Fig. 36.1
Magaw at the head of the table, giving what appears to be ether anesthesia. (Courtesy of the American Association of Nurse Anesthetists Archive.)
In the article, Magaw said:
I gave in a brief way our method of administering ether and chloroform. This is a method we have found, after several years’ experience, to be the most satisfactory. I shall only report the cases on whom this method was used during this last year. I can report that out of this number, 1092 cases, we have not had an accident; we have not had occasion to use artificial respiration once; not one case of ether pneumonia; neither have we had any serious renal results.
Magaw also wrote, “That it is believed that if ether is given with plenty of air and the drop method, there are few, if any, bad results…the mortality can be much diminished by the careful selection of the anesthetic [4].”
Magaw reported administering open-drop chloroform and ether without a fatality attributable to the anesthesia, a considerable feat given a death rate due to anesthesia of perhaps 1:2000 in later years. Surgeons sent nurses to observe and learn from Magaw [4]. In December 1906, she published a review of her work inSurgery, Gynecology, and Obstetrics:
“At St. Mary’s Hospital our preference has always been ether. In 14,380 anaesthetics given by me, I have yet to see a death directly from the anaesthetic, but, no doubt, have had my share of trouble in its administration, although artificial respiration with us is almost unheard of. In my series of cases, the ‘open Method’ has been the method of choice. We have tried almost all methods advocated that seemed at all reasonable, such as nitrous oxide gas, as a preliminary to ether (this method was used in 1,000 cases), a mixture of scopolamine and morphine as a preliminary to ether in 73 cases, also chloroform and ether, and have found them to be very unsatisfactory, if not harmful, and have returned to ether ‘drop method’ each time, which method we have used for over ten years. [5]”
In 1908, surgeon George Crile (1864–1943), at Lakeside Hospital in Cleveland, subsequently the teaching hospital for Case Western Reserve University, asked Agatha Hodgins (1877–1945) to become his personal anesthetist. Hodgins perfected administration of nitrous oxide-oxygen anesthesia, and Crile recalled,
“In 1909 I was able to report before the Southern Surgical and Gynecological Association that Miss Hodgins had administered nitrous oxide in 575 major operations, and in August 1911, I reported before the American Surgical Association, 10,787 surgical operations performed by me under either ether, or nitrous oxide supplemented by ether, with no anesthetic death. I reported also the use of morphine and scopolamine as adjuncts to ether or nitrous oxide anesthesia in over three thousand operations. [2]”
Between 1909 and 1915, local and visiting surgeons at Lakeside Hospital were sufficiently impressed by Hodgins’ talent that they sent their nurses to be trained by her. She thus became a major participant in the education of physicians and nurse anesthetists at Lakeside Hospital [6,7].
The contributions of America’s nurse anesthetists to care in surgical units and hospitals during World War I increased the demand for nurse anesthetists after the war. The war prompted the first US military effort to train anesthetists. Nurses were taught anesthesia in 6-month on-the-job training programs, at four formal educational centers: St. Vincent’s Hospital, Portland, OR (1909); St. John’s Hospital, Springfield, IL (1912); The New York Post-Graduate Hospital, New York City, NY (1912); and Long Island College Hospital, Brooklyn, NY (1914). A diploma was issued upon completion, but there was no mention of an assessment or graduation examination.
After World War I, new nurse anesthesia educational programs moved into university hospitals and major community hospitals [1]: Johns Hopkins, Baltimore, MD (1917); the University of Michigan, Ann Arbor, MI (1919); Charity Hospital, New Orleans, LA (1917); Barnes Hospital, St. Louis, MO (1917), Presbyterian Hospital, Chicago, IL; Grace Hospital, Detroit, MI (1918); Grady Memorial Hospital, Atlanta, GA (1918); St. Joseph’s Hospital, Tacoma, WA; St. Mary’s Hospital, Minneapolis, MN; and Lakeside Hospital, Cleveland, OH (1915). The programs took 3 to 6 months, and there were no certification examinations upon completion.
