About Dawn Clark, MSN, DNP, CRNA: Dawn Clark has worked as the Assistant Chief Certified Registered Nurse Anesthetist at Kaiser Permanente for over 17 years. In this role, Dr. Clark provides general, regional, and obstetrical anesthesia to patients across the lifespan, and also serves as the Education Coordinator for the Antioch Medical Center. Prior to her position at Kaiser Permanente, she worked as a full-time Staff CRNA at UC Davis Medical Center.
In addition to her positions in clinical work and staff leadership, Dr. Clark has held numerous academic and clinical education positions throughout her career. She 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 for over eight years.
Dr. Clark earned her BSN from the University of Wisconsin-Milwaukee in 1986. After graduating from her BSN program, she worked as a Staff RN and Nurse Corps Officer for the United States Navy for four years. Before enrolling in her MSN program, Dr. Clark was a Staff RN in the Critical Care Unit and ER at Sutter Delta Memorial Hospital and Mount Diablo Medical Center. She earned 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.
[OnlineFNPPrograms.com] May we have a brief overview of your academic and professional background in nursing?
[Dawn Clark, MSN, DNP, CRNA] 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 on 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, 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 Masters Degree programs and thought I should have a DNP to teach at that level. I attended Rush University in Chicago, IL, DNP program with the focus on leadership and education. I graduated with honors in June 2012.
[OnlineFNPPrograms.com] Could you please describe your past and current responsibilities as a preceptor? How do you collaborate with your students to set learning objectives for the academic term, what kinds of tasks/responsibilities are your students expected to take on, and what kinds of guidance do you provide them with?
[Dawn Clark, MSN, DNP, CRNA] The first clinical rotation for nurse anesthesia students is often the scariest for them. They learn how to intubate patients in the simulation laboratory at SMU but have never intubated a person and they are extremely nervous the first few times. The usual focus for the first few days in the OR is the airway: mask ventilating the patient, intubation and placing a laryngeal mask airway (LMA). Prior to starting the case, I discuss the patient’s medical history, medications, the type of surgery and the anesthesia plan. I am one on one with the nurse anesthesia student for the day and the student prepares a care plan for each patient we have in our OR for the day. The care plans are completed by the student the evening before and they often call me at home to discuss the cases. Each care plan has patient specific details such as medications they are taking, laboratory results, co-existing diseases with a detailed anesthetic risk for each co-existing disease, specific anesthesia medication dosages are calculated for the patient and an anesthetic plan A and plan B.
If plan A does not work then we go to plan B. For example: If the surgeon requests a local anesthetic (given by the surgeon at the surgical sight) and we provide sedation, sometimes the surgeon needs more than that type of anesthesia so we would convert to a general anesthetic requiring placement of an endotracheal tube or LMA. Nurse anesthesia students are taught from day one that there is always a backup plan for each anesthetic given.
During the first few days in clinical, the student focuses on securing the airway. After the airway is secured, I have the student focus on the vital signs, watching for any changes which may require deepening the anesthetic, providing pain medications, treating an increase or decrease in heart rate, paying attention to the surgery and monitoring the fluid intake and output.
After the surgery is underway, I discuss the co-existing diseases and the anesthesia implications. I ask about different medications and when to use them, the onset time, peak and duration of the medication as well as the pharmacodynamics and pharmacokinetics for the medications we use in anesthesia. The first semester in the program is all didactic so the student should know all the answers.
As the nurse anesthesia student progresses in their clinical program, they become more independent. They can do the preoperative evaluation without assistance, they are confident in their airway skills, they can take the patient to the OR, place the monitors on the patient, are vigilant and respond appropriately to the changes seen in the patient and are confident in waking the patient up at the end of surgery. They are also confident in their regional anesthesia skills such as placing a subarachnoid block (spinal anesthesia) and epidural catheters. When the student is at this stage, my focus is on their national board exam. I ask questions and review anesthesia principles with them as well as pharmacology and pathophysiology. The goal is by the time the nurse anesthesia student graduates, they will be able to work independently and successfully pass the national board exam.
[OnlineFNPPrograms.com] For current and prospective MSN students, what advice do you have for them in terms of making the most of their clinical placements? What are the challenges that students encounter when trying to obtain clinical placements, and how do you recommend they address these challenges?
