Internal (facility) issue and questions

gobluern · Jan 23, 2014

Is this in Birmingham? I know several practicing CRNA's in Alabama and this isn't happening anywhere they work.

allnurses Guide · Jan 23, 2014

I wanted to get some CRNA's take on this as it was a bit troubling to me since I am about to start CRNA school. I have decided I might run into the same issue one of my collegues and would like to know how you would handle it. So, the situation I speak of is this. According to my collegue, a CRNA, a change is occuring at the hospital where he works. He is reporting to me that MDA's are making sure to get to patients first and tell them that he will be putting them to sleep, and the "Nurse" (used in a derogatory manner) will be monitoring you. He also reported to me that they will be changing the CRNA's badges to only read "RN". There will also be a change in that hospital as to what CRNA's are allowed to do (undetermined as of yet). I know this seems somewhat trivial, but I fear it will lead to further restrictions on the autonomy of CRNA's in the area. I also feel like it is a lack of respect to make a CRNA make his badge to only say RN as the badge is something that depicts who we are to people who do not know. I just wanted to get some CRNA's from different regions opinions on this. Have you seen this happen in your facility? If you did how would/did you handle it? Thank you for your responses in advance.

The problem at some facilities is the MDAs are on the medical staff where CRNAs are not and have all the control. They can essentially do what they want as far as controlling a CRNAs practice in that ACT practice. I would imagine that that facility will see a mass exodus of CRNAs. I tell all my patients that I am the one that will be taking care of them during their operation. I would refuse to be misrepresented or belittled by another medical professional. There are plenty of jobs for CRNAs. I would just find another one.

The other route is to fight it which would depend on how receptive to APRNs/CRNAs your facility is and who you actually work for as to whether this will have a chance of succeeding. An anesthesia group owned by MDAs that is not pro-CRNAs there is almost no chance of winning, but if you are hospital employee you can take this up all the way chain of command. It would also be important to contact the state chapter of the AANA and let them know what is going on.

Powertrip · Jan 23, 2014

Is this in Birmingham? I know several practicing CRNA's in Alabama and this isn't happening anywhere they work.

Yes go blue, I was told this was in the process of happening right now at UAB. This was told to me by one person who is practicing there currently. I would say his name, but I feel I would need his permission for that.

Goose Xx, MSN, RN, EMT-P, CRNA · Jan 23, 2014

Not an issue at our facility. Most of our docs are good to deal with. We (CRNA's) do the preops and formulate our own plans. Today the doc I was working with just stopped and said that he was working with me and went on his way. But we also have 41 CRNA's in our group and get along good and I feel we have a fairly combined voice.

We have been told several times that they would not be able to function without us due to amount of OR's and out of department anesthetics provided.

jwk · Jan 23, 2014

I wanted to get some CRNA's take on this as it was a bit troubling to me since I am about to start CRNA school. I have decided I might run into the same issue one of my collegues and would like to know how you would handle it. So, the situation I speak of is this. According to my collegue, a CRNA, a change is occuring at the hospital where he works. He is reporting to me that MDA's are making sure to get to patients first and tell them that he will be putting them to sleep, and the "Nurse" (used in a derogatory manner) will be monitoring you. He also reported to me that they will be changing the CRNA's badges to only read "RN". There will also be a change in that hospital as to what CRNA's are allowed to do (undetermined as of yet). I know this seems somewhat trivial, but I fear it will lead to further restrictions on the autonomy of CRNA's in the area. I also feel like it is a lack of respect to make a CRNA make his badge to only say RN as the badge is something that depicts who we are to people who do not know. I just wanted to get some CRNA's from different regions opinions on this. Have you seen this happen in your facility? If you did how would/did you handle it? Thank you for your responses in advance.

I agree with your opinion about the nametags - that seems to be a misrepresentation of the role of the CRNA. Referring to the CRNA's as "the nurse" is can certainly be thought of as being derogatory, although in some contexts, it's may be OK.

As far as the scope of practice within a given facility - the hospital, through the medical staff credentialling process, is totally within their rights to decide scope of practice for ANY medical professional in their facility, be it CRNA, AA, MD, PA, CNM, etc. Similarly, if an anesthesia group employs CRNA's, they can decided the scope of practice for the CRNA employees of their group. A hospital or group may limit scope of practice, but they cannot expand scope of practice beyond that which is specified under law.

