Practice and education of nurse
anaesthetists
Beverly Henry1 & Maura McAuliffe2
A survey was conducted of the anaesthesia services provided by nurses and the education available to them in this field
in 107 countries. Among the procedures carried out were general anaesthesia, spinal blocks and tracheal intubation.
The implications of the findings for health planning and policy-making are discussed with particular reference to
workforce structure and women's involvement in it.
Voir page 269 le reÂsume en francËais. En la paÂgina 270 figura un resumen en espanÄol.
With a view to providing baseline data for quantitative studies on anaesthesia services provided by
nurses and for health planning and policy-making in
this field, an exploratory international survey was
conducted between 1993 and 1996. In approaching
this study we made the following principal working
assumptions:
± health for all through primary care depends on
cost-effective training and performance;
± a sufficient number of appropriate health workers
is needed to ensure access to care for all people;
± international standards for nurse anaesthetists
should be based on data relating to training and
practice.
The first phase of the study involved locating
qualified nurse anaesthetists by contacting ministries
of health and nursing organizations in 191 countries.
Nurses were reported to be providing anaesthesia
services in 107 countries and to be assisting with
anaesthesia in 10 countries, and 624 persons knowledgeable in this field were identified in 112 countries.
These 624 individuals were invited to participate in
the second phase of the investigation. Of the 293
from 96 countries who responded, 42% were men
and 58% were women; 92% of the respondents were
nurse anaesthetists, the rest being doctors and
technicians.
A questionnaire on practice, education and
regulation was distributed in English, French, German and Spanish. With regard to practice, the
following matters were covered:
± participation in surgical, emergency and maternity
care;
± performance of preoperative anaesthetic evaluations and anaesthesia induction and provision of
intraoperative and postoperative care;
± provision of care under medical supervision, with
medical assistance, or working alone.
In the field of education the following matters
were considered:
± content and duration of basic training for nurses;
± availability, content and duration of classroom and
clinical training in anaesthesia;
± availability and type of continuing education.
This appears to have been the first study of its
kind, although a survey of medical anaesthesiologists
in 32 countries was conducted in 1988 (1) and an
analysis of education programmes for nurse anaesthetists was performed in 1994 (2).
Clearly, the scope of the present investigation
was limited. For instance, there was an average of
only three respondents per country, and in general
they gave their considered opinions and personal
observations without external verification. However,
it should be noted that in most countries there are no
accessible valid databases concerning the provision
of anaesthesia and its outcomes.
Practice
Reprint No. 3261
A majority of the nurses had 6±15 years of experience
in anaesthesia in small, medium-sized or large
hospitals. About a fifth worked in rural localities,
the rest in urban areas. Approximately three-quarters
of the anaesthetics given in rural communities were
administered by nurses, half of whom did this work
without a medical anaesthetist in attendance. About a
third of the participants reported that nurse anaesthetists were often involved in providing analgesia
during labour, after delivery and during the performance of caesarean sections. Over four-fifths
indicated that anaesthetics given in the latter
circumstance were administered by nurses and half
reported that this happened without the supervision
Bulletin of the World Health Organization, 1999, 77 (3)
#
1
Professor, College of Nursing, University of Illinois, Chicago.
Address: 845 South Damen Avenue, Chicago, Illinois 60612, USA
(e-mail: bhenry@uic.edu).
2
Associate Professor, Uniformed Services, Graduate School of Nursing.
Address: 4301 Jones Bridge Road, Bethesda, Maryland 20814, USA
(e-mail: mauramca@aol.com).
World Health Organization 1999
267
Policy and Practice
of a medical anaesthetist. In the African Region, 86%
of the anaesthesia given for caesarean sections was
administered by nurses working alone.
