How did the COA determine the entrance requirements for applicants to nurse anesthesia educational programs, including the requirement for a minimum of one year of critical care experience?
In developing Standards (both master’s and doctoral) related to admissions requirements, the COA strengthened the existing standard and defined “Critical Care Experience” to ensure students enrolled in nurse anesthesia programs possess the appropriate professional preparation.
Master’s Standard III, C13b: At least one year of experience as a RN in a critical care setting (see Glossary “Critical Care Experience”)
Practice Doctorate Standard C.2.3: A minimum of one year full-time work experience, or its part-time equivalent, as a RN in a critical care setting. The applicant must have developed as an independent decision-maker capable of using and interpreting advanced monitoring techniques based on knowledge of physiological and pharmacological principles (see Glossary "Critical Care Experience")
Critical Care Experience - Critical care experience must be obtained in a critical care area within the United States, its territories or a U.S. military hospital outside of the United States. During this experience, the registered professional nurse has developed critical decision making and psychomotor skills, competency in patient assessment, and the ability to use and interpret advanced monitoring techniques. A critical care area is defined as one where, on a routine basis, the registered professional nurse manages one or more of the following: invasive hemodynamic monitors (such as pulmonary artery catheter, CVP, arterial); cardiac assist devices; mechanical ventilation; and vasoactive infusions. Examples of critical care units may include but are not limited to: Surgical Intensive Care, Cardiothoracic Intensive care, Coronary Intensive Care, Medical Intensive Care, Pediatric Intensive Care, and Neonatal Intensive Care. Those who have experiences in other areas may be considered provided they can demonstrate competence with managing unstable patients, invasive monitoring, ventilators, and critical care pharmacology.
The COA considered the following evidence and expert opinion in defining the clinical experience pre-requisite for entry into nurse anesthesia programs:
- While one year was the minimum for acute care experience, an average of 3.4 years was reported by the NBCRNA FY2013 Annual Summary of NCE Performance Data. Furthermore, the Council has strengthened the Standard to require a minimum of one year of critical care experience.
- There are no data that demonstrate the number of years of critical care experience improves critical thinking abilities, nor does it enhance nurse anesthesia skill acquisition or success within the program.
- This requirement is unique to nurse anesthesia education: none of the other advanced practice professions (e.g., physicians, dentists, optometrists, physician assistants, or other APRNs) has critical care experience pre-requisites.
- Required critical care experience can be likened to a required internship. Following a four-year baccalaureate degree, two years of critical care experience, in addition to three years of doctoral education, would ostensibly lengthen the nurse anesthesia education process to nine years.
- An article by Burns (AANA Journal, June 2011) concluded that the amount of critical experience was negatively correlated to academic success and progression. Candidates most likely to succeed demonstrated positive correlation with overall GPA and science GPA.
- An article by Wong and Li (AANA Journal, June 2011) concluded that personality characteristics (i.e., confidence and commitment) may be more accurate predictors of academic and clinical success in nurse anesthesia education.
Should a standardized entrance examination(s) be required for applicants to nurse anesthesia educational programs?
A valid, reliable entrance examination, specific to nurse anesthesia, does not exist. Programs are required to enroll students who are academically and experientially prepared for nurse anesthesia education in the following ways:
- Applicants have achieved academic success in baccalaureate-level degrees thereby demonstrating critical thinking abilities consistent with that level of education.
- Successful completion of the NCLEX requires critical thinking abilities appropriate for the registered nurse role and responsibilities.
- Applicants are required to complete one year of full-time work experience as a registered nurse in a critical care setting. Critical care nursing experience fosters the development of clinical competencies and critical thinking abilities gained at the entry-into-nursing practice level.
- The COA’s Standards for Accreditation of Nurse Anesthesia Educational Programs and Standards for Accreditation of Nurse Anesthesia Programs: Practice Doctorate glossaries define “Critical Care Experience” to ensure that applicants and programs have a clear understanding of the minimum critical care acumen for admission to nurse anesthesia programs. The knowledge, skills, and abilities outlined in this definition require the RN to possess and utilize critical thinking abilities.
- Students enrolled in programs awarding doctoral degrees are required to possess both ACLS and PALS certification before beginning clinical activities. These certifications verify adult and pediatric life support competencies, including the diagnosis and management of life-threatening conditions.
