Arkansas Association of Nurse Anesthetists (ARANA)
Position Statement Regarding HB 2613
(Removes Supervision Requirement for CRNAs)
This document was prepared to assist Arkansas legislators, policymakers, and the public in understanding the practice of anesthesia by Certified Registered Nurse Anesthetists (CRNAs). Included is a brief summary of the current CRNA supervision requirement under the Arkansas Nurse Practice Act and the rationale for removing the current restrictive requirement. More than 65 percent of all hospitals in Arkansas are staffed by CRNAs only. Removing the supervision requirement will ensure continued access to CRNA services that are so essential to Arkansas healthcare.
HB 2613 Amendment
The Arkansas Nurse Practice Act (NPA) (ACA 17-87-120) currently defines practice as a CRNA as "administration of anesthetics under the supervision of, but not necessarily in the presence of, a licensed physician, licensed dentist, or other person lawfully entitled to order anesthesia." HB 2613 would amend this provision to define practice as a CRNA as “administration of anesthetics when requested by, but not necessarily in the presence of, a licensed physician, licensed dentist, or other person lawfully entitled to order anesthesia." [Emphasis added.]
Why Supervision is Unnecessary
Requiring supervision of CRNAs via state law is unnecessary, as evidenced by the numerous states that do not require supervision but still maintain high quality anesthesia care.
Thirty-eight states do not have a supervision requirement concerning nurse anesthetists in nursing or medical laws or regulations. Even taking into account state hospital licensing regulations, there are still 32 states that do not require physician supervision of CRNAs. Kansas, Kentucky, Mississippi, and Tennessee are among these 32 states.
There is no evidence that anesthesia care in states that do not require supervision is in any way inferior to anesthesia care in states that require supervision. One would expect that if the lack of a supervision requirement were problematic, there would be an outcry among hospitals, patients, and concerned legislators and regulators. While supporters of such supervision requirements like to cite the parade of horribles that will occur if a state doesn't mandate supervision, the truth is that negative effects simply do not occur in the absence of such requirements. CRNAs provide high quality anesthesia care, regardless of whether the state in which they are working requires supervision.
The standards and guidelines of the nurse anesthesia profession do not require CRNAs to be physician supervised.
The American Association of Nurse Anesthetists’ “Scope and Standards for Nurse Anesthesia Practice” (available at http://www.aana.com/crna/prof/scope.asp) describes the scope of practice of CRNAs. The scope of practice in this document does not require physician supervision. This is a clear recognition by the nurse anesthesia profession that CRNAs are qualified to provide anesthesia care without such supervision.
Supervision requirements do not improve quality of care.
Proponents of state-mandated physician supervision argue that it increases quality of care, but there is no evidence to support this proposition. Public policy should be based on facts, not unsupported scare tactics. The central pertinent fact is this – all the credible evidence to date demonstrates that the quality of care that nurse anesthetists provide is superb, regardless of whether nurse anesthetists are physician supervised. There is no evidence that CRNAs who practice in states that require supervision are practicing in a safer and more competent manner than CRNAs in states that do not require supervision. A synopsis of published information comparing CRNA and anesthesiologist patient outcomes is available at http://www.aana.com/crna/prof/quality.asp.
According to a 1999 report from the Institute of Medicine, anesthesia care is nearly 50 times safer today than it was 20 years ago. This is due to advances in medical technology and pharmacology, among other factors. Anesthesia outcomes are affected by such factors as provider vigilance, attention, concentration, and organization, not whether the provider is an anesthesiologist or a CRNA or whether the CRNA is supervised.
Requiring supervision can increase surgeon concerns about liability. These concerns, no matter how unwarranted, can delay patient care, increase cost, and limit access to healthcare services.
Courts generally have not found surgeons liable for the actions of nurse anesthetists based solely on a statutory or regulatory duty to "supervise." State supervision requirements generally have not been interpreted to impose a duty on a supervising surgeon to substantively control the course of the anesthetic. In other words, courts have generally found that it is appropriate for a supervising surgeon to rely upon the nurse anesthetist's expertise concerning substantive decisions regarding the anesthesia process, e.g., regarding the techniques to be used, and the drugs to be administered.
Nevertheless, state supervision requirements are intimidating to surgeons who fear such requirements may increase their potential liability. Removing supervision requirements reflects the reality of practice, rather than reinforcing perceptions that have no basis in fact. Surgeons often erroneously feel that a state-mandated supervision requirement makes surgeons liable in every instance for the acts of CRNAs. Removing supervision requirements will increase surgeon comfort in utilizing CRNAs. It is important that the healthcare system maximizes utilization of CRNAs because CRNAs are generally a lower cost provider than their physician counterpart, while still rendering superb anesthesia care.
Rural facilities where CRNAs are the only provider of anesthesia care may find some difficulty in recruiting surgeons because of liability concerns. These concerns are exacerbated when surgeons are erroneously told that their liability risks will increase when surgeons work with CRNAs rather than anesthesiologists. Such inaccurate information can make it difficult for rural facilities without the services of anesthesiologists to recruit surgeons.
State statutes or regulations requiring the supervision of nurse anesthetists may inhibit the recruitment and retention of CRNAs.