The percentages of participants reporting that
nurse anaesthetists performed certain essential functions, with or without physician anaesthetists in
attendance, are indicated below:
± ordering pre-anaesthetic medication
42%
± epidural block
44%
± immediate postoperative care management 54%
± spinal block
57%
± tracheal intubation
75%
± tracheal extubation
77%
± induction of general anaesthesia
78%
± intraoperative anaesthetic management
78%
Half the respondents reported that tracheal
extubation was performed by nurse anaesthetists
acting alone, while 47%, 45% and 45% said that this
was the case for intraoperative anaesthetic care
management, tracheal intubation and general anaesthetic induction respectively. The function reported
as being performed most often by a medical doctor
alone was that of ordering pre-anaesthetic medication. According to 30% of the respondents, nurses
working alone ordered pre-anaesthetic medication,
while 20% reported that nurse anaesthetists worked
in outpatient pain clinics.
Education and training
Three-quarters of the participants stated that programmes were available in their countries for training
nurses in the administration of anaesthesia. Special
training for nurses in this matter was obligatory
according to 92% of the respondents. Almost 60%
reported that nurse anaesthetists received two to
three years of basic training, and 20% said that such
training lasted over three years. On being asked about
the duration of their own training in anaesthesia,
periods of 12 months or less, 12±22 months, and
over 22 months were indicated by 40%, 19% and
40% respectively. The most frequent reports of
previous specialty experience referred to periods of
about two years in intensive care, obstetrics and
surgery.
Advanced anatomy and physiology had been
included in the educational programmes of 81% of
the participants; advanced pharmacology, including
consideration of anaesthetic agents and adjunctive
drugs, in those of 87%; the chemistry and physics of
anaesthetic drugs in those of 65%; and the basic
principles of practice for nurse anaesthetists in those
of 91% of the participants.
Only half the respondents indicated that
continuing education programmes in anaesthesia
were available in their countries. Such programmes
were commonest in the European Region and least
available in the African Region and the South-East
Asian Region. Participation in continuing education
was reported by 61% of the respondents; those
268
working in urban areas reported more opportunities
for such education than those working in rural areas.
Implications for health planning and
policy
Many nurses are contributing significantly to the
development of health for all through their work in
the field of anaesthesia in both rural and urban areas.
With regard to planning human resources for social
equity and improved workforce structure, nursing
offers employment opportunities for women in
particular. Although anaesthesia seems to be the
nursing specialty attracting the largest number of
men, a majority of the nurses in this field are women,
fulfilling key roles in maternity and surgical teams.
The attainment of health for all requires proper
planning and training and the use of the most suitable
categories of workers to perform preventive, curative
and caring functions. Nurse anaesthetists are less
costly than physicians (3), a fact that has policy
implications for expenditure on and access to care.
Moreover, it is worth noting that health promotion,
disease prevention and community needs receive
special attention in many nursing programmes
because of the desire of educators to achieve a
balance between curative and preventive care.
The results of the survey may be of value to
planners and policy-makers concerned to achieve the
right numbers of health workers in different
categories. The following suggestions made by
participants in the survey for improving anaesthesia
practice among nurses may be of particular interest.
.
Access to continuing anaesthesia education for
nurses should be increased.
.
There should be supportive governmental legislation aimed at protecting nurses, controlling quality
and enabling nurse anaesthetists to practise to
their full capacity.
.
Access to information resources and equipment
should be increased.
.
Improvements should be made in working
conditions, including hours of work, salaries and
safety.
The future of nurse anaesthesia practice and
education depends heavily on government leadership
in improving the organization and regulation of
nursing and health services. Interdisciplinary training,
the development of national standards for nursing
education and practice, and the creation of suitable
staffing patterns are among the requirements for
attracting well-qualified men and women into the
nursing workforce, raising the status of nurse
anaesthesia, and increasing people's access to health
care. n
Acknowledgements
The authors are grateful for the support of the
American Association of Nurse Anesthetists, the
Bulletin of the World Health Organization, 1999, 77 (3)
Practice and education of nurse anaesthetists
Council of Recertification of Nurse Anesthetists, the
International Federation of Nurse Anesthetists, and
the WHO Collaborating Centre for International
Nursing Development in Primary Health Care at the
University of Illinois, Chicago.
