With the changes seen in the last few years with health care, CRNAs will be needed more in the future. We have been around for over 100 years and are needed in every setting: hospitals, outpatient surgery centers, dental offices, plastic surgery practices, rural and urban areas and as educators for future CRNAs.
About Dr. Dawn Clark, CRNA, MSN, DNP: Dr. Dawn Clark is the Assistant Chief Certified Registered Nurse Anesthetist for Kaiser Permanente’s Antioch Medical Center, a position she has held for over 17 years. As Assistant Chief CRNA, Dr. Clark provides general, regional, and peripheral anesthesia to pediatric, adult, and obstetrical patients, while also completing administrative duties such as coordinating improvements to policies and procedures, overseeing the tasks of anesthesia staff, and managing continuing education sessions for CRNAs at the Medical Center. In 2014, she also took on a clinical position at Somnia Anesthesia Services. Prior to her work at Kaiser Permanente, Dr. Clark was a full-time Staff CRNA at UC Davis Medical Center.
In addition to her clinical and staff leadership, Dr. Clark has an extensive background in nurse anesthesia education, having served as a Clinical Coordinator during her time at UC Davis Medical Center, as a Clinical Preceptor for Samuel Merritt University CRNA students, and as Assistant Professor and Co-Chairperson for the Admission Committee at Samuel Merritt University’s Program of Nurse Anesthesia.
Dr. Clark earned her BSN from the University of Wisconsin-Milwaukee in 1986, her MSN with a concentration in Nurse Anesthesia in 1997 from Samuel Merritt University, and her DNP in Leadership and Education in 2012 from Rush University. Prior to enrolling in her MSN program, Dr. Clark worked as a Staff RN in the Critical Care Unit and ER at Sutter Delta Memorial Hospital and Mount Diablo Medical Center. She also served as a Staff RN and Nurse Corps Officer for the United States Navy for four years.
[OnlineFNPPrograms.com] Could we please have an overview of your professional and academic path in nurse anesthesia?
[Dr. Dawn Clark, CRNA, MSN, DNP] I earned my Bachelor of Nursing degree from the University of WI-Milwaukee in 1986. Once I received my BSN I was commissioned as a United States Navy Nurse Corps officer and was stationed at Oak Knoll Naval Hospital in Oakland, CA. I was in the Navy Reserves for 2 years as a Naval Corpsman and decided to go on active duty after I graduated in 1986 to get the nursing experience that was required to get a job. I took the Board of Registered Nursing (BRN) exam in CA in 1987 after I reported in for active duty. At that time it was a two day exam with a test booklet, a pencil, a timer and people walking around the room watching everyone. During my time as a Navy Nurse Corps Officer, I worked on the medical surgical unit for 18 months then transferred to the Critical Care unit where I stayed until I was released from active duty in February, 1990.
In 1990 I worked for five years for Sutter Delta Memorial Hospital in Antioch, CA, in the Critical Care Unit, Telemetry Unit and the Emergency Department. I participated in committees, taught classes and was a preceptor for nursing students. I knew I needed the experience in critical care as well as emergency room in order to apply to the Program of Nurse Anesthesia (PNA) at Samuel Merritt University (SMU) in Oakland, CA. Additional requirements for the SMU PNA were: BSN, grade point average (GPA) of 3.5 or higher, proof of leadership ability, the graduate record exam, reference letters, and basic life support (BLS) and advanced cardiac life support (ACLS) certification.
In 1995 I was accepted to the PNA at SMU. It was not an easy program. I was in the second class which meant SMU was still figuring out the academic and clinical rotation process. In 1997 I earned my Masters of Science degree in Nursing, graduated with honors and joined Sigma Theta Tau, the national honor society in nursing. To become a Certified Registered Nurse Anesthetist (CRNA), I had to graduate from an accredited college, take a national certification exam given through our national organization the American Association of Nurse Anesthetists (AANA), obtain an advanced practice license from CA BRN and maintain my registered nursing license. I renew all three licenses every two years and complete the required continuing education for each license. I am required by my job to maintain my BLS and ACLS certification which requires renewal every two years.
My first job as a CRNA was at the University of California- Davis Medical Center (UCDMC) in Sacramento, CA. I was the clinical coordinator for the SMU PNA students at UCDMC and became a preceptor to nurse anesthesia students in the operating room (OR). I continue to be a preceptor to the nurse anesthesia students. While working at UCDMC I did trauma anesthesia, neuroanesthesia, burn patients, a variety of every type of case and all ages. My youngest patient was 13 hours old and my oldest patient was 106 years old.
