research paper on nurse anesthetist

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• Nagoya J Med Sci
• v.83(3); 2021 Aug

Certified registered nurse anesthetist and anesthesiologist assistant education programs in the United States

Takahiro tamura.

1 Department of Anesthesiology, Nagoya University Graduate School of Medicine, Nagoya, Japan

2 Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA

Tetsuro Sakai

Richard henker.

3 Department of Nurse Anesthesia, University of Pittsburgh School of Nursing, Pittsburgh, USA

John M. O’Donnell

Department of Anesthesiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-Ku, Nagoya 466-8550, Japan

Tel: +81-52-744-2340, Fax: +81-52-744-2342, E-mail: [email protected]

In Japan, a relative shortage of practicing anesthesiologists continues to be a national issue. To address this issue, some Japanese medical institutions have started developing curriculums to train non-physician perioperative anesthesia personnel, including nurse practitioners and perianesthesia nurses. We urgently need to establish a national standard for the education programs that train these extended non-physician anesthesia care providers. A certified registered nurse anesthetist educational program at a large academic medical center in the United States is described in detail as a reference. Highly systematic educational programs using simulation, didactics, and full clinical subspecialty rotations are ideal if not easily achievable in many current training institutions in Japan. Anesthesia assistant education programs in the United States can be used as an additional reference to create a national educational program in Japan.

INTRODUCTION

In Japan, a relative shortage of practicing anesthesiologists continues to be a national issue. The number of physician anesthesia providers in Japan reported by the World Federation of Societies of Anesthesiology (2019) is 12,208, or 9.64 per 100,000. This sharply contrasts with the 67,000 physicians or 20.82 per 100,000 giving anesthesia in the US. Other than physicians, 57,000 nurse anesthetists provide anesthesia care in the US. Certified registered nurse anesthetists (CRNAs) and anesthesiologist assistants (AAs) perform tasks under physician anesthesiologists’ supervision. In some areas in the US, CRNAs can provide anesthesia independently; for instance, most anesthetics in rural areas are provided by nurse anesthetists.

In Japan, the shortage of anesthesia providers often results in the cancellation of scheduled surgeries and prolonged working hours for anesthesiologists. In recent years, with advances in medical care and technology, the average human life expectancy (currently 84.2 years) has been gradually increasing. 1 Also, the number of surgeries is progressively growing due to the expansion of various new operations and surgical indications. In addition to providing surgical anesthesia, anesthesiologists’ range of activities is expected to be further broadened by expanding the field of anesthesia to focus on ensuring the safety and security of patients. This widened range of activities includes preoperative outpatient care, postoperative pain management, and sedation outside the operating room. In Japan, there are instances when surgeons have to manage the anesthesia care of their surgical patients themselves due to the shortage of anesthesiologists. Hospitals often have to hire locum tenens anesthesiologists to meet the demand for surgical cases. These conditions are certainly not ideal for the safety of surgical patients and the stability of hospital finances.

To address this issue, five Japanese medical institutions have started developing curriculums to train non-physician perioperative anesthesia personnel, including nurse practitioners and perianesthesia nurses. 2 , 3 National standards for nurse anesthetist and anesthesiology assistant education programs need to be developed in Japan to provide consistent and safe anesthesia care.

We describe herein CRNA and AA educational programs 4 at a large academic medical center in the US as references.

Certified Registered Nurse Anesthetists

The discipline of nurse anesthesia was developed in the late 1800s. Sister Mary Bernard was the first nurse to specialize in nurse anesthesia at St. Vincent Hospital in Erie, Pennsylvania, in 1877. 5 As few physicians focused their attention on anesthesia, nurse anesthetists learned anesthesia from surgeons and their own experiences. During World War I, they performed anesthesia for many wounded patients. The first formal nurse anesthesia educational program was established at St. Vincent Hospital (Erie, Pennsylvania, USA) in 1909. The title “certified registered nurse anesthetist (CRNA)” was first introduced in 1956. CRNAs can perform tasks under the supervision of physicians as well as independently depending on State regulations. The National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA) administers the certification examination for nurse anesthetist trainees. The University of Pittsburgh School of Nursing Nurse Anesthesia Program partners to offer the program with the University of Pittsburgh Medical Center (UPMC). The current nurse anesthesia program’s foundations can be traced to the individual training programs in the late 1950s at Presbyterian and Montefiore University Hospitals in Pittsburgh. These two hospital programs merged in 1972, and the Nurse Anesthesia Program is now in the Department of Nurse Anesthesia at the University of Pittsburgh School of Nursing. Fortunately, the University of Pittsburgh Nurse Anesthesia Program was ranked #4 in the US News & World Report rankings of Best Nursing Graduate Program since 2016, with the overall Doctor of Nursing Practice program ranking #9 in the United States in 2019. 6 The University of Pittsburgh Nurse Anesthesia Program has been ranked in the top 10 by US News & World Report since 1998.