The 6-month training programs initiated by the Armed Forces in World War II, and the subsequent 3- to 6-month civilian programs noted in the preceding paragraph established the minimum duration of required training (Fig. 36.2). In 1951, the requirement increased to a minimum of 1 year, and in 1962 became 18 months. This trend continued to the 1990s, at which time programs required a master’s degree that demanded 24 to 36 months of training [8].
Fig. 36.2
Beginning with World War I, the required duration of training for nurse anesthetists was approximately 6 months, growing in roughly 6-month increments consistent with the need for progressively greater knowledge and skills
In 1930, at the biennial American Nurses Association (ANA) convention, Agatha Hodgins asked the ANA for recognition of nurse anesthetists as a subgroup within the organization. The ANA declined, as the ANA organizational structure did not envision such a possibility. Hodgins then led in the formation of a national professional organization for nurse anesthetists. The process began with the formation of the Lakeside Alumni in 1923. At the first Alumni meeting, Hodgins presented a plan for a national organization of nurse anesthetists. A tentative constitution and bylaws were drawn up, but not until 17 June 1931, in the Department of Anesthesia at University-Lakeside Hospital in Cleveland, was the organizational meeting for the proposed association held. A motion was proposed that a national association be formed, and the motion passed to form the National Association of Nurse Anesthetists (NANA). The NANA became, thereby, the oldest specialty nursing organization in the US. The early aims of the NANA were to place qualified anesthetists, supply continuing education, and provide professional recognition [1].
The 1930s
Because Hodgins became ill, Gertrude Fife (1902–1980), assistant director of the School of Anesthesia at University Hospitals in Cleveland, assumed a leadership role in the newly formed NANA. As president of the NANA at its first meeting in September 1933, Fife spoke on “The Future of the Nurse Anesthetist.” She called for “establishment of a national board of examination for nurse anesthetists, arguing that such an examination would certify to surgeons that nurse anesthetists’ knowledge in their field met the approval of an examining board – a board chosen and functioning to safeguard the interests of surgeons, hospitals, and the public [9].” At this first convention, the trustees established minimum standards for schools of anesthesia, specifically: duration of course, 4 months; number of cases of clinical experience, 250; and hours of class instruction, 75.
The second annual NANA meeting, in 1934, saw the appointment of an Education Committee to study the feasibility of establishing a national examination for nurse anesthetists, and standards for schools of nurse anesthesia. Fife observed that:
“We must find a way whereby the hospitals and surgeons who employ nurse anesthetists can be assured that they have received the proper training, and are qualified to do the work” [10]. “An examining board should be chosen and every applicant applying for membership in the organization should be required to pass an examination. The examining board would be responsible for the preparation of the examination – the arrangements whereby the examination would be taken within the State – and responsible for the final decision which would allow the National Association to issue to the individual who successfully passes the examination a certificate signifying that the individual is sanctioned by this organization.” [10]
Although state board registration could have accomplished this end, Fife reasoned that such registration was impractical; a national solution was needed. The national examining board she envisioned would (1) prepare the examination, (2) arrange for examination locations in each state, and (3) award certificates to successful candidates [10].
At the fourth annual meeting, in 1936, the NANA Education Committee continued to pursue its goal of establishing a national board of examiners, one that would be recognized by organizations that depended on nurse anesthetists. The Committee’s report emphasized that a national examination and certification of nurse anesthetists should be compatible with professional trends in associated branches of medicine, including the newly created American Board of Surgery and the Council on Dental Education. Both organizations had been established in part for certification purposes [11]. The Education Committee’s discussions with members of the American Board of Surgery and the American Hospital Association (AHA) suggested that those organizations would endorse the proposed examination for nurse anesthetists, and the inspection and accreditation of schools in anesthesia, as well as an examination and/or certification of currently active nurse anesthetists [12].
By the sixth annual meeting, in 1938, the Education Committee had (1) compiled a list of schools offering training in anesthesia to graduate nurses; and (2) obtained AHA endorsement of NANA plans for the inspection of schools of anesthesia for nurse anesthetists. On the basis of that inspection, the NANA foresaw that the AHA would approve those schools having curricula equivalent to the standard already adopted by the AHA [13].
