A Certified Registered Nurse Anesthetist’s (CRNA) day begins with an inspection of the OR he or she is assigned to, with priority over the OR table and anesthesia equipment. Immediately before seeing the patient, a CRNA reviews the patient’s chart for any red flags, including information the patient may not willingly divulge. Examples of red flags include: a previous surgery, current medications (particularly cardiac medication and narcotics), and BMI. All of these factors can significantly impact how the patient will respond to anesthesia and surgery.
When meeting the patient, both a conversation and a physical exam ensue, as this is the final opportunity to determine what the CRNA can reasonably expect hemodynamically from the patient during the case. While inspecting the patient’s anatomy, a CRNA may ask how many stairs they can climb before getting winded, or how many pillows they use to sleep comfortably at night. All of this information combined will inform the American Society of Anesthesiology (ASA) score assigned the patient, which is a scale from one to five, one being a healthy patient and five being a moribund patient. This will be announced during the surgical time out.
In New York and Pennsylvania, CRNAs do not have APN status. In New York, this means that CRNAs work under the supervision of an anesthesiologist or the operating physician. This anesthesiologist is expected to be present for induction, intubation, emergence, and extubation, as well as frequent check-ins throughout the case. By contrast, CRNAs in Pennsylvania work in cooperation with a surgeon or dentist and the CRNA’s performance shall be under the overall direction of the chief or director of anesthesia services.
In all other states where CRNAs do have APN status, they perform collaborative care, which involves much less oversight. Nurse anesthetists practice under supervision of the surgeon with no physician anesthesiologist requirement in 49 states and completely independent of a physician in 17 states.
What every CRNA must carry over from days as a critical care nurse is nursing intuition, strong assessment skills, and a sense of resilience. It is not a position for shrinking violets; your voice as the patient’s advocate is more important than ever. A patient may be deemed unfit for general anesthesia based on assessment. The CRNA who cancels a surgery will find it is almost never received well by the patient, nor the surgical team or the nursing team who prepared for surgery. A significant portion of any CRNA’s day may be making decisions on the patient’s behalf that are unpopular.
On any given day, depending on what type of surgeries are being done in a given OR, a CRNA may see one patient or twelve during a twelve-hour shift. While doing a series of quick hysteroscopies on young women may mean your patients are healthier, the challenge is to keep pace and to do so without sacrificing thoroughness. Having every patient’s life essentially in your hands is nothing to take lightly, no matter how clean their health record may be. After each case, the CRNA has to make sure every patient is stable in recovery before leaving them with the PACU team. It’s then on to the next patient to do it all over again.
In order to become a Certified Registered Nurse Anesthetist, you must graduate with a minimum of a master’s degree from an accredited nurse anesthesia program and pass the national certification exam, which is administered by the National Board of Certification and Recertification for Nurse Anesthetists.
The term “midwife” literally means “with woman.” Although nurse-midwives are best known for their work during pregnancy and specifically labor and delivery, nurse midwives care for women’s health in a comprehensive way. Certified nurse midwives (CNM) are advanced practice nurses specializing in prenatal care, labor and delivery, postpartum care, gynecology, well women’s health care, and family planning. They work anywhere other advanced practitioners do: in the hospital, at the clinic, and at home.
In the past, many people thought of midwives as only assisting women in home births, water births, and labor without anesthesia. Although some women may choose to deliver their babies in this way, midwives actually oversee all types of births, including those that are more conventional in the hospital. Nurse midwives have the credentials and authority to empower patients, so the kind of care given is according to their preferences and in their best interest.
Despite common misunderstandings, nurse midwives are qualified
to care for women during various stages of life. Furthermore, as prescribers
and independent providers, they are able to manage all types of pregnancies,
whether straightforward or complicated. Like other advanced practice nurses,
many midwives have years of experiences as registered nurses in labor and
delivery and other areas of women’s health. Many contend that the unique
experience of working as a registered nurse before advancing is what sets nurse
practitioners, including midwives, apart from their physician counterparts.
Within midwifery, there are stratified scopes of practice and levels of education; this is both location and training-dependent. Just like other advanced practice nurses, midwives work with varying degrees of independence from physician oversight in an ever-changing climate of advanced practice patient care. The majority of midwives hold a master’s or doctorate nursing degree (CNM); there are also certified midwives (CM) who have passed their advanced practice boards while maintaining a bachelor-level degree of education. For those who don’t have a bachelor’s, master’s, or doctorate degree can qualify to be a certified professional midwife (CPM). They are either trained through apprenticeship and/or formal education, and their scope of practice is narrower than CNMs.
As standards of health care providers evolve, the accreditation process for nurse midwives has increasing standards. The good news is that nurse midwives are learning through rigorous training and experience to provide high-quality patient care independently. Nurse midwives are more than the overseers of alternative birthing methods. They are fully licensed and independent women’s health providers.
For more information on this career path, visit DailyNurse.com/nurse-midwife.
I am a cardiac acute care nurse in a large Northeast suburban trauma hospital. I arrive at work twenty minutes early so that I can get to know my patients. I then check the chart for admitting diagnosis, pending labs, exams, point-of-care testing needs, etc. I do this because no matter how much I trust the nurse giving me the report, I recognize that any human is more liable to make mistakes and oversights after working at this level of intensity for thirteen hours.