The Mission of the University of Pittsburgh Nurse Anesthesia Program

The primary purpose of the Nurse Anesthesia Program in the University of Pittsburgh School of Nursing is to educate registered nurses in both the science and art of anesthesia so that they will become efficient and skilled in utilizing various techniques of anesthesia intelligently, scientifically, and safely ( Table 1 ). In addition to practicing skills, graduates gain research and scholarship skills that provide a foundation for future work as doctorally prepared Nurse Anesthetists. The program’s graduate standards are shown in Table 2 .

Program Mission

Graduate Standards for the University of Pittsburgh Nurse Anesthesia BSN to DNP Program

Nurse Anesthesia Program Curriculum at the University of Pittsburgh School of Nursing

Nurse anesthesia practice covers the continuum of care from preoperative assessment to discharge from the post-anesthesia care unit. Nurse anesthetists interview and assess each patient to best formulate and implement an individualized plan of care while collaborating with members of a multi-disciplinary health care team. The rigorous curriculum features courses addressing the chemistry and physics of anesthesia, evidence-based practice, advanced pharmacology, and professional role development. The curriculum also emphasizes simulation education, with the average student experiencing more than 120 hours of simulation coursework. The three-year plan is shown in Online Supplementary Table 1 . By the end of the program, students manage a minimum of 800 anesthesia cases and document more than 2,000 clinical hours. The nurse anesthesia program curriculum is offered in a full-time format over 36 months (nine terms), and classes begin each January. The curriculum comprises 86 credits (course and clinical). One credit is equivalent to one hour of classroom time and a minimum of four hours of clinical instruction each week, or 15 hours of lecture and a minimum of 60 hours of clinical instruction for a 15-week semester. On average, each student completes more than 40 hours of clinical each week during the program. After the first two terms, the curriculum design integrates classroom, simulation, and clinical experiences. The curriculum comprises 39 core credits and 47 anesthesia specialty credits. The clinical experience required for graduation is shown in Table 3 .

Clinical experiences required to submit an application for the CRNA National Certification Examination (Council on Accreditation of Nurse Anesthesia Educational Programs Appendix)

Nurse anesthesia programs in the United States are accredited by the Council on Accreditation of Nurse Anesthesia Educational Programs (COA) which is recognized by the United States Department of Education (USDE). A self-study document is provided to the COA before two reviewers visit each site to evaluate compliance with the Standards for Accreditation of Nurse Anesthesia Programs (2019). This document defines standards for faculty qualifications, students, resources, teaching, curriculum, clinical instruction, and evaluation processes conducted by nurse anesthesia programs. Reviewers from the COA meet with students, faculty, and staff at clinical sites teaching students in the program. The frequency of accreditation visits depends upon recommendations from the site’s prior accreditation visit.

Students that have completed the curriculum take the National Certification Examination provided by the NBCRNA. Passing the exam provides the student with the CRNA credential required for practice as a nurse anesthetist in the US. Some states also require nurse anesthetists to provide documentation of specific clinical and didactic coursework and pay an additional fee to be licensed as advanced practice registered nurses (APRNs).

Finally, necessary expenses and acceptance rate are described. Students are required to attain a final course grade of at least 80% in each course that they take. This course pass threshold is established at the University and School levels and is consistent with doctoral programs across the United States. The probability of passing the overall course of study in the Pitt Nurse Anesthesia Program once admitted is has averaged 95% over the last two decades. The probability of passing the National Certification Examination for Nurse Anesthetists on the first attempt nationally on the first attempt over the past five years is 84.1%. The National Certification Examination is administered by the NBCRNA. The performance of the University of Pittsburgh Program has historically been better than this. The required tuition is currently about $104,000 (for Pennsylvania resident), or about $124,000 (for non- Pennsylvania resident) for the entire 36 month curiculum.