There can be any number of different reasons for these changes but two come to mind - neither one are answers you will like. One is the competition for cases and procedures that is common in academic centers. In those types of hospitals, there is frequently an attitude that basically boils down to "the residents get first crack" at bigger cases, invasive lines, and/or regionals and blocks.

The other quite honestly is "you reap what you sow". The increasing claims of CRNA's that they are the equivalent of an anesthesiologist, or that anesthesiologists simply aren't necessary, are understandably not appreciated by anesthesiologists. Like it or not, some of these actions are the result of such claims. Similarly, you will continue to find fewer and fewer anesthesiologists that have any interest in supporting CRNA education and training. MD's that were willing to teach CRNA's a few years ago now wonder "why am I training those who seek to replace me?" Good question.

allnurses Guide · Jan 23, 2014

I agree with your opinion about the nametags - that seems to be a misrepresentation of the role of the CRNA. Referring to the CRNA's as "the nurse" is can certainly be thought of as being derogatory, although in some contexts, it's may be OK.
As far as the scope of practice within a given facility - the hospital, through the medical staff credentialling process, is totally within their rights to decide scope of practice for ANY medical professional in their facility, be it CRNA, AA, MD, PA, CNM, etc. Similarly, if an anesthesia group employs CRNA's, they can decided the scope of practice for the CRNA employees of their group. A hospital or group may limit scope of practice, but they cannot expand scope of practice beyond that which is specified under law.
There can be any number of different reasons for these changes but two come to mind - neither one are answers you will like. One is the competition for cases and procedures that is common in academic centers. In those types of hospitals, there is frequently an attitude that basically boils down to "the residents get first crack" at bigger cases, invasive lines, and/or regionals and blocks.
The other quite honestly is "you reap what you sow". The increasing claims of CRNA's that they are the equivalent of an anesthesiologist, or that anesthesiologists simply aren't necessary, are understandably not appreciated by anesthesiologists. Like it or not, some of these actions are the result of such claims. Similarly, you will continue to find fewer and fewer anesthesiologists that have any interest in supporting CRNA education and training. MD's that were willing to teach CRNA's a few years ago now wonder "why am I training those who seek to replace me?" Good question.

It is never OK to refer to CRNAs just as RNs when they are filling the role of a CRNA. In this particular case it is meant to equate CRNAs with RNs and diminish their professional standing. It is the same as when the ASA likes to use the term anesthesia RN/nurse instead of CRNA in their publications and PAC announcements.

The medical staff can limit CRNA credentialing on a whim and this is one of major reasons that APNs are encouraged to be formally considered on the medical staff not nursing staff. You cannot have a say if you are not on the medical staff or in most cases not even allowed at the medical staff meetings. What is said to your face is often going to be quite different behind closed doors.

Residency training is always an issue and always will be, but there should be some limits because all anesthesia providers need to keep up their skills. A staff MDA can quickly lose their skills in a residency environment just as easily as CRNAs when the residents are always doing the blocks, CVLs, etc.

Reap what you sow is pure nonsense. CRNAs have been around for 150+ years and have had independent practice for 150+ years. CRNAs are not trying to invent new practice standards we are trying to maintain what nurse anesthetists have always had (independent practice) and has slowly been degraded over the years by MDAs more interested in their money and egos than anything else. The ASA doesn't give a crap about patient care when it comes to CRNA autonomy. This is an issue about money and egos.

I will add since I am sure JWK will pipe in with something about the "downtrodden" AAs and CRNA having a double standard that AAs are just a political tool. AAs cannot practice independently. AAs do extend anesthesia services. The AA profession IMHO has only one purpose and that is to help MDAs remain in control with a type of provider that has to be medically directed and can only work with MDAs, if this wasn't true then the ASA would not be trying expand AAs into every state.

