3: THE EVOLUTION OF ADVANCED PRACTICE NURSING ROLES ■ 83and direct- entry midwifery students. The Doctor of Nursing Practice (DNP) degree,
however, is not a requirement for entry into clinical practice. Nurse- midwives and cer-
tified midwives educated before 2010 without a graduate degree are permitted to retain
licensure to practice. As of February 2015, there are currently 11,018 nurse- midwives
and 88 certified midwives, and 39 accredited graduate nurse- midwifery programs in
the United States (ACNM). In 2013, nurse- midwives and certified midwives attended
320,983 births in the United States.
■ DEVELOPMENT OF THE NURSE ANESTHETIST ROLE
The roots of the certified registered nurse anesthetist (CRNA) emerged during the
American Civil War (1861– 1865) when surgeons needed the assistance of the Catholic sis-
ters and Lutheran deaconesses trained as nurses to administer chloroform to wounded
soldiers during surgery (Wall, 2005). Ten years after the Civil War, Dr. William Mayo
of St. Mary’s Hospital in Rochester, Minnesota, recognized the value of training nurse
anesthetists, because unlike medical students who watched the surgery while admin-
istering anesthesia, nurses observed the patient, which resulted in reduced mortality
rates (Keeling, 2007). In 1889, Dr. Mayo trained and hired nurses Edith Granham and
Alice Magaw to serve as his anesthetists. By 1913, his 6- month program included theo-
retical education and clinical practice.
Despite the success of the Mayo training program for nurse anesthetists, other phy-
sicians began to question the authority of nurses to administer anesthesia (Keeling, 2009).
Both the New York State Medical Society and the Ohio State Medical Board tried unsuc-
cessfully to bar nurse anesthetists from practicing medicine without a license. In Frank
vs. South (1917), a landmark case, the Kentucky appellate court ruled in favor of nurse
anesthetist Margaret Hatfield, stating that she was not practicing medicine because she
was under the supervision of and subordinate to licensed physician Dr. Louis Frank.
During World War I, Mayo physicians and Dr. George W. Crile of the Lakeside Hospital
anesthesia program in Cleveland, Ohio, advocated for nurse anesthetists to provide pain
relief to wounded soldiers (Keeling, 2009). In addition, nurse anesthetist Agatha Hodgins
and Dr. George Crile developed novel anesthetic techniques, including the use of nitrous
oxide– oxygen combinations, and scopolamine and morphine as anesthetic adjuncts.
As medicine was laying claim to the specialty of anesthesiology during World
War II due to scientific advances, shortages of anesthesiologists on the battlefield
necessitated the training of nurse anesthetists (Keeling, 2009). In 1945, certifica-
tion became a practice requirement for CRNAs (National Board of Certification and
Recertification of Nurse Anesthetists, 2010). The Korean War provided yet another
opportunity for the expansion of the profession. By the early 1960s, the army estab-
lished nurse anesthesia programs at Walter Reed Hospital and Letterman General
Hospital. Although the number of nurse anesthesia programs decreased during the
1970s due to decreased funding, lack of affiliation with universities, and physician
opposition, by 1998, nurse anesthesia educational programs were offered at the mas-
ter’s level (Diers, 1991; Keeling, 2009).
Anesthesia delivery is currently accomplished by three main methods: anesthesi-
ologists working as the sole provider, an anesthesia care team (ACT), or by independ-
ent CRNAs. The ACT, where a physician anesthesiologist may supervise one to four
CRNAs, is the most common form of delivery. CRNAs work independently, mostly
in rural areas, where they deliver approximately 70% of anesthetics in rural hospitals
(Fallacaro, Obst, Funn, & Chu, 1996).