In this offering, we'll be discussing scope of practice. Scope of practice is certainly a term that you all will be familiar with, however, less of you will be familiar with the origins of this concept. In order to better understand the current status of scope of practice, we'll start out by examining the historical underpinnings of this term. My name is Dr. Joshua Carr, and I will be guiding you through the course of nursing over a period spanning almost 10,000 years. I know this may seem a bit excessive for a lesson on scope of practice, but to truly understand modern nursing practice and our role in the healthcare system, we must understand where we came from. I have no financial relationships to disclose, and I want to be clear that the opinions and arguments that I offer today are my own and do not reflect the positions of any organizations that I may be affiliated with. I would also like to acknowledge Sarah DeGregorio and her excellent book, Taking Care, upon which I lean heavily to guide the story that I'm relating to you today. If you find anything in this presentation interesting, I highly encourage you to read Ms. DeGregorio's work to get a deeper understanding of the true power of nursing. A little bit about my background might help you understand how I came to my positions and what influenced my perspective as it exists today around scope of practice. My first experience in healthcare was as an emergency medical technician. In terms of scope of practice, the expanded skillset that pre-hospital care allowed was definitely part of what attracted me to that profession while I was completing my undergraduate studies in health science. Back then, my understanding of nursing was heavily influenced by the negative popular culture representation of nursing and nurses as subservient, handmaidens, sex objects, angry crowns, or perhaps at best, paraprofessionals playing a supporting role to heroic doctors. It would take my experience as an army medic to change my ingrained prejudice against the profession of nursing and ultimately lead me to become a nurse myself. The objectives for this course are to evaluate, recognize, and describe historical, modern, and future factors that have and will determine scope of practice for nurses and advanced practice nurses. I hope that by the end of this presentation, you have a better understanding of why our current scope of practice exists in this form, how scope of practice is influenced by geographical location, facility norms, state and federal laws, and regulations. There exists in human beings one large barrier to understanding the origins of any particular practice, tradition, or circumstance. That is, we are inexorably tied to the perspective of our lifetime. It is hard for us to imagine all the people, events, and ways of life that have come before our current setting in time and place. The truth about nursing as a global concept is that it is as old as human history. Long before there were professional licenses, boards, hospitals, universities, or even defined societal roles, there was nursing. Nursing took place among family groups, tribes, villages, and cultures as humanity evolved. So many of us, me included, have been limited in our education about the history of nursing even as we ourselves became nurses. If there were historical lessons taught in our undergraduate programs, they likely focused on a rather modern figure born in the context of Victorian England who went to war in Crimea or a handful of other relatively modern figures from the 19th and 20th centuries. Lawrence Nightingale is practically the only historical nursing figure that most people can identify and to take nothing away from her excellent work in applying statistical evaluation to healthcare and her advancement of hygiene that truly did save lives and improve health for thousands. She is but one thread on a colorful and intricate tapestry that has been woven over generations. I've made the claim that nursing is as old as human history, but how do we know this? Well, the answer is quite simple. There is a wealth of archaeological evidence of humans throughout the centuries that survived despite disease, injury, paralysis, and other debilitating conditions that should have ended their lives very prematurely, but that survived for several years and sometimes decades. This can only be explained by the often invisible role of nursing care. For example, in this picture, you see the skeleton of a 16-year-old boy with disabling spina bifida that forced him to live life in a crouched, bent-over position with paralytic legs. This boy survived long past his ability to care for himself in a time, 8,000 years ago, where there were no hospitals, no defined healing professions as we know them today, and certainly no medication or equipment in the modern sense. Someone had to care for, feed, bathe, position, treat the ailments associated with altered mobility that go along with this condition. That is nursing. Unfortunately, this history of nursing is obscured by the sands of time because it often takes place without celebration, often happens in private, and almost never makes it into the historical record. There are exceptions to this obscurity. Some ancient civilizations do have a record of the activities of nurses. For example, in ancient Egypt, midwifery practices are well documented. Likewise, in India, a famous leader, Ashoka, dedicated his life to reinventing his legacy into one of care and compassion by encouraging the creation of treatment centers and educational opportunities, perhaps even the first nursing school, where physicians and nurses cared for the ill and injured in organized and effective fashion. In this setting, nurses were revered for high character and exceptional quality of care. They were both men and women, and their efforts were rewarded and