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Allied's average salary offer for CRNAs in 2002 was $129,285, up 9.5 percent from $118,000 in 2001. The upper end of CRNA salaries was equivalent to what many primary care physicians are offered. Anesthesiologists earn about $240,000 per year, in comparison. An AANA membership survey in 2001 found that the median CRNA salary was $113,000 annually.

Job vacancies and above-average nursing salaries are starting to attract candidates into the field. Lester, outgoing president of AANA, added that enrollment has increased to 1,800 students per year in CRNA master's-level programs from a low of less than 600 CRNAs certified in 1989. Unlike other nursing programs that are bulging to capacity, the nation's 88 accredited nurse anesthesia programs are being expanded to accommodate more students-perhaps 2,000 per year-which could help relieve the CRNA shortage.

CRNAs must have a bachelor's degree in nursing and at least one year of critical care practice before entering a CRNA program. Nurse anesthetists also must pass a national certification exam through the Council on Certification of Nurse Anesthetists. For what it costs to educate one anesthesiologist, 10 CRNAs can be trained, according to a 1996 study, the AANA said,

Guy magnet

A characteristic of nurse anesthetists unique in comparison to other nursing specialties is the preponderance of men in the field. The AANA reports that 44 percent of CRNAs are men, compared with less than 5 percent in all of nursing. Male nurses were actively recruited by military order in the 1960s to serve as CRNAs in Vietnam, and many medics who served in Vietnam entered the field of nurse anesthesia in larger numbers after the war. Many sought specialized training in nursing after returning home.

"Men have been attracted by the salaries-CRNAs have always been paid more than other nurses," Lester said. "There is also the autonomy of our practice and the lure of using cutting-edge equipment. I think most of all it is the challenge that has drawn men to anesthesia nursing."

Tom McKibban, a CRNA at Susan B. Allen Memorial Hospital in El Dorado, Kan., and incoming AANA president, believes the "take-charge attitude of men" leads them to the profession.

"I went into nursing specifically to go into anesthesia," McKibban said.

CRNAs historically have worked with considerable autonomy. Today, in more than half the states, CRNAs are not required to be supervised by a physician, and no state requires supervision of CRNAs by an anesthesiologist.

"We have a long history of nurses administering anesthesia, dating from the Civil War," when ether was given through a glass inhaler, Lester said.

Among the first nursing specialists, anesthetists were brought into the operating room to counter the high mortality rates surgeons were reporting with unattended anesthesia, according to the AANA. The first formal educational programs preparing nurse anesthetists were established in 1909, according to the AANA.

While in larger hospitals, CRNAs work as part of anesthesia care teams headed by an anesthesiologist, and the level of autonomy of CRNAs varies depending on hospital policies and state regulations. New York, for example, requires supervision by a surgeon; in California, physician supervision is not required.

"In our hospital, we have one anesthesiologist per three nurse anesthetists. The anesthesiologist is present when the patient goes to sleep and is available in the suite if needed," said Katherine Farrell, CRNA, staff nurse anesthetist for the Anesthesia Group of Onondaga PC at St. Joseph's Hospital Health Center in Syracuse, N.Y. "I pick the drugs I want to use, and if I have questions or concerns, I can consult with the anesthesiologist."

Farrell works in the hospital's operating room, where she handles more seriously ill patients, and in two affiliated outpatient surgery centers. "There is a real art to out-patient surgery," Farrell said. "We must get them to sleep quickly and wake them up in a short period of time."

The relationship between anesthesiologists and nurse anesthetists has historically been collegial, but with the independence of CRNAs and a controversial new Medicare rule, new debate over supervision and CRNA practice is introducing some polarization between the two professions. (See related story.)

Nurses first

CRNAs stress that their nursing skills are as critical in the anesthesia process as their technical skills, because patients fear anesthesia more than they do the surgical procedure.