There are so many practice settings which utilize anesthesia services. Anesthesia services are utilized for dental, podiatry, surgery, obstetrics, and pain management practices. 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.
About Valerie Bell, DNP, CRNA: Valerie Bell has over 27 years of experience as a certified registered nurse anesthetist across numerous medical settings. She is currently a CRNA 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. Prior to her current position at UMH, Dr. Bell worked as a CRNA at Jackson Memorial Hospital, Spectrum Health Services, Inc., Mariners Hospital, Absolute Anesthesia Services, Apalach Anesthesia Associates, and Southern Anesthesia Services, Inc.
Dr. Bell has also played an active role in educating graduate nursing students at multiple institutions. In addition to her current work as an Assistant Professor of Clinical Nursing at the University of Miami, she has been an ICU Preceptor at Presbyterian University Hospital, a Resident Preceptor at Jackson Memorial Hospital, a Guest Lecturer at Barry University’s Graduate Anesthesia Program, and a Clinical Faculty Member and Co-Clinical Coordinator at Florida International University. Her past roles at the University of Miami School of Nursing and Health Studies include Senior Lecturer, Director of Simulation within the Nurse Anesthesia Program, and Associate Program Director for the Nurse Anesthesia Program.
Dr. Bell earned her Bachelor of Science in Nursing from the University of Pittsburgh in 1986, and her Master’s of Science in Nursing in 1991 from the same institution, within their Graduate Anesthesia Program. She received her Doctor of Nursing Practice from the University of Miami School of Nursing and Health Studies in 2011, and also earned a Master of Arts in Counseling Psychology from Trinity International University in 2006.
[OnlineFNPPrograms.com] Could you please give us an overview of your academic and professional path in nurse anesthesia?
[Dr. Bell, DNP, CRNA] My educational background began as a freshman at the University of Pittsburgh. As part of the nursing program, I was so excited to begin my clinical pathway and learn to provide care in the most basic of ways. By my junior year, we had begun an undergraduate chapter of Chi Eta Phi. The exposure to the women of the graduate chapter changed my life. These women were smart, strong, resilient, and exceptional nurses. I shadowed one of the nurses, Ella Thomas, who happened to be a CRNA. WOW!!! I wanted to be just like her and do what she did. Her level of knowledge about pharmacology and physiology was amazing, how could one person know so much! So I went on to graduate and work at the biggest academic hospital in Pittsburgh. I worked two years in the liver transplant ICU and was exposed to the sickest, most critically ill patients. Knowing that I wanted to go back to school for anesthesia eventually, I wanted to round out my work experience by working a year in the post anesthesia care unit. I applied and was accepted to the University of Pittsburgh for my master’s in anesthesia. We were the first class to earn a master’s as it transitioned from a certificate program. Lots of changes to the educational process, but it was a phenomenal education. The clinical process involved rotating through eight different hospitals, which involved different areas of focus. Having such a diverse educational experience really prepared me for my own clinical practice. I was confident that the skills I had obtained were the perfect foundation to launch my own career.
I’ve worked in many clinical settings over the course of my career from large academic settings, to small private hospitals, to education at a large private university. I’ve earned a second master’s in counseling psychology, and I earned my DNP (Doctorate of Nursing Practice) in 2011. Nursing has been a wonderfully diverse and challenging career. Working in the clinical setting, you get to affect other human beings at their greatest moment of need. 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. 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.
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. As I reflect on my time as an educator, it was rewarding, frustrating, compelling and challenging.
[OnlineFNPPrograms.com] Could you please describe your role and responsibilities as a Certified Registered Nurse Anesthetist for the University of Miami? What kinds of medical conditions and challenges do your patients face, and how do you help them manage their conditions?
