Experienced CRNA on Experience Needed to be a CRNA

[yoga]

This thread is something I have wanted to do for awhile. After over 50 years in active anesthesia practice and after a recent serious hospitalization requiring the attention and care of critical care nurses, I have some thoughts about a recurring topic on this site--how much and what kind of experience is necessary to become a CRNA?

It was interesting to note that just about all of the critical care nurses in the hospital where I was a patient, expressed an interest in becoming a CRNA. Of all of them (probably over 25), there was only one who I believe would be a good candidate for our profession. She has done her homework, has talked to program directors at several schools, and is committed to getting as much experience as she can before applying. She also had excellent assessment skills that she was able to translate to care.

While I am uncomfortable writing this, but most of the others talked about money as soon as they found out I was a CRNA. (someone posted it on top of my chart). They were looking for shortcuts to the profession, but most of all they were protocol and guideline nurses. Maybe that is what is required today to be a critical care nurse, but I personally believe that in anesthesia, one has to be able to pull information out of their head in a second and be able to apply it to the clinical situation in another split second. There is not a protocol for independent thinking.

Those of you who want to be a CRNA, should attempt to get as much experience as you can and work on your critical thinking and independent application of facts skills. I hope admissions committees of programs can figure out a way to assess these skills.

jan

[MmacFN]

*clap* *clap*

[EMTRNBSN]

There is not a protocol for independent thinking.
jan

Bravo! BRAVO! BRAVISSIMO!

unfortunately, IMHO, the CRNA education industry is also primarily motivated by paychecks vs. proficiency...

etc etc....
anywho...it's too damned depressing to think about...

so glad to see you back, lady... love, light, and an absolutely GINORMOUS e-hug!

[Anesthesiologist]

Dear Jan,

First of all, welcome back from your surgery. I hope you are recovering well. I am a new visitor to these forums. I have been learning a lot about the CRNA perspective here, and I am getting to know some outstanding members of your profession.

I feel compelled to respond to this post because of the degree to which your viewpoint on this issue resonates with my own. I posted something similar in another thread just yesterday, in fact.

I think that the broad, negative generalizations that anesthesiologists make about CRNAs on other websites are unwarranted. I believe that each individual should be evaluated according to his or her own specific merits and abilities. I think it is utterly foolish to make blanket statements that all physicians are superior to all nurses. I do not doubt there are some CRNAs out there who easily outperform some anesthesiologists.

However, I think that the excellent CRNAs in practice are being highly diluted by the flood of new entrants to the profession. The flood gates appear to be wide open, without sufficient regard to rigorous entrance requirements. Because of my good working relationship with my nurse colleagues, I am often approached by nurses wanting to become CRNAs. I, too, think that quite few of them are qualified. I find more of them are enamored with high salaries and not nearly as interested in pathophysiology.

I think that anesthesiologists' interaction with these type of individuals -- who far outnumber the excellent CRNAs -- really colors our views on the CRNA profession as a whole. All CRNAs and SRNAs will cite their extensive ICU experience. A number of them even cite that they read the same books as anesthesiologists. But you admit something that countless physicians have already noted -- that many of the nurses in the ICU simply follow protocols and do not exercise independent decision-making abilities. They are not "managing" patients at all, at least not in the truest sense of the word.

As I mentioned elsewhere, I do not think that anesthesiologists represent the biggest threat to the CRNA profession. There are too few anesthesiologists to cover the anesthetic needs of this country. The country NEEDS CRNAs.

The bigger threat is that your professional stature (in the eyes of surgeons, anesthesiologists, and the public) will be harmed by the masses of mediocre (or even dangerous) CRNAs being pumped out -- many of them arguing loudly how they are 100% equivalent to anesthesiologists, and how the ICU experience equates to (or even exceeds) physician training.

I personally have no problem with qualified CRNAs working independently. But legislature about practice rights has to be made based on the standard abilities of a group, not based on the abilities of a group's best members. Either that, or independent practice rights must be earned on an individual basis.