[Dawn Clark, MSN, DNP, CRNA] The nurse anesthesia students have a required number of cases to be completed in order to graduate from their program of nurse anesthesia. On average, the nurse anesthesia students complete almost 2500 clinical hours and administer about 850 cases. Each graduate is required to have cases in cardiac, thoracic, labor and delivery, gynecology, ears, nose and throat surgeries, trauma, general surgery, neurosurgery, orthopedic surgeries and pediatrics. Each program has clinical sites under contract to provide the nurse anesthesia student with the required cases. If a student is nearing graduation and is deficit in one area of the required cases, the student asks the clinical coordinator of their program to be scheduled at a clinical site to obtain the required cases. The nurse anesthesia programs accept a certain number of students each year to guarantee the ability to provide them with the required clinical experience.
The best advice for each clinical experience is to utilize the experience of their preceptor. Ask questions, ask for challenging cases and stay later if the case is a great learning experience. It is also important to note that every day the student is in clinical it is like an interview. The nurse anesthesia profession is relatively small and a very close knit group. The students are looked at as potential hires at every clinical sight so professionalism, vigilance, asking for help and working as a team is extremely important.
[OnlineFNPPrograms.com] In your opinion, what is the ideal working relationship between preceptor and student? Is it more collegial or is it structured more like a mentor-mentee relationship? How frequently do you typically interact with your students on a daily and weekly basis, and for what span of time during students’ clinical placements?
[Dawn Clark, MSN, DNP, CRNA] In the SMU PNA, the first few rotations for the juniors (students just starting their clinical rotations) are three months at one facility two times a week. The student/preceptor assignments are usually with one particular preceptor for the first few weeks. The second rotation is often two to three months two days a week and in the fifth month of clinical it changes to four days per week. At this point the junior becomes a senior. The following rotations can be one month or two months all four days a week until the last semester, right before graduation in which the students have the equivalent of five days a week. The one month rotations are usually in the advanced areas of anesthesia such as cardiac (open heart surgeries), trauma, and labor and delivery. The very last few weeks of clinical; right before graduation, if the nurse anesthesia student has a job prospect, they are often assigned to that specific clinical site so the staff can get to know them better and both can decide if that facility is a good fit for the student.
Initially, the first five months, the nurse anesthesia student is in the operating room eight hours a day. As they progress to four days a week, initially they are eight hour days. As they near graduation, the student is exposed to longer shifts such as twelve hour shifts and weekends. As a CRNA, we work various shifts and various days of the week. We can work anywhere from eight hour days to 24 hour shifts. Anesthesia is a 24 hour day, 7 days a week profession. The role of a preceptor is to mentor the student to become an independent, high quality, safe practitioner.
The ideal preceptor/student relationship, in my opinion; is one of mentor and mentee. I feel MY job is to guide, teach and provide continued high quality, safe anesthesia to my patients. When a student has their first rotation in the OR, I know they are focused on securing the airway, getting a “feel for” being in the OR and trying to put together what they have learned into actual practice. I make sure they are safe, I give instruction and I understand how they feel. I discuss the cases with them, talk about intubation techniques and guide them. I am told by my students that they love working with me. They say the reason why is because if they fail at the initial intubation (which we all do no matter if you are seasoned or brand new) they love that I direct them, give them a second chance so they can succeed. There have been times when I had to take over the intubation because the situation called for me to. That is also a learning experience and the most important thing is I talk about it afterwards with the student.
Anesthesia is a humbling experience no matter if you are a student or have been a CRNA for years. The best advice I can give to students is to know your limits, know your recourses/backup and never have a doubt to call for some help. I give myself two tries at intubating; if I am not successful, I immediately have the staff in the OR call for assistance. Sometimes I am successful before they come in and sometimes I need their help. The same goes with attempting a subarachnoid block for an orthopedic surgery. If I am struggling for more than ten minutes, the call goes out for assistance. In my mind it is not a failure for me, it is for the patient. Therefore the message here is: the patient is first! Asking for assistance does not make you weak–it makes you strong! We all have our “off” days. That happens to the best of us. Been there! The key is to utilize your resources!
[OnlineFNPPrograms.com] How do you recommend students prepare themselves for the increase in the length of their shifts from eight to twelve to at times 24 hours? When you were a student, was this transition difficult for you? How do you help the students you precept to manage this part of their clinical rotations?