ReÂsumeÂ
Formation et fonctions de l'infirmieÁre anestheÂsiste
Aux Etats-Unis ce sont les infirmieÁres qui assurent
l'anestheÂsie dans 65% des interventions chirurgicales ou
obsteÂtriques ± et jusqu'aÁ 85% en milieu rural. Dans ce
pays, la formation des infirmieÁres anestheÂsistes existe
depuis plus de 100 ans.
Selon les speÂcialistes de la planification des
services de santeÂ, les infirmieÁres anestheÂsistes sont
parmi les personnels infirmiers les plus demandeÂs dans
de nombreux pays. On dispose cependant de bien peu
d'information sur leur formation et l'exercice de leur
profession. Les enqueÃtes donnent jusqu'aÁ preÂsent peu
d'indication sur les pays ouÁ les infirmieÁres assurent des
soins anestheÂsistes, sur le roÃle ou les fonctions de ces
infirmieÁres ou encore sur la formation qu'elles recËoivent
en vue de la pratique clinique.
De 1993 aÁ 1996, on a donc proceÂde aÁ une enqueÃte
preÂparatoire internationale afin de pouvoir disposer aÁ
l'avenir, pour la planification et la prise de deÂcision, de
donneÂes fondamentales sur les fonctions du personnel
infirmier dans ce domaine. On est parti du principe que
l'objectif de la sante pour tous par les soins de santeÂ
primaires eÂtait lie aÁ une formation et aÁ une exeÂcution des
taÃches d'un bon rapport couÃt-efficaciteÂ; qu'il fallait un
nombre suffisant de dispensateurs de soins de santeÂ
qualifieÂs pour garantir l'acceÁs de tous aux soins; que des
normes internationales concernant les infirmieÁres anestheÂsistes eÂtaient neÂcessaires et que ces normes devaient
s'inspirer des donneÂes actuellement disponibles sur la
formation et la pratique.
La premieÁre phase de l'eÂtude a consiste aÁ recenser
les infirmieÁres anestheÂsistes dans les Etats membres de
l'OMS. A cet effet, une demande reÂdigeÂe en quatre
langues a eÂte adresseÂe aux ministres de la sante et aux
organisations professionnelles d'infirmieÁres de 191 pays.
Les reÂponses provenant de 107 pays situeÂs dand les six
ReÂgions de l'OMS font ressortir que l'anestheÂsie est
assureÂe par le personnel infirmier. Ont eÂte aussi
communiqueÂes avec ces reÂponses les coordonneÂes des
personnes qui, dans leur propre pays et aÁ l'eÂtranger, sont
consideÂreÂes comme les mieux informeÂes sur la pratique
de l'anestheÂsie par le personnel infirmier, ce qui a donneÂ
624 noms pour 112 pays, une information qui a eÂteÂ
retenue comme eÂchantillon de commodite pour la
deuxieÁme phase de l'eÂtude. Au total, 293 personnes
(soit un taux de reÂponse de 40%) provenant de 96 pays ±
rangeÂs en quatre cateÂgories selon leur niveau de
Bulletin of the World Health Organization, 1999, 77 (3)
deÂveloppement ± situeÂs dans les six ReÂgions de l'OMS
ont reÂpondu au questionnaire d'enqueÃte qui avait eÂteÂ
reÂdige en allemand, en anglais, en espagnol et en
francËais. En tout, 123 rubriques avec glossaire terminologique ont eÂte utiliseÂes pour recueillir des donneÂes sur la
pratique, la formation et la reÂglementation.
