Abstract
Background
Manpower and the quality of nurse anesthetists (NA) have become critical concerns in Taiwan over the past few decades because of increasing clinical demand and the supervision of NAs by anesthesiologists. To understand manpower distribution, clinical load, job description and limitations, and job satisfaction of NAs, we conducted a cross-sectional survey in Taiwan in 2005.
Methods
The structure of the questionnaire was initially developed by a drafting group that included members of the Taiwan Society of Anesthesiologists and the Taiwan Association of Nurse Anesthetists. The validity and reliability of the questionnaire was evaluated by specialists. The survey contained questions regarding the demographic characteristics of manpower (anesthesiologist/NA ratio), clinical work load, present job roles, professional expectations, job satisfaction, and reasons for career transfer. The questionnaires were mailed to the superintendents or matrons of NAs, and the administrators of anesthesiology departments across 228 institutions with different accreditation levels and 1953 NA staff between February 1 and December 31, 2005.
Results
The validity and reliability of the questionnaire for the department chief and anesthesiology nursing staff was 0.8 and 0.7, respectively. Questionnaires were returned by 113 executives (39 anesthesiology department directors, 74 NA superintendents or matrons) with a response rate of 49.6%, and from 1452 NAs with a response rate of 74.3%. The average clinical load (2002 – 2004) for the anesthesiologists was 1500 – 1700 cases/year and 350 – 380 cases/year for the NAs. The manpower ratio of attending anesthesiologists to NAs was 1:4.3, while the medical centers held the highest ratio. The job stipulation for NAs in Taiwan was compatible with that in the United States and there was a high consistency of opinions between the directors and NA superintendents or matrons. The average rate of career transfer was relatively low (5.5%). From the executives' view, the concerns regarding management of NAs included limited staff capacity, recruiting difficulty, shortage of
Conclusion
This study represents the first large-scale assessment of the distribution, clinical load, and job satisfaction for NAs in Taiwan. The roles of NAs, which include preoperative preliminary preparation and postoperative intensive care, need to be more well-defined. To improve the quality of NAs and anesthetic care in Taiwan, it is vital to establish an official accreditation system and formal education programs, to institute well-defined and standardized job descriptions, and to improve resource allocation for NAs.
Keywords
anesthesia; health manpower; nurse anesthetists; personal satisfaction; questionnaires;
1. Introduction
A worldwide shortage of anesthesia specialists is the main driving force for the training of nurse anes-thetists (NA) as a substitute for anesthesiologists in clinical practice.1,2 The irrational and incompre-hensive health insurance coverage drafted by the Taiwan National Health Insurance System, with the scheme enforced in 1990, has had a profound ef-fect on hospital administrators with regard to finan-cial considerations. Their response was to employ more NAs to perform anesthetic work under an-esthesiologist supervision to reduce expenditure. As a result, medical graduates hesitate to choose the specialty of anesthesiology, aside from the notion that the profession is relatively risky and poorly paid. According to a survey conducted by the Taiwan Society of Anesthesiologists in 2003, anesthesiolo-gists managed an average of 1500−1700 cases annu-ally, which is 3.4-fold and 2.1-fold greater than the number of cases managed by American and Japanese anesthesiologists, respectively.3
The training of nurse anesthetists has neither been considered as a formal educational component in the arena of medicine nor is it recognized or cer-tified by the Ministry of Health of Taiwan. In terms of the curricula and training program, the Taiwan Association of Nurse Anesthetists claimed that these were partially adopted from teaching materials de-veloped by the Association of American Nurse Anesthetists (AANA).4,5 However, the discreetness and relative importance of training programs are actually institution-dependent and the format and content of the training programs differ between institutions. Therefore, the quality of NA training in Taiwan is inconsistent and questionable.
To better understand the present status of the distribution of NAs in Taiwan, we conducted a cross-sectional survey directed at the administrators of anesthesiology, superintendents or matrons of NAs, and NA staff within the anesthesiology depart-ments of various medical institutes with different accreditation levels. The scope of this analysis mainly focused on the demographic distribution of NA manpower, the ratio of NAs to anesthesiologists in each institute, job descriptions, professional ex-pectations and job satisfaction of NAs, factors that might be provide valuable and objective references for future policy-making.