appreciated by the society they served. During the Byzantine Empire in the early 12th century, Empress Irene of Hungary and her husband, Emperor John II, constructed a hospital inside one of the largest monasteries of the time. This hospital contained educational centers, a nursing home, a library, and even specialty care wards. This hospital was known as the Pantokrator Monastery, and it employed a regular permanent nursing staff comprised of men and women who received the same compensation and operated in 12-hour shifts. The patients at the Pantokrator were treated according to organized care plans developed in association with physicians who would rotate in and out of the facility. While you can make out the loose framework of a modern system of care, this era would prove to be a high point for nursing and healthcare that soon devolved as the Middle Ages progressed. The success of the Pantokrator was unfortunately not to be duplicated and spread as a concept throughout the rest of Europe. As the 13th, 14th, and 15th centuries obscured the successes of older civilizations, healthcare became a largely decentralized and disorganized concept that relied upon the acumen of a varied group of practitioners from all walks of life and in all settings. During this period, individuals might be very skilled herbalists, midwives, barber-surgeons, or clergy members. They might just as easily be unskilled, opportunistic frauds. The process of determining which practitioner was skilled and helpful was largely determined by trial and error or word of mouth. Professional reputation held in communities was perhaps the most reliable way for those seeking healthcare to determine who was likely to help them through an illness or injury. Also during this time, nursing care became once again the responsibility of an unpaid workforce that would likely be a family member or, if you were well-off, perhaps an enslaved person. In the absence of formalized training programs, the most skilled practitioners were likely those who received apprenticeship-like training and gained experiential knowledge by attending to the suffering and dying. Whatever nursing knowledge and skill had been developed up to this point was about to receive its greatest challenge. As formalized education in the university system began to take hold, the existing network of healers, midwives, and, for all intents and purposes, community nurses would be forced into the shadows, into subservience, or even out of existence. The separation of health tasks into strict definitions, a system of hierarchy, and a scope of practice is taking root. This is due to the elevation of a particular type of knowledge, the type that can only be gained through university training over other types of knowledge. Unfortunately, university training was available only to a very small group of privileged persons and almost exclusively to men. Even more unfortunately, the desire to dominate and monopolize this new system would lead to the systematic oppression of those who did not fit the new paradigm. Even though everyone who had been previously practicing in health-related fields was operating from a similar base of knowledge to those who had a degree, the concept of scope of practice would soon be used to devalue their efforts. It is not like new theories or discoveries were guiding the efforts of this new class of physicians or that fantastic discoveries and advancements had been made in pharmacopoeia. Rather, the impetus to create a hierarchy based in laws and enforced brutally was either economic or social. Lay knowledge and the work of women nurses was soon to be systematically undermined and outlawed. By the 1840s, the stereotype of a nurse as an incompetent, untrained, drunk, or sex worker was pervasive enough to make its way into the literature of the day. It was and is a requirement of change that the pressure to adapt outweighs the force of resistance. In the case of nursing, those seismic changes are all too often a direct result of the tragedy of warfare. Dating back to those ancient cultures that were mentioned at the beginning of this discussion, nurses have always found a place alongside the battlefield injured. In the United States, this association dates all the way back to the Revolutionary War. In this context, the role of nursing was not of the professional nurse and not of the healer, but rather as a companion and confidant. George Washington recognized the value to the troops' morale of having women to counsel and comfort during times of despair. Martha Washington herself would frequently travel to the encampments during respite periods to provide just this type of care to the Revolutionary soldiers. While this role certainly holds value, it did little to advance the science or change the status of nursing. However, subsequent conflicts would push the profession forward against all odds. It was from a deficient dichotomous perception of nursing, either the morally questionable and incompetent, or the sanctified and dutiful, that nursing was elevated, to a degree, by that modern nursing hero mentioned earlier, Florence Nightingale. She was an upper class, well-educated, well-trained nurse, and in many ways, that was the only type of person that could have enough social status to cut through the prejudices of her day and endure into our contemporary understanding. However, her success came with significant compromises, including the exclusion of the lower class or racially different, and the embrace of a hierarchical system that required obedience to the medical staff and enforcement of an oppressive work environment. Because of her success and recognition, her style of nursing became the idealized vision of how nurses should be and act, and her worldview became the new standard of society. Despite the breadth of this mainstream perspective, there