14

At the association's second annual meeting in Philadelphia, Sep-tember 25-27, 1934, the most dramatic issue to be brought beforethe members was the report of actual and rumored legislative activ-ity against nurse anesthetists, highlighted by the Dagmar Nelsontrial.* The program for the accreditation of schools of anesthesiafor nurses, boldly proclaimed the previous year, was as yet withoutsubstance. And whether the association was to go toward legal regis-tration of nurse anesthetists or toward certification of individuals bythe association had not been aired thoroughly let alone decided. Tothe members, discussions of the association's educational programand the pros and the cons of registration versus individual certifica-tion were without immediacy, but no nurse anesthetist had to be toldhow a series of legal actions throughout the country would affecther personally. Mrs. Fife, as president, referred to all three issuesin her annual address:

Our present problem is not a problem of defense, but of organization,to lead us to more clear-cut methods and more uniform standards ofteaching the subject of anesthesia. It is not a case of a threatened educa-tional revolution. It is a case of stimulating the leaders in all schools ofanesthesia to give more thought to the methods and the value of moreintensive training with a view to greater efficiency. ... The apparent

*During 1934, in addition to the Dagmar Nelson trial and the opinion of the at-torney general of Indiana (see Part Three, Chap. 13, p. 212), legal activity withrespect to nurse anesthesia included the introduction into the New York Senate onMarch 5, 1934, of an act to amend the education law in relation to the administra-tion of anesthetics. This measure was an outgrowth of a resolution passed on April 3,1933, by the New York State Medical Society that "measures be taken to obtain legis-lation which will include anesthesia under the practice of medicine or limit the prac-tice of anesthetics to duly licensed dentists and physicians." (McKay, Cora: Letter toRuth M. Nash dated April 22, 1933.) The act, as introduced by Senator Crawford,read that "A person practices medicine . . . who undertakes to or does administer ananaesthetic to any human being." The act did not proceed to passage as a conse-quence of opposition to the bill, initiated by Cora McKay, president of the New Yorkassociation of nurse anesthetists. (McKay, Cora: Letter to Ruth M. Nash dated March17, 1934.)

215

216 History of Anesthesia

indifference to the significance of the work displayed by the schoolsthat are attempting to teach the subject in a few weeks or a few monthsmust be discouraged, and on the other hand the hospitals must be en-couraged to allow their graduate anesthetists more time for advancementand study, and contact with others in the field-a privilege especiallyavailable at the meetings of this organization.

. . The formation of this organization was for the purpose of elevatingthe standards of anesthesia, and there is no doubt but that if we accom-plish the standardization of the schools of anesthesia we shall have at-tained one of our great objectives ....

. . The meetings of the National Association will afford many the op-portunity of coming together to discuss the advanced ideas, but due tothe fact that these meetings are held great distances each year from manyof our members, it is imperative that we encourage state organizations,to act as clearing houses, in order that more frequent meetings can beheld and more direct contact can be secured with the individualmember....

An intensive program to organize within the states cannot be over-emphasized. In the past six months we have heard rumors, and in someinstances actual steps are being taken by a certain group of doctors inthe medical profession, to try to limit the right to administer anestheticsto those who hold medical degrees. This movement is the result of theeconomic disturbances, and is not being viewed with favor by the moreprominent surgeons and hospitals throughout the country.... The ques-tion as to who is rightfully qualified to administer an anesthetic, ifbrought to an issue, will be dealt with squarely by those responsible forthe care and safety of the patient, and the outcome will again demon-strate the leadership and courage of the hospital executives and surgeonswho have formulated and followed policies insuring the greatest serviceto the community and the protection of human lives.

