Guide to Certified Registered Nurse Anesthesia

Certified registered nurse anesthetists (CRNAs) are advanced practice registered nurses who specialize in administering anesthesia and other pain management medications to patients in a number of medical situations, including surgery, labor and delivery, trauma stabilization and treatment, podiatry, dentistry, and palliative care. According to the American Association of Nurse Anesthetists (AANA), CRNAs are the primary providers of anesthesia in both rural areas and for the U.S. military. CRNAs play an important role in acute care settings, as their work helps to ensure that patients undergoing surgical operations and other procedures receive the care and monitoring they require for a safe operation.

CRNAs’ role differs from those of other nurse practitioners in that their daily work is highly specialized, focusing on preparing, attending, and monitoring a patient throughout a particular surgical procedure. CRNAs’ patient population can vary according to the medical setting in which they work, as well as the type of anesthesia in which they wish to specialize. For example, CRNAs can work on a designated anesthesia team at a large tertiary hospital that serves a wide variety of patients, or they may function as the sole anesthesia professional at a small surgical center or private practice. In large medical settings, CRNAs may rotate across numerous departments depending on patient needs and staff availability, or focus on particular patient populations, such as mothers during labor, trauma patients, or individuals undergoing certain types of surgery. In more specialized settings, CRNAs may exclusively see one type of patient population, such as pregnant mothers or patients suffering from chronic pain who need regular palliative care services.

Depending on their work environment, CRNAs may work in collaboration with surgeons and other physicians, critical care nurses, anesthesiologists, dentists, podiatrists, and medical assistants. In certain states, CRNAs are authorized to practice independently of physician supervision; in these states, CRNAs may have more flexibility in the types of settings in which they can work. In addition to serving patients in clinical settings, CRNAs can also engage in academic education and staff training.

To become a CRNA, individuals must hold a current registered nurse license in their state of residence, and complete a minimum of a year of critical care nursing experience. Prospective CRNAs must complete a graduate nursing program in anesthesiology from an institution that has been accredited by the Council on Accreditation of Nurse Anesthesia Educational Programs. Their program must include clinical internships in settings that are relevant to nurse anesthesia, such as intensive care units, surgical units, and/or emergency departments. After earning their graduate degree in nurse anesthesia, RNs must take and pass a national certification examination administered by the National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA). Prospective CRNAs should also research and fulfill any state-specific credentialing requirements in order to practice in their region of residence.

Note: According to the American Association of Nurse Anesthetists, by 2025 CRNAs will be required to hold a DNP to practice. As a result, many nursing programs have begun transitioning their MSN program to a DNP program to meet this requirement.

Where CRNAs Work

CRNAs can work in many different medical environments, including but not limited to hospitals, freestanding surgical centers, dentists’ offices, and other settings that care for patients who require pain management medication either during surgery or to manage chronic pain. Dr. Valerie Bell, PhD, CRNA, is a Certified Registered Nurse Anesthetist at the University of Miami Hospital, and also serves as an Assistant Professor of Clinical Nursing at the University of Miami School of Nursing and Health Studies. In an interview with OnlineFNPPrograms.com, she explained the wide variety of settings in which she has worked as a CRNA.

“There are so many practice settings which utilize anesthesia services. Anesthesia services are utilized for dental, podiatry, surgery, obstetrics, and pain management practices,” she said, “I’ve worked independently as a CRNA in a small 50-bed community hospital where I was the only anesthesia provider on site. I’ve worked in same day surgery centers, plastic surgery centers, alongside other CRNAs, and I’ve worked in large teaching hospitals where you collaborate within the Anesthesia Care Team.”

Below is a description of several common settings that typically employ CRNAs.

Hospital Surgical and Acute Care Departments

CRNAs are trained to support patients who are suffering from a wide array of medical conditions that require surgery. Surgical and acute care departments, emergency rooms, ob/gyn, orthopedics, and palliative care are a few examples of departments in which CRNAs can work at a medical center. CRNAs can rotate between different units depending on the surgical needs of patients, or they may specialize in a particular type of patient population or condition. For example, on a given day, a CRNA in a hospital setting might be assigned to the orthopedics, neurosurgery, labor and delivery, and/or gynecological departments. While the specific type of anesthetic procedure may differ between their patients, CRNAs generally must apply the same principles of pharmacology, human physiology, and understanding of potential co-morbidities to each surgical procedure they attend.