Currently, anesthesiologists have a far better process for standardizing 1) the quality of their trainees, 2) the quality of the training, and 3) the assessment of the final product. CRNAs should have the same.

While I am embarrassed at the black-and-white vitriol that is spewed about CRNAs by some anesthesiologists, I do believe the you have identified the grain of truth that underlies it.

Perhaps you, with your past involvement in the AANA, are in the best position to change this situation and to alter the dialogue between CRNAs and anesthesiologists. Not all anesthesiologists are concerned only about protecting their turf. This pie is too big for either group alone.

I wish you a speedy recovery.

This thread is something I have wanted to do for awhile. After over 50 years in active anesthesia practice and after a recent serious hospitalization requiring the attention and care of critical care nurses, I have some thoughts about a recurring topic on this site--how much and what kind of experience is necessary to become a CRNA?

It was interesting to note that just about all of the critical care nurses in the hospital where I was a patient, expressed an interest in becoming a CRNA. Of all of them (probably over 25), there was only one who I believe would be a good candidate for our profession. She has done her homework, has talked to program directors at several schools, and is committed to getting as much experience as she can before applying. She also had excellent assessment skills that she was able to translate to care.

While I am uncomfortable writing this, but most of the others talked about money as soon as they found out I was a CRNA. (someone posted it on top of my chart). They were looking for shortcuts to the profession, but most of all they were protocol and guideline nurses. Maybe that is what is required today to be a critical care nurse, but I personally believe that in anesthesia, one has to be able to pull information out of their head in a second and be able to apply it to the clinical situation in another split second. There is not a protocol for independent thinking.

Those of you who want to be a CRNA, should attempt to get as much experience as you can and work on your critical thinking and independent application of facts skills. I hope admissions committees of programs can figure out a way to assess these skills.

jan

[EMTRNBSN]

1. However, I think that the excellent CRNAs in practice are being highly diluted by the flood of new entrants to the profession. ...
   
2. I am often approached by nurses wanting to become CRNAs. .... I find more of them are enamored with high salaries and not nearly as interested in pathophysiology.
   
3. many of the nurses in the ICU simply follow protocols and do not exercise independent decision-making abilities.
   
4. As I mentioned elsewhere, I do not think that anesthesiologists represent the biggest threat to the CRNA profession. There are too few anesthesiologists to cover the anesthetic needs of this country. The country NEEDS CRNAs.
   
5. The bigger threat is that your professional stature (in the eyes of surgeons, anesthesiologists, and the public) will be harmed by the masses of mediocre (or even dangerous) CRNAs being pumped out --
   
6. legislature about practice rights has to be made based on the standard abilities of a group, not based on the abilities of a group's best members. Either that, or independent practice rights must be earned on an individual basis.

CRNAs should have a far better process for standardizing 1) the quality of their trainees, 2) the quality of the training, and 3) the assessment of the final product.

yeppers! lifting a glass in your general direction, sir...

[Esper]

In light of recent applicants that I have met, I as well have changed my position stance on this. While I feel that there are people with one year experience that are fully qualified, we are getting too many people in it for the money and are happy to be hourly workers.

I don't agree with the 3 year requirement, but I think it should be bumped up to 2 and all schools should be required to be 36 months in length.

While it has been discussed before and generally loathed on this forum, I'm also for a recertification test.

[Anesthesiologist]

I don't agree with the 3 year requirement, but I think it should be bumped up to 2 and all schools should be required to be 36 months in length.

Hi Dave,

The point is that time itself in the ICU is not sufficient. Anesthesia requires more mission-critical decision making than the ICU, because WE are inducing significant physiologic insult on the patient -- i.e., the insults are iatrogenic -- and these insults are occurring on a much more condensed time scale. If an ICU nurse has worked for a decade in a circumstance where he or she follows protocols but 1) demonstrates no understanding of the clinical picture or the actual disease process and 2) exercises no in independent thinking, then that experience is not relevant to the practice of anesthesia. This situation more common than some folks here would care to admit.

