The palace par excellence, the Four Seasons Hotel George V is a jewel of elegance and refined sophistication in the heart of Paris. Behind its superb Art Deco façade, step into the realm of excellence. You will be impressed by the abundance and beauty of the exquisite flower arrangements enhancing the lobby, the interior court, the superb restaurant “Le cinq”. The Four Seasons Hotel George V provides an outstanding service, discretely attentive and courteous. You will spend memorable moments in this world of ultimate luxury.
Steps from the Champs-Elysées, with private terraces that command all Paris and vibrant facilities accented by 17th-century tapestries and floramastery, Four Seasons Hotel George V Paris has come to define fine service in the City of Light and around the world.
The Four Seasons Hotel George V features 245 guest rooms, including 59 suites and 30 with private terrace. A landmark since 1928, this historic building reflects the very highest Four Seasons standards of comfort and convenience.
Enjoy fine dining at Michelin-starred Restaurant Le Cinq, light snacks at Le Bar, and elegant tea or cocktails in La Galerie, with its summer terrace.
Enjoy the extensive health club and luxurious full-service spa, with swimming pool, saunas, steam bath and whirlpool, fitness instructors and the latest training equipment.
Exclusive couture shops are nearby, and the enchantments of Paris minutes away in any direction.
Trump International Hotel
Overlooking the Chicago River and the city's Magnificent Mile - within walking distance to shopping on Michigan Avenue. From the outside, Trump International Hotel & Tower is a soaring composition of polished stainless steel and iridescent-tinted glass - a spectacular showcase of beautiful style and design. For guests, the interiors are contemporary-styled accommodations starting with 600 square feet of living space with 10-foot floor-to-ceiling windows with unobstructed lake, river or city views.
218 rooms and 121 suites, each with an urban style kitchen area, 10-foot floor-to-ceiling windows, a sitting area with a sofa bed, WiFi, 42 inch LCD TV and luxurious bathrooms with Kohler Deep soaking tubs, separate shower and in-mirror TV portal. Suites boast full size urban style kitchens with Snaidero Italian wood cabinetry, granite countertops and stainless steel appliances from Miele, Sub-Zero and Wolf.
218 rooms and 121 suites, each with an urban style kitchen area, 10-foot floor-to-ceiling windows, a sitting area with a sofa bed, WiFi, 42 inch LCD TV and luxurious bathrooms with Kohler Deep soaking tubs, separate shower and in-mirror TV portal. Suites boast full size urban style kitchens with Snaidero Italian wood cabinetry, granite countertops and stainless steel appliances from Miele, Sub-Zero and Wolf.
The Royal Hawaiian
Of all Hawaii hotels, only The Pink Palace of the Pacific has remained an icon of luxury and romance for over 75 years. A Waikiki landmark recognized around the world, The Royal Hawaiian Hotel is the ultimate vacation destination for honeymooners, families, and anyone seeking elegance from a bygone era. Each of the 528 rooms and suites are unique unto themselves, perfectly wedding modern comfort and old world luxury. In the Royal Tower, each room comes with an intimate lanai for a private vantage point on the ocean. In the Historic Building, elegant furnishings include four-poster beds and Queen Anne-style writing desks. And for unsurpassed sophistication, the Prestige Suites offer spacious accommodation and a host of select amenities. For the chefs of The Royal Hawaiian, preparation and presentation demand equal attention. Every meal is an occasion to remember. The Surf Room, the fine dining restaurant, is a showcase of continental classics and contemporary Hawaiian cuisines that draw inspiration from the ocean's daily bounty and locally grown ingredients. For casual dining, the breezy Beach Club Cafe features light menus of American fare and simple island cuisine. For a truly extraordinary Hawaiian meal, don't miss the legendary oceanfront luau. And for tropical drinks, live music, and ocean views, the Mai Tai Bar is a must.
The Carlyle, a Rosewood Hotel
A timeless classic, The Carlyle, A Rosewood Hotel, has been called home by leaders in world affairs, business, society, entertainment and the arts since its debut in 1930. Brilliantly positioned on Madison Avenue, it is a true New York landmark -- a showcase of great art, a purveyor of privacy and a sanctuary of refined taste. Guests feel truly ensconced in an elegant private residential atmosphere, which includes a discreet and polished staff as well as world-class dining and entertainment. Located in the heart of Manhattan, The Carlyle offers sweeping views of Central Park and easy access to the encircling Upper East Side galleries and boutiques, as well as the nearby "Museum Mile." Each of the Carlyle's 180 rooms and suites have been individually decorated and appointed with the finest fabrics, rugs, boudoir chairs and Frette linens. The walls are adorned with original Audubon prints, architectural renderings by Piranesi and English country scenes by Kips. Some accommodations feature private terraces, grand pianos and spectacular views of the city's skyline. Suites, priced by size, space and exposure, offer separate sitting rooms with powder room.
Hotel de Crillon
Designated as a unique historical monument, the Hotel de Crillon is an elegant 18th century luxury hotel situated on the world famous Place De La Concorde in the heart of Paris. Only a few steps away from the Champs-Elysees, the Faubourg Saint Honore shopping area and all major museums, the Hotel de Crillon is the place to stay in Paris. This mythical hotel is rich in history and culture. Decorated in a Louis XV style, the hotel's 147 guest rooms and suites include Presidential apartments and the exceptional Louis XV and Leonard Bernstein suites. With 140 square meters of terrace, tall windows allowing abundant light, warm colors and wood-paneling, these renowned suites offer magnificent views of Paris, the Eiffel Tower proudly visible from a luxurious bubble-bath. Offering its guests the highest level of personalized service is the ultimate goal of Hotel de Crillon.
The gourmet restaurant Les Ambassadeurs, the former ballroom of the Dukes de Crillon, is the perfect venue for an intense and unforgettable moment. Guests can also try L'Obe restaurant with its Parisian atmosphere and creative Cuisine.
The gourmet restaurant Les Ambassadeurs, the former ballroom of the Dukes de Crillon, is the perfect venue for an intense and unforgettable moment. Guests can also try L'Obe restaurant with its Parisian atmosphere and creative Cuisine.
Cassa Hotel and Residences
Cassa Hotel and Residences, located in the heart of midtown Manhattan, boasts 165 elegantly designed rooms. Offering a boutique hotel experience of sophisticated style and quiet indulgence, Cassa Hotel and Residences is rich in texture, contemporary in design, yet warm and inviting. Whether traveling for business or pleasure, you'll be wrapped in total comfort and luxury. Cassa's location and unassuming service make it the perfect choice for short term or extended stays.
The Surrey New York
The Surrey New York
Exceptional moments at The Surrey extend well beyond your accommodations. Whether you prefer entertaining in the private rooftop garden, indulging in a relaxing massage at the Spa or dining at your favorite table at Cafe Boulud, personality and personal preferences inform our service from the moment you make your reservation.
Built in 1926 as a residence hotel, the original Surrey was home to many of New York’s most eccentric celebrities over the years. JFK. Betty Davis. Claudette Colbert. Famous faces who recognized the allure of exceptional, discreet service. In re-creating The Surrey, we collaborated with acclaimed interior designer Lauren Rottet and paid special attention to maintaining the integrity of this history while modernizing what has become New York's most intimate address. Rottet's inspiration was a New York City townhouse passed down through the generations, the keeper of a lifetime of memories.
Exceptional moments at The Surrey extend well beyond your accommodations. Whether you prefer entertaining in the garden, indulging in a relaxing massage at the spa or dining at your favorite table at Cafe Boulud, personality and personal preferences inform our service from the moment you make your reservation.
Our generously appointed 190 guest salons and suites, including Presidential and Penthouse suites, go well beyond the standard. Uncommonly elegant touches such as Duxiana mattresses, Sferra bedding and Pratesi terry robes await each guest’s arrival. Exceptional finishes such as white marble baths, double sinks and soaking tubs are offered in our deluxe suites, and for those who desi
Exceptional moments at The Surrey extend well beyond your accommodations. Whether you prefer entertaining in the private rooftop garden, indulging in a relaxing massage at the Spa or dining at your favorite table at Cafe Boulud, personality and personal preferences inform our service from the moment you make your reservation.
Built in 1926 as a residence hotel, the original Surrey was home to many of New York’s most eccentric celebrities over the years. JFK. Betty Davis. Claudette Colbert. Famous faces who recognized the allure of exceptional, discreet service. In re-creating The Surrey, we collaborated with acclaimed interior designer Lauren Rottet and paid special attention to maintaining the integrity of this history while modernizing what has become New York's most intimate address. Rottet's inspiration was a New York City townhouse passed down through the generations, the keeper of a lifetime of memories.
Exceptional moments at The Surrey extend well beyond your accommodations. Whether you prefer entertaining in the garden, indulging in a relaxing massage at the spa or dining at your favorite table at Cafe Boulud, personality and personal preferences inform our service from the moment you make your reservation.
Our generously appointed 190 guest salons and suites, including Presidential and Penthouse suites, go well beyond the standard. Uncommonly elegant touches such as Duxiana mattresses, Sferra bedding and Pratesi terry robes await each guest’s arrival. Exceptional finishes such as white marble baths, double sinks and soaking tubs are offered in our deluxe suites, and for those who desi
The Peninsula Chicago
Since its grand opening in 2001, The Peninsula Chicago has been awarded numerous accolades including the prestigious Mobil Five-Star and the AAA Five-Diamond awards for the last two consecutive years. Located in the heart of Chicago's "Magnificent Mile," The Peninsula Chicago is the city's most luxurious and sophisticated hotel, offering guests all possible amenities and services. The Peninsula Chicago's 339 luxurious guestrooms and suites are among the largest in the city and are exquisitely furnished in a contemporary yet classical style, with a state-of-the-art electronic system that provides guests the ability to control guestroom features with the touch of a button.
Rated as one of the top ten urban spas in the country, The Peninsula Spa is an oasis in which to rejuvenate oneself. The 14,000 sq ft combined spa and fitness center is located on the top two floors of the hotel, offering unparalleled views of the city. Guests are invited to indulge in pampering beauty therapies, experience the latest in exercise facilities, and relax at the pool and sundeck.
With four distinctive restaurants and a bar, guests can choose from a diverse array of superb dining options, including the legendary Peninsula Afternoon Tea, served in The Lobby. The hotel also provides 24-hour Room Service. Offering a grand ballroom and six additional meeting and event accommodations for a total of more than 9,000 sq ft of space, The Peninsula Chicago provides flexibility for intimate meetings or lavish galas and affairs. The winning combination of elegant hotel facilities, uncompromising service, and haute cuisine is aimed at exceeding one's expectations.
Rated as one of the top ten urban spas in the country, The Peninsula Spa is an oasis in which to rejuvenate oneself. The 14,000 sq ft combined spa and fitness center is located on the top two floors of the hotel, offering unparalleled views of the city. Guests are invited to indulge in pampering beauty therapies, experience the latest in exercise facilities, and relax at the pool and sundeck.
With four distinctive restaurants and a bar, guests can choose from a diverse array of superb dining options, including the legendary Peninsula Afternoon Tea, served in The Lobby. The hotel also provides 24-hour Room Service. Offering a grand ballroom and six additional meeting and event accommodations for a total of more than 9,000 sq ft of space, The Peninsula Chicago provides flexibility for intimate meetings or lavish galas and affairs. The winning combination of elegant hotel facilities, uncompromising service, and haute cuisine is aimed at exceeding one's expectations.
Hotel Hassler
Hotel Hassler
For over a century, the Hassler has been recognized as one of the prime hotels in Europe. This small and atmospheric hotel pays careful attention to detail in order to make every guest's stay an unforgettable one. With an unbeatable location atop the Spanish Steps, the Hassler is easy to find but very difficult to leave. Italy's most luxurious offers 82 rooms and 13 suites, three of which are Presidential Suites. Each room is unique, and elegantly furnished with antiques while equipped with modern leisure. The suites with breath-taking views of the Eternal City feature exquisite boiserie and frescos. The walls are decorated with original paintings by titian and tintoretto schools and the furniture is in original 18th century Louis XV style. The large bathrooms are finished in precious Italian marble and 23-carat gold plated faucet. On the 6th floor, you will enjoy fine Italian cuisine at Imago, the Hassler's recently renovated panoramic restaurant. Dining options also include the Salone Eva Restaurant & Bar, and the Palm Court garden Restaurant & Bar during the warmer weather seasons. On the 3rd floor, guests are invited to relax and treat themselves to a variety of beauty and wellness treatments at Amorvero SPA. Discover the magic of the Hassler during your next stay in the Eternal City.
For over a century, the Hassler has been recognized as one of the prime hotels in Europe. This small and atmospheric hotel pays careful attention to detail in order to make every guest's stay an unforgettable one. With an unbeatable location atop the Spanish Steps, the Hassler is easy to find but very difficult to leave. Italy's most luxurious offers 82 rooms and 13 suites, three of which are Presidential Suites. Each room is unique, and elegantly furnished with antiques while equipped with modern leisure. The suites with breath-taking views of the Eternal City feature exquisite boiserie and frescos. The walls are decorated with original paintings by titian and tintoretto schools and the furniture is in original 18th century Louis XV style. The large bathrooms are finished in precious Italian marble and 23-carat gold plated faucet. On the 6th floor, you will enjoy fine Italian cuisine at Imago, the Hassler's recently renovated panoramic restaurant. Dining options also include the Salone Eva Restaurant & Bar, and the Palm Court garden Restaurant & Bar during the warmer weather seasons. On the 3rd floor, guests are invited to relax and treat themselves to a variety of beauty and wellness treatments at Amorvero SPA. Discover the magic of the Hassler during your next stay in the Eternal City.
Charleston Place
Charleston Place evokes the feeling of a grand 17th century residence from the Italian marble lobby with its signature Georgian Open Arm staircase and 12-foot crystal chandelier to lush personal suites. The staff of Charleston Place is dedicated to entertaining its guests with the finest in Southern hospitality, and has become the choice of celebrities, princes and politicians.
Charleston Place is one of the finest hotels in Charleston, SC. Located in the heart of Charleston's historic downtown, Charleston Place offers unparalleled luxury accommodations including beautifully appointed rooms and suites, award winning dining at the Palmetto Cafe and Charleston Grill restaurants, and a full-service Spa with rooftop indoor outdoor pool and Jacuzzi.
Charleston Place is one of the finest hotels in Charleston, SC. Located in the heart of Charleston's historic downtown, Charleston Place offers unparalleled luxury accommodations including beautifully appointed rooms and suites, award winning dining at the Palmetto Cafe and Charleston Grill restaurants, and a full-service Spa with rooftop indoor outdoor pool and Jacuzzi.
Armani Hotel Dubai
Soaring high above Downtown Dubai in the iconic Burj Khalifa, the world's tallest tower, Armani Hotel Dubai is the world's first hotel designed and developed by Giorgio Armani. Reflecting the pure elegance, simplicity and sophisticated comfort that define Armani's signature style, the hotel is the realisation of the designer's long-held dream to bring his sophisticated style to life in the most complete way and offer his customers a Stay with Armani experience. Every detail in the hotel bears the Armani signature, beginning with the warm Italian-style hospitality and moving to each element of the design from the Eramosa stone floors to the zebrawood panels, bespoke furnishings and personally designed hotel amenities.
Sophisticated colors, clean lines and unique textures blend together seamlessly wit! h the tower's stunning architecture and natural light to create an atmosphere of calm serenity where guests can retreat into a world of minimalist elegance
Sophisticated colors, clean lines and unique textures blend together seamlessly wit! h the tower's stunning architecture and natural light to create an atmosphere of calm serenity where guests can retreat into a world of minimalist elegance
Hotel information
Hotel information : Free broadband including wireless Internet access is available throughout the hotel. There are 2 conference rooms with state-of-the-art audiovisual equipment. |
Food & beverage : The restaurant "Sapori" and the chic "H12 - Wine & Bar" provide a culinary centrepiece for any visit to the hotel. The gourmet restaurant is one of the city's hot spots, serving contemporary, hip and innovative Italien cuisine and Austrian classics. "H12 - Wine & Bar", meeting point of Vienna's business people and the "chic" society, offers Milan-style aperitifs and the latest lounge music entertainment. |
Area information : The Radisson SAS Style Hotel has a unique location, next to Kohlmarkt, Graben and Freyung, allowing guests to enjoy the heart of one of Europe's leading cultural capitals. The city's most exciting upmarket retail and fashion quarter and the world famous coffee house Café Central are close to the hotel. Vienna International Airport (VIE) is 25 kilometres from the hotel, or about 35 minutes by car.Historical attractions such as St. Stephen's Cathedral, the State Opera and the Hofburg Imperial Palace are within walking distance. Near the hotel, guests will find convenient public transport connections, and the famous meeting places of Hofburg Congress, Palais Niederösterreich, Palais Ferstel and Palais Daun-Kinsky are located just around the corner from the hotel. |
Hotel Policies & Fees
Awards and Affiliations
- This property is on this year's Expedia Insiders' Select list, an annual selection of the top hotels based largely on traveler opinions as well as value and Expedia expert input.