2. Methods
The cross-sectional institutional survey was ap-proved and sponsored by the Department of Health, Executive Yuan, Taiwan (DOH94-MA-1025) and con-ducted between February 1 and December 31, 2005. The target of this survey included the direc-tors of anesthesiology departments, superinten-dents or matrons of NAs and NA staff in medical institutes with various accreditation levels, including medical centers, and regional and district hospitals. The structure of the questionnaire was developed through discussions of a drafting group, which contained members of the Taiwan Society of Anesthesiologists and the Taiwan Association of Nurse Anesthetists, to identify the major issues re-lated to NAs. The topics identified by the drafting group included the current status of NA training, utilization of manpower, factors affecting supply and demand of NAs and how to overcome imbal-ance. Members of the Taiwan Association of Nurse Anesthetists also proposed topics such as job spec-ification and job satisfaction, in addition to the concerns raised by members of the drafting group representing anesthesiologists.
The content of the questionnaire was derived from consensus of opinion and essentially com-prised: (1) location and level of accreditation of the institute; (2) number of operations with or without anesthesia, the number of anesthesiolo-gists and NAs, and their basic demographic data; (3) job description and expectations reported by the senior anesthesiologists and superintendents or matrons of NAs; (4) reasons for training NAs by the institution and the mobilization of staff; (5) difficulties in staff recruitment and possible solu-tions; (6) factors affecting NA job satisfaction; and (7) willingness to continue practicing anesthesia or the possibility of job transfer. The validity and the reliability of the questionnaire were initially eval-uated and modified through a pilot study involving personnel from various backgrounds, including ad-ministrators of anesthesia services, superinten-dents or matrons of NAs and members of the Taiwan Association of Nurse Anesthetists. The formal ques-tionnaire was sent to the target population by mail and receipt was confirmed by telephone to im-prove the response rate. Data were recorded using SPSS version 11.5 (SPSS Inc., Chicago, IL, USA) and analyzed by χ2 tests to investigate differences between institutes.
3. Results
The validity and reliability of the questionnaire was 0.8 and 0.7, respectively, after modification of the pilot version. The total number of question-naires delivered to the various strata of personnel was 228, and 113 questionnaires were returned (39 from anesthesiology department administrators and 74 from NA superintendents or matrons) with a response rate of 49.6%. In terms of the location of the institute, there was no significant geographic difference between hospitals and administrators of anesthesia services and superintendents of NA (Pearson’s χ2 = 0.445, df = 3, p = 0.931). Furthermore, there were no significant differences in response rate among hospitals, directors of anesthesiologists or NAs across the geographical regions or level of accreditation of hospitals in Taiwan (Pearson’s χ2 = 0.369, df = 2, p = 0.831) (Tables 1 and 2).
3.1. Clinical load and ratio of supervision of NAs by anesthesiologists
In the 74 institutes surveyed, the average number of cases managed by each anesthesiologist was 1577−1704 annually, compared with 355−386 for NAs, with an anesthesiologist-to-NA ratio of 1:4.2 to 1:4.4 (2002−2004; Table 3). In terms of the case load of hospitals according to accreditation level, anesthesiologists in medical centers had higher case loads (1680−1740 cases/year) than those in regional and district hospitals (1740 cases/year and 1192 cases/year, respectively; Table 4). In terms of the case load for NAs, staff in regional hospitals were responsible for more cases (392−421 cases/year) in 2002−2004 than NAs in medical centers or district hospitals (Table 4). The ratio of anesthesiol-ogists to NAs was 1:4.5 to 1:4.8 in medical centers, 1:4.2 in regional hospitals and 1:3.4 in district hospi-tals (Table 5).
