Exploring a Common Practice Question: CRNAs Asked to Practice as RNs
By Lynn Reede, CRNA, DNP, MBA Senior Director, Professional Practice, Ewa Greenier, MPH, MBA Professional Practice Specialist, and Barbara Anderson, JD Assistant Director, Professional Practice
AANA members contact the Professional Practice Division with a variety of issues that impact their practice. One question that is being asked more frequently pertains to healthcare organizations requesting that the Certified Registered Nurse Anesthetist (CRNA) practice in roles traditionally associated with registered nurses (RNs) in addition to practicing as a CRNA. Although there isn’t a simple answer to this question, the AANA believes that it is incumbent upon the individual CRNA to ensure his or her competency when delivering any patient care. The question and response are unique to each practice setting, and often requires a multifaceted approach for best resolution. The two examples presented below are representative of the practice inquiries the AANA Professional Practice Division receives.
I am a CRNA. My facility is asking me to take on the role and responsibilities, outside of anesthesia practice, of an RN. Am I able to practice in the RN role? What practice standards will I need to meet?
The CRNA may practice as an RN with an active RN license in the state if the role is within the scope of RN practice in the facility and state, and if the CRNA has all of the current core competencies for the specific RN role. Because elements of nurse anesthesia practice appear similar to RN practice, it does not mean that the CRNA is able to step into the role and leave behind the standards required for nurse anesthesia practice. The CRNA may be held to the higher standard of care, consistent with the scope of practice for CRNAs in a given state.
I am a CRNA. My facility is asking me to provide sedation as an RN where I am limited to the drugs, doses, and timing of administration as ordered by the procedure physician. What standards will I be held to?
This scenario is different from the example above, as administration of sedation is within the scope of practice of a CRNA. In this case, if the CRNA is working as an RN, the standards required of the CRNA to deliver anesthesia care must be implemented (e.g., preanesthesia evaluation, appropriate monitoring). The Code of Ethics for the Certified Registered Nurse Anesthetist affirms that “the CRNA, as an independently licensed professional, is responsible and accountable for judgments made and actions taken in his or her professional practice. Neither physician orders nor institutional policies relieve the CRNA of responsibility for his or her judgments made or actions taken.”
In either scenario, CRNAs should understand what the facility’s need is and discuss with their facility the value and capabilities of CRNAs as well as the potential concerns for all parties involved if the CRNA is expected to assume an RN role. CRNAs functioning as RNs may cause role confusion and blur the lines of communication and reporting among nursing, medical, and allied health staff and administration. This practice may confuse patients and other individuals such as regulatory and accreditation surveyors. However, if a CRNA is working as an RN, the CRNA must have the same core competencies as the RN working in that role. Regardless of the role they assume, CRNAs cannot separate themselves from their advanced practice background and may be held to their highest level of education and training.
These two examples represent the tip of the iceberg of this complex issue. The core questions for the CRNA and the facility when discussing the issue are: Does the CRNA have the education and core competencies to perform in the specific RN role? Will the CRNA be able to meet the anesthesia standard of care? And could the CRNA be providing reimbursable anesthesia services? CRNAs should work with their facility to understand the facility’s needs and considerations behind such a request. CRNAs can continue to show their value by being involved in other aspects of the facility’s operations and providing expertise beyond anesthesia care, thus maximizing the contributions made to the facility. For example, CRNAs can help with planning and optimizing staffing resources, providing education to other clinicians, or developing quality improvement initiatives. A CRNA who is considering performing functions in an RN role should also be cognizant of how he or she would be covered for the purposes of professional liability.
The Professional Practice Division is completing a comprehensive analysis that will examine the various factors that apply to the CRNA practicing as an RN by reviewing sources such as peer-reviewed literature, legal cases, expert opinion, and membership survey data. AANA members may receive an anonymous survey, which will help us better understand the frequency of this practice and steps CRNAs have taken to address this issue. In addition, as reimbursement models evolve, the Practice Committee and Board of Directors will continue to provide guidance about optimizing CRNA staffing models.
If you have any information or resources that are useful in addressing this issue, including resources from your facility, please contact us at firstname.lastname@example.org or (847) 655-8870.