Why I think year ICU experience isn’t enough by “There, I Said It” CRNA

[MmacFN]

This is an interesting little diatribe i read by a CRNA clinical instructor.



Why I think year ICU experience isn’t enough by “There, I Said It"

I am a Nurse Anesthetist and a Clinical Instructor of Anesthesiology at a large metropolitan teaching institution.

I have been a clinical instructor for some years, and have seen many students come and go. We have so many applicants to our program, and each time the interviewing process becomes more and more difficult, as each applicant appears to be cream of the crop. The difficult decisions as to who will be accepted into the program come from a comprehensive process that involves input from many individuals of varying levels of practice; from student nurse anesthetists to department chairs.

According to the AANA, requirements for admission to an accredited program of nurse anesthesia include a minimum of 1 year of acute care experience, such as in ICU or ER. Herein lies my beef. Applicants or students who think 1 year of acute care experience is enough to perform at an acceptable level, in my view, are sorely mistaken. I feel this requirement should be changed. Can one truly master the art of ICU or ER nursing in 1 year?? Is a year enough time to glean an adequate level of skills or experience in adult critical care or ER nursing? After one year, can you throw up epi, levophed, dobutamine, dopamine, nitro, etc. and truly be comfortable with what you are doing?? Do you think you’ll be able to insert a swan and know what in the hell you’re doing? How much code experience occurs over 1 year? Is a year time enough to mature the development of interpersonal relationships with other members of the health care team much less the patient? Ask yourself these questions and I bet your answer will be no, no and no!

The students who have slithered through the interview process with what looks good on paper but have never been realized in practice have a hell of a time in residency. The clinical instructor has to work overtime to protect the patient from the student. I daresay there are those individuals that just have met the minimal requirements and are truly stellar students. However, these are few and far between.

I suggest the minimal requirement in an acute care setting be increased to at least 3 years. Applicants, if you barely have the minimal requirements for admission, ask yourself if you truly have enough experience to entertain delivering anesthesia care to an elderly individual with an aortic aneurysm, a child with epiglottitis, or an individual with multiple gunshot wounds to the chest and abdomen.

Signed,
There, I Said It

[armygas]

http://www.nurseanesthetist.org/blog/2007/02/19/there-i-said-it-tells-all/

I must say, its a case by case basis......

I was a labor and delivery nurse for 4 years thats "all" I did..... I think I turned out OK

I will compare my "stats" with anyone, mah boot is gettin lonely...... LOL

[ed3]

AA programs would love that…

:tapedshut:

[armygas]

AA programs would love that…

:tapedshut:

Remember I said a case by case basis..... I can't help it I am a statistical outlier stud type!!


Have you ever worked in OB? I worked at the New York Hospital which at that time was performing 6,000 deliveries per year with many of them being high risk.....

I can go on and on with my stats and experience if you like?

(but remember high risk OB is a whole different world.... great experience in "turning it off and on" if you know what I mean and the "ear" you get by listening to heart tones is priceless in the OR. If you can look AT YOUR PT and "hear" how they are doing, that is awesome......)

BTW what is your experience? I will send you my CV if you like?
(i feelz mah bootz gettin warm....hehehe)

[ed3]

:) I didn't mean it the way you interpreted it. I actually agree with you. I am a student; so I will not get in to a long discussion...people here don't like that. :laugh:

[armygas]

:) I didn't mean it the way you interpreted it. I actually agree with you. I am a student; so I will not get in to a long discussion...people here don't like that. :laugh:

No sweat my friend, I am actually one of the few who revels in a good debate.

It has taken me a few years to realize that things aren't personal and when I learned that the debates became fun. Don't take these things personal just reflect the "sense" of the question or statement back at the originator.

..............and have fun (but make sure you can back up ANY statement you make, otherwise you will always come up short on any debate)

So remember, experience backed up by peer-reviewed journals (i.e. ones on PUBMED) and you are set to "lace up your boots" and enter the octagon.


:)
Mike

[ed3]

Yes Sir/Ma’am… :pray:

I sent you a PM.

[MmacFN]

hehe

Well, here is what i think.

In general, the vast majority of people who have one year experience (anywhere), will not be as prepared or as "clinically acute" as those with more experience. They will not do well when things change, when there is a clinically challenging situation or when something unusual happens which is out of the "norm" or not covered on the protocol order sheet. They are not the 'resource' people where they work. Thats not really a statement, its an observational truism from someone with 'experience'.

Having said that...

