Journal of Clinical Anesthesia (2016) 30, 51–58

Original Contribution

The history of the nurse anesthesia

profession☆,☆☆
William T. Ray PhD, MNSc, CRNA (Assistant Professor)a,b ,
Sukumar P. Desai MD (Assistant Professor)c,⁎
a
Department of Anesthesiology, University of Cincinnati, Cincinnati, OH, USA
b
Nurse Anesthesia Major, University of Cincinnati College of Nursing, Cincinnati, OH, USA
c
Department of Anaesthesia, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA

Received 22 April 2014; revised 23 July 2015; accepted 12 November 2015

Keywords:
Abstract Despite the fact that anesthesia was discovered in the United States, we believe that both
Nurse anesthetist;
physicians and nurses are largely unaware of many aspects of the development of the nurse anesthetist
Nurse anesthesia;
profession. A shortage of suitable anesthetists and the reluctance of physicians to provide anesthetics in
CRNA;
the second half of the 19th century encouraged nurses to take on this role.
History
We trace the origins of the nurse anesthetist profession and provide biographical information about its
pioneers, including Catherine Lawrence, Sister Mary Bernard Sheridan, Alice Magaw, Agatha Cobourg
Hodgins, and Helen Lamb. We comment on the role of the nuns and the effect of the support and encouragement
of senior surgeons on the development of the specialty. We note the major effect of World Wars I and II on the
training and recruitment of nurse anesthetists. We provide information on difficulties faced by nurse anesthetists
and how these were overcome. Next, we examine how members of the profession organized, developed training
programs, and formalized credentialing and licensing procedures. We conclude by examining the current state of
nurse anesthesia practice in the United States.
© 2016 Elsevier Inc. All rights reserved.

1. Introduction registered nurse anesthetists (CRNAs), are not aware of the

history of the profession of nurse anesthesia [1].
Although nurses have administered anesthesia for more
than a century, many health care providers, including certified
☆
2. Early years
This material was presented, in part, at the 18th Annual Spring Meeting
of the Anesthesia History Association, on May 4, 2012, in Kansas City,
Kansas. Before the first public demonstration of successful ether
☆☆
This work was supported by intramural funds. The authors do not have anesthesia by William T.G. Morton on October 16, 1846, at
any financial conflicts of interest to disclose. Massachusetts General Hospital, surgery was by no means
⁎ Correspondence: Sukumar P. Desai, MD, Department of Anesthesiol-
an everyday occurrence [2,3]. Pain associated with surgery
ogy, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75
Francis Street, Boston, MA 02115, USA. Tel.: + 1 617 525 7921; fax: + 1 and the high rate of complications dissuaded patients and
617 277 2192. surgeons from most forms of elective surgery. The discovery
E-mail address: [email protected] (S.P. Desai). of anesthesia might have been expected to result in an

http://dx.doi.org/10.1016/j.jclinane.2015.11.005
0952-8180/© 2016 Elsevier Inc. All rights reserved.
52 W.T. Ray, S.P. Desai

