130 Years of Anesthesia Nursing

The origins and rocky history of nursing’s most controversial specialty

Old photo of Alice Magaw on the left, and a bottle of anesthesia medication on the right

The nurses who provide anesthesia to surgical, obstetrical and pain management patients today follow in the footsteps of some of the most outspoken and technically adept members of the nursing profession.

Thanks to their efforts, certified registered nurse anesthetists (CRNAs) became the first recognized group of advanced practice nurses, and later the first to qualify for independent Medicare reimbursement.

The progress this specialty has achieved has not come without a fight, and the battles over nurse anesthetists’ scope of practice and legal standing are far from over. Ongoing tensions between nurses anesthetists and anesthesiologists have resulted in several major lawsuits over the years, including a spellbinding 1934 case that went all the way to the California Supreme Court.

In the Beginning

Nurses first administered anesthesia during the American Civil War, after some military surgeons noticed that nurses gave full attention to the whole patient — a sharp contrast with medical students, who tended to be more interested in the surgery itself.

Catholic nuns also played a prominent role. Many of the country’s earliest hospitals were established by Catholic orders, and by the late 1800s, their sisters were sometimes trained in administering anesthesia. The first recorded example of a nurse anesthetist in the U.S. was Sister Mary Bernard, who began practice in Erie, Pa., in 1887.

Alice Magaw

However, the true forerunner of the modern nurse anesthetist was Alice Magaw, who in 1889 became a nurse at what was then called St. Marys Hospital in Rochester, Minn., working with Charles H. Mayo, M.D. Together, Magaw and Mayo made the hospital now known as Mayo Clinic an international showplace for advanced anesthesia and surgical technique.

Surgical anesthesia in those days was often imprecise and extremely hazardous, but Magaw, whom Mayo dubbed “the Mother of Anesthesia,” eventually completed more than 14,000 documented procedures without a single fatality. Her work established many of the contemporary standard procedures for surgical anesthesia. Learn more about Alice Magaw’s remarkable career in this profile.

One of Magaw’s earliest disciples was Franc Florence Henderson, who began her career in 1904. Henderson continued to refine Magaw’s methods, further improving safety by minimizing the amount of anesthetic required. In 1914, Henderson published a paper on ether anesthesia in The Saint Paul Medical Journal, a rare honor for a nurse.

Infighting at the AANA

In 1915, Canadian-born nurse anesthetist Agatha Hodgins established America’s first postgraduate anesthesia training program, the Lakeside School of Anesthesia in Cleveland. That program’s alumnae association evolved into the National Association of Nurse Anesthetists, organized in 1931 as the specialty’s first professional organization. It became the American Association of Nurse Anesthetists (AANA) in 1939.

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The early history of the AANP was sometimes rocky, marked by clashes of strong personalities, but the organization made enormous strides for the anesthesia nursing specialty, including the establishment of a formal certification program, a national qualifying examination for nurse anesthetists, and accreditation standards for anesthesia training programs. (In 1952, the U.S. Department of Health, Education and Welfare formally recognized the AANA’s authority to grant accreditation and certification.)

Physicians Take Anesthetists to Court

The early internal conflicts among influential nurse anesthetists paled next to the specialty’s greatest and most persistent obstacle: entrenched hostility from anesthesiologists, then known as “physician anesthetists.”

As early as the 1920s, physicians and physician groups sought to bar nurses from administering anesthesia and define the specialty as the exclusive purview of medical doctors. Even Florence Henderson, who’d moved to Los Angeles in 1917, was forced out of her job as a nurse anesthetist in the late ‘20s; she remained active in nursing organizations, but earned her living by running a boarding house.

In 1934, a group of prominent Los Angeles physicians filed a lawsuit against Henderson’s friend and one-time colleague, nurse anesthetist Dagmar Nelson, alleging that Nelson was violating the California Medical Practice Act by providing anesthesia without a medical license.

Although the physicians, led by William Chalmers-Francis, M.D., claimed their goal was to protect the public from unqualified practitioners, the suit primarily reflected the doctors’ economic concerns about competition from nurses, who could provide the same service at a lower cost. In fact, the plaintiffs argued that by practicing without a medical license, nurse anesthetists were personally damaging the incomes of all licensed physician anesthetists!

