In this month’s episodes, Nursing Notes Live will look into the nursing specialty of the nurse anesthetist. I got the chance to chat with several of these advanced practice nurse specialists in our panel segment this month. Joining me are former American Association of Nurse Anesthetists President Terry Wicks, Nickie Damico, assistant professor and director of professional practice at the Virginia Commonwealth University Department of Nurse Anesthesia in Richmond, Virginia, and Timothy Holt Smith, a CRNA at Johns Hopkins Bayview Medical Center in Baltimore, Maryland.
Nursing Notes Live is an audio extension of the national award-winning monthly e-newsletter, Nursing Notes - which offers the latest industry news, trends and updates in nursing. You can subscribe to the e-newsletter at www.discovernursing.com. Each month’s Nursing Notes issue will be accompanied by a couple of episodes of Nursing Notes Live, which will expand on the content and provide you greater insights into the topics presented in the e-newsletter. You can listen to previous podcasts on the Nursing Notes by Johnson & Johnson Facebook page or NursingNotesLive.com; or visit iTunes to subscribe to the podcast!
With your host Jamie Davis, RN, NREMTP, the Podmedic.
MP3 Audio Podcast
Transcript of the Discussion:
Jamie: Terry, this is the oldest nursing specialty. How did nurse anesthetist become a specialty when there weren’t other nursing specialties per se at the time?
Terry: Early in the 20th century, most of the anesthesia was administered by interns and junior surgery residents who really were more interested in becoming surgeons. They were in the operating room simultaneously watching the surgery and administering the anesthesia. Not surprisingly, knowing what we do about anesthesia agents at the time, a lot of patients didn’t do so well. So some enterprising surgeons decided to have dedicated nursing staff, learned to administer anesthesia, particularly at the Mayo Clinic in Minneapolis. That really was the birth of the profession as a specialty for nurses. For a long, long, long time, nurse anesthetists were the only healthcare specialty, if you will, that administered an anesthesia and then anesthesiologists sort of came along after that, years after that, and our two professions grew along parallel paths. As recently as the middle of 1970’s there were probably equal numbers of nurse anesthetists and anesthesiologists in the country. The numbers are not significantly different today but there are a few more anesthesiologists than CRNAs.
Jamie: That’s amazing to hear that story. Really, nurses set the standard of care for the specialty and were there doing it actively as specialists before doctors were. I wasn’t aware of that. That’s pretty fascinating.
Terry: You’re not going to have doctors tell you that.
Jamie: Well, of course, we won’t. But we all know what really goes on, right?
Jamie: Tim, were you going to say something?
Timothy: I was going to say, Terry was talking about the Mayo Clinic. Alice Magaw who was sort of – she was a nurse and she was friends with, I think, Charles Mayo’s wife who was also a nurse. She really started the ball rolling. She saw that the mortality was pretty high at that time. She started talking to patients. Since she was doing it on a consistent basis, she learned to really taper down from the amount of anesthetic that was being given because nobody was keeping records at the time. To make a long story short, she wrote five academic articles. The last one was about her experience of 14,000 anesthetics without a catastrophe occurring. People came from all over the place to the Mayo Clinic to see how this team worked. I think it’s pretty fascinating that she talked. She was a nurse. She spoke with patients. She made suggestions. She told them about what was going to happen. She was pretty much the art of nursing and the art of what we do in providing anesthesia.
Jamie: Really a nurse first which is what I love to see. I was looking at some of the articles and things that are going to be coming out in the Nursing Notes newsletter and one of those things was talking a little bit about the fact that this isn’t just a situation where you talk to the patient for a few moments and then they’re asleep the rest of the time. There really is good nursing care and good patient contact going on there. Nickie, I think you were talking about that a little bit?
Nickie: We can get very caught up in all of the technology that’s required to administer general anesthetics. Of them all, especially this, at heart, we are all still nurses and we very much value that background that we have.
Jamie: It’s nice to hear, Tim, when you were telling us a story about that here we have a nurse, again, using that nursing research-based approach to best practices and taking it back to the patient and helping them make informed decisions which I think is something nurses excel at in all of the fields. It’s great to see that happening here. Nickie, what do you see is the biggest hurdle right now for you having the type of patient contact that you’d like to have or do you really get an opportunity to have that contact?
