What was the rationale for establishing a minimum total case number requirement of 600 cases, rather than the proposed 650 cases in the first draft Standards?
In establishing the minimum total case number requirement, the Standards Revision Task Force (SRTF) carefully assessed over a 3 year period the clinical requirements of other accrediting agencies such as the Accreditation Council for Graduate Medical Education (ACGME) requirements for anesthesiology residents, comments from the community of interest obtained through 4 Calls for Comments and 8 Hearings and Focus Sessions held on the draft Standards, 2 surveys, and the analysis of NBCRNA transcript data. The SRTF considered various options in establishing the minimum total case number requirement. This included a review of the literature related to clinical competency and the use of a benchmarking process. In addition the COA established a minimum number of clinical hours. This new requirement recognizes the value of students providing anesthesia care for longer and more complex cases versus an increased number of less complex cases (refer FAQ below).
What was the rationale for requiring a minimum number of clinical hours?
The COA established a minimum number of clinical hours as a new requirement that recognizes the value of students providing anesthesia care for longer and more complex cases versus an increased number of less complex cases. The required number of clinical hours was increased from a proposed number of 1,600 hours in draft one to a required number of 2,000 hours (refer Trial Standards for Accreditation of Nurse Anesthesia Programs: Practice Doctorate
, Glossary, pg.33).
How did the COA establish the clinical experience requirements for the Standards for Accreditation of Nurse Anesthesia Programs – Practice Doctorate?
When creating the new Standards, the Standards Revision Task Force performed a comprehensive literature review to determine whether the literature supported increasing the number of regional anesthesia case requirements. Of the literature available and reviewed, the most relevant studies (see below), as well as the requirements specified for other anesthesia learners, were among the factors used to support the rationale for the decision. There are no conclusive studies to support how many experiences are required to reach competence with the techniques. The opportunity for nurse anesthesia students to perform regional anesthesia techniques varies greatly from one clinical site to another (as it does for the CRNAs at these sites). The minimal clinical experience requirements take this variation into consideration, while also ensuring that all students have a minimum number of case experiences in these techniques.
Pre- and post-anesthesia assessment and management of patients is a requirement of the AANA Standards for Nurse Anesthesia Practice (2/2013), and the AANA Scope of Nurse Anesthesia Practice (6/2013). Students are required to perform a comprehensive history and physical assessment (Standard C21, b10) and perform a pre-anesthetic assessment and formulate an anesthesia care plan (Standard C21, c3) according to the current Standards for Accreditation of Nurse Anesthesia Programs
. These same requirements are included in the Standards for Accreditation of Nurse Anesthesia Programs – Practice Doctorate (
Standards D.8 & D.15). Post-anesthesia assessment is a component of the perianesthetic process/continuum, which is addressed in Standards C17 and C21, b1 (Standards for Accreditation of Nurse Anesthesia Educational Programs). The Standards for Accreditation of Nurse Anesthesia Programs – Practice Doctorate addresses the perianesthesia continuum in Standard D.5.
De Oliveira Filho GR. The construction of learning curves for basic skills in anesthetic procedures: an application for the cumulative sum method. Anesthesia & Analgesia. 2002; 95(2): 411-416.
Konrad C, Schupfer G, Wietlisbach M, Gerber, H. Learning manual skills in anesthesiology: is there a recommended number of cases for anesthetic procedures? Anesthesia & Analgesia. 1998; 86(3): 635-639.
Kopacz D. The regional anesthesia "learning curve”: what is the minimum number of epidural and spinal blocks to reach consistency? Regional Anesthesia. 1996; 21(3): 182-190.
Smith MP, Sprung J, Zura A, Mascha E, Tatzlaff J. A survey of exposure to regional anesthesia techniques in American anesthesia residency training programs. Regional Anesthesia and Pain Medicine. 1999; 24(1): 11-16.
How do the COA Standards support the full scope of nurse anesthesia practice?
The scope of nurse anesthesia practice is determined by education, experience, state and federal law, and facility policy. The Standards for Accreditation of Nurse Anesthesia Educational Programs and the Standards for Accreditation of Nurse Anesthesia Programs – Practice Doctorate are designed to prepare graduates with competencies for entry into anesthesia practice. A crosswalk between the AANA Scope of Nurse Anesthesia Practice and the Standards for Accreditation of Nurse Anesthesia Programs – Practice Doctorate shows how the standards address the elements of the scope (refer reference below). Entry into practice competencies for the nurse anesthesia professional prepared at the practice doctoral level are those required at the time of graduation to provide safe, competent, and ethical anesthesia and anesthesia-related care to patients for diagnostic, therapeutic, and surgical procedures. Entry into practice competencies should be viewed as the structure upon which nurse anesthetists continue to acquire knowledge, skills, and abilities along the practice continuum that starts at graduation (proficient), and continues throughout their entire professional careers (expert). The Standards require that the curriculum be designed to focus on the full scope of nurse anesthesia practice (Standard E.2).
