Chapter 2

Nurse Anesthesia Specialty Practice and Education in the United States

Francis Gerbasi, Betty Horton, Lisa J. Thiemann and John C. Preston

In existence for nearly 150 years, the specialty practice of nurse anesthesia has become one of the most challenging and rewarding areas of advanced nursing practice. Nurse anesthetists, together with their professional association, the American Association of Nurse Anesthetists (AANA), have been role models for members of other nursing groups and allied health organizations. This chapter describes current educational requirements to become a Certified Registered Nurse Anesthetist (CRNA), the roles of the CRNA, and the roles the councils and the AANA play for the profession.

Nurse Anesthesia Educational Requirements

The upgrading of academic credentials for CRNA educators and their graduates has always been closely tied to the goals of the professional association— advancing the art and science of anesthesia.¹ Nurse anesthesia leaders have been responsible for increasing the requirements for curricular content, faculty qualifications, and academic credentials for graduates since early in the twentieth century. Over time, nurse anesthesia programs have moved from apprenticeships at hospitals into degree-granting institutions fulfilling the vision of early anesthesia leaders for a university education for nurse anesthetists. This movement into academia required identifying the locations of programs in the nation, determining the essential characteristics of programs, agreeing on curricular requirements, inspecting programs, and developing a program approval process.

Nurse Anesthesia Education Today

Nurse anesthesia programs are governed by the Standards for Accreditation of Nurse Anesthesia Educational Programs.² The processes used to accredit programs are focused on ensuring compliance with the Standards and the Council on Accreditation of Nurse Anesthesia Educational Programs’ (COA) Accreditation Policies and Procedures.³ Revisions to the Standards and the accreditation policies occur periodically to ensure they continue to reflect the current requirements to prepare graduates for entry into practice, meet U.S. Department of Education (USDE) and the Council for Higher Education Accreditation (CHEA) recognition requirements and promote improvement in nurse anesthesia education.⁴ In 2011 the COA initiated a major revision of its standards with the purpose of establishing new practice doctorate standards. The new standards will be used by the COA to assess programs transitioning to award practice doctoral degrees. The COA requires all students accepted into an accredited nurse anesthesia program on January 1, 2022, and thereafter to graduate with doctoral degrees (refers to Standard III, Criterion C2).²

Nurse Anesthesia Program Requirements

Nurse anesthesia programs are required to demonstrate compliance with the Standards and the Accreditation Policies and Procedures. The requirements include the need for programs to assess their integrity and educational effectiveness through ongoing evaluation and assessment. Programs must continually monitor and evaluate their didactic and clinical curriculum, including, but not limited to, curricular content, admissions policies, faculty, and clinical sites used for student educational experiences. In addition to programs’ internal assessment processes, programs must submit annual reports to the COA, complete self-studies and host onsite COA visits at a maximum of every 10 years. The COA monitors programs’ indicators of success and the attainment of their stated outcomes. This includes programs’ pass rates on the National Board of Certification and Recertification for Nurse Anesthetists’ (NBCRNA) national certification examination (NCE). Programs must demonstrate graduates take the NCE examination and pass it in accordance with the COA’s pass-rate requirement.³ The COA also monitors programs’ attrition and employment rates. Programs are required to post their first-time NCE pass rates, attrition rates, and the employment rates of its graduates on their websites and to link their websites to the COA’s list of recognized programs.⁵ These stringent requirements help ensure the effectiveness of nurse anesthesia clinical and didactic education and also that the public is being provided with accurate information related to student achievement.

The COA has requirements related to the administration of nurse anesthesia programs. The requirements include programs’ management of faculty and students, fiscal management, maintenance of COA accreditation and other higher-education accreditation requirements of the universities, faculty continuing education, and program evaluations. The COA Standards require that nurse anesthesia programs employ Certified Registered Nurse Anesthetists (CRNAs) with graduate degrees in the roles of program administrator and assistant program administrator. In addition, programs must demonstrate they provide an extensive educationally sound curriculum combining both academic theory and clinical practice. Programs must develop and implement policies and procedures that use outcome criteria to promote student learning while simultaneously enhancing the programs’ quality and integrity.