As nurse anesthetists we cannot turn a deaf ear to this controversy....We must find a means whereby the hospitals and surgeons employingnurse anesthetists can be assured that the nurse anesthetists have re-ceived the proper training and are qualified to do the work. This couldbe accomplished by obtaining state board registration. I do not believethat state board registration is either practical or possible at this time.Our National Association should immediately take steps whereby thisservice would be given to the hospitals and surgeons through this or-ganization. An examining board should be chosen by the National Asso-ciation, and every applicant applying for membership in the organiza-tion should be required to pass an examination. The examining boardwould be responsible for the preparation of the examination-the ar-rangements whereby the examination would be taken within the state-and responsible for the final decision which would allow the NationalAssociation to issue to the individual who successfully passes the ex-

Legislation 217

amination a certificate signifying that the individual is sanctioned by thisorganization.l

To cope with legislation adverse to nurse anesthetists, the mem-

bers at the second annual meeting empowered the president to ap-

point a legislative committee and to retain Kenneth Guild as legal

advisor to the association if it was found necessary by the legislative

committee and the trustees.

A shift in the concept of an accreditation program for schools of

anesthesia for nurses was apparent in a proposal made by Mrs. Fife

during the business session:

I feel that we must institute some rule where each member . . . willhave to take an examination. I don't think we are going to get any-where if we still continue without accredited schools of anesthesia, and Ithink it would be difficult to accredit schools unless you accredit individ-uals, and when you do that you automatically accredit the schools.2

Thereupon, a recommendation was made that the state affiliates

should conduct examinations, but that standards for the training of

nurse anesthetists should be established first. A motion then was

made by Verna Rice that a committee be appointed to:

ascertain the theoretical studies incorporated in the curriculum of theschools of anesthesia; that said committee report its findings, with recom-mendations of theoretical studies to be incorporated in the curriculumof standardized schools of anesthesia to the Board of Trustees of theNational Association of Nurse Anesthetists, within six months of thedate this motion is made.3

Miriam Shupp amended the motion to include clinical as well as

classroom instruction in the study to be made by the committee, and

the motion was carried.

In the proposed revisions to the bylaws, the most important

changes to be presented to the members were in the article govern-

ing election to office. The first of these proposed that the first vice-

president become a member of the Board of Trustees and was

accepted. The second, which was referred back to committee, was

that the first vice-president should be the candidate receiving the

second largest number of votes for the presidency. The third pro-

1Fife, Gertrude: Address of the president, Bull. Nat. A. Nurse Anesthetists 3:5, 1935.2Proceedings of the Second Annual Meeting of the National Association of Nurse

Anesthetists, Philadelphia, September 25, 1934.Slbid.

218 History of Anesthesia

posal was that the president and the treasurer should be eligible forunlimited re-election, and this also was referred back to committee.

The election of officers at the second annual meeting took an un-expected turn. The nominating committee's candidate for thepresidency was Florence Boswell, who had been the executive secre-tary during the preceding year. When her name was presented tothe convention during the course of the election procedure, a mo-tion was made that Mrs. Fife be retained in the office of the presi-dent, to which there were a number of seconds. Mrs. Boswell thenread the following excerpt from the minutes of the meeting of theBoard of Trustees on May 5:

The Nominating Committee asked Mrs. Fife if she would serve asPresident of the Association for the second year. Mrs. Fife declined thenomination. Mrs. Boswell was then asked to allow her name to be pre-sented and Mrs. Boswell said that only with the consent of Mrs. Fifeand if the Nominating Committee and Board of Trustees felt that shecould be of service to the organization, she would accept such position. 4

Mrs. Boswell withdrew as a candidate, and Mrs. Fife was electedto a second term as president. The other officers for the 1934-35organization year were: Hilda Salomon, first vice-president; RosalieMcDonald, second vice-president; Cora McKay, third vice-president;Lou E. Adams, Cleveland Clinic Hospital, Cleveland, treasurer.Anna Willenborg, St. Joseph's Hospital, Chicago, was elected trustee,with Miss Hodgins, Helen Lamb, Aida Allwein and Ruth Nash re-maining on the governing board.

Two other actions by the members at the second annual meetingdeserve mention. The first was a recommendation that a committeebe appointed to be responsible for the regular publication of a bul-letin. The second was the decision that the association's headquar-ters should remain at the University Hospitals of Cleveland untilsuch time as it would be possible to move the office to the head-quarters of the American Hospital Association in Chicago andemploy a full-time executive secretary.*

During that year rumors of adverse legislation were rife, and al-though the worst was anticipated with respect to antinurse anes-

4Bull. Nat. A. Nurse Anesthetists 2:18, 1934.*On January 8, 1935, Florence Boswell resigned as executive secretary, and Mary

Lucile Goodman, Mrs. Fife's first assistant at the University Hospitals, was appointedto replace her. During 1935 office space was taken temporarily at 2073 Adelbert Road,Cleveland.

