Qualifications and Capabilities of the Certified Registered Nurse Anesthetist

This document has been prepared by the American Association of Nurse Anesthetists (AANA) to provide information about the qualifications and capabilities of Certified Registered Nurse Anesthetists (CRNAs). The practice of anesthesia is a recognized specialty within the profession of nursing. As one of the first nursing specialty groups, CRNAs have a longstanding commitment to high standards in a demanding field. As independently licensed healthcare professionals, CRNAs are responsible and accountable for their practice.
 
In order to be a CRNA one must:
  1. Graduate from a nurse anesthesia educational program accredited by the Council on Accreditation of Nurse Anesthesia Educational Programs (COA) or its predecessor.
  2. Pass the certification examination administered by the Council on Certification of Nurse Anesthetists or its predecessor.
Since its organization in 1931, the AANA has placed its responsibilities to the public above or equal to its responsibilities to its membership. The association has produced education and practice standards, implemented a certification process for nurse anesthetists (1945) and developed an accreditation program for nurse anesthesia education (1952). It was a leader in forming multidisciplinary councils with public representation to fulfill the profession's autonomous credentialing functions.
 
Today, more than 48,000 CRNAs administer 34 million anesthetics in the United States each year. In addition, CRNAs administer anesthesia for all types of surgical cases, from the simplest to the most complex. CRNAs are the primary anesthesia professionals in rural America; in some states CRNAs are the sole providers in nearly 100 percent of the rural hospitals. CRNAs work in every setting in which anesthesia is delivered: traditional hospital surgical suites and obstetrical delivery rooms, ambulatory surgical centers, and the offices of dentists, podiatrists, and plastic surgeons.

Education of Nurse Anesthetists 
The nurse anesthesia profession is known for its highly respected educational system and its strong commitment to quality education. As of November 2014, there were 114 accredited nurse anesthesia educational programs in the United States, all affiliated with or operated by academic institutions. The programs range from 24 to 36 months in length, depending upon university requirements, and all are at the master's degree level or higher. This sophisticated educational system provides a graduate level science foundation along with clinical anesthesia experience to prepare student registered nurse anesthetists to become competent nurse anesthesia professionals.

Academic Requirements
The didactic curricula of nurse anesthesia programs are governed by Council on Accreditation of Nurse Anesthesia Educational Program (COA) standards and provide students the scientific, clinical, and professional foundation upon which to build sound and safe clinical practice. The basic nurse anesthesia academic curriculum and prerequisite courses focus on coursework in anesthesia practice: pharmacology of anesthetic agents and adjuvant drugs including concepts in chemistry and biochemistry; anatomy, physiology, and pathophysiology; professional aspects of nurse anesthesia practice; basic and advanced principles of anesthesia practice including physics, equipment, technology and pain management; research; and clinical correlation conferences.
 
Most programs exceed these minimum requirements. In addition, many require study in methods of scientific inquiry and statistics, as well as active participation in student-generated and faculty-sponsored research.
 
Clinical residencies afford supervised experiences for students during which time they are able to learn anesthesia techniques, test theory, and apply knowledge to clinical problems. Students gain experience with patients of all ages who require medical, surgical, obstetrical, dental, and pediatric interventions.
 
Accreditation of Educational Programs
The COA is recognized by the U.S. Department of Education and the Council for Higher Education Accreditation as the sole accrediting authority for nurse anesthesia educational programs. The COA provides for systematic self-study and on-site evaluation of all nurse anesthesia educational programs, and publishes a list of accredited nurse anesthesia educational programs annually. This list is also available at www.aana.com.
 
Certification and Recertification of Nurse Anesthetists
The National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA) is the certifying body that administers the national certification examination. Each graduate of a nurse anesthesia educational program must pass the national certification examination before he or she can be certified as a CRNA.
 
Recertification is required of CRNAs on a biennial basis. The recertification program is administered by The National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA), which reviews CRNA qualifications regarding (1) current licensure as a registered nurse, (2) continuing education (40 CE credits), (3) certification that he or she has been substantially engaged in the practice of anesthesia during the two-year period, and (4) verification of the absence of mental, physical or other problems that could interfere with the practice of anesthesia.
 
Clinical Practice
CRNAs practice according to their expertise, state statutes or regulations, and institutional policy.
 
CRNAs administer anesthesia and anesthesia-related care in four general categories: (1) preanesthetic preparation and evaluation; (2) anesthesia induction, maintenance and emergence; (3) postanesthesia care; and (4) perianesthetic and clinical support functions. The CRNA scope of practice includes, but is not limited to, the following:
(a) Performing and documenting a preanesthetic assessment and evaluation of the patient, including requesting consultations and diagnostic studies; selecting, obtaining, ordering, or administering preanesthetic medications and fluids; and obtaining informed consent for anesthesia.
 
(b) Developing and implementing an anesthetic plan.
 
(c) Selecting and initiating the planned anesthetic technique that may include general, regional, and local anesthesia and intravenous sedation.
 
(d) Selecting, obtaining, or administering the anesthetics, adjuvant drugs, accessory drugs, and fluids necessary to manage the anesthetic, to maintain the patient's physiologic homeostasis, and to correct abnormal responses to the anesthesia or surgery.
 
