Scope of Practice

paindoc · Feb 26, 2008

I disagree. The lack of education of CRNAs providing interventional or comprehensive pain management is exactly the issue. While there are similarities between anesthesiology and nurse administered anesthesia, there are profound differences between the two above specialties and interventional pain medicine. The tacit assumption that CRNAs may treat pain, any pain, providing they have a weekend course in anything, is based on an outdated view of pain medicine that existed in 1994. If the few CRNAs practicing interventional pain medicine do not recognize these differences, they will end up fighting a war with the 1,000,000 physicians in this country. The overwhelmining political and numerical advantage will result in an extreme setback to CRNAs as a whole, not only to those that are playing in a field of medicine in which they have no background, no CRNA school education, no substantial post CRNA training other than a weekend course in order to learn an entire medical specialty with very few similarities to CRNA practice or training, and perform no research. If it is really all about patient safety, I cannot think of a more poignant example of substandard care than to have untrained uneducated individuals from CRNAs to FPs performing interventional pain procedures.

Qwiigley, BSN, MSN, DNP, RN, CRNA · Feb 27, 2008

Out of all of the CRNAs in the USA, how many actually do pain without a pain MD?

paindoc · Feb 28, 2008

Nearly all are in rural areas at this time, so most are without a pain physician available, supervising, or for consultation.

APNgonnabe · Feb 28, 2008

I would like to know the answer to Qwiigley's question. And please excuse me if I'm off base but it seems, at least to me, that Paindoc problems seems to be w/ those few(I hope) CRNA's who have started surgeries (are we talking actual making cuts). Im sure he has several other points and honestly I do not have a lot of knowledge of the post, only my observations.

Be Kind...at least educational

Home Health Columnist / Guide · Feb 29, 2008

prior to 1960's rn's rarely took blood pressures routinely on patients yet along perform ekg reading or interpret it---province of the physician. today it is expected standard of practice along with many advanced skills like changing tracheostomy tubes and entire vent circuits for homebound patients.

as scientific advances occur along with education programs dedicated to providing training, both physicians and nurses add practice skills to their repetore. since ob/gyn mds in my area are now providing "medical aesthetics" ie laser hair removal and treatments, crna's who's education includes extensive pharmacology training should be able to expand their practice into pain mgmt.

napes recognizes, reinforces and supports the aana
position statement on pain management which states: “the management of pain is the central component of total anesthesia care. recognizing the individual patient's right to the treatment of pain, nurse anesthetists acknowledge that it is their professional and ethical responsibility to participate in the management of pain.”
“by virtue of education and individual clinical experience, crnas possess the necessary knowledge and skills to employ therapeutic, physiological, pharmacological, and psychological modalities in the management of acute and chronic pain. crnas adhere to a total patient care philosophy directed at the promotion and maintenance of health and well being with special emphasis on the alleviation of pain.”
http://napeseminars.com/pages/mission.html

paindoc · Feb 29, 2008

CRNAs have extensive pharmacology training in IV drugs used for anesthesia and a peripheral working knowledge of other drugs that may interact with anesthesia. They are completely untrained during CRNA school in the use, pharmacokinetics, pharmacodynamics, side effects, idiopathic reactions, and drug interactions of nearly all medications used in the clinical practice of pain management OR pain medicine. Attempting to acquire this knowledge by reading throwaway journals or attending a little weekend course is inadequate preparation for clinical practice and endangers patient safety due to an extreme overexpansion of a AANA position statement developed prior to 1994. A nurse practitioner is far better situated to treating pain than a CRNA because their training is relevant to the field of non-interventional pain medicine while that of a CRNA is not. CRNAs perceive their scope of practice to encompass the treatment of pain, all pain, with whatever fly-by-night knowledge they can acquire since the appropriate patient-safety oriented formal training programs in pain management do not exist for CRNAs.

jwk · Feb 29, 2008

Prior to 1960's RN's rarely took blood pressures routinely on patients yet along perform EKG reading or interpret it---province of the physician. Today it is expected standard of practice along with many advanced skills like changing tracheostomy tubes and entire vent circuits for homebound patients.
As scientific advances occur along with education programs dedicated to providing training, both physicians and nurses add practice skills to their repetore. Since OB/GYN MDs in my area are now providing "medical aesthetics" ie laser hair removal and treatments, CRNA's who's education includes extensive pharmacology training should be able to expand their practice into pain mgmt.

There's far more to pain management than sticking a needle in someone's back. To compare it to laser hair removal (performed by office staff, not the physician) is an amazing oversimplification of the issue. You simply can't take what is literally a weekend course and claim that you are a pain management specialist. The only way you do that is lie to the patient - either lying by claiming you're something you're not, or lying by omission, not telling the patient the true level of your training. "I'm an expert after taking a class over the weekend. That's just as good as a physician with a full year fellowship in pain management".

Biotechnology · Feb 29, 2008

I just thought that I should give my :twocents: on the issue. Now I understand where CRNA's feel like they should have a say in pain management, because I believe there is a place in pain management that they could be part of...especially when you are giving pain meds during procedures. That makes total sense!!! I gotcha on that.....What I DON'T understand is where CRNA's feel that they should bring a patient to radiology or the OR/.. make a lumbar cuts into a patients back, placing spinal leads for pain stimulators using C-arm, placing Baclacin Pumps (sp?) into patients etc. etc.....ya'll get my drift all after a weekend course. These are the things that separate pain physicians from anesthetist....the physicians do an extra 2-3 years to learn this stuff. Now I understand what nurseKaren is trying to say, that things are evolving...but they are evolving with the proper education to back it up! Now maybe in the future, it will change but for now, at least the part of pain management that I am refering to should remain in the physicians court. (Now I should also note that I am referring to what pain management does in my state and what they do in the OR that I work in....)

n_g · Feb 29, 2008

Prior to 1960's RN's rarely took blood pressures routinely on patients yet along perform EKG reading or interpret it---province of the physician. Today it is expected standard of practice along with many advanced skills like changing tracheostomy tubes and entire vent circuits for homebound patients.
As scientific advances occur along with education programs dedicated to providing training, both physicians and nurses add practice skills to their repetore. Since OB/GYN MDs in my area are now providing "medical aesthetics" ie laser hair removal and treatments, CRNA's who's education includes extensive pharmacology training should be able to expand their practice into pain mgmt.

