Rest Easy
With demand high for CRNAs, nurse anesthetists enjoy autonomy, comfortable salaries and the rewards of tending to their patients

By Margaret Watson
October 9, 2003

As a certified nurse anesthetist in rural Nebraska, Steve Wooden, MS, CRNA, travels quite a bit. But he doesn't always hit the road.

Instead, his services are in such high demand in remote areas of the state, he takes to the cockpit of his private plane to pilot himself to various operating rooms.

"I do a lot of traveling, as much as 100 miles or more to do a case or two. Without CRNAs, small hospitals would have a hard time providing surgery services, or even staying in business," said Wooden, of Anesthesia Services of Nebraska in Broken Bow.

On a typical day, Wooden may administer anesthetic for a toddler's spinal tap, fly to another town for a major surgery or for a birth, and head back to Broken Bow to give a local or spinal analgesia for a patient's chronic back pain.

Nurse anesthetists are among the most highly sought-after health professionals today, benefiting from a higher profile in the field and a growing workload. CRNAs administer about 65 percent of the anesthetics given in this country each year, working collaboratively with physicians to care for patients before, during and after surgery. The percentage of anesthesia given by CRNAs has increased from about 49 percent in 1971.

Hot commodity

Why the surge in demand? CRNAs are cost-effective providers of anesthesia service at a time when numbers of inpatient and outpatient surgeries are rapidly increasing, reported Allied Consulting Inc., a Texas professional staffing firm. With a concurrent nationwide shortage of anesthesiologists and managed care's imperative to reduce costs, CRNAs represent a savings to hospitals.

"We perform [a lot of] the same clinical functions as an anesthesiologist," said Rodney Lester, Ph.D., CRNA, nurse anesthesia division director and associate professor of clinical nursing at the University of Texas-Houston Health Science Center School of Nursing. "Day surgery and short surgical procedures have increased, so a CRNA may be able to do 10 to 12 anesthetics per day as opposed to six or seven. We have enough CRNAs to take care of everyone, but patients for elective surgeries may have to wait a little later in the day."

About 80 percent of CRNAs work as partners in care with anesthesiologists, while the remaining 20 percent function as sole anesthesia providers collaborating with surgeons and other licensed physicians. In anesthesia care teams, anesthesiologists provide medical direction for up to four CRNAs, and CRNAs typically administer the anesthetics and remain in the operating room with the patient the entire time.

The ratio of anesthesiologists to CRNAs is set by the hospital or surgery center, based on the sickness of the patients and the amount of manpower the institution can afford, Lester said.

The demand for CRNAs, particularly in rural communities, has produced an 11 percent vacancy rate for CRNA job positions, according to a recent study by the American Association of Nurse Anesthetists. Allied Consulting reported it conducted more searches for CRNAs in 2002 than for any other type of health care professional.

"This is a tough market for recruiting. CRNAs can literally go anywhere they want to go," said Larry Hornsby, CRNA, president of Anesthesia Solutions, which staffs both CRNAs and anesthesiologists for a hospital in Mobile, Ala. "If someone is burned out with late hours at a large hospital, they can go to an ambulatory center across town, and salaries are increasing."

Allied's average salary offer for CRNAs in 2002 was $129,285, up 9.5 percent from $118,000 in 2001. The upper end of CRNA salaries was equivalent to what many primary care physicians are offered. Anesthesiologists earn about $240,000 per year, in comparison. An AANA membership survey in 2001 found that the median CRNA salary was $113,000 annually.

Job vacancies and above-average nursing salaries are starting to attract candidates into the field. Lester, outgoing president of AANA, added that enrollment has increased to 1,800 students per year in CRNA master's-level programs from a low of less than 600 CRNAs certified in 1989. Unlike other nursing programs that are bulging to capacity, the nation's 88 accredited nurse anesthesia programs are being expanded to accommodate more students-perhaps 2,000 per year-which could help relieve the CRNA shortage.

CRNAs must have a bachelor's degree in nursing and at least one year of critical care practice before entering a CRNA program. Nurse anesthetists also must pass a national certification exam through the Council on Certification of Nurse Anesthetists. For what it costs to educate one anesthesiologist, 10 CRNAs can be trained, according to a 1996 study, the AANA said,

Guy magnet

A characteristic of nurse anesthetists unique in comparison to other nursing specialties is the preponderance of men in the field. The AANA reports that 44 percent of CRNAs are men, compared with less than 5 percent in all of nursing. Male nurses were actively recruited by military order in the 1960s to serve as CRNAs in Vietnam, and many medics who served in Vietnam entered the field of nurse anesthesia in larger numbers after the war. Many sought specialized training in nursing after returning home.

"Men have been attracted by the salaries-CRNAs have always been paid more than other nurses," Lester said. "There is also the autonomy of our practice and the lure of using cutting-edge equipment. I think most of all it is the challenge that has drawn men to anesthesia nursing."

Tom McKibban, a CRNA at Susan B. Allen Memorial Hospital in El Dorado, Kan., and incoming AANA president, believes the "take-charge attitude of men" leads them to the profession.

"I went into nursing specifically to go into anesthesia," McKibban said.

CRNAs historically have worked with considerable autonomy. Today, in more than half the states, CRNAs are not required to be supervised by a physician, and no state requires supervision of CRNAs by an anesthesiologist.

"We have a long history of nurses administering anesthesia, dating from the Civil War," when ether was given through a glass inhaler, Lester said.

