Growth in an Anesthesiologist- and Nurse Anesthetist-Supervised Sedation Nurse Program Using Propofol and Dexmedetomidine

In 2007, the Department of Anesthesia at the University of Iowa established an anesthesiologist-supervised nurse-managed sedation program. In 2008, the use of propofol and dexmedetomidine by nurses was approved in Iowa. We reviewed 11,038 elective sedation cases done between January 1, 2007, and June 30, 2014. Caseload increased from 170 to 470 cases/quarter. Propofol use increased from 0% to approximately equal to 70% of cases and dexmedetomidine from 0% to approximately equal to 25% of cases. There were no safety issues. The number of nurses working each day (on average) increased from 2.2 to 4.7, but supervising providers remained at 1/day. There were no changes in general anesthesia or monitored anesthesia care cases performed for comparable procedures. Trained, supervised nurses can safely administer propofol or dexmedetomidine to selected patients for a wide variety of procedures.

The first men in leadership positions in the american association of nurse anesthetists

PURPOSE

This exploratory study focuses on the American Association of Nurse Anesthetists. It sheds light on the process by which men gain access to leadership positions in a female-dominated setting. It also expands the narrative of the professional association's history.

CONCLUSIONS

As soon as men became eligible for membership in 1947, they gained access to leadership positions in disproportionate numbers and at a faster pace than women at the national level and in a number of states. The specific pattern of findings is consistent with volitional relational practices, suggesting that women facilitated the integration and empowerment of male colleagues who constituted a small minority in the association.

MANAGEMENT IMPLICATIONS

The paper discusses the need to understand and manage the interactions between relational practices that are gendered female and views of leadership as male-gendered.

Toward globalization of a profession

The International Federation of Nurse Anesthetists [IFNA] has been striving to promote quality education and practice standards since it began in 1989. Many organizations throughout the world have recognized these efforts including the International Council of Nurses. This Guest Editorial summarizes IFNA's achievements and introduces IFNA's new initiative to enhance the quality of anesthesia care worldwide through an approval process for education programs.

Economics and the education of nurse anesthetists: Part 2

Economic assumptions and other factors affecting the economics of nurse anesthesia education are presented in Part 2 of this 2-part column. In Part 1, published in the October 2004 issue of the AANA Journal, general economic principles and healthcare economic principles in particular were described, explained, and related to the current US healthcare system.

New ways of working in anaesthesia

Change and the NHS are synonymous; it is inevitable that new ways of working are explored to ensure an effective service. This article explores the possibility of using nonmedically trained anaesthetists in the operating theatre. It examines a current pilot being undertaken by the NHS Changing Workforce Programme (DoH 2002a) and discusses how much impact this is likely to have in theatre.

An American tale - professional conflicts in anaesthesia in the United States: implications for the United Kingdom

Professional conflict between nurse anaesthetists and anaesthesiologists in the United States of America is well known in the UK but has not been explored and documented in detail. We present an account, based on critical analysis of published literature and other documentary evidence, of the historical, professional and financial factors which have led to this. In the USA, anaesthesia developed as a nursing specialty until physicians began to take on this work after the Second World War. Payment arrangements between the 1960s and the 1990s made anaesthesiology a lucrative career choice for medical graduates and this led both to considerable growth in the number of anaesthesiologists and to a strengthening of the resolve of nurse anaesthetists to retain their scope of work and preserve their professional status. Changes in payment regulations in the 1980s and 1990s threatened anaesthesiologists' income and led to re-appraisal of evidence over relative cost-effectiveness and safety of different provider models. More recently, the terms of engagement have shifted from disputes over evidence to political lobbying to promote the professional capabilities and status of each of the anaesthesia providers. Factors of relevance to possible changes in the provision of anaesthesia in the United Kingdom are highlighted.

Nurse anesthesia research: a follow-up study

We describe a follow-up study comparing nurse anesthesia research in the 1990s with findings of a previous study. Research reported in the AANA journal in 1995 and 1996 (n = 38 studies) was compared with the earlier description of research from 1985-1986 (n = 18) and 1975-1976 (n = 14) periods. The amount of research published in the Journal has increased steadily, with a stable focus on clinical practice. In addition, there has been an increase in educational and safety-related research reported. In an attempt to locate research published in other nursing and medical journals, we found and reviewed additional articles (n = 28) authored or coauthored by CRNAs during the 1995-1996 period. By the 1990s, all studies demonstrated at least 1 indicator of theoretical orientation. Convenience samples of hospitalized patients were the most common type of sample. As in the earlier study, there was minimal reporting on reliability and validity of data and the psychometric evaluation of instruments. Recommendations include increased emphasis on methodological studies, multisite studies, programs of research, and collaboration among CRNAs, nurses in other specialties, and people in other disciplines.

The state of ambulatory surgery and perianesthesia nursing

The continued success of the ambulatory surgery environment of care has been achieved through patient, physician, and nursing staff satisfaction. The growth in this industry has been greatly influenced by advances in technology, as well as the development and administration of newer anesthetic agents. The implications delineated in this article provide an overview of what is in store for the specialty of perianesthesia nursing. Issues of competency, professional excellence, patient expectations, continuous quality improvement, research, and ethics have become part of the daily lexicon. Never before has the professional nurse been counted on for so much, and future expectations of the nurse continue to grow. To survive, the nurse needs to expand the boundaries of nursing practice as they have been defined. Nurses are the backbone of the delivery of patient care, nurses are on the front line guiding the patient through every care decision, and nurses are positioned to influence the continued evolution of ambulatory surgery and perianesthesia nursing care.

