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Introduction   

You may have heard of nurses going back to school to become a nurse anesthetist or a “CRNA”. This is pretty common in the ICUs I have worked in. But what exactly is a nurse anesthetist? What do they do? And how does one become a nurse anesthetist? In this course, we will answer all those questions and give you all the information you need about the world of nurse anesthesia. 

Definition 

To start with, let’s define “CRNA”. CRNA stands for Certified Registered Nurse Anesthetist; it is the acronym for the license that a nurse anesthetist carries. This is comparable to “RN” for a registered nurse. There has been a push by some to change the title of advanced practice nurses in anesthesia to “nurse anesthesiologist” so you may also hear this term (1).  

So, what is a “certified registered nurse anesthetist” actually? A CRNA is an advanced practice nurse, like a nurse practitioner or nurse midwife, who specializes in anesthesia. While a midwife focuses on pregnancy and neonates, a CRNA focuses on the safe administration of anesthesia.  

A CRNA’s role revolves around inducing anesthesia and keeping the patient safe and stable while in this anesthetized state. CRNAs were the very first anesthesia providers dating back to the American Civil War (2). Understanding of anesthesia has changed dramatically in the last 150 years, but CRNAs continue to be an important part of the world of anesthesia.  

Education 

To become a nurse anesthetist, one must go through several steps. First, the person must become a registered nurse, and practice nursing in an intensive care unit. Admission to a nurse anesthesia program requires a minimum of 1-2 years of experience in an intensive care unit (2). Most programs require 2 years of experience, with a preference for more. The “maintenance” phase of anesthesia after the patient has been anesthetized and surgery begins is similar to caring for a sedated intubated patient in the ICU. This is the reason why ICU experience is a requirement for nurse anesthesia programs.  

Next, the person must acquire a bachelor’s degree, if they did not do so with their initial nursing education. All nurse anesthesia programs are now required to be doctorate programs. Some programs also have specific requirements for courses that must be completed before applying to their nurse anesthesia program. A statistics course is a common specific requirement. The majority of programs also require the applicant to be CCRN certified, which involves paying a fee and taking an exam on critical care management (3).  

Next, the nurse must apply to and be accepted into a nurse anesthesia program. This generally involves filling out an application form, writing an essay, and paying an application fee. If selected for interview, the person will be asked to interview for acceptance into the program. In my experience, this usually involves a panel of faculty and one or two anesthesiologists or staff CRNAs.  

Once accepted into a program, the student must complete their doctorate. Programs are generally three years of continuous schooling, although a few programs are longer. Most programs are organized so that the first year is primarily classroom learning, while the second and third years are primarily clinical experience. Classroom learning focuses on pharmacology, anatomy, pathophysiology, anesthetic considerations for specific procedures, anesthetic assessments, and proper airway and line placement. Graduation from the doctorate program also requires completion of a doctoral research project.  

After graduation, the CRNA-to-be must pass the National Certification Examination (NCE) (2). This is akin to taking the NCLEX before being licensed as an RN. After passing the NCE the person is officially a certified registered nurse anesthetist! The final step before going to work as a CRNA is being credentialed by the facility you will work for. Credentialing involves submitting paperwork, including a background check and proof of licensure and takes 30-90 days depending on the employer (2).  

Like a registered nurse, CRNAs must complete continuing education to maintain their licensure. CRNAs must complete 60 hours of continuing education every 4 years and must include courses on airway management, anesthesia equipment, clinical pharmacology, and pathophysiology (9). CRNAs must also complete 40 hours of professional development through teaching, research, or publishing every 4 years (9).  

CRNAs must also take the Continued Professional Certification (CPC) assessment every 8 years – essentially retaking their boards (9). Fortunately, most CRNA positions do offer paid time off to complete these continuing education requirements.  

CRNA Practice 

What does a practicing CRNA do? CRNAs provide anesthesia care for patients undergoing a procedure that requires anesthesia. Most commonly, this is surgery, but it can also be for diagnostic tests such as MRI or bone marrow biopsies. Anesthesia care includes a pre-anesthetic and post-anesthetic assessment and intra-operative management.  

A pre-anesthetic assessment includes interviewing the patient about their anesthesia history, pertinent medical history, and medications, as well as an airway examination. Intra-operative management includes induction of anesthesia, placing any needed airway and lines, positioning the patient for surgery, monitoring and treatment of ventilation and hemodynamics, emergence from anesthesia, and extubating. A post-anesthetic assessment focuses on mental status, pain, nausea, vital signs, and any potential side effects from anesthesia or the surgery itself.  