Nickie: Again you’re sort of tend to get caught up in the technology and you can find yourself limited in the time that you have to bond and establish rapport and really spend time with that patient and make sure that you’re getting all the information that you need from them to be able to safely plan their care. I think we find that we just make that time and that is something that we value very much and we realize the importance of having – and you just take the time to do it. You get better at focusing that time and we are limited with the amount of time it takes to establish these things but we still realize that that’s very important and we still take the time to do that.
Terry: Nickie, don’t you think that, as anesthesia professionals and have a nursing background, our focus is certainly on the technical aspects of what we’re doing. We’re plugged into blood pressures, and heart rates and EKG patterns and all that sort of thing, and fluid balance and all that. I was sort of taught early in my nursing career that we are advocates for the patients and that translates directly into the operating room. I feel like I’m plugged in mostly to those people from the moment I put my hand on them and shake their hand or touch their shoulder preoperatively. I engage them. I make it a point to do that. As healthcare [unintelligible] over the past several years and there’s more paperwork and more things to sign, and more checklists, it seems like the operating room nurses have been relegated to do that stuff. My focus still, from the time I meet the patient until the drug start going to the IV, is to be plugged in to that patient emotionally, to reassure them, to educate them. That’s the most satisfying part of my job. Obviously, I love what I do in the OR and that’s very gratifying, as well, but when that patient wakes up and they see my face and I may know that they’ve come through this comfortable and safe, that’s the rewarding part of that for me.
Nickie: Absolutely. I completely agree and I think that very often I describe my job as being very privileged. I’m privileged to have the role that I have in this process and to be interested by our patients to take care of them. To be able to be a part of that and to be there for them and very much to engage with them and help them through this very much with the technical things that we do and the interventions that we do in the operating room. But, absolutely, I think the most rewarding thing and the most valuable thing that we do for patients is to let them know that we care about them and that we’re there for them and that we will coach and help them through this whole process. Not just the other technical things that we do.
Timothy: I work in a hospital where the anesthesia care team is present. We work with the anesthesiologist in the care. You can see a big difference when a physician, an MDA, speaks with the patient and then you get a chance to get in and relate to the patient. The care of the nurse is definitely present there. What Terry is saying and also what Nickie was saying, you have a limited time but you are definitely tuned in to that patient and you’re trying to meet their needs, you’re trying to read them, and trying to hopefully fulfill giving them reassurance and giving them a lot of positive suggestions. When they wake up, like Terry says, they know you’re there because you are there and that’s not always with our – the people we work with are not always there. I think patients do. It makes you feel good, makes you feel really good.
Jamie: It’s an amazing thing when you think about it and boil down what patients are asking you to do. They’re putting so much trust to say, “All right, I’m going to let you put me to sleep and cut me open and then wake me back up again successfully.” That is – if you look at it from that standpoint – it is incredibly just a trust position. I’m just glad nurses are part of that. I think it shows again and again nurses are one of the most or THE most trusted profession out there. I know from my own experience that how disorienting for me to come out from under general anesthesia and how important to hear that comforting voice and to see that person that, in your mind, a few moments ago, was talking to.
Terry: Well, there’s no question. Having been a patient myself, you do appreciate it when someone takes care of you. I’ve had a couple of anesthetics. I have the advantage of knowing the people that took care of me. Still there’s an enormous vulnerability when you’re a patient, as you suggested. It doesn’t matter how much you know. You still feel vulnerable. You lose your identity when they take your clothes away. You surrender the power of your self-determination in hopes that you’re going to have an improvement in your health or maybe even a curative experience or maybe just find out more about what’s going on inside of you that something’s wrong. To have someone reach out to you and touch you emotionally and reassure you before you have that experience, it is a life-changing event. I know from being ill, when I was a young Army officer and the nurse reaching out to me and giving me information when I did not know what was going to happen, that changed the way I take care of my patients and it changed for the rest of my life. I think that’s the power that nursing brings to anesthesia. That separates us from other anesthesia providers. As we have that nursing background and we certainly have the technical knowledge and the knowledge of anatomy and physiology and pharmacology and pharmacokinetics and all that important technical stuff but we never leave that nursing background behind. We bring that with us to the OR every single day.
