Countries where anesthesia is administered by nurses Lt Col MAURA S. McAULIFFE, CRNA, PhD Rockville, Maryland BEVERLEY HENRY, RN, PhD, FAAN Chicago, Illinois Introduction Nurse anesthetists make significant In many countries anesthesia is administered pri- contributionsto healthcare worldwide. A marily by nurses. Yet few, including many in nurs- little known fact is that, in many countries ing, are aware of the major contribution to health of the world, nearly all anesthesiais that nurses, functioning as anesthetists, make. Even provided by nurses. This international some history books overlook nurses in anesthesia, survey, in five languages, was done to provide and little has been written about the education, information about nurse anesthesiacare practice, and legal regulation of nurse anesthetists delivered in countries in the regions of the worldwide. world designated by the World Health Two significant occurrences provided the im- Organization. petus for this study. First, in 1978, the World PhaseI, reported here, of a three-phase Health Organization (WHO) proclaimed its goal project, determined that nurses administer of health for all by the year 2000, in which nurses anesthesia in at least 107 of the world's nearly are viewed as major contributors and anesthesia as 200 countries. They administeranesthesia in an essential service. Second, the idea for an inter- developed, developing, and least developed national professional organization took root countries, as well as in all regions of the through which nurse anesthetists from all coun- world. A goal of disseminatingdata in this tries could collaborate, culminating, in 1989, in article is to further validate these 1992-1994 the formation of the International Federation of study findings. Readers are encouragedto Nurse Anesthetists (IFNA). contact the authors with follow-up The IFNA was founded by nurse anesthetists information. from the 11 countries of Austria, Germany, Fin- Supportfor the study was provided by land, France, Iceland, Norway, South Korea, Swe- the American Association of Nurse den, Switzerland, United States, and the then Yu- Anesthetists, Council on Recertification of goslavia.* In 1993, IFNA reported that nurses may Nurse Anesthetists, and the International be practicing anesthesia in many other countries.1 Federationof Nurse Anesthetists. Our study was supported by the IFNA, in support of its charter, and because of such regional Key words: Anesthesia, international, events as the formation of the European Economic nurse anesthesia, World Health Community in which reciprocity between profes- Organization. sionals from about 40 countries is a goal. Data suggesting that many of the world's na- *Today there are 22 member countries of the IFNA, and several others have petitioned for membership. October 1996/ Vol. 64/No. 5 469 tions have nurses performing as anesthetists have line information about nurse anesthesia in coun- been communicated from nurse anesthetists in the tries in all regions of the world and at four levels of United States and Europe who have visited coun- national development (least developed, develop- tries or served in their country's military, or who ing, developed, and countries in transition) as cat- have gone abroad with charitable organizations. egorized by WHO. The information could then However, it has been difficult to confirm this ob- serve as a basis for an in-depth study assessing the servation or to supplement it with factual informa- commonalities and differences in nurse anesthesia tion. Thus IFNA thought it essential that a study context, practice, and education worldwide. This be done of nurse anesthetists worldwide. knowledge, in turn, could be used as a basis for decisions about human resources and education. Study background, purpose, aims In 1992, although there was some data about The main strategy in health for all is the de- the utilization of nurse anesthetists, little system- velopment in every country of a health system in- atic information could be found about nurses in frastructure, starting with primary healthcare for anesthesia for the majority of the world's coun- the delivery of countrywide services that reach the tries. Therefore the first aim of our study was to entire population. Primary healthcare is essential determine in which countriest nurses are provid- healthcare based on practical, scientifically sound, ing anesthesia services and to locate nurse anesthe- and socially acceptable methods made accessible tists in these countries for inclusion in Phase II. to all individuals and families in communities.2 Our second aim was to describe the practice, edu- Primary healthcare is intended to be flexible, cation, and regulation of the nurses identified in adaptable to local cultural conditions, and applica- Phase I. These were ascertained through a Phase ble to all nations-developed and developing II study which is reported elsewhere. alike.3 It includes maternal and child healthcare, prevention of common diseases, appropriate treat- Methodology ment of common injuries and diseases including An exploratory descriptive design and survey the provision of certain surgical procedures-for methodology was used. Review of the literature which the administration of anesthetics such as failed to reveal any previous comprehensive study. ether, halothane, ketamine, nitrous oxide, thiopen- There were two parts to the survey. In the first tal and bupivacaine is essential. 