Legislation 219

thetist activity, in only one state were the fears borne out. InJanuary, 1935, Carin Pedersen of New Hampshire learned of theintroduction of a restrictive bill (House Bill 196) into the legis-lature. This bill was killed in committee.

On February 18, 1935, the American Hospital Association Boardof Trustees condemned such legislation in the following resolution:

Resolved, That it is the judgment of the Trustees of the AmericanHospital Association that any legislation which bars, or tends to bar, theuse of properly trained anesthetists would be a mistake and a stepbackward.5

Mr. Guild, the attorney for the nurse anesthetists' association, keptthe Board of Trustees informed of possible sources of adverse activ-ity, and the association for the first time considered the possibilityof an active public relations campaign to present the facts of nurseanesthesia service to the public.

The most important committee project recommended at the 1934convention was the preparation of a curriculum outline for schoolsof anesthesia for nurses.* The work, as assigned to the educationalcommittee, consisted of two parts: (1) an outline of minimum re-quirements for existing schools of anesthesia and (2) an outline of aproposed curriculum to be prepared by the educational committeeand advocated by the organization for acceptance by the schools ofanesthesia desiring to raise their standards of education.

To Miss Hodgins, the "extent and importance of the work" as-signed to the educational committee were such that it seemed a logi-cal step to form within the national association a department ofeducation, whose "wider function" should be the investigation ofeducational problems and the compiling and disseminating of edu-cational material.6 During the summer of 1935 Miss Hodgins workedout a plan for such a department of education. Although this planwas not accepted by the Board of Trustees, it directed attention tothe association's need for a staff to co-ordinate its educational pro-gram.

In the preparation of the first curriculum outline, opinions and

5Bull. Nat. A. Nurse Anesthetists 3:26, 1935.6Hodgins, Agatha: Letter to Gertrude Fife dated August 8, 1935.*Agatha Hodgins, who was appointed chairman of the educational committee to

carry out this project, resigned in December, 1934, and was succeeded by Helen Lamb.

220 History of Anesthesia

ideas were solicited from the nurse directors of leading schools ofanesthesia, and the report of Helen Lamb, chairman of the educa-tional committee, at the third annual meeting in St. Louis, October1-3, 1935, contained the specific recommendations that

(1) A curriculum be endorsed for Schools of Anesthesia whose grad-uates are to merit highest rating by the National Association of NurseAnesthetists.

(2) The curriculum propose specific material desired to be taught, aminimum number of acceptable recorded hours of organized teachingand a minimum acceptable number of anesthetics administered by eachstudent graduated;

(3) These minima be:Length of course, 6 months (with one year advocated)Recorded hours of class room instruction, 95Recorded hours of operating room instruction, 18Number of cases administered, 325 (of which 25 should be ob-stetrical; 25 may be dental; 25 may be spinal, locals, et cetera).7

The other important matter at the third annual meeting was theadoption of a code of regulations to replace the association's bylaws.Except for the change in name, the differences between the old andthe new regulations were few and were concerned primarily with therelationships between the state and the sectional associations andthe national.

In the new code the president, the first vice-president and thetreasurer were on the Board of Trustees, which was composed ofeight members in all, and the executive secretary and the historianwere listed as officers. The executive secretary was to be appointed;she was not a member of the Board of Trustees and did not havea vote at meetings of the Board. The historian was to be elected andcould succeed herself without restriction as to the number of termsof office.

Provision was made for seven committees: membership, program,public relations, revisions, education, publication and finance.

The public relations committee was really a committee on legis-lation and was to "make recommendations to the Board of Trusteesfor the protection of the professional rights of the members of theAssociation and the public." It was to assist in the establishment ofa public relations committee in each state and in each sectional asso-

7Report of educational committee, Bull. Nat. A. Nurse Anesthetists 4:56, 1936.