Property Amenities
Hilton Dubai Jumeirah's guests can relax in the hotel's outdoor pool, make use of the luxurious health club or stroll through the exotic gardens. Energetic guests can try the numerous watersports facilities or enjoy a game of pool, darts and table football in one of the bars. Families with children can enjoy a fully supervised kids club with organised activities, two playgrounds with a bouncy castle and a baby sitting service. Guests with business needs will benefit from a business centre with fully-equipped meeting rooms. Numerous dining options are available and there are six bars in which to relax and enjoy a drink
hotel
A hotel is an establishment that provides paid lodging on a short-term basis. The provision of basic accommodation, in times past, consisting only of a room with a bed, a cupboard, a small table and a washstand has largely been replaced by rooms with modern facilities, including en-suite bathrooms and air conditioning or climate control. Additional common features found in hotel rooms are a telephone, an alarm clock, a television, and Internet connectivity; snack foods and drinks may be supplied in a mini-bar, and facilities for making hot drinks. Larger hotels may provide a number of additional guest facilities such as a restaurant, a swimming pool or childcare, and have conference and social function services. Hotel rooms are usually numbered (or named in some smaller hotels and B&Bs) to allow guests to identify their room. Some hotels offer meals as part of a room and board arrangement. In the United Kingdom, a hotel is required by law to serve food and drinks to all guests within certain stated hours; to avoid this requirement it is not uncommon to come across private hotels which are not subject to this requirement.In Japan, capsule hotels provide a minimized amount of room space and shared facilities. In the United Kingdom, Australia, Canada and Ireland (and rarely in some parts of the United States), the word may also refer to a pub or bar and might not offer accommodation. In India and Bangladesh, the word may also refer to a restaurant.
Ata Villa Pamphili *
Atahotel Villa Pamphili is in front of Villa Pamphili Park, two miles from the Vatican (to which it is linked via a complimentary bus service), and approximately 22 miles east of Fiumicino/Leonardo da Vinci Airport. Bus service stops at the underground station of Cipro-Musei Vaticani. An additional daily, complimentary courtesy bus operates to/from Trastevere Station, from where it will be possible to reach the airport Fiumicino through railway line FM1 (running approximately every 15 minutes from track 5). Th
Ripa Hotel * Ripa Hotel
This all-suites hotel is located in Rome's oldest quarter, Trastevere, a mile from the Vatican and approximately 10 miles from Rome International Airport. On-site facilitys include restaurant, bar, nightclub, sushi bar, and fitness room with available personal trainer. All rooms have cable TV, minibars, and radio alarm clocks.
Hassler Roma * Hassler Roma
This unique hotel is famous for the special atmosphere that makes guests feel at home away from home. The city s most distinguished address is an exquisite setting atop the Spanish Steps, in the very heart of Rome, within walking distance of the Villa Borghese park, Via Veneto and Via Condotti and the most fashionable boutiques. With its centennial tradition, the hotel is owned by the Wirth family, the famous dynasty of Swiss hoteliers. The world renowned Penthouse has the largest terrace in Rome and a spectac ...
Starhotels Michelangelo
Starhotels Michelangelo is two blocks from Saint Peter's Basilica and Square and approximately 19 miles from Fiumicino International Airport. This location is also half a mile from the Vatican Museum and Castle San Angelo and one mile from Piazza Navona and the Pantheon. Hotel amenities include the complimentary breakfast, restaurant, and cocktail lounge. The hotel also offers room service, valet laundry service, a concierge, parking (surcharge), and currency exchange. All rooms feature soundproofing, datapo ...
Rome Marriott Grand Hotel Flora * Rome Marriott Grand Hotel Flora
Rome Marriott Grand Hotel Flora * Rome Marriott Grand Hotel Flora
On the famous Via Veneto, overlooking the Villa Borghese, the Marriott Grand Flora is approximately 35 miles from Leonardo Da Vinci International Airport. Hotel amenities include the rooftop restaurant, cocktail lounge, and room service. Other services include valet laundry, concierge services, and valet parking. Rooms feature dataports, cable TV, weekday newspaper delivery, minibars, safes, and hairdryers.
On the famous Via Veneto, overlooking the Villa Borghese, the Marriott Grand Flora is approximately 35 miles from Leonardo Da Vinci International Airport. Hotel amenities include the rooftop restaurant, cocktail lounge, and room service. Other services include valet laundry, concierge services, and valet parking. Rooms feature dataports, cable TV, weekday newspaper delivery, minibars, safes, and hairdryers.
Designed by Philippe Starck
Designed by Philippe Starck, the Delano is located in South Beach's Art Deco District, directly on the ocean, and approximately 12 miles from the Miami International Airport. The hotel is a block from Lincoln Road Mall and five miles from Key Biscayne. Located in the heart of South Beach, Delano is the ultimate world-class urban resort and self-contained destination. It is a cool haven of relaxation in the middle of one of the world?s most vibrant cities. Boasting Americas first Indoor/Outdoor Lobby, the hotels public spaces create the feeling of an interwoven village with almost no separation between indoors and out. With its soaring and unforgettably beautiful Lobby, legendary white Guestrooms, lushly landscaped Orchard, breathtaking Pool, renowned Agua Bathhouse and stunning private beach, Delano epitomizes Simple Chic for a modern world. Hotel amenities include the indoor/outdoor lobby, landscaped orchard, Agua Bathhouse, private beach, and swimming pool. Dining is available at Blue Door (modern French cuisine), Brasserie (casual dining), and Blue Sea (fresh seafood, caviar, and sushi). Guests can also enjoy Rose Bar and the lobby lounge. Room service is available 24 hours. The Delano's all-white recently renovated guestrooms feature down comforters and pillows, designer toiletries, bathrobes, hairdryers, irons and ironing boards, minibars, safes, and wireless Internet access.
The Subject of Health
Now it seems to us that we should begin with the subject of health, for prevention is better than cure. O what a priceless boon is a sound body and good health: a boon which is denied to some from birth, and which few really appreciate till it be taken from them. It has long impressed the writer what a remarkable thing it is that any of us enjoy any health at all, seeing that we have six thousand years of sinful heredity behind us! It is due alone to the goodness and kindness of God that the great majority enter this world with more or less sound bodies and reach youth in the bloom of health. But sin and folly then take heavy toll and the constitutions of millions are wrecked before middle life is reached. Nor is it always brought about by wicked intemperance and dissipation. Often it is the outcome of ignorance, through failure to heed some of the most elementary laws of hygiene. Alas the majority of people will learn in no other school than that of hard and bitter experience and consequently most of them only discover how to live when the time comes for them to die. True we cannot put old heads on young shoulders, yet if the inexperienced are too proud to heed the counsels of the mature then they must reap the consequences.
Now surely, other things being equal, the Christian ought to enjoy better health than the non-Christian. Why so? Why, because if his walk be regulated by God’s Word he will at least be preserved from those diseases which are the fruit of certain transgressions. The English word "holiness" means wholeness, soundness. The more we are kept from sinning the more shall we escape its consequences. "Godliness is profitable unto all things (the body as well as the soul), having promise of the life that now is, and of that which is to come" (1 Tim. 4:8). One of the basic laws of health is the Sabbatic statute. "The Sabbath was made for man" (Mark 2:27), for his good, because he needed it. It was made for man that he might be a man, something more than a beast of burden or a human treadmill. His body needs it as truly as does his soul. This has been unmistakably demonstrated in this country. When France collapsed and the British Isles faced the most desperate crisis of their long history, the government foolishly ordered that those in the coal mines and munitions factories must work seven days a week, but they soon learned that the workmen produced less than they did in six days—they could not stand up to the additional strain.
By resting from manual toil on the Sabbath man is enabled to recuperate his strength for the labors of the week lying ahead, yet that cannot be accomplished by attending one meeting after another on that day, nor by exhausting one’s strength through lengthy walks to and from the services—moving the tent nearer the altar is the remedy—still less by profaning the Sabbath in carnal "recreation." Another Divine precept which promotes health is, "he that believeth shall not make haste" (Isa. 28:16). Side by side with the speeding tempo of modern life we behold the multiplying nervous disorders, and those who are murdered or maimed on the highway. For many years we have avoided motor cars, buses and trains whenever the distance to be covered was not too great to walk, not using them more than two or three times in a twelve-month. Rushing around, hurrying and scurrying hither and thither, is not only injurious but a violation of the Divine rule: "He that hasteth with his feet sinneth" (Prov. 19:2)—which means exactly what it says.
"Take therefore no anxious thought for the morrow" (Matt. 6:34). How good health is promoted by obedience to this precept scarcely needs pointing out. It is carking care and worry which disturbs the mind, affects circulation, impairs digestion, and prevents restful sleep. If the Christian would cast all his care on the Lord (1 Pet. 5:7) what freedom from anxiety would be his. "The joy of the Lord is your strength" (Neh. 8:10)—physically as well as spiritually. What a tome to a wearied body and tired mind it is to delight ourselves in the Lord: "a merry heart doeth good like a medicine" (Prov. 17: 22). "My son, attend to My words . . . for they are life unto those that find them and health to all his flesh" (Prov. 4:20, 22): do we really believe this? "Fear the Lord and depart from evil: it shall be health to thy navel and marrow to thy bones" (Prov. 3:7, 8).
Godly living is conducive to healthiness of mind and body, and other things being equal that will be one of its bi-products. By "other things being equal" we mean: as in the case of one who is not suffering for the sins of his father; who did not ruin his constitution by debauchery before conversion; and who exercises ordinary common sense in attending to the elementary rules of hygiene. One who is "temperate in all things" (1 Cor. 9:25) will escape many or all of those ills which is the price which has to be paid for intemperance. Scripture does not require us to be either Spartans or Epicureans but to "let our moderation be known unto all" (Phil. 4:5). God "giveth richly all things to enjoy" (1 Tim. 6:17), yet not to abuse. "Every creature of God is good and nothing to be refused" (1 Tim. 4:4) providing it is used aright, but His choicest creatures p rove harmful if used to excess. God has provided great variety in nature, and each one has to learn for himself what best suits him and deny himself of that which disagrees.
Now surely, other things being equal, the Christian ought to enjoy better health than the non-Christian. Why so? Why, because if his walk be regulated by God’s Word he will at least be preserved from those diseases which are the fruit of certain transgressions. The English word "holiness" means wholeness, soundness. The more we are kept from sinning the more shall we escape its consequences. "Godliness is profitable unto all things (the body as well as the soul), having promise of the life that now is, and of that which is to come" (1 Tim. 4:8). One of the basic laws of health is the Sabbatic statute. "The Sabbath was made for man" (Mark 2:27), for his good, because he needed it. It was made for man that he might be a man, something more than a beast of burden or a human treadmill. His body needs it as truly as does his soul. This has been unmistakably demonstrated in this country. When France collapsed and the British Isles faced the most desperate crisis of their long history, the government foolishly ordered that those in the coal mines and munitions factories must work seven days a week, but they soon learned that the workmen produced less than they did in six days—they could not stand up to the additional strain.
By resting from manual toil on the Sabbath man is enabled to recuperate his strength for the labors of the week lying ahead, yet that cannot be accomplished by attending one meeting after another on that day, nor by exhausting one’s strength through lengthy walks to and from the services—moving the tent nearer the altar is the remedy—still less by profaning the Sabbath in carnal "recreation." Another Divine precept which promotes health is, "he that believeth shall not make haste" (Isa. 28:16). Side by side with the speeding tempo of modern life we behold the multiplying nervous disorders, and those who are murdered or maimed on the highway. For many years we have avoided motor cars, buses and trains whenever the distance to be covered was not too great to walk, not using them more than two or three times in a twelve-month. Rushing around, hurrying and scurrying hither and thither, is not only injurious but a violation of the Divine rule: "He that hasteth with his feet sinneth" (Prov. 19:2)—which means exactly what it says.
"Take therefore no anxious thought for the morrow" (Matt. 6:34). How good health is promoted by obedience to this precept scarcely needs pointing out. It is carking care and worry which disturbs the mind, affects circulation, impairs digestion, and prevents restful sleep. If the Christian would cast all his care on the Lord (1 Pet. 5:7) what freedom from anxiety would be his. "The joy of the Lord is your strength" (Neh. 8:10)—physically as well as spiritually. What a tome to a wearied body and tired mind it is to delight ourselves in the Lord: "a merry heart doeth good like a medicine" (Prov. 17: 22). "My son, attend to My words . . . for they are life unto those that find them and health to all his flesh" (Prov. 4:20, 22): do we really believe this? "Fear the Lord and depart from evil: it shall be health to thy navel and marrow to thy bones" (Prov. 3:7, 8).
Godly living is conducive to healthiness of mind and body, and other things being equal that will be one of its bi-products. By "other things being equal" we mean: as in the case of one who is not suffering for the sins of his father; who did not ruin his constitution by debauchery before conversion; and who exercises ordinary common sense in attending to the elementary rules of hygiene. One who is "temperate in all things" (1 Cor. 9:25) will escape many or all of those ills which is the price which has to be paid for intemperance. Scripture does not require us to be either Spartans or Epicureans but to "let our moderation be known unto all" (Phil. 4:5). God "giveth richly all things to enjoy" (1 Tim. 6:17), yet not to abuse. "Every creature of God is good and nothing to be refused" (1 Tim. 4:4) providing it is used aright, but His choicest creatures p rove harmful if used to excess. God has provided great variety in nature, and each one has to learn for himself what best suits him and deny himself of that which disagrees.
Ocean Place in Miami Beach
Ocean Place in Miami Beach, Fla., is two miles from shops of Lincoln Road and three miles from the Port of Miami. Other nearby attractions include the Opium Gardens, Miami Beach Convention Center and American Airlines Arena. At this Miami oceanfront property, guests can relax in the library and media room, watch the widescreen plasma television in the lounge or play a game of pool in the ocean view billiards room. Guests can stay active with the on site fitness and aerobics studio or take a dip in the pool on a hot day. The property also offers garage parking. Each two bedroom, two bathroom unit has everything guests need for a comfortable stay in South Floridia. Guests have the option of dining at one of the nearby restaurants, or staying in and preparing a meal in their full kitchen. After a long day exploring Miami, guests will want to watch their cable television with surround sound and DVD player, or enjoy a quiet evening on the terrace with outdoor seating. Units also have a fully furnished dining area and washer and dryer. Whether guests are seeking a quiet getaway or a home base for adventure, they will find it at Ocean Place. With its convenient location, privacy and space afforded by suite living and wide range f on site amenities, this Miami resort is an ideal place to spend a weekend, week or a longer stay.
Venetian Hotel Las Vegas
The Venetian Resort Hotel Casino is a luxury hotel and casino resort situated between Harrah's and The Palazzo on the east side of the Las Vegas Strip in Paradise, NV, United States, on the site of the old Sands Hotel. The hotel tower contains 40 stories and rises 475 feet (145 m). The Venetian is owned and operated by the Las Vegas Sands Corporation. The Venetian also serves as the seat of the corporate headquarters for its parent company.
The Venetian is (along with the adjacent Sands Expo Convention Center and The Palazzo Hotel and Casino Resort) part of the largest five-diamond hotel and resort complex in the world with 4,049 suites, 4,059 hotel rooms, and a 120,000-square-foot (11,000 m2) casino
The Venetian is (along with the adjacent Sands Expo Convention Center and The Palazzo Hotel and Casino Resort) part of the largest five-diamond hotel and resort complex in the world with 4,049 suites, 4,059 hotel rooms, and a 120,000-square-foot (11,000 m2) casino
The Palms Hotel South Miami Beach
The Palms Hotel South Miami Beach is located at 3025 Collins Avenue which is only a twelve mile journey from the Miami International Airport.