It always sounds so inflammatory when an anesthesia resident on SDN says it, but Yoga has said the same thing. The admissions process for CRNA school needs to assess whether the applicant has a sound knowledge base and an ability to exercise sound, independent judgement -- NOT just how many years in the ICU the nurse has worked.

[Anthony]

We have gone through many a discussion about the ability to measure the ability of independent judgement. Myself and others have consistently stated that not only experience but a quality experience is a basic requirement...here is a reposting:

I'd like to know exactly what people think they gain from the ICU experience that translates into the requirement for acceptance to anesthesia school. And how does that experience help you as a CRNA?

I have asked this of my fellow faculty members where I teach and have been told that ..it... supposedly allows the development maturity of thinking in stressful situations.

Simply put - I believe this to be correct and incorrect...

In my view, there are 3 categories of students - when I look at the degree of experience they bring to the clinical realm.

1. Those who have not matured, regardless of years of experience - that their most common reaction to stressful situations in the OR is to freeze (insert picture of thousand yard stare) or start crying - I had one run out of the room once during a near code.

2. Those who have matured but individual display of decision making or differential diagnosis was not encouraged. These individuals first knee jerk reaction is to call for help & ask for guidance. If no guidance is available they freeze. As CRNAs, they may not freeze - but depend on guidance and support.

3. Those who have the required amount of "matured" experience to allow them to think through situations and problem solve - on their own.

Now overlay the following skill sets on the above:

A. Exceptional students (prior and during CRNA school - organized, well prepared, good processing skills, etc... )
B. Excellent grasp on advance anatomy, pharm, pathological states (to include identification and treatment), and... on-the-fly assessment skills (situational awareness)
D. Excellent communication (able to articulate issues)
C. Embracing that power comes from the use of knowledge to augment their clinical actions rather than pure memorization for testing sake (zero extrapolation ability with the latter). This rote memorization is a perfect example of "book smart & clinically dumb"...

Having a dose of the above "healthy" skill sets allows the students in category 1 and 2 rise to the occasion..... and those in category 3 with these skills to tend to become incredibly exceptional.

But lacking in any areas of the skill sets -well... places those who are in the first 2 categories at an incredible disadvantage, especially if they are lacking in skill set B and C - these students are commonly prone to "Paralysis by analysis" - even by graduation.

I have found that skill set B and C is the weakest in most students - but is also an essential skill of independent practice. Most/All can memorize but few exercise depth in understanding. The important point here is that knowledge applied is knowledge retained

I have seen that those who start out in categories 1 and 2 and never improve on the key skill sets are ultimately drawn to very directed practices and... autonomy... is very intimidating and out of the question.

So one can get some great ICU experience...but... in my interactions with interns, it is worthless, if some other very fundamental skills are nonexistent.

tone

BTW these observations are not all inclusive ...just my ramblings

[EMTRNBSN]

stand by for all the sidebar snipes about....

anesthesia residents who

1) demonstrate no understanding of the clinical picture or the actual disease process and
2) exercise no independent thinking, ...

trust me..."This situation is more common than some folks here would care to admit." ;-)

remember folks, the conversation is NOT about how effed up the other kids are, but rather, what CRNAs need to do to unscrew themselves...

[Anesthesiologist]

Haha!

Well, anesthesia residents are not immune to this problem -- esp. in their early stages of training :-)

The difference is that a sound (broad and deep) clinical knowledge base and independent decision making are the specific focus and the specific endpoint of an anesthesiologist's training. One cannot get anesthesia board certification without a rigorous vetting of these two things. It should also be true of a CRNA's training. However, these are NOT the specific foci of an ICU nurses training.

stand by for all the sidebar snipes about....

anesthesia residents who

1) demonstrate no understanding of the clinical picture or the actual disease process and
2) exercise no independent thinking, ...

trust me..."This situation is more common than some folks here would care to admit." ;-)

remember folks, the conversation is NOT about how effed up the other kids are, but rather, what CRNAs need to do to unscrew themselves...