I do believe that people can come into CRNA school, pass and get certified with one year experience. I also believe there are statistical outliers who can excel clinically without that experience. I would put these people at less than 5%. Also, lets not confuse high marks on tests in CRNA school with clinical acumen cause they are often unrelated.

I also think those with the minimal experience will be well behind those with good experience after graduation. This translates into a weaker clinician upon graduation. Over time the experience gap closes somewhat.

More important than years of experience is quality. Many ICUs and ERs exist where the RNs are little more than automatons going through the motions for a paycheck. These people have no place in CRNA school. However, even taking quality of experience into account, more is always better assuming its good.

CD, the reason i jump on you when you say these things is because your coming from a position of absolute ignorance yet cocky about it. You are not even an RN yet tho you are quick to suggest the experience one gains over years is irrelevant.

In anycase, one of the biggest things that separates AAs from CRNAs is the experience CRNAs bring to the table as RNs. While most CRNA programs are 27-30 months of anesthesia classes, AAs learn everything you already knew as an RN and get their anesthesia didactic & clinical experience in 24-27 months. It doesn't take a genius to tell the difference.

[ed3]

I was cocky?

At the time, I pointed out I was making an observation from the perspective of an outsider. I never claimed to be an expert. I said I wanted to become a CRNA as quickly and efficiently as possible. I never said experience was irrelevant.

[MmacFN]

I may have misunderstood you.

Its an interesting and contraversial topic that many feel stongly about.

The last discussion was HERE (http://www.nurse-anesthesia.org/showthread.php?p=3047)

[ed3]

I will give you the benefit of the doubt and assume you were not referring to me in your spill about the difference between AAs and CRNAs.

[MmacFN]

Actually it was a general comment. However, it is true that AAs believe themselves equal to CRNAs. This is because they "dont know what they dont know". They equate nursing experience to "wiping ass" when thats not even on the radar in my history.

The point for you specifically was that taking the efficient route (another way for fastest) is not always the best plan. To each his/her own, but when students choose that clinical instructors notice. My own has mentioned she notices a huge difference b/t those with one year and others. Its not a coincidence that so many feel this way.

Let me ask this. Why is it your in such a rush? Why not get the experience that will make you a great SRNA?

[skipaway]

As a member of a selection committee, I place experience as the #1 requirement for a student's acceptance. I think the 1 yr requirement is unacceptable and I would agree with the 3 yr requirement that the original posted letter suggests. Yes, there are some very bright people out there who do well as an SRNA with 1 yr. but I definitely see the differences compared to an SRNA with greater experience.

There I Said It...

[ed3]

Life is short. I want to have a career that I am passionate about, and one that can provide a good quality of life sooner, rather than later. I enjoy my nursing clinicals and I adore the patients, but it is not something I want to do for the rest of my life (or any longer than needed). I am 21 now; I plan on being a CRNA by the time I am in my late 20’s… not just beginning my career at 35. I’m not knocking anyone who did, its just not what I want for myself. You have no idea how much pressure I am under to succeed. My parents almost cried when they found I wanted to become a RN (they know its hard work, and they are severely unappreciated). They wanted me to do something more prestigious, not become an :moon: wiper. So it is really a combination of things.

[MmacFN]

ah well.

To each his own and i wish you luck! Keep us updated as to how it all goes!

[assilem]

My parents almost cried when they found I wanted to become a RN (they know its hard work, and they are severely unappreciated). They wanted me to do something more prestigious, not become an :moon: wiper. So it is really a combination of things.

And therein lies the problem that most people are having with this topic....

[gasmn2b]

Wow, I seem to be having a little deja vu from a similar diatribe I posted on an "a website that won't be named" here. LOL! most know what I am referring to.
Anyway, as an ICU nurse for 8 years and a damn good one at that. I still lacked certain experiences that I felt could make me stronger during my program. I've seen young nurses go completely to the crapper when all hell is breaking loose.
So to anyone who wants the "quickest" route to a CRNA program, the recurring theme I see is to make yourself as competitive as possible. So, I say to you, is someone with good grades and 1 year minimun experience the stronger practitioner than one of good grades and several years experience? You decide what you want to put on a CV for the program director to look at. I am not saying don't try, because you will never know if you don't. But, don't be surprised by the letter you get in the mail either.

[skipaway]

My parents almost cried when they found I wanted to become a RN (they know its hard work, and they are severely unappreciated). They wanted me to do something more prestigious, not become an :moon: wiper. So it is really a combination of things.
Wait till your parents need a "butt wiper." Then they may change their minds about a very noble profession.