Dr. Dawn Clark, MSN, DNP, CRNA is the Assistant Chief CRNA at Kaiser Permanente’s Antioch Medical Center, where she provides anesthesia services for multiple medical departments. In an interview with OnlineFNPPrograms.com, she explained how the CRNA role involves tailoring anesthesia services to each patient in the operating room (OR). “My core responsibilities have always been providing the type of anesthesia the patient needs for the type of surgery they are having,” she said, “I work with registered nurses, anesthesiologists, surgeons, surgical technicians, surgical assistants, physician assistants, assistant managers, managers, directors, secretaries and we all communicate with each other to provide the best care for our patients.”

Dr. Clark also explained how, despite the varied needs and health statuses of the patients she treats, there exists a common thread between her work with all of them, in that all patients have complicated conditions that require a strong understanding of co-morbidities, human physiology and pharmacology, and surgical procedures. “I provide anesthesia for a variety of surgeries and patients,” she said, “Obstetrical anesthesia can be challenging. Some patients have a list of co-morbidities so I have to know the pathophysiology of those co-morbidities, how they are treated, how they can affect anesthesia and how anesthesia can affect the patient. I have to have an in-depth understanding of pharmacology of anesthesia medications as well as the medications the patient is prescribed. When I work in the main OR, the same applies to each patient with regard to co-morbidities, medications and anesthesia.”

Katherine Ford, MSN, CRNA, is a Certified Registered Nurse Anesthetist who has worked at several large medical centers, including Lakeway Regional Medical Center and UCLA Harbor Medical Center. In an interview with OnlineFNPPrograms.com, she explained how her workday involved rotating between several different operating rooms across multiple departments. “My typical day of work was a 12-hour shift [at UCLA Harbor Medical Center],” she said, “I would be assigned to a specific operating room, for example orthopedics or gynecological.” At her current role at Lakeway Regional Medical Center, Ms. Ford works with many patients with spinal and neurological conditions. “Lakeway Regional is one of Austin’s premier orthopedic spine and neurology centered hospitals,” she said, “The Austin Spine and Neuro Texas groups both operate at this facility bringing the most acute spine and neurological patients.”

Private Practices

CRNAs can also work in small private practice settings, where they collaborate with physicians, registered nurses, and other medical staff to provide anesthesia. In some states, CRNAs are authorized to work independently of physicians, which can afford them more flexibility to specialize in a particular area of anesthesia. In her interview with OnlineFNPPrograms.com, Ms. Ford described her transition to independent practice, where she specialized in palliative care and plastic surgery.

“After years of being in an acute care setting (UCLA Harbor), I was introduced to the idea of working in a more independent practice. Living in California (an opt-out state), I decided what a privilege it was to be able to do anesthesia without direct supervision of an anesthesiologist,” she explained, “I began to network with other CRNAs and to actively seek out anesthesia opportunities that would prepare me to become a sole provider. I met two wonderful mentors, Lisa Pulver, CRNA and Greg Wright, CRNA who allowed me to work with them to provide anesthesia in the Beverly Hills and Santa Monica area.”

Ms. Ford also explained the differences between working in private practice and working in a larger hospital setting. “First, to work in independent practice you need to have anesthesia experience under your belt. I wouldn’t recommend this type of work for a new CRNA,” she advised, “When you are the sole anesthesia provider at a facility, you are in charge of the patient and equipment. For example, if the oxygen goes out, you need to change your own tank. Trouble shooting issues and taking care of the patient when you are on your own takes autonomy, critical and quick thinking, and organization.”

Dentist Offices, Palliative Care Clinics, and Freestanding Surgery Centers

In addition to hospitals and private practice settings, CRNAs can work in a variety of outpatient medical environments in which patients require low-level administrations of anesthesia. Examples of such environments include freestanding surgery centers, palliative care clinics, and dentist offices. Freestanding surgery centers are non-hospital medical settings that perform outpatient surgeries and other procedures that do not require patients to recover overnight. CRNAs can work in these environments to administer anesthesia in much the same way that they do in larger hospital settings. As they are outpatient, freestanding surgery centers tend to see patients who are not suffering from severe conditions. CRNAs may also contract with dentist offices to provide anesthesia to patients undergoing invasive dental procedures, as well as palliative care clinics where they may administer low levels of anesthesia to help patients manage severe and chronic pain.

