|
By Gene A. Blumenreich, JD
AANA General Counsel
Fine & Ambrogne, Boston, Mass.
On March 1, 1987, the AANA Board of Directors unanimously adopted the position statement on relationships between healthcare professionals, which is printed at the conclusion of this article. The purpose of this statement is to provide a context -- the reality of practice -- to assist those, including lawyers and judges, who are interpreting "supervision" or "direction" or who are otherwise attempting to understand the relationship between nurse anesthetists and physicians, dentists, podiatrists or other healthcare professionals.
Various licensing laws regulating nurse anesthetists require the nurse anesthetist to work under the supervision or direction of a physician. Licensing laws were designed to establish quality standards within professions and provide legislative recognition of the scope of a profession's practices. Licensing laws protect the public, not the profession and, in the health care field, generally describe practice rather than define it. Therefore, to understand health care licensing laws, one must first understand the reality of the profession's practice settings.
Reality of the practice settings
For example, in the major cases which established that nurse anesthetists were not illegally practicing medicine, the courts considered the reality of practice in interpreting Medical Practice Acts. In Frank v. South, (175 Ky. 416), the court took note that there was a 'usual custom as to the administration of anesthetics by trained nurses in the country at large" (p. 418). In Chalmers-Frances v. Nelson, (6 Cal 2d 402) the Court remarked that:
There was much testimony as to the recognized practice of permitting nurses to administer anesthetics and hypodermics. One of the plaintiff's witnesses testified to what seems to be the established and uniformly accepted practice and procedure followed by surgeons and nurses, and that is that it is not diagnosing nor prescribing by the nurses within the meaning of the Medical Practice Act. (p. 404)
The AANA's Position Statement is especially important in view of the American Society of Anesthesiologists' campaign to convince surgeons that they are automatically responsible for the actions of a nurse anesthetist. Courts have consistently confirmed that mere supervision or direction is not sufficient to establish liability. In order for a surgeon to be held liable for the negligence of a nurse anesthetist, there must be a determination that the surgeon was m control of the procedure giving rise to the negligence. Is control required? Clearly not under nurse anesthesia licensing laws, as numerous courts have indicated; and clearly not in practice, as the AANA Position Statement makes clear.
Some states require that nurse anesthetists be supervised by a physician, others provide for direction and others provide for supervision and direction. In the reality of practice, the functions performed by nurse anesthetists in working with physicians, dentists, podiatrists or other health care providers are no different in states requiring supervision than in states requiring direction. In the reality of practice, these words are used interchangeably and do not have distinct meanings. They represent a legislative effort to describe a relationship.
What is the relationship being described? There are probably as many types of professional relationships between nurse anesthetists and supervising physicians, dentists, podiatrists or other professionals as there are nurse anesthetists and other health care providers. Which one of these millions of relationships was intended to be described by the statutes? The answer is: All of them.
The California legislature set forth its intent in adopting the California nursing statutes:
"Nursing is a dynamic field, the practice of which is continually evolving to include more sophisticated patient care activities. It is the intent of the Legislature in amending this section at the 1973-74 session to provide clear legal authority for functions and procedures which have common acceptance and usage. It is the legislative intent also to recognize the existence of overlapping functions between physicians and registered nurses and to permit additional sharing of functions within organized healthcare systems which provide for collaboration between physicians and registered nurses...."
What the AANA Position Statement does
The AANA Position Statement recognizes that "supervision" is necessarily a general term designed to include a large variety of practice settings. The "right" relationship must take into account a number of factors and conditions. To believe that one of these potential relationships is legislatively required is to promote stereotypes over reality. All of these practice settings satisfy the legal requirements of "supervision." The AANA Position Statement reaffirms that supervision does not require control. In fact, given the education, training and responsibilities of nurse anesthetists, in all but truly unique cases, control of the nurse anesthetist by one providing statutory supervision would be inappropriate.
The AANA Position Statement also suggests that, in practice, the relationship between nurse anesthetist and physician, dentist, podiatrist or other healthcare professional is often one of consent.
As they have in the past, one can expect that there will be some who will be critical of the AANA Position Statement. There are those who, for their own purposes, will seek to define supervision so as to restrict the scope of practice of nurse anesthetists.
State licensing laws are not intended to address "turf battles" among competitors. State licensing laws pro- viding for the scope of practice of nurse anesthetists are clearly not designed to protect physicians or physician specialty groups. The AANA Position Statement may be criticized by those who wish it were different, but it clearly describes the reality of practice.
As independently licensed health professionals, CRNAs are responsible for services they provide pursuant to that license. Some aspects of anesthesia delivery require interdependence between members of various health disciplines. Many different terms can and have been used to describe the working relationships between these individuals. These terms have sometimes been undefined or ill-defined and have posed confusion to those seeking clear definition.This position statement represents the AANA's interpretation of some generally used terms and other terminology as it applies to nurse anesthesia practice. By defining this terminology, we reaffirm our belief in an environment in which CRNAs have opportunities to realize their potential as providers.The statement realistically describes the settings in which practitioners carry out their respective disciplines. By doing so, positive outcomes continue to be realized including:
- Improved quality of patient care.Increased patient satisfaction. Reduced healthcare costs.
- Collaboration among healthcare professionals.
The terms supervision and direction are used interchangeably in licensing laws and nurse practice acts. These terms are often undefined and are to be interpreted in the context of the reality of practice.Supervision and direction are general terms which describe a relationship between a nurse anesthetist and a physician, dentist, podiatrist or other health care professional with whom the nurse anesthetist works in varying degrees of collaboration. Supervision or direction refers to a variety of different practice settings within a continuum. While all satisfy the legal requirement, practice settings take into account the education, experience, and capabilities of the nurse anesthetist, the rules and guidelines of the institution in which anesthesia is to be provided, and the needs and desires of the patient, nurse anesthetist, physician, dentist, podiatrist, or other health care professional. It is not unusual for nurse anesthetists to practice with the general agreement of the authorized health care provider. Supervision and direction as required in licensing laws or nurse practice acts can be found in the consent of the authorized health care provider.In the context of the realities of anesthesia practice today, CRNAs commonly practice with the consent of another licensed provider -- a physician, dentist, podiatrist, or other health care professional. Consent is an agreement to the proposed plan of anesthesia care, and may be either formal, informal, or implied.
Supervising healthcare providers have not been held liable for the negligence of a nurse anesthetist because they were exercising the statutory requirement of supervision. Where the courts have imposed liability on the supervising health care provider, it has been where he or she controlled the procedure or contributed to the injury. Control is a level of supervision not required by nurse practice acts.
Adopted by the AANA Board of Directors, March 1, 1987.
This article is not intended as legal advice nor is it advice on the law of any state. If legal advice or other expert assistance is required, the services of a competent professional person should be sought.
Back to Legal Briefs Table of Contents
|