Located within easy walking distance of many of the region’s most popular attractions, the Palms Hotel South Miami Beach is a good choice for any traveler. It is only a short stroll to the shopping and dining along Lincoln Road and the nightlife of Ocean Drive, but is also near the Port of Miami and the Convention Center as well.
Each of the 243 rooms in the Palms Hotel South Miami Beach are as luxurious as the rest of the hotel and are outfitted with luxury linens and bedding, signature toiletries, plasma TVs with satellite service, entertainment centers, minibars and beverage stations, personal safes, high speed wireless Internet and many other amenities.
The Palms Hotel South Miami Beach is a large and upscale facility which offers a wide range of services and amenities to all of its guests. These include an Aveda spa, large outdoor swimming pool, therapeutic steam rooms, exercise classes, tropical grounds and gardens, a private beach, a signature restaurant and much more.
Located within easy walking distance of many of the region’s most popular attractions, the Palms Hotel South Miami Beach is a good choice for any traveler. It is only a short stroll to the shopping and dining along Lincoln Road and the nightlife of Ocean Drive, but is also near the Port of Miami and the Convention Center as well.
Each of the 243 rooms in the Palms Hotel South Miami Beach are as luxurious as the rest of the hotel and are outfitted with luxury linens and bedding, signature toiletries, plasma TVs with satellite service, entertainment centers, minibars and beverage stations, personal safes, high speed wireless Internet and many other amenities.
The Palms Hotel South Miami Beach is a large and upscale facility which offers a wide range of services and amenities to all of its guests. These include an Aveda spa, large outdoor swimming pool, therapeutic steam rooms, exercise classes, tropical grounds and gardens, a private beach, a signature restaurant and much more.
Fauxtoshop: 15 Phenomenal Forced-Perspective Photos
How do you make a full-sized commercial airplane look like a toy, or give the illusion that your human subject is touching a cloud? Photoshop is an easy answer, but a much more low-tech method produces results that are just as amazing: forced perspective photography. Just as in filmmaking when miniatures convincingly stand in for buildings, landscapes or fantastical creatures, the trick is all in positioning, lighting and timing.
The Old Tower of Pisa Trick
(image via: martyportier)
Everyone is familiar with this iteration of the forced-perspective photography trick: pretending to hold up the Leaning Tower of Pisa. It’s all about where you place your subject in relation to the background. At least this photographer took a different tack, giving his model a ‘relaxed’ pose.Pluck a Sphere of Light
(image via: mr. moog)
Take that same idea and apply it in a new way and you’ve got the kind of photo that makes you look twice. To achieve this effect, photographer Lee ‘Mr. Moog’ used shallow focus and allowed the lens of his camera to render out-of-focus points of lights as little floating spheres.Mind Your Step
(image via: maybemaq)
Is that the foot of a giant descending from the sky to crush a priceless historical site into bits of gravel? From this angle, it sure looks like it.The Scariest Watering Can Ever
(image via: froodmat)
When a watering can is big enough to suck you up into its spout, you’d better run.Blowing in the Wind
(image via: jeppe olsen)
Photographer Jeppe Olsen took a whole set of forced perspective photos out in the Salar de Uyuni salt flats in Bolivia, which provide a minimalist background ideal for deceptive shots like this one, making both the foreground and background subjects stand out equally.Fixing the Washington Monument
(image via: mjsmith01)
What kind of monstrous crane would be required to pluck the Washington Monument right out of the ground? The silhouetted crane and illumination of the monument make this photo even more effective.Miniature Woman
(image via: alexandre duarte)
Forced perspective photography takes more than just selective focus or using the blur/sharpen tool in Photoshop. Clever positioning and light are also crucial elements in a successful photograph.Tiny Plane Crash
(image via: maybemaq)
In some cases – like this one – timing is everything. No special effects or Photoshop necessary.Hold On Tight!
(image via: emikw)
One of the famed natural formations in Arches National Park, Utah is in the palm of this photographer’s hand when sharp focus is maintained on the entire image.Giant Jesus and the Toy Plane
(image via: david leeth)
Even 900-foot-tall stone Jesus gets bored sometimes, so having a toy plane to play with is a plus.Toy Cars, or Giant Man?
(image via: erkannix)
This is definitely one of those photos that make you go, “what?” It’s hard to tell exactly how the photographer achieved this effect, but according to his Flickr, there was no Photoshop involved.Please Don’t Fall, Cloud
(image via: p0rg)
The artist says “I kept messing it up and not aligning myself ( I was using tripod & self timer) and did it about 10 or so times. When I was happy with the result, I turned and saw that an old man walking his dog had stopped to watch my bizarre antics. He smiled and walked off. I must have looked completely mad because he was not in line with the cloud, so he would have seen my press my camera, run like a madman to the same spot 10 times and preform a melodramatic pray to god.”Hanging Out
(image via: laura deangelis)
“Three years ago, I picked this guy up, put him in my pocket and claimed him as my own,” says photographer Laura DeAngelis.Splitting Headache
(image via: the moronic inferno)
Believe it or not, this photo wasn’t staged. Photographer Dave Brownlee calls it ‘serendipity’ that the heads and bodies of four separate people just happened to line up so well.Puzzling Place, Indeed
(image via: richard heeks)
In this case, it’s the location that’s providing the illusion, not a trick of photography. The Puzzle Museum in Keswick, England contains an oddly-shaped room with a sloping ceiling, walls and floor so that from a certain vantage point, turning one person into a terrifying giant.Pedagogy Without Humanism: Foucault and the Subject of Education
Abstract
Education is commonly understood as an interaction between subjects; an interaction between the educator, who already is a subject, and the child, who has to become a subject by means of the pedagogical activities of the educator. Postmodernism has seriously challenged the common (modern) understanding of human subjectivity. The question therefore is what his challenge entails for our understanding of the process of education.In this paper this question is taken up in the context of a distinction between two conceptions of education: education as manipulation and education as communication. It is argued that the manipulative conception is closely related to the modern understanding of human subjectivity, as is the critique leveled against the communicative conception. In order to find out whether the postmodern "deconstruction" of the modern understanding of human subjectivity opens up new possibilities for a communicative understanding of education, Foucault's analysis of the emergence and subversion of the modern conception of man is presented and discussed.
Although Foucault's work points into the direction of the recognition of the primacy of the intersubjective - and in this sense supports a communicative understanding of education - his deconstruction also makes clear that intersubjectivity cannot be understood as a new deep truth about man. This means that pedagogy has to do without humanism. The paper concludes with some reflections on such a pedagogy without humanism.
EducationAtlas Articles
What kind of salary can I expect with a management degree?What kind of salary can I expect with a Business Administration and Management Degree? This is a fair question and one that many prospective and current management students ask themselves when looking at careers in business. What can I expect to make? After all there is an opportunity cost to attending school, the foregone wages [...]
What are the Job Responsibilities of a business administration manager?
What Are the Job Responsibility of a Business Administration Manager? The responsibilities of a manager with a job in business administration are many and varied. The types of responsibilities will change based on the type of industry one finds a career in, for example retail, manufacturing, or services. In addition, managers’ find their job descriptions [...]
How to Prepare for the GMAT?
How Do I Prepare for the GMAT? Taking the GMAT can be your doorway into higher education in business and accounting, and therefore a better career later on. Although initially it may seem like a daunting challenge, it is one that many choose to face every year. If this is the direction you are interested [...]
How to Study Math, Science and Engineering
How to Study Math, Science and Engineering Accredited online Mathematics programs: Request Free Information Accredited online Science programs: Request Free Information Accredited online Engineering programs: Request Free Information If you’re intelligent enough to get into school and work toward a degree in math, engineering or science, then it’s a safe bet that you’re intelligent enough [...]
Study for Free with the Armed Forces Tuition Assistance
Armed Forces Tuition Assistance Many recruits are attracted to service in the US military due to the many benefits available for college after service. But did you know that a great deal of your college can be 100% paid for while still in the service? By taking full advantage of the Armed Forces Tuition Assistance [...]
Subject:Alternative education
Books in this subject area deal specifically with alternative education: also known as
non-traditional education or educational alternative, this is a broad term that may be used to refer to all forms of education outside of traditional education (for all age groups and levels of education). This may include not only forms of education designed for students with special needs (ranging from teenage pregnancy to intellectual disability), but also forms of education designed for a general audience and employing alternative educational philosophies and methods
non-traditional education or educational alternative, this is a broad term that may be used to refer to all forms of education outside of traditional education (for all age groups and levels of education). This may include not only forms of education designed for students with special needs (ranging from teenage pregnancy to intellectual disability), but also forms of education designed for a general audience and employing alternative educational philosophies and methods
The NASA High Intensity Radiated Fields (HIRF) Laboratory
The HIRF Laboratory is a state of the art facility for generating radiated electromagnetic environments for testing the EM susceptibility, immunity and compatibility of flight critical avionics. It is located at NASA Langley Research Center in Building 1220. The test data acquired are used to study avionic-upset and to characterize fault-tolerant systems. The lab includes three reverberation chambers, TEM cells, high power amplifiers, source generators, indirect lightning waveform and impulse generators, and measurement equipment. The lab has expertise in reverberation chamber theory and operation, evaluation of portable electronic device (PED) compatibility with aircraft systems, aircraft coupling measurements and RF propagation, flight spectrum measurements and EMI assessments, and EMI/EMC testing. The lab is currently supporting research in the Aviation Safety’s Integrated Vehicle Health Management program, particularly HIRF and lightning effects on metal and composite aircraft and wireless sensor technologies.
Elegant Mother's Bracelets, Celebrating Life's Most Precious Gift's...
We invite you to view our stunning collection of keepsake mothers jewelry comprised of custom designed Mothers Bracelets, Name Bracelets, Handstamped Pendants, Family Birthstone Jewelry, Childrens Heirloom Bracelets and breathtaking Mothers Rings. Our unique designs are inspired by creations of the past, reflecting classic simplicity
and understated elegance. Most designs available personalized or non-personalized.
Special Features :
Manufacturer :
we have more than 10 years of expertise in fashion jewelries and accessories, including bracelets, earrings, necklaces, rings, brooches, hairclips and jewelry boxes. Our extensive product range also covers gifts, such as costume mirrors, key rings, bag charms and photo frames. Over 500 buyers in Europe, Asia, the Middle East and Africa source from us. You can count on us too.
Over 800 new designs monthly
have obtained the gold prize of Asian Fashion Jewelry & Accessories Design Competition in 2006. Our 34 designers with more than five years of experience each work out over 800 new designs every month. can also develop a new sample for you according to your specific requirements in 10 days.
Using imported materials
Over 3,500 staff at our 450,000-square-meter factory are ready to handle your volume orders. Our seven production lines output 90,000 dozens of fashion jewelries and 10,000 dozens of gifts every month. use imported materials, including resins from Japan, furs from Italy and rhinestones from Austria. Our 110 QC staff conduct strict inspections during the whole production process from material check to product test.
How to maintain your Jewelry?
Do not sleep, have a bath, swim wearing jewelry.
Do not use water, washing liquid or other liquid wich containing alcohol for cleaning.
Simulation jewelry should be stored in jewelry boxes (bags) or soft velvet and avoid long-term exposure to moist air or under strong light.
Use clean, soft,dry cloth to polish the jewelry after wearing
we have more than 10 years of expertise in fashion jewelries and accessories, including bracelets, earrings, necklaces, rings, brooches, hairclips and jewelry boxes. Our extensive product range also covers gifts, such as costume mirrors, key rings, bag charms and photo frames. Over 500 buyers in Europe, Asia, the Middle East and Africa source from us. You can count on us too.
Over 800 new designs monthly
have obtained the gold prize of Asian Fashion Jewelry & Accessories Design Competition in 2006. Our 34 designers with more than five years of experience each work out over 800 new designs every month. can also develop a new sample for you according to your specific requirements in 10 days.
Using imported materials
Over 3,500 staff at our 450,000-square-meter factory are ready to handle your volume orders. Our seven production lines output 90,000 dozens of fashion jewelries and 10,000 dozens of gifts every month. use imported materials, including resins from Japan, furs from Italy and rhinestones from Austria. Our 110 QC staff conduct strict inspections during the whole production process from material check to product test.
How to maintain your Jewelry?
Do not sleep, have a bath, swim wearing jewelry.
Do not use water, washing liquid or other liquid wich containing alcohol for cleaning.
Simulation jewelry should be stored in jewelry boxes (bags) or soft velvet and avoid long-term exposure to moist air or under strong light.
Use clean, soft,dry cloth to polish the jewelry after wearing
Essence and Existence
Essence
Essence is properly described as that whereby a thing is what it is, an equivalent of the to ti en einai of Aristotle (Metaph., VII, 7). The essence is thus the radical or ground from which the various properties of a thing emanate and to which they are necessarily referred. Thus the notion of the essence is seen to be the abstract counterpart of the concrete entity; the latter signifying that which is or may be (ens actu, ens potentiâ), while the former points to the reason or ground why it is precisely what it is. As furnishing in this manner an answer to the question What? (Quid?) — as, e.g., What is man? — essence is equivalent to quiddity; and thus, as St. Thomas remarks (I, Q. iii, a. 3), the essence of a thing is that which is expressed by its definition.Synonyms
NatureEssence and nature express the same reality envisaged in the two points of view as being or acting. As the essence is that whereby any given thing is that which it is, the ground of its characteristics and the principle of its being, so its nature is that whereby it acts as it does, the essence considered as the foundation and principle of its operation. Hence again St. Thomas: "Nature is seen to signify the essence of a thing according as it has relation to its proper operation" (De ente et essentia, cap. i).
Form
Furthermore, essence is also in a manner synonymous with form, since it is chiefly by their formal principle that beings are segregated into one or other of the species. Thus, while created spiritual things, because they are not composed of matter and form, are specifically what they are by reason of their essences or "forms" alone, the compounded beings of the corporeal world receive their specification and determination of nature, or essence, principally from their substantial forms.
Species
A further synonym of essence is species; but it is to be carefully noted that essence in this connexion is used rather with a logical or metaphysical connotation than with a real or physical one. This distinction is of considerable importance. The real or physical essence of compound entities consists in, or results from, the union of the constituent parts. Thus if we consider man as a being composed of matter and form, body and soul, the physical essence will be the body and soul. Apart from any act of abstraction, body and soul exist in the physical order as the constituents of man. On the other hand, we may consider man as the result of a composition of genus proximum and differentia ultima, i.e. of his animality and his rationality. Here the essence, humanity, is metaphysical or logical. Thus, while the real essence, to speak still only of composite beings, consists in the collection of all those physical component parts that are required to constitute the entity what it is, either actually or potentially existent, without which it can be neither actual nor potential, the logical essence is no more than the composition of ideas or notions, abstracted mentally and referred together in what are known as "second intentions".
Distinction between metaphysical and physical essence
This consideration provides a basis for the distinction of essences according to the degree of physical and metaphysical complexity or simplicity which they severally display. The Supreme Being has — or rather is — a unique and utterly simple essence, free from all composition, whether physical or metaphysical. Moreover, in God — otherwise, as we shall see, than in creatures — there is no distinction of any kind between His essence and His existence. Spiritual created beings, however, as free from the composition of matter and form, have physically simple essences; yet they are composite in that their essences are the result of a union of genus and differentia, and are not identical with their existence. In the angel the essence is the species consequent on this union. Corporeal creatures not only share in metaphysical complexity of essence, but have, on account of their material composition, a physical complexity as well.The characteristic attributes of the essence are immutability, indivisibility, necessity, and infinity.
Immutability.— Since the essence of anything is that whereby the thing is what it is, it follows directly from the principle of contradiction that essences must be immutable. This, of course, is not true in the sense that physical essences cannot be brought into being or cease to exist, nor that they cannot be decomposed into their constituent parts, nor yet that they are not subject to accidental modification. The essence of God alone, as stated above, is so entirely free from any sort of composition that it is in the strictest sense immutable. Every essence, however, is immutable in this, that it cannot be changed or broken up into its constituent parts and yet remain the same essence. The attribute is transcendental and is applied to essence precisely as it is essence. Thus, while the essence of any given man may be broken up into body and soul, animality and rationality, man as man and humanity as humanity is changeless. One individual ceases to exist; the essence itself, whether verified or not in concrete actuality, persists. The definition, "man is a rational animal", is an eternally immutable truth, verifiable whenever and wherever the subject man is given, either as a concrete and existent entity, or as a mere potentiality.
