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Introduction

This document has been prepared by the American Association of Nurse Anesthetists (AANA) to provide information about the qualifications and capabilities of Certified Registered Nurse Anesthetists (CRNAs). As one of the first nursing specialty groups, Certified Registered Nurse Anesthetists represent a longstanding commitment to high standards in a demanding field. They provide one-on-one care to their patients before, during and after the operation by delivering quality anesthesia services for surgical and obstetrical procedures, combined with a personal concern for the health and welfare of the individual.

A Certified Registered Nurse Anesthetist (CRNA) must:

1. Graduate from an approved school of nursing and hold current state licensure as a registered nurse.

2. Graduate from a nurse anesthesia educational program accredited by the AANA Council on Accreditation of Nurse Anesthesia Educational Programs or its predecessor.

3. Successfully complete the certification examination administered by the AANA Council on Certification of Nurse Anesthetists or its predecessor.

4. Comply with criteria for biennial recertification as defined by the AANA Council on Recertification of Nurse Anesthetists. These criteria include evidence of (a) current licensure as a registered nurse, (b) active practice as a CRNA, (c) appropriate continuing education and (d) verification of the absence of mental, physical and other problems which could interfere with the practice of anesthesia.

5. Comply with the state requirements in those states regulating the advanced practice of nursing.

The AANA, since its organization in 1931, has placed its responsibilities to the public above or equal to its responsibilities to its membership. The association has produced educational and practice standards, implemented a certification process for nurse anesthetists in 1945 and developed an accreditation program for nurse anesthesia education in 1952. The AANA was a leader in forming multidisciplinary councils with public representation to fulfill the profession's autonomous credentialing functions.

Over 20,000 CRNAs provide quality anesthesia care to more than 65% of all patients undergoing surgical or other medical intervention which necessitates the services of an anesthetist. In addition, CRNAs administer anesthesia for all types of surgical cases, from the simplest to the most complex. CRNAs are the sole anesthesia providers in approximately 33% of hospitals in the United States. Of the 24 million anesthetics administered annually, approximately 20% are administered by CRNAs working alone, 50% are administered by CRNAs collaborating with physician anesthesiologists, and 30% are administered by anesthesiologists alone or with residents or anesthesia assistants.

Anesthesia practice is based on a substantial and credible foundation of academic theory and clinical practice, enabling the CRNA to individualize anesthesia care for each patient. As independently licensed health professionals, CRNAs are responsible and accountable for their professional acts.

Education of Nurse Anesthetists

Nurse anesthesia educational programs are a minimum of 24 months in length. These programs provide an educationally sound curriculum combining theory and clinical practice. Students are given the opportunity to integrate classroom content with direct application of state-of-the-art techniques in the provision of anesthesia care to all patient populations in all risk categories. The education of nurse anesthetists also includes experiences in the management of respiratory care and emergency resuscitation of patients in intensive care units, postanesthesia care units and other acute care areas.

Academic Curriculum Requirements

Minimum academic curriculum requirements for nurse anesthesia programs are as follows:

• Professional Aspects of Nurse Anesthesia Practice, 45 hours or 4.5 quarter hours

• Advanced Anatomy, Physiology and Pathophysiology, 135 hours or 13.5 quarter hours

• Chemistry and Physics Related to Anesthesia, 60 hours or 6.0 quarter hours

• Advanced Pharmacology, 75 hours or 7.5 quarter hours

• Principles of Anesthesia Practice, 75 hours or 7.5 quarter hours

• Clinical and Literature Review Conferences, 35 hours or 3.5 quarter hours

Most programs exceed these minimum requirements. In addition, many require study in methods of scientific inquiry and statistics and active participation in studentgenerated and faculty-sponsored research.

Clinical Curriculum Requirements

The clinical component of the nurse anesthesia educational program mandates that each student administer a minimum of 450 anesthetics to patients, representing at least 800 hours of anesthesia time. To meet this requirement, students provide these services under the supervision of qualified clinical instructors, which include CRNAs or anesthesiologists.

These requirements further specify that each student's anesthesia experiences will include (1) the major anesthetic techniques and monitoring modalities in current use, (2) patients of all ages from birth through senescence and (3) patients whose concomitant medical interventions are representative of the broad spectrum of medical specialty procedures utilized today. Most of the accredited nurse anesthesia educational programs far exceed these minimum requirements.

Admission Prerequisites

Admission to nurse anesthesia educational programs requires graduation from an approved school of nursing, a BSN or other appropriate bachelor's degree, current licensure as a registered professional nurse and a minimum of 1 year of professional nursing experience in an acute care setting.

Most applicants have acquired extensive clinical backgrounds as professional nurses in such settings as coronary, respiratory, postanesthesia and surgical intensive care units, emergency rooms or as members of a trauma or cardiac surgical team. Thus, applicants to nurse anesthesia programs have demonstrated a high level of clinical competence as licensed professional nurses by incorporating theory into clinical decision making and clinical skills in the provision of direct patient care.

