Question

Jacob is a CRNA working in the labor and delivery department of a private for-profit hospital. He has been employed there full-time for 10 years. He currently is the lead CRNA for 5 other CRNAs that work on the unit. He has been researching DNP programs and has decided to complete an application with an online DNP program. He has an upcoming meeting with his director in a couple of weeks for which he wants to discuss he return to school and also discuss changes in nursing anesthesia practice that may impact current hospital policies and procedures ethically and legally. During his monthly meeting with the director of the unit, he decides to share his desire to pursue another degree to expand his knowledge base, make him a better leader, and help promote better health care delivery and care outcomes. He discusses reducing his hours in order to allow him time to pursue his degree. The director tells Jacob that at this time reducing his hours to accommodate his desire to return to school would not be an option. The director also tells Jacob that the changes in nursing anesthesia practice that may affect their internal policies will need to be addressed at a later meeting. After the meeting, Jacob is discouraged, feels a lack of administrative support, and now is uncomfortable in his leadership role.

What ethical perspectives influenced your pursuit of a DNP degree? please provide reference

Answer 1

As advanced practice nurses, Certified Registered Nurse Anesthetists (also recognized by the titles CRNA, nurse anesthetist, Certified Registered Nurse Anesthesiologist, and nurse anesthesiologist) are proud to be part of America’s most trusted profession. Patients who require anesthesia for surgery, labor and delivery, emergency care, or pain management know they can count on a CRNA to stay with them throughout their procedure, advocate on their behalf, and provide high-quality, patient-centered care. Likewise, healthcare facilities depend on CRNAs to serve the most patients for the least cost; deliver quality care to rural and other medically underserved areas; and positively impact the nation’s growing healthcare cost crisis. CRNAs are the answer to achieving a safer healthcare environment and more cost-efficient healthcare economy. This document was prepared by the American Association of Nurse Anesthetists (AANA) on behalf of its 53,000 members and the patients they serve to define the increasing role and value of CRNAs and provide an accurate description of anesthesia practice in today’s U.S. healthcare system.

Nurse anesthetists have been the backbone of anesthesia delivery in the United States since the American Civil War. The first U.S. healthcare providers to specialize in anesthesiology, these pioneering nurses introduced a grateful public to a world of previously unimagined healthcare possibilities. Since the late 1800s, anesthesiology has been recognized as the practice of nursing; it wasn’t until nearly 50 years later that physicians entered the field and anesthesiology also gained recognition as the practice of medicine. Over the years, despite numerous legal challenges by organized medicine, the courts have consistently upheld the doctrine of anesthesiology as nursing practice.

Provider Types

CRNAs and physician anesthesiologists are the predominant anesthesia professionals in the United States. Another anesthesia provider type is anesthesiologist assistants (AAs). These healthcare workers serve as assistants to physician anesthesiologists, and by law can only practice under the direct supervision of a physician anesthesiologist. Anesthesia services are provided the same way by nurses and physicians; in other words, when anesthesia is provided by a CRNA or by a physician anesthesiologist, it is impossible to tell the difference between them. Both CRNAs and physician anesthesiologists provide anesthesia for the same types of surgical and other procedures, in the same types of facilities, for patients young to old; one provider type is not required over the other in any given situation. In fact, most of the hands-on anesthesia patient care in the United States is delivered by CRNAs. Yet, while CRNAs are not required by federal or state law to work with physician anesthesiologists (except in New Jersey, which requires CRNAs to enter into a joint protocol with a physician anesthesiologist), in many healthcare settings CRNAs and physician anesthesiologists work together to provide quality patient care. Landmark research, however, has confirmed that anesthesia is equally safe regardless of whether it is provided by a CRNA working solo, a physician anesthesiologist 2 working solo, or a CRNA and physician anesthesiologist working together.

The practice of anesthesiology for CRNAs and physician anesthesiologists includes, but is not limited to, the following:

• Patient care before, during and after surgery

• Patient care before, during and after labor and delivery

• Diagnostic and therapeutic procedures

• Trauma stabilization and critical care interventions

• Acute and chronic pain management

• Management of systems and personnel that support these activities

Education

The preparation of CRNAs for practice enables them to provide every type of anesthesia-related service and anesthetic drug, practice in every type of setting and participate in every type of procedure where anesthesia is required, and handle emergency situations. Because of their extensive knowledge base and robust clinical experience prior to becoming a CRNA, these anesthesia experts are well-equipped to have an immediate impact as healthcare professionals upon graduation. The nursing- and anesthesiology-focused education and training required to become a CRNA is extensive and in many ways similar to the education and training of a physician anesthesiologist. It takes 7-8 ½ years of coursework and clinical hours for a student registered nurse anesthetist (also known as SRNA, nurse anesthesia resident, nurse anesthesiology resident) to attain a master’s or doctoral degree in nurse anesthesia; during that time the SRNA will, on average, amass nearly 9,400 hours of clinical experience. To be accepted into a nurse anesthesia educational program, an applicant must attain a minimum of one year of experience as a registered nurse in a critical care setting within the United States, its territories, or a U.S. military hospital outside of the United States. However, the average experience of RNs entering nurse anesthesia educational programs is 2.9 years. CRNAs are the only anesthesia professionals required to attain clinical experience prior to entering an educational program. All CRNAs are board certified, while only 75 percent of physician anesthesiologists are board certified, according to the Anesthesia Quality Institute (AQI) report titled Anesthesia in the United States 2013. The medical- and anesthesiology-focused education and training required to become a physician anesthesiologist is also extensive and not unlike the education and training of a CRNA. It takes approximately 8 years of medical- and anesthesiology-focused education and training to attain a degree as a physician specializing in anesthesiology prior to sitting for the medical board examination—roughly the same amount of time it takes to become a CRNA. Anesthesiology residents graduate with approximately 12,120 hours of clinical experience, not significantly more than the number attained by CRNAs during their education and training. However, the American Society of Anesthesiologists (ASA) inflates years of schooling to 12-14 by including a fouryear bachelor’s degree attained prior to entering medical school, and a post-residency fellowship in an anesthesiology subspecialty such as chronic pain management, which many physician anesthesiologists do not pursue. The bachelor’s degree is typically not healthcare-focused. The ASA also inflates the number of clinical hours attained by residents to approximately 14,000-16,000, which is 2,000-4,000 hours more than the actual number of 12,120. An important difference between clinical education hours attributed to nurse 3 anesthesia students and anesthesiology residents is that the hours claimed by SRNAs are those actually spent providing patient care, while the hours claimed by anesthesiology residents are all hours spent in the facility, including those hours not involved in patient care.

