NOTENagoya J. Med. Sci. 83. 609–626, 2021doi:10.18999/nagjms.83.3.609Certified registered nurse anesthetist and anesthesiologistassistant education programs in the United StatesTakahiro Tamura1,2, Tetsuro Sakai1, Richard Henker3 and John M. O’Donnell31Department of Anesthesiology, Nagoya University Graduate School of Medicine, Nagoya, JapanDepartment of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine,Pittsburgh, USA3Department of Nurse Anesthesia, University of Pittsburgh School of Nursing, Pittsburgh, USA2ABSTRACTIn Japan, a relative shortage of practicing anesthesiologists continues to be a national issue. To addressthis issue, some Japanese medical institutions have started developing curriculums to train non-physicianperioperative anesthesia personnel, including nurse practitioners and perianesthesia nurses. We urgentlyneed to establish a national standard for the education programs that train these extended non-physiciananesthesia care providers. A certified registered nurse anesthetist educational program at a large academicmedical center in the United States is described in detail as a reference. Highly systematic educationalprograms using simulation, didactics, and full clinical subspecialty rotations are ideal if not easily achievablein many current training institutions in Japan. Anesthesia assistant education programs in the United Statescan be used as an additional reference to create a national educational program in Japan.Keywords: anesthetists, education, nurse, programAbbreviations:CRNAs: certified registered nurse anesthetistsAAs: anesthesiologist assistantsNBCRNA: National Board of Certification and Recertification for Nurse AnesthetistsUPMC: University of Pittsburgh Medical CenterCOA: Council on Accreditation of Nurse Anesthesia Educational ProgramsThis is an Open Access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 InternationalLicense. To view the details of this license, please visit ).INTRODUCTIONIn Japan, a relative shortage of practicing anesthesiologists continues to be a national issue.The number of physician anesthesia providers in Japan reported by the World Federation ofSocieties of Anesthesiology (2019) is 12,208, or 9.64 per 100,000. This sharply contrasts withthe 67,000 physicians or 20.82 per 100,000 giving anesthesia in the US. Other than physicians,57,000 nurse anesthetists provide anesthesia care in the US. Certified registered nurse anesthetistsReceived: July 8, 2020; accepted: November 30, 2020Corresponding Author: Takahiro Tamura, MD, PhDDepartment of Anesthesiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-Ku,Nagoya 466-8550, JapanTel: 81-52-744-2340, Fax: 81-52-744-2342, E-mail: [email protected]

610Takahiro Tamura et al(CRNAs) and anesthesiologist assistants (AAs) perform tasks under physician anesthesiologists’supervision. In some areas in the US, CRNAs can provide anesthesia independently; for instance,most anesthetics in rural areas are provided by nurse anesthetists.In Japan, the shortage of anesthesia providers often results in the cancellation of scheduledsurgeries and prolonged working hours for anesthesiologists. In recent years, with advances inmedical care and technology, the average human life expectancy (currently 84.2 years) has beengradually increasing.1 Also, the number of surgeries is progressively growing due to the expansionof various new operations and surgical indications. In addition to providing surgical anesthesia,anesthesiologists’ range of activities is expected to be further broadened by expanding the fieldof anesthesia to focus on ensuring the safety and security of patients. This widened range ofactivities includes preoperative outpatient care, postoperative pain management, and sedationoutside the operating room. In Japan, there are instances when surgeons have to manage theanesthesia care of their surgical patients themselves due to the shortage of anesthesiologists.Hospitals often have to hire locum tenens anesthesiologists to meet the demand for surgicalcases. These conditions are certainly not ideal for the safety of surgical patients and the stabilityof hospital finances.To address this issue, five Japanese medical institutions have started developing curriculumsto train non-physician perioperative anesthesia personnel, including nurse practitioners andperianesthesia nurses.2,3 National standards for nurse anesthetist and anesthesiology assistanteducation programs need to be developed in Japan to provide consistent and safe anesthesia care.We describe herein CRNA and AA educational programs4 at a large academic medical centerin the US as references.Certified Registered Nurse AnesthetistsThe discipline of nurse anesthesia was developed in the late 1800s. Sister Mary Bernard wasthe first nurse to specialize in nurse anesthesia at St. Vincent Hospital in Erie, Pennsylvania,in 1877.5 As few physicians focused their attention on anesthesia, nurse anesthetists learnedanesthesia from surgeons and their own experiences. During World War I, they performedanesthesia for many wounded patients. The first formal nurse anesthesia educational programwas established at St. Vincent Hospital (Erie, Pennsylvania, USA) in 1909. The title “certifiedregistered nurse anesthetist (CRNA)” was first introduced in 1956. CRNAs can perform tasksunder the supervision of physicians as well as independently depending on State regulations. TheNational Board of Certification and Recertification for Nurse Anesthetists (NBCRNA) administersthe certification examination for nurse anesthetist trainees. The University of Pittsburgh School ofNursing Nurse Anesthesia Program partners to offer the program with the University of PittsburghMedical Center (UPMC). The current nurse anesthesia program’s foundations can be traced tothe individual training programs in the late 1950s at Presbyterian and Montefiore UniversityHospitals in Pittsburgh. These two hospital programs merged in 1972, and the Nurse AnesthesiaProgram is now in the Department of Nurse Anesthesia at the University of Pittsburgh Schoolof Nursing. Fortunately, the University of Pittsburgh Nurse Anesthesia Program was ranked #4in the US News & World Report rankings of Best Nursing Graduate Program since 2016, withthe overall Doctor of Nursing Practice program ranking #9 in the United States in 2019.6 TheUniversity of Pittsburgh Nurse Anesthesia Program has been ranked in the top 10 by US News& World Report since 1998.The Mission of the University of Pittsburgh Nurse Anesthesia ProgramThe primary purpose of the Nurse Anesthesia Program in the University of Pittsburgh Schoolof Nursing is to educate registered nurses in both the science and art of anesthesia so that