Total Educational Sequence

The current educational sequence for CRNAs is as follows: A bachelor's degree, licensure as a registered nurse, a minimum of 1 year of professional nursing experience in an acute care setting and a minimum of 24 months in an accredited nurse anesthesia educational program. The extension of programs beyond 24 months in length relates principally to the graduate academic requirements for research and completion of a project or thesis. Nurse anesthesia educational programs exist either in a certificate or master's degree framework. Since nurse anesthesia is built on a professional nursing and basic science foundation, the minimum time sequence required to qualify as a CRNA is 7 years from college entrance. The profession has demonstrated its commitment to graduate education, with more than half of all its programs offering a master's degree.

Faculty

Faculty for nurse anesthesia educational programs are multidisciplinary in character and are composed of CRNAs, anesthesiologists, graduate nursing faculty, specialty physicians and other graduate faculty in basic, medical and social sciences. Each faculty member must be qualified by education and experience to meet specific educational objectives. CRNA program directors must possess a minimum of a master's degree.

A large number of CRNA faculty members have earned doctoral degrees in nursing, basic sciences, education or administration. Many hold university undergraduate or graduate faculty appointments throughout the country and regularly participate in governing mechanisms, research and inter- and i ntrad iscipli nary academic affairs. In addition to their responsibilities for nurse anesthesia students, CRNA faculty members take part in the academic and clinical instruction of students from a variety of disciplines, including physician and dental trainees.

The AANA Education Committee reviews and recommends standards for education of nurse anesthetists to the AANA Council on Accreditation of Nurse Anesthesia Educational Program. The Committee facilitates the growth of existing and the start of new nurse anesthesia educational programs through sponsorship of the Assembly of School Faculty and Faculty Development Workshops.

On a national level, the AANA Assembly of School Faculty convenes twice a year to discuss educational issues. This collegial body, composed of the community of interest-CRNAs, anesthesiologists, educators, administrators and representatives from the AANA and AANA councils on accreditation, certification, recertification and public interest-assures participation and input by all individuals concerned with nurse anesthesia education.

Accreditation of Nurse Anesthesia Educational Programs

The AANA Council on Accreditation of Nurse Anesthesia Educational Programs is recognized by the United States Department of Education and the Council on Post-Secondary Education Accreditation (COPA) as the accrediting agency for nurse anesthesia programs. This council provides for systematic self-study and on-site evaluation of all nurse anesthesia educational programs. The Council on Accreditation publishes a list of accredited nurse anesthesia educational programs twice a year.

Certification of Nurse Anesthetists

The AANA Council on Certification of Nurse Anesthetists is the certifying body and conducts the national certification examination. Each graduate of a nurse anesthesia program must successfully pass the national certification examination before he or she can be credentialed as a CRNA.

Recertification of Nurse Anesthetists

For recertification, mandatory continuing education (CE) is required of CRNAs on a biennial basis. The recertification program is administered by the AANA Council on Recertification of Nurse Anesthetists. This council reviews CRNA qualifications with reference to (a) current licensure as a registered nurse, (b) active practice as a CRNA, (c) continuing education (40 contact hours of approved CE) and (d) verification of the absence of mental, physical and other problems which could interfere with the practice of anesthesia.

Publications

CRNAs have authored numerous book chapters, monographs and articles on clinical, educational and research subjects in a variety of refereed professional journals such as AANA Journal, Anesthesiology, Anesthesia and Analgesia, Journal of the American Society of Regional Anesthesia, Journal of the American Medical Association, Nursing Research, Hospitals, etc. The first noted articles by nurse anesthetists appeared in the Northwestern Lancet in 1899, the St. Paul Medical Journal in 1900 and in Surgery, Gynecology and Obstetrics in 1906. Contributions to the AANA Journal are reviewed by an intradisciplinary editorial board for appropriate content and quality of presentation. The AANA Journal seeks quality contributions on anesthesia and related issues from CRNAs, physicians and other appropriate professionals.

Research

Nurse anesthetists have been involved as collabora tors, consultants, assistants, interpreters and utilizers of research findings since the turn of the century. Early studies usually were confined to descriptive methodo logies, with the findings published in medical or nursing journals. In more recent years, many CRNAs have utiliz ed experimental designs and expanded their research activities into the area of basic science. The movement of nurse anesthesia educational programs into graduate educational frameworks has allowed students to Int graduate with basic skills for undertaking research. In addition, there is a growing number of CRNA faculty, credentialed at the graduate level, who regularly sponsor and consult in research endeavors and act as project directors for funded research in university settings.

At the AANA Annual Meeting, educational sessions are conducted in research methodology and grantsmanship. The AANA also sponsors a "Research in Action" session at its annual meeting for presentation of research papers. In addition, CRNAs have reported on their research at a variety of national and international meetings, including those sponsored by nurses, physicians, physiologists and pharmacologists. Research by CRNAs has been funded by private and governmental grants, including some from the AANA Education and Research Foundation.

Clinical Practice

Professional certification attests to individual competence in a specialty area based on fulfillment of prescribed criteria. Such credentials should afford the public an awareness of the qualifications and capabilities of its health care providers. The title of Certified Registered Nurse Anesthetist (CRNA) signifies that the individual meets the prescribed criteria and is qualified to provide the following services in a competent and compassionate manner.