In 1999 I was hired by Kaiser Permanente Oakland Medical Center as an Assistant Chief CRNA. I worked in the OR, participated on OR/Surgical and anesthesia/post-anesthesia care unit committees. I was also the education coordinator and taught classes to the anesthesia technicians as well as arranged for lecturers at our monthly department meeting. In June 2003 I transferred to Kaiser Permanente-Diablo Service Area, Walnut Creek, CA. I became the Assistant Chief CRNA and education coordinator at this facility. In November 2007, Kaiser Permanente opened a new hospital in Antioch, CA. I was part of a small group sent in to transform the empty ORs and anesthesia workrooms into functioning work spaces prior to the opening. Since the hospital opened, I became the Assistant Chief at this new facility.
In 2005 through 2013 I was an Assistant Professor for the PNA at SMU. I taught Advanced Principles of Anesthesia II, was an oral exam examiner, co-chaired and chaired the admissions committee, developed scenarios and participated as an instructor in the Simulation lab. I was also co-faculty for the anesthesia competency and pharmacology exams.
In 2010 I decided to go back to school to earn a Doctorate of Nursing Practice (DNP) because I was teaching in the Masters Degree program and thought I should have a DNP to teach at that level. I attended Rush University in Chicago, IL, to complete my DNP program with a focus on leadership and education. I graduated with honors in June 2012.
[OnlineFNPPrograms.com] Could you please describe your role and responsibilities as Assistant Chief Certified Registered Nurse Anesthetist for Kaiser Permanente?
[Dr. Dawn Clark, CRNA, MSN, DNP] 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. In these committees we discussed 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. The “time out” process is a safety check which is done in the OR, before the patient receives anesthesia to clarify the right patient, right procedure, all the instruments are sterile and accounted for and any concerns or special requests regarding the patient and/or procedure.
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. I work closely with my Chief CRNA, the Chief Anesthesiologist and the anesthesiologist liaison for KPAMC. 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. In order to provide the CEUs, I submit a package to the AANA every October to obtain preapproval status for the following year. I am a Star Leader in Kaiser Permanente Diablo Service Area and am required to take various leadership classes each year and attend an offsite retreat with all the Star Leaders. One year the offsite retreat had the group volunteer for Habitat for Humanity and we prepared the property for the houses to be constructed. We went back the next year and saw the houses built on the property we prepared which was an awesome experience.
[OnlineFNPPrograms.com] What kinds of medical conditions and challenges do your patients face, and how do you help them manage their conditions?
[Dr. Dawn Clark, CRNA, MSN, DNP] I provide anesthesia for a variety of surgeries and patients. When I work on the Labor and Delivery unit, I place epidural catheters for laboring mothers, place spinal anesthesia if the patient is having a Cesarean section and sometimes I have to provide general anesthesia with an endotracheal tube if there is an emergency and the baby needs to be delivered immediately. 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. An anesthesia plan is developed after assessment of the patient, a history and physical is completed, the type of surgery and age of the patient. I always have a backup plan in case the first plan is not going to work. For example: when the surgeon states the surgery can be done with localized medication and I provide sedation but the patient is not tolerating that type of anesthesia, I convert to a general anesthetic. My goal for everyone one of my patients is safe, high quality care and for them to have a positive experience after the surgery and anesthesia.
[OnlineFNPPrograms.com] You have worked as a CRNA at Kaiser Permanente for over 17 years. Could you please elaborate on your past roles in certified registered nurse anesthesia at Kaiser Permanente, what your core responsibilities were, and how you collaborated with a larger team of healthcare professionals to care for patients?
[Dr. Dawn Clark, CRNA, MSN, DNP] My core responsibilities have always been providing the type of anesthesia the patient needs for the type of surgery they are having. 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. Clear communication is extremely important especially in an emergency situation.
Since I started in anesthesia I have seen many changes. The medications and equipment we use continue to change and/or improve. For example, I trained using the inhaled anesthesia agent called Halothane and today Halothane is nonexistent in operating rooms (ORs). It has been replaced by Sevoflurane. For a patient who may be difficult to intubate, we now have a glide scope which is a laryngoscopy blade that has a camera on the tip of the blade and we can watch the intubation on a small screen. This is often what I used because the registered nurse in the OR who assists me can see what I am seeing and can help manipulate the airway externally to aid in successful intubation. The glidescope confirms to me and everyone that the endotracheal tube is in the trachea just past the vocal cords so there is no question it is in the correct place. Every patient is different, so the anesthesia I may provide to one patient can be different with the next patient having the same surgery.
[OnlineFNPPrograms.com] What is the difference between pre, intra, and post-operative anesthesia services, and how does pediatric anesthesia differ from adult anesthesia and geriatric anesthesia? What goes into developing an effective anesthesia plan for a particular patient?
[Dr. Dawn Clark, CRNA, MSN, DNP] Preoperative anesthesia care occurs when I introduce myself to the patient, obtain a history and physical, discuss the procedure, discuss the anesthesia choices, answer their questions and provide sedation prior to going to the operating room. If I am taking a patient for a Cesarean section, I do not give sedation medication prior to going to the OR because it would sedate the baby and the baby could be born with a depressed respiratory system.