Timothy: I think it’s really rewarding. I’m involved - like Nickie and I’m not sure about Terry - in teaching clinically future nurse anesthetists and to watch the students - they’re watching you initially. They’re participating but they’re watching you and listening to you. It’s really beautiful to watch as they progress in their experience as students. To see they use their nursing ways and their nursing empathy and techniques. It’s quite rewarding to see that.
Jamie: Nickie, just a quick question. You’re in a university setting. When a student comes in and wants to become a nurse anesthetist, is there a period of time they have to have already been a nurse and therefore applying to advanced practice level or is this something that you progress right through your RN, your BSN, and directly into a nurse anesthetist program?
Nickie: There are things that - applied for a program. In order to be accepted into the program, they do have to have experience as an RN. They have to have a Bachelor’s in Nursing. They have to have at least one year of experience in acute care nursing. Today, the applicants that we’re seeing very often have much more experience in nursing than that but the minimum is a year before they can come into anesthesia so that they can really have had exposure and experience with managing patients, critically-ill patients, experience with patients who are on mechanical ventilation, titrate drips and should be familiar with the pharmacology and some of the pressors, et cetera. They do need a nice background and a solid foundation in nursing before they can get into anesthesia.
Jamie: They really bring that basis in nursing care to the career field and I think that’s one of the things that make it such a point of place where people can be touched positively by a nurse. I happen to read something that talked about nurse anesthetist being one of the more stressful nursing professions. I think there’s a lot of stress in many cases being involved with being a nurse. What makes being a nurse anesthetist something that’s more stressful? What are some of the things that are going on now to help those nurses deal with that stress? Tim, I think you are involved with some things doing with this.
Timothy: In working with patients over the years, I found that from patients, at least, in patient stress, by making suggestions and learning about the principles of positive suggestions which lead into that sounds sort of a nebulous area, hypnosis, can make a big difference in dealing with stress. I stumbled into this whole thing by making suggestions to patients about stop smoking and I didn’t know what the heck I was doing or the technique I was using. I had two patients that had come back who had stopped smoking. I usually go down to Williamsburg in the fall for Anesthesiology Faculty Associates, which Nickie is probably very familiar with. They had a gentleman who spoke about anesthesia and hypnosis. That put things together. He’s a nurse anesthetist – Ron Eslinger from Tennessee. That sort of helped me blossom into a lot of areas in dealing with stress and stress management. We’re all under a lot of stress, but I think it’s how you balance your life. Stress management is one of the components but our jobs are stressful at times. But I don’t think it’s as stressful now, I guess, as when I was younger. I don’t know if I have adapted and developed good stress techniques, management techniques, and exercise and eat right. Like Chuck Biddle would say, “Make sure you get enough sleep” and all these other factors which make for a healthy lifestyle. But if you develop healthy coping mechanisms, you can deal with the stress because you have the knowledge. We are well-trained professionals and if you’re working with a group of people that are willing to work together – it’s stressful but I think it’s manageable.
Nickie: I think what we do can be quite stressful in a number of ways. We deal with patients who, just by the nature of the fact that they’re coming for a procedure or surgery, they are in a crisis of sorts. We talked a little bit about that. Really engaging and putting yourself into this and being there for the patient. I think that when you do put yourself out there, it does demand a lot of you in terms of really reaching out to them and plugging in. I think that can, you know, again you’re dealing with people who are in a crisis of sorts every day. There are certainly other aspects that create stress in terms of the schedules. This is a [core] requirement. We work in a business that we operate every day of the year, twenty-four hours a day sometimes. So the hours that are required of us, particularly, if you’re new into the profession and perhaps being in a position where you’re taking a lot of calls and doing a lot of hours that way. It can be quite stressful just because of the nature of what we deal and the situations we deal with. I do agree that having and establishing good coping mechanisms early in your career can really avert that. You can find ways to deal and manage that but it can become overwhelming in some situations. We do try to impress upon our students while they’re in the program that the rigors of the training program will require them to develop good coping skills. Then also just for their happiness in their lifelong satisfaction with their job and the work that they’re going to be doing every day the rewards to the specialty are great, but it also requires a great deal of you personally. If you try to establish that very early and find good things in your career, you’re working with people that you like to work with, that you get along with well and having a life outside of the operating room, you certainly can do a lot to attenuate that. I think for many of us we do find that the position does demand a lot of you and so you do have to have that, these coping mechanisms.