In 1939, interest in nurse anesthesia as a career received a major endorsement in “Anesthesia – a Career,” in the August issue ofRN Magazine. The article drew 400 inquiries [14]. That year also saw formalization of a vital aspect of the anesthesia curriculum: Training in anesthesia programs had to be at least 6 months, and a NANA Curriculum Committee was formed to evaluate and present a curriculum in keeping with progressive education. Finally, in that year, the NANA resolved to change its name to the American Association of Nurse Anesthetists (AANA) [15].
From 1933 through the 1940s, the AANA studied ways to ensure the quality of the programs offered by schools of nurse anesthesia. In cooperation with the American Hospital Association, education committees of the AANA initiated efforts to establish a program for the inspection of schools. In 1945, the AHA’s Council on Professional Practice proposed to put the program into operation. Representatives of the AANA and the AHA met in 1946, and recommended that the AANA, rather than any other agency, initiate the program. To undertake this action, the AANA board of trustees appointed an Approval Committee (to certify the quality of each school). Workshop conferences and the preparation of questionnaires preceded initiation of the program of school inspections. For the initial inspection of schools, the AANA board of trustees would appoint advisors from the field of adult education, and these advisors, with a nurse anesthetist, would visit each school of anesthesia to recommend accreditation. As originally envisioned, schools would be revisited at three-year intervals. This program of school evaluation was put into effect in the 1950s [8].
The 1940s
In 1940, AANA president Miriam Shupp (1901–1988), noted that a national examination of applicants could be used to measure their eligibility for AANA membership. “We have,” she said, “arrived at that period in our development when this project can and should be put into effect to assure the members of AANA and those who employ nurse anesthetists that only properly qualified people are being admitted to membership [16].” Such a requirement had immediate appeal. It would motivate schools of anesthesia to improve their instructional programs, and the success of their graduates on the national examination would provide a measure of each school’s quality [16].
At the ninth annual meeting, in 1941, AANA president Helen Lamb (1899–1973), envisioned development and operation of a national examination program by early 1943. The Education Committee laid the groundwork by requesting question sets from schools of anesthesia for use in the examination. Selection of the actual questions for the examination would be the responsibility of the yet-to-be-named examining board [17].
The AANA board of trustees appointed a Certification Program Committee, to plan for the examination of association members. A potentially contentious plan was to test anesthetists who had extensive experience in administering anesthetics but were not graduates of an approved school of anesthesia [18]. A 1942 resolution by the Certification Program Committee avoided this controversy, and was adopted by the AANA. The resolution required all AANA members to be certified by examination, except that the examination requirement would be waived for currently active members [19].
World War II, A Turning Point
World War II accelerated the coming of age of all anesthesia providers, nurses and physicians alike. Because the war drained the country of such providers, hospitals all over the US scrambled to fill the void, coping with the shortage in diverse ways. Some looked to the AANA’s standards as criteria for training their students. However, because the AANA had no control over the quality of instruction, it was deeply concerned that those standards might not be met. How could the AANA ensure that these variously trained practitioners possess the skills required to safely provide anesthesia? [20]
Until the Examination Program came into being, the AANA knew little about the anesthesia programs being offered by schools around the country. What knowledge the AANA did have, was pieced together from questionnaires completed by program directors, information on applications for membership, and a fledgling school-visit program that the war had curtailed. There was great uncertainty about the adequacy of graduates applying for membership, because of doubts about the quality of training received in newly organized and older courses, and because of the lack of standards for approval of courses and schools. World events now added urgency to fulfillment of plans for a national board of examinations, plans that had been under discussion since 1933 [20].
The plan for the Certification Program, approved at the 1942 AANA meeting, was submitted to the Council on Professional Practice of the AHA. The AHA voiced reservations about what it saw as a conflict between the goal of raising the quality of service provided by nurse anesthetists and the exemption of those who were practicing. The AHA was also concerned that waiving the certification requirement for currently active members might weaken the program by including unqualified anesthetists. Finally, because the certification examination would only test theoretical knowledge, the AHA remained skeptical of the examination’s ability to test the practical skills of the candidates [21]. Some AANA members also objected to paying a fee for an examination that gave successful candidates no advantages over anesthetists who remained uncertified.