Barrier to SRNA Education

An increasingly common barrier to CRNA practice created by physician anesthesiologists is intended to impede SRNA preparation by limiting their access to clinical training sites and procedures. Other restrictive measures that have specifically resulted from the ASA’s 2018 publication of its amended Anesthesia Care Team (ACT) Statement include facilities requiring restrictive 1:1 CRNA-to-student-nurse anesthetist supervision ratios that prevent CRNAs from leaving the operating room to allow students the ability to develop independently. The ASA’s stated rationale is to protect employment opportunities for physician anesthesiologists. In the AANA’s view, this sort of blatant protectionism is, at a minimum, unethical. All anesthesia students should be afforded the required clinical training opportunities necessary to become fully prepared for entry into practice. Patients depend on this. Licensure CRNAs are licensed by the states and authorized by law and regulation to practice nurse anesthesia in all 50 states and the District of Columbia; they are the only independently licensed practitioners required to be board certified to practice. Physician anesthesiologists are licensed by the states and authorized by law and regulation to practice anesthesiology in all 50 states and the District of Columbia; however, they are not required to be board certified. Unlike CRNAs or physician anesthesiologists, AAs are not licensed to practice independently in any state. Due to this limitation, AAs do not help improve patient access to surgical, labor and delivery, and emergency care; however, they do increase costs for anesthesia services paid by facilities and patients due to two anesthesia providers needing to be involved in the care of a single patient.

For AAs, there is only one anesthesia delivery model:

Medical direction by a physician anesthesiologist. While a healthcare facility cannot employ an AA without also employing a costly physician anesthesiologist who earns nearly three times as much as an AA or CRNA, a facility can employ a CRNA in place of both, thereby ensuring quality patient care is delivered and the facility’s bottom line is favorably impacted.

In this model, the CRNA is the sole anesthesia provider. The CRNA-only model may vary by state. In some states, CRNAs work without physician supervision; in other states, they are required to be supervised by a physician. The physician could be, but is not required to be, a physician anesthesiologist. Often the supervising physician is a surgeon or other proceduralist. Currently, there are 17 states that have no physician supervision requirement for CRNAs whatsoever, meaning these states have opted out of the federal Medicare physician supervision requirement for CRNAs. Without any burdensome supervision requirement for CRNAs, healthcare facilities in these states can structure and staff their anesthesia departments to function as efficiently, cost-effectively, and safely as possible. Physician supervision of CRNAs is not and never has been a matter of patient safety. Its requirement has always been tied to the ability of a facility to receive reimbursement from the Centers for Medicare & Medicaid Services (CMS) for anesthesia care provided to Medicare patients.

Physician Supervision of CRNAs

Medical supervision is a billing term under Medicare which pertains to when one physician anesthesiologist oversees more than four CRNAs (or AAs) concurrently administering anesthesia to patients undergoing surgical or other procedures. In this model, the physician anesthesiologist doesn’t provide hands-on care, but is available in case he/she is needed to assist in any of the concurrent cases. Research has confirmed that patient safety is not enhanced by this anesthesia delivery model, and that the cost of having a physician anesthesiologist available “just in case” is often greater than the cost of adding two additional CRNAs to the anesthesia department

Physician Anesthesiologist Direction of CRNAs

Medical direction is a billing term under Medicare which pertains to when a physician anesthesiologist directs the anesthesia care of up to four CRNAs (or AAs) providing anesthesia for four different cases concurrently; however, for medical direction to be achieved legally and the physician anesthesiologist to be compensated, the physician anesthesiologist must meet seven requirements of the Tax Equity and Fiscal Responsibility Act of 1982, Pub. L. 97–248 (TEFRA) for each case. For obvious reasons, medical direction, with its TEFRA requirements, is the model in which physician anesthesiologist billing fraud occurs most frequently. It is virtually impossible for a physician anesthesiologist to meet the seven TEFRA requirements in concurrent cases (regardless of whether there are two, three or four concurrent cases) without significant delays occurring in each of the cases as the physician anesthesiologist moves from room to room.

Physician Anesthesiologist-only Model

In this model, the physician anesthesiologist is the sole anesthesia provider. The physician anesthesiologist provides hands-on patient care and stays with the patient throughout the procedure—exactly the way a CRNA functions all the time whether working solo or with a physician anesthesiologist. The physician anesthesiologist-only model is the least commonly used delivery model in the United States. While it is more 5 economical than the medical-direction and medical-supervision models, research has confirmed that it is far less cost-effective and no safer than the CRNA-only model.

Military

Nurses first gave anesthesia to wounded soldiers on the battlefields of the American Civil War; now, more than 150 years later, service members in all branches of the U.S Armed Forces rely on independently practicing CRNAs for anesthesia care, especially on the front lines of American military actions around the world. In these austere settings where physician anesthesiologists are rarely deployed, CRNAs typically are the sole anesthesia professionals caring for U.S. service men and women.