immediate increase in the number and complexity of surgical of ‘germs’ must go the credit for the greatest contributions to
operations, but this did not occur [4]. Although the germ the relief of human suffering during the years between 1860
theory of disease was known, the concept of antisepsis had and 1900” [17]. The birth of feminism and their changing
not been extended to surgical operations [5]. Postoperative status post–Industrial Revolution led women to seek higher
infections were the rule rather than the exception, and early education. Nursing experiences in the Crimean War
surgeons believed that pus in the wound was a sign of (1853-1856) and the Civil War (1861-1865) allowed
satisfactory healing [6-8]. Antibiotics were not introduced women to challenge male dominance in hospitals and
into medical practice until the Second World War [9], and “demand improvements in hospital housekeeping and the
opposition to the use of anesthetics to dull pain associated care of the sick” [17].
with surgery was actually opposed by medical practitioners, Nursing as a religious calling was never stigmatized, but
lay persons, and the clergy [10,11]. Therefore, for a variety women practicing nursing outside religious orders were
of reasons, anesthesia remained unpopular and unrefined for viewed as socially and morally corrupt. After experiences in
nearly 50 years after its discovery. Anesthesia was consid- the wars, educated women began a campaign to train others
ered dangerous due to high mortality associated with the in the field of nursing, thus opening up a new vocation for
aspiration of gastric contents, asphyxiation due to respiratory women.
obstruction, or unrecognized events such as low blood Perhaps the most famous of all nurses and the woman
pressure or cardiac arrhythmias, in the absence of clinical considered the founder of modern nursing, Florence
monitoring [12]. Anesthesia training programs did not exist Nightingale (1820-1910) grew up in a prominent family in
in the late 19th century, and the job of administering Victorian England. She surprised her family by choosing
anesthetics was often assigned to medical students, house such a career (or perhaps a career at all), and during the
officers, nurses, or orderlies, none of whom received formal Crimean War (1853-1856), she was given credit for
instruction in anesthetic procedures [13,14]. advancing nursing by emphasizing cleanliness, hygiene,
and ventilation. She established the first nursing school at St
Thomas' Hospital in London and is also remembered as a
great social reformer, statistician, and writer [2,20].
3. A shortage of trained personnel However, even after training programs were established,
nurses continued to face challenges in the male-dominated
As surgical techniques improved and the demand for medical system until there was a strong demand for
anesthesia increased, surgeons believed anesthesia to be a their services, created by the discovery of germs. Once
“mixed blessing” because patients were aware of the the germ theory of disease was understood and the
existence of pain-free surgery, but anesthesia was associ- importance of preventing infection accepted, a “new” nurse
ated with high mortality, and there was a shortage of emerged. Her function was no longer limited to providing
qualified anesthetists [1,15-17]. Thus, the job fell to anyone comfort, food, and housekeeping but now also required
who was willing and available: mostly medical students and knowledge and application of science. As science expanded
less senior physicians. However, most physicians were not the role of the physician by improving our understanding
interested in a position they considered to be subordinate of disease and how to surgically treat illness, the nurse's
and were more eager to learn the skills and techniques of the role also broadened. Nurses assumed duties once limited to
surgeon. Surgeons, on the other hand, were eager to find physicians; in the operating room, this included administer-
well-educated and intelligent professionals to fill the role of ing anesthesia.
anesthetist. Unable to convince enough other physicians
to undertake the administration of anesthesia, surgeons
turned to graduate nurses to fill this role [2,17-19].
Although surgeons had identified nurses as likely candi- 5. Pioneer nurse anesthetists
dates for “occasional anesthetist,” many issues continued to
plague medicine at this time, including lack of cleanliness Catherine S. Lawrence (1820-1904) (Fig. 1) has been
and asepsis. identified as the first nurse to administer anesthesia, which
occurred during the Civil War, 1861 to 1865 [21]. It was
during the Battle of Bull Run of 1863 that she administered
chloroform to wounded soldiers who needed emergency
4. Advent of nursing as a profession operations in the battlefield [17,21]. Nevertheless, it still took
several years for nurses to step forward and formally answer
The transformation of nursing into a profession required the call to provide anesthesia. Reasons for this delay included
changes in the way society viewed women. However, lack of training, the nonemergency nature of civilian surgical
Thatcher in her 1953 History of Anesthesia, With Emphasis practice after the war was over, and the paucity of role
on the Nurse Specialist, recognized the important contribu- models and sponsors. However, the wartime concept of
tions of women to the field: “To women and to the discovery nurses providing anesthesia care gradually took root as
The history of the nurse anesthesia profession 53

Fig. 1 Catherine Lawrence (1820-1904) in a photograph taken during the Civil War. American Association of Nurse Anesthetists.
Reproduced with permission.

surgeons trained and encouraged nurses to take on this anesthesia duties in 1877 at St Vincent's Hospital in Erie,
important role. Surgeons who had been searching for a Pennsylvania. Her influence spread throughout the Midwest,
vigilant anesthesia provider began supporting nurses as and many other Catholic nuns who were also nurses began
ideally suited for the role. Thatcher, also in her History of training to administer anesthesia. Nuns of the Third Order of
Anesthesia, With Emphasis on the Nurse Specialist, stated the Hospital Sisters of St Francis from Muenster, Germany,
nurses were ideal for the role as they would “…be satisfied
with a subordinate role that the work required, make
anesthesia their one absorbing interest, not look on the
situation of anesthetist as one that put them in a position to
watch and learn from the surgeon's technique, accept
comparatively low pay and, have a natural aptitude and
intelligence to develop a high level of skill in providing the
smooth anesthesia and relaxation the surgeon demanded”
[17]. Thus, the profession of nurse anesthetist was born.

