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?
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.
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.
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.
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  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?
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 . GT was originally developed by Glaser and Strauss  and refined by others, including Glaser , Strauss , Strauss and Corbin , Schreiber and Stern , and Charmaz . 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.
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  takes place within a larger sociopolitical context, Keeping Vigil Over the Profession, presented in this paper.
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 . 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.
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.