[Dr. Bell, DNP, CRNA] As a CRNA at the University of Miami Hospital, I work as part of the anesthesia care team. The anesthesia care team is comprised of a CRNA and an Anesthesiologist working together to provide the best care for our patients. I am responsible for the development of an anesthetic plan, which begins with a review of the patient’s history, a thorough physical assessment, and then formulating the specific medications and amounts I will administer to the patient for their anesthetic course. This also involves starting IV’s, intubating the patient, starting arterial lines and central lines if necessary, and monitoring the patient’s condition throughout the surgical event, and initiating any treatment when the patient’s condition varies from baseline. Part of our job is to safely wake, or emerge, the patient from anesthesia. This includes extubating the patient as smoothly as possible, and assuring they have adequate pain control.
[OnlineFNPPrograms.com] Prior to your current position at the University of Miami, you worked as a CRNA in a wide variety of settings, including Jackson Memorial Hospital, Spectrum Health Services, Inc., and Mariners Hospital. Could you please elaborate on these past roles, what your core responsibilities were, and how you collaborated with a larger team of healthcare professionals to care for patients?
[Dr. Bell, DNP, CRNA] There are so many practice settings which utilize anesthesia services. Anesthesia services are utilized for dental, podiatry, surgery, obstetrics, and pain management practices. 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. Different practice settings have varying levels of independence. Some settings have no supervision or direction, while others have a more interdependent model. It also depends on what state you practice in, and whether it’s a city or rural setting. Seventeen states have opted out of the federal requirement of physician supervision rule in order to be reimbursed by CMS (providers of Medicare/Medicaid), so it’s changing the picture as to how anesthesia is being delivered. In fact CRNA’s are the primary providers in rural areas which are typically areas of the country which are medically underserved.
[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. Bell, DNP, CRNA] The differentiation between pre, intra, and post op anesthesia services is the surgical event or procedure. Pre-op services include everything that happens before surgery or 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. 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.
The goal of preop anesthesia services is to prepare the patient, and provide the anesthesia provider with as much information and knowledge as possible to provide a smooth intraoperative anesthetic.
Intraoperative anesthesia services involve 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. 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 losing 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. A big part of the intraop process is management of pain. We can address our patients’ pain by adjusting the levels of our anesthetic agents, giving opioids, or non-steroidals. 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 care is managing the patients after their surgery or procedure. This includes airway management, pain control, monitoring for anesthetic or surgical complications. This care lasts for anesthesia until we transfer care to another provider, such as an intensivist or the patient is discharged to the floor or home.
The care CRNAs provide to patients differs depending on the age of the patient. The difference between pediatric, adult, and geriatric anesthesia care is the fact that you are dealing with patient populations with a very different physiologic status. Each population has their own developmental milestones, which relate to the type and quantity of anesthesia they receive.
Based on cellular and receptor growth or degeneration, our patients respond differently. This is even the case within each population; genetics play an important role in the drugs we include or exclude in our anesthetic plan.
The development of an effective anesthetic plan involves knowing as much as you can about the patient’s medical history by conducting a thorough interview. Once you have an understanding of the physiology surrounding their 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. 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, and to allow us to anticipate events that are most likely to occur, and develop a plan of action to deal with those events. 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.
[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. Bell, DNP, CRNA] While an undergrad, I shadowed a CRNA that was part of my sorority. I was amazed by her knowledge and skill. She was a force to be reckoned with, strong, confident, and intelligent, I wanted to be just like her. I worked in a liver transplant ICU for two years, going into my third year, I was beginning to feel bored and needed a challenge. I wanted to continue to learn and grow, so I worked in a recovery room for a year to gain a more intimate look at the anesthesia and surgical process. With my years in ICU coupled with PACU, I finally felt ready to embark on the journey to becoming a CRNA. All the experience I had was excellent preparation to starting my education.
Now a CRNA for 25 years, 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. 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.
[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. Bell, DNP, CRNA] The most rewarding aspect of being a CRNA is the opportunity to help someone through surgery, and when it’s all over, they say “that wasn’t so bad.” You get to help people through a scary time, by being present in their story.