6. Early American hospitals and nurse anesthetists

Pennsylvania Hospital in Philadelphia was the first general

hospital in the United States, and founding father Benjamin
Franklin (1706-1790) played a major role in establishing it in
1751 [22]. The next hospital to be founded was the New York
Hospital in 1791 [23], and the third US hospital was
Massachusetts General Hospital in 1811 [24,25].
During the 19th century, most medical care was provided
in the home by members of the patient's family. Conditions
in institutions that preceded hospitals were unhygienic, and
mortality was extremely high. Thus, these early hospitals
primarily catered to the needs of the poor and the indigent
[2,26,27].
Catholic nuns played an important role in the training of
nurses and also in anesthesia [28]. The earliest recorded
nurse to specialize in anesthesia was Sister Mary Bernard Fig. 2 Sister Mary Bernard Sheridan (1860-1924). American
Sheridan (1860-1924) (Fig. 2). Sister Bernard took over Association of Nurse Anesthetists. Reproduced with permission.
54 W.T. Ray, S.P. Desai

established a community in Springfield, Illinois, and on June

22, 1879, they founded St John's Hospital. At St John's, the
administration of chloroform and ether was taught to the
nurses by surgeons, and many of the Franciscan Sisters were
assigned as anesthetists throughout the Midwest. Nurse
anesthesia became “undoubtedly a prevailing practice in
many Catholic hospitals” [2,17]. In 1883, Minnesota was
devastated by a tornado. Mother Alfred Moes and the Sisters
of Saint Francis proposed building a hospital to aid the sick
and injured in Southern Minnesota. However, they stipulated
that William W. Mayo (1819-1911) and his sons work at the
hospital. The Mayos agreed, and in 1889, St Mary's Hospital
opened with 27 beds [29]. Although Catholic nuns seemed to
be the most influential force in teaching nurses to administer
anesthesia in the late 1800s, it was William W. Mayo who
should be credited for promoting the popularity of nurse
anesthesia practice [30]. Mayo and his sons William J. Mayo
(1861-1939) and Charles H. Mayo (1865-1939) were well
known for their surgical skills. Surgeons traveled from across
the country to their clinic in Minnesota to observe operations
and learn their surgical techniques. However, the visiting
surgeons were also impressed with the skillful and capable
nurses administering anesthesia at the head of the operating
table [29,30].
One of the most impressive and well-known nurse
anesthesia pioneers was Alice Magaw (1860-1928)
(Fig. 5), who came to St Mary's Hospital in Rochester,
Minnesota, in 1893. She was trained by the Graham sisters,
Edith (1871-1943) and Dinah (1860-1947), and began Fig. 3 Agatha Cobourg Hodgins (1877-1945). American Asso-
working as a nurse anesthetist for Charles H. Mayo, who ciation of Nurse Anesthetists. Reproduced with permission.
bestowed on her the title of “Mother of Anesthesia” due to
her natural aptitude and mastery of safe administration of estimated so as to be of any value, as it depends largely on
open-drop ether [2,17,31]. In addition to being skilled, the temperament of the patient, pathological condition
Magaw documented and evaluated all her anesthesia present, time consumed in anaesthetizing, and operating”
procedures, culminating with a landmark article in nurse- [33]. Before Magaw's refinement of the open-drop method,
anesthesia history [32]. An even larger work (A Review of Thatcher describes patients often requiring artificial respira-
Over Fourteen Thousand Surgical Anesthesias) was pub- tion, physical restraint, or even resuscitation due to
lished in 1906, reporting huge number of open-drop ether anesthesia errors by untrained anesthetists. Magaw's work
anesthetics, incredibly without a single fatality [1,33]. In this highlighted the benefits of the trained anesthetist, allowing
work, Magaw outlined her technique for administering great advances in the practice of medicine. As the reputation
anesthesia. She reported assessing each patient preopera- and success of the Mayo Clinic spread, so did the renown of
tively to determine that patient's needs and surgical the Mayo Clinic nurse anesthetists. Thatcher documents
requirements, stressing the “accustomed” relationship be- testimonials from across the United States and England of the
tween surgeon and anesthetist. She wrote, “One must be gratitude and praise directed to the Doctors Mayo and
quick to notice the temperament” of the patient and Magaw for the advances made in the delivery of anesthesia,
determine how to approach the administration of the and many surgeons and hospitals sent their nurses to the
anesthetic. She stressed the need to gain the confidence of Mayo Clinic to be trained by Alice Magaw.
the patient and to prepare the patient “for each stage of the The sustainability and historical longevity of the practice of
anesthesia with an explanation of just how the anesthetic is nurse anesthesia can be attributed to excellent working
expected to affect him.” Magaw also promoted individual- relationships between nurse anesthetists and surgeons.
izing the anesthetic plan: “It is a mistake to think that the Impressed by the provision of superior anesthesia by nurses
same elevation of the head will do for all patients” and stated at St Mary's, following the example of the Mayo Clinic,
that the secret to the open-drop method was not to rush prominent Cleveland surgeon George Washington Crile
anesthetic but to “talk [the patient] to sleep,” recommending (1864-1943) recruited Agatha Cobourg Hodgins (1877-1945)
adjustment of the anesthesia plan to meet the patient's needs. (Fig. 3) as his personal anesthetist in 1908 [2,17,34]. Later in the
“The dose required for each individual patient cannot be 19th century, other prominent surgeons also employed personal
The history of the nurse anesthesia profession 55