611Nurse Anesthetist Education Programs in the United Statesthey will become efficient and skilled in utilizing various techniques of anesthesia intelligently,scientifically, and safely (Table 1). In addition to practicing skills, graduates gain researchand scholarship skills that provide a foundation for future work as doctorally prepared NurseAnesthetists. The program’s graduate standards are shown in Table 2.Table 1Program Mission1. Offer a superior graduate nurse anesthesia educational program2.  Respond to the needs of the community and the patients for whom our students provideanesthesia nursing care3.  Engage in research activities throughout the nurse anesthesia program curriculum with the intentto strengthen understanding of the evidence base for anesthesia practice4.  Engage in scholarly activities throughout the nurse anesthesia program curriculum with theintent to extend frontiers of knowledge in anesthesiaTable 2Graduate Standards for the University of Pittsburgh Nurse Anesthesia BSN to DNP ProgramPatient safety - the graduate must demonstrate the ability to:1. Be vigilant in the delivery of patient care2.  Refrain from engaging in extraneous activities that abandon or minimize vigilance whileproviding direct patient care3. Conduct a comprehensive equipment check4. Protect patients from iatrogenic complicationsPerianesthesia - the graduate must demonstrate the ability to:1. Provide individualized care throughout the perianesthesia continuum2. Deliver culturally competent perianesthesia care3. Provide anesthesia service to all patients across the lifespan4. Perform a comprehensive history and physical assessment5. Administer general anesthesia to patients with a variety of physical conditions6. Administer general anesthesia for a variety of surgical and medically-related procedures7. Administer and manage a variety of regional anesthetics8. Maintain current certification in ACLS and PALSCritical thinking - the graduate must demonstrate the ability to:1. Apply knowledge to practice in decision making and problem solving2. Provide nurse anesthesia services based on evidence-based principles3. Perform a preanesthetic assessment before providing anesthesia services4. Assume responsibility and accountability for diagnosis5. Formulate an anesthesia plan of care before providing anesthesia services6.  Identify and take appropriate action when confronted with anesthetic equipment-relatedmalfunctions7. Interpret and utilize data obtained from noninvasive and invasive monitoring modalities8. Calculate, initiate, and manage fluid and blood component therapy9.  Recognize, evaluate, and manage the physiological responses coincident to the provision ofanesthesia services