Nevertheless, this is a difficult job. To make it look easy takes a lot of practice. Like a duck, smooth on top, and the feet are working like crazy. Healthcare has changed since I started practicing. Obama care has made it possible for many more people to access the health care system. Lots of people haven’t had care for a long time, and now they present with many co-morbidities and much sicker. We have surveys that base our reimbursement on the results, we have bundling, and pay for performance. I think there is greater stress within the healthcare system, and we are developing ways to accommodate all the new rules and regulations. I still believe that Nursing is a worthwhile profession, but I think we have to be smarter about how we deliver care. We must be thoughtful providers and intelligent business associates. We as nurses need to be at the table where system wide decisions are made. Which is why I’m in favor of the DNP. The education offered through this degree enables nurses to have the knowledge and language to create policy and produce change, which ultimately affects patient care.
Preparations for the challenges within the field begin the very first day. Pay attention, get involved in the conversations, whether you think you have anything to contribute or not. Search the evidence for better ways, if you find a better way, say so.
[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. Bell, DNP, CRNA] The first thing I would suggest is to shadow a CRNA several times with different cases. You will get a full scope as to what you are in for. Talk to current students. Anesthesia school is tough, and you need to go into it with your eyes wide open. Save, save, save! You are going to have a lot of demands placed on you, and you won’t be able to work. The more money you have before you start, the less stress you will have, and the less debt you will have after school. Take a graduate level anatomy & physiology course and a pathophysiology course. A pharmacology course will help as well. If your undergraduate GPA is weak, demonstrating that you can complete graduate level courses will be in your favor. Most anesthesia programs will not allow you to transfer these courses, but they will strengthen your knowledge base and get you back into studying like a student.
Be a good educational consumer. Research several programs and find the one that is a good fit. When you graduate from an accredited CRNA program, you’ll be eligible for boards. However the pathway to completion are quite different. Some programs offer clinicals at one hospital, while others have clinical sites out of state. Some programs are culturally diverse, and some are not. Do your homework and make you selection based on what you know about yourself.
Once you are in, use every moment to further your educational experience, even when you think the experience is trivial or useless. You will get out of your education what you put into it. This is graduate level education–it’s up to you to make it great. Every case has something to offer, even if you’ve done it a hundred times. Every practitioner has something to offer; take the best of what they offer, and leave the rest behind. Work with the CRNAs who’ve been labeled as difficult. Chances are they are difficult because they have high standards and are not going to let poor performance slide just because they want to be liked. Keep a check on your attitude. Stay open and receptive to feedback. If you stay humble and receptive, CRNA’s are more likely to give you a wider variety of practice experience. If you are labeled as unteachable, you are sabotaging and minimizing your own education.
[OnlineFNPPrograms.com] As an Assistant Professor of Clinical Nursing and an Associate Program Director of the Nurse Anesthesia Program at the University of Miami, what classes do you teach? What advice and guidance do you give graduate nursing students who are pursuing their degrees in nurse anesthesia?
[Dr. Bell, DNP, CRNA] I see great things for our profession if managed appropriately. As I stated above, we need well-educated, articulate professionals to continue advocating for our profession. Because of our practice excellence, leaders vision, and local lobbying effort, we are afforded many practice opportunities and freedoms. We could stand to lose those opportunities if we relent in our efforts to educate people and politicians about what we do and who we are. Programs are transitioning to DNP programs and that is a good thing. More education is not necessarily better, but better education is always necessary. One of the most recent IOM report recommendations is to allow ARNPs to function at the full scope of their training and education. Another is that ARNP become the first line access point in the health care system. We need to be ready to embrace these recommendations and be fully prepared to engage when the opportunities present themselves. Keep learning, stay aware of the healthcare culture, and be ready! The future is bright, and we as CRNA’s are a big part of it!
Thank you Dr. Bell for participating in our APRN career guide interview series!