Given the variability in the definition of critical thinking, and the paucity of valid/reliable tools to assess critical thinking, universities and programs are provided the latitude to assess these attributes in ways consistent with institutional policy and available evidence. Examples include submitted essays, spontaneous writing exercises, the Graduate Record Examination, Miller’s Analogy Test, and others. In addition, a variety of critical care nursing examinations are offered by several certifying organizations. Given that universities and anesthesia programs establish their own admissions requirements and there are many examinations available, it would be very difficult to a) define which examination(s) would be acceptable, b) produce evidence supporting why they are acceptable, and c) convince universities that any specific examination is a critical admission criterion. No evidence exists that any certification examination available to registered nurses (for example, the CCRN) predicts success in nurse anesthesia educational programs.
What is the role of the Council in regard to the profit margins of nurse anesthesia programs?
The Council does not play a role in the profit margins of anesthesia programs. However, the COA’s Standards require programs to provide evidence that adequate resources exist to support the size and scope of the program to appropriately prepare students for practice and to promote the quality of graduates including:
a. Financial resources that are budgeted and used to meet accreditation standards,
b. Physical resources including facilities, equipment, and supplies,
c. Learning resources including clinical sites, library, and technological access and support,
d. Faculty and support personnel, and
e. Student services including but not limited to assistance (such as financial aid), health services, insurance, placement services, and counseling.
The Practice Doctorate Standard B.7* and 2004 Standard II, Criteria B3 also require that the CRNA program administrator has the authority to prepare and administer the program budget. Failure to fully comply with one or more of the COA Standards marked with an asterisk is considered to be of critical concern in decisions regarding nurse anesthesia program accreditation.
The Council reviews the financial and other resources of programs through several mechanisms: programs are required to provide budget and resource information each year when they complete their annual reports for submission to the Council; evaluations of programs are completed by faculty and students at the midpoint of their accreditation cycle (or more often if required) and in preparation for an onsite visit; and programs submit a completed self study and host an onsite review when the program is due for review for continued accreditation. If the Council determines there may not be sufficient resources available to meet the Standards, the program administrator is notified and requested to address the Council’s concerns in writing, and include supporting documentation.
Please note that at its January 2014 meeting the COA approved a new “Program Resources and Student Capacity” policy. This policy establishes benchmarks for each program’s class size based on adequacy of resources. Programs cannot increase their class sizes without obtaining prior approval. Programs must demonstrate reasonable assurance there are adequate resources as delineated in Practice Doctorate Standard A10* and current Standard II, Criteria B1*,B2, B4*, and B5.
What is the process for granting initial accreditation to new nurse anesthesia programs?
The COA's process for the accreditation of a new nurse anesthesia program is focused on ensuring the program's compliance with the accreditation Standards. The process, as identified in the COA's Accreditation Policies and Procedures, is consistent with the recognition requirements of both the U.S. Department of Education (USDE) and the Council for Higher Education Accreditation (CHEA). Please note the COA does not consider workforce (i.e. the supply and demand for CRNAs) in its accreditation review process. This would be inconsistent with USDE and CHEA recognition requirements and have antitrust implications.
Prospective programs need to undergo a series of activities required by the COA prior to receiving their initial accreditation.
This begins with Council Policies: “Capability Review for Accreditation” (pp. C-1—C-3) and establishing “Eligibility for Accreditation” (pp. E-1—E-3).
Prospective programs seeking COA accreditation may not admit students to the nurse anesthesia program or enroll students in courses with anesthesia in the title or with anesthesia-related content before initial COA accreditation is granted.
The first step in the process for a new nurse anesthesia program is for the sponsoring institution to file a letter of intent with the COA. The letter of intent must be from the chief executive officer of the sponsoring institution and reflect the institution's legal authority to grant the degree and its commitment to provide the necessary resources to establish a program that meets accreditation requirements.
Following the COA's acceptance of the letter of intent, a new program starts an accreditation review process. The process includes the submission of evidence of eligibility (i.e., legal authority to grant the degree and meet all state regulatory requirements including requirements of the state boards of higher education and state boards of nursing), a self study (i.e., a program’s written explanation regarding how it meets each accreditation criterion with supporting documentation), payment of required fees, and hosting an onsite review. The onsite review is conducted by experienced nurse anesthesia educators and practitioners who are approved and trained by the COA to serve in their capacity as an extension of the COA (ref. policies “Onsite Review,” p. O-2—O-4 and “Onsite Reviewers and Fellowship Review Committee: Application and Appointment,” O-7—O-11).
