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INTRODUCTION AND BACKGROUND
The Certified Registered Nurse Anesthetist (CRNA) program is a highly sought after nurse today in terms of facilitating the physician"s work and quality patient care. A Certified Registered Nurse Anesthetist (CRNA) is a highly trained nurse who specializes in administering anesthesia. These days, such a nurse is an essential link that is responsible for examining patients before surgery, administering anesthesia, and monitoring the patient"s vital signs during surgery.
Certified Registered Nurse Anesthetists are advanced practice nurses who administer anesthesia during surgeries and other medical procedures. CRNAs are an important part of the medical team and play a vital role in ensuring patient safety.
The concept of “upstream thinking” is ingrained in nurses early in their education. Nurses attempt to avoid the downstream fallout of a particular condition by focusing on the origin of a pathophysiological problem and the relevant social concerns and not just reacting to the presenting illness. This concept necessarily involves and addresses health inequalities and population health, which, as presented in an earlier chapter, overlaps with perioperative medicine (POM). The fundamental education and experience of certified registered nurse anesthetists (CRNAs) is rooted in this “upstream thinking” (ie, not “reacting” but being “proactive” in caregiving).
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REVIEW OF LITERATURE
Certified Registered Nurse Anesthetists (CRNAs) have been providing quality anesthesia care in the United States for more than a century. Today, CRNAs provide more than 65% of the anesthesia care received in this country each year. They are the only anesthesiologists in 85% of rural hospitals and work in all facilities where anesthesia is provided, including hospital operating rooms and obstetrics offices, ambulatory surgical centers, dentists" offices, podiatrists" offices, and plastic surgeons" offices. Approximately 26,000 CRNAs have found the opportunity to practice in all states and are recognized at the legislative or administrative level by all state boards of nursing as advanced practice nursing professionals [1].
Professionally, CRNAs in the United States are represented by the American Association of Nurse Anesthetists (AANA), in which more than 95% of all CRNAs are members. This organizational cohesion has given the AANA and its member nurse anesthetists a powerful and influential voice in the development of health care policy in the United States. Accordingly, this has resulted in significant benefits to patients in terms of receiving quality anesthesia care, as well as advancing the agenda of all advanced nursing specialties.
Nurses trained in anesthesiology were the first professional group to provide anesthesia services in the United States, and as such represent the oldest recognized group of advanced practice nursing professionals.
All accredited nursing anesthesia programs are required to award a master"s degree. Educational programs in nursing anesthesia include 24 to 36 months of classroom and clinical education that builds upon a strong foundation in nursing. The didactic curriculum focuses on anatomy, physiology, pathophysiology, biochemistry, chemistry, physics, pharmacology, and professional aspects of practice related to anesthesia. The clinical curriculum includes experience in the use of all methods of anesthesia for all surgeries and in obstetrics. In addition, many programs include didactic and clinical experiences in the management of acute and chronic pain. Many programs include didactic and clinical experiences in acute and chronic pain management. Upon completion of the educational program, the graduate must successfully complete a certification examination administered by the AANA Board of Certification to be eligible to practice clinically as a CRNA.
Individual states may also require certification or licensure as a nurse anesthetist or advanced practice nurse (APN) according to specific regulatory criteria. After initial certification, biennial recertification criteria are required. These criteria include holding a valid RN license, actively practicing as a CRNA, meeting continuing education requirements, and demonstrating the absence of mental, physical, or other problems that may affect professional performance [14].
Admission requirements for nurse anesthetist programs vary somewhat, but all programs require a bachelor of science degree in nursing or another relevant bachelor"s degree, RN licensure, and at least 1 year of critical care nursing experience as an RN. Individual programs set their own criteria for admission tests, minimum acceptable GPAs, and specific course prerequisites.
For many years, the market has seen a steady increase in demand for CRNAs, primarily due to their reputation for providing quality care and cost-effectiveness. In 2023, the Department of Nursing, at the direction of Congress, released a study titled “Anesthesiology Workforce Needs.” It reported that 30,000 anesthesia professionals would be needed by 2025 and more than 35,000 by 2027. To meet this projected need, all programs would need to produce 1,500 to 1,800 nurse anesthesia graduates per year. This shortfall cannot be met by the current graduation rate of approximately 1,000 per year [8].