A further issue, never stated outright, but implicit throughout the case, was the fact that most contemporary nurse anesthetists were female, while physician anesthetists were primarily male. (Today, about 40 percent of CRNAs are men, but that definitely wasn’t the case in the 1920s and ‘30s.)

Nelson’s attorneys argued that she had not violated the Medical Practice Act because she worked under the direct supervision of a surgeon, who had ultimate responsibility for her practice. The judge agreed, eventually ruling in Nelson’s favor.

Although the plaintiffs appealed the ruling, the California Supreme Court upheld the original decision in May 1936, affirming nurse anesthetists’ legal right to practice, at least under the supervision of physician.

The Continuing Battle for Autonomy

The Nelson ruling provided an important legal precedent, but it raised a new and equally controversial question: whether certified registered nurse anesthetists should be allowed to practice autonomously, without physician supervision. Even now, 85 years later, that issue still hasn’t been completely resolved, although the standards of education and training for nurse anesthetists have continued to improve.

Nursing Education

Thanks to AANA lobbying, CRNAs won the right to be directly reimbursed by Medicare in 1986, but federal rules still required nurse anesthetists to be supervised by a physician. In 2001, the Centers for Medicare and Medicaid Services (CMS) instituted new rules enabling individual states to opt out of the physician supervision requirement for CRNAs at the governor’s discretion, which a growing number of states have done.

However, the American Society of Anesthesiologists (ASA) continues to strenuously oppose attempts to grant full practice authority to CRNAs, even after an influential 2010 Health Affairs study demonstrating that states that opted out of the physician supervision requirements had no more anesthesia deaths or complications than states that retained those requirements.

U.S. armed services no longer require physician supervision for CRNAs, but, due in part to ASA pressure, the Department of Veterans Affairs excluded CRNAs from 2016 policy changes allowing advanced practice nurses in the Veterans Health Administration (VHA) to practice without physician supervision. The ASA organized another campaign to oppose full practice authority for VHA nurse anesthetists in the winter of 2020–21.

Despite these obstacles, the U.S. now has more than 60,000 CRNAs, who are among the most highly educated of all RNs. According to the AANA, the average clinical experience of nurse anesthesia program graduates is more than 9,300 hours, including 2,600 hours in the anesthesia program itself!

Anesthesia nursing is also the nation’s highest paid nursing specialty. According to the federal Bureau of Labor Statistics, the median annual salary for nurse anesthetists in 2020 was $183,580, over 60 percent more than the median salary for nurse practitioners or certified nurse midwives.

Before Ether

By Aaron Severson

Surgery has been practiced for at least 2,500 years, but for much of that time, many procedures were harrowing for both patient and provider. Early surgeons needed nerves of steel to perform delicate operations on patients who were often writhing and screaming in agony.

The idea of rendering patients unconscious (or at least insensate) during surgery is almost as old as surgery itself, but reliably accomplishing that goal without further injuring or even killing the patient was easier said than done. Lacking proper anesthetic, surgeons sometimes resorted to bloodletting, suffocation, thumps on the head or copious amounts of alcohol.

Party Drugs

By Aaron Severson

While you might think the availability of reasonably reliable surgical anesthesia in the 1840s would have been cause for celebration, the practice drew widespread criticism from religious and academic authorities, who warned that the artificial suppression of pain (particularly during childbirth) was a threat to decency.

One reason was that most early surgical anesthetics were also well-known recreational drugs. Nitrous oxide, for example, was called “laughing gas” decades before it was ever used for dental work. English chemist Humphrey Davy, the first scientist to study the effects of nitrous oxide inhalation, noted in 1800 that the gas “may probably be used with advantage during surgical operations,” but he soon became more interested in nitrous oxide’s euphoric effects. By the 1830s, nitrous oxide had become a popular party drug among the intelligentsia.

Even chloroform, which briefly displaced ether for surgical use in the late 1800s, was sometimes used as a recreational intoxicant, as of course were later opioid anesthetics like morphine and heroin.

ELIZABETH HANINK RN, BSN, PHN, is a Working Nurse staff writer with extensive hospital and community-based nursing experience.

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