Anesthesiologist Assistant (AA)

The AA’s role is designed to support anesthesia care under the direct supervision of anesthesiologists. Their responsibilities are similar to those of CRNAs. However, AAs work only under the direct supervision of anesthesiologists in the anesthesia care team’s environment. The AA profession was conceived in the 1960s by three university anesthesiology department chairs in response to a shortage of physician anesthesiologists. 7 In 1969, the first AA training program began accepting students at Emory University in Atlanta, Georgia, while a second program was started at Case Western Reserve University in Cleveland, Ohio. Currently, there are 18 AA schools, and applicants must have a bachelor’s degree. Each state determines the places where AAs can work; AA education programs have expanded to 18 states (Alabama, Colorado, District of Columbia, Florida, Georgia, Kentucky, Michigan, Missouri, New Hampshire, New Mexico, North Carolina, Oklahoma, Ohio, South Carolina, Texas, Vermont, West Virginia, and Wisconsin). AAs train for their profession through a different route than CRNAs. Nursing licensure and healthcare experience are not mandatory. Many AAs have a pre-medical background and have completed a comprehensive educational and clinical program at the graduate level. They can receive a degree through a 24–28-month program. The curriculum and graduation requirements are like those of CRNAs discussed above. AAs must pass a certification examination administered by the National Commission for Certification of Anesthesiologist Assistants in collaboration with the National Board of Medical Examiners.

Differences exist between AA and CRNA education programs regarding prerequisites, actual conditions for supervision, and accreditation maintenance. These differences exist because the two professions were developed through different paths. High school graduates are directly admitted to four-year, full-time pre-licensure baccalaureate nursing programs; they are educated to become professional nurses whose practice is based upon nursing and related sciences. Graduates of the program are professional nurses with the necessary base for graduate education and continuing professional development. All nurse anesthesia programs require applicants to have at least one year of full-time experience as ICU nurses. Nurse Anesthesia educational programs require an additional three years of full-time study and then completion of the National Certification Examination.

AA program applicants generally present with a background of science-related studies, and a baccalaureate degree from an accredited college or university in the US or Canada. All applicants will need to have completed the core requirements for application to most US medical schools, although any degree is accepted. Thus, neither the AA nor the CRNA certification can be obtained only through four years of university education, and the prerequisites and pathways for obtaining each certification differ. According to the most current statistics, the mean total yearly compensation for a full-time CRNA in the US is over $170,000 compared to the average AA annual salary of around $100,000 in the US. There are similar responsibilities on the face of it, and they often both work in anesthesia teams with anesthesiologists. However, they have different educational pathways and accreditation bodies. CRNAs have prior experience as critical care nurses and can work without direct anesthesiologist supervision, allowing them to take call and provide services in consultation with physicians, including the surgeon. Some CRNAs appear to oppose the spread of AA programs, and some physicians have supported AAs as CRNA replacements ( Table 4 ).

Differences between certified registered nurse anesthetists (CRNAs) and anesthesiologist assistants (AAs)

Reflection on the Current Perioperative Nurse Anesthetist Educational System in Japan

Although it is challenging to create new national certifications such as CRNA in Japan, it is expected that comprehensive anesthesia management opportunities will increase in the future, with nurse practitioners and perioperative nurses playing a role. To widely spread the anesthesia nurse practitioner in Japan, the following three matters become the main points considering Japanese law and the present medical system.

First, in Japan, creating a unified certification for anesthesia nurse practitioners to ensure these professionals’ skills and care quality is ideal. The number of facilities that train perioperative anesthesia nurses or practitioners is increasing in Japan. However, there are several certification bodies and certification names. Furthermore, in some cases, the qualification can only be used at a qualification facility. By creating a unified qualification in Japan, these certified anesthesia nurse practitioners would be able to relocate to institutions without concern regarding losing privileges. Also, nurses can expand the field of hospital activities, including a shorter workday style and part-time work.

Second, current educational programs for anesthesia nurse practitioners in Japan overwhelmingly lack in their vigor in simulation and clinical training compared to those in the US. One solution would be to increase anesthesia nurse practitioners’ opportunities to learn alongside anesthesiologists in simulation education and clinical training.

Third, currently, there is little financial incentive to become an anesthesia nurse practitioner in Japan. It does not demand a standard wage like the United States. The incentive for working day as an anesthesia nurse practitioner may be easy to introduce early. It is reasonable for these highly-trained anesthesia nurse practitioners to receive better wages than those of nurse practitioners. The institutions may be financially well-off and continue to provide high quality care by hiring these anesthesia nurse practitioners instead of relying on locum anesthesiologists’ anesthesia care. With the development of anesthesia nurses, anesthesiologists and surgeons will perform more operations, and the development of acute-phase medical care, including surgery, will lead directly to management development for hospitals. Improving incentives for surgeons and anesthesiologists has been controversial for some time, but there is no sign of progress. The government or each hospital is entering a period that requires establishing an incentive system for the individual for perioperative management, including surgeons, anesthesiologists, and anesthesia nurse practitioners in Japan.