Military Medical Settings

As mentioned previously, CRNAs are the primary anesthesia providers for the U.S. Military. Similar to CRNAs who work in civilian settings, certified registered nurse anesthetists who are employed in military settings can work across many different departments, including emergency care, delivery rooms, surgery centers, and critical care units.

What CRNAs Do

CRNAs provide pre-operative, intra-operative, and post-operative care to patients. Pre-operative anesthesia services are defined as a thorough evaluation of a patient’s health status, an interview of the patient during which he or she is informed of the upcoming anesthetic services to be administered, and the development of a complete anesthesia plan. Intra-operative anesthesia services are defined as continued anesthesia administration during their procedure and the monitoring of patients during the operation. Post-operative anesthesia services are comprised of medical care, support, and monitoring to ensure that patients have a safe recovery period post-operation. In addition to clinical work with patients, CRNAs can also engage in staff training and leadership, research and program development, and academic instruction at nursing schools.

Pre-Operative Anesthesia Services

The pre-operative phase of anesthesia services involves creating a detailed anesthesia plan that is tailored to the patient’s health status and surgical procedure. To develop this plan, CRNAs interview the patient, conduct a physical assessment to detect any health conditions that may impact the type or dosage of anesthesia a patient should receive during his or her operation, and then consult and collaborate with other medical professionals to create the anesthesia plan.

In her interview with OnlineFNPPrograms.com, Dr. Bell explained the detailed health evaluation she conducts with each of her patients, and why this evaluation is so important for a safe surgical procedure. “Items that are part of developing a patient anesthesia plan include a preoperative evaluation, which may be in person or over the phone. Typically the patient is asked about his or her physical health, surgical history, any events which have occurred during any previous anesthetics, any allergies, any medications that he or she may be taking,” she said, “After assessing the patient’s history, this is the time to order any pertinent labwork or tests, such as ECG or x-rays. Also a very important element in the pre-op assessment is the evaluation of the patient’s airway. We assess how wide the patient can open their mouth, the visibility of the structures of the mouth, how flexible their neck is, and the condition of their teeth. We do this to determine the ease or difficulty in managing the patient’s airway. Airway management can include utilizing a simple face mask, a supraglottic device, intubation with an endotracheal tube, or having to utilize a videolaryngoscope or a fiber-optic scope to accomplish intubation.”

After interviewing the patient and conducting a health evaluation, CRNAs develop a customized anesthesia plan for the patient by integrating the information they have gathered with their own understanding of human physiology and pharmacology. “Once you have an understanding of the physiology surrounding [the patient’s] history, you incorporate the type of surgery and anticipate the untoward effects of the surgery. These elements join with a deep understanding of the pharmacology, which will be necessary to produce a plan that will safely carry the patient through the surgical event,” Dr. Bell explained in her interview. The anesthesia plan also must be adaptable to account for unexpected events during the surgical procedure.

“The anesthesia care plan is the blueprint which we use to manage the case. We use it as a point of communication, to prioritize care, to allow us to anticipate events that are most likely to occur, and develop a plan of action to deal with those events,” Dr. Bell continued, “Anticipation is everything, and by developing an anesthesia care plan, we plan for the worst event, and hope that it never happens, but if it does, we are ready to intervene.”

CRNAs also educate the patient on what he or she will experience while under anesthesia, and address any of their concerns prior to the operation. In her interview with OnlineFNPPrograms.com, Ms. Ford explained how she informs patients of the potential health risks of anesthesia during an operation, and also answers any of their questions. “After my initial anesthesia setup and anesthesia machine check, I would meet the patient in the pre-operative holding area to interview my first patient of the day,” she said of her time as a CRNA at UCLA Harbor Medical Center. “I discussed the anesthesia that would be provided and performed a thorough head to toe health assessment. Once the patient’s questions were answered, I would have the patient sign a legal anesthesia consent acknowledging that they are aware of the risks and benefits of anesthesia. Next, I would collaboratively generate an anesthesia plan with my attending anesthesiologist for the day and document this plan in our electronic medical record system.”