Il est ressorti que 21% des personnels de cette
cateÂgorie exercËaient dans une localite rurale ouÁ ils
assuraient les trois quarts des anestheÂsies. Selon plus des
quatre cinquieÁmes des reÂponses (83%), les anestheÂsies
pour ceÂsarienne eÂtaient pratiqueÂes par des infirmieÁres et
la moitie des reÂponses indiquait que ces anestheÂsies se
faisaient sans la supervision d'un meÂdecin anestheÂsiste.
On a examine l'accomplissement des principales phases
de l'acte anestheÂsique, y compris la mesure dans laquelle
elles eÂtaient assureÂes par des infirmieÁres, avec ou sans
l'aide d'un meÂdecin : preÂmeÂdication (42%); induction
d'une anestheÂsie geÂneÂrale (78%); intubation endotracheÂale (75%); rachi-anestheÂsie (44%); surveillance de
l'anestheÂsie per-opeÂratoire (78%); extubation (77%); et
prise en charge postopeÂratoire immeÂdiate (54%).
Les trois quarts des reÂponses indiquaient qu'il
existait des programmes de formation des infirmieÁres
anestheÂsistes dans le pays concerneÂ; 92% de ces
reÂponses preÂcisaient qu'une formation speÂcialiseÂe eÂtait
indispensable pour la pratique; 81% du personnel
infirmier avaient une formation avanceÂe en anatomie et
en physiologie; 87% une formation avance e en
pharmacologie; 65% une connaissance des aspects
chimiques et physiques de l'anestheÂsie; et 91% une
connaissance des principes de base de la pratique de
l'anestheÂsie dans le cadre des soins infirmiers. Or la
moitie seulement des reÂponses indiquait que des
programmes de formation permanente pouvaient eÃtre
suivis.
Les infirmieÁres anestheÂsistes font partie inteÂgrante
des soins de sante primaires et sont une solution moins
oneÂreuse que les meÂdecins. Les pouvoirs publics jugeront
les reÂsultats de cette eÂtude dignes d'inteÂreÃt au stade de la
planification et de la deÂfinition des orientations pour la
reÂpartition des personnels. Les enseignants pourront tirer
parti de la section de l'eÂtude concernant la teneur des
programmes de formation. En tout eÂtat de cause, il
ressort que les infirmieÁres anestheÂsistes ont leur place
dans l'instauration de la sante pour tous et qu'elles
continueront d'y jouer un roÃle important.
269
Policy and Practice
Resumen
FormacioÂn y funciones del personal de enfermerõÂa anestesista
En los Estados Unidos la anestesia es administrada por
personal de enfermerõÂa en un 65% de los casos
quiruÂrgicos y obsteÂtricos, y hasta en un 85% de dichos
casos en los zonas rurales. La formacioÂn de enfermeras
anestesistas se remonta a hace maÂs de cien anÄos en los
Estados Unidos.
SeguÂn los expertos en planificacioÂn sanitaria, la de
anestesista es una de las especialidades de enfermerõÂa
maÂs solicitadas en numerosos paõÂses. No obstante,
apenas se dispone de informacioÂn sobre la formacioÂn y
los funciones del personal de enfermerõÂa en cuestioÂn. Los
estudios anteriores sobre el personal sanitario han
aportado pocos datos sobre los paõÂses donde las
enfermeras administran anestesia, sobre su papel y
funciones y sobre coÂmo se forma a dicho personal con
miras a la praÂctica clõÂnica.
Se decidio por consiguiente realizar un estudio
internacional, que se llevo a cabo entre 1993 y 1996, a
fin de obtener datos basales para la planificacioÂn
sanitaria y la elaboracioÂn de polõÂticas en el futuro en
relacioÂn con la administracioÂn de anestesia por personal
de enfermerõÂa. Se partio de la consideracioÂn de que la
salud para todos mediante la atencioÂn primaria exige
una formacioÂn y un desempenÄo eficaces en relacioÂn con
el costo, de que se necesita un nuÂmero suficiente de
dispensadores de atencioÂn sanitaria para asegurar el
acceso universal a la asistencia, y de que se requieren
normas internacionales para el personal de enfermerõÂa
anestesista, basadas en los datos disponibles sobre la
formacioÂn que reciben y sobre el ejercicio de sus
funciones.