Legislation 221

ciation and was to have "advisory responsibility on educational

problems involving legislation." 8

The educational committee was to "assist in the development of

educational standards, establish and maintain a central bureau of

information, compile and have on record a list of recognized schools

of anesthesia and qualified instructors . . . [and] have advisory

responsibility on all educational problems except those involving

legislation." 9

The four classes of membership were: active, associate, honorary

and sustaining. The categories of associate, honorary and sustaining

membership perpetuated the principle of lay membership. The

qualifications for active membership were:

[An] . . . applicant shall have been graduated from an accredited school

of nursing and have passed the required State Board examination for

nurses and actively continued her registration if so required by the State

in which she is registered and have engaged for not less than three years

in the practice of the administration of anesthetic drugs prior to 1936

and must be so engaged at the time of applying for Individual member-

ship. Any candidate for Individual membership who has not been en-

gaged in the practice of the administration of anesthetic drugs for at

least three years prior to 1936, but who has been graduated from a

recognized school of anesthesia, shall be eligible for membership.l°

In two specific ways the new code of regulations spelled out the re-

lationship of the affiliated associations to the national. The first was

that no member holding an office in a state or a sectional association

could at the same time hold an office in the national association.

The second was that the article on membership threw the weight

of the initiative to the affiliated groups. Members of affiliated state

or sectional associations, by virtue of that affiliation, became mem-

bers of the national association, provided the affiliated association

complied with the policies and the requirements for individual

membership in the national organization. Persons residing in states

in which there was no affiliated association could apply for individ-

ual membership in the national association. The financial arrange-

ments provided that the initiation fee and one half the annual dues

of members joining state affiliates should be turned over to the

national association.

8Code of Regulations, National Association of Nurse Anesthetists, 1935.

9lbid.lOlbid.

222 History of Anesthesia

In view of subsequent changes in the membership requirements,it is of interest to note that the admission of male nurse anesthetistswas discussed at the third annual meeting and reference was madeto a previous decision of the trustees that they should not be ad-mitted.

At this meeting Hilda Salomon was elected president; Verna Rice,first vice-president; Olive L. Berger, Johns Hopkins Hospital, Balti-more, second vice-president; Eva M. Dickson, Brooklyn Hospital,Brooklyn, third vice-president; and Gertrude Fife, treasurer. MaryLucile Goodman was reappointed executive secretary. Trustees wereHelen Lamb, who was re-elected; Miriam Shupp, Strong MemorialH-ospital, Rochester, N. Y., who was appointed to fill the unexpiredterm of Aida Allwein; and the incumbents Miss Hodgins, Ruth M.Nash and Anna Willenborg.

The state of the association at this stage in its development wasdescribed in a letter that Mrs. Fife addressed to the trustees justbefore the convention:

It is definitely our responsibility as members of the Board of Trusteesto not only take care of the immediate problems but to plan construc-tively for the future....

It was our feeling that during these first few years, when policies werebeing developed and procedures for routine matters evolved, that it wasessential to have the president at headquarters. During my term of officeI have made a great effort to organize the handling of matters at head-quarters in such a way that when changes occurred that it would nothandicap to too great a degree the functioning of the organization.Standardized forms for handling financial and other records and routinecorrespondence have been developed and are in constant use, therebyeliminating to a great degree the burden placed upon the headquartersstaff, and it is now expedient to have the president chosen from someother section of the country than from headquarters.

It is my opinion, however, that the Executive Secretary should remainin office several years. Due to the fact that the Executive Secretary isresponsible for the smooth running of the headquarters office in regardto keeping of records, routine correspondence and general detail, heraccumulated experience naturally makes her more valuable, and rendersthe work lighter for the officers and Board of Trustees.

