successfully transplanted to France (together with several other medical strategies),90 and persisted after 1945, although with stricter limits to the nurse anaesthetist actions. Attempts in France in the 1950s and 1970s to bring back physicians’ complete control of anaesthesia failed.

Anaesthesia care in Germany and Italy was heavily influenced by surgeons, with a major emphasis on regional anaesthesia for most operations. In Germany, specialisation in anaesthesia proved to be very difficult, with surgeons employing unqualified staff to administer anaesthesia under their direction.29 Both in Germany and Italy, training programmes for physician anaesthesiologists were only developed after World War II. A similar situation prevailed in Japan, with surgeons administering anaesthetics until training programmes for anaesthetists were established after 1945. Even when shortages in qualified personnel occurred, strong opposition from the JSA limited the practice of anaesthesia to physicians. In Italy and Japan, social issues reflecting sex-based hierarchies and the low socio-economic status of nurse professionals also help explain the absence of nurse anaesthesia.33,91

In Canada, the medical education system was closely related to the British one, and it maintained higher ideals and standards compared with the United States92,93 and closer ties with academia. Furthermore, as Canada was a colony when anaesthesia was introduced, regulations and standards leaned towards the British tradition. As in United Kingdom, Canadian nurse anaesthetists employed in the army during the World Wars simply returned to civilian life, discontinuing their anaesthesia practice.94,95

In the United States and France, the number of physicians and nurses devoted to the full-time practice of anaesthesia is currently evenly matched. In both nations, professional associations are strong and politically active and the joint model of anaesthesia care delivery – involving competition between the two groups – is expected to continue.

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Summary

Medical changes occur in a social context, and our study serves as a good example. We have shown sharp differences in how anaesthesia services are delivered in similarly affluent modern nations. Beside the primary explanations offered, other factors may have had a role in creating this diversity: the academic teaching of medicine vs. the apprentice/proprietary model in US medical schools, socio-demographic traits that enhanced the empowerment of professional nurses (e.g. the geographical distribution of the population and the ease in accessing healthcare institutions), the power relationships between nurses and physicians and others.

We described above several efforts by governments to introduce new anaesthesia providers under supervision by physicians, implementing a team approach. Despite studies showing that there is no difference in safety among the different approaches,96,97 such efforts had mixed outcomes against the diverse backgrounds.

In the Group of 7 countries, the increase in healthcare expenditure is now probably the major force driving the evolution of healthcare delivery. In an attempt to both decrease the costs of delivering care and increase the access to care, many tasks that were previously performed by physicians are being transferred to nonphysician providers. Will anaesthesia follow in the same path in the five Group of 7 countries without nurse anaesthesia? Other factors remaining unchanged, the future will reveal whether economic factors will change the status of nurse anaesthesia in the Group of 7 countries.

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Acknowledgements relating to this article

Assistance with the review: none.

Financial support and sponsorship: departmental funds.

Conflicts of interest: none.

Comment from the Editor: this Editorial is part of the ‘History of Anaesthesia’ series that is edited by Dr Alistair McKenzie.

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