were those who emerged to prove a contrary case. For example, Mary Seacole, a Jamaican nurse who was denied the ability to serve during the Crimean War alongside Florence Nightingale, but found a way to provide care to British soldiers at the front lines, without an officially sanctioned posting, and a great personal danger to herself. Also, Walt Whitman, who served as a nurse during the Civil War, despite being fundamentally unqualified by virtue of the fact that he was a male. And Clara Barton, the future founder of the American Red Cross, who served Civil War soldiers across racial lines and outside of the strict prerequisites assigned to nurses during that conflict. And finally, Mabel Stoppers, who led the decades-long effort to integrate nursing in the American Armed Forces. It was the efforts of these individuals, and others like them, who eventually pushed nursing beyond the rigid Victorian model and into a more modern age. If you have learned about another nurse in your undergraduate education, it is likely that it might be our next subject. Dorothea Dix achieved a national reputation by her work with the mentally ill, and because of this, she was identified by the Surgeon General as an appropriate candidate to raise a nursing workforce to help during the Civil War. She was appointed as the Superintendent of Army Nurses, and began her recruitment efforts with some very specific ideas about who could serve in the newly imagined workforce. She recruited only those between the ages of 30 and 50, and refused to work with nuns due to staunch anti-Catholic opinions. This left her with limited options among trained nurses, because they typically either came from religious orders or from the lower classes. Dix was a particular fan of Nightingale, and as such, she followed what she believed was the Nightingale model of recruiting morally pure, plain-looking, white women, regardless of nursing skill, to attend to the needs of the Union Army. Over time, she was able to recruit approximately 3,000 nurses, but many others found alternative avenues to service, including those mentioned earlier who did not fit the profile, such as Walt Whitman and Clara Barton. Importantly, African-American nurses, exemplified by Susie King Taylor, also served honorably and selflessly, and they were able to overcome the prejudice of the day and advance the cause of nursing for posterity. The start of the 20th century finds the Armed Forces of the United States with only the remnants of the nursing workforce that it had during the Civil War. The Nurse Corps was officially founded in 1901, and at that time, only a few hundred nurses made up the standing reserves for the Armed Forces. But just as in past conflicts, as the war efforts ramped up, so too did the need for skilled nurses on the battlefield. By the end of World War I, although the numbers were substantial, the makeup of the Army Nurse Corps was still limited to white females. It would take a second World War for the first black nurses to be admitted. Additionally, males were not represented in the Army Nurse Corps until 1955, when Edward Lyon, a nurse anesthetist from Kings Park, New York, was commissioned a second lieutenant in the Army Nurse Corps, that gender integration would be achieved. By this point, you might be wondering if the history lesson is ever going to end and the discussion of scope of practice is ever going to begin. If that's the case, I would just like to point out that this entire historical journey has involved the origin story for the modern understanding of scope of practice. Ancient cultures and practitioners through the ages could have no concept of scope of practice. If someone was available to help and was skilled in the field of medicine, and was skilled in the healing arts, they would prove themselves over time, and their scope of practice would be both self-defined and self-governed. It is only after recognizing that the concept of scope is based in a hierarchy and an environment of exclusion that we can truly appreciate how important control over the modern concept of scope of practice is to the nursing profession. Scope of practice is often wielded as a bludgeon by those in power to suppress, limit, and contain threats to the medical class system in its current form. By acquiescing to the male-dominated social order of Victorian England, Florence Nightingale was able to create a role for professional nursing, but it was a role that was acceptable to the physicians of the day only because it allowed them to maintain control of healthcare. Expanding beyond the confines of that role has proved to be the modern day challenge for nursing science. When nurses seek to reclaim some of the social status and independence that was deliberately taken from them, they quickly find themselves in a battle with organized medicine that can be both ruthless and grim. One such nurse was a pioneering nurse anesthetist named Sophie Winton, who answered the call to duty for service in World War I, during which she personally anesthetized thousands of casualties in military field hospitals, endured grave personal danger, and was appropriately recognized and highly decorated for her service. However, once Miss Winton returned to civilian life and came to work in the state of California, she found that physicians, who formerly had little interest in anesthesia, were actively trying to discredit and supplant nurses like her. Economic forces, such as the rise of the Great Depression, and increasing compensation for anesthesia services, had made her once uncontested expertise the object of scorn. Never one to acquiesce to pressure, Sophie became one of the earliest examples of an independent practitioner by opening up her own surgical care center and a pioneering practice in dental anesthesia. She is said to have provided anesthetics to some of