En la fase 1 del estudio, destinada a localizar a
personal de enfermerõÂa anestesista en los Estados
Miembros de la OMS, se sondeo por correo, en cuatro
idiomas, a los ministerios nacionales de salud y
organizaciones nacionales de enfermerõÂa de 191 paõÂses.
Un total de 107 paõÂses, de todas las regiones de la OMS,
respondieron que las enfermeras administraban anestesia. Facilitaron ademaÂs nombres y direcciones de las
personas que, en su paõÂs y fuera de eÂl, mejor conocõÂan el
tema; se consiguio asõ una lista de 624 contactos de 112
paõÂses, que constituyeron la muestra uÂtil que se empleo a
continuacioÂn en la fase 2 del estudio. Se les envio un
cuestionario Ðen alemaÂn, espanÄol, franceÂs e ingleÂsÐ,
al que respondieron 293 personas (40%) desde
96 paõÂses, de cuatro niveles de desarrollo, de las seis
regiones de la OMS. A fin de reunir datos sobre el
ejercicio profesional, la formacioÂn y la regulacioÂn de esa
actividad, el cuestionario incluõÂa 123 puntos y un
glosario de teÂrminos.
Se hallo que el 21% del personal trabajaba en
localidades rurales y que en esas comunidades la
administracioÂn de anestesia corrõÂa a cargo de enfermeras
en las tres cuartas partes de los casos. En maÂs de las
cuatro quintas partes de los casos (83%) se senÄalo que
era tambieÂn ese personal el encargado de administrar la
anestesia en las operaciones de cesaÂrea, la mitad de las
veces sin la supervisioÂn de un meÂdico anestesista. Se
analizo el desempenÄo de las siguientes funciones baÂsicas
de anestesia, considerando en particular la proporcioÂn de
los casos en que dichas funciones eran desempenÄadas
por personal de enfermerõÂa, con o sin asistencia meÂdica:
prescripcioÂn de medicacioÂn preanestesia (42%); induccioÂn de anestesia general (78%); intubacioÂn traqueal
(75%); anestesia subdural (44%); gestioÂn intraoperatoria de la anestesia (78%); extubacioÂn traqueal (77%),
y gestioÂn del postoperatorio inmediato (54%).
Aproximadamente un 75% senÄalaron que en su
paõÂs habõÂa programas de formacioÂn para adiestrar a
enfermeras anestesistas; el 92% consideraba que el
ejercicio de esas funciones exigõÂa una formacioÂn especial;
el 81% habõÂa cursado estudios especiales de anatomõÂa y
fisiologõÂ a avanzadas, y el 87% de farmacologõÂ a
avanzada; el 65% habõÂa asistido a un curso de quõÂmica
y fõÂsica de la anestesia; y el 91% habõÂa estudiado
principios ba sicos de anestesia para personal de
enfermerõÂa. Sin embargo, soÂlo la mitad de quienes
contestaron refirieron la existencia de programas de
formacioÂn continua.
El personal de enfermerõÂa anestesista es un
componente esencial de la atencioÂn primaria y una
alternativa maÂs econo mica que los meÂdicos. Los
resultados del estudio deberõÂan servir a los funcionarios
puÂblicos para planificar una distribucioÂn equilibrada de
los recursos humanos y establecer las polõÂticas oportunas
para ello. Los profesores pueden aprovechar las
conclusiones del estudio referentes al contenido de los
programas de formacioÂn. La idoneidad del personal de
enfermerõÂa anestesista y su contribucioÂn presente y
futura son requisitos obvios para hacer realidad la salud
para todos.
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270
3. Gunn IP. Health education costs, provider mix, and health care
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1996, 64: 48±52.
Bulletin of the World Health Organization, 1999, 77 (3)