Preanesthesia Preparation

The preanesthesia evaluation of patients is vital in the preparation of patients for anesthesia and for developing individualized anesthesia care plans. The CRNA is competent to:

1. Collect a health history and perform a physical examination appropriate to anesthesia practice.

2. Request and interpret the results of diagnostic laboratory tests including complete blood counts, urinalysis, blood gases, electrolytes, enzymes, digoxin levels and pulmonary function tests.

3. Assess and implement appropriate treatment for such problems as pulmonary insufficiency and fluid and electrolyte imbalance which require improvement or correction prior to anesthesia.

4. Evaluate the anesthetic risk of the patient, including making decisions regarding the patient's fitness for anesthesia at the proposed time.

5. Develop an anesthesia care plan and coordinate it with the planned diagnostic or therapeutic intervention.

6. Select premedications and evening sedation and/or make decisions to withhold certain medications.

7. Obtain an informed consent for anesthesia and establish a personal rapport with the patient to dispel fear and anxiety.

Intraoperative Care

The intraoperative care of the patient by CRNAs involves services provided which create an optimal environment for the proposed medical intervention. This includes making the patient insensitive to pain, with or without unconsciousness, as may be required for the procedure or as desired by the patient. It also includes maintaining vital physiologic functions within appropriate ranges for the patient's well-being. To achieve this, the CRNA is competent to:

1. Implement the anesthesia care plan based on the preoperative evaluation and other patient considerations, utilizing a variety of general or regional anesthetic techniques as may be desirable.

2. Manage fluid therapy and blood replacement, identifying and correcting volume, electrolyte or coagulation abnormalities.

3. Obtain arterial blood samples and interpret blood gas analyses to evaluate respiratory and metabolic status.

4. Recognize cardiac dysrhythmias and implement appropriate interventions.

5. Use and interpret both simple and sophisticated monitoring modalities.

6. Recognize abnormal patient responses to anesthesia, surgery and/or adjunctive medication and implement corrective actions as may be appropriate.

Postoperative Care of Patients

The CRNA is qualified and competent to provide the following services during the postoperative period:

1. Evaluate and treat patients for anesthesia-related problems or complications, collaborating as necessary with physicians and other nurses involved in the patient's care.

2. Provide consultation upon request by physicians or other health care providers pertaining to postoperative analgesic, antiemetics, fluid and electrolytes and cardiovascular and respiratory homeostasis.

3. Release patients from postanesthesia care units in accordance with pre-established criteria.

Subspecialization

Some CRNAs have chosen to specialize in pediatrics, obstetrics, cardiovascular, plastic, dental or neurosurgical anesthesia. In addition, some CRNAs also hold credentials in other fields such as critical care nursing and respiratory care. In addition to the American Association of Nurse Anesthetists, many CRNAs hold membership in a variety of anesthesia and subspecialty organizations, including the following:

• International Anesthesia Research Society

• Society of Neurosurgical Anesthesia and Neurologic Supportive Care

• American Society of Regional Anesthesia

• American Association of Critical Care Nurses

• American Society of Post-Anesthesia Nurses

• Association of Operating Room Nurses

• American Association of Respiratory Care

Activities Outside the Operating Room

CRNAs are consulted on a 24-hour basis and are an integral part of the health care team, lending their expertise in airway management, respiratory care, fluid and electrolyte problems, resuscitative efforts and other related clinical activities. Many CRNAs are certified by the American Heart Association as Advanced Cardiac Life Support (ACLS) providers, as well as ACLS instructors.

Nurse anesthesia education provides CRNAs with the theoretical base to participate in pain management. Many CRNAs are involved in the administration of regional nerve blocks to assist physicians in diagnosing neurological deficits and/or in modifying pain. Pain management is an expanding area of nurse anesthesia practice and research.

CRNAs serve on a variety of institutional committees and participate as instructors in staff development and continuing education programs for both professional and non-professional staff members.

CRNAs hold staff and committee appointments with state and federal government agencies such as state boards of nursing and the U.S. Food and Drug Administration. CRNAs also are actively involved in standard setting organizations such as the American National Standards Institute and the National Fire Protection Association.

Administrative Role

Current data indicate that more than 6,000 CRNAs perform administrative functions for departments of anesthesia. The services provided by these department heads are extremely important to the overall functioning of an anesthesia department and correlate directly with the efficiency and quality of service provided. These functions include department management, quality assurance, risk management, continuing education, data and fiscal management.

The Interdependent Nature of Anesthesia Care

Anesthesia care is provided in conjunction with other types of health care. CRNAs work in a variety of practice situations as employees of hospitals, as employees of physicians or physician groups and as private practitioners -individually or in groups.

Regardless of the practice setting, CRNAs collaborate with anesthesiologists, surgeons, obstetricians, dentists and/or other medical, nursing and allied health professionals who may be involved in the care of individuals requiring anesthesia services. Such collaboration and integration can assure patients that their various health care providers are committed to excellence in health care.