Why Not Perioperative Experience?

[RNJohnny23]

I know that this has been asked before in different ways, but bear with me, please. And I apologize in advance for the frustration that will probably come across. Nothing personal :)

I would like to know why it is that Perioperative experience is not accepted for Nurse Anesthesia schools? I am well aware that Surgery experience is considered unacceptable by all schools. I'm just trying to understand and alleviate my frustrations.

As a Perioperative Nurse (Pre-op, OR, and PACU) in a rural-suburban area, I've worked with Anesthetists and Anesthesiologists for the last 10 years. There are no Anesthesia Techs where I work--there's just me. I set up their central line kits and Swans (as well as programing the monitor), I've trouble-shot the gas machine, vents, and monitors. I've set up and managed all the drips and lines in CVOR. I have handled all the tools of their trade. I know the difference between a MAC and Miller blade. I've extubated patients in PACU, under supervision, of course. I've managed airways while administering Moderate/Conscious Sedation. I've assisted in codes.

All that sure sounds like what AANA calls "acute care," to me. So please tell me what exposure ICU would give me that the OR, PACU and CVOR haven't? I mean the way the folks on hear make it sound, there is no "instruction" in the CRNA programs...you just have to know everything before you get there.

I'd really like to hear from someone who worked in the OR before becoming a CRNA or, even better OR to CRNA to CRNA Instructor.

Again sorry for the tone, but I'm frustrated by my--possibly erroneous--belief that I am just as capable of being successful without ICU as a nurse who has ICU experience, at least in the part of the country I'm from. I know there are things I don't know, but isn't that what school is for?

[duluthrn]

Since you don't (and I'm assuming have never) worked in an ICU, it's going to be hard for you to compare your OR experience to what it's like in the ICU. Just because you know the tools does not mean you know how to use them on patients. There is a big difference between setting up a Swan and actually using it to interpret a patient's hemodynamic status and knowing how to intervene appropriately. The best way to answer your question would be to shadow in an ICU (or preferably work in one) and see what it's like or call a couple CRNA schools and ask them how they define acute care experience.

[RNJohnny23]

No, I've never worked in an ICU and you're correct that knowing the tools isn't the same as knowing how to use them. But there are ICU's that hardly ever see Swans, like those in rural areas, but according to the letter of most NA schools' prereqs. they would be considered over someone like me.

What I'm getting at is that it would be impossible for anyone's experience, regardless of how intense, whether in ICU, CVICU or what have you, to be perfect and complete.

Regardless, I'm just frustrated and a bit irritated that even thought I've been assisting Anesthetists for 10 years, in some really hairy situations, as stated above, that I'm not considered qualified.

Also, it's annoying that the RNFA, the traditional Perioperative APN, is dying and there is nothing that I've seen to replace it.

Anyway, thanks for the response.

[traumaRUs, MSN, APRN]

I'm sorry you are so frustrated. If CRNA is your goal, have you considered transferring to an ICU?

I do take exception to the statement the the "RNFA, the traditional Perioperative APN" - as that is not true. An RNFA is just that, a first assistant in the OR, not an APN.

[wtbcrna, MSN, DNP, CRNA]

The individual schools decide what is considered "acute care experience", but yes there are a few CRNA schools that would accept your experience as meeting the acute care requirement.

This is how my school defines acute care experience. "At least one year of experience as an RN in an acute care setting defined as work experience during which an RN has developed as an independent decision maker capable of using and interpreting advanced monitoring techniques based on knowledge of physiological and pharmacological principles"

[Snowbird17]

The schools want you to have a solid understanding of managing an acute patient, hemo-dynamics, vent, and the meds associated with that. Knowing the equipment, even intubating and extubating is not the hard part- it's managing the patient. PA catheters are outdated from the most part. I do still care for patients with one on occasion. Now, we are using NICOMs. This means I don't have to wedge, but still need to know how to interrupt and treat the numbers.

I am sorry but pre-op and PACU patients are not really that acute. If they become unstable or acute, what do you do with them? Send them to the ICU, right? In fact, most ICU's will recover their own intubated patients- like a CABG for example. Those patients typically bypass the PACU and head straight to ICU.

I think you should look at it from the inverse. You want to be successful in an anesthesia program and then as an anesthetist, so you want the skills to do that. These go beyond knowing a MAC from a Miller, and how to deflate a cuff and pull a tube. You need to know why you are extubating, why you wouldn't, vent settings, how to titrate pressors, etc. Does that make sense?

It would be really tough to start school with a group of students that had this foundation. I am sure your instructors are not going to spend one second teaching you something you should already know, and it would be really difficult to try to learn basic foundations of critical care nursing simultaneously with the anesthesia curriculum.