Nurses can only expand into areas that physicians don't want to do. Take for example IV placement. It's so common and low yield that the physicians were more than happy to let the nurses do them. However, don't be expecting physicians to share entire specialties. Take a look at CRNA's and NP's. The most that they have been able to achieve is autonomy, but not scope expansion. You won't see any nurses doing solo surgery or work independently in specialties such as cards, GI, derm. The problem is that the nurses have boxed themselves in with their practice acts. For nurses to go outside of their original scope whether it be primary care or delivering gas, you have to change the practice acts, which typically requires legislative changes and probably judicial challenges. The ANA thought they were being clever by disguising "advanced" nursing as the domain of nursing and not medicine. Well folks, this is one direct effect of that tactic.

n_g · Feb 29, 2008

I disagree. The lack of education of CRNAs providing interventional or comprehensive pain management is exactly the issue. While there are similarities between anesthesiology and nurse administered anesthesia, there are profound differences between the two above specialties and interventional pain medicine. The tacit assumption that CRNAs may treat pain, any pain, providing they have a weekend course in anything, is based on an outdated view of pain medicine that existed in 1994. If the few CRNAs practicing interventional pain medicine do not recognize these differences, they will end up fighting a war with the 1,000,000 physicians in this country. The overwhelmining political and numerical advantage will result in an extreme setback to CRNAs as a whole, not only to those that are playing in a field of medicine in which they have no background, no CRNA school education, no substantial post CRNA training other than a weekend course in order to learn an entire medical specialty with very few similarities to CRNA practice or training, and perform no research. If it is really all about patient safety, I cannot think of a more poignant example of substandard care than to have untrained uneducated individuals from CRNAs to FPs performing interventional pain procedures.

He's made a good point. Rocking the boat is not always the wisest thing to do. Because of their overt attempt at changing the scope without working with all parties including the pain doctors, CRNA's in LA are now formally banned from doing pain, whereas before they did it under the radar. The genie is out of the bottle now and don't be surprised if pain docs file some sort of challenge in every state. If nurses want to expand their scope especially into medical territory, there has to be agreement by the doctors. NP's were created and exist because the doctors allowed it to happen. You can't do a run around the doctors.

foraneman · Mar 1, 2008

:typing

For instance, since CRNAs treat heart conditions during surgery and in the ICU, what would prohibit CRNAs to train themselves in interventional cardiology and begin to do TEEs, echocardiograms, etc on patients? Then why not cardiac caths?

CRNAs currently perform TEEs. Rather than "training themselves", they attend the same "weekend' program you do. Your cardia cath comment is absurd as you know.

Since 80% of patient visits to physicians and NPs in the US are for pain, the CRNAs are in effect declaring war on medicine and are setting up their own parallel medical system based on weekend training courses.

Where have you been the last 20 years? Nothing "new" is happening here...except more anesthesiologists have decided they want "in" on the pain $$$$

There is Zero interventional pain training available in CRNA schools throughout the country.

That is patently false. :nono:

There is simply no end to where CRNAs may take their scope of practice as they are now emboldened to take on the traditional medical boundaries.

Ultimately, the practice of putting the cart before the horse may badly backfire for CRNAs that perceive their scope of practice to be whatever weekend course they can enroll into.

Oh Brother....

allnurses Guide · Mar 1, 2008

CRNAs have extensive pharmacology training in IV drugs used for anesthesia and a peripheral working knowledge of other drugs that may interact with anesthesia. They are completely untrained during CRNA school in the use, pharmacokinetics, pharmacodynamics, side effects, idiopathic reactions, and drug interactions of nearly all medications used in the clinical practice of pain management OR pain medicine. Attempting to acquire this knowledge by reading throwaway journals or attending a little weekend course is inadequate preparation for clinical practice and endangers patient safety due to an extreme overexpansion of a AANA position statement developed prior to 1994. A nurse practitioner is far better situated to treating pain than a CRNA because their training is relevant to the field of non-interventional pain medicine while that of a CRNA is not. CRNAs perceive their scope of practice to encompass the treatment of pain, all pain, with whatever fly-by-night knowledge they can acquire since the appropriate patient-safety oriented formal training programs in pain management do not exist for CRNAs.

Let's see, the medical students at my school must also be completely untrained in "pharmacokinetics, pharmacodynamics, side effects, idiopathic reactions, and drug interactions of nearly all medications used in the clinical practice of pain management OR pain medicine" since we are in the same medical pharm class and we have already covered those topics or maybe it was just my imagination....That is one of three pharm classes that we have to take in my program.

If anyone is more likely to start doing new procedures or change their practice after a "weekend course" or after a "fly-by-night" course it is much more likely to be a physician since they have almost absolutely no control on their scope of practice. I have personally known FPs to do C-sections, tonsillectomies, interventional pain management and a variety of other procedures they were never board certified for or had any kind of formal training in other than someone showing them once or twice.