The COA Standards also identify the minimum admission requirements. Admission to nurse anesthesia programs requires graduation from a school of nursing, a baccalaureate degree, current licensure as a registered nurse, and at least 1 year of professional experience in a critical care setting. The critical care experience must provide experiences for the registered nurse to develop as an independent decision maker capable of using and interpreting advanced monitoring techniques based on knowledge of physiologic and pharmacologic principles. Programs determine what types of work experience are acceptable for admission. Typical critical care areas include surgical, cardiothoracic, coronary, medical, pediatric, neurologic, and neonatal intensive care units.

Nurse Anesthesia Program Curriculum

The didactic curricula of nurse anesthesia programs are governed by the COA Standards and help ensure students are provided with the scientific, clinical, and professional foundation upon which to build sound and safe clinical practice. Based on the 2011 COA Annual Report data from all nurse anesthesia programs, the number of graduate semester credits for nurse anesthesia programs are greater than other graduate degrees in health professions.⁶ The curriculum of graduate nurse anesthesia programs includes courses in anatomy, advanced physiology/pathophysiology, advanced health assessment, advanced pharmacology, chemistry, biochemistry, physics, professional issues, equipment, technology, pain management, research, clinical conferences, chemical dependency, and wellness (refer to Standard III, Criterion C14 and C21).² Courses in nurse anesthesia practice provide content such as induction, maintenance, and emergence from anesthesia; airway management; anesthesia pharmacology; and anesthesia for special patient populations such as obstetrics, geriatrics, and pediatrics. In addition, students are instructed in the use of anesthesia machines and other related biomedical monitoring equipment. Programs must evaluate students’ knowledge and skills to ensure they are meeting the programs’ stated objectives as they progress in the program.

The methods used to deliver nurse anesthesia curricula are changing as new technologies are being applied in higher education. Based on COA 2011 Annual Report data, more than 60% of nurse anesthesia programs use some form of distance education in their provision of didactic instruction.⁶ Programs’ distance education offerings vary from several core courses to programs in which the majority of the didactic curriculum is provided using distance education. In addition, 98% of programs report having access to some form of simulation (e.g., simple models, computer, full-body patient simulation).⁶ The involvement of individual programs ranges from the use of simulation to supplement traditional content delivery methods to the utilization of simulation to entirely deliver curricular content.

The clinical curriculum of nurse anesthesia education provides students with an opportunity to apply didactic knowledge in clinical practice. Programs prepare graduates with the knowledge and skills to administer all types of anesthesia, including general, regional, and selected local and moderate sedation to patients of all ages for all types of surgeries. Students use a variety of anesthesia drugs, manage fluid and blood replacement therapy, and interpret data from sophisticated monitoring devices. Additional clinical responsibilities include the insertion of invasive catheters, the recognition and correction of complications that occur during the course of an anesthetic, the provision of airway and ventilatory support during resuscitation, and pain management. To meet COA Standards and be eligible to take the NCE, a student must have performed a minimum of 550 anesthetics, which must include specialties such as pediatric, obstetric, cardiothoracic, and neurosurgical anesthesia.² The anesthesia experiences include the care of not only healthy but critically ill patients of all ages for elective and emergency procedures. In most programs, the minimum number of clinical experiences is surpassed early in the clinical practicum. Based on 2011 certification transcript data, nurse anesthesia programs provide an average of 846 cases, 1683 hours of anesthesia clinical experience, and 2519 total clinical hours for each student.⁷

During students’ clinical experiences, they must be supervised by CRNAs or anesthesiologists who provide instruction in the administration and monitoring of various techniques, including both general and regional anesthesia. The clinical faculty evaluates the technical and critical thinking skills of students. The entry into practice competencies for the nurse anesthesia professional are those required at the time of graduation to provide safe, competent, and ethical anesthesia care to patients for diagnostic, therapeutic, and surgical procedures (refer to Standard III, Criterion C21).²

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