Intra-operative anesthesia is the anesthesia the patient receives in the OR. When the patient arrives in the OR, the monitors are applied to measure their blood pressure, watch their heart rate and monitor the blood oxygen saturation. Depending on the anesthesia needed either the patient receives regional anesthesia such as a spinal anesthetic or a general anesthesia using inhalation agents. During the surgery the vital signs are recorded every 5 minutes, narcotics are titrated to the patient’s heart rate and blood pressure and sometimes medications are used to increase or decrease the patient’s blood pressure. Intravenous fluids are controlled, monitored and recorded as well as blood loss and urine output. The patient is kept warm using a warming blanket and their temperature is monitored. At the end of surgery the anesthesia agents are turned off and the patient wakes up in the OR.
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. 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.
In order to develop an anesthetic plan the following is needed: type of surgery, age of the patient, patient’s history and physical, any drug allergies, height and weight, daily medications, drug or alcohol use, smoking history, when they last ate, any history of anesthesia, any personal or family history of anesthesia problems, any loose, missing or removable teeth, any piercings anywhere in the body, pregnancy status for females less than 50 years old, laboratory results, EKG and any other tests or X-ray results. Once the information is obtained an initial anesthesia plan is developed with a secondary plan in case the first one needs to be changed. Reasons to change to a secondary plan is the surgeon requests a different anesthesia than was first ordered or the patient doesn’t want the first plan. Changes are often made in anesthesia and CRNAs are trained to be able to provide whatever the patient and surgeon need.
The age of the patient affects the anesthesia. The pediatric patient has different anatomy and physiology than the adult patient. For example: intubation can be difficult due to their anterior larynx and the narrowest part of their airway is at the cricoid. They have a decreased total lung capacity, a higher respiratory and metabolic rate which predisposes them to faster oxygen desaturation. Medications used for the pediatric patient are drawn up based on their exact kilogram weight and exact dose of emergency medications are ready to be administered intramuscularly if there is no intravenous access. The geriatric patient also has anatomical and physiological changes that affect anesthesia care. For example they have an increase in body fat, a decrease in skeletal muscle mass, decreased blood volume and decreased skin elasticity. These changes affect the onset, peak and duration of medications, they have a slightly lower cardiac output and placing intravenous or arterial lines can be a challenge. These small examples of the differences with the pediatric and geriatric patient compared to an adult are significant when giving anesthesia.
[OnlineFNPPrograms.com] Why did you decide to become a Certified Registered Nurse Anesthetist? What professional and academic experiences motivated you to work in this field?
[Dr. Dawn Clark, CRNA, MSN, DNP] When I was in nursing school working on my BSN, I thought I wanted to go on to medical school to be a cardiovascular surgeon. I was fascinated with the heart and thought I would love to be a cardiovascular surgeon. During my last clinical rotation, I chose to go to the OR to observe an open heart surgery. I found I was more interested in what the anesthesiologist was doing than the surgery. The anesthesiologist told me nurses can do anesthesia and that I should consider that field. I was fascinated and never knew about CRNAs until he told me. I decided to work as registered nurse, investigate what was needed to be a CRNA and work on meeting the requirements. I loved the thought of taking total care of one patient at a time, making independent decisions regarding their care, working with all ages, working as a team in the OR and providing the safest, high quality of care to all patients.
I learned that a nurse anesthesia program was going to open in 1994 in Oakland, CA. I had the critical care experience, met the academic grade point average, had the score needed on the graduate record exam and all the letters of recommendation. I was on many committees so I had the leadership requirement met. When the program opened, I applied and was accepted. I have never regretted my decision! I love being a CRNA.
[OnlineFNPPrograms.com] What have been some of the most rewarding aspects of working as a CRNA? On the other hand, what specific challenges have you encountered in this field of work, and how have you managed these challenges?
[Dr. Dawn Clark, CRNA, MSN, DNP] As a CRNA, every day is different. When I work in the main OR, I have a scheduled room with gynecological, orthopedic, urology, podiatry, and general surgery or ears/nose and throat surgeries. I prepare for all my cases first thing in the morning. 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. Patients often thank me after their surgeries. A successful anesthetic and surgery with a happy patient is the best reward I can get.
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. 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.