Intra-Operative Anesthesia Services

Intra-operative anesthesia services are all the procedures and tasks involved in the administration of anesthesia during a surgical procedure. “[Intra-operative anesthetic services involve] starting IV’s, intubating the patient, starting arterial lines and central lines if necessary, monitoring the patient’s condition throughout the surgical event, and initiating any treatment when the patient’s condition varies from baseline,” Dr. Bell explained, “[It also includes] everything that happens once the patient has been induced. This is managing the airway, inserting any necessary lines for monitoring, providing supportive care to maintain vital signs, including altering levels of anesthetic agents, vasopressors, and administering pain medications.”

During the surgical procedure, CRNAs must be highly attentive and responsive to the patient’s vitals and how the patient is responding to both the surgery and to the anesthetic. “This is a critical time in the anesthetic process as you are in a continual state of assessment of the patient’s condition, as well as assessing what’s going on with the surgery itself. You are paying attention to everything, monitoring the amount of blood loss, determining how much fluid the patient is loosing and making sure you replace it appropriately, making sure the patient is at the right level of anesthesia, not too light, not to deep, but just right,” Dr. Bell explained. “We give enough pain meds throughout the case to ensure the patient awakens as pain free as possible while still maintaining the respiratory drive.”

Post-Operative Anesthesia Services

Post-operative anesthesia services include waking the patient and monitoring their recovery post-operation. Tasks involved in this step of the process include extubating the patient, developing a post-operation pain management plan for patients, and following up with patients in the post-anesthesia recovery room to ensure their pain post-operation is under management. “Part of our job is to safely wake, or emerge, the patient from anesthesia,” Dr. Bell said, “This includes extubating the patient as smoothly as possible, and assuring they have adequate pain control.” Post operative care also includes managing the patient’s airway, controlling their pain, and monitoring post-operation for any complications arising from the surgery or anesthesia.

After the extubation of the patient, CRNAs report the details of the operation to the recovery room medical staff, and also participate in the post-surgery care of the patient. “Post-anesthesia care occurs after the patient leaves the OR. Post operative orders are written by the CRNA for pain medications, anti-nausea medications and anything pertinent to the care of the patient for the time the patient spends in the post anesthesia care unit,” Dr. Clark explained, “The CRNA gives report to the recovery room nurse about the anesthesia used, the surgery, the intra-operative vital signs, fluid intake and output and anything specific to the patient and surgery.” CRNAs care for their patients post-surgery until they are transitioned to another medical provider or are cleared for discharge to the floor or their home.

Staff Leadership and Training

As they gain more experience in medical settings, CRNAs can also take on leadership roles by training staff, evaluating health outcomes across different departments, and developing programs to improve these outcomes. As the Assistant Chief CRNA at Kaiser Permanente Antioch Medical Center, Dr. Clark is on numerous committees that evaluate and work to improve the quality of health care services to the Labor and Delivery, Mother/Baby, and Neonatal Units.

“As the Assistant Chief for Kaiser Permanente Antioch Medical Center (KPAMC), I am a member of the following committees for Labor and Delivery, Mother/Baby unit and the Neonatal Unit: patient safety committee, collaborative care committee and the critical events team training committee,” she explained, “In these committees we discuss ways to provide for patient and staff safety, review and discuss adverse outcomes, update policy and procedures, implement the mandates from our parent company such as initiating the Massive Hemorrhage Protocol, stream lining the “time out” process, and developing scenarios for implementation during the critical events team training. […]
I work with the manager of the anesthesia department to oversee the anesthesia technicians, handle any staff problems, recertify my colleagues on the use of the glucometer and I-stat machines and report any changes that occur in my facility to the department.”