Among the first nursing specialists, anesthetists were brought into the operating room to counter the high mortality rates surgeons were reporting with unattended anesthesia, according to the AANA. The first formal educational programs preparing nurse anesthetists were established in 1909, according to the AANA.

While in larger hospitals, CRNAs work as part of anesthesia care teams headed by an anesthesiologist, and the level of autonomy of CRNAs varies depending on hospital policies and state regulations. New York, for example, requires supervision by a surgeon; in California, physician supervision is not required.

"In our hospital, we have one anesthesiologist per three nurse anesthetists. The anesthesiologist is present when the patient goes to sleep and is available in the suite if needed," said Katherine Farrell, CRNA, staff nurse anesthetist for the Anesthesia Group of Onondaga PC at St. Joseph's Hospital Health Center in Syracuse, N.Y. "I pick the drugs I want to use, and if I have questions or concerns, I can consult with the anesthesiologist."

Farrell works in the hospital's operating room, where she handles more seriously ill patients, and in two affiliated outpatient surgery centers. "There is a real art to out-patient surgery," Farrell said. "We must get them to sleep quickly and wake them up in a short period of time."

The relationship between anesthesiologists and nurse anesthetists has historically been collegial, but with the independence of CRNAs and a controversial new Medicare rule, new debate over supervision and CRNA practice is introducing some polarization between the two professions. (See related story.)

Nurses first

CRNAs stress that their nursing skills are as critical in the anesthesia process as their technical skills, because patients fear anesthesia more than they do the surgical procedure.

"We're concerned with the patient's psychological well-being, as well as physical condition. We help manage the patient's fear before surgery with our nursing skills, rather than simply using drugs," Wooden said.

During preop interviews, CRNAs reassure patients and families on the anesthesia procedures. This is usually their first contact with the patient, unlike the surgeon who likely has held several preliminary discussions with the patient to discuss the operation.

"I have about five minutes after meeting the patient to establish a rapport and have them trust me to put them to sleep safely and wake them up again," Farrell said.

Simple human contact like placing a hand on the patient's shoulder provides great reassurance while doing the preoperative interview, said Duane Laurelton, CRNA, of Mid-Columbia Anesthesia PC in Hood River, Ore. Getting the patient to open up is important, so that the CRNA can uncover a medical condition or something the patient has done that could compromise their well-being under anesthesia.

"This could be something like undetected hypertension or that a child ate some chips in the car on the way to surgery," Laurelton said. "A CRNA must talk to the surgeon about canceling surgery because of patient safety, especially with elective surgery, and the surgeon is more willing to defer to our judgment in these circumstances."

Patients also have questions about what sensations or awareness they may have during surgery and concerns about pain after surgery. A patient may have had an unpleasant experience decades before when ether was used, recalling the overwhelming ether odor and terrible nausea after the surgery. CRNAs assure their patients that today's anesthetic agents allow more precise control of consciousness, disappear more quickly from the bloodstream and result in fewer side effects like nausea.

Because no single drug will put the patient to sleep and relieve pain, CRNAs design a combination of agents to meet the surgical and medical needs of each patient, tailoring the time, depth of anesthesia and amount of sedation. They administer inhalation anesthetic agents, sedatives, muscle relaxants and many other drugs that act to help maintain normal body functions, even reducing the pH in the stomach acid to keep it from burning if there is any nausea. Synthetic narcotics today provide potent analgesic pain relief but last only a few minutes after the surgery, unlike morphine, which affected patients considerably after surgery.

A patient's greatest fear is waking during surgery, Wooden said. Wooden assures patients that incidents of awareness during surgery are extremely low because the CRNA is always there to "monitor the monitors."

CRNAs prep the operating suite "like a pilot preparing for flight, with an extremely thorough setup of the anesthesia machines and any drugs and medication we might need," said Susan Willis, chief CRNA at Parkland Memorial Hospital in Dallas.

Parkland has 35 staff CRNAs delivering 50 percent to 60 percent of the anesthetics in 13,000 cases per year, including 10,000 OB cases.

The nurse anesthetist stays with the patient throughout the surgery, continuously monitoring vital signs and medication levels with state-of-the-art equipment. For example, a pulse oximeter attached to a patient's finger gives a constant recording on a screen of whether the patient has adequate blood oxygen.

"In the past, we had to look for symptoms to recognize a problem, such as a patient beginning to turn blue," McKibban said. "Now, with our monitoring equipment, we have a heads-up on what is happening to the patient so we can intervene before there is a problem."

The CRNA oversees the patient's recovery until admitted to a floor bed or until discharged from day surgery.

"As soon as the patient is awake enough after surgery to have interaction, I bring in the family to see them and facilitate the reconnection between family and the patient. This is especially important when the patient is a child," Wooden said.

Long hours, often without a break, and being on call are downsides to working as a CRNA in both metropolitan hospitals and in rural areas, where the CRNA may have little backup.

"I've missed only one day due to illness in 26 years of practice, because if I did, cases would have to be canceled," McKibban said. "This is a common plight where one CRNA may cover two or three hospitals, 24/7."

Sitting at the head of the operating table is stressful. "We have a tremendous amount of responsibility, and can literally have a patient's life in our hands if something goes wrong," Farrell said.

Despite the downsides, Willis said CRNAs express significant job satisfaction.

"The salaries help, and our caseload is varied and challenging. We see immediate results because we can complete cases start to finish several times per day," she said.

Contact Margaret Watson at hotlinkcom@yahoo.com