(e) Selecting, applying, or inserting appropriate noninvasive and invasive monitoring modalities for collecting and interpreting patient physiological data.
 
(f) Managing a patient's airway and pulmonary status using endotracheal intubation, mechanical ventilation, pharmacological support, respiratory therapy, or extubation.
 
(g) Managing emergence and recovery from anesthesia by selecting, obtaining, ordering, or administering medications, fluids, or ventilatory support in order to maintain homeostasis, to provide relief from pain and anesthesia side effects, or to prevent or manage complications.
 
(h) Releasing or discharging patients from a post-anesthesia care area, and providing post-anesthesia follow-up evaluation and care related to anesthesia side effects or complications.
 
(i) Ordering, initiating or modifying pain relief therapy, through the utilization of drugs, regional anesthetic techniques, or other accepted pain relief modalities, including labor epidural analgesia.
 
(j) Responding to emergency situations by providing airway management, administration of emergency fluids or drugs, or using basic or advanced cardiac life support techniques.
 
(k) Additional nurse anesthesia responsibilities which are within the expertise of the individual CRNA.
 
The functions listed above are a summary of CRNA practice and are not intended to be all-inclusive. A more specific list of CRNA functions and practice parameters is detailed in the AANA Scope of Nurse Anesthesia Practice and Standards for Nurse Anesthesia Practice.
 
Clinical Support Services Provided Outside of Operating Room
CRNAs also provide clinical support services outside of the operating room. Anesthesia and anesthesia-related services are expanding to other areas, such as MRI units, cardiac catheterization labs and lithotripsy units. Upon request or referral these services include providing consultation and implementation of respiratory and ventilatory care, as well as identifying and managing emergency situations, including initiating or participating in cardiopulmonary resuscitation that involves airway maintenance, ventilation, tracheal intubation, pharmacologic, cardiopulmonary support, and management of blood, fluid, electrolyte and acid-base balance.
 
Administrative and Other Professional Roles
Many CRNAs perform administrative functions for departments of anesthesia. The services provided by these department directors and managers are extremely important to the overall functioning of an anesthesia department and directly affect the efficiency and quality of service provided. These functions include personnel and resource management, financial management, quality assurance, risk management and continuing education.
 
CRNAs serve on various institutional committees and participate as instructors in staff development and continuing education programs for both professional and nonprofessional staff members.
 
CRNAs hold staff and committee appointments with state and federal governmental agencies such as state boards of nursing and the U.S. Food and Drug Administration. CRNAs are also actively involved in professional and standard-setting organizations such as the American Society for Testing and Materials.
 
Research
Nurse anesthetists have been involved as investigators, collaborators, consultants, assistants, interpreters and users of research findings since the beginning of the 20th century. Movement of nurse anesthesia educational programs into graduate educational frameworks has allowed students to graduate with basic skills for undertaking research. In addition, there is a growing number of CRNA faculty, credentialed at the graduate level, who regularly sponsor and consult in research endeavors and act as project directors or principal investigators for funded research in university settings. The AANA Foundation is a nonprofit organization that promotes and facilitates research. The foundation established the Doctoral Mentorship Program to encourage seasoned researchers and novice researchers to share ideas and help each other. The group includes CRNAs with doctoral degrees as well those in doctoral programs.

At the AANA Nurse Anesthesia Annual Congress, educational sessions are conducted in research methodology and grantsmanship. To respond to the current healthcare environment, the AANA has focused on quality and outcome-based research. The AANA, in cooperation with the AANA Foundation, provides venues for communicating research findings.
 
Additionally, CRNAs have presented their research at a variety of national and international meetings, including those sponsored by nurses, physicians, physiologists and pharmacologists. Research by CRNAs has been funded by private and governmental grants, as well as by the AANA Education and Research Foundation.
 

The AANA's research component has grown and is supported by the AANA Foundation. The AANA Foundation approves and funds small grants for CRNAs and nurse anesthesia students. In 1998, the Research Scholar award was the first large grant awarding up to $25,000. The award was initiated to encourage CRNAs to conduct research of greater magnitude. 

Publications
CRNAs have authored numerous books, chapters in books, monographs and articles on clinical, educational and research subjects in a variety of refereed professional publications such as the AANA Journal, Anesthesiology, Anesthesia and Analgesia, Journal of the American Society of Regional Anesthesia, Journal of the American Medical Association, and Nursing Research.
 
Subspecialization
Some CRNAs have chosen to specialize in pediatric, obstetric, cardiovascular, plastic, dental or neurosurgical anesthesia. Others also hold credentials in fields such as critical care nursing and respiratory care. In addition to their membership in the AANA, many CRNAs also belong to a variety of anesthesia and subspecialty organizations, including the following:
  • International Anesthesia Research Society
  • American Society of Regional Anesthesia
  • American Association of Critical Care Nurses
  • American Society of Perianesthesia Nurses
  • Association of PeriOperative Room Nurses
  • American Association of Respiratory Care
  • American Pain Society
  • Society of Office Based Anesthesia
  • Society for Obstetrical Anesthesia Perinatology
  • Society for Ambulatory Anesthesia