Terry: I think too as you progress through your career, there is a certain amount of adaptation that takes place. Things like what you’re saying Tim that you found stressful or your career doesn’t seem to have the same visceral impact. And, Nickie, you mentioned students. I think that you hit the nail on the head. For these young folks who are going to school, that have been in the workforce and have been in relatively lucrative clinical positions, to have to interrupt their livelihood to go to school and perhaps uproot their families, leave from established support groups. Then they tolerate fatigue and they set high standards for themselves, and the faculty they set high standards for them. Their education experience is really stressful. I think for you, Tim and Nickie, to encourage them to develop good coping mechanisms, to carve out places in their daily lives, to spend some time with family, some quality time, to have some personal time to do things that are self-actualizing to them, and to be sure to sustain at least a little bit of that balance, helps them transition more quickly as clinical anesthetist and to restore a healthy balance so that they do have resilience and remain adaptive and don’t make bad health choices down the road or develop maladaptive coping mechanisms which could ultimately lead to some real problems. As you grow through your career, clinical stress is a much a problem to cope with. Maybe it’s dealing with the hospital administration or changes in rules and practice situations that can drive you up the wall.
Timothy: At the University of Maryland, which is one of the two clinical schools that come through our facility, I have been very interested in this. Since the beginning of the program, I’ve been – except for the first class – I have been going on their first day of orientation. I do an hour-long stress management seminar on relaxation techniques and a couple of ways of viewing things. These students, like Terry was saying, this people that are coming in to these programs are the crème-de-la-crème of their nursing units. All of a sudden, they’re put in to a situation where they are at the bottom of the sea. They are no longer the big dogs. There are variations in their ages also. Some of these people are a little older or more mature. Some of these people, they have a tough time. But we found some people really respond to this thing that we’ve done at the University of Maryland. There are a lot that haven’t because you see broken relationships; you see some mental illness issues; you see abusive behavior of substances or whatever. Being a student and going in to nurse anesthesia is extremely demanding.
Jamie: One of the things that - I just want to touch on briefly because we’re running out of time and winding down – but, Terry, I’ll start with you, one of the challenges that’s facing advanced practice nursing professions all over the country right now are the varied approaches and ways that the Nurse Practice Acts for their individual states allow them to practice to the full extent or not practice to the full extent of their abilities. What is the American Association of Nurse Anesthetists doing to help try to bring this together and try to unify so that there’s a standard of practice in every state? Because certainly that’s the question that’s being asked by a lot of advanced practice nursing associations and I wonder if you have any insights into what direction this oldest of nursing specialties is going in to try to achieve that goal.
Terry: That’s a really good question. It’s a difficult process because, as you know, every state has its own Nurse Practice Act. As a general rule, across-the-board they’re pretty respectful of the scope of practice of nurse anesthetists. There are places where things are a little tighter than others. The American Association of Nurse Anesthetists really has put a heartfelt effort into encouraging AANA members on a state level to get involved with their state boards, to run for positions on the boards, so that that voice can be heard. I think that is very helpful. Also, at the organizational level, the AANA is involved in dialogue with the National Council and State Boards of Nursing and I think that on-going dialogue helps as well. The other place where restrictions in practice tend to take place is at the institutional level. It doesn’t matter how liberal or how supportive the state board regulations are for nursing that the institution is still at liberty to privilege nurse anesthetists as tightly or as loosely as they want to. We do have an educational process too that has to take place with institutions and administrations to let them know what their nurse anesthetists are capable of so that they take full advantage of those skills to deliver the most efficient health care.
