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Research News: Nurse Anesthesia
RESEARCH NEWS
Research News: Nurse Anesthesia Mary W. Stewart, PhD, RN IS THE PRACTICE of nurse anesthetists nursing? The American Association of Nurse Anesthetists (AANA), representing more than 42,000 Certified Registered Nurse Anesthetists (CRNAs), clearly defines the role as advanced practice nursing. The history of nurse anesthetists is long and impressive. As early as the Civil War (1861-1865), nurses were providing anesthesia care. In 1877, Sister Mary Bernard of Pennsylvania was recognized as the first nurse to specialize in anesthesia. Today, few in the United States would argue against their legitimacy. ‘‘CRNAs practice in every setting where anesthesia is available and in some states are the sole anesthesia professionals in nearly 100% of rural hospitals.’’1 The question of nursing as the foundation for nurse anesthesia is less certain in countries where the role is yet to be adopted. Confessing their own hesitation of accepting CRNAs into the Canadian health care system, the authors of this original research explored the role and practice of CRNAs. They gave particular attention to how nurse anesthesia practice is nursing. Keeping Vigil Over the Patient: A Grounded Theory of Nurse Anaesthesia Practice by Schreiber R, MacDonald M. J Adv Nurs. 2010;66; 552-561. Background and Purpose: The oldest recognized nursing specialty, nurse anesthesia, is practiced in more than 100 countries. Acknowledging the need for alternate anesthesia care providers, the Mary W. Stewart, PhD, RN, is Professor, Special Assistant to the Dean, and Director of PhD Program at the University of Mississippi Medical Center School of Nursing, Jackson, MS. Conflict of interest: None to report. Address correspondence to Mary W. Stewart, University of Mississippi Medical Center, School of Nursing, 2500 North State Street, Jackson MS 39216-4505; e-mail address: [email protected]. Ó 2011 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 doi:10.1016/j.jopan.2011.03.005
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Canadian Anesthesia Society is part of a movement to widely adopt CRNAs in Canada. However, limited understanding of the role contributes to the belief by many Canadian nurses that nurse anesthesia is not nursing. The authors planned and conducted a rigorous qualitative study of nurse anesthesia practice in the United States (US). The purpose of the study was to develop a grounded theory of CRNA practice with the hope of gaining an understanding of whether and how nursing is an integral part of that practice. Methods: Because of the lack of theory regarding nurse anesthesia practice, the authors’ decision to use Grounded Theory was appropriate. Data collection and analysis occur at the same time in this research design. As the experiences of participants are revealed, concept and themes are identified. Multiple sources were used for gathering information over a period of 16 months. Specifically, the researchers used the following to uncover data: interviews with 18 informants (practitioners, leaders, students) from the 2006 AANA Annual Meeting; AANA archives (documents, historical records, and memorabilia); observation of scientific sessions, convention procedures, relationships among attendees; interviews with four experts on regulatory, legal, practice, and financial issues, followed by 11 telephone interviews with informants identified through previous contacts; visits to two hospitals, an outpatient surgery clinic, and a school of anesthesia; interviews with CRNAs, RNs, educators, students, physicians, and a director of anesthesia; and field notes. Interviews were recorded, transcribed verbatim, and compared with notes to ensure accuracy. Participants represented 10 states comprising rural
Journal of PeriAnesthesia Nursing, Vol 26, No 3 (June), 2011: pp 176-178
RESEARCH NEWS
and urban settings and ranged from 0 to 40 years of experience in anesthesia nursing. A majority (23/ 41) of interviewees were female. Researchers used the classic constant-comparative method of grounded theory to code concepts and explore relationships among them. Theoretical saturation, the point where no new theoretical codes/ relationships are found, was reached in December 2007. The researchers used a peer debriefing group to challenge data interpretations and ensure their understandings were grounded in the data. In addition, study participants reviewed the results to confirm that the findings were consistent with their own practice and understanding. Results: Schreiber and MacDonald described their findings using a spherical figure. The participants defined the basic social problem as keeping the patient safe throughout surgery. The resolution to this problem was labeled ‘‘Keeping Vigil over the Patient.’’ The role of the CRNA is to keep a state of watchfulness against dangers to the patient undergoing surgical procedures. CRNAs use four strategies in being vigilant: 1. 2. 3. 4.