4 Achieving health part, respondents were asked "In your country, do for all requires special training to safely adminis- nurses give or help with the giving of anesthesia?" ter these anesthetics, and in many countries nurses In the second part, participants were asked to pro- as well as physicians receive this training. vide names and addresses of nurses who give anes- In an effort to ensure health for all, policy thesia in urban and rural areas and to provide the makers in many nations are using cost-effective names and addresses of others in their respective strategies including the efficient use of their na- countries who may have data about nurses who tion's human resources for health.5 Proceedings of give anesthesia. We also included an area for any the conference of WHO and Pan American Health comments respondents wished to include. The sur- Organization entitled Health Manpower Out of Bal- vey was translated by language specialists, from ance: Conflicts and Prospects address a concern about English into French, German, Portuguese, and the worldwide overproduction of physicians. 6-9 Spanish. Policy makers at the conference agreed that cost- In 1992-1994, the surveys, in five languages, efficient strategies for healthcare manpower plan- were sent to individuals or organizations in 191 ning avoid the use of expensive medical practi- countries; of these 177 were member-states of tioners in work where less costly, properly trainedt WHO, two were associate members, and 12 were personnel can produce as efficiently and reserve sent to other areas or countries. After 3 months, all physicians to perform primary medical care. In nonrespondents received a second survey, and 3 many places nurses who have received special months following that a third follow-up survey was training are providing much of the obstetrical and mailed. The request in the surveys for names of anesthesia care. Roemer predicts, in countries others knowledgeable about nurse anesthesia pro- where the demand for primary care physicians is duced 91 additional names from 43 countries. Each rising, the need for nurse anesthetists will also was sent a survey. A total of 914 surveys (including rise.' 0 follow-up surveys) were mailed to the following in The purpose of our study was to provide base- 191 countries: tWhile there has been much debate on the use of the terms "trained" as opposed to "educate," in this article, the two words will be used interchangeably. tMember states of WHO based upon a WHO July 6, 1992 listing of member states. 470 Journalof the American Association of Nurse Anesthetists 1. National Nursing Organizations in 154 countries, 47% of developing countries, 67% of least countries of which 43% responded (addresses pro- developed countries, and 59% of countries in tran- vided by the International Council of Nurses sition reported that nurses administer anesthesia. (ICN); 104 were ICN members and 50 were nurs- By world region (as shown in Table II), our ing organizations from countries in contact with data reflect that nurses administer anesthesia in the ICN). 76% of the countries in the African region; 57% of 2. Ministries of Health in 164 countries from the American region, 67% of the European region; which 49% responded (addresses of 164 of the 177 27% of the Eastern Mediterranean region; 36% of member states and two associate members of WHO the Southeast Asia region; and in 41% of the coun- were provided by WHO). tries in the Western Pacific region. Respondents 3. Nursing administration leaders (n = 119) in from 10 countries reported that nurses assist in the 76 countries of which 50% responded (addresses administration of anesthesia, and in 18 countries, provided through the University of Illinois at Chi- the evidence was incomplete or conflicting. (In the cago WHO Collaborating Center). 12 countries of Afghanistan, Algeria, Bermuda, 4. Nurses (n = 22) from 16 countries of which Chile, Cyprus, Kuwait, Lebanon, Malta, Morocco, 72% responded (addresses provided by the Ameri- Peru, Somalia, and Tunisia, the evidence for the can Association of Nurse Anesthetists