Practice and education of nurse anaesthetists
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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. ReÂsume 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 sante 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 sante 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 donne 624 noms pour 112 pays, une information qui a eÂte 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 eÂte 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 fisiologõ a avanzadas, y el 87% de farmacologõ 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. References 1. Grogono A, Williams D, Kelly D. Anesthesia world-wide. Telford, Pennsylvania, 1988. 2. Kelly J. An international study of education programs for nurses providing anesthesia care. Journal of the American Association of Nurse Anesthetists, 1994, 62: 484±495. 270 3. Gunn IP. Health education costs, provider mix, and health care reform; a case in point Ð nurse anesthetists and anesthesiologists. Journal of the American Association of Nurse Anesthetists, 1996, 64: 48±52. Bulletin of the World Health Organization, 1999, 77 (3)