Dr. Clark also participates in staff education at Kaiser Permanente. “As the Education Coordinator and Liaison for the Kaiser Permanente Antioch Medical Center, I work with all levels of management to help solve problems or create positive changes in the workflow for our patients. Sometimes the workflows and changes are anesthesia related and other times related to the Operating Room flow. As the Education Coordinator, I obtain the necessary paperwork yearly to provide continuing education units to the CRNA staff, develop scenarios for critical event team training simulations, and serve as an instructor for the days the critical event team training takes place,” she explained, “I am in charge of giving continuing education units (CEUs) each month to the CRNAs who attend our monthly meetings and sending the attendance list into the AANA so the attendance can be documented for each CRNA.”

Academic Education

CRNAs can also take on academic positions at nursing schools, where they can train the next generation of certified registered nurse anesthetists. Faculty members of accredited certified registered nurse anesthetist programs can instruct students in advanced physiology and pathophysiology, pharmacology, chemistry and biochemistry, advanced physical assessment, and other topics that are relevant to human biology and anesthesia procedures. As an Assistant Professor of Clinical Nursing and Assistant Program Director at the University of Miami School of Nursing, Dr. Bell finds the mentorship aspect of her job to be particularly gratifying. “As an educator and Assistant Program Director it becomes increasingly important to try to convey these principles of excellence to the next generation of nurses,” she told OnlineFNPPrograms.com, “As I reflect on my time as an educator, it was rewarding, frustrating, compelling and challenging.”

The Challenges and Rewards of Being a Certified Registered Nurse Anesthetist

Working as a certified registered nurse anesthetist can be a highly challenging job in that CRNAs deal with high-risk situations several times a day, and must therefore be vigilant, adaptable, and highly knowledgeable about how to address certain situations during surgical procedures that could endanger the health of the patient. The complexity of patient conditions and the existence of co-morbidities can make the development and implementation of an anesthesia plan quite challenging.

“Some challenges as a CRNA are with the very sick patients, morbidly obese patients and emergency cases. The very sick patients require careful titration of medications, may require an arterial line, some need blood transfused and some may need medications to keep their blood pressure within the patient’s normal range,” Dr. Clark noted, “Patients who have had a recent or current upper respiratory infection or asthma can have bronchospasms at any point during the surgery. Vigilance is the most important thing the CRNA can do to keep the at risk patients safe.”

To address these challenges, CRNAs should build a strong background in critical care concepts, human physiology, and pharmacology. “Any registered nurse interested in becoming a CRNA should have a strong intensive care nursing background,” Dr. Clark advised, “Anesthesia is an extension of intensive care nursing with more in-depth training in anatomy, physiology and pharmacology. The experience as an intensive care nurse is invaluable to becoming a CRNA.” However, the challenges that CRNAs face in treating patients can also translate into a reward in the form of intellectual engagement. “As a CRNA, every day is different,” Dr. Clark said, “Some patients seem to be straight forward then some challenges occur either during the induction of anesthesia or during the surgery. I am prepared for any unplanned event which keeps me vigilant. When I work on the Labor and Delivery Unit, I never know what is going to happen during the day. I love the fact that in any situation that arises, I can handle it safely and in the best interest of my patient. Anesthesia is fluid, I never really know what I will experience during my day and I love that aspect. Boredom is never a problem as a CRNA.”

Ms. Ford cited her relationship with colleagues, the respect and appreciation she receives for her work, and the engaging challenge of the job to be substantial rewards of her professional path. “A career as a Certified Nurse Anesthetist rests much on scientific knowledge, but it also remains very much a mixture of science and art,” she said, “One of the biggest rewards of working as a CRNA is the respect that you get from other healthcare professionals and patients. I enjoy the combination of having a strong medical background and using my natural intuition while taking care of a patient’s physiological and psychological needs. A career as a CRNA for me is far from boring.”

Dr. Bell noted that one of the primary rewards of nurse anesthesia is walking through the surgical process with patients, and being there for them every step of the way. “Part of the satisfaction of providing anesthesia is the ability to help someone through possibly the worst day in his or her life. They are afraid of the diagnosis, they are afraid of the impending pain, and all of the unknowns that lie before them. Your presence as a calming entity at their bedside at that very moment becomes paramount,” she said, “The fact that you possess the knowledge and skills to see them safely through their procedure is secondary; the humanity that you bring to their life is what becomes more important than any medication you can administer.”