[Dawn Clark, MSN, DNP, CRNA] Initially the students start out with eight hour shifts in the operating room (OR). As they progress through the program and become a senior, their hours go to 12 hour shifts. When they are in the last few months of clinical, they are given 16 hour shifts, weekend shifts and some may request 24 hour shifts. When I was a student, I had long hours in the operating room from the start. I often did 12 to 16-hour shifts and turned around to come back the next day. I was also told it was an option for me but the experience I gained working after “normal” hours was exponential not to mention a reality to come. When I work with students who have never been in the OR, I focus on what they need just to familiarize themselves in this setting. When students are further along in their program, I encourage them to take the offers of call shifts, night shifts and weekend shifts since it is a reality in this profession and best to have their initial “off shift” experiences with a CRNA.
[OnlineFNPPrograms.com] What are some of the primary questions and concerns your students have when preparing for and completing their clinical placements? How do you help your students address these concerns?
[Dawn Clark, MSN, DNP, CRNA] The nurse anesthesia programs I believe are different from other APN programs in that the University or College the nurse anesthesia student attends already has the clinical sites under contract to accept the nurse anesthesia student into their ORs for their clinical experience.
When the nurse anesthesia student first enters the OR, they are extremely nervous. They have had four months of intense didactic and have spent many hours in the simulation laboratory where they are given scenarios in the laboratory that have occurred in the OR and when their first clinical rotation begin they are very anxious and excited to begin to utilize the training they have been receiving for the months prior to their first clinical days.
When the nurse anesthesia student starts their clinical experience it is important to find out what cases they will have on their clinical day the night before. They need to research those patients, research any co-existing diseases pertinent to the patient, develop a care plan for EACH patient with the history of the patient written on it, and in-depth write-up of the coexisting diseases with the anesthesia implications, knowledge of the surgery and its potential anesthesia implications, medications the student plans to use and the dosage is also written down on the care plan along with an estimated loss of blood and the amount of intravenous fluid needed for the patient is calculated on the care plan.
In addition there is an anesthesia plan A and plan B. Sometimes the first anesthesia plan (A) does not work so a backup plan needs to be determined and the student needs to be ready for it. This is true as a CRNA. I always have a plan B! In addition, any medications the patient is taking needs to be identified and researched for any anesthesia or surgical implications.
The Surgical case is very important to have researched since they dictate the type of anesthesia required as well and some anesthesia affects that could be caused by the surgery. For example: a patient having a laparoscopic cholecystectomy, with the insufflation in to the abdomen of carbon dioxide used during the procedure can lead to the patient having a vagal reaction to the insufflation of carbon dioxide resulting in bradycardia which could lead to asystole. It is vital for the CRNA to be vigilant with the beginning of the insufflations of carbon dioxide and if bradycardia occurs, the surgeon is asked by the CRNA to stop for a moment. They are told there is bradycardia and the patient is treated with atropine or glycopyyrulate (both medications increase the heart rate one works faster than the other), whichever is needed at that time. This is common with carbon dioxide insufflation of the abdomen, the surgeons are aware of this and it is almost always benign. This is just one example where knowing the surgery and its implications is vital to the quality of care and safety of the patient.
[OnlineFNPPrograms.com] How do you recommend students prepare for the presentation of their cases to colleagues and their supervisors? What components should be included in this presentation to make it thorough, effective, and actionable?
[Dawn Clark, MSN, DNP, CRNA] Students review their patients before their clinical day. With this day and age of computers, they are given access to their clinical assignment prior to their clinical day. The students write up a care-plan which includes the following: Sex, age, procedure, diagnosis, history, current outpatient medications, laboratory tests, EKG (when ordered), echocardiograms (when ordered), potential blood loss, intravenous fluid requirements during surgery, radiology reports and any surgical/anesthetic history. In addition the student develops a plan A for their choice of anesthetic as well as a plan B. In anesthesia, there always has to be a backup plan in case the first one is not sufficient to meet the surgical needs or the first plan fails. For example: If a patient is scheduled for a hip replacement under spinal anesthesia and it appeared as though the spinal medicine was placed correctly but when incision is made the patient feels some discomfort; in this case the plan B would be to put this patient under a total general anesthetic. Another example is when the surgeon thinks they can do a procedure using local anesthetic with anesthesia giving sedation then decides more anesthesia is needed; the conversion would be to go to a general anesthetic.