Indivisibility.— Similarly, essences are said to be indivisible; that is to say, an essence ceases to be what it is when it is broken up into its constituents. Neither body nor soul alone is man. Neither animality nor rationality, taken separately, is humanity. Therefore, precisely as essence, it is indivisible.
Necessity.— In like manner necessity is predicated of essences. They are necessary in that, though they may be merely possible and contingent, each must of necessity always be itself. In the order of actual being, the real essence is necessarily what it is, since it is that whereby the thing is what it is; in the order of the merely possible, it must necessarily be identical with itself.
Infinity.— Finally, essences are said to be eternal and infinite in the negative sense that, as essences, there is no reason for their non-existence, nor for their limitation to a given number of individuals in any species.
From what has been said, the distinction between essence considered as physical and as metaphysical will be apparent. It is the metaphysical essence that is eternal, immutable, indivisible, necessary, etc.; the physical essence that is temporal, contingent, etc. In other words, the metaphysical essence is a formal universal, while the physical essence is that real particularization of the universal that provides the basis for the abstraction.
Non-Scholastic views
So far the present article has been occupied in exhibiting the Scholastic view with regard to essence, and in obtaining a certain precision of thought rather than in raising any problems intimately connected with the subject. Notice must be taken, however, of a philosophical tradition which has found adherents mainly among British philosophers and which is at variance with the Scholastic. This tradition would treat as futile and illusory any investigation or discussion concerning the essences of things. By those who hold it, either- the fact of essence is flatly denied and what we conceive of under that name is relegated to the region of purely mental phenomena;
- or, what practically amounts to the same thing, that fact is judged to be doubtful and consequently irrelevant;
- or again, while the fact itself may be fully admitted, essence is declared to be unknowable, except in so far as we may be said to know that it is a fact.
Hobbes and Locke, Mill, Hume, Reid, and Bain, the Positivists and the Agnostics generally, together with a considerable number of scientists of the present day, would not improperly be described as either doubtful or dogmatically negative as to the reality, meaning, and cognoscibility of essence. The proponents and defenders of such a position are by no means always consistent. While they make statements of their case, based for the most part on purely subjective views of the nature of reality, that the essences of beings are nonentities, or at least unknowable, and, as a consequence, that the whole science of metaphysics is no more than a jargon of meaningless terms and exploded theories, they, on the other hand, express opinions and make implicit admissions that tell strongly against their own thesis. Indeed, it would generally seem that these philosophers, to some extent at least, misunderstand the position which they attack, that they combat a sort of intuitive knowledge of essences, erroneously supposed by them to be claimed by Scholastics, and do not at all grasp the theory of the natures of things as derived from a painstaking consideration of their characteristic properties. Thus even Bain admits that there may in all probability be some one fundamental property to which all the others might be referred; and he even uses the words "real essence" to designate that property. Mill tells us that "to penetrate to the more hidden agreement on which these more obvious and superficial agreements (the differentiæ leading to the greatest number of interesting propria) depend, is often one of the most difficult of scientific problems. And as it is among the most difficult, so it seldom fails to be among the most important". Father Rickaby in his "General Metaphysics" gives the citations from both Mill and Bain, as well as an important admission from Comte, that the natural tendency of man is to inquire for persistent types, a synonym, in this context, for essences. The philosophical tradition, or school, to which allusion is made — although we have anticipated its assertions by the admissions into which its professors have allowed themselves to be drawn by the exigencies of reason and human language — may be divided roughly into two main classes, with their representatives in Locke and Mill. Locke got rid of the old doctrine by making the "supposed essences" no more than the bare significations of their names. He does not, indeed, deny that there are real essences; on the contrary, he fully admits this. But he asserts that we are incapable of knowing more than the nominal or logical essences which we form mentally for ourselves. Mill, though, as we have seen, he occasionally abandons his standpoint for one more in keeping with the Scholastic view, professedly goes further than Locke in utterly rejecting real essences, a rejection quite in keeping with his general theory of knowledge, which eliminates substance, causality, and necessary truth.
The considerations previously advanced will serve to indicate a line of argument used against scepticism in this matter. The Scholastics do not and never have claimed any direct or perfect acquaintance with the intimate essences of all things. They recognize that, in very many cases, no more than an approximate knowledge can be obtained, and this only through accidental characteristics and consequently by a very indirect method. Still, though the existence of the concrete beings, of which the essences are in question, is contingent and mutable, human knowledge, especially in the field of mathematics, reaches out to the absolute and necessary. For example, the properties of a circle or triangle are deducible from its essence. That the one differs specifically from the other, and each from other figures, that their diverse and necessary attributes, their characteristic properties, are dependent upon their several natures and can be inferred by a mathematical process from these — so much we know. The deductive character of certain geometrical proofs, proceeding from essential definitions, may at least be urged as an indication that the human mind is capable of grasping and of dealing with essences.
Similarly, and even from the admissions of the opponents of the Scholastic tradition given above, it may reasonably be maintained that we have a direct knowledge of essence, and also an indirect, or inductive knowledge of the physical natures existent in the world about us. The essences thus known do not necessarily point to the fact of existence; they may or may not exist; but they certify to us what the things in question are. The knowledge and reality of essences emerges also from the doctrine of universals, which, although formally subjective in character, are true expressions of the objective realities from which they are abstracted. As Father Rickaby remarks: "In the rough the form of expression could hardly be rejected, that science seeks to arrive at the very nature of things and has some measure of success in the enterprise"; and again, "In short, the very admission that there is such a thing as physical science, and that science is cognitio rerum per causas — a knowledge of things, according to the rationale of them — is tantamount to saying that some manner of acquaintance with essences is possible; that the world does present its objects ranged according to at least a certain number of different kinds, and that we can do something to mark off one kind from another." (General Metaphysics, c. III.)
Existence
Existence is that whereby the essence is an actuality in the line of being. By its actuation the essence is removed from the merely possible, is placed outside its causes, and exists in the world of actual things. St. Thomas describes it as the first or primary act of the essence as contrasted with its secondary act or operation (I Sent., dist. xxxiii, Q. i, a. 1, ad 1); and again, as "the actuality of all form or nature" (Summa, I, Q. iii, a. 4). Whereas the essence or quiddity gives an answer to the question as to what the thing is, the existence is the affirmative to the question as to whether it is. Thus, while created essences are divided into both possible and actual, existence is always actual and opposed by its nature to simple potentiality.With regard to the existence of things, the question has been raised as to whether, in the ideal order, the possible is antecedent to the actual. The consideration here does not touch on the real or physical order, in which it is conceded by Scholastics that the potentiality of creatures precedes their actuality. The unique actuality, pure and simple (as against such theorists as von Hartmann, maintaining an absolute primitive potentiality of all existence), that necessarily precedes all potentiality, is that of God, in Whom essence and existence are identical. We are concerned with the question: Is the concept of a possible entity prior to that of an existing one? Rosmini answers this question in the affirmative. The School generally takes the opposite view, maintaining the thesis that the primitive idea is of existent entity — that is, essence as actualized and placed outside of its causes — in the concrete, though confused and indeterminate. Such an idea is of narrow intension, but extensively it embraces all being. The thesis is supported by various considerations, such as that the essence is related to its existence as potential to actual, that the act generally is prior to potentiality, and that this latter is known, and only known, through its corresponding actuality. Or, we know the possible being as that which may be, or may exist; and this necessary relation to actual existence, without which the possible is not presented to the mind, indicates the priority, in the line of thought, of the actually existent over the merely possible. Existence is thus seen to be in some sense distinguished from the essence which it actuates.
The question agitated in the School arises at this point: What is the nature of the distinction that obtains between the physical essence and the existence of creatures? It is to be borne in mind that the controversy turns not upon a distinction between the merely possible essence and the same essence as actualized, and thus physically existent; but on the far different and extremely nice point as to the nature of the distinction to be drawn between the actualized and physically existent essence and its existence or actuality, by which it is existent in the physical order. That there is no such distinction in God is conceded by all. With regard to creatures, several opinions have been advanced. Many Thomists hold that a real distinction obtains here and that the essence and existence of creatures differ as different entities. Others, among them Dominicus Soto, Lepidi, etc., seem to prefer a distinction other than real. The Scotists, affirming their "formal distinction", which is neither precisely logical nor real, but practically equivalent to virtual, decide the point against a real distinction. Francisco Suárez, with many of his school, teaches that the distinction to be made is a logical one. The principal arguments in favour of the two chief views may be summarized as follows: —
Thomists:
- If essence and existence were but one thing, we should be unable to conceive the one without conceiving the other. But we are as a fact able to conceive of essence by itself.
- If there be no real distinction between the two, then the essence is identical with the existence. But in God alone are these identical.
- A real physical essence is actual in the line of being and not merely possible. But this actuality must belong to it, as a physical essence; for it is, ex hypothesi, neither nothing nor merely possible, and the actuality of an essence is its existence. Cardinal Franselin cast the argument in this form: "Est omnino evidens in re positâ extra suas causas, in statu actualitatis, ne ratione quidem abstrahi posse formalem existentiam" (De Verbo Incarnato).
- It is inconceivable how the existence of a real or physical essence should differ from the essence of its existence.
Christian Tours >> 8 Days Protestant
8 Days Protestant
Christian Tours >> 8 Days Protestant
DAY 1 – ARRIVAL
Our Representative will meet you at the airport, and we will go to Jerusalem and you will stay overnight in Jerusalem.
DAY 2 – MOUNT OF OLIVES, TEMPLE MOUNT, MOUNT ZION
We'll ascend to the Mount of Olives to the Chapel of the Ascension and enjoy a view of Jerusalem. We'll descend to the Garden of Gethsemane. On to St. Peter Galicantu built over Caiaphas House. We'll drive to the Old City of Jerusalem and continue on foot to the Western (Wailing) Wall and the Temple Mount. On Mount Zion, we'll visit the Cenacle (Room of the Last Supper and the Pentecost) and King David’s Tomb. We will have dinner and stay overnight in Jerusalem.
DAY 3 – OLD CITY, GARDEN TOMB, BETHLEHEM.
We'll enter the Old City via St. Stephen’s gate to visit the Pool of Bethesda. We will continue to Litostrotos where Pilate judged Jesus. Then we'll walk via the Damascus Gate to the Garden Tomb. Visit the Museum of the History of Jerusalem at David’s Citadel. We will move on to the biblical city of Bethlehem, spread along the Judean Hills, to visit the Church of Nativity, birthplace of Jesus and the first church ever built. View on the Shepherd’s Field, where the angel announced the birth of Jesus to the shepherds. We will have dinner and stay overnight in Jerusalem.
DAY 4 – EIN KAREM- NEW CITY OF JERUSALEM.
We'll drive to Ein Karem to the biblical village in which St. John the Baptist was born. Visit the Church of St. John the Baptist. Visit the church of Visitation, to commemorate the visit of Mary to Ein Karem, and the meeting between St. John the Baptist’s Mother Elizabeth. Then we can continue on to Yad Vashem Holocaust Museum, to see the memorial to the loss of millions of human lives during WWII. We'll Proceed to the Israel Museum, to see the Dead Sea Scrolls, housed in the Shrine of the Book, the most exciting archeological discovery of this century. We will have dinner and stay overnight in Jerusalem.
DAY 5 JUDEAN DESERT-DEAD SEA-MASSADA-QUMRAN
Our route will lead us via the Judean Desert, and the shores of the Dead Sea, through the King David-Ein Gedi Oasis to the mountain fortress of Massada. We'll ascend by cable car to visit King Herod’s Palaces, the Roman Camp and the ancient Synagogue. We'll continue along the Dead Sea shoreline to Qumran, where we can visit the caves in which the Dead Sea Scrolls were discovered. We'll return for dinner and stay overnight in Jerusalem.
DAY 6- JERICHO-NAZARETH-CAPERNAUM-SEA OF GALILEE
Depart Jerusalem via Jericho, the oldest city in the world where we'll visit the ancient Tel and view the Mount of Temptation. We'll continue along the Jordan Valley to Nazareth, where Jesus spent his childhood. We'll visit the Basilica of the Annunciation, and Joseph’s Carpenter Shop. Continue via Kana to the site of Jesus’ first miracle. Arrive at Capernaum, and visit the Church of the Multiplication of Loaves and Fishes in Tabgha. Then we'll come to a stop where we'll view the Mount of Beatitudes. Enjoy a boat trip across the Sea of Galilee. We will have dinner and stay overnight in Tiberias.
DAY 7 – ACCO-HAIFA-CAESREA-JAFFA-TEL-AVIV
We'll drive through the Galilee Hills to the ancient city of Acco (Acre), the Crusaders City and port. We will also visit the excavations of the Crypt of St. John, the Crusader fortress, and the Museum. We'll continue south along the coastal road to Haifa, the third largest city in Israel. Sights there will include the beautifully kept Persian Gardens surrounding the Bahai Shrine and the Carmelite Church on Mt. Carmel. At the foot of Mt. Carmel is Elijah’s Cave, sacred to Jews, Christians and Moslems. We will continue on to Caesarea for visits to the ancient Crusaders City, the large Roman Amphitheater and the Aqueduct. We'll proceed along the Mediterranean to the Old City of Jaffa (Joppa) and the City of John and Simon the Tanner. We will have dinner and stay overnight in Tel – Aviv or Natania on the Mediterrane
Christian Tours >> 8 Days Protestant
DAY 1 – ARRIVAL
Our Representative will meet you at the airport, and we will go to Jerusalem and you will stay overnight in Jerusalem.
DAY 2 – MOUNT OF OLIVES, TEMPLE MOUNT, MOUNT ZION
We'll ascend to the Mount of Olives to the Chapel of the Ascension and enjoy a view of Jerusalem. We'll descend to the Garden of Gethsemane. On to St. Peter Galicantu built over Caiaphas House. We'll drive to the Old City of Jerusalem and continue on foot to the Western (Wailing) Wall and the Temple Mount. On Mount Zion, we'll visit the Cenacle (Room of the Last Supper and the Pentecost) and King David’s Tomb. We will have dinner and stay overnight in Jerusalem.
DAY 3 – OLD CITY, GARDEN TOMB, BETHLEHEM.
We'll enter the Old City via St. Stephen’s gate to visit the Pool of Bethesda. We will continue to Litostrotos where Pilate judged Jesus. Then we'll walk via the Damascus Gate to the Garden Tomb. Visit the Museum of the History of Jerusalem at David’s Citadel. We will move on to the biblical city of Bethlehem, spread along the Judean Hills, to visit the Church of Nativity, birthplace of Jesus and the first church ever built. View on the Shepherd’s Field, where the angel announced the birth of Jesus to the shepherds. We will have dinner and stay overnight in Jerusalem.
DAY 4 – EIN KAREM- NEW CITY OF JERUSALEM.
We'll drive to Ein Karem to the biblical village in which St. John the Baptist was born. Visit the Church of St. John the Baptist. Visit the church of Visitation, to commemorate the visit of Mary to Ein Karem, and the meeting between St. John the Baptist’s Mother Elizabeth. Then we can continue on to Yad Vashem Holocaust Museum, to see the memorial to the loss of millions of human lives during WWII. We'll Proceed to the Israel Museum, to see the Dead Sea Scrolls, housed in the Shrine of the Book, the most exciting archeological discovery of this century. We will have dinner and stay overnight in Jerusalem.
DAY 5 JUDEAN DESERT-DEAD SEA-MASSADA-QUMRAN
Our route will lead us via the Judean Desert, and the shores of the Dead Sea, through the King David-Ein Gedi Oasis to the mountain fortress of Massada. We'll ascend by cable car to visit King Herod’s Palaces, the Roman Camp and the ancient Synagogue. We'll continue along the Dead Sea shoreline to Qumran, where we can visit the caves in which the Dead Sea Scrolls were discovered. We'll return for dinner and stay overnight in Jerusalem.