612Takahiro Tamura et al10.  Recognize and appropriately manage complications that occur during the provision ofanesthesia services11. Use science-based theories and concepts to analyze new practice approaches12.  Pass the national certification examination administered by the National Board of Certificationand Recertification for Nurse AnesthetistsCommunication - the graduate must demonstrate the ability to:1.  Utilize interpersonal and communication skills that result in the effective exchange of information and collaboration with patients and their families2.  Utilize interpersonal and communication skills that result in the effective interprofessionalexchange of information and collaboration with other healthcare professionals3.  Respect the dignity and privacy of patients while maintaining confidentiality in the deliveryof interprofessional care4. Maintain comprehensive, timely, accurate, and legible healthcare records5.  Transfer the responsibility for care of patients to other qualified providers in a manner thatassures continuity of care and patient safety6. Teach othersLeadership - the graduate must demonstrate the ability to:1. Integrate critical and reflective thinking in his or her leadership approach2. Provide leadership that facilitates intraprofessional and interprofessional collaborationProfessional role - the graduate must demonstrate the ability to:1. Adhere to the code of ethics for the certified registered nurse anesthetist2. Interact on a professional level with integrity3. Apply ethically sound decision-making processes4. Function within legal and regulatory requirements5. Accept responsibility and accountability for his or her practice6. Provide anesthesia services to patients in a cost-effective manner7.  Demonstrate knowledge of wellness and substance use disorder in the anesthesia professionthrough completion of content in wellness and substance use disorder8. Inform the public of the role and practice of the CRNA9. Evaluate how public policy-making strategies impact the financing and delivery of healthcare10. Advocate for health policy change to improve patient care11. Advocate for health policy change to advance the specialty of nurse anesthesia12. Analyze strategies to improve patient outcomes and quality of care13. Analyze health outcomes in a variety of populations14. Analyze health outcomes in a variety of clinical settings15. Analyze health outcomes in a variety of systems16. Disseminate research evidence17. Use information system/technology to support and improve patient care18. Use information system/technology to support and improve healthcare systems19. Analyze business practices encountered in nurse anesthesia delivery settingsNurse Anesthesia Program Curriculum at the University of Pittsburgh School of NursingNurse anesthesia practice covers the continuum of care from preoperative assessment todischarge from the post-anesthesia care unit. Nurse anesthetists interview and assess each patient

613Nurse Anesthetist Education Programs in the United Statesto best formulate and implement an individualized plan of care while collaborating with membersof a multi-disciplinary health care team. The rigorous curriculum features courses addressingthe chemistry and physics of anesthesia, evidence-based practice, advanced pharmacology, andprofessional role development. The curriculum also emphasizes simulation education, with theaverage student experiencing more than 120 hours of simulation coursework. The three-yearplan is shown in Online Supplementary Table 1. By the end of the program, students managea minimum of 800 anesthesia cases and document more than 2,000 clinical hours. The nurseanesthesia program curriculum is offered in a full-time format over 36 months (nine terms),and classes begin each January. The curriculum comprises 86 credits (course and clinical). Onecredit is equivalent to one hour of classroom time and a minimum of four hours of clinicalinstruction each week, or 15 hours of lecture and a minimum of 60 hours of clinical instructionfor a 15-week semester. On average, each student completes more than 40 hours of clinical eachweek during the program. After the first two terms, the curriculum design integrates classroom,simulation, and clinical experiences. The curriculum comprises 39 core credits and 47 anesthesiaspecialty credits. The clinical experience required for graduation is shown in Table 3.Table 3Clinical experiences required to submit an application for the CRNA National Certification Examination(Council on Accreditation of Nurse Anesthesia Educational Programs Appendix)Patient Physical StatusClass IClass IIClass III–VI (total of a, b, c & d)a. Class IIIb. Class IVc. Class IVd. Class IVTotal casesSpecial casesGeriatric 65 yearsPediatricPediatric 2 to 12 yearsPediatric (less than 2 years)Neonate (less than 4 weeks)Trauma/emergencyObstetrical management (total of a & b)a. Cesarean deliveryb. Analgesia for laborPain management encountersAnatomical CategoriesIntra-abdominalIntracranial (total of a & b)a. Openb. ClosedMinimum RequiredCasesas appropriateas appropriate20050100as appropriate600Preferred Numberof Casesas appropriateas appropriate3001001005as appropriate7001002003010as appropriate303010101575255504015155075532010