[OnlineFNPPrograms.com] What have been some of your most educational and/or rewarding experiences thus far as a preceptor? On the other hand, what challenges have you encountered as a preceptor, and how have you managed these challenges?
[Dawn Clark, MSN, DNP, CRNA] The most rewarding experiences when precepting a nurse anesthesia student is when they are successful at a technique they have had trouble with or have never done before. For example, some students struggle with intubating a patient. I go over the technique with them, I use the laryngoscope blade (the intubating instrument) and using my hands I show them the way to move the tongue out of the way and advance the blade into the correct spot for successful intubations. Positioning the patient in a good position for intubating is also important. When I see the student follow my instructions and they are successful I feel rewarded and they are extremely happy with their success.
When a student first places an epidural catheter in a patient as I instruct them and they are successful, I again feel rewarded. Their success verifies the import part I play in their education and help them grow to become independent practitioners. I am always up front and honest with the student. I may give them an assignment as in bringing an orange in and using the epidural needle or spinal needle to poke into the orange. This is a great method for allowing the student to feel the different layers the needle goes through. When the student is near to graduation, I give them the space to do the whole case with little intervention from me. To see how successful they have grown in the profession from when they first started is awesome. I feel this is a way I pay it forward in my profession.
After the nurse anesthesia student graduates, possess the national exam and is practicing independently, I often run into them at conferences. I love seeing them as a CRNA and I often get hugs and always a thank you for my help in them succeeding in this profession. That is the best thing I can do as a preceptor is to see their success and feel proud of how they grew from a student to a successful CRNA with some of my guidance. I feel it is SO VERY important to nurture, teach and share my experience with the future CRNAs of this country. Someday they will be the one taking care of me and my loved ones.
I have had challenges as a preceptor. I have had students disregard what I tell them and my instruction. A few have had attitudes and state they do not need to learn a new way or they think they know what to do and tend to give a negative attitude when they are corrected. I don’t confront them in front of the OR staff, but I will ask them to move out of the way and I take over. After an incident where I ask them to move I have a talk with them about what happened, how they were inappropriate and document it on their daily evaluation form I fill out. It is rare that I have to do that, but have on occasion. On only one occasion (in the 20 years I have been a preceptor) I had to ask a student to leave the OR. I had to speak to the University and had this student placed on probation. The job a CRNA does is extremely important. We provide high quality, safe anesthesia and I felt this person was unsafe so I went up the appropriate channels to have this addressed.
[OnlineFNPPrograms.com] What advice do you have for nurse practitioners who would like to become preceptors, in terms of preparing for this role? Why did you decide to become a clinical preceptor, and what steps did you have to take to become a preceptor?
[Dawn Clark, MSN, DNP, CRNA] I feel after graduating as an Advanced Practice Nurse (APN) in any area, the APN is qualified to be a preceptor in their profession. The APN is the expert in their field and has experiences to share. To be a preceptor you have to have patience, good communication skills and love sharing your knowledge. You also have to feel comfortable correcting mistakes and giving constructive, appropriate criticism. Some of my colleagues who are preceptors do ask for a day off to do their own cases and take a breather from precepting and that is great. It does take more energy and time when one is a preceptor so to ask for a break for a day or two I feel is healthy for both the preceptor and the student.
Since I graduated with my degree in Nurse Anesthesia, I have always been in a preceptor role. I love sharing my experiences as a student and as a CRNA. I have always taught nurse anesthesia students in the OR and for about eight years I taught a course called Advanced Principles of Anesthesia II at SMU. I continue to be a preceptor to help keep the profession strong, safe and provide the BEST care to all our patients. The success of future CRNAs lies in the hands of the preceptors in the clinical arena. This is the most important place to apply learned principles of anesthesia, realize the use of the anesthesia medications, understanding the minute by minute changes that occur in the OR during the surgery and how to immediately make the correct decision at that moment to aid in a successful surgical/anesthetic outcome.
I love my profession and I want others to love the profession. I feel I can help them by teaching them in the OR to handle immediate changes in the patient as a result of the surgery or anesthesia as well as anticipating what may occur during surgery. A CRNA is ALWAYS vigilant and ready to make the appropriate decision at the appropriate moment. That is why the clinical areas and preceptors are so VITAL to the CRNA education and I feel what I love to do (being a preceptor) is so important. As a preceptor, a CRNA; it is again, my way of paying it forward as a CRNA.
Thank you Dr. Clark for participating in our preceptor interview series!