MeTheRN, BSN, MSN, RN · Jan 23, 2014

The ASA hired scientists to conduct a study, and the results concluded that the general public viewed the term "nurse anesthetist" less favorably than "certified registered nurse anesthetist." Ever since then, I'm wary of anyone referring to CRNA's as nurses or anesthesia nurses. Maybe I'm just paranoid, but I reintroduce myself as a CRNA and spend some time explaining exactly what my role is.

jwk · Jan 24, 2014

Reap what you sow is pure nonsense. CRNAs have been around for 150+ years and have had independent practice for 150+ years. CRNAs are not trying to invent new practice standards we are trying to maintain what nurse anesthetists have always had (independent practice) and has slowly been degraded over the years by MDAs more interested in their money and egos than anything else.

Maybe a different phrase would make you happier, but the sentiment would be the same. The push for true independent practice is a fairly recent phenomenon - you know - that opt-out thing. If that's not important, why is it being pursued? Surely you have seen claims by CRNA's that they're every bit as good as physicians. Surely you don't deny that CRNA's are moving into areas that were previously considered the practice of medicine (chronic pain, fluoroscopy, etc.) I know you're aware of the threat by the AANA to sue the ASA over an op-ed piece in The Hill. All of these things add up. Do you really expect anesthesiologists to just roll over and let you do whatever you want to do? And although your version of why AA's exist is far different than the reality, I'm not going to lose any sleep when an AA is hired for a position previously held by a CRNA. Again - you reap what you sow.

allnurses Guide · Jan 26, 2014

Maybe a different phrase would make you happier, but the sentiment would be the same. The push for true independent practice is a fairly recent phenomenon - you know - that opt-out thing. If that's not important, why is it being pursued? Surely you have seen claims by CRNA's that they're every bit as good as physicians. Surely you don't deny that CRNA's are moving into areas that were previously considered the practice of medicine (chronic pain, fluoroscopy, etc.) I know you're aware of the threat by the AANA to sue the ASA over an op-ed piece in The Hill. All of these things add up. Do you really expect anesthesiologists to just roll over and let you do whatever you want to do? And although your version of why AA's exist is far different than the reality, I'm not going to lose any sleep when an AA is hired for a position previously held by a CRNA. Again - you reap what you sow.

The push for independence has never changed. CRNAs have always had it. The flow of money is what has changed. MDAs haven't been able to bill for medical "supervision" for an unlimited supply of CRNAs for many years now so they have been trying to control the anesthesia market any way they can. The ASA wants to limit CRNA independence to keep their members bottom lines as high as possible.

Opt-out is joke. Opt-out is just a way to reverse something that should have never happened. The limiting of CRNAs billing is just another way for ASA to try to limit the CRNA profession.

There are CRNAs that have been doing chronic pain management for decades, safely, and effectively(new research will soon be published on that). The fluoroscopy issue is also a joke any medical provider can learn to do fluoroscopy. That is just another bid by the ASA to limit practice. The ASA has tried to do the same thing with regional/PNBs, US-guidance etc.

The ASA continues to makes libelous and slanderous statements all the time about CRNAs. There is no other political organization that would tolerate that kind of behavior why should the AANA/CRNAs.

The reality behind AAs is that if MDAs stop being allowed to bill for medical supervision then AAs will virtually cease to exist overnight. AAs are political pawns. There is no need for the AA profession. AAs just fill a niche that could easily be replaced by changing the billing requirements and having MDAs and CRNAs do their own cases.

I know there is a much better way to work with MDAs other than ACT practices. The military and many hybrid civilian anesthesia practices are proof of that. The AA profession by their own scope of practice can never be part of these type practices, and have no hope for future in ever tightening medical reimbursement market.

loveanesthesia · Jan 29, 2014

The name tag might seem like a small issue, but it's not. Name tags are a method of informing the public of the qualifications of those providing care. I would not wear a name tag stating RN when I am providing anesthesia.

foraneman · Jan 29, 2014

If the MD tells a patient that he is putting the patient to sleep and that a "nurse" will be "monitoring" them, and then fails to in fact administer the anesthetic in its entirety from induction to emergence, and/or the "nurse" is involved in the administration of the anesthesia beyond simple "monitoring", the MD has committed fraud and can be held liable for their misrepresentation to the patient. Should there be an untoward event the MDA will have no defense to a claim from the patient that he lied to the patient as to who would be substantially involved in the administration of the anesthetic. He would in fact likely take on the liability of the CRNA where no such responsibility would have existed before. From a liability standpoint such an approach is monumentally stupid. Not to mention unethical and void of any patient oriented reasoning.