the Hollywood stars of her era, and she became wealthy enough to financially support the California court case that would become a landmark for the nurse anesthesia profession. Legal challenges to the ability of nurses to practice in the field of anesthesiology have both advanced and defined the profession of nurse anesthesia in the United States from the beginnings of the 20th century and continued into the 21st century. There is no indication that these legal challenges will stop anytime soon. Early decisions in favor of nurse anesthetists, such as Frank versus South in Louisville, Kentucky, and Chalmers-Francis versus Nelson in California, allowed the profession to grow and develop into the vibrant and rewarding career that it is today. A full discussion of the history of nurse anesthesia is addressed in another presentation, so I will limit my remarks to the following summary. When anesthesia is performed by a nurse, it is the practice of nursing, and it is therefore under the purview of boards of nursing. Anesthesia is not exclusive to medicine or nursing, and it is within the scope of practice for both professions. So now that we are here, it is time for a discussion that defines the profession and a discussion that defines what we mean when we say scope of practice. In the simplest terms, it is the concept that defines who can do what to whom and in what clinical setting. Scope of practice in our current state often represents what is considered a legal basis to perform a service and receive compensation for that service. It typically requires the permission of a government or regulatory agency and can present parameters for activities that take place under the discretion of that agency. As mentioned previously, the regulatory agency that is most often in charge of determining the activities, interventions, and roles of both nurses and nurse anesthesiologists is a state board of nursing. Unfortunately, because of the historical evolution of the profession of nursing and the remnants of the hierarchical control brought about by the lawmakers and institutions of the past, boards of nursing can be subject to the retained conceit among some members that nurses should play a subservient role and that scope of practice should be used as a constraint to be placed upon practitioners who are overstepping the natural boundaries of their role. This may result in a false paratime, wherein the board feels that it is its duty to stand in the way of growth in the name of protecting the public. This attitude presents an exceptional challenge when the board is addressing or investigating areas within advanced practice nursing that may significantly stray from the education and training of the board members. All too often, the first impulse is to hold up a stop sign. Ultimately, all scope of practice issues require public trust. That trust can only be maintained if regulatory bodies, lawmakers, and perhaps most importantly, individual practitioners keep the safety of the public at the center of the decisions that they make. This is where the critical elements of competence, education, and continuous quality assurance are introduced. By extension, the right and responsibility to determine the qualifications, requirements, and certifications that allow entry into and continued membership in a role that has a defined scope of practice must belong to the profession itself. Given the history that we examined, it is quite easy to imagine that if the control of any of these aspects were given to an outside entity, the effect on scope of practice could be dramatic and devastating. In 1955, the American Association of Nurse Anesthesiology was recognized by the Department of Education as the accrediting body for schools of nursing anesthesia. And in 1956, the certified registered nurse anesthetist credential was officially adopted. Today, the National Board of Certification and Recertification for Nurse Anesthetists and the Council on Accreditation remain in place to ensure our continued ownership and stewardship of both education and certification. To paraphrase Dr. Jeffrey A. Brown from the AANA Journal in 1976, control of training, peer review, and reimbursement rights are essential to professional autonomy. The ability to exercise this autonomy may be a defining characteristic of a profession and it is certainly foundational to defining scope of practice. In order to preserve our control, it is essential that a high standard of care is maintained. And so far, we have done just that. And we continuously collect the data that proves it. In the relatively recent history of nurse anesthesiology, there have been a couple of very important legislative milestones that have not only helped to ensure our continued ability to self-govern, but also our ability to control our reimbursement rights. The first of these was the Omnibus Budget Reconciliation Act of 1986, signed into law by President Reagan and enacted in 1989. This landmark legislation authorized CRNAs to become the first nursing specialty and the first non-physician group to receive direct reimbursement by the Centers for Medicare and Medicaid Services. For those of you who aren't aware, Medicare is the single largest payer of healthcare services in the United States. And the ability to receive direct payment from this payer opened the door for reimbursement from many other insurers. Subsequently, in 2001, the ability to opt out of the supervision requirements included in the CMS regulations was authorized. The positive financial impact of this legislation has also bolstered opportunities to participate in a full scope of practice for CRNAs. When facilities are free to establish financially viable practice models without needless and cumbersome supervision requirements, one person working and two people being compensated, it encourages the practitioners