Engaging with the patient Finessing the human-technology interface Massaging the message Foregrounding nursing
Engaging with the patient includes building intimacy and a relationship, keeping in touch—literally—with the patient; and engaging spiritually with the patient. The spiritual connection emerged in various ways, eg, the CRNA sees their role as a guide through a frightening experience and often used positive imagery to facilitate a sense of calm and trust. Finessing the human-technology interface takes into account the intimidating atmosphere of the OR and the need to educate patients about the environment and routines. Massaging the message refers to how the CRNA manages interactions among the OR team, including controversies between the surgeon and CRNA or the CRNA and the anesthesiologist. If the patient’s safety is in jeopardy, the CRNA will advocate firmly. At the same time, if the conflict is one of mere preference, the CRNA will acquiesce to the physician. This is one way the CRNA strives to maintain an
177
anxiety-free environment, which is helpful to everyone in the room. Foregrounding nursing is the foundation of the previous three strategies. Participants legitimized the CRNA role through nursing’s long history in anesthesia care and focused educational preparation to practice in the advanced nursing role. In response to how nursing is integral to anesthesia care, one participant in the article responded, ‘‘What part of it is medicine? Where’s the diagnosis and treatment of illness? This is supportive care . the entire time.’’ Nurses distinguish their care from physicians in ‘‘how’’ anesthesia is provided. For nurses, it is about supporting the patient through surgery, relieving pain and anxiety, and delivering them safely to a point where they can care for themselves or other nurses can care for them. Conclusions: This study is the first grounded theory work on the enactment of nurse anesthesia practice in the US. Researchers concluded that the findings resonated with their personal understanding of nursing. Nursing is integral to the role of the CRNA and offers great promise for expanding and enhancing anesthesia care in Canada. What many see as a role that is split between medicine and nursing, the CRNAs in the US seamlessly operate with a firm foundation of nursing. Moreover, the participants in this study were passionate and positive about their contributions to patient care. These findings and understandings should facilitate adoption of the CRNA role in Canada and other countries where nurse anesthesia has much room for growth. PeriAnesthesia Nursing Implications: The first responsibility we have as perianesthesia nurses is to question assumptions that nurse anesthesia providers are not practicing nursing. Addressing the ignorance of advanced practice nursing roles, and CRNA contributions in particular, is a duty we all share. The Institute of Medicine’s report on the Future of Nursing: Leading Change, Advancing Health2 urged policy makers to remove barriers that hinder advanced practice registered nurses, including CRNAs, from practicing to their fullest extent. Bettin3 also cited recent studies that revealed the efficacy and financial feasibility of CRNA care. These findings compel us to support the role of the CRNA.
MARY W. STEWART
178
Further, we can learn from the CRNA example of ‘‘loving our work’’ that was articulated in this study. Because we work closely with CRNAs, anesthesiologists, surgeons, and other OR personnel, perianesthesia nurses can influence the patterns of appropriate, respectful communication in anesthesia settings. Placating others by dismissing the value of our own informed perspectives is not healthy and could strip the joy of nursing from us. Nurses can help nurses overcome this negative pattern.
Finally, as part of sustaining the passion of nurses working in anesthesia care, perianesthesia nurses need to share our stories of CRNA providers and patient care with health care policy makers globally. To be a worldwide leader in health care encompasses more than complicated technology and political agendas. US nurses can set the stage for international understanding of the contributions of CRNAs; it is in everyone’s best interest to do so.
References 1. American Association of Nurse Anesthetists. A brief look at nurse anesthesia history. 2011. Available at: http://www .aana.com/brieflookhistory.aspx. Accessed March 20, 2011. 2. National Academy of Sciences. The future of nursing: Leading change, advancing health. Institute of Medicine of the National Academies. 2010. Available at: http://iom.edu/
Reports/2010/The-Future-of-Nursing-Leading-Change-AdvancingHealth/Report-Brief.aspx. Accessed March 20, 2011. 3. Bettin C. IOM’s future of nursing report reinforces findings of anesthesia studies in Health Affairs and Health Economic$. 2010. Available at: http://www.aana.com/news.aspx? id528106. Accessed March 20, 2011.