CRNA’s scope of practice is determined by the state and institution in which they work. In about half the states, CRNAs are required to be under the supervision of an anesthesiologist, and in the other half CRNAs can provide anesthesia independently. Supervision requires that the physician be present for induction of anesthesia, be actively involved in the anesthesia plan, be immediately available throughout the anesthetic, and be present at emergence from anesthesia (6). Anesthesiologists can supervise up to 4 CRNAs at once (6). Keep in mind that even if a CRNA works in a state where they have the authority to practice independently, individual institutions can set their requirements for medical supervision.  

Unless working in an outpatient setting, practicing as a CRNA generally involves being on-call. If an emergency surgery needs to be performed, an anesthesia provider must be available to administer anesthesia for the surgery. CRNAs are also considered to be the airway and line placement experts – as this is part of their everyday duties – and may be called on to place an airway or line.  

CRNA Salary and Outlook 

CRNAs have a high level of responsibility and generate a lot of revenue for healthcare facilities. Accordingly, they are paid well. The average salary for CRNAs in 2023 was $173,000-250,000, depending on the state in which they work (4). In general, more rural states where CRNAs practice independently pay higher than urban areas or states in which CRNAs practice under physician supervision.  

CRNAs are currently in high demand and short supply. This is leading to continued increases in salaries and sign-on bonuses in order to recruit anesthesia providers. CRNA jobs are projected to increase 38% in the next 10 years, much higher than the overall job increase of 3% (5). This means that there will be many jobs available for CRNAs in the future.  

Practicing as a CRNA is different from practicing as an RN, in that anesthesia providers can bill directly for their services (6). This gives CRNAs the ability to practice not only as an employee of a hospital or surgery center but also as contractors. Practicing as a contracted anesthesia provider generally involves higher pay but without the benefits of a long-term employee. CRNAs can even build their own anesthesia business and bill insurance providers directly. 

CRNAs have high job satisfaction, according to a national survey of CRNAs (8). They attributed their satisfaction to their higher levels of autonomy and their compensation (8). CRNAs that reported lower satisfaction commonly reported a lack of autonomy or inability to practice to the full extent of their training (8). CRNAs place a great deal of importance on autonomy in their practice.  

This information is based on information from the United States, but CRNAs can also practice in other countries. The International Federation of Nurse Anesthetists is a great resource for determining in which countries a CRNA can work and how their role may differ in these different countries (7).  

Case Study – Author’s Story  

As a current CRNA student about halfway through a nurse anesthesia program, I can offer some insight into the process of becoming a CRNA. Gaining the accolades needed to become a competitive applicant required intention and extra work outside of working in an ICU for 2 years. To be a competitive applicant, I worked my way into roles as a nurse preceptor and charge nurse and volunteered to join committees. Working to achieve all of these things and hoping it is enough to get accepted to a program is difficult, as was being turned down in my first year of applying to schools. 

Once I was accepted into a program the transition back into school life was an adjustment but not difficult. Starting clinical was a much harder transition. It is difficult being a novice again in a new field with high levels of responsibility. I would say this difficult period lasted about the first 6 months, with good days and bad days. The reality of administering anesthesia is busy and stressful for the first 30 minutes to an hour at the start and end of each case, with the middle usually being uneventful. If something does go wrong in the middle of the case, it can again be stressful as you are the provider responsible for diagnosing and correcting the problem.  

On a more positive note, the anesthesia school itself has been very supportive. They want you to succeed and represent the school well, and they do their best to help you through the program. Although there is a certain amount of stress and feeling uncomfortable when in the clinical setting, most of my days have been positive, and I do enjoy the work. There is satisfaction in seeing a problem and fixing it quickly, and it is rewarding to see patients wake up who are feeling well after major surgery.  

Conclusion

In conclusion, nurse anesthesia is a unique advanced practice role that nurses can choose to pursue. Becoming a CRNA involves gaining experience in an intensive care unit, applying to a nurse anesthesia program, completing a doctorate, and taking boards to be licensed. The role of a CRNA is to provide safe anesthesia care, keep the patient anesthetized and safe during surgery, perform pre- and post-anesthesia assessments, and place necessary airways and lines. CRNA jobs are in high demand, pay well, and opportunities are expected to grow in the future. The road to becoming a CRNA is difficult and somewhat long, but it offers a great and rewarding career. Hopefully, this course has clarified the role of CRNA and what training they must go through. If you have been interested in following the road to a CRNA, hopefully, this course has armed you with the knowledge you need to make an informed decision.  

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