DAY 6- JERICHO-NAZARETH-CAPERNAUM-SEA OF GALILEE
Depart Jerusalem via Jericho, the oldest city in the world where we'll visit the ancient Tel and view the Mount of Temptation. We'll continue along the Jordan Valley to Nazareth, where Jesus spent his childhood. We'll visit the Basilica of the Annunciation, and Joseph’s Carpenter Shop. Continue via Kana to the site of Jesus’ first miracle. Arrive at Capernaum, and visit the Church of the Multiplication of Loaves and Fishes in Tabgha. Then we'll come to a stop where we'll view the Mount of Beatitudes. Enjoy a boat trip across the Sea of Galilee. We will have dinner and stay overnight in Tiberias.
DAY 7 – ACCO-HAIFA-CAESREA-JAFFA-TEL-AVIV
We'll drive through the Galilee Hills to the ancient city of Acco (Acre), the Crusaders City and port. We will also visit the excavations of the Crypt of St. John, the Crusader fortress, and the Museum. We'll continue south along the coastal road to Haifa, the third largest city in Israel. Sights there will include the beautifully kept Persian Gardens surrounding the Bahai Shrine and the Carmelite Church on Mt. Carmel. At the foot of Mt. Carmel is Elijah’s Cave, sacred to Jews, Christians and Moslems. We will continue on to Caesarea for visits to the ancient Crusaders City, the large Roman Amphitheater and the Aqueduct. We'll proceed along the Mediterranean to the Old City of Jaffa (Joppa) and the City of John and Simon the Tanner. We will have dinner and stay overnight in Tel – Aviv or Natania on the Mediterrane
A Brief History Of Star Wars Holiday Merchandise
If you live in North America, you know Star Wars. The first Star Wars movie was produced by George Lucas in the 1970s and the popularity of the franchise has grown ever since.Six live-action and one animated movie later, Star Wars is a huge pop culture phenomenon around the world and, of course, the incredible popularity of these movies has helped spawn some great items for Star Wars collectors.
Until 1996, Star Wars Christmas-themed items were simply not available. The two holiday items that had been produced were "Holiday Special" a television show that aired in November of 1978 and "Christmas in the Stars" a record that was released in 1980. Neither of those productions was successful so Star Wars fans would have to wait awhile before having the opportunity to collect holiday-themed items.
A lot changed after 1995. Star Wars holiday-themed items appeared. Star Wars fans now have their pick of decorations with which to adorn their Christmas trees and homes. Manufacturers like Hallmark, Christopher Radko, Rawcliffe, Hasbro and Kurt S. Adler all produce interesting Star Wars memorabilia.
For some, one item will do as an indication of their love of Star Wars. Others, however, are working at building a complete collection. The wonderful assortment available today allows you to celebrate the holiday season in true Star Wars style!
Please do not forget to rate this page with the star system at the top and to leave your comments at the bottom. I look forward to reading your answers to my polls and duels! Unfortunately, I do not have any Star Wars Christmas items listed in my eBay store but I do usually have some other Star Wars items. Be sure to check them out at Treasures By Brenda
Keeping vigil over the profession: a grounded theory of the context of nurse anaesthesia practice
Background
Nurse anaesthetists in the US have faced continued, repeated challenges to their profession. Regardless, they have met these challenges and have established themselves as major anaesthesia care providers. In this paper we address the research question: How do certified registered nurse anaesthetists (CRNAs) manage the socio-political context in which they provide care for their patients?
Methods
Grounded theory was used to explore how nurse anaesthetists protect and promote their profession. Purposive, snowball, and theoretical sampling was used and data were collected through participant observation and interviews conducted at a conference of the professional association, an educational program, by telephone, email exchanges, and time spent in operating rooms and an outpatient surgical clinic. Analysis included coding at increasingly abstract levels and constant comparison.
Results
The basic social process identified was Keeping Vigil Over the Profession, which explains how nurse anaesthetists protect and promote their profession. It is comprised of three contextual categories: Establishing Public Credibility through regulatory and educational standards, Political Vigilance and taking action in governmental and policy arenas, and Tending the Flock through a continuous information loop between local and administrative/political levels.
Conclusions
From our study of the context of nurse anaesthesia practice, it is clear that CRNAs are dedicated to protecting their ability to provide high quality patient care by maintaining constant vigilance over their profession.
Background
In 1931, Agatha Hodgins brought together in Cleveland 40 nurse-anaesthetists from 12 states to form the National Association of Nurse Anaesthetists (NANA--later American Association of Nurse Anesthetists--AANA). Within weeks, state organizations began forming, and almost immediately the profession faced its first legal challenge; in California Dagmar Nelson was charged with practicing medicine without a license. After a lengthy court battle, in 1934, the state Supreme Court ruled that nurse anaesthesia was not the illegal practice of medicine, and that anaesthesia performed by a nurse was nursing. This was only the first of many legal and political challenges faced by nurse anaesthetists, thus the need to Keep Vigil Over the Profession has always been present for them.
In an earlier report [1] we presented a grounded theory of nurse anaesthesia practice and its relationship to nursing and nursing knowledge: Keeping Vigil Over the Patient. In this paper we report findings related to the study question: How do certified registered nurse anaesthetists (CRNAs) manage the sociopolitical context in which they provide care for their patients?
Methods
We used grounded theory to explore CRNA practice. As a qualitative, systematic approach, grounded theory (GT) is often used to explore social processes in context. GT involves the iterative collection and analysis of data to formulate explanatory theories grounded in the world of participants [2]. GT was originally developed by Glaser and Strauss [3] and refined by others, including Glaser [4], Strauss [5], Strauss and Corbin [6], Schreiber and Stern [7], and Charmaz [8]. Because we were interested in the processes that CRNAs use as they enact their role, GT was the method of choice. We were influenced by Strauss [5,9] in our examination of the contextual influences on situated interaction and CRNA practice.
Consistent with GT methodology, we sought variation in data sources and participant experiences, using multiple techniques. First, we attended the 2006 meeting of the American Association of Nurse Anesthetists (AANA), where we conducted participant observation, used purposive and snowball sampling to recruit participants, conducted interviews (n = 18), gathered documents, and visited and examined the association's archives. We interviewed key informants about socio-political matters like regulatory and legal issues, scope of practice, billing and reimbursement. Scientific sessions, convention rituals, and mentoring relationships were observed. We also conducted e-mail and telephone follow-up to clarify issues. Theoretical sampling led us to conduct additional interviews with new informants. Most interviews were taped and transcribed verbatim; interviews not recorded were documented in field notes.
Participants' years of CRNA experience ranged from student through 40 years, and participants represented a minimum of 10 states; many had military experience, had worked in several states in both rural and urban settings, and some had worked in locum tenens positions. Eighteen of 41 participants were men.
Based on emerging theoretical concepts, we conducted a site visit to a small city in the American Northwest to explore the context of CRNA practice. We observed anaesthesia practice in an outpatient clinic and in two hospitals, visited an educational program and observed practicing CRNAs supervising students. We gathered data through document review, formal and informal interviews, and observations in clinical settings. Throughout the study we wrote or recorded field notes documenting our observations, interactions, and analytic ideas.
Data Analysis
Analysis began with entry to the field and continued concurrently with data collection. Throughout we met and discussed emerging findings and agreed on interpretations and memoing. We assigned increasingly abstract codes and compared incoming data to other data, to concepts, and to emerging categories. We constantly made comparisons among ideas about actions and interactions occurring in the data. Finally, we constructed a theory of nurse anaesthesia practice, Keeping Vigil comprising two major categories. Keeping Vigil Over the Patient, which theorizes nurse anaesthesia practice and is reported elsewhere [1] takes place within a larger sociopolitical context, Keeping Vigil Over the Profession, presented in this paper.
Rigour
We used widely accepted techniques to ensure rigour, including constant comparison, "negative" case analysis, participant checks, persistent observation, and prolonged engagement in the field [3,10]. We also used peer debriefing within a GT seminar [11]. We listened to the tapes repeatedly, while reading and re-reading the text. Selected participants reviewed the findings and provided feedback to ensure our interpretations were consistent with their experience and understanding.
Limitations
As in all qualitative research, findings cannot be generalized widely. However, if the findings fit in explaining other situations and circumstances, then they can be said to be theoretically generalizable [12,13]. Participants included only active members and employees of the AANA and it is unclear whether or how well these findings would explain the actions and interactions of non-active members or non-members. Yet, the AANA works to keep members actively informed and involved, and its membership includes an estimated 95% of nurse anesthetists in the country.
Ethical Considerations
The study was conducted in accordance with the Canadian Tri-Council [14] guidelines on human subject research, including informed consent. The study received approval of the Human Research Ethics Committee of the University of Victoria and the Board of Directors of AANA.
Results
In this paper we report on Keeping Vigil Over the Profession comprising three major contextual categories that influence how CRNAs Keep Vigil Over the Patient: Establishing Public Credibility, Political Vigilance, and Tending the Flock. To keep vigil over the patient, CRNAs must also keep vigil over the profession (see Figure 1). This vigilance operates in the background of CRNA practice and works to buffer it from ongoing threats. Participants are convinced that without such vigilance, the continuous political and legal challenges launched against them would whittle away at CRNA practice, imposing ever-increasing limits on their scope. This vigilance also operates internally within the professional organization, working to keep the membership informed, cohesive, and speaking with a unified voice.
thumbnailFigure 1. Keeping Vigil Over the Profession.
Establishing Public Credibility
A primary concern of Hodgins and her colleagues that continues today is the need to establish the credibility of the nurse anaesthesia role in the eyes of the public. CRNAs must not only practice safely, but they must be seen to be practicing safely. Thus, nurse anaesthetists needed to set a high standard and demonstrate the safety and worth of their practice. In practice, they also needed to establish themselves as trustworthy, safe providers of anaesthesia care. They did this by adopting a protected title for nurse anaesthetists, establishing standards of practice and a standardized curriculum, as well as personal-professional credibility.
Adopting a title
Early in its history (1956), AANA members adopted the title Certified Registered Nurse Anaesthetist, or CRNA. This title recognizes the national certification that was already established and enshrined the "nurse" part of nurse anaesthesia, which was and continues to be viewed by practitioners as the foundation and spiritual home of their practice. The following quote is a typical example of the commitment to nursing within CRNA practice and identity:
I think the reason why nurse anaesthesia is a nursing role is that we are able to combine all that good science stuff along with our nursing stuff. You have an opportunity to take care of someone who is in a huge anxiety part of their life and alleviate that anxiety through just touching them on the shoulder, touching them on the head, telling them "This will be OK, and I'm going to take really good care of you." And to me, that's nursing.
So strong is the commitment to nursing that an attempt at an AANA meeting to drop "nurse" from the title was widely defeated, which is notable in light of the fact that, although affiliated with universities, approximately 40% of CNRA educational programs are still housed outside schools or departments of nursing.
Identifying an agreed-upon title for the role allowed the professional association to mount public relations campaigns about the role and the title, and enabled them to create and distribute recruitment materials to attract students to the profession. By having a professional name that was recognized and accepted by all, the group prevented many of the nomenclature arguments and irregularities within nursing that have dogged the more recent development of the nurse practitioner (NP) role in Canada where there is no inter-provincial agreement on title and title protection NPs.
Developing practice standards
Similarly, formation of NANA/AANA created a forum and the means to develop practice standards and establish curricula. Creation and ongoing revision of standards of practice promoted a high quality of care and helped ensure the status of the CRNA role. It further allowed members to define for the public the nature of their care, as well as identify a level of excellence for CRNAs to achieve. CRNAs could enumerate their qualifications to those who might question their preparation to provide safe care.
In addition, NANA/AANA approved educational programs, and laid the groundwork for the accreditation and certification processes that continue today, although AANA no longer accredits nurse anaesthesia programs or certifies CRNAs. In 1975, as a result of challenges by the American Society of Anaesthesiology (ASA) to the U.S. Office of Education, the AANA relinquished these responsibilities to five independent Councils. Since 1975, the AANA has been the sole professional organization that represents all CRNAs in all situations public and private at both state and federal legislative levels. CRNAs could now point to these developments to demonstrate the rigour of their training and their high practice standards. This works today both at the individual level, in establishing personal-professional credibility with physicians, and within institutions and the nursing community. It also works at the state and national level, in lobbying for legislation and regulation that support a broad scope of CRNA practice.
Establishing educational programs
The creation and adoption of a standardized curriculum for preparation of nurse anaesthetists began in 1935, with a report from the AANA Education Committee. The report contained recommendations regarding subjects to be taught, hours of classroom and clinical instruction, and a minimum number of cases to be administered by the student to get a diploma. The AANA report served the same purpose that the 1910 Flexner Report did for physicians, using educational standards to position CRNAs and their practice in a politically advantageous place. To support members in meeting these educational requirements, AANA sponsored refresher courses between 1947 and 1951.
Over time, CRNA educational preparation has been increased. This began with requirements for specific program lengths, which kept expanding; however, it took a long time for CRNAs to agree on the need for baccalaureate or graduate education. For example, the "1985 Proposal" to mandate a minimum of baccalaureate preparation, failed at the AANA conference that year. Nonetheless, there was a general recognition of a need for degree level preparation, and in 1998 it became a requirement that CRNAs be prepared at the graduate (master's) level. Presently discussions are underway regarding doctoral preparation, in light of the American Association of Colleges of Nursing (AACN) plan to advance preparation for NPs (and CRNAs) to a clinical doctorate. There is ambivalence among CRNAs with respect to this proposal because some are concerned that the DNP (doctorate in nursing practice) appears to be more relevant to NPs and is not specific to CRNA needs. The debate is ongoing [15,16] although participants recognize the inevitability of a requirement for doctoral preparation and the importance of moving in parallel with other advanced practice nurses (APNs). Nonetheless, the AANA has issued a position statement that all CRNAs graduating in 2025 and beyond should be accredited at the doctoral level.
The idea of a DNP and other clinical doctorates arose from recognition of the importance of practice-based higher education in providing safe patient care. Admittedly, some would argue that the promotion of clinical doctorates for APNs is, in part, a political maneuver "which creates parity with other healthcare professionals" [15]. Yet, this reinforces the ongoing challenges experienced by CRNAs and their need for constant political vigilance.
Establishing personal-professional credibility
In tandem with the AANA's activities to establish and enhance the credibility of the profession, individual practitioners have credibility issues as well. In addressing their own personal-professional credibility, CRNAs reinforce the collective work to establish the credibility of the profession in the public eye. Many participants talked about the need to establish their own personal-professional credibility in their relationships with physicians, and the documentary record shows that this has long been the case [16,17]. The earliest CRNAs worked closely over long periods of time with a single physician who fully supported their development as nurse anaesthetists. Examples of this include Agatha Hodgins and Dr. George Crile at the Lakeside Hospital in Cleveland, or Alice Magaw and the Mayo brothers.
Participants described how they had to establish credibility when they encounter anaesthesiologists who are unfamiliar with, or resistant to, their practice or with CRNA practice in general. For these anaesthesiologists, seeing is believing, and credibility could only be achieved by the CRNA demonstrating competence and establishing a level of trust with medical staff, as described by this participant:
It takes time for them to have a level of trust. I think it all comes down to trust. And I don't think I could go into any practice and work with an anaesthesiologist without earning their respect and trust, and then it becomes more of a supportive type role.... What they say behind our backs? Probably what we say behind their backs, you know? There's good and there's bad and um, but I think it just comes down to earning respect and trust and I think it goes both ways.
This participant hints at the intricate relationship between CRNAs and anaesthesiologists, in that they intentionally focus on the well being of the patient and providing high quality care, which diffuses conflict in the operating room [18].
Maintaining Sociopolitical Vigilance
From the beginning, participants identified that CRNAs have faced ongoing challenges requiring constant vigilance of the socio-political context in which anaesthesia practice takes place. Maintaining socio-political vigilance includes two subcategories: monitoring challenges and politicking.
Monitoring challenges
The AANA and its members continuously scan the environment for threats to the profession. Our analysis of participants' descriptions revealed three related types of threats faced by CRNAs: challenges to professional autonomy, challenges to the scope of practice, and encroachment on their practice by others, notably the anaesthesia assistant (AA). Many threats have come from the ASA or their proxies, resulting in continuous lobbying and counter-lobbying by AANA and its members at the state and federal level over regulations and legislation related to CNRA autonomy, scope of practice, and reimbursement for services.