Nickie: We can make an important point about - very much this comes down to an institution’s specific issue in many cases where the state mandates maybe liberal but, at the institutional level, you will see restriction in the process of nurse anesthetists. I think what that comes down to is we have to look to ourselves and ensure, like you mentioned, that we are practicing within the, you know, the skills that we are personally trained and able to do and practice within those guidelines. I think we look to ourselves to be sure that we are well-educated to be able to perform all of the procedures and all of the skills that nurse anesthetists are able to do and then show that to them by being able to do that on a personal level at your institution. I think it does vary so much from place to place and it depends on the nurse anesthetists who were there and then first should be standard of practice for that institution and then it perpetuates. That might be perpetuating in terms of a very liberal scope of practice or perpetuates in a very restricted scope of practice. It does very much come down to an individual and an institution-specific situation.
Timothy: I think one of the beauties of being a nurse and doing nursing things but also being a nurse anesthetist is you can choose the type of practice area you want to work in. There are places in this country, many rural areas, where a good portion of the anesthetics administered are by nurse anesthetists. There are a lot of nurse anesthetists that practice in facilities that don’t have anesthesiologists and these people, I think, these nurse anesthetists, are very skilled, very knowledgeable and very comfortable in what they do. I have classmates that have – I know of CRNAs that have gone into areas like these and are very happy with their ability to more or less be free dogs. I think in more populated areas, certain hospitals, they can restrict you on what you do. But we have the choice. We have the ability to choose where we want to work and what we don’t.
Jamie: Nickie, we’re wrapping up here. Someone, a nurse, is considering that they want a career change and are looking at becoming a nurse anesthetist. If they were to approach you and say, “What should I do to prepare myself and be ready to move in to this career and start and apply to a program? What do I need to have in place before I even consider reaching the point where I fill out an application?”
Nickie: Again, I mentioned that the minimal requirements are that you have a Bachelor’s degree in nursing, you have a year of critical care experience and that you’re working from that state. Those things are prerequisites. But I think probably the most important advice that I can give someone who is seeking a career in nurse anesthesia is that they really need to spend some time with a nurse anesthetist and get to know exactly what it is that we do on a day-to-day basis. I think it does take going into the operating room with a nurse anesthetist, talking to nurse anesthetists, to get a really good feel for all of these things and to get a good feel for what we do every day. That’s probably, I think, usually the best advice that I can give someone who’s in that position because so often they see one aspect of the nurse anesthetist’s role but they don’t see the full scope of what we do. It’s a very exciting career but I do think it’s not for everyone. The best thing you can do is go into the operating room, chat with someone, and talk to them about why they chose it, why they like what they do, why they don’t like what they do, so that you can be an informed consumer if you will because it is very rigorous. If you’re not very sure before you get into this that that’s what you want to do and you understand what it is you’re asking to take on, then it’s just not going to work out. I think that’s probably what I would say helps the most is to be very clear about what it is nurse anesthetists do and what you’re getting into when you send in that application.
Jamie: Terry, any final thoughts for someone who wants to become a nurse anesthetist?
Terry: Yes, I think just to echo what Nickie said, I think it is important to have that exposure. Then I think once you made that decision, that commitment to submit an application and do an interview and hopefully get admitted, I think you really have to be prepared to get your personal house in order because your personal life is going to get neglected for about 30 months or so. It’s good to be – have your financial situations squared away, your personal life squared away, you do a really very honest and cold look at your relationship with your spouse if you are involved in a committed relationship and make sure that that’s strong. Then I think you just put your nose to the grindstone and go.
Jamie: I want to thank all three of you for taking the time to sit with me and I know we went a little bit over the intended time frame but this has just been a fascinating conversation and I really appreciate the frank and honest discussion here and really a good look at nursing profession that has done so much for the profession in general and continues to advance nursing practice in their specialty. Thanks to all three of you.
Don’t forget to check out the entire May, 2011 issue of Nursing Notes, focusing on nurse anesthetists. This month’s Nursing Notes newsletter includes articles on the ways these nurses provide comfort and care to their patients, how nurses in this specialty deal with their high stress positions, and also a quick look at recent UZIT scholarship awardees. You can read the entire issue online at www.discovernursing.com and don’t forget to catch our other Nursing Notes Live episode this month where we talk with this month’s Featured “Get to Know Nurse” CRNA, Don Wood. You’ll find this and our other podcast episodes at www.NursingNotesLive.com, the Nursing Notes by Johnson & Johnson Facebook page, and in the podcast area in iTunes.