An applicant program must demonstrate by appropriate documentation within the self study and verification by the onsite reviewers that the program is in compliance with the Standards, including the following requirements:
- Potential for professional and educational growth of students and faculty,
- A curriculum to enable graduates to attain certification as nurse anesthetists, including sequencing of courses for the entire program and a description of each course,
- Written agreements with sufficient accredited clinical sites to provide required cases and experiences for the total number of students to be enrolled when the program is fully implemented (e.g., first-, second-, and third-year classes),
- Appropriately qualified administrative personnel, faculty, and resources to comply with the Council's Standards for Accreditation of Nurse Anesthesia Educational Programs and/or Standards for Accreditation of Nurse Anesthesia Programs: Practice Doctorate, and
- A three-year financial plan providing evidence of sufficient financial resources to implement and sustain an accredited program.
After the onsite review is completed, the reviewers’ prepare a written summary report to which the program must respond in writing, with supporting documentation, to all areas identified as partial- or non-compliance with the Standards.
Only after all of these activities have been successfully completed will the COA review the program. During its review, the COA analyzes all of the documentation associated with these steps in the accreditation process and makes an accreditation decision based on the program's ability to demonstrate compliance with the Standards
The Council then renders one of the following decisions: deferral, grant initial accreditation, or deny initial accreditation. If initial accreditation is granted, the program may admit students. The Council will determine the program’s initial class size based upon existing documentation of adequate resources, including but not limited to, the following:
- Program space, including classrooms, labs, etc.,
- Volume and variety of clinical experiences/number of sites,
- Number of qualified administrative, didactic and clinical faculty,
- Support personnel, and
- Student services that demonstrate they are sufficient to provide for the total number of students (ref. policy “Program Resources and Student Capacity,” pp. P-15—P-17).
After the program receives initial accreditation, it then must complete a self study and host an onsite review five years after the admission of its first class of students (ref. policy “Accreditation after Graduation of First Class of Students,” p A-1).
Please note that the COA does have a mechanism for third parties to submit comments and concerns regarding programs being considered for initial and continued accreditation. Comments will be limited to the program’s compliance with the Standards. Should anyone desire to submit official comments, please note that the program will be provided a copy of the comments and will have the opportunity to respond to them. The COA will then have the opportunity to consider the comments of both parties (ref. policy “Third-Party Presentation,”pp. T-3—T-5).
What role should accreditation Standards play in regulating the CRNA workforce?
None. The COA does not and cannot consider workforce (i.e., supply and demand for CRNAs) in its accreditation decision-making process. COA activities in this regard would be inconsistent with U.S. Department of Education and Council for Higher Education Accreditation recognition requirements. It would also have antitrust implications.
Instead, the COA requires programs to demonstrate substantial compliance with the Standards, which address program quality assessment and improvement. While the COA does not make accreditation decisions based on the number of CRNA practitioners in the geographic area of a particular program, the Standards do require each program to provide adequate didactic and clinical resources for all students. Recently, the COA revised this requirement by establishing an approved class size for each nurse anesthesia program preparing students for entry into practice, based on the adequacy of resources (refer to Accreditation Policies and Procedures, “Program Resources and Student Capacity,” P-15). The COA requires programs to verify that there are adequate resources to support an educational program that meets the Standards and to secure prior approval before increasing the number of students. Approval is required even if the program increases the number by one student. In addition, programs are required to provide information on student enrollment data annually.
How do students “teach others?”
Students can demonstrate compliance with the competencies expressed in Standard III, Criterion C21e4 and Practice Doctorate Standard D.30 by completing class presentations (face-to-face, virtual), making presentations to staff in the clinical setting (such as grand rounds type presentations), podium and poster presentations at local, state, national meetings, patient education (including preoperative interviews), and other methods.
Can non-CRNA faculty serve as advisors to SRNAs?
CRNA faculty members have a unique perspective on the advisor-advisee relationship compared with non-CRNA faculty members. In addition, CRNA faculty members have a distinctive understanding of what is expected of the SRNA in the clinical setting and of the graduate. There is a difference between official academic advising and scholarly work advising; while a non-CRNA might chair a scholarly work committee, a CRNA must serve as a committee member. Due to the qualifications, experiences, and perspectives of CRNA faculty members, only CRNA faculty members may serve as official academic advisors to SRNAs. This does not preclude the SRNA from consulting with any non-CRNA faculty member who can assist the SRNA during his/her educational experience.
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