A critique of Michael L. Millenson's book, Demanding medical excellence: doctors and accountability in the information age, and its relevance to CRNAs and nursing

Michael L. Millenson's well-documented book, Demanding Medical Excellence: Doctors and Accountability in the Information Age, is a wake up call to both medicine and nursing for somewhat different reasons. Millenson decries the lack of scientific-based medical practice and medicine's failure to wake up due to its own historical studies. He cites data that 85% of current practice has not been scientifically validated despite medicine's claims of the physician-scientist. He outlines a historical chronology of advocacy for better practice based on concerns and studies that demonstrates significant differences in patient outcomes, adjusted for case mix, across hospitals studied. Millenson advocates the development of a broader base of benchmarking and best practices, reflected in clinical practice guidelines, recognizing the resistance of physicians to their use. He further advocates incorporating more fully information-age computers in the delivery of quality care by programming them to the tasks they are best suited for in informing and alerting us to flawed memories, orders, and abnormal laboratory and radiologic data. The relevance of Millenson's book to CRNAs and nursing in general is twofold: (1) He discusses the National Halothane Study and the subsequent Stanford Institutional Differences Study. The latter study confirmed what was found in the National Halothane Study concerning significant differences in patient outcomes across studied hospitals but did not address the role of the hospital's primary anesthesia provider, anesthesiologists, or CRNAs in these differences, as did the latter. He addresses the lack of publication and dissemination of the institutional outcome differences of these studies performed in the 1960s and 1970s, but he does not address the anesthesia provider portion of the Stanford Study. (2) While Millenson does mention nursing briefly and advocates its involvement in clinical practice guideline development, he does not discuss the profession's own concerns about the lack of scientific validation of our nursing practice. Research serves as a principal cornerstone for scientifically based clinical practice guidelines or best practices. Millenson and others address some of the problems associated with current research and the problems associated with the peer review system in the publication of methodologically flawed and politically motivated published studies. The Abenstein and Warner study in Anesthesia and Analgesia in 1996 is a prime example of the latter. A recent British Medical Journal editorial characterized medical literature as disorganized and biased (BMJ.1998;317[7152]:160). It further cites a study that found that over 95% of articles in medical journals did not meet minimum standards for quality or clinical relevance. While that figure may be high, we know that flawed and biased research is within the MEDLINE database, even though some studies have been retracted based on overt fraud. However, retraction has not stopped other researchers or practitioners from publishing retracted research in their own publications. Consumers of MEDLINE should be aware of this problem and be prepared to question the validity of research prior to adopting their conclusions. In the development of "best practices," flawed research may be as bad as personal biases and flawed memories. The potential adverse implications of flawed research for scientifically (evidenced) based practice and for health policy decisions by government and health payers with regard to the delivery of health services and its reimbursement requires that all involved do a better job of assuring that only valid, methodologically sound, and unbiased research is published, is included in the MEDLINE database, and is used in the care afforded to people in need.

The nurse anesthesia profession. A past, present, and future perspective

The author presents a very detailed description of the history of the nurse anesthetist, including a time line of important dates in history. Discussion of the present state of affairs in nurse anesthesia centers around the practice setting, requirements for attaining Certified Registered Nurse Anesthetist (CRNA) status, and educational qualifications and capabilities. The article ends with a brief history and current status of the American Association of Nurse Anesthetists as well as a discussion about the future of the CRNA.

The development of anaesthetic and recovery nurse education

The development of education for anaesthetic and recovery nurses is a relatively recent concept. Until the mid 1980s, anaesthetic and recovery nursing education in Britain was seen as an integral part of theatre nursing. Therefore, in order to trace the developments in anaesthetic and recovery nursing, it is necessary to explore the development of the role of the nurse in theatre.

Factors influencing nurse anesthesia educational programs: 1982-1987. Report of the National Commission on Nurse Anesthesia Education

Factors that affected nurse anesthesia educational programs between 1982 and 1987 are examined to determine their effect on school closings and on those schools that are still in operation. Findings are cited, and recommendations for future action are made.

Perceptions of CRNAs: current and future roles--Part II

The purpose of this study was twofold. First, to identify current roles and future role perceptions for Certified Registered Nurse Anesthetists (CRNAs) using the delphi methodology. Second, to analyze the level of agreement or disagreement of anesthesiologists and CRNAs with the identified roles. A survey instrument was developed using the delphi methodology which involved five CRNAs and five anesthesiologists. The instruments with a dimensional rating scale were labeled "Current Roles for CRNAs" and "Future Role Perceptions for CRNAs." The former instrument contained 26 items and the latter contained 28 items. Participants in this study were randomly selected from the active memberships of the American Association of Nurse Anesthetists and the American Society of Anesthesiologists. Usable responses were obtained from 369 of the 684 CRNAs and 354 of the 1,400 anesthesiologists. Analysis of the data revealed there were significant differences between the two professions on all roles. There was evidence of extreme polarity on roles relating to expanded practice, independent practice, the role of CRNAs on the anesthesia care team, and nontraditional practice settings. CRNAs differed from anesthesiologists in their role as nurse anesthesia educators. Anesthesiologists who worked with CRNAs were influenced in their support of CRNA roles, except for roles in independent and expanded practice, and responded differently from anesthesiologists who did not work with CRNAs. The conclusions were as follows: 1. CRNAs and anesthesiologists differ in support for expanded practice in both current and future perceptions. 2. CRNAs and anesthesiologists differ on the issue of independent practice. 3. The perception of anesthesiologists relative to the anesthesia care team appeared to be influenced by a working relationship with CRNAs.(ABSTRACT TRUNCATED AT 250 WORDS)