After receiving the report, I introduce myself to my patients. The nursing ratio on my unit is 3:1 and at times up to 5:1. If the patient is awake, I assess them right away after introductions. I bring a computer-on-wheels (COW) in the room with me to document everything. The COW minimizes distractions and allows me to assess anything I forgot if needed. Next, I administer scheduled medications.
I find it most effective to complete tasks while in the room with the patient. The hallway is an obstacle course of distractions. For example, it may seem reasonable to step out while your patient is on a nebulizer treatment knowing the treatment takes five to eight minutes to complete. In a high-acuity unit, eight minutes is an eternity. Therefore, no matter how much I plan, I can almost guarantee I will be sidetracked by a new task in that short time. On good days, my charting is done by 10 a.m., which happens about 60% of the time. This allows me to have my afternoons free to address anything that comes up. Afternoons are less predictable because usually the night shift has set up and stabilized the patient for the mornings.
The hospital I work in is not unionized, so taking breaks is not enforced. We are entitled to one 30-minute and one one-hour break during a twelve-hour shift. Some nurses follow that timing fastidiously on each shift, while some nurses don’t take a break at all. I strongly discourage that. I perform better when I take a few 15-20 minute breaks throughout the day when my patients are settled. Otherwise, I use the extra time to prepare for later tasks, such as setting up and labeling IV medications. This ensures I leave on time, and I always do.
I have the opportunity today to precept new nurses and I always encourage them to find their own rhythm. In the beginning, I used to follow my preceptor and make an index card with a table of all the medications and point-of-care testing for each patient. Once I found my stride, I realized this card was actually wasting more time than it was saving, and I relied on the EMR instead anyway. Who knows? That may change again.
Evolving and learning are constant features of acute care nursing. A day in the life of an acute care nurse may be a misnomer as, lucky for me, no two patients are the same and no two days are the same.
To learn more about a career in acute care nursing, visit here.
It may seem like it would take a superhero to balance full-time nursing work with continuing education and perhaps even a personal life, but take heart. It is possible, even without sacrifice. Continuing nursing education, whether for an advanced degree, studying for specialty certification, or keeping current on evidence-based practice, is a matter of discipline. That life is about quality rather than quantity is also true in the balancing act of being a working student.
The first step in nursing education is organizing the details: What would a full-time course load look like? Will it require cooperation from your employer, and if so, how willing are they to accommodate you? Will your employer help you pay tuition and what are the limits of that? What are your other commitments and how flexible are they?
One suggestion for making it work is to look at a typical week of your life and block out times that you are unavailable. This includes times that you spend with your family, running errands, and yes, even playing and relaxing. Make your class schedule around that, while at the same time remembering that there will be homework.
When you apply to school, start the process early and give yourself the luxury of time in the application process; it is easier done in small nibbles than large bites. Your application can be painlessly completed one transcript, personal statement paragraph, and reference request at a time.
Once enrolled, having the discipline to give your schoolwork quality attention will allow you to feel fulfilled and purposeful rather than deprived. When you study, turn your phone and TV off, ask for privacy, set a timer, and focus. And when you’re done, be done. Don’t give up anything important to you. Continue exercising, knitting, playing music, or whatever gives you pleasure and reprieve.
The last thing your patient or your family needs is an angry, tired nurse. Even if it’s one class at a time, you’re doing it. So…do it, but do it as you continue high-quality patient care and high-quality self-care.
If you ask any nurse why they went into nursing, their response will undoubtedly have a foundation of compassion. Whether it’s an anecdote about a family member, a childhood role model, or a personal experience, a career in nursing starts by caring.
And yet, in a modern health care system burdened by precarious political conditions, technology evolving at breakneck speed, and specialties becoming super-specialties, it’s easy to lose touch with sentiment.
The onus on nursing seems to be heavier than ever, and the workload seems to focus on skills and tasks rather than human connection. Within such a context, reminding a nurse (if you can catch him or her) that they need to give report to another unit may understandably yield a frustrated grunt.
Yet despite how inconvenient, time-consuming, and even unpleasant hand-off may seem, its purpose is not to frustrate the nurse but rather to serve the patient.
Remember SBAR? Have you heard that acronym since nursing school? Health care today is filled with endless acronyms and buzzwords. SBAR and others serve as simple solutions to the impossibly complex knowledge nursing requires. Likely to many nurses’ chagrin, SBAR is evolving, and even specializing, just like nursing; now there is SHARED, PEARLS, and IPASS, to name a few.
What does compassion have to do with giving report? If every nurse gave hand-off as if the patient was their loved one, it is likely that every scratch would be scrutinized, every medication change would be reviewed in minute detail, and personal details would be emphasized (e.g., “She hates when you call her Patty. Call her Trish.”).
Giving good report is not an advanced science, but a simple art that can be mastered with a few pointers rooted in the principle of quality care:
- Write pertinent information down; do not go by memory.
- Do not multitask while giving or receiving report.
- Be thorough; don’t assume the other nurse “should” already know something.
- Whether SBAR or not, use a simple guideline to be sure you have covered all your bases.
Caring nurses are thorough nurses. If the care that attracted a nurse to the field can inform every report they give (and every other task), nursing can become even more meaningful, efficient, and effective.