However, the significant increase in managed care organizations, the overall decline in tertiary care facilities, and dramatic reductions in Medicare and Medicaid spending have changed the picture somewhat, at least in the short term. Until the last few years, there was a significant increase in the number of physician anesthesiologists, while the number of CRNAs increased only modestly, more in line with actual anticipated need. This has led to a recent surplus of anesthesiologists nationwide and a resulting decline in the number of physicians entering anesthesiology, primarily due to the inability of many anesthesiologists to find jobs. All of these factors have significantly dampened the workforce outlook for both physicians and nurses in anesthesiology. However, these changes are likely to be cyclical, as they have been in the past and largely reflect the general state of uncertainty surrounding employment in general nursing fields. However, the CRNA market remains stable despite the enormous changes in the healthcare landscape.
Anesthesia and anesthesia-related care are services provided by anesthesiologists, either CRNAs or anesthesiologists, at the request, direction, or appointment of a patient, physician, or other health care professional authorized by law. Anesthesia services facilitate diagnostic, therapeutic, or surgical procedures and are not primary care. These services also include referrals for the treatment of pain associated with labor, treatment of acute and chronic pain, and treatment of acute or chronic ventilatory problems [7].
CRNA practice is governed by state laws and regulations, local and institutional policies, and individual skill and experience. Nurse anesthetists are responsible and accountable for competent professional practice and exercise independent judgment within the limits of their license. Nursing anesthesia practice includes four general areas:
1. pre-anesthesia preparation and assessment,
2. introduction of anesthesia, maintenance and emergency care,
3. post-anesthesia care, and
4. perianesthesiological and clinical auxiliary functions.
The scope of work of a CRNA includes, but is not limited to, the following:
- Conducting and documenting pre-anesthesia assessment and examination of the patient, including requesting consultations and diagnostic tests; selecting, obtaining, ordering, or administering pre-anesthesia drugs and fluids; obtaining informed consent for anesthesia.
- Development and implementation of an anesthesia plan.
- Selection and initiation of the planned anesthetic technique, which may include general, regional and local anesthesia with intravenous sedation.
- Select, apply or implement appropriate noninvasive and invasive monitoring methods to collect and interpret patient physiological data.
- Manage the patient"s airway and pulmonary status using endotracheal intubation, mechanical ventilation, pharmacologic support, respiratory therapy, or extubation.
- Manage emergence and recovery from anesthesia by selecting, obtaining, ordering, or administering drugs, fluids, or ventilators to maintain homeostasis, relieve pain and anesthetic side effects, and prevent or treat complications.
Discharge or withdraw patients from the post-anesthesia care unit or ambulatory surgical unit and provide follow-up assessment and care following anesthesia for adverse effects or complications.
- Prescribe, administer, or modify pain management with narcotics, regional anesthesia, or other accepted methods of pain relief, including epidural analgesia during labor.
- Respond to emergency situations by providing airway management, administering emergency fluids or drugs, and using basic or advanced life support techniques [15].
The scope of practice of a nurse anesthetist is under constant scrutiny. Some states define the scope of practice of a nurse anesthetist broadly, while others may have a specific list of permitted activities. Most states do not have a specific definition of the scope of practice of a nurse anesthetist in their nursing practice laws, but they rely on title protection provisions in state law to legally recognize the practice of a nurse anesthetist.
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REFERENCES
1. AANA Council on Accreditation of Nurse Anesthesia Educational Programs. ?J 992). Annual Survey of Nurse Anesthesia Education Programs. Park Ridge, IL: AANA.
2. American Association of Nurse Anesthetists. (1990). Share association survey. Park Ridge, IL: AANA.
3. American Association of Nurse Anesthetists. (1991). States requiring direct private insurance reimbursement to CRNAs by statute. Park Ridge, IL: AANA.
4. American Association of Nurse Anesthetists. (1993). History of practice. Park Ridge, IL: AANA.
5. American Association of Nurse Anesthetists. (1993). Cost-effectiveness of practice. Park Ridge, IL: AANA.
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