Last year I was of the opinion that we should plan to have the officeof the Executive Secretary a paid position. I am now of the opinion thatthe organization is not quite ready for it, and I would suggest that thisoffice be regarded as a voluntary contribution for at least another year.It would in any event be necessary to employ an office secretary, and I

Legislation 223

do not believe that the organization is financially able to meet two

salaries when there are so many other calls on the Association finances,

particularly in view of an intensive educational program, and possible

legislative difficulties. I am at this time recommending that the allot-

ment of money for office secretarial service be increased. It would have

been impossible this year to have taken care of the amount of corres-

pondence from headquarters if we had not had a conscientious and hard

working office secretary. Again, much of the office secretary's work in the

National organization has been contributed from the University Hos-

pitals. Mrs. Peck, although being willing to work long hours in the

evening, has been of necessity allowed to use some of the time of the

Department to take care of National affairs. In fact, the last three weeks

before the convention there was very little departmental work taken

care of by the secretary. Her time was practically entirely devoted to

National business ....I doubt very much if we shall see any legislation introduced adverse to

the interests of the nurse anesthetist during the coming year. The situa-

tion in Indiana may develop into a court case as in California, in which

event we should be prepared to meet the situation.... I am of the opin-

ion that there is very little that we can do except to concentrate on a

very intensive educational program, and to make certain as far as possi-

ble that each person entering the field and accepting a position is pre-

pared to give the individual hospital the services of a well trained, effi-

cient anesthetist.The work of the Educational Committee this year has showed progress.

The present preliminary report, although necessarily incomplete, should

be available for publication after this meeting. Revisions will be made

from time to time, otherwise we would not be going forward, but we must

take our first step, and I believe it is in the right direction. Before

anything is done in grading schools or whatever program is developed

by this organization, we should have a pattern for the various Schools

of Anesthesia to go by.What is going to be our next step? Miss Hodgins has proposed the

formation of an Educational Society within the National organization,

but regardless of whether or not the present committee is enlarged, the

point that I wish to bring out is, along what lines is our educational

program going to move? How are we going to accredit schools? Are we

going to establish an accrediting committee to investigate schools, and if

an accrediting committee is established, is it going to be effective, or

merely a group to report the conditions existing in the present Schools

of Anesthesia? I personally feel that if we establish an accrediting com-

mittee that we should invest great authority in that committee and that

it should be a potent committee.We know that there are existing evils in some of the schools, and

should we continue to merely study the field? Unless we give careful

thought to the working out of details of how we are going to control the

224 History of Anesthesia

existing evils, we have no reason to function as an organization that isset up to raise the standards. I am still more firmly convinced than Iwas two years ago that a National Board of Examiners could be formedwithin our organization. In the first place, what will give the nurseanesthetist protection? The answer is-state registration. When we con-sider that we must go to each state legislature in order to obtain stateregistration, and that therefore in every state we must have a bill pre-pared and we must have a lobbying committee, which will undoubtedlycost anywhere from $1000 to $2500, depending upon the fight we have-are we prepared from the financial standpoint to undertake such a pro-gram in even one state? In my opinion we are not, and furthermore, Ibelieve that we would meet with great opposition and would be courtingtrouble if we attempted such a thing at this time.

If the National organization appointed say seven people on an exam-ining board, including possibly two or three outstanding surgeons (thedetails of which could be worked out later) to prepare examinationquestions periodically, to be given to every student before graduationfrom any School of Anesthesia that wished to be recognized by the Na-tional, we at least would be able to make certain that the members of theNational organization were qualified. Someone within the state who isnot connected with the school could act for the Examining Board inseeing that the examination was conducted in an ethical manner. Acertificate similar to State Board certificates could be awarded to theapplicant passing the examination, and I believe that in a few years thesuperintendents and surgeons generally would require their anesthetiststo be recognized by the National Association. After all, the superinten-dents and surgeons are not interested in whether the examining boardhas obtained legislative sanction-they are interested in making certainthat their anesthetists are equipped to give anesthetics. If at a later datewe were fortunate enough to gain state registration, then the problemwould be in the hands of the State Examining Board, and undoubtedlyif the National Board standards are kept high, the State Board wouldaccept their findings....

I believe everyone agrees that our organization, even up to this point,has made the schools more cognizant of the fact that there should bedefinite standards, and there is evidence that the schools are making aneffort to meet whatever requirements may be advocated by the National.We must keep at least one step ahead of this trend, and in order to doso more definite lines of action are necessary. We shall unquestionablybe sidetracked from time to time, but it is obvious that if we have adefinite course to follow, our progress will be more rapid.1l

llFife, Gertrude: Letter to Board of Trustees of National Association of Nurse Anes-thetists dated September 30, 1935.