Any registered nurse interested in becoming a CRNA should have a strong intensive care nursing background. 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. A strong leadership background is needed. When the patient first arrives into the OR, anesthesia is the first priority. Everyone in the room is quiet and focuses on the induction of anesthesia. There are times I had to quiet the room down or ask someone in the room for emergency assistance. The riskier times for the patient in anesthesia are on induction and emergence. During these times, the CRNA has to have control over the noise in the room if help from other OR personnel is needed. As a CRNA I am very comfortable asking people to quiet down, turn the music off or help me. Sometimes during the surgery, the patient could develop a problem. When a problem is noticed and it has something to do with the surgery, I tell the surgeon to stop, explain what the problem is and ask for a few minutes to correct the problem. I am very comfortable asking the surgeon to stop and they stop immediately and focus on me. For example: for a laparoscopic cholecystectomy, upon insufflation of the abdomen with the carbon dioxide, the patient’s heart rate can decrease to extremely low level requiring either atropine or glycopyrulate. The surgeon will stop insufflating until the heart rate returns to normal. Vigilance, intensive care nursing experience, leadership qualities in addition to the requisite courses taken and clinical experiences in nurse anesthesia school are what it takes to be an excellent CRNA.
When a registered nurse is training to become a CRNA, it is important for them to take advantage of all the experiences in the clinical setting. Ask questions of the preceptor, go for harder cases and always be prepared for the day before the preceptor arrives. The clinical experience is where you gain the ability to one day work alone in the OR as a CRNA. Always have a written care plan with two anesthesia plans for each patient and be prepared to discuss the care-plans with your preceptor. Creating these care-plans every day helps solidify the information and can lead to unanswered questions. An important fact for all potential CRNAs is when you are in your clinical rotations; treat every day as an interview day. From day one, clinical sites are looking for future CRNAs and the work a student does in the OR tells the staff at that site whether they would be interested in hiring you or not.
With the changes seen in the last few years with health care, CRNAs will be needed more in the future. We have been around for over 100 years and are needed in every setting: hospitals, outpatient surgery centers, dental offices, plastic surgery practices, rural and urban areas and as educators for future CRNAs. By the year 2023, all graduating CRNAs are required to have a DNP. This change has been happening over the last few years. There are many programs across the United States that have converted to the DNP prepared CRNA. In addition, recertification by the AANA is changing. There will be special requirements for obtaining CEUs and in 2020 I am required to take a recertification exam. This will be the first time the exam is given so it will be a trial exam. In 2028, I will have to take the recertification exam and have to pass it to be recertified.
[OnlineFNPPrograms.com] For current and prospective MSN students who are interested in becoming certified registered nurse anesthetists, what advice can you give them about optimally preparing for this field while pursuing their degree?
[Dr. Dawn Clark, CRNA, MSN, DNP] For a prospective MSN student interested in the Program of Nurse Anesthesia (PNA), I suggest to first read the Watchful Care: A History of America’s Nurse Anesthetists written by Marianne Bankert. This book gives a lot of insight into how the CRNA practice started. This book can be found on the AANA website. This website also has general information for the public describing a CRNA and anyone can access that side of the AANA website. Anyone interested in becoming a CRNA should shadow a CRNA in the OR to see firsthand what the CRNA does. During the interview process in applying to a PNA, the interviewee is often asked if they shadowed a CRNA. Participation on committees and in a leadership role is important. Experience in intensive care nursing is required as well as a higher GPA earned in their undergraduate program. Each program requires a different GPA so it is important to research Nurse Anesthesia Programs of interest. Every university with a Program of Nurse Anesthesia lists the requirements for their program. Statistics is a course that will be extremely useful when doing research during the program. Extracurricular activities and volunteer work whether in the community and/or your facility shows the admission committee you branch out and are comfortable working as a team in settings other than the hospital unit you work in. Vigilance, attention to detail and communication skills are extremely important in becoming a CRNA.
[OnlineFNPPrograms.com] Could you please describe the responsibilities you have as Education Coordinator and Liaison for the Antioch Medical Center? In addition, what classes did you teach as an Assistant Professor at Samuel Merritt University? How has your work in staff and student education impacted your clinical work, and vice versa?
[Dr. Dawn Clark, CRNA, MSN, DNP] 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. I help set up the scenarios then observe as the staff work through the scenario. After the scenario is completed, there is a debriefing session and every one learns from what they just went through. The positive things and where some improvement could be made are discussed. Often we find system problems that we work to fix after the training day is completed.
I continue to precept nurse anesthesia students in the OR. I enjoy this because I can share my knowledge and expertise with them. I also learn some of the latest changes in anesthesia from them since they are the ones in class and receiving the up-to-date information regarding anesthesia. Depending on where they are in the program I will ask questions pertinent to the courses they are in. I was an instructor in their program for eight years and know what they are studying as well as when their competency, pharmacology and oral exams occur. The closer they get to the oral exams; I will ask the students questions relevant to the oral exams and tell them how to prepare for these exams. The most rewarding aspect of being a CRNA for me is the ability to always pay it forward.
Thank you Dr. Clark for participating in our APRN career guide interview series!