CRNA autonomy has been contested periodically in American courts, as physicians have repeatedly sued (largely unsuccessfully) CRNAs for practicing medicine without a license. Although there is growing recognition at the regulatory level that the nature of practice overlaps between and among health professions, there are ongoing attempts by anaesthesiologists to curtail autonomous CRNA practice by lobbying for supervisory requirements for state Medicare/Medicaid and third-party payers (private insurance companies). One participant spoke of the political landscape in her state as, "They [state medical association] have 20 lobbyists to our one. Big machine." Challenging autonomous practice via payment schemes is a common strategy to reach the same outcome through the back door, and such challenges are frequent. As one participant described this, "The only downside [to anaesthesia practice] is that it's so contentious. We have to fight for it all the time."
CRNAs also face challenges to their autonomy from hospital policies that require medical supervision of CRNA practice, regardless of the fact that there is no legislation requiring them to work under medical direction or supervision of an anaesthesiologist [19,20]. In teaching hospitals, the common practice is to have an anaesthesiologist "supervising" CRNAs and anaesthesia residents in two to four operating rooms. Often the anaesthesiologist's focus is on the practice of the residents, because the CRNAs are usually much more experienced and able to function by using the anaesthesiologist as a consultant, if at all. At the same time, this hierarchical arrangement appears as an optical illusion that somehow the anaesthesiologist is the "captain of the ship".
Related closely to threats to autonomy are local and national political struggles to safeguard the scope of practice and compensation [17]. Although the overall trend is toward fewer regulatory constraints to APN in the US [20], the medical establishment has successfully constrained the CRNA scope of practice in several states. For example, in some states CRNAs are unable to provide regional anaesthesia because of wording of the Medicare/Medicaid payment conditions. Interventional pain management by CRNAs, as might be provided in a pain clinic, is controversial, and in a state where medical organizations claim that it is solely the practice of medicine, CRNAs currently are restrained from performing certain pain management techniques. One participant explained:
The limits on CRNAs in Louisiana ... do not relate to Medicare/Medicaid billing. Rather, this was an outcome that emerged from dueling Board of Nursing and Board of Medicine positions and litigation that, unfortunately, did not end positively for the nurse anaesthetists ... it's clearly an aberration - at least to date - as no other state has yet adopted such a prohibition concerning nurse anaesthetists.
There are also states in which Medicare/Medicaid and/or third-party payers do not reimburse CRNAs at the same rate as anaesthesiologists performing the same service, and often there is no legal ban in place to forbid this practice.
At the same time CRNAs are also threatened by the encroachment of the anaesthesiologist assistant (AA) role. The AA role varies across the country, from that of the technician ensuring equipment and supplies are prepared for the day's surgeries to a "physician assistant specialist" [21], administering and monitoring anaesthesia under the direction of an anaesthesiologist. Currently, the AA role is regulated in a two states, although it exists under medical direction within hospitals, so it is difficult to estimate the number of recognized AAs practicing.
As can be seen, CRNAs face continuous threats to their profession. Both individually and collectively, they understand that their practice is contingent upon being able to identify, prevent, and address challenges to the profession.
Politicking
CRNAs recognize that they need to be effective in pushing back against possible impediments to the profession and the role. Nonetheless, as noted elsewhere [1], although the ASA and AANA are locked in conflict, CRNAs ensure that this conflict does not affect patient care. Given the nature and constancy of these threats, it has been necessary for CRNAs to be politically vigilant, acting jointly through the AANA, which works to keep its membership together and speaking with one voice. As a collective, AANA represents a critical mass of CRNAs, and has resources to provide its membership with the skills and key messages to be effective in promoting their profession. For example, the AANA has a branch office in Washington, DC, steps from the Capitol Building, where a full time professional lobbyist and up to six other staff monitor political happenings at the national and state levels. They prepare briefs and send out electronic updates and bulletins to the membership about matters such as progress of legislation, lobbying efforts and messages, and upcoming committee hearings. They also maintain a system to gather information about state and local initiatives with potential impact on practice, and to provide support and information to members to deal with these. Thus, mechanisms are in place and well practiced to launch public relations campaigns and counter-offensives as needed, which has enabled the group to speak with one voice, something they have continued to do over the years. To date, this has proven effective.
In addition to monitoring political developments, staff at the Washington, DC office also conducts an annual Assembly of States, a workshop aimed at providing participants with the skills needed to work effectively with the media and get their message across to the public in a clear manner. The workshop includes up to 10 participants per state, including state leadership and boards of directors. Over the course of a week, they learn about government, legislative initiatives, Medicare/Medicaid rules, the political process, and how to be useful to elected officials. The week culminates with groups of two to three participants going to the capital and meeting with their congressperson or senator, taking their key messages and practicing their new skills. Participants are then prepared to go back to their home states and become involved with promoting the profession at a political level. One CRNA noted the importance of this work:
That's one thing that's wonderful about the AANA. They try very hard to teach their people the political landscape and how to stay involved, because if you're not involved politically, others will legislate you out of business.
Thus, in these ways, CRNAs are able to protect their profession by Maintaining Political Vigilance. They are able to identify threats to their practice and work in a skilful way as individuals and as a collective to disarm challenges and promote the profession. With an estimated 65% of all anaesthesia given in the US administered by CRNAs, the results of their efforts are clear.
Tending the Flock
We were struck by the many ways in which CRNAs, individually and through AANA, attend to themselves and the collective membership. This is an empowered group of nurses, and the AANA conference was a stark contrast to the many other nursing conferences we have attended in Canada and the US. Because AANA represents virtually all CRNAs, and because threats to the profession are continuous, considerable effort is made to nurture and strengthen the group. This is done through two sub-processes, nurturing ourselves and celebrating traditions.
Nurturing ourselves
CRNAs nurture themselves by attending to their own health and the health and future of the profession. The health of AANA membership was a particular concern, and this was evident at the conference with early morning golf and walks, and a lifestyle booth with nutritional and other handouts, including a video on prevention and treatment of substance use. There was also a presentation on the high (10%) risk of substance use within anaesthesia practice (including both nurses and physicians), in which the presenter raised the issue of mandatory drug testing. One reason for the focus on substance use was the recent overdose death of a highly respected, much loved AANA president. This was not believed to be a planned suicide, but the result of an accidental overdose while self medicating. There was a general recognition that perfectionism and CRNAs' considerable knowledge of drugs could easily lead them to feel somewhat grandiose about their ability to handle drugs, as this participant explained:
So I can completely understand people saying, I know this drug, it can't happen to me, I know ... but um, it's very scary. And it's very sad and devastating and um, I just don't ever want to see any of my colleagues...and I know I will some day. I mean most of the senior people that I know, they all know people that it's happened to. So, I'm really hoping that can, the wellness initiative will really help our profession become stronger physically, mentally, spiritually, everything.
The forthrightness with which participants, both at the conference and during our site visit, talked about substance use was striking. We heard variations on this discussion throughout the study from many participants, some of whom were friends of the AANA president who died from an overdose.
CRNAs also nurture themselves through mentoring future generations of anaesthetists. Guiding students is a serious concern of CRNAs, and they talked with particular pride about this:
It's frequently mentioned that nurses eat their young and they do. They do. But nurse anaesthesia doesn't do that. We really... I don't think that you'll find anybody that says that we do. We really mentor because we have a nurse that we're mentoring to do what we do and that's different I think.
Participants were insistent that nurse anaesthesia instruction was qualitatively different than what medical residents receive, as these quotes demonstrate:
The difference between CRNA training and resident training is unbelievable, in terms of the mentoring and the attention. A resident gets...( ) ...give them a month one on one, month of July, one on one, whether it be with a senior resident or one of the CRNAs, one on one, and then you're [medical resident] out [on your own].
In fact, in my program, the residents told us that they felt we got better anaesthetic education, than they did because they were left to their own devices to educate themselves, whereas we were given formalized instruction and testing.
Participants emphasized that their tradition of mentoring students and monitoring their learning closely helped to prevent mistakes. In fact, CRNAs' malpractice costs have decreased by 42% in the past 18 years [16] and malpractice rates for CRNAs are reported to be lower than those of anaesthesiologists [22].
We observed a CRNA working with a student in difficulty, and saw her posing questions to help him focus on what was salient, asking, for example, "Given this patient's age and weight, where do you want to keep his BP?" In this way, she was asking the student to bring classroom learning into the practice arena while keeping an eye on the parameters she was willing to allow him.
Nurturing ourselves was also evident at the conference, where there were opportunities for CRNAs to sponsor students by paying their registration fees and bringing them along as shadows throughout the conference, introducing them to others and explaining what they were seeing. All CRNA programs require students to become associate members of the AANA, which allows them to become non-voting members of national and state committees, and further mentors them to become involved in the AANA when they graduate. Some programs pay students' AANA dues while they are in the program. During their programs, students are required to attend and participate in either national or regional/state meetings of AANA, and report back to their student colleagues. Students are encouraged to present posters at conferences, usually on their final research projects, and we observed many excellent examples. In addition, CRNAs are expected to be preceptors to students as part of their daily work and take this on willingly. In these ways, the fostering and guidance of students was a serious responsibility, and a part of Tending the Flock on which CRNAs took pride in themselves.
Celebrating traditions
CRNAs also Tended the Flock through the many traditions they celebrated. This was particularly evident at the 75th anniversary meeting of AANA's founding, where there was a Pioneer's Breakfast, a meeting of the history committee, and where the organization's archives were displayed. Each of these communicated the diverse and important CRNA traditions to the flock. There was considerable formality at the opening and closing ceremonies, much more than we were used to at Canadian events. For example, at these events, the officers and board members, formally dressed, were introduced to applause as they marched down a spotlighted aisle to the front podium. The happenings were all projected on giant screens. At the banquet, the persons accompanying these dignitaries (partners or family members of whatever gender or sex) were also introduced in this way. The events were thoroughly choreographed preventing awkward moments as people received various awards, shook hands, turned to be photographed, and returned to their places, all set to a trumpet fanfare. Those members in the military attended in full dress uniform, presenting a striking vision.
At the banquet, members were seated by state and as each state was called (with appropriate music and film footage on the big screens), members jumped up, waved their napkins, and loudly cheered themselves and their state(s). Some went to considerable effort to produce costumes to reinforce their various allegiances. It resembled a pep rally, with a roll call of states, territories, public health, and the military that took about an hour as a prelude to dinner. Throughout these events, there was a strong undercurrent of patriotism. In this way, there was serious intent along with an element of fun as these events unfolded, and these traditions fostered and strengthened bonds within the membership.
Discussion
In this report, we theorized the multi-level context of nurse anaesthesia practice in the US to provide an understanding of the significant contextual influences on practice. In a related article [1], we presented a substantive theory of CRNA practice, Keeping Vigil over the Patient. As qualitative researchers, we acknowledge these findings represent our interpretation of the data from the perspective of "outsiders"-- nurses who are not nurse anaesthetists. This may preclude a full understanding of CRNA practice and the influences on that practice as experienced by CRNAs. We believe, however, that we offer a useful perspective on one area of APN that has relevance to the broader profession. There is much we can learn from the way CRNAs in the US ensure safe and high quality care for their patients, manage the challenges to their professional autonomy, and promote and advance the wellbeing of their members.
What stood out for us were two of the three categories in Keeping Vigil over the Profession: Political Vigilance and Tending the Flock. The first category, Establishing Public Credibility was not new to us, nor is it new to APN. The processes of adopting a title, developing practice standards, developing regulatory and credentialing mechanisms, and establishing accredited educational programs are consistent with developments in the larger APN arena [23]. What is perhaps most noteworthy is that nurse anaesthesia was the first specialty group in nursing to do this [16]. Much of this development was related to challenges in establishing credibility with the medical profession and the public at large, but also with nursing colleagues. The relationship between CRNAs and the larger profession of nursing, primarily as represented by their professional associations (AANA and ANA), has not always been an easy one and tensions remain. There is, however, growing professional collaboration between these groups. For example, there is an increasing trend to house nurse anaesthesia programs in colleges or schools of nursing [16]. In the early years, when anaesthesia programs were introduced, there was often opposition to having these programs in university nursing schools.
The other observation we made is the explicit link between establishing personal-professional credibility and collective credibility for the profession at large. The personal really is political. Early CRNAs worked closely with pioneer surgeons to provide anaesthesia in ground-breaking cases, thereby giving them credibility to develop practice and educational standards [1,16,17]. CRNAs today, although not working solely with specific physicians, establish trust and credibility with surgeons and anaesthesiologists in practice, which confirms collective credibility. It is possible that the credibility of CRNAs and their record of safe and competent practice fuels opposition to the CRNA role by the ASA. This relationship between personal credibility and collective professional credibility has been noted in relation to the acceptance of other APN roles, particularly nurse practitioners [24,25].
The category of Political Vigilance was one of the findings that most impressed us, although this type of vigilance is not unique to CRNAs or the AANA. What is unique is the widespread acceptance of, and engagement in, political activities among CRNAs. In fact, political activism is a dominant value among nurse anaesthetists and CRNAs engage in political activities because it is among the "dominant rules of behaviour" [25]. What is important about this political activity is that it is not just about vigilance in defending the practice rights of the profession, but vigilance in patient care and safety. We have not seen the value for political activism reported elsewhere as being so explicitly a core value or as prevalent in practice among other nursing specialty or professional groups. The importance of political activism to nurse anaesthetists is also implicitly reflected in the Nurse Anaesthesia Practice Model [26], in which one of the essential professional values is a social one. Value is placed on enhancing and preserving the CRNA role in the health care system in society at large, on the legal responsibility for competent care, and on continuous improvement in standards of care, education, and collaboration.
The importance of political vigilance is evident in the successful countering of many court challenges brought against CRNAs over the years for practicing medicine without a license. We know that other advanced practice nurses have faced similar challenges but it seems that the frequency and intensity of challenges has been greater for CRNAs, particularly in the last two decades [27]. It is not just the legal challenges that require maintaining vigilance, but also the attacks against scope of practice at the policy and institutional level as well. In fact, our CRNA participants told us that the constraints that physicians attempt to impose on their practice are primarily at the policy level, but may relate to institutional, state or national policies.
We wonder if the intensity of the legal and policy constraints that anaesthesiology groups attempt to impose on CRNA practice relate to the extent of competition they perceive. Nurse practitioners often practice in settings and with populations that do not always place them in direct competition with physicians. The same is true for CRNAs working in rural settings, where they are the primary anaesthesia providers. However, when CRNAs work side by side with anaesthesiologists in cities, their scope of practice overlaps almost entirely. Because of this overlap, there exists the potential for CRNAs to replace anaesthesiologists. This has led to anaesthesiologists lobbying for the "team model" of practice in which an anaesthesiologist "supervises" CRNAs. Although supervision may be a myth at the practice level [28], it has been successful in sustaining physician incomes in the face of any competition. Despite the effort it takes the AANA to counter these policy constraints, the fact that they are not enshrined in legislation provides opportunities to lobby to support and advance CRNA practice. But, constant vigilance is needed.
The third category, Tending the Flock, was perhaps the most surprising and exciting finding in our study. We observed CRNAs to be an empowered group of nurses and their practices in nurturing themselves stood in stark contrast to our own experiences in nursing, and to our observations at professional meetings and conferences. Our participants talked extensively about working to mentor the next generation of practitioners, and their willingness to engage in this mentoring role. Our own experience has been that it is challenging to find practice opportunities for students and we often face unwillingness among some practitioners to take on a mentoring role, often because of challenges in the workplace. This did not appear to be the case among the CRNAs in this study.
The frequent comments by participants that CRNAs do not "eat their young" was particularly telling. We could not find anything in the literature suggesting that the kind of horizontal violence or bullying characterized by the ugly metaphor of "eating our young" was evident in CRNA practice. We found several recent articles about this phenomenon in perioperative nursing practice [29,30] and other areas of nursing [31-33]. The usual explanation for such behaviour lies in theories of oppression and feminism, and in particular, the theory of oppressed group behaviour, popularized in nursing by Roberts [34] and taken up by other authors [35-37]. Because nursing is largely a female profession, it is vulnerable to sex-role stereotyping and gender oppression [38]. Although Farrell [31,39] has challenged the reliance on theories of oppression as the primary explanation for horizontal violence, he and others provide evidence that intra-professional conflict and horizontal violence is common in nursing. That we did not find it in our study suggests that there are unique characteristics of CRNAs, their role, and the organizational arrangements within which they work that make this type of behaviour unlikely. We also explored the literature for evidence of horizontal oppression among other advanced practice roles and found that it was also limited [24]. The high degree of professional autonomy, the higher level of education, and the broad scope of responsibility and accountability of APNs may account for this. In addition, the fact that 46% of CRNAs in the US are men [40] may have changed intraprofessional dynamics such that the largely gendered aspect of horizontal violence in other areas of nursing is ameliorated in CRNA practice.
