Certified Registered Nurse Anesthetists, Advanced Practice Registered Nurses

CRNAs should not be referred to as “mid-level practitioners,” “nonphysicians,” “physician extenders,” “dependent practitioners,” or “allied health practitioners”
  
Position Statement
Introduction
Historically, in some settings, publications, policies and law, the Certified Registered Nurse Anesthetist (CRNA) has been referred to as a “midlevel provider” or “physician extender.”  These and other terms are not representative of nurse anesthesia practice.  Each healthcare professional has a unique title that is representative of his or her education, licensure, certification, and expertise.
 
Position
CRNAs should be referred to as “Certified Registered Nurse Anesthetist,” “CRNA,” or “nurse anesthetist” to address CRNA practice in their workplace; in policy, publications, and presentations; and in other scenarios where CRNAs are identified.  If CRNAs  are referred to as part of a group, terms such as “advanced practice registered nurse (APRN),” “advanced practice professional,” “advanced practice clinician,” “qualified licensed practitioner,” “clinician,” or “healthcare professional” reflect their role and are preferable depending on the setting or purpose.1
 
The American Association of Nurse Anesthetists (AANA) opposes terms such as “mid-level practitioner,” “nonphysician,” “physician extender,” “dependent practitioner,” and “allied health practitioner” to refer to CRNAs either individually or as part of a group.  We urge use of the terms “Certified Registered Nurse Anesthetist,” “CRNA,” or “nurse anesthetist” by healthcare policymakers, insurers, organizations, employers, healthcare professionals, and others for accurate and clear identification of the professional title.    
 
Terms such as “mid-level practitioner” are outdated and anachronistic in the current healthcare system.  Use of these terms can cause confusion for patients and others.2  The National Academies of Sciences, Engineering, and Medicine (formerly the Institute of Medicine)3 and the Federal Trade Commission have repeatedly called for APRNs, including CRNAs, to practice to the full extent of their education, training, and certification in the interest of patient access to safe, high-quality care and competition in the marketplace to help promote innovation and control healthcare price growth.4 
 
CRNA Practice
The AANA’s Scope of Nurse Anesthesia Practice reflects that CRNAs are licensed, independent practitioners who provide comprehensive anesthesia services.  CRNAs are not extenders of physicians, nor are they dependent on physicians to provide anesthesia services.  CRNAs practice both autonomously and in collaboration with other healthcare professionals on the interprofessional team to deliver high-quality, holistic, patient-centered, evidence-based anesthesia and pain care services.  Nurse anesthetists care for patients of all acuity levels across the lifespan of the patient in a variety of settings for procedures including, but not limited to, surgical, obstetrical, diagnostic, therapeutic, and pain management.  CRNAs serve in leadership roles in healthcare delivery organizations and academic institutions and receive direct reimbursement for anesthesia care from Medicare and major commercial plans.

Background
Terms such as “mid-level provider,” “nonphysician,” and “physician extender” were created by physicians, physician groups, and physician-led organizations and corporations.5  “Mid-level” implies that CRNAs provide only average care, which numerous studies refute (see CRNAs: Safe Care and CRNAs: The Future of Anesthesia Care Today Research; also see Important Research and Studies).  This term fails to inspire confidence in the patients served by CRNAs.2,6,7  The term “mid-level” incorrectly implies that the standard of care followed by CRNAs is lower than the standard of care followed by anesthesiologists.   In fact, the practice of anesthesia is a recognized nursing and medical specialty unified by the same standard of care. 

Similarly, “nonphysician” and “physician extender” are negative terms that imply that CRNAs do not provide the same high level of care as physicians.  The terms “allied health practitioner” and “dependent practitioner” are likewise inaccurate descriptions of the CRNA role.  All of these terms are vague, confusing, misleading and hinder the delivery of safe, patient-centered care. 
 
Conclusion
Healthcare professionals should be referred to by their individual titles to reflect their unique roles.  CRNAs should be referred to as “Certified Registered Nurse Anesthetist,” “CRNA,” or “nurse anesthetist.”
 
References
  1. The Advanced Practice Registered Nursing (APRN) Consensus Work Group and the National Council of State Boards of Nursing (NCSBN) APRN Advisory Committee. Consensus Model for APRN Regulations: Licensure, Accreditation, Certification & Education. 2008; http://www.aacn.nche.edu/education-resources/APRNReport.pdf. Accessed June 23, 2016.
  2. Bishop C. Advanced practitioners are not mid-level providers. J Adv Pact Oncol. 2012; Sep-Oct; 3(5):287-288.
  3. The National Academies of Sciences, Engineering, and Medicine (formerly the Institute of Medicine).  The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2011.
  4. Gilman DJ, Koslov TI. Policy Perspectives: Competition and the Regulation of Advanced Practice Nurses. 2014; http://www.ftc.gov/system/files/documents/reports/policy-perspectives-competition-regulation-advanced-practice-nurses/140307aprnpolicypaper.pdf. Accessed June 17, 2016.
  5. Hoyt KS. Why the terms "mid-level provider" and "physician extender" are inappropriate. Adv Emerg Nurs J. Apr-Jun 2012;34(2):93-94.
  6. Pappas MD. Stop Calling Nurse Practitioners Mid-Level Providers. 2014; http://www.kevinmd.com/blog/2014/07/stop-calling-nurse-practitioners-mid-level-providers.html. Accessed June 22, 2016.
  7. American Association of Nurse Practitioners. Use of Terms such as Mid-level Provider and Physician Extender. 2015; https://www.aanp.org/images/documents/publications/useofterms.pdf. Accessed June 22, 2016. 


Adopted by AANA Board of Directors July 2016.

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