Research News: Nurse Anesthesia Mary W. Stewart, PhD, RN IS THE PRACTICE of nurse anesthetists nursing? The American Association of Nurse Anesthetists (AANA), representing more than 42,000 Certified Registered Nurse Anesthetists (CRNAs), clearly defines the role as advanced practice nursing. The history of nurse anesthetists is long and impressive. As early as the Civil War (1861-1865), nurses were providing anesthesia care. In 1877, Sister Mary Bernard of Pennsylvania was recognized as the first nurse to specialize in anesthesia. Today, few in the United States would argue against their legitimacy. ‘‘CRNAs practice in every setting where anesthesia is available and in some states are the sole anesthesia professionals in nearly 100% of rural hospitals.’’1 The question of nursing as the foundation for nurse anesthesia is less certain in countries where the role is yet to be adopted. Confessing their own hesitation of accepting CRNAs into the Canadian health care system, the authors of this original research explored the role and practice of CRNAs. They gave particular attention to how nurse anesthesia practice is nursing. Keeping Vigil Over the Patient: A Grounded Theory of Nurse Anaesthesia Practice by Schreiber R, MacDonald M. J Adv Nurs. 2010;66; 552-561. Background and Purpose: The oldest recognized nursing specialty, nurse anesthesia, is practiced in more than 100 countries. Acknowledging the need for alternate anesthesia care providers, the Mary W. Stewart, PhD, RN, is Professor, Special Assistant to the Dean, and Director of PhD Program at the University of Mississippi Medical Center School of Nursing, Jackson, MS. Conflict of interest: None to report. Address correspondence to Mary W. Stewart, University of Mississippi Medical Center, School of Nursing, 2500 North State Street, Jackson MS 39216-4505; e-mail address: [email protected]. Ó 2011 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 doi:10.1016/j.jopan.2011.03.005
176
Canadian Anesthesia Society is part of a movement to widely adopt CRNAs in Canada. However, limited understanding of the role contributes to the belief by many Canadian nurses that nurse anesthesia is not nursing. The authors planned and conducted a rigorous qualitative study of nurse anesthesia practice in the United States (US). The purpose of the study was to develop a grounded theory of CRNA practice with the hope of gaining an understanding of whether and how nursing is an integral part of that practice. Methods: Because of the lack of theory regarding nurse anesthesia practice, the authors’ decision to use Grounded Theory was appropriate. Data collection and analysis occur at the same time in this research design. As the experiences of participants are revealed, concept and themes are identified. Multiple sources were used for gathering information over a period of 16 months. Specifically, the researchers used the following to uncover data: interviews with 18 informants (practitioners, leaders, students) from the 2006 AANA Annual Meeting; AANA archives (documents, historical records, and memorabilia); observation of scientific sessions, convention procedures, relationships among attendees; interviews with four experts on regulatory, legal, practice, and financial issues, followed by 11 telephone interviews with informants identified through previous contacts; visits to two hospitals, an outpatient surgery clinic, and a school of anesthesia; interviews with CRNAs, RNs, educators, students, physicians, and a director of anesthesia; and field notes. Interviews were recorded, transcribed verbatim, and compared with notes to ensure accuracy. Participants represented 10 states comprising rural
Journal of PeriAnesthesia Nursing, Vol 26, No 3 (June), 2011: pp 176-178
RESEARCH NEWS
and urban settings and ranged from 0 to 40 years of experience in anesthesia nursing. A majority (23/ 41) of interviewees were female. Researchers used the classic constant-comparative method of grounded theory to code concepts and explore relationships among them. Theoretical saturation, the point where no new theoretical codes/ relationships are found, was reached in December 2007. The researchers used a peer debriefing group to challenge data interpretations and ensure their understandings were grounded in the data. In addition, study participants reviewed the results to confirm that the findings were consistent with their own practice and understanding. Results: Schreiber and MacDonald described their findings using a spherical figure. The participants defined the basic social problem as keeping the patient safe throughout surgery. The resolution to this problem was labeled ‘‘Keeping Vigil over the Patient.’’ The role of the CRNA is to keep a state of watchfulness against dangers to the patient undergoing surgical procedures. CRNAs use four strategies in being vigilant: 1. 2. 3. 4.