[DebbieC]

I am restraining myself only with great difficulty....:tapedshut:

[zippys2k21]

But is that first year of ICU really a full year of ICU? Approximately 6-8 weeks is just orientation. My ICU for example had class for a few weeks on top of orientation. Some people even extend their orientation.

I have asked people who were applying to CRNA school in my unit if they felt they were ready. They said yes. I asked them if they felt comfortable with the 5kg baby with the open chest on every inotrope and presser in the book on the verge of going on ecmo. They say NO!.

In the end it all comes down to the individual. The most competitive and qualified person will be accepted. At the two programs I applied to the acceptance rate was about 6%. Good Luck.

[MmacFN]

well said Zip.


At our facility the ICU and ER orientation was 3 months. Both attended a critical care class we taught which took another month of one day a week as part of their full time schedule.

So these RNs were off orientation taking care of the "least sick" patients on the unit or the ER. They were typically not given what most of us considered "sick" patients in the unit or the "acute rooms" in the ER till after the 1st year. Most of them were still following the "protocol" without truly putting it all together for another 3-4 months. None of them really complained about it since they were well aware of their novice status, especially when one of their "easy" patients went bad.

This isnt really about you CD, this is about a general trend many have noticed for some time. You cant be blamed for wanting to 'get on with life'. It is easy to dismiss experience when one doesn't have it.

I think the best way to sum it up is this;

If your mom were very sick and was in the ICU or ER needing multiple interventions etc. Do you want a 1 year or less RN taking care of her or someone with experience? Of course thats a rhetorical question but it highlights the point that experience cannot be "taught" to anyone. This valuable experience results in solid foundation on which to build anesthesia education.

[armygas]

If your mom were very sick and was in the ICU or ER needing multiple interventions etc. Do you want a 1 year or less RN taking care of her or someone with experience?

Be careful, this is the same type of argument that is trying to be used against us (MD vs CRNA type of argument).

[MmacFN]

Not really.

They are suggesting education makes the difference while im suggesting education w/o experience is irrelevant. Book learnin' and application in clinical practice are wholly seperate things :)

Nice try Pot Stirrer :P ehheheh


Be careful, this is the same type of argument that is trying to be used against us (MD vs CRNA type of argument).

[armygas]

Not really.

They are suggesting education makes the difference while im suggesting education w/o experience is irrelevant. Book learnin' and application in clinical practice are wholly seperate things :)

Nice try Pot Stirrer :P ehheheh

I am such a "phallic symbol" LOL

[FutrCRNA]

I am such a "phallic symbol" LOL

Why don't we have one of those "smilies"? A camoflaged phallus in Army's honor. (Yeah, there are a million puns I could insert here, but this is a family channel...)

[armygas]

Why don't we have one of those "smilies"? A camoflaged phallus in Army's honor. (Yeah, there are a million puns I could insert here, but this is a family channel...)


HA!

[ed3]

This isn’t really about my parents. Since I made the mistake of mentioning them I will say that I want to make my parents proud, but I do not live my life for them. Not that it really matters, but my parents are well aware that RNs do more than clean up patients. They were speaking about the perception many people have of nursing.

Assilem- I think I know what you are trying to say, but I am not 100% sure. I apologize, but I am a very direct when it comes to responding to someone individually, and I don’t want to put words in your mouth…so what exactly is the problem people are having with this topic in your opinion?

Debbie, if you really want to say something you are more than welcome to speak your mind. I am curious to know what you are going to say. I didn’t know you had a problem sharing things… :salook:

[NursePink]

This subject has always been a big 'bone of contention' with me. There's nothing I can say here that hasn't already been said. While I think it takes time to learn the science & technicalities of what great acute care nurses possess, I think there is also a huge mental component involved. Neophytes in nursing very rarely come to the table with the ability to function effectively when the chit hits the fan. How can one possibly be able to 'put it all together' in a potentially tragic situation when they've been exposed to it for such a short time??? Doesn't matter if it's in a high acuity ICU, PICU, NICU, or OB (I'm with you Army... OB can be some skeery stuff). It's all SO important. And like Mike said... one who thinks it's not... is blind to what they don't know. And as far as I'm concerned... dangerous.