anesthesia for his thoracic cases. Not only did she provide
anesthesia for the first successful pneumonectomy, she also
authored a chapter on anesthesia for Graham's textbook.
Pioneering heart surgeon Claude Schaeffer Beck (1894-1971)
from University Hospital of Cleveland employed Gertrude L.
Fife (1902-1980) as his personal anesthetist. Nurse anesthetist
Olive Louise Berger (1898-1981) was at the head of the table
when Alfred Blalock (1899-1964) performed the pioneering
Blalock-Taussig procedure for “blue babies” at Johns Hopkins
Hospital in 1944. She remained his personal nurse anesthetist
for many years and instructed others in anesthesia techniques.

7. Initial challenges

The first challenge to the nurse's right to administer

anesthesia came in 1911 from Francis Hoeffer McMechan
(1879-1939), a native Cincinnati physician, who felt that the
field of anesthesia should belong solely to physicians.
McMechen challenged the practice of nurse anesthesia with
the Ohio Medical Board [35], which along with Ohio State
Attorney General ruled in 1916 that only a registered physician
could administer anesthesia. Surgeons at the Lakeside Hospital
in Cleveland, such as Crile, initially obeyed the ruling.
Fig. 4 Helen Lamb (1899-1979). American Association of Nurse
Anesthetists. Reproduced with permission.
However, in 1917, Crile and his supporters successfully
lobbied the Ohio legislature to create an exemption within the
Medical Practice Act for nurses who were educated appropri-
anesthetists for their practice. Chest surgeon Evarts Ambrose ately to administer anesthesia under the supervision of a
Graham (1883-1957) from Barnes Hospital in St Louis physician [2,36]. Therefore, the Lakeside Hospital School of
recruited Helen Lamb (1899-1979) (Fig. 4) to administer Nurse Anesthesia was able to reopen in 1917.

Fig. 5 Alice Magaw (1860-1928) administering anesthesia at the Mayo Clinic. American Association of Nurse Anesthetists. Reproduced
with permission.
56 W.T. Ray, S.P. Desai

The second challenge for nurse anesthetists in the practice As the profession continued to evolve, educational
of anesthesia occurred in 1917 in Kentucky. The Louisville requirements slowly became more stringent, and it was
Society of Anesthetists suggested to the Kentucky Attorney difficult to meet the need for anesthetists during WWI. The
General that only people who had medical knowledge and Army and Navy sent their nurses to the Mayo Clinic and
training should administer an anesthetic, which the Attorney Pennsylvania Hospital for a 6-week course. Agatha Hodgins
General supported. Thus, expulsion from the Society was traveled to France with Crile in 1914 to conduct research and
threatened if nurse anesthetists were used; this threat was teach anesthesia to nurses and physicians. Reputation and
extended to hospitals that used nurse anesthetists. Louis contributions by nurse anesthetists in WWI prompted an
Frank (1867-1941), a Louisville surgeon, and his anesthetist, increased need and period of growth [17,40].
Margaret Hatfield (circa 1889-1964), filed suit against the In addition to working closely with George W. Crile,
Kentucky Medical Society and won at the appellate level Agatha Hodgins also founded the National Association of
[1,37]. However, perhaps the most noteworthy challenge Nurse Anesthetists (NANA) on June 17, 1931, in Cleveland,
occurred in 1934, when nurse anesthetist Dagmar Nelson OH, after her request to form a specialty section for
(1892-1958) was charged by a physician, William Vane anesthesia was denied by the American Nurses Association
Chalmer-Francis (1876-1950), with practicing medicine and [17]. Helen Lamb (1899-1979) was a prominent nurse
violating California Medical Practice by administering educator who founded and was director of the School of
anesthesia without a license. The case went all the way to Anesthesia at Barnes Hospital in St Louis [17]. She
California Supreme court, but Nelson was given favorable codeveloped the von Foregger gas machine with Richard
ruling at each level of the case [38]. The Dagmar Nelson case von Foregger (1872-1960). Later in her career, she
was won via precedents set by early nurse anesthetists. established the curriculum and minimum standards for
Blumenreich (1984) identifies 2 lines of reasoning along schools of nurse anesthesia and was American Association
which the California Supreme Court ruled that Nelson was of Nurse Anesthetists (AANA) president 1940 to 1942
not engaged in the illegal practice of medicine [39]. First, the [41,42]. Prominent CRNA Alice Maude Hunt (1880-1956)
Court reasoned that Nelson's practice of anesthesia was in was appointed Assistant Professor of Anesthesia in the
“accordance with the uniform practice in operating rooms” Department of Surgery in 1930 at Yale University. In 1949,
not only in Los Angeles but also throughout the country she became the first nurse anesthetist to publish a textbook of
including the Mayo Clinic, where Nelson had trained and anesthesia [43].
“where…one hundred thousand surgical operations had been Despite the rapid growth of the nurse anesthetist
performed” with anesthetic administered by nurses [17]. profession following the Great War, WWII again precipitat-
Second, the Court reasoned that nurse anesthetists were ed a shortage of anesthetists. A recruitment campaign was
following physician orders. Thatcher's reasoning was as begun, but this was quickly followed by concern about the
follows: “most anesthetics are drugs and admittedly drugs emergence of “ill advised and unjustified schools” [2,17].
have always been applied and administered without question Helen Lamb in turn stressed the importance of maintaining
by nurses pursuant to medical direction” [17]. Although there educational standards even in times of shortages. By the end
were barriers to the progress of nurse anesthesia, the strong of WWII, the military had trained more than 2000 nurses to
and productive relationships between surgeons and anesthe- provide anesthesia using a program patterned by the NANA
tists remained a key factor in the continued evolution of the [2,3]. The quality of nurse anesthesia education was again
nurse anesthetist profession. upgraded following WWII, and although university affilia-
tion was advised, most programs were still hospital based. In
1933, the NANA established an Education Committee to
develop educational standards, and by 1952, formal
8. Early training programs and the effects of
accreditation standards were in place [44].
World Wars I and II