614Takahiro Tamura et alOropharyngealIntrathoracic (total of a, b, & c)a. Heart1. Open heart cases (total of a & b)a. With cardiopulmonary bypassb. Without cardiopulmonary bypass2. Closed heart casesb. Lungc. OtherNeckNeuroskeletalVascularMethods of AnesthesiaGeneral anesthesiaInhalation inductionMask managementSupraglottic airway devices (total of a & b)a. Laryngeal maskb. OtherTracheal intubation (total of a & b)a. Oralb. NasalAlternative tracheal intubation/endoscopic techniques(total of a & b)a. Endoscopic techniques (total of 1 & 2)1. Actual tracheal tube placement2. Simulated tracheal tube placement3. Airway assessmentb. Other techniquesEmergence from anesthesiaRegional techniquesActual administration (total of a, b, c, & d)a. Spinal (total of 1 & 2)1. Anesthesia2. Pain managementb. Epidural (total of 1 & 2)1. Anesthesia2. Pain managementc. Peripheral (total of 1 &2)1. AnesthesiaUpperLower2. Pain 555051553002535105010501050

615Nurse Anesthetist Education Programs in the United StatesUpperLowerd. Other (total of 1 & 2)1. Anesthesia2. Pain managementManagement (total of 1 & 2)1. Anesthesia2. Pain managementModerate/deep sedationArterial TechniqueArterial puncture/catheter insertionIntra-arterial blood pressure monitoringCentral Venous CatheterPlacement – Non-PICC (total of a & b)a. Actualb. SimulatedPlacement – PICC (total of a & b)a. Actualb. SimulatedMonitoringPulmonary Artery CatheterPlacementMonitoringOtherUltrasound-guided techniques (total of a & b)a. Regionalb. VascularIntravenous catheter placementAdvanced noninvasive hemodynamic monitoring35502550253010155as appropriateas appropriate1551010100as appropriateas appropriateNurse anesthesia programs in the United States are accredited by the Council on Accreditationof Nurse Anesthesia Educational Programs (COA) which is recognized by the United StatesDepartment of Education (USDE). A self-study document is provided to the COA before tworeviewers visit each site to evaluate compliance with the Standards for Accreditation of NurseAnesthesia Programs (2019). This document defines standards for faculty qualifications, students,resources, teaching, curriculum, clinical instruction, and evaluation processes conducted by nurseanesthesia programs. Reviewers from the COA meet with students, faculty, and staff at clinicalsites teaching students in the program. The frequency of accreditation visits depends uponrecommendations from the site’s prior accreditation visit.Students that have completed the curriculum take the National Certification Examinationprovided by the NBCRNA. Passing the exam provides the student with the CRNA credentialrequired for practice as a nurse anesthetist in the US. Some states also require nurse anesthetiststo provide documentation of specific clinical and didactic coursework and pay an additional feeto be licensed as advanced practice registered nurses (APRNs).