3.2. Present pattern versus expected pattern of clinical practice by NAs from the views of physician administrators and NA superintendents
In terms of the expected duties of NAs, including preanesthetic visits, intraoperative patient care and postanesthetic care/visits, the opinions of adminis-trating anesthesiologists and NA superintendents were consistent (Table 6). In terms of independency of practice, the NA superintendents demanded greater total independency for NAs than the administrators of the anesthesiology departments (28.4 vs. 7.7%; Table 6). Overall, administrators of anesthesiology and NA superintendents had similar expectations regarding supervision of NAs by an anesthesiologist (61.5 vs. 62.2%; Table 7), but this was inconsistent with the current pattern of supervision (66.7 vs. 86.5%; Table 6). In terms of the expectation of job assignment to NA, the administrators of anesthesi-ology department and NA superintendents unani-mously favored supervision by anesthesiologists in clinical anesthesia and the duty of postanesthetic care/visits (Table 7).
3.3. Career satisfaction of nurse anesthetists
In terms of the survey of career satisfaction, 1953 questionnaires were sent to NAs, of which 1452 questionnaires were returned and analyzed (re-sponse rate: 74.3%). The assessment of job satis-faction was evaluated using five-point Likert scales (very satisfied, satisfied, acceptable, dissatisfied and very dissatisfied). The satisfaction rate was defined as the percentages of NAs reporting they were satisfied or very satisfied. The best perceived aspect of job satisfaction was self-achievement from applying professional knowledge (58.3−62.7%; Table 8), followed by work harmony with medical colleagues (43.4−72.9%). NAs in medical centers showed the lowest career satisfaction for most items in comparison with NAs from regional and dis-trict hospitals (Table 8). Although NAs reported dis-satisfaction with their job, their intent to continue the profession was high (84.6−92.5%; Table 9).
3.4. Mobilization and recruitment of NAs
In the hospitals surveyed, the total numbers of NAs was 1358, 1396 and 1422 in 2002, 2003 and 2004, respectively, representing a 2.8−4.7% increase each year. In contrast, the job transfer rate was 4.1, 5.2 and 7.2% (average: 5.5%) for the 3 consecutive years. To overcome staff shortages, recruitment and training of NAs is necessary. However, most in-stitutes reported several obstacles in terms of re-cruitment: (1) uncertain job assignment, 54%; (2) limited number of available experienced NAs, 46%;(3) limited institutional resources, 41%; (4) lengthy duration of NA training, 30%.
4. Discussion
This nationwide cross-sectional survey is the first study to investigate human resource factors of NAs in Taiwan. Key findings are as follows. First, anesthe-siologists in Taiwan manage a relatively high number of cases each year (1500−1700 cases/year), than anesthesiologists in developed countries, although this case load is offset by a unique practice with some clinical work performed by NAs under the supervi-sion of an anesthesiologist. Second, the number of anesthesiologists versus the number of NAs is in the ratio of 1:4.2 to 4.4, which means that each anesthesiologist supervises approximately four NAs at one time to cope with the clinical need (Table 1). This ratio implies that each anesthesiologist has sub-stantial responsibility during daily practice and explains why NAs experience such great demands.6 Third, the anesthesiologist to NA ratio in medical centers was higher than that in hospitals (4.7 vs. 3.4 in 2002, 4.5 vs. 3.6 in 2004; Table 2). This implies that the anesthesiologists in medical centers have even greater responsibility in the management of high-risk patients.