Engaging with the patient Finessing the human-technology interface Massaging the message Foregrounding nursing
Engaging with the patient includes building intimacy and a relationship, keeping in touch—literally—with the patient; and engaging spiritually with the patient. The spiritual connection emerged in various ways, eg, the CRNA sees their role as a guide through a frightening experience and often used positive imagery to facilitate a sense of calm and trust. Finessing the human-technology interface takes into account the intimidating atmosphere of the OR and the need to educate patients about the environment and routines. Massaging the message refers to how the CRNA manages interactions among the OR team, including controversies between the surgeon and CRNA or the CRNA and the anesthesiologist. If the patient’s safety is in jeopardy, the CRNA will advocate firmly. At the same time, if the conflict is one of mere preference, the CRNA will acquiesce to the physician. This is one way the CRNA strives to maintain an
177
anxiety-free environment, which is helpful to everyone in the room. Foregrounding nursing is the foundation of the previous three strategies. Participants legitimized the CRNA role through nursing’s long history in anesthesia care and focused educational preparation to practice in the advanced nursing role. In response to how nursing is integral to anesthesia care, one participant in the article responded, ‘‘What part of it is medicine? Where’s the diagnosis and treatment of illness? This is supportive care . the entire time.’’ Nurses distinguish their care from physicians in ‘‘how’’ anesthesia is provided. For nurses, it is about supporting the patient through surgery, relieving pain and anxiety, and delivering them safely to a point where they can care for themselves or other nurses can care for them. Conclusions: This study is the first grounded theory work on the enactment of nurse anesthesia practice in the US. Researchers concluded that the findings resonated with their personal understanding of nursing. Nursing is integral to the role of the CRNA and offers great promise for expanding and enhancing anesthesia care in Canada. What many see as a role that is split between medicine and nursing, the CRNAs in the US seamlessly operate with a firm foundation of nursing. Moreover, the participants in this study were passionate and positive about their contributions to patient care. These findings and understandings should facilitate adoption of the CRNA role in Canada and other countries where nurse anesthesia has much room for growth. PeriAnesthesia Nursing Implications: The first responsibility we have as perianesthesia nurses is to question assumptions that nurse anesthesia providers are not practicing nursing. Addressing the ignorance of advanced practice nursing roles, and CRNA contributions in particular, is a duty we all share. The Institute of Medicine’s report on the Future of Nursing: Leading Change, Advancing Health2 urged policy makers to remove barriers that hinder advanced practice registered nurses, including CRNAs, from practicing to their fullest extent. Bettin3 also cited recent studies that revealed the efficacy and financial feasibility of CRNA care. These findings compel us to support the role of the CRNA.
MARY W. STEWART
178
Further, we can learn from the CRNA example of ‘‘loving our work’’ that was articulated in this study. Because we work closely with CRNAs, anesthesiologists, surgeons, and other OR personnel, perianesthesia nurses can influence the patterns of appropriate, respectful communication in anesthesia settings. Placating others by dismissing the value of our own informed perspectives is not healthy and could strip the joy of nursing from us. Nurses can help nurses overcome this negative pattern.
Finally, as part of sustaining the passion of nurses working in anesthesia care, perianesthesia nurses need to share our stories of CRNA providers and patient care with health care policy makers globally. To be a worldwide leader in health care encompasses more than complicated technology and political agendas. US nurses can set the stage for international understanding of the contributions of CRNAs; it is in everyone’s best interest to do so.
References 1. American Association of Nurse Anesthetists. A brief look at nurse anesthesia history. 2011. Available at: http://www .aana.com/brieflookhistory.aspx. Accessed March 20, 2011. 2. National Academy of Sciences. The future of nursing: Leading change, advancing health. Institute of Medicine of the National Academies. 2010. Available at: http://iom.edu/
Reports/2010/The-Future-of-Nursing-Leading-Change-AdvancingHealth/Report-Brief.aspx. Accessed March 20, 2011. 3. Bettin C. IOM’s future of nursing report reinforces findings of anesthesia studies in Health Affairs and Health Economic$. 2010. Available at: http://www.aana.com/news.aspx? id528106. Accessed March 20, 2011.