616Takahiro Tamura et alFinally, necessary expenses and acceptance rate are described. Students are required to attaina final course grade of at least 80% in each course that they take. This course pass thresholdis established at the University and School levels and is consistent with doctoral programsacross the United States. The probability of passing the overall course of study in the PittNurse Anesthesia Program once admitted is has averaged 95% over the last two decades. Theprobability of passing the National Certification Examination for Nurse Anesthetists on the firstattempt nationally on the first attempt over the past five years is 84.1%. The National CertificationExamination is administered by the NBCRNA. The performance of the University of PittsburghProgram has historically been better than this. The required tuition is currently about 104,000(for Pennsylvania resident), or about 124,000 (for non- Pennsylvania resident) for the entire36 month curiculum.Anesthesiologist Assistant (AA)The AA’s role is designed to support anesthesia care under the direct supervision of anesthesiologists. Their responsibilities are similar to those of CRNAs. However, AAs work only underthe direct supervision of anesthesiologists in the anesthesia care team’s environment. The AAprofession was conceived in the 1960s by three university anesthesiology department chairs inresponse to a shortage of physician anesthesiologists.7 In 1969, the first AA training programbegan accepting students at Emory University in Atlanta, Georgia, while a second program wasstarted at Case Western Reserve University in Cleveland, Ohio. Currently, there are 18 AAschools, and applicants must have a bachelor’s degree. Each state determines the places whereAAs can work; AA education programs have expanded to 18 states (Alabama, Colorado, Districtof Columbia, Florida, Georgia, Kentucky, Michigan, Missouri, New Hampshire, New Mexico,North Carolina, Oklahoma, Ohio, South Carolina, Texas, Vermont, West Virginia, and Wisconsin).AAs train for their profession through a different route than CRNAs. Nursing licensure andhealthcare experience are not mandatory. Many AAs have a pre-medical background and havecompleted a comprehensive educational and clinical program at the graduate level. They canreceive a degree through a 24–28-month program. The curriculum and graduation requirementsare like those of CRNAs discussed above. AAs must pass a certification examination administeredby the National Commission for Certification of Anesthesiologist Assistants in collaboration withthe National Board of Medical Examiners.Differences exist between AA and CRNA education programs regarding prerequisites, actualconditions for supervision, and accreditation maintenance. These differences exist because the twoprofessions were developed through different paths. High school graduates are directly admittedto four-year, full-time pre-licensure baccalaureate nursing programs; they are educated to becomeprofessional nurses whose practice is based upon nursing and related sciences. Graduates of theprogram are professional nurses with the necessary base for graduate education and continuingprofessional development. All nurse anesthesia programs require applicants to have at least oneyear of full-time experience as ICU nurses. Nurse Anesthesia educational programs requirean additional three years of full-time study and then completion of the National CertificationExamination.AA program applicants generally present with a background of science-related studies, anda baccalaureate degree from an accredited college or university in the US or Canada. All applicants will need to have completed the core requirements for application to most US medicalschools, although any degree is accepted. Thus, neither the AA nor the CRNA certification canbe obtained only through four years of university education, and the prerequisites and pathwaysfor obtaining each certification differ. According to the most current statistics, the mean totalyearly compensation for a full-time CRNA in the US is over 170,000 compared to the average

617Nurse Anesthetist Education Programs in the United StatesAA annual salary of around 100,000 in the US. There are similar responsibilities on the faceof it, and they often both work in anesthesia teams with anesthesiologists. However, they havedifferent educational pathways and accreditation bodies. CRNAs have prior experience as criticalcare nurses and can work without direct anesthesiologist supervision, allowing them to take calland provide services in consultation with physicians, including the surgeon. Some CRNAs appearto oppose the spread of AA programs, and some physicians have supported AAs as CRNAreplacements (Table 4).Table 4Scope s between certified registered nurse anesthetists (CRNAs) and anesthesiologistassistants (AAs)CRNAsCan practice in all 50 states and every US territoryLicensed Independent Practitioners in US Military (LIP)# Preoperative evaluation# General Anesthesia# Neuraxial anesthesia# Regional anesthesia# Pain management# Postop management# Intravascular access# During COVID-19, the Centers for Medicare and MedicaidServices suspended supervision requirements for CRNAs# Opt out in 18 states requiring no supervision# Medical supervision# Medical directionMean total annual compensation for full-time CRNAs is over 170,000 in the USAAsCan practice in18 statesSupervision byanesthesiologistAverage annual AAsalary is around 100,000 in the US# Hospitals# Same day surgery centers# Offices of dentists, podiatrists, ophthalmologists, and plasticsurgeons# Pain clinics# Critical access hospitalsReflection on the Current Perioperative Nurse Anesthetist Educational System in JapanAlthough it is challenging to create new national certifications such as CRNA in Japan, it isexpected that comprehensive anesthesia management opportunities will increase in the future, withnurse practitioners and perioperative nurses playing a role. To widely spread the anesthesia nursepractitioner in Japan, the following three matters become the main points considering Japaneselaw and the present medical system.First, in Japan, creating a unified certification for anesthesia nurse practitioners to ensure theseprofessionals’ skills and care quality is ideal. The number of facilities that train perioperative