at that location to exercise all the tools and techniques available in order to deliver full service anesthesia care and it increases the likelihood that they will receive support in that endeavor from the facility or entity where they practice. It is obvious that scope of practice cannot be solely described as a list of actions, interventions, or activities that is static. If we rely upon the knowledge of the past to dictate the activities of the present, we will soon find ourselves obsolete in the future. Because of this fact, scope of practice must be an idea that is constructed of potential and possibility. Just as making an herbal tea was essential to the healers and nurses of the past, so too is proficiency in ultrasound technology to the practitioners of the present. Furthermore, we cannot imagine all that the future will bring to the science of nursing or anesthesia. We must always allow ourselves and our practice room to grow. Sometimes a practitioner may find themselves personally confronted with a question of scope. When faced with the opportunity to provide a service or perform an action and the internal or external question arises, is this okay for me to do? There are some questions you can pose to determine if you are engaged in legitimate practice of nurse anesthesiology. First, is it related to anesthesia? If not, is it related to nursing? Skills that are in both fields are within your realm of responsibility, but we're not here to do surgery. Next, is it within the standard of care for the community? The standard of care for anesthesia is one standard. So regardless of whether physicians or nurses are engaged in the practice, as long as you're meeting the standard of care for that community, you should be covered. Is it consistent with the ethical standards for the profession? Guidance for this can be found from our national organization, the American Association of Nurse Anesthesiology, or if you have specific questions, hospitals and healthcare facilities often have ethical boards that you can take any questions to for guidance. Next, is it evidence-based? Not everyone is going to be as well informed about changes and updates to anesthesia practice as you. Just because somebody doesn't know of a particular skill or technique doesn't mean it's not okay. As long as you have the evidence to back it up, it may be okay for you to do. Perhaps most importantly, are you competent? Have you been trained on this particular skill? Have you experienced this skill or situation in the past? And are you licensed to do it in the state? And have the authorization from the medical staff to do it in the facility? Next, do you have all the necessary equipment and resources to do it safely? And lastly, will your liability insurance cover it? If you are being reimbursed, you are not covered by good Samaritan laws. However, if you are doing something out in the community and you're not being reimbursed, you may have additional protections. There are many other factors that can affect the scope of practice in a particular practice location. It is important to read and understand the bylaws of any facility where you will practice nurse anesthesiology. It is also important to ensure that you are familiar with the equipment, personnel, institutional norms, expectations, and processes of any location where you practice anesthesia. Practices can vary widely within a state based upon these local determinations and may even vary within health systems based upon the location or medical staff direction. In this regard, knowledge is power. Always strive to ensure that what you are doing is foremost safe, but also allowable by all the applicable standards. And if you find that the facility in question is artificially restricting you, fight to change the rules. Lastly, I'll add, be sure to be in contact with and support your state nurse anesthesia organizations. They can provide you direct guidance about the state laws, regulations, and codes that determine how and where you practice in that state. For example, the map on this page will show you how prescriptive authority varies all across the country. Just make sure that you know that you are in a place that will honor, respect, and allow you to practice in a way that you enjoy. The profession of nurse anesthesiology is well placed to grow and thrive in the near future. However, complacency and inattention always threaten to undermine our professional autonomy and negatively impact both our job satisfaction and our quality of life. Some of the strengths of this profession are the quality of our care, our unique nursing perspective in anesthesia, and the economic advantages associated with our practice models. One weakness that we have is our lack of recognition in the marketplace. Everyone that hears this can impact that weakness. Please speak up about our profession and don't be afraid to have uncomfortable conversations that are related to our skills, abilities, and yes, our scope of practice. Broadcasting and speaking about the work of CRNAs in person and on any platform available is an opportunity that we have on an almost daily basis. If we don't continuously work to ensure the existence of this profession in the modern healthcare marketplace, we are sure to suffer the same fate as those skilled healers, herbalists, midwives, and barbers did during the Renaissance. I would like to thank you all for your time and attention during this presentation. I sincerely hope that you learned something and that you can carry something forward into your current and perhaps future profession. Good luck and please be in touch.

nursing history

scope of practice

nurse autonomy

Florence Nightingale

Mary Seacole

nurse anesthetists

regulatory bodies

nursing evolution

professional autonomy

historical development

regulatory agencies

nursing advocacy