Advice for Registered Nurses Interested in Becoming CRNAs

Registered nurses who are interested in becoming CRNAs must complete a graduate nursing degree program in certified registered nurse anesthesia from an institution that has been accredited by the Council on Accreditation of Nurse Anesthesia Educational Programs. To be eligible for a graduate nursing program in nurse anesthesia, individuals must hold a current registered nurse license in their state of residence, and have earned a Bachelor of Science in Nursing or a bachelor’s degree in a related field. They must also have completed a minimum of one year of critical care nursing experience. Accredited CRNA graduate programs may also have other requirements that students must fulfill to be eligible for admission; prospective students should research multiple programs and contact the admissions departments of these programs for the most up-to-date information.

Due to the high-risk situations CRNAs monitor and manage on a daily basis, graduate-level training in nurse anesthesia from an accredited program will include discussion of general, local, regional, and neuraxial anesthesia and when to use each; advanced human physiology, pathophysiology, and pharmacology; advanced health assessments; the human body’s specific response to different types of anesthesia; how to monitor patients’ vitals and fluid levels; how to safely intubate and extubate a patient; and how to develop a post-anesthesia recovery plan.

In her interview with OnlineFNPPrograms.com, Dr. Bell advised prospective CRNAs to learn as much about the profession as possible prior to beginning their graduate nurse anesthesia program, and to build a strong base of knowledge in the core principles of nurse anesthesia both during and beyond their academic program. “I think it is of the utmost importance for graduate RNs to have a solid understanding of physiology, pathophysiology, and pharmacology before they start anesthesia school. Take the worst assignment, volunteer for the sickest patients, and really understand why you are doing what you are doing,” she said, “You need to really begin to develop a deep understanding of the care you provide. Understanding why you are using that drug, or that vasopressor over another vasopressor, will put you ahead of the curve in your nursing process and your decision to journey through the rigorous program of anesthesia. Critical thinking is essential to the safe delivery of anesthesia. You have to be good problem solvers and observers. You alone have to interpret the data and formulate an opinion, then be willing to act on that opinion. You need to be right because someone’s life will be depending on it.”

After completing their graduate program in nurse anesthesia, prospective CRNAs must take and pass a national certification examination administered by the National Board of Certification and Recertification for Nurse Anesthetists. They must also research and fulfill any state-based credentialing requirements prior to practicing in their region of residence. Recertification by the NBCRNA is required of CRNAs every four years, and involves the completion of a certain number of continuing education courses.

Once they begin practice, new CRNAs should work to stay up to date on the developments of the profession, and to continually seek professional growth opportunities by networking with other CRNAs and by potentially joining an association such as the American Association of Nurse Anesthetists. In her interview, Ms. Ford emphasized the importance of communication and forming a strong connection with one’s coworkers. “[C]ommunication with your manager or health care team, knowing your job description, and creating a cordial camaraderie with your colleagues, will produce a high degree of job satisfaction,” she said.

In addition to being vigilant about their patients’ health before, during, and after surgical procedures, CRNAs should also work to incorporate self care measures into their regular routine, and to seek a healthy work-life balance to avoid burnout. “[A] career as a CRNA is physically and emotionally demanding,” Ms. Ford cautioned, “Maintaining a recipe for optimism, belief in your self, and ambition will help yield a successful CRNA career. I have learned so far that some things are out of my control. If I could say that I did everything safely for a patient, then I know I did the best I could do. Creating a work life balance is my main priority. Exercising your brain and body is extremely important in this career and will supply energy and spirit.”

Certified registered nurse anesthesia is a field that requires intensive academic and professional preparation, as well as continued maintenance of one’s skills and qualifications as the medical field and the CRNA profession continue to evolve. By staying apprised of the developments in their field, connecting with their colleagues, proactively improving their skills and knowledge both on the job and through additional training, and maintaining a steady work-life balance, prospective and practicing CRNAs can build a successful and impactful career supporting patients during some of the most high-stakes medical situations they will experience.

About the Author: Kaitlin Louie is the Managing Editor of OnlineFNPPrograms.com, and creates informational content that aims to assist students in making informed decisions about graduate programs. She earned her BA & MA in English from Stanford University.