Untoward pathophysiological events: simulation as an experiential learning option to prepare anesthesia providers.

Untoward pathophysiological conditions coupled with anesthesia delivery can lead to critical incidents. Anesthetists must be armed with a set of complex skills to respond effectively in acute situations. A survey of nurse anesthetists was conducted in which respondents were asked to report the frequency that they had experienced one of 24 select events in their practice in the last 60 days. They were asked to rank how meaningful it would be for graduate students to experience the same or a similar event in their training in order to be prepared for practice. Also, they were asked to rate, among 6 proposed curricular changes, those which would best address student learning needs. Seven events were identified as having occurred more than 13 times; hypertension, hypotension, bradycardia, acute hemorrhage, hypothermia, coronary constriction, and oliguria. The mean score for how important it was thought for students to experience untoward events in their training was 4.11, with a range of 3.54 for Addisonian crisis to 4.54 for experience in managing hypertension. Recommended curricular change scores ranged from a low of 3.33 for adding more theory in course work to 4.58 for adding simulator experience in the laboratory for critical events. This article identifies anesthetist learning needs from the practitioner's perspective and assists programs in adapting curricula accordingly. Overwhelmingly, respondents believe experiential learning is required to prepare anesthetists to manage untoward events. The rare occurrence of most critical events is a strong rationale for the use of simulator technology as the preferred method to address these learning needs.

The development and testing of the patient record pain management assessment tool.

The article reports a study whose purpose was to develop and test the Patient Record Pain Management Assessment Tool, an instrument to evaluate compliance with the American Pain Society's quality assurance standards on acute pain and cancer pain in chart documentation. Content validity, overall validity, and interrater reliability were all found to be acceptable. The instrument is therefore a useful tool for documenting the level of pain management practice in institutional settings.

An inefficient mix: a comparative analysis of nurse and physician anesthesia providers across New York State.

This study describes the rural and urban distribution of anesthesia providers across New York state and contrasts these findings with national distributions. It also documents the existence of an inefficient anesthesia provider mix that favors physicians over nurse anesthetists and has a major impact on the cost of anesthesia delivery in New York.

Frustrated wants and entitlements: fundamental components of CRNA job satisfaction.

A comparative study was conducted examining CRNA feelings of deprivation or resentment as they relate to their job satisfaction. Deprivation is described in Faye Crosby's Theory of Relative Deprivation (1976), which posits that six psychological preconditions (wanting, comparison other, deserving, past expectations, future expectations, and lack of self-blame) have an impact on individual perceptions and can influence job satisfaction. Relative deprivation is defined as a sense of grievance or feeling of resentment that one has been unjustly deprived of some desired thing. It is also sometimes referred to as the discrepancy between one's legitimate expectations and one's actual situation. The three hypotheses examined compare the influence of the six Crosby preconditions of relative deprivation and the three background variables of gender, education, and individual job autonomy on CRNA-felt deprivation. Results from three-way analysis of variance indicated that of the three background variables, only degree of autonomy was found to be significant in explaining felt deprivation. That is, irrespective of gender or educational level, CRNAs reporting higher degrees of job autonomy had lower feelings of deprivation or resentment about their jobs than did individuals reporting limited job autonomy. Degree of autonomy, thus being the key background determinant of CRNA-felt deprivation (F = 14.609, P < .01). Further analysis employing multiple regression revealed that when both the background and the Crosby psychological variables were examined together, the explained variance in deprivation was dramatically increased by the psychological variables far in excess of the background variables. The two psychological variables of wanting and deserving were found as most significant in explaining CRNA felt deprivation. Results indicate the importance of CRNA frustrated wants (wanting) and CRNA perceived entitlements (deserving) as key factors contributing to CRNA job satisfaction above and beyond the three background variables studied.

The practice and distribution of Certified Registered Nurse Anesthetists in federally designated nurse shortage areas.

Certified Registered Nurse Anesthetists (CRNAs) provide the majority of clinical anesthesia services to underserved populations in rural America. The United States Office of Shortage Designation, Bureau of Primary Health Care, has compiled a list of counties in the United States with a shortage of nurses. This study examines the distribution of CRNAs within these predominantly nonmetropolitan areas employing the Department of Agriculture's Rural-Urban Continuum classification system. Findings indicate a shortage of CRNAs in designated nurse shortage areas, and demographic characteristics of these practitioners hint at incentives and disincentives for nurse anesthesia clinical practice in rural areas.

The national distribution of Certified Registered Nurse Anesthetists across metropolitan and nonmetropolitan settings.

The purpose of this study is to describe the metropolitan and nonmetropolitan distribution of Certified Registered Nurse Anesthetists actively practicing across the United States. More than 3,000 counties of the United States were categorized according to degree of urbanization by utilizing the rural-urban continuum codes for metropolitan and nonmetropolitan counties developed within the U.S. Department of Agriculture. Zip code information was used to locate all actively practicing CRNAs by county of residence. Applying the rural-urban continuum codes to this database revealed a descriptive national distribution of CRNAs across geographical areas. Data show that 81.3% (18,086) of CRNAs reside in metropolitan counties and that 18.7% (4,182) reside in nonmetropolitan areas. The greatest number of CRNAs (8,519) are found in central counties of metropolitan areas of one million population or more. The lowest number of CRNAs (90) are found in completely rural counties of fewer than 2,500 urban population adjacent to a metropolitan area, and 160 CRNAs reside in counties of fewer than 2,500 population not adjacent to a metropolitan area. Differences in age, gender distribution, educational credentials, and population ratios are also noted between metropolitan and nonmetropolitan CRNAs.

A biting commentary on monitored anesthesia care with conscious sedation.

In summary, a continued emphasis needs to be placed on better operationalization of the concept of MAC and its components, not merely for reimbursement, but for practice sake. Quality risk evaluation and patient assessment guidelines unique to MAC and conscious sedation need to be established and closely adhered to. In 1988, the AANA Board of Directors adopted suggested guidelines for registered professional nurses engaged in the administration of intravenous conscious sedation. These guidelines were an addendum to Position Statement 2.2 entitled "Qualified Providers of Conscious Sedation" and are found in the Professional Practice Manual for the Certified Registered Nurse Anesthetist. It is incumbent upon all CRNAs who provide such services to not only be familiar with but also practice in accordance with these guidelines. Finally, as HCFA directs each Medicare carrier to determine when MAC is the appropriate standard of care, we as providers must recognize the same. Within each case scheduled under MAC lies the challenge to provide and maintain a high degree of vigilance in perhaps the more minor surgical procedure, while always anticipating and recognizing the potential for the unexpected that can make it hard for any professional to swallow.