618Takahiro Tamura et alanesthesia nurses or practitioners is increasing in Japan. However, there are several certificationbodies and certification names. Furthermore, in some cases, the qualification can only be usedat a qualification facility. By creating a unified qualification in Japan, these certified anesthesianurse practitioners would be able to relocate to institutions without concern regarding losingprivileges. Also, nurses can expand the field of hospital activities, including a shorter workdaystyle and part-time work.Second, current educational programs for anesthesia nurse practitioners in Japan overwhelmingly lack in their vigor in simulation and clinical training compared to those in the US. Onesolution would be to increase anesthesia nurse practitioners’ opportunities to learn alongsideanesthesiologists in simulation education and clinical training.Third, currently, there is little financial incentive to become an anesthesia nurse practitionerin Japan. It does not demand a standard wage like the United States. The incentive for workingday as an anesthesia nurse practitioner may be easy to introduce early. It is reasonable forthese highly-trained anesthesia nurse practitioners to receive better wages than those of nursepractitioners. The institutions may be financially well-off and continue to provide high qualitycare by hiring these anesthesia nurse practitioners instead of relying on locum anesthesiologists’anesthesia care. With the development of anesthesia nurses, anesthesiologists and surgeons willperform more operations, and the development of acute-phase medical care, including surgery,will lead directly to management development for hospitals. Improving incentives for surgeonsand anesthesiologists has been controversial for some time, but there is no sign of progress. Thegovernment or each hospital is entering a period that requires establishing an incentive system forthe individual for perioperative management, including surgeons, anesthesiologists, and anesthesianurse practitioners in Japan.Advocacy by anesthesiologists, surgeons, existing nurses, and hospitals is necessary to create aunified approval for anesthesia nurse practitioners in Japan, and it is impossible to implement itimmediately. If an educational institution such as ours takes the lead, we believe that advocacyas a hospital will be born and that discussions on the unification of approval will deepen.ResponsibilityIn the current situation in Japanese law, anesthesia nurse practitioner practice under thesupervision of anesthesiologists. However, it should not be forgotten that responsibility is involved.For reference, the responsibilities of anesthesiologists in the United States are described below.Whether it is an anesthesiologist or the surgeon, having physician supervision does not providefull protection for the CRNA. There is only one state in the US where an anesthesiologist’ssupervision is required (New Jersey). In every other state requiring supervision, a physician canbe the anesthesiologist or a surgeon. This is true in Pennsylvania, and there are many CRNApractices with this model. Each practitioner is independently responsible for their actions, and ifthey deviate from a plan of care or the standard of care, they are potentially liable. Typically,the CRNA and MD are named in a suit, and damages are awarded according to the jury orjudge’s responsibility assignment.CONCLUSIONEstablishing educational standards for perioperative nurse anesthetists and including theseprofessionals as integral members of anesthesia management teams should be the strategy toaddress the national shortage of anesthesiologists in Japan. Understanding the content of CRNAand AA educational programs in the US is essential for discussing strategies to determine the

619Nurse Anesthetist Education Programs in the United Statesbest method to train those extended anesthesia care providers in Japan. It is vital to determineeducational standards for anesthesia nurse practitioners, who would better meet the current needfor additional anesthesia care providers in Japan. It is also necessary to establish a unifiedcertification process with which anesthesia nurse practitioners would be able to mobilize theirskills in the county.ACKNOWLEDGEMENTThe authors thank Ms. Christine Burr (Scientific Writer, Department of Anaesthesiology andPerioperative Medicine/Department of Surgery, University of Pittsburgh School of Medicine,Pittsburgh, PA, USA) for her editorial assistance with the manuscript.DISCLOSURE STATEMENTNone of the authors has any conflicts of interest to declare about this work.REFERENCES1234567International comparison of life expectancy [in Japanese]. 8/dl/life18-04.pdf. Accessed July 8, 2020.Japan Association of Nursing Programs in Universities [in Japanese]. . Accessed July 8, 2020.Japanese Organization Nurse Practitioner Faculties [in Japanese]. July 8, 2020.Matsusaki T, Sakai T. The role of Certified Registered Nurse Anesthetists in the United States. J Anesth.2011;25(5):734–740. doi: 10.1007/s00540-011-1193-5.History of American Association of Nurse Anesthetists. y/our-history. Accessed July 8, 2020.Best Nursing Schools: - US News & World Report. rsing-schools/dnp-rankings. Accessed July 8, 2020.Pinegar M, Townsend T. The Role of Anesthesiology Assistants in the Anesthesiology Patient Care Team.Mo Med. 2019;116(1):63–66.

620Takahiro Tamura et alAppendix: Supplementary dataSupplementary Table 1 Three-year full-time curriculum plan

The discipline of nurse anesthesia was developed in the late 1800s. Sister Mary Bernard was the first nurse to specialize in nurse anesthesia at St. Vincent Hospital in Erie, Pennsylvania, in 1877.5 As few physicians focused their attention on anesthesia, nurse anesthetists learned ane