Given the choice between practicing in states that don't require supervision, and those that do, it is logical to assume that some nurse anesthetists will choose to practice in states without artificial barriers to practice. Nurse anesthetists are educated and clinically trained to provide anesthesia independent of supervision. In order to attract and retain quality healthcare providers, state law should reflect the reality of practice and not inhibit a provider's capability.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards do not require physician supervision of nurse anesthetists.
The JCAHO’s accreditation standards do not require physician supervision of CRNAs. This is powerful evidence that requiring such supervision is not essential to the provision of quality anesthesia care. The JCAHO is the largest voluntary accreditor of hospitals in the United States.
Removing a state-mandated supervision requirement does not mean that an individual facility cannot impose such a requirement.
Given the lack of evidence that a state-mandated supervision requirement improves the quality of patient care, the most equitable and prudent action is to leave specific decisions concerning this matter to individual facilities. Decisions about working relationships between providers, in the absence of evidence justifying state intervention, should be made at the local facility level, not by state law.
Elimination of statutory or regulatory supervision requirements does not change employment relationships.
Hospitals and physicians need not be concerned about losing control over their employed CRNAs if a supervision requirement is eliminated. Elimination of such a requirement does not provide any mechanism to change employment relationships. It also does not provide any mechanism to increase the cost of anesthesia or change the way anesthesia is reimbursed.
The National Council of State Boards of Nursing (NCSBN) Model Nursing Practice Act and Model Nursing Administrative Rules for advanced practice registered nurses do not contain a supervision requirement.
All state boards of nursing belong to the NCSBN, which serves as one of the boards' primary policy advisers. The NCSBN Model Nursing Practice Act and Model Nursing Administrative Rules do not include supervision of advanced practice registered nurses such as CRNAs. This is further evidence that such restrictions are unnecessary. The Model Nursing Practice Act's scope of practice for Advanced Practice Registered Nurses, including CRNAs, is contained on pages six and seven of Chapter Two of the model at http://www.ncsbn.org/pdfs/chapter2.pdf.
Third-party commentators who are neither physicians nor nurses have opposed physician supervision requirements for CRNAs.
Barbara Safriet, an Associate Dean at Yale Law School, has stated in an influential published article:
Provisions such as these [requiring supervision] are both needless and detrimental. They are unnecessary because APNs, like physicians, are trained to use independent professional judgment in providing care. Like other professionals (such as physicians), they know the boundaries of their competence, they know when to consult with and refer to other health care providers, and they know that they have both an ethical and legal duty to do so when appropriate.
Mandatory physician …supervision intrudes unduly upon the professional judgment and recognized expertise of APNs. Instead of encouraging them to practice fully within the bounds of their competence – a goal in which all of society has a stake – this restriction forces them to constantly question, and to seek authoritative affirmation of, their practice boundaries.
One is left with the disquieting, but compelling, conclusion that the continuation of these restrictions [such as supervision requirements] has more to do with protecting the competitive position of physicians than with protecting the public health.
Jeffrey C. Bauer, a noted health care economist and author of the book, Not What the Doctor Ordered: How to End the Medical Monopoly in Pursuit of Managed Care, has stated:
After extensive study of the relevant published literature and many personal experiences with both anesthesiologists and nurse anesthetists, I have found absolutely no justification for the … requirement that certified registered nurse anesthetists (CRNA) be supervised. CRNAs are every bit as qualified as anesthesiologists within a commonly defined scope of practice, and their outcomes are at least as good as those of their physician counterparts. Anesthesiologists’ efforts to maintain supervisory authority can only be explained as indefensible acts of monopoly behavior.
CRNAs Will Not Administer Anesthesia Independent of a Request to Do So
If HB 2613 is enacted into law, CRNAs will administer anesthesia "when requested by" a licensed physician, dentist, or other person lawfully entitled to order anesthesia. CRNAs communicate closely with the surgeons with whom they work; this would not change if HB 2613 is enacted. A CRNA does not provide anesthesia to a surgical patient unless the nurse anesthetist has first been requested to do so. The very nature of nurse anesthesia practice requires CRNAs to actively communicate with other healthcare providers, with each provider contributing his or her respective expertise to the overall care of the patient.
· Education and experience required to become a CRNA include:
Ø A Bachelor of Science in Nursing (BSN) or other appropriate baccalaureate degree.
Ø A current license as a registered nurse.
Ø At least one year of experience as a registered nurse in an acute care setting.
Ø Graduation with a master’s degree from an accredited nurse anesthesia program. As of March 30, 2005, there were 94 nurse anesthesia programs with more than 1,000 affiliated clinical sites in the United States. They range from 24-36 months, depending upon university requirements. All programs include clinical training in university-based or large community hospitals.
Ø Pass a national certification examination following graduation.
Ø In order to maintain their certification, CRNAs must obtain a minimum of 40 hours of continuing education every two years.
· Nurse anesthesia education focuses on the development of clinical judgment and critical thinking. CRNAs are qualified to make judgments regarding all aspects of anesthesia care based on their education, licensure, and certification.
· CRNAs practice in every setting in which anesthesia is delivered: traditional hospital surgical suites and obstetrical delivery rooms; critical access hospitals; ambulatory surgical centers; the offices of dentists, podiatrists, ophthalmologists, plastic surgeons, and pain management specialists; and U.S. Military, Public Health Services, and Department of Veterans Affairs healthcare facilities.
· Anesthesia has been a recognized practice of nursing for more than 125 years.