The examination program was approved at the 1944 AANA meeting, and the bylaws were amended to make successful completion of the qualifying examination a requirement for AANA membership. A Committee on Examinations was established, consisting of five members appointed by the board of trustees. The Committee’s charge was to prepare a master set of questions for each examination, to prepare instructions for test-takers, and to grade the examinations [21]. The revised bylaws also established the Committee on Credentials, which replaced the Membership Committee. This new committee would accept or reject the qualifications of each applicant for the examination [21].
As 1944 drew to a close, the AANA invited 34 schools of anesthesia to participate in creating the examination. Thirty-four were selected perhaps on the basis of being better known to the educators, and perhaps because 34 was a workable number for construction of examination questions. Twenty-four schools submitted examination questions; all but two sent essay-type questions. The examination questions were drawn from these submissions. The Certification Program Committee then worked jointly with the Committee on Examinations, to prepare application forms for AANA membership, to create a transcript for each student, to refine the logistics of the program and examination, to prepare revisions of bylaws, and to develop test questions and a study outline [22].
Therefore, 12 years after it was proposed, the first qualifying examination was administered on June 4, 1945. A passing grade was a prerequisite for AANA membership, thus justifying the term “qualifying examination.” This one aspect of eligibility set it apart from a state board examination or a certification examination [23].
Overseen by examination proctors chosen by the chairman of the Committee on Examinations and AANA’s executive secretary, the examinees tackled the 38-page examination, which included true-false, fill-in, essay, and multiple-choice questions. There was no oral or practical component. The examination consisted of five parts: I, anatomy and physiology; II, anesthetic agents and medications; III, clinical aspects; IV, principles and techniques in administration of therapeutic cases; and V, miscellany, which included history, ethics, terminology, organization and management of an anesthesia and gas therapy department, and explosion hazards and safeguards [20,24]. It consisted of true-false, short essay, and fill-in-the-blank questions about the uses (including those beyond anesthetic administration) of helium, carbon dioxide, nitrogen, oxygen therapy, and cyclopropane. The five content areas carried equal weight, and passing or failing the test was based on the average score [20,24]. The grades for the first group of examinees were not revealed to them or their schools. However, after the second examination, the AANA provided percentile ranking reports to each anesthesia school [24].
Ninety-two nurse anesthetists from 39 hospitals in 28 states and Hawaii took the first examination. Eighty-nine passed with a grade of 70% or more. One was disqualified for not having been authorized to sit for the test [24].
At last, 12 years after it was first proposed, the nurse anesthesia profession had established criteria enabling the AANA to “raise the standards of membership and the educational standards of schools of anesthesia, as well as increase the excellence of the services individual nurse anesthetists provided to patients, surgeons and society [20].” Comments from some of those taking the first examination reveal the diverse impact of this test on these new professionals [20]:
JH, Charity Hospital, New Orleans: “We had been well prepared by our instructors at Charity Hospital, so I did not find the questions overly difficult. I did not take anesthesia lightly. I worked and studied very hard…the examination was a definite step forward.”
EC, Grace Hospital, Detroit: “I thought the examination was a good idea…Nurse anesthesia was a very hard job. I started at $250 a month and was on call every day and every other weekend…The examination was hard, too, considering the 9-month course I had taken in anesthesia. It took me all day to write it.” (Note: Course length was a minimum of six months, but each program could impose a longer, but not shorter time.)
MD, Mercy Hospital, Chicago: “That examination was so difficult that I remember thinking if I ever took another one it would be for a medical degree…Nevertheless, it was a good idea.”
BM, Grace Hospital, Detroit: “I can’t recall a single question. Although the limited academic training I had received was not helpful in the examination, my hands-on experience served me well, not only on the examination but throughout the 35 years I practiced.”Related posts:
History Reflected in the Evolving Approaches to Anesthesia for a Patient Undergoing Cholecystectomy
Major Anesthesia-Related Events in the 2000s and Beyond
1846–1860: Following the Discovery of Anesthesia
A History of Research in Anesthesia
The Evolution of Premedication
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