As the popularity of nurse anesthesia grew, so did the

demand and need for formalized training. The first 4 such 9. Professional organization
programs were started between 1909 and 1914 [17]: St
Vincent's Hospital in Portland, Oregon 1909 (Agnes McGee), Nurse anesthetists formed a professional organization to
St John's Hospital in Springfield, Illinois 1912 (Mother further their professional development, training, interests,
Magdalene Wiedlocher), The New York Post Graduate and political strength. The NANA spearheaded the estab-
Hospital in New York City 1912 (Minnie Lister), and Long lishment of anesthesia educational standards in 1935 [2,17].
Island College Hospital Brooklyn, New York 1914 (Louise In 1939, its name was changed to the American Association
McMurray). Another well-known early program was Lakeside of Nurse Anesthetists (AANA) [2,17]. The credentialing of
Hospital School of Nurse Anesthesia, established in 1915 by trained nurse anesthetists and adoption of the title “certified
Agatha Hodgins and George W. Crile. The first graduating registered nurse anesthetist” occurred in 1956 [45]. In the
class consisted of 6 physicians, 2 dentists, and 11 nurses [17]. mid-1970s, the AANA established, through bylaws changes,
The history of the nurse anesthesia profession 57

independent councils to manage accreditation, certification, we provide detailed historical information about nurses who
and recertification [46]. learned the techniques of safe delivery of anesthetics and
The Council on Accreditation of Nurse Anesthesia took over the ill-defined job of the anesthetist. We discuss
Educational Programs has been recognized by the United how military conflicts precipitated sudden demands for
States Department of Education as the accrediting agency for anesthetists and how short-term training programs were
nurse anesthesia educational programs since 1975 [44]. The established to meet this demand. Nurses accepted the
Council on Certification of Nurse Anesthetists and the challenge, most likely because safe administration of
Council on Recertification of Nurse Anesthetists were anesthesia was not believed by physicians to be sufficiently
together incorporated in 2007 as the National Board of challenging to require a full-time commitment. Most pioneer
Certification and Recertification of Nurse Anesthetists [44]. nurse anesthetists had the strong support of senior surgeons,
Advancing quality education to ensure that nurse who saw the value of a reliable and adequate supply of
anesthetists are prepared to deliver safe, quality care has safe anesthetists. Formal training programs for nurse
been a basic tenet of the AANA since its founding. Over the anesthetists began in 1909 in Portland, Oregon [17], and
years, the AANA has promoted development of educational one of the first residency programs for physicians was
standards to keep pace with the evolving needs of society for created in Madison, Wisconsin, in 1927 [50]. Nurse
high-quality anesthesia care. In 1998, nurse anesthesia anesthetists and physician anesthesiologists currently operate
education moved from hospital based programs to university in near-equal numbers, providing more than 40 million
based graduate education; in 2022, the doctoral degree will anesthetics annually in the civilian and military setting
be fully implemented [44]. throughout the United States [51].

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