Conclusions
From our study of the context of nurse anaesthesia practice, it is clear that CRNAs are dedicated to protecting their ability to provide high quality patient care by maintaining constant vigilance over their profession. To do this, they actively engage in establishing their own personal credibility, as well as the credibility of the profession. They have a strong commitment to nurturing themselves and the next generation of CRNAs through Tending the Flock, which ensures strong and confident practitioners and a powerful professional association. Their commitment to political vigilance not only protects patients, but also ensures a place for CRNAs in the US health care system.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
Both authors participated in the conceptualization and design of the study and collected data in all its phases. RS conducted telephone interview and email exchanges to saturate the data set. Both authors participated in data analysis. RS prepared the first draft of the results section and MM prepared the first draft of the discussion. Both authors revised, edited, read and approved the final manuscript.
Acknowledgements
manuscript preparation. The authors further wish to acknowledge Dan Simonson, Betty Horton, Frank Maziarski and Frank Purcell for their insights.
References
Nurse anaesthetists in the US have faced continued, repeated challenges to their profession. Regardless, they have met these challenges and have established themselves as major anaesthesia care providers. In this paper we address the research question: How do certified registered nurse anaesthetists (CRNAs) manage the socio-political context in which they provide care for their patients?
Methods
Grounded theory was used to explore how nurse anaesthetists protect and promote their profession. Purposive, snowball, and theoretical sampling was used and data were collected through participant observation and interviews conducted at a conference of the professional association, an educational program, by telephone, email exchanges, and time spent in operating rooms and an outpatient surgical clinic. Analysis included coding at increasingly abstract levels and constant comparison.
Results
The basic social process identified was Keeping Vigil Over the Profession, which explains how nurse anaesthetists protect and promote their profession. It is comprised of three contextual categories: Establishing Public Credibility through regulatory and educational standards, Political Vigilance and taking action in governmental and policy arenas, and Tending the Flock through a continuous information loop between local and administrative/political levels.
Conclusions
From our study of the context of nurse anaesthesia practice, it is clear that CRNAs are dedicated to protecting their ability to provide high quality patient care by maintaining constant vigilance over their profession.
Background
In 1931, Agatha Hodgins brought together in Cleveland 40 nurse-anaesthetists from 12 states to form the National Association of Nurse Anaesthetists (NANA--later American Association of Nurse Anesthetists--AANA). Within weeks, state organizations began forming, and almost immediately the profession faced its first legal challenge; in California Dagmar Nelson was charged with practicing medicine without a license. After a lengthy court battle, in 1934, the state Supreme Court ruled that nurse anaesthesia was not the illegal practice of medicine, and that anaesthesia performed by a nurse was nursing. This was only the first of many legal and political challenges faced by nurse anaesthetists, thus the need to Keep Vigil Over the Profession has always been present for them.
In an earlier report [1] we presented a grounded theory of nurse anaesthesia practice and its relationship to nursing and nursing knowledge: Keeping Vigil Over the Patient. In this paper we report findings related to the study question: How do certified registered nurse anaesthetists (CRNAs) manage the sociopolitical context in which they provide care for their patients?
Methods
We used grounded theory to explore CRNA practice. As a qualitative, systematic approach, grounded theory (GT) is often used to explore social processes in context. GT involves the iterative collection and analysis of data to formulate explanatory theories grounded in the world of participants [2]. GT was originally developed by Glaser and Strauss [3] and refined by others, including Glaser [4], Strauss [5], Strauss and Corbin [6], Schreiber and Stern [7], and Charmaz [8]. Because we were interested in the processes that CRNAs use as they enact their role, GT was the method of choice. We were influenced by Strauss [5,9] in our examination of the contextual influences on situated interaction and CRNA practice.
Consistent with GT methodology, we sought variation in data sources and participant experiences, using multiple techniques. First, we attended the 2006 meeting of the American Association of Nurse Anesthetists (AANA), where we conducted participant observation, used purposive and snowball sampling to recruit participants, conducted interviews (n = 18), gathered documents, and visited and examined the association's archives. We interviewed key informants about socio-political matters like regulatory and legal issues, scope of practice, billing and reimbursement. Scientific sessions, convention rituals, and mentoring relationships were observed. We also conducted e-mail and telephone follow-up to clarify issues. Theoretical sampling led us to conduct additional interviews with new informants. Most interviews were taped and transcribed verbatim; interviews not recorded were documented in field notes.
Participants' years of CRNA experience ranged from student through 40 years, and participants represented a minimum of 10 states; many had military experience, had worked in several states in both rural and urban settings, and some had worked in locum tenens positions. Eighteen of 41 participants were men.
Based on emerging theoretical concepts, we conducted a site visit to a small city in the American Northwest to explore the context of CRNA practice. We observed anaesthesia practice in an outpatient clinic and in two hospitals, visited an educational program and observed practicing CRNAs supervising students. We gathered data through document review, formal and informal interviews, and observations in clinical settings. Throughout the study we wrote or recorded field notes documenting our observations, interactions, and analytic ideas.
Data Analysis
Analysis began with entry to the field and continued concurrently with data collection. Throughout we met and discussed emerging findings and agreed on interpretations and memoing. We assigned increasingly abstract codes and compared incoming data to other data, to concepts, and to emerging categories. We constantly made comparisons among ideas about actions and interactions occurring in the data. Finally, we constructed a theory of nurse anaesthesia practice, Keeping Vigil comprising two major categories. Keeping Vigil Over the Patient, which theorizes nurse anaesthesia practice and is reported elsewhere [1] takes place within a larger sociopolitical context, Keeping Vigil Over the Profession, presented in this paper.
Rigour
We used widely accepted techniques to ensure rigour, including constant comparison, "negative" case analysis, participant checks, persistent observation, and prolonged engagement in the field [3,10]. We also used peer debriefing within a GT seminar [11]. We listened to the tapes repeatedly, while reading and re-reading the text. Selected participants reviewed the findings and provided feedback to ensure our interpretations were consistent with their experience and understanding.
Limitations
As in all qualitative research, findings cannot be generalized widely. However, if the findings fit in explaining other situations and circumstances, then they can be said to be theoretically generalizable [12,13]. Participants included only active members and employees of the AANA and it is unclear whether or how well these findings would explain the actions and interactions of non-active members or non-members. Yet, the AANA works to keep members actively informed and involved, and its membership includes an estimated 95% of nurse anesthetists in the country.
Ethical Considerations
The study was conducted in accordance with the Canadian Tri-Council [14] guidelines on human subject research, including informed consent. The study received approval of the Human Research Ethics Committee of the University of Victoria and the Board of Directors of AANA.
Results
In this paper we report on Keeping Vigil Over the Profession comprising three major contextual categories that influence how CRNAs Keep Vigil Over the Patient: Establishing Public Credibility, Political Vigilance, and Tending the Flock. To keep vigil over the patient, CRNAs must also keep vigil over the profession (see Figure 1). This vigilance operates in the background of CRNA practice and works to buffer it from ongoing threats. Participants are convinced that without such vigilance, the continuous political and legal challenges launched against them would whittle away at CRNA practice, imposing ever-increasing limits on their scope. This vigilance also operates internally within the professional organization, working to keep the membership informed, cohesive, and speaking with a unified voice.
thumbnailFigure 1. Keeping Vigil Over the Profession.
Establishing Public Credibility
A primary concern of Hodgins and her colleagues that continues today is the need to establish the credibility of the nurse anaesthesia role in the eyes of the public. CRNAs must not only practice safely, but they must be seen to be practicing safely. Thus, nurse anaesthetists needed to set a high standard and demonstrate the safety and worth of their practice. In practice, they also needed to establish themselves as trustworthy, safe providers of anaesthesia care. They did this by adopting a protected title for nurse anaesthetists, establishing standards of practice and a standardized curriculum, as well as personal-professional credibility.
Adopting a title
Early in its history (1956), AANA members adopted the title Certified Registered Nurse Anaesthetist, or CRNA. This title recognizes the national certification that was already established and enshrined the "nurse" part of nurse anaesthesia, which was and continues to be viewed by practitioners as the foundation and spiritual home of their practice. The following quote is a typical example of the commitment to nursing within CRNA practice and identity:
I think the reason why nurse anaesthesia is a nursing role is that we are able to combine all that good science stuff along with our nursing stuff. You have an opportunity to take care of someone who is in a huge anxiety part of their life and alleviate that anxiety through just touching them on the shoulder, touching them on the head, telling them "This will be OK, and I'm going to take really good care of you." And to me, that's nursing.
So strong is the commitment to nursing that an attempt at an AANA meeting to drop "nurse" from the title was widely defeated, which is notable in light of the fact that, although affiliated with universities, approximately 40% of CNRA educational programs are still housed outside schools or departments of nursing.
Identifying an agreed-upon title for the role allowed the professional association to mount public relations campaigns about the role and the title, and enabled them to create and distribute recruitment materials to attract students to the profession. By having a professional name that was recognized and accepted by all, the group prevented many of the nomenclature arguments and irregularities within nursing that have dogged the more recent development of the nurse practitioner (NP) role in Canada where there is no inter-provincial agreement on title and title protection NPs.
Developing practice standards
Similarly, formation of NANA/AANA created a forum and the means to develop practice standards and establish curricula. Creation and ongoing revision of standards of practice promoted a high quality of care and helped ensure the status of the CRNA role. It further allowed members to define for the public the nature of their care, as well as identify a level of excellence for CRNAs to achieve. CRNAs could enumerate their qualifications to those who might question their preparation to provide safe care.
In addition, NANA/AANA approved educational programs, and laid the groundwork for the accreditation and certification processes that continue today, although AANA no longer accredits nurse anaesthesia programs or certifies CRNAs. In 1975, as a result of challenges by the American Society of Anaesthesiology (ASA) to the U.S. Office of Education, the AANA relinquished these responsibilities to five independent Councils. Since 1975, the AANA has been the sole professional organization that represents all CRNAs in all situations public and private at both state and federal legislative levels. CRNAs could now point to these developments to demonstrate the rigour of their training and their high practice standards. This works today both at the individual level, in establishing personal-professional credibility with physicians, and within institutions and the nursing community. It also works at the state and national level, in lobbying for legislation and regulation that support a broad scope of CRNA practice.
Establishing educational programs
The creation and adoption of a standardized curriculum for preparation of nurse anaesthetists began in 1935, with a report from the AANA Education Committee. The report contained recommendations regarding subjects to be taught, hours of classroom and clinical instruction, and a minimum number of cases to be administered by the student to get a diploma. The AANA report served the same purpose that the 1910 Flexner Report did for physicians, using educational standards to position CRNAs and their practice in a politically advantageous place. To support members in meeting these educational requirements, AANA sponsored refresher courses between 1947 and 1951.
Over time, CRNA educational preparation has been increased. This began with requirements for specific program lengths, which kept expanding; however, it took a long time for CRNAs to agree on the need for baccalaureate or graduate education. For example, the "1985 Proposal" to mandate a minimum of baccalaureate preparation, failed at the AANA conference that year. Nonetheless, there was a general recognition of a need for degree level preparation, and in 1998 it became a requirement that CRNAs be prepared at the graduate (master's) level. Presently discussions are underway regarding doctoral preparation, in light of the American Association of Colleges of Nursing (AACN) plan to advance preparation for NPs (and CRNAs) to a clinical doctorate. There is ambivalence among CRNAs with respect to this proposal because some are concerned that the DNP (doctorate in nursing practice) appears to be more relevant to NPs and is not specific to CRNA needs. The debate is ongoing [15,16] although participants recognize the inevitability of a requirement for doctoral preparation and the importance of moving in parallel with other advanced practice nurses (APNs). Nonetheless, the AANA has issued a position statement that all CRNAs graduating in 2025 and beyond should be accredited at the doctoral level.
The idea of a DNP and other clinical doctorates arose from recognition of the importance of practice-based higher education in providing safe patient care. Admittedly, some would argue that the promotion of clinical doctorates for APNs is, in part, a political maneuver "which creates parity with other healthcare professionals" [15]. Yet, this reinforces the ongoing challenges experienced by CRNAs and their need for constant political vigilance.
Establishing personal-professional credibility
In tandem with the AANA's activities to establish and enhance the credibility of the profession, individual practitioners have credibility issues as well. In addressing their own personal-professional credibility, CRNAs reinforce the collective work to establish the credibility of the profession in the public eye. Many participants talked about the need to establish their own personal-professional credibility in their relationships with physicians, and the documentary record shows that this has long been the case [16,17]. The earliest CRNAs worked closely over long periods of time with a single physician who fully supported their development as nurse anaesthetists. Examples of this include Agatha Hodgins and Dr. George Crile at the Lakeside Hospital in Cleveland, or Alice Magaw and the Mayo brothers.
Participants described how they had to establish credibility when they encounter anaesthesiologists who are unfamiliar with, or resistant to, their practice or with CRNA practice in general. For these anaesthesiologists, seeing is believing, and credibility could only be achieved by the CRNA demonstrating competence and establishing a level of trust with medical staff, as described by this participant:
It takes time for them to have a level of trust. I think it all comes down to trust. And I don't think I could go into any practice and work with an anaesthesiologist without earning their respect and trust, and then it becomes more of a supportive type role.... What they say behind our backs? Probably what we say behind their backs, you know? There's good and there's bad and um, but I think it just comes down to earning respect and trust and I think it goes both ways.
This participant hints at the intricate relationship between CRNAs and anaesthesiologists, in that they intentionally focus on the well being of the patient and providing high quality care, which diffuses conflict in the operating room [18].
Maintaining Sociopolitical Vigilance
From the beginning, participants identified that CRNAs have faced ongoing challenges requiring constant vigilance of the socio-political context in which anaesthesia practice takes place. Maintaining socio-political vigilance includes two subcategories: monitoring challenges and politicking.
Monitoring challenges
The AANA and its members continuously scan the environment for threats to the profession. Our analysis of participants' descriptions revealed three related types of threats faced by CRNAs: challenges to professional autonomy, challenges to the scope of practice, and encroachment on their practice by others, notably the anaesthesia assistant (AA). Many threats have come from the ASA or their proxies, resulting in continuous lobbying and counter-lobbying by AANA and its members at the state and federal level over regulations and legislation related to CNRA autonomy, scope of practice, and reimbursement for services.
CRNA autonomy has been contested periodically in American courts, as physicians have repeatedly sued (largely unsuccessfully) CRNAs for practicing medicine without a license. Although there is growing recognition at the regulatory level that the nature of practice overlaps between and among health professions, there are ongoing attempts by anaesthesiologists to curtail autonomous CRNA practice by lobbying for supervisory requirements for state Medicare/Medicaid and third-party payers (private insurance companies). One participant spoke of the political landscape in her state as, "They [state medical association] have 20 lobbyists to our one. Big machine." Challenging autonomous practice via payment schemes is a common strategy to reach the same outcome through the back door, and such challenges are frequent. As one participant described this, "The only downside [to anaesthesia practice] is that it's so contentious. We have to fight for it all the time."
CRNAs also face challenges to their autonomy from hospital policies that require medical supervision of CRNA practice, regardless of the fact that there is no legislation requiring them to work under medical direction or supervision of an anaesthesiologist [19,20]. In teaching hospitals, the common practice is to have an anaesthesiologist "supervising" CRNAs and anaesthesia residents in two to four operating rooms. Often the anaesthesiologist's focus is on the practice of the residents, because the CRNAs are usually much more experienced and able to function by using the anaesthesiologist as a consultant, if at all. At the same time, this hierarchical arrangement appears as an optical illusion that somehow the anaesthesiologist is the "captain of the ship".