CRNAs practice in a variety of settings; the level of autonomy of practice is determined by many factors. All CRNAs, regardless of whether they work with anesthesiologists, should be prepared to practice autonomously; however, nurse anesthesia educational programs must provide supervision for nurse anesthesia students according to the Standards for Accreditation of Nurse Anesthesia Educational Programs
(Standard V, Criteria E10, E11, and E13) and the Standards for Accreditation of Nurse Anesthesia Programs – Practice Doctorate
(Standards F.5, F.7, and F.8). While students may experience clinical training in practices where CRNAs function autonomously, the students themselves should never be practicing completely independent of supervision by a CRNA and/or anesthesiologist.
Although the COA does not require students to obtain clinical experience in rural and small practice settings, many programs provide students with opportunities in these clinical settings based on their availability. While experience within CRNA-only practices is desirable it is not always possible for programs to establish clinical rotations of this nature. The COA recently conducted a survey of owners and partners of CRNA-only practice groups in order to determine their willingness to provide clinical education for anesthesia students, as well as to identify barriers to groups serving as clinical sites. Several anesthesia providers in CRNA-only practice settings responded that they would be willing to be contacted by a nurse anesthesia program to discuss receiving anesthesia students; the COA provided their names and contact information to anesthesia program administrators. As an additional resource for programs, the COA maintains a list of CRNA-only practices that have expressed interest in serving as clinical sites. Individuals at CRNA-only practices may contact the COA if willing to be contacted by programs.
Gombkoto RLM, Walker JR, Horton BJ, Martin-Sheridan D, Yablonky MJ, Gerbasi FR. Council on Accreditation of Nurse Anesthesia Educational Programs Adopts Standards for the Practice Doctorate and Post-graduate CRNA Fellowships. AANA J. 2014; 82(3):177-183.
What is the COA’s process for revising the Standards?
The process for major revision of the Standards is described in the “Standards for Accreditation: Development, Adoption, and Revision” policy in the COA’s Accreditation Policies and Procedures manual. Please refer to this policy for a complete description.
For a description of the most recent major revision of the Standards, please see the following article:
Gombkoto RLM, Walker JR, Horton BJ, Martin-Sheridan D, Yablonky MJ, Gerbasi FR. Council on Accreditation of Nurse Anesthesia Educational Programs Adopts Standards for the Practice Doctorate and Post-graduate CRNA Fellowships. AANA J. 2014;82(3):177-183.
Highlights of the process are described below but please refer to the Accreditation Policies and Procedures manual for the complete policy.
Major (substantive) revisions are defined as major revisions to the Standards that may affect the nature of the educational program, its mission and objectives, and the allocation of its resources. The COA is responsible for determining the need for major changes to the Standards and for initiating such actions, and will consider recommendations for major revisions received from appropriate persons, councils, programs, or institutions.
If the COA determines a major revision is in order, a Standards Revision Task Force (SRTF) is appointed and a multiyear timeline is prepared for completing the change. The timeline affords the constituencies of the SRTF, including the AANA Board of Directors and AANA Education Committee, a meaningful opportunity to provide input into the change and presents a progress report to the COA.
In the Development and Adoption Phase, the SRTF develops and reviews consecutive drafts of the new Standards based on input from the communities of interest.
In the Implementation Phase, an orientation to the new Standards is offered by the COA at the first Assembly of School Faculty held after the adopted Standards have been published and distributed. Open discussion relative to the new Standards is conducted at the Assembly of School Faculty (ASF) relative to the need for and/or feasibility of the changes. From the reports received and the recommendations made at the ASF, the revised Standards (and revised self study, if needed) will be finalized. If at any point during the revision process inadequate consensus on a given point in the revision is present, selected steps in this process may be repeated.
The adopted Standards will be implemented by programs within one year. Programs undergoing onsite visits during this year can elect to be reviewed under the adopted Standards or the previous Standards. Following implementation of the Standards, the COA will conduct reviews of the standards on a yearly basis (or as needed).
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