In the United States, a nurse is required to have a bachelor degree and receives a minimum of 2 years of formal education and clinical practice in anesthesia before passing the national board ex-amination to become a NA.4,5,7 In Taiwan, however, NAs require a nursing background and receive a non-uniform anesthesia training course lasting 6−12 months, depending on the hospital, and works without governmental certification. In the United States, there are four types of nursing specialists that can become certified as advanced practice nurses, namely a clinical nurse specialist, nurse practitioner, nurse midwife and NA. There are es-tablished guidelines for the education, certifica-tion and licensing of NA in the United States and most programs involve a minimum of 24 months of postgraduate training,7,8 including 45 hours of pro-fessional classes, 135 hours of anatomy, physiol-ogy, pathophysiology and clinical pharmacology, 45 hours of chemistry and physics, 90 hours of princi-ple of anesthesia and 45 hours of clinical case dis-cussion. All of the classes have been certified by the Council on Accreditation for Nurse Anesthesia Education Program and are approved by the Commission on Recognition of Post-Secondary Accreditation. Furthermore, at least 790 or more anesthesia cases must be encountered during the training program. Graduates from the NA programs are expected to pass board examination offered by the Council of Certification of Nurse Anesthetists to become a certified registered NAs (CRNA),7,8 which is followed by 40 hours of continuing education every 2 years for recertification.7,8 Although a NA system has been practiced openly since 1959 in Taiwan, the educational goals of NA training have never been standardized. It was not until 2006 that the School of Nursing at Taipei Medical University started the undergraduate (3-year) and postgraduate (2-year) NA programs and formulated a curriculum similar to that of the AANA to train NAs in Taiwan. The development of the curriculum is still in progress.Individual clinical privilege can take a variety of forms, depending on the work that exists within the practice.7,9 Registered NAs are not required to be legally certified and are not obliged to attend con-tinuing education programs to practice in Taiwan. As a result, the quality of anesthetic care provided by NAs might be inconsistent and questionable. Similarly, the lack of job descriptions for NA and increased non-clinical responsibilities due to ad-ministrative considerations also hampers the re-cruitment of new staff and provision of professional training. Although the NA system is widely practiced in the United States and Taiwan, there are some major differences between the two systems. NAs in the United States are allowed to practice without the supervision of an anesthesiologist in some states, but this is not possible in Taiwan. Clinical privilege is the process by which individuals are credited within institutions to provide specific patient-care services. In the United States, CRNAs are priv-ileged to give anesthesia and their responsibilities are consistent with established law, including pre-anesthetic preparation and evaluation, intraopera-tive care, postan esthesia care, and life support functions. There are also other non-clinical re-sponsibilities of CRNAs, including administrative/management duties, quality assessment, education, research, committee appointments, interdepart-mental liaison and clinical/administrative oversight of other departments.7,9
Over the last five decades, the role of NAs in Taiwan has expanded beyond the scope of nursing care, but their clinical privileges have not been de-fined.10 Currently, there are 2550 registered NAs in Taiwan and their clinical privileges are generally regulated under Nursing Personnel Law (Article 24) enforced by the Department of Health. The official job description for registered nurses (including NAs) includes: (1) to assist invasive examinations; (2) to assist invasive therapeutic interventions; (3) to as-sist various surgical procedures; (4) to assist baby delivery; (5) to assist therapeutic or diagnostic ra-diographic intervention; (6) to assist chemother-apy; (7) to assist hyperbaric or photodynamic therapy; (8) drug administration; (9) psychother-apy; and (10) to monitor and evaluate patient vital signs. In fact, the present patterns of practice for NAs in Taiwan might fall into one of four different categories: (1) to conduct anesthesia without an-esthesiologist supervision (legally supervised by a surgeon in certain anesthetic procedures); (2) to conduct anesthesia without anesthesiologist su-pervision (officially supervised by a surgeon) after hours; (3) to conduct anesthesia wholly under the supervision of an anesthesiologist; and (4) being solely an assistant of an anesthesiologist during anesthesia services.10 Our data revealed a consensus of opinion between anesthesiologist administrators and NA superintendents in terms of NA duties being supervised by an anesthesiologist or acting as an as-sistant to the anesthesiologist rather than practic-ing anesthesia independently.11,12 According to our survey, the uncertainty and poorly defined job de-scriptions have resulted in limited availability, re-cruitment and job mobilization of NAs in Taiwan, which are of major concern. Staff in medical centers expressed their dissatisfaction, mainly due to a stressful institutional environment. However, the survey also showed that most NAs in Taiwan have high job satisfaction and sense of self-achievement, and are reluctant to change jobs.13,14 In terms of improving the recruitment of NAs, the administra-tors of anesthesiology departments and superin-tendents of NAs should consider providing: (1) better salary; (2) advanced medical education; and (3) well-defined job descriptions for working NAs.
In conclusion, there is still a great demand for NAs in Taiwan but, because of the lack of official certification and standardized curricula for initial training programs and continuous education, the quality of NAs is poor. To improve the quality of NAs and the overall quality of anesthetic care in Taiwan, we believe that establishment of a standardized NA accreditation system (including formal education programs and continuing education), and improved working environments with well-defined practice guidelines are urgently required.