I agree you should shadow in the ICU. It might be eye-opening. Do I think that some Pre-Op/PACU nurses could succeed in a program, sure. I don't think schools set the admission requirements to be exclusive, I think they have found that strong ICU nurses possess the skills and knowledge necessary to be successful.

In your favor, you do have great insight into the role of an anesthesia provider. That would be a huge plus when applying. You know what you are getting into. I would still recommend getting a solid ICU experience first though. It will make you more competitive, as well as more likely to succeed!

Question: How do you assist anesthesiologists in hairy situations? I am curious.

[RNJohnny23]

I didn't mean to offend you. Perhaps, I should have said expanded role? I am a bit offended that you think of assisting in the OR, as somehow less than what you do. At least that's what your comment implies. But let's not argue, we all perform a vital function in the care of our patients, regardless of how much education, certification, etc. we have.

[rnforcrna]

I have worked in the OR and in the ICU. After spending just one day in the ICU, I feel like I have accomplished more than a whole year in the OR.

In the OR you may be responsible for going to pick up Neo but then you hand it off to anesthesia.

In the ICU you are responsible for giving and titrating the med. You must know what you are doing.

In the OR you are just a little run rat.

[Snowbird17]

I think OR nurses work very hard! I do not envy being trapped in a sterile enviroment, with no windows, standing all day and dealing with demanding docs. I did not mean to imply that your job is any less than mine at all. We are just trained to do very different functions, and you are right- all nurses play vital roles!

You have a different foundation than I do as an ICU nurse. CRNA schools build on the ICU foundation, that is all I meant to get across. I apologize if my post came across in any other way!

Regardless, good luck in your endeavors!

[MeTheRN, BSN, MSN, RN]

I am sorry but pre-op and PACU patients are not really that acute. If they become unstable or acute, what do you do with them? Send them to the ICU, right? In fact, most ICU's will recover their own intubated patients- like a CABG for example. Those patients typically bypass the PACU and head straight to ICU.

I think you should look at it from the inverse. You want to be successful in an anesthesia program and then as an anesthetist, so you want the skills to do that. These go beyond knowing a MAC from a Miller, and how to deflate a cuff and pull a tube. You need to know why you are extubating, why you wouldn't, vent settings, how to titrate pressors, etc. Does that make sense?

Agreed.

You very well could get into CRNA school with you skills. I know some schools will admit PACU nurses who deal heavily with vented patients. Your familiarity will more be a tremendous asset in clinicals.

But I don't think the didactics would be doable without knowing up close and personal what happens when you administer 10mcg of epinephrine and how it affects preload, afterload, and contractility. Without being able to look at a panel of hemodynamics and decide whether you need fluids, a pressor, or a diuretic, you simply would not be able to expand upon it on the first pass.

You could get into a program with your exp, but you'd have to work like crazy to make up for what you haven't seen in an ICU.

Dealing with vent dependent patients will teach you A LOT about weaning and vent settings, more than you could ever imagine in the OR. I also agree with a previous poster who said that in the ICU, you take care of the sickest patients whereas in the OR you get a wide range of perfectly healthy patients to unstable patients. The constant exposure to failing human bodies is what teaches you how to keep them stable when administering anesthesia while they are being operated on.

So if you want to be a CRNA, just transfer to an ICU and learn from it. After a year, apply to the school and dazzle them with your hands-on exp!

[RNJohnny23]

I just thought I'd follow-up. I did transfer to an ICU and am at the 8 month mark. It's a rural ICU (really a combination of ICU and PCU) and probably not the experience that Anesthesia schools want. Haven't had a Swan and don't think I will, a handful of art lines, but I have had some really awful DKA/Sepsis, Mixed pH disorders, several crash intubations, several pressors and other things. Several, unpreventable deaths. I'm now in-charge on days and several of the staff and management wanted me to take the Manager position when it came up a couple months ago, but that's not for me. I've definitely grown as a bedside RN (we're all RN's, can't we think of something to call me other than "bedside," LOL), but I knew that would happen.

I've also been presented with a new career path that I had no concept of before: ACNP. I didn't know what they did, but I do now. Don't know if I'll be able to work that out either, but at least I have what I think is a very strong resume with ICU, Open Heart Surgery, and Cath Lab.

So in short, I probably will never join the CRNA ranks, but I have a lot of company there. I did want to thank everyone who responded to this post for reading and responding. It's frustrating to know that you are capable of something, want to do it, but not be able to get things in line to make it happen. Sorry if I offended anyone. Thanks again.

[CRNA, DNSc]

Things happen the way they are supposed happen for a reason and we may never know the reason why. Best wishes to you in your future path wherever it may take you!