Advocacy by anesthesiologists, surgeons, existing nurses, and hospitals is necessary to create a unified approval for anesthesia nurse practitioners in Japan, and it is impossible to implement it immediately. If an educational institution such as ours takes the lead, we believe that advocacy as a hospital will be born and that discussions on the unification of approval will deepen.

Responsibility

In the current situation in Japanese law, anesthesia nurse practitioner practice under the supervision of anesthesiologists. However, it should not be forgotten that responsibility is involved. For reference, the responsibilities of anesthesiologists in the United States are described below. Whether it is an anesthesiologist or the surgeon, having physician supervision does not provide full protection for the CRNA. There is only one state in the US where an anesthesiologist’s supervision is required (New Jersey). In every other state requiring supervision, a physician can be the anesthesiologist or a surgeon. This is true in Pennsylvania, and there are many CRNA practices with this model. Each practitioner is independently responsible for their actions, and if they deviate from a plan of care or the standard of care, they are potentially liable. Typically, the CRNA and MD are named in a suit, and damages are awarded according to the jury or judge’s responsibility assignment.

Establishing educational standards for perioperative nurse anesthetists and including these professionals as integral members of anesthesia management teams should be the strategy to address the national shortage of anesthesiologists in Japan. Understanding the content of CRNA and AA educational programs in the US is essential for discussing strategies to determine the best method to train those extended anesthesia care providers in Japan. It is vital to determine educational standards for anesthesia nurse practitioners, who would better meet the current need for additional anesthesia care providers in Japan. It is also necessary to establish a unified certification process with which anesthesia nurse practitioners would be able to mobilize their skills in the county.

ACKNOWLEDGEMENT

The authors thank Ms. Christine Burr (Scientific Writer, Department of Anaesthesiology and Perioperative Medicine/Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA) for her editorial assistance with the manuscript.

DISCLOSURE STATEMENT

None of the authors has any conflicts of interest to declare about this work.

Supplementary Table 1

Three-year full-time curriculum plan

Abbreviations

CRNA-conducted research: is it being done?

Affiliation.

• 1 Georgetown University Hospital, Washington, DC, USA.
• PMID: 12078465

An emphasis on research was established with the 1998 Council on Accreditation of Nurse Anesthesia Educational Programs (COA) requirement that all nurse anesthetists graduate with a master's level of education. Nursing research is essential to expand the profession's knowledge base and to establish a foundation for evidence-based practice. However, to date there are no existing data indicating whether practicing CRNAs are conducting research or to what extent. The purpose of this study was to determine whether research is conducted by Certified Registered Nurse Anesthetists (CRNAs) and what factors influence whether CRNAs engage in research. A quantitative descriptive design was used. Random sampling from the total AANA membership roster was done. A questionnaire developed by the researchers and evaluated by content experts was used to obtain data after the questionnaire was validated with a pilot study. Of 370 questionnaires mailed, 173 (46.8%) were returned. Results revealed a small percentage of CRNAs are involved in the research process at some level. The majority of CRNAs conducting research did not receive preparation in the research process from their educational curriculum. There was a significant relationship between working in a teaching hospital and whether CRNAs conducted research. Many barriers were identified.

Publication types

• Research Support, Non-U.S. Gov't
• Clinical Nursing Research / statistics & numerical data*
• Middle Aged
• Nurse Anesthetists / statistics & numerical data*
• Surveys and Questionnaires

Nurse Anesthesia: NA Databases/Journals

• NA Databases/Journals
• Find a Print Book This link opens in a new window
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• MNUR6132 & 6136 Simulation
• MNUR 6233 & 6237 Regional Anesthesia & Ultrasound Science 1 & 2
• MNUR 6321 Healthcare Informatics
• MNUR 6323 Research Evidence into Practice
• MNUR 6341 Professional Aspects of Nurse Anesthesia Practice
• MNUR 6342 Healthcare Management
• MNUR 6343 Health Policy and Law
• MNUR 6344 Leadership in Advance Practice Nursing
• NRSG 6379 - Fundamentals of Anesthesia II
• MNUR 6411 Biochemistry for Nurse Anesthetist
• MNUR 6413 & 6415 Advanced Pharmacology 1 & 2
• MNUR 6422 Research & Statistical Methods
• MNUR 6434 Advance Health Assessment & Diagnosis
• MNUR 6612 Anatomy and Physiology I & II
• MNUR 6631 Introductory Concepts & Principles of Anesthesia Practice
• MNUR 6735 Anesthesia for Surgical Procedures & Special Populations
• Certification Review
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