Related closely to threats to autonomy are local and national political struggles to safeguard the scope of practice and compensation [17]. Although the overall trend is toward fewer regulatory constraints to APN in the US [20], the medical establishment has successfully constrained the CRNA scope of practice in several states. For example, in some states CRNAs are unable to provide regional anaesthesia because of wording of the Medicare/Medicaid payment conditions. Interventional pain management by CRNAs, as might be provided in a pain clinic, is controversial, and in a state where medical organizations claim that it is solely the practice of medicine, CRNAs currently are restrained from performing certain pain management techniques. One participant explained:
The limits on CRNAs in Louisiana ... do not relate to Medicare/Medicaid billing. Rather, this was an outcome that emerged from dueling Board of Nursing and Board of Medicine positions and litigation that, unfortunately, did not end positively for the nurse anaesthetists ... it's clearly an aberration - at least to date - as no other state has yet adopted such a prohibition concerning nurse anaesthetists.
There are also states in which Medicare/Medicaid and/or third-party payers do not reimburse CRNAs at the same rate as anaesthesiologists performing the same service, and often there is no legal ban in place to forbid this practice.
At the same time CRNAs are also threatened by the encroachment of the anaesthesiologist assistant (AA) role. The AA role varies across the country, from that of the technician ensuring equipment and supplies are prepared for the day's surgeries to a "physician assistant specialist" [21], administering and monitoring anaesthesia under the direction of an anaesthesiologist. Currently, the AA role is regulated in a two states, although it exists under medical direction within hospitals, so it is difficult to estimate the number of recognized AAs practicing.
As can be seen, CRNAs face continuous threats to their profession. Both individually and collectively, they understand that their practice is contingent upon being able to identify, prevent, and address challenges to the profession.
Politicking
CRNAs recognize that they need to be effective in pushing back against possible impediments to the profession and the role. Nonetheless, as noted elsewhere [1], although the ASA and AANA are locked in conflict, CRNAs ensure that this conflict does not affect patient care. Given the nature and constancy of these threats, it has been necessary for CRNAs to be politically vigilant, acting jointly through the AANA, which works to keep its membership together and speaking with one voice. As a collective, AANA represents a critical mass of CRNAs, and has resources to provide its membership with the skills and key messages to be effective in promoting their profession. For example, the AANA has a branch office in Washington, DC, steps from the Capitol Building, where a full time professional lobbyist and up to six other staff monitor political happenings at the national and state levels. They prepare briefs and send out electronic updates and bulletins to the membership about matters such as progress of legislation, lobbying efforts and messages, and upcoming committee hearings. They also maintain a system to gather information about state and local initiatives with potential impact on practice, and to provide support and information to members to deal with these. Thus, mechanisms are in place and well practiced to launch public relations campaigns and counter-offensives as needed, which has enabled the group to speak with one voice, something they have continued to do over the years. To date, this has proven effective.
In addition to monitoring political developments, staff at the Washington, DC office also conducts an annual Assembly of States, a workshop aimed at providing participants with the skills needed to work effectively with the media and get their message across to the public in a clear manner. The workshop includes up to 10 participants per state, including state leadership and boards of directors. Over the course of a week, they learn about government, legislative initiatives, Medicare/Medicaid rules, the political process, and how to be useful to elected officials. The week culminates with groups of two to three participants going to the capital and meeting with their congressperson or senator, taking their key messages and practicing their new skills. Participants are then prepared to go back to their home states and become involved with promoting the profession at a political level. One CRNA noted the importance of this work:
That's one thing that's wonderful about the AANA. They try very hard to teach their people the political landscape and how to stay involved, because if you're not involved politically, others will legislate you out of business.
Thus, in these ways, CRNAs are able to protect their profession by Maintaining Political Vigilance. They are able to identify threats to their practice and work in a skilful way as individuals and as a collective to disarm challenges and promote the profession. With an estimated 65% of all anaesthesia given in the US administered by CRNAs, the results of their efforts are clear.
Tending the Flock
We were struck by the many ways in which CRNAs, individually and through AANA, attend to themselves and the collective membership. This is an empowered group of nurses, and the AANA conference was a stark contrast to the many other nursing conferences we have attended in Canada and the US. Because AANA represents virtually all CRNAs, and because threats to the profession are continuous, considerable effort is made to nurture and strengthen the group. This is done through two sub-processes, nurturing ourselves and celebrating traditions.
Nurturing ourselves
CRNAs nurture themselves by attending to their own health and the health and future of the profession. The health of AANA membership was a particular concern, and this was evident at the conference with early morning golf and walks, and a lifestyle booth with nutritional and other handouts, including a video on prevention and treatment of substance use. There was also a presentation on the high (10%) risk of substance use within anaesthesia practice (including both nurses and physicians), in which the presenter raised the issue of mandatory drug testing. One reason for the focus on substance use was the recent overdose death of a highly respected, much loved AANA president. This was not believed to be a planned suicide, but the result of an accidental overdose while self medicating. There was a general recognition that perfectionism and CRNAs' considerable knowledge of drugs could easily lead them to feel somewhat grandiose about their ability to handle drugs, as this participant explained:
So I can completely understand people saying, I know this drug, it can't happen to me, I know ... but um, it's very scary. And it's very sad and devastating and um, I just don't ever want to see any of my colleagues...and I know I will some day. I mean most of the senior people that I know, they all know people that it's happened to. So, I'm really hoping that can, the wellness initiative will really help our profession become stronger physically, mentally, spiritually, everything.
The forthrightness with which participants, both at the conference and during our site visit, talked about substance use was striking. We heard variations on this discussion throughout the study from many participants, some of whom were friends of the AANA president who died from an overdose.
CRNAs also nurture themselves through mentoring future generations of anaesthetists. Guiding students is a serious concern of CRNAs, and they talked with particular pride about this:
It's frequently mentioned that nurses eat their young and they do. They do. But nurse anaesthesia doesn't do that. We really... I don't think that you'll find anybody that says that we do. We really mentor because we have a nurse that we're mentoring to do what we do and that's different I think.
Participants were insistent that nurse anaesthesia instruction was qualitatively different than what medical residents receive, as these quotes demonstrate:
The difference between CRNA training and resident training is unbelievable, in terms of the mentoring and the attention. A resident gets...( ) ...give them a month one on one, month of July, one on one, whether it be with a senior resident or one of the CRNAs, one on one, and then you're [medical resident] out [on your own].
In fact, in my program, the residents told us that they felt we got better anaesthetic education, than they did because they were left to their own devices to educate themselves, whereas we were given formalized instruction and testing.
Participants emphasized that their tradition of mentoring students and monitoring their learning closely helped to prevent mistakes. In fact, CRNAs' malpractice costs have decreased by 42% in the past 18 years [16] and malpractice rates for CRNAs are reported to be lower than those of anaesthesiologists [22].
We observed a CRNA working with a student in difficulty, and saw her posing questions to help him focus on what was salient, asking, for example, "Given this patient's age and weight, where do you want to keep his BP?" In this way, she was asking the student to bring classroom learning into the practice arena while keeping an eye on the parameters she was willing to allow him.
Nurturing ourselves was also evident at the conference, where there were opportunities for CRNAs to sponsor students by paying their registration fees and bringing them along as shadows throughout the conference, introducing them to others and explaining what they were seeing. All CRNA programs require students to become associate members of the AANA, which allows them to become non-voting members of national and state committees, and further mentors them to become involved in the AANA when they graduate. Some programs pay students' AANA dues while they are in the program. During their programs, students are required to attend and participate in either national or regional/state meetings of AANA, and report back to their student colleagues. Students are encouraged to present posters at conferences, usually on their final research projects, and we observed many excellent examples. In addition, CRNAs are expected to be preceptors to students as part of their daily work and take this on willingly. In these ways, the fostering and guidance of students was a serious responsibility, and a part of Tending the Flock on which CRNAs took pride in themselves.
Celebrating traditions
CRNAs also Tended the Flock through the many traditions they celebrated. This was particularly evident at the 75th anniversary meeting of AANA's founding, where there was a Pioneer's Breakfast, a meeting of the history committee, and where the organization's archives were displayed. Each of these communicated the diverse and important CRNA traditions to the flock. There was considerable formality at the opening and closing ceremonies, much more than we were used to at Canadian events. For example, at these events, the officers and board members, formally dressed, were introduced to applause as they marched down a spotlighted aisle to the front podium. The happenings were all projected on giant screens. At the banquet, the persons accompanying these dignitaries (partners or family members of whatever gender or sex) were also introduced in this way. The events were thoroughly choreographed preventing awkward moments as people received various awards, shook hands, turned to be photographed, and returned to their places, all set to a trumpet fanfare. Those members in the military attended in full dress uniform, presenting a striking vision.
At the banquet, members were seated by state and as each state was called (with appropriate music and film footage on the big screens), members jumped up, waved their napkins, and loudly cheered themselves and their state(s). Some went to considerable effort to produce costumes to reinforce their various allegiances. It resembled a pep rally, with a roll call of states, territories, public health, and the military that took about an hour as a prelude to dinner. Throughout these events, there was a strong undercurrent of patriotism. In this way, there was serious intent along with an element of fun as these events unfolded, and these traditions fostered and strengthened bonds within the membership.
Discussion
In this report, we theorized the multi-level context of nurse anaesthesia practice in the US to provide an understanding of the significant contextual influences on practice. In a related article [1], we presented a substantive theory of CRNA practice, Keeping Vigil over the Patient. As qualitative researchers, we acknowledge these findings represent our interpretation of the data from the perspective of "outsiders"-- nurses who are not nurse anaesthetists. This may preclude a full understanding of CRNA practice and the influences on that practice as experienced by CRNAs. We believe, however, that we offer a useful perspective on one area of APN that has relevance to the broader profession. There is much we can learn from the way CRNAs in the US ensure safe and high quality care for their patients, manage the challenges to their professional autonomy, and promote and advance the wellbeing of their members.
What stood out for us were two of the three categories in Keeping Vigil over the Profession: Political Vigilance and Tending the Flock. The first category, Establishing Public Credibility was not new to us, nor is it new to APN. The processes of adopting a title, developing practice standards, developing regulatory and credentialing mechanisms, and establishing accredited educational programs are consistent with developments in the larger APN arena [23]. What is perhaps most noteworthy is that nurse anaesthesia was the first specialty group in nursing to do this [16]. Much of this development was related to challenges in establishing credibility with the medical profession and the public at large, but also with nursing colleagues. The relationship between CRNAs and the larger profession of nursing, primarily as represented by their professional associations (AANA and ANA), has not always been an easy one and tensions remain. There is, however, growing professional collaboration between these groups. For example, there is an increasing trend to house nurse anaesthesia programs in colleges or schools of nursing [16]. In the early years, when anaesthesia programs were introduced, there was often opposition to having these programs in university nursing schools.
The other observation we made is the explicit link between establishing personal-professional credibility and collective credibility for the profession at large. The personal really is political. Early CRNAs worked closely with pioneer surgeons to provide anaesthesia in ground-breaking cases, thereby giving them credibility to develop practice and educational standards [1,16,17]. CRNAs today, although not working solely with specific physicians, establish trust and credibility with surgeons and anaesthesiologists in practice, which confirms collective credibility. It is possible that the credibility of CRNAs and their record of safe and competent practice fuels opposition to the CRNA role by the ASA. This relationship between personal credibility and collective professional credibility has been noted in relation to the acceptance of other APN roles, particularly nurse practitioners [24,25].
The category of Political Vigilance was one of the findings that most impressed us, although this type of vigilance is not unique to CRNAs or the AANA. What is unique is the widespread acceptance of, and engagement in, political activities among CRNAs. In fact, political activism is a dominant value among nurse anaesthetists and CRNAs engage in political activities because it is among the "dominant rules of behaviour" [25]. What is important about this political activity is that it is not just about vigilance in defending the practice rights of the profession, but vigilance in patient care and safety. We have not seen the value for political activism reported elsewhere as being so explicitly a core value or as prevalent in practice among other nursing specialty or professional groups. The importance of political activism to nurse anaesthetists is also implicitly reflected in the Nurse Anaesthesia Practice Model [26], in which one of the essential professional values is a social one. Value is placed on enhancing and preserving the CRNA role in the health care system in society at large, on the legal responsibility for competent care, and on continuous improvement in standards of care, education, and collaboration.
The importance of political vigilance is evident in the successful countering of many court challenges brought against CRNAs over the years for practicing medicine without a license. We know that other advanced practice nurses have faced similar challenges but it seems that the frequency and intensity of challenges has been greater for CRNAs, particularly in the last two decades [27]. It is not just the legal challenges that require maintaining vigilance, but also the attacks against scope of practice at the policy and institutional level as well. In fact, our CRNA participants told us that the constraints that physicians attempt to impose on their practice are primarily at the policy level, but may relate to institutional, state or national policies.
We wonder if the intensity of the legal and policy constraints that anaesthesiology groups attempt to impose on CRNA practice relate to the extent of competition they perceive. Nurse practitioners often practice in settings and with populations that do not always place them in direct competition with physicians. The same is true for CRNAs working in rural settings, where they are the primary anaesthesia providers. However, when CRNAs work side by side with anaesthesiologists in cities, their scope of practice overlaps almost entirely. Because of this overlap, there exists the potential for CRNAs to replace anaesthesiologists. This has led to anaesthesiologists lobbying for the "team model" of practice in which an anaesthesiologist "supervises" CRNAs. Although supervision may be a myth at the practice level [28], it has been successful in sustaining physician incomes in the face of any competition. Despite the effort it takes the AANA to counter these policy constraints, the fact that they are not enshrined in legislation provides opportunities to lobby to support and advance CRNA practice. But, constant vigilance is needed.
The third category, Tending the Flock, was perhaps the most surprising and exciting finding in our study. We observed CRNAs to be an empowered group of nurses and their practices in nurturing themselves stood in stark contrast to our own experiences in nursing, and to our observations at professional meetings and conferences. Our participants talked extensively about working to mentor the next generation of practitioners, and their willingness to engage in this mentoring role. Our own experience has been that it is challenging to find practice opportunities for students and we often face unwillingness among some practitioners to take on a mentoring role, often because of challenges in the workplace. This did not appear to be the case among the CRNAs in this study.
The frequent comments by participants that CRNAs do not "eat their young" was particularly telling. We could not find anything in the literature suggesting that the kind of horizontal violence or bullying characterized by the ugly metaphor of "eating our young" was evident in CRNA practice. We found several recent articles about this phenomenon in perioperative nursing practice [29,30] and other areas of nursing [31-33]. The usual explanation for such behaviour lies in theories of oppression and feminism, and in particular, the theory of oppressed group behaviour, popularized in nursing by Roberts [34] and taken up by other authors [35-37]. Because nursing is largely a female profession, it is vulnerable to sex-role stereotyping and gender oppression [38]. Although Farrell [31,39] has challenged the reliance on theories of oppression as the primary explanation for horizontal violence, he and others provide evidence that intra-professional conflict and horizontal violence is common in nursing. That we did not find it in our study suggests that there are unique characteristics of CRNAs, their role, and the organizational arrangements within which they work that make this type of behaviour unlikely. We also explored the literature for evidence of horizontal oppression among other advanced practice roles and found that it was also limited [24]. The high degree of professional autonomy, the higher level of education, and the broad scope of responsibility and accountability of APNs may account for this. In addition, the fact that 46% of CRNAs in the US are men [40] may have changed intraprofessional dynamics such that the largely gendered aspect of horizontal violence in other areas of nursing is ameliorated in CRNA practice.
Conclusions
From our study of the context of nurse anaesthesia practice, it is clear that CRNAs are dedicated to protecting their ability to provide high quality patient care by maintaining constant vigilance over their profession. To do this, they actively engage in establishing their own personal credibility, as well as the credibility of the profession. They have a strong commitment to nurturing themselves and the next generation of CRNAs through Tending the Flock, which ensures strong and confident practitioners and a powerful professional association. Their commitment to political vigilance not only protects patients, but also ensures a place for CRNAs in the US health care system.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
Both authors participated in the conceptualization and design of the study and collected data in all its phases. RS conducted telephone interview and email exchanges to saturate the data set. Both authors participated in data analysis. RS prepared the first draft of the results section and MM prepared the first draft of the discussion. Both authors revised, edited, read and approved the final manuscript.
Acknowledgements
manuscript preparation. The authors further wish to acknowledge Dan Simonson, Betty Horton, Frank Maziarski and Frank Purcell for their insights.
References
Subscribe to:
Posts (Atom)