Mark J. Lema, M.D., Ph.D. Editor

What Could Have (Should Have) Happened

“The current shortage of Certified Registered Nurse Anesthetists is predicted to worsen in the next 10 years…”¹

An article in the February 2003 American Association of Nurse Anesthetists (AANA) Journal identifies the obvious shortage of nurse anesthetists and studies the reasons for an 8.2-percent dropout rate for student nurses. In addition to the high attrition rate (one of every 12 nurses in training leaves nurse anesthetist programs), a shrinking workforce fueled by “baby boomer” retirements also was identified. The article then presents data acquired by polling the entire enrollment of student nurses (n=2,008) in the United States. About 55 percent of the students responded (40 percent male, 60 percent female, which mirrors nurse anesthetist gender distribution).

It seems that the major factor influencing this high attrition rate is “the failure to be properly socialized into the profession.”² Nurses are understandably attracted to nurse anesthesia initially for the economic rewards (higher salary). In addition, after 12-18 months in the training program, student nurses are still positively oriented toward the bureaucratic focus rather than the patient-centered approach. “This scale dealt with the importance of following doctors’ orders, keeping one’s distance from patients and the importance of technical responsibilities of the job.”¹ By graduation, student nurses more closely identify with their patient-centered clinical roles.

This nurse anesthetist recruitment and workforce crisis, in my opinion, has a number of intangibles that would not have been queried by this well-designed psychological/sociological questionnaire. I believe that the decades of acrimonious interactions between nurse anesthetists and anesthesiologists have resulted in many nurses opting to select other areas of advanced practice nursing in order to avoid the political hassle (and lobby expense!) encountered by the nurse anesthetists. Moreover, the dramatic shortage of nurses practicing traditional nursing has caused the applicant pool to “dry up.” Critical care nursing experience is a requisite for nurse anesthesia training. With the recent focus by powerful factions such as the Leapfrog Group to improve critical care, more nurses are likely to be cajoled into staying in intensive care unit (ICU) practices or opt to become critical care nurse practitioners. Finally, anesthesiologists (like me) no longer “recruit” ICU nurses to their hospitals to consider the field of nurse anesthesia. First, they feel that their effort will eventually work against their current mode of (safe) anesthesia care team practice because of the nurse anesthetist independent-practice movement. Second, they may fear the immediate deleterious effects of reducing their ICU nursing ranks, which may then delay the throughput of ICU-designated surgeries.

From all accounts, the practice of nurse anesthesia is in serious trouble with respect to recruitment and retention of its constituents. Predictions of a 25-percent shortage of nurse anesthetists over the next 10 years are being disseminated through the usual grapevine. In addition, their officers have been “recycled” into other posts, ostensibly due to a lack of interest in running for office by new nurse anesthetists. Unofficial statistics of up to 25 percent of nurse anesthetists no longer belonging to AANA indicates major cracks in their organizational foundation. Yet, despite these internal problems, AANA continues to drive the wedge between the potential union of cooperative (but not collaborative) practice with ASA.

I cannot help but reflect on what could have and should have been done in the early developments of ASA-AANA relations. The simple acceptance of an anesthesia care team mode of practice would have preserved AANA’s current practice arrangements for their constituents while opening their specialty to the expanding opportunities now facing nurse practitioners. However, their leadership’s isolationist approach, initially rebuffing both ASA and the American Nurses Association, has left them vulnerable to the cataclysmic changes facing health care today.

It is quite possible that a harmonious relationship between these two professions, which could have been cultivated in the 1920s, may have led to the following developments:

• Nurse anesthetist-directed critical care practitioners

• Nurse anesthetist-directed pain management practitioners

• Joint annual meetings of ASA and AANA

• Collaborative research to improve patient safety

• Physician anesthesiologists helping in the nurse anesthetist recruitment process

• Widespread physician participation in nurse anesthesia education

• Better practice arrangements with respect to additional procedures

• Millions of dollars to use for education and research instead of for lawyers and lobbyists

• One voice in Congress to improve patient safety and/or reimbursement

• Widespread simulation centers for both physicians and nurses

• A paradigm of physician-nurse supervision interaction and cooperation that would have served as a template for other specialties to adopt.

Instead of simply acknowledging that physicians with twice as much education and training in anesthesia-related practice should lead a care team model, AANA has embarked on a campaign of name-calling, specialty-bashing and unethical misinformation, all for the single purpose of control and greed in the guise of independent practice. Now that they are committed to this course of action, the AANA leadership must contend with these current impediments to their success:

In order to increase the ranks of student nurse anesthetists, recruiters must draw from a critically short supply of nurses in general and ICU nurses specifically. This recruitment is counterproductive in a time when patient safety in the ICU is being emphasized by major corporations (e.g., Leapfrog).

Nurse anesthetists are spending millions of dollars trying to convince governors that independent practice will improve access to care in rural areas. Does the AANA leadership really believe that if given the option to work in a major city within a rural state or in the less populated areas of that state, most nurse anesthetists will opt for the latter?

Moreover, why would governors want to support independent practice for a dying breed of providers while simultaneously alienating physician anesthesiologists whose numbers are increasing? With the rise in anesthesiology resident positions across the country, is it really in the best interest for a governor to dissuade residents from training or practicing in their state by opting out of the Medicare rules for participation?

With nurse anesthetist salaries beyond the $100,000 range and with their numbers shrinking, can they really make an argument against the expansion of anesthesiologist assistants (AAs) whose training applicants do not directly undermine the efforts to increase the general nursing workforce?

As anesthesiology, AA and even nurse practitioner programs continue to increase their numbers, what impact will nurse anesthetists have in bucking the trend? Is fighting for independent practice really the consensus of the vast majority of the rank-and-file nurse anesthetists? If the 25 percent nonparticipation in AANA membership is accurate, I would surmise that an increasing number of nurse anesthetists espouse ASA’s anesthesia care team model or are disgruntled over current AANA policy. Even if AANA succeeds in this political victory, what impact will it have if fewer nurses practice anesthesia with each successive year? How many surgeons will feel comfortable or can comply with the practice of general anesthesia in their offices supplied only by an independent nurse anesthetist? Are there so many as to make any real difference?

As Robert Frost once wrote about the road not taken, so too, the AANA might reflect on what might have been. As for ASA and the American Academy of Anesthesiologists’ Assistants, they will continue to expand, develop and improve in order to provide the safest and most cost-effective means of delivering anesthesia to the estimated 35 million to 40 million surgical patients. Nurse anesthetists who adhere to the anesthesia care team model may soon have the opportunity to choose between two organizations regarding membership. ASA directors are discussing a proposal to extend its “Educational” membership to nurse anesthetists who openly support the care team model. Should approval be granted, AANA may then discover if its course of action was in the best interests of its constituents.

– M.J.L.

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