In my 4 days of work this week (just for an example)... I had a 2 y/o laryngospasm with O2sats into the 60s THREE times. I had a pulmonary artery rupture coming of cardiopulmonary bypass, and the pt hemorrhaging out of her endotracheal tube. I had a pt s/p esophagectomy with a tracheogastric fistula... acidotic & unstable as hell on one lung ventilation with PIPs in the 80s and PaCO2>PaO2. You get the idea. How can someone with ONE year of critical care experience (and as pointed out... on orientation for up to a third of that) possiby have the tools & mental capacity to pull it off to a point that is the absolute best for the pt?? If the CRNA can't stay mentally in control of the situation, the whole room is going to freak out and it's the patient who will suffer. Hell... I was an acute care nurse for 7 years before anesthesia, and some days the possibilities (MH crisis, amniotic fluid embolism, ventricular rupture) scare the piss outta me.

As far as I'm concerned.... 3 years of some high acuity nursing is the minimum that's acceptable. Without that... how do we defend our credibility where the AA issue is concerned???

My opinion... off my soapbox now. Actually... that's just a fragment of my soapbox where this subject is concerned. :eek5:

[betterlatethanever]

Chris,

Some great points mentioned and I am in the majority with a longer experience tract. Sounds like u had a really rough day....sorry about that! I guess the proof is in the pudding. The thing some people forget about experience is that unfortunately the "test" does not incorpoprate experience or clinical skills to passs and become certified. Mike and I have discussed this to great lengths prior to this discussion ... which I do fel is a great discussion.
Chris

[NursePink]

Hey Chris

Actually... I've come to enjoy those types of days. They keep the job exciting, & I'm all about the adrenalin rush. I just felt it was a good example of why experience is important.

Yes... unfortunately... no experience required to pass the big test. One can only hope that school faculty & administrators monitor closely for those who need more hands-on time.

PS - My latest nickname is "M&M Pink" haha

[betterlatethanever]

NICE new nickname

can't say a name I would want hehehe

[ed3]

How long has the acute care experience been required?

Loisane made some pretty good points in the other thread. That thread was just getting interesting, but I understand why it was moved.

[athomas91]

i agree w/ the article... and i will gladly take the heat over it... am i saying that there are those w/ only 1 yr experience who HAVEN'T made good CRNA's - nope... i AM saying that experience CAN ONLY make you a better CRNA because it gives you a broader base to build on. I also wholeheartedly believe that if the AANA wants to advance the CRNA profession that "up"ing the requirement status is a positive move in that Docs can't argue "well they only have 1 year of experience" before a program which in no way equals a "residency" requirement. i completely agree it is a not knowing what you don't know situation... i can tell you i have had 2 cases already in my short career that have been saved by experiences i had prior to school - that even the doc's/surgeons/rn's ect were oblivious to - if i had of only had one year of experience - i would have missed out on those few experiences that really paid off. i am all for advancing yourself as quickly/efficiently as possible...i just don't think it should be done at the expense of a profession.

[ed3]

I am not arguing the fact that more is experience is better. I think you (athomas) actually summed it up when you said some people with one year of experience are capable of being competent CRNA’s. Whether or not that statement applies to every single applicant is not the point. Most CRNA’s have been practicing for over ten years (66% according to crnajobs.com), so many practicing CRNA’s do not even have the acute care experience. I am not being sarcastic or cocky. I hope this is not taken the wrong way.

Having said that, I do see what people are saying about the profession being more credible if the minimum requirement was increased. But from what I have read (in my posistion of ignorance), I do not believe that would stop doctors from arguing about CRNAs. The bickering seems to be more related to territory/money than MDs honestly believing CRNA’s are unsafe providers due to the minimum admission requirements for CRNA programs. I can see how MDAs would still find ways to discredit nursing experience.

[MmacFN]

CD;

I dont blame you one bit for deciding to go the route you have. It IS a valid option and you are taking it. I say all the power to you!

I hope none of this banter is coming off as an attack on you. Just a discussion about what the future of the profession needs to be/do to advance.

[ed3]

Ok, I’ll stay out of it. :) I just hope you all don’t start protesting about the minimum acute care experience being increased to 14 years until the annoying person on nure-anestheisa.org is accepted into a program. This is an issue that could potentially affect me, which is the only reason I decided to comment. Some people seem to be pretty adamant about increasing the minimum requirement. There is good and bad at every level of experience (more only helps, but AEB some practicing CRNA’s, it is not essential).



:deadhorse:

[rnanes]

I agree with the idea that it is the individual situation and experience. I am a very "seasoned" (13 years) rn with a history of nicu and L&d experience. I did my 2 years of hell in a scvicu, but i could not have made it through the program without that combined with my maturyit as both a person and as a nurse who has seen and done alot in the world of medicine. I have been told by more that 10 preceptors that my experience as a seasoned vet show thru and i do think this has helped me. I would bet that the babies of our program, although straight A students may struggle clinically .