My Journey Through CRNA School - From ICU Nurse to Clinical Residency

As a first-generation college graduate, my nursing journey began exactly 11 years ago. My life was filled with much uncertainty as it was unclear if this was the route I wanted my life to take.

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Never in a million years did I, as an 8-year-old, chubby Pakistani immigrant child, who spoke not a single word of English, think that I would stand where I do today: blessed beyond measure, acquiring the highest level of skill and education to care for my patients and your loved ones. However, the first day of community college anatomy class with cadavers gave me the vision I needed to find my purpose. As I held a human heart in my hand for the very first time, I knew immediately that my life’s work and purpose was to serve humanity. 

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Now, having been in CRNA school for a little over two years and preparing to begin my senior and final year, I am able to reflect on the many tumultuous and blessed moments that have occurred since entering the nursing profession and climbing this steep educational ladder. 

But before we delve deeper into my journey and the transition from bedside nursing to critical care nursing and here today to anesthesia, it’s essential to describe what a Nurse Anesthetist (CRNA) is and a brief description of their rigorous educational and training requirements. 

• CRNAs are advanced practice registered nurses who practice with a high degree of autonomy and professional respect. 
• CRNAs are qualified to make independent judgments regarding all aspects of anesthesia care based on their education and licensure. 
• They are the only anesthesia professionals with critical care experience prior to beginning formal anesthesia education. 
• Prospective students must work as a baccalaureate (BSN)-prepared registered nurse in critical care for a minimum of one year (average experience of applicants: 3-5 years) before they can be accepted into graduate school (now DNP programs). The length of this experience requirement varies by program – I personally worked for over five years as a registered nurse before I began applying to CRNA programs; one year of which was in the Medical-Surgical unit and four of which were in the Trauma ICU and Trauma resuscitation unit. 
• Graduates of nurse anesthesia programs have an average of 9,369 hours of clinical experience, including 733 hours during their baccalaureate nursing program, 6,032 hours as a critical care registered nurse, and 2,604 hours during their nurse anesthesia program. 
• After a rigorous graduate program and meeting or exceeding the required 2,000 clinical hours – which again, varies by program – nurse anesthesia program graduates become board-certified experts who care for and provide every type of anesthesia to patients of all ages and illnesses. 

The Acceptance: 

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I received the news of my acceptance to CRNA school in October of 2019. In November, I took a celebratory, one final hurrah trip to Istanbul, Turkey as well as Mecca, Saudi Arabia with my family. In December of that same year, our world and subsequently our lives would change forever as a cluster of patients in Wuhan, Hubei Providence, China would begin to experience shortness of breath and markedly high fevers. This would eventually go on to initiate the start of the global COVID-19 pandemic. I continued to work in our poly-trauma ICU as well as other critical care units around the hospital throughout the early stages of the pandemic. I watched people die in a horrific and lonely way every day, even more so than before, as this was a disease we had no understanding of. 

In hindsight, this was the most dangerous time to be in such an environment as there was no way to rapidly “test” incoming trauma patients, nor was there any development of an effective vaccine. Each day was a game of Russian roulette and we all prayed we would not bring home what we were seeing and experiencing to our loved ones at home. 

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I would go on to work until the end of April 2020 and officially part ways with bedside nursing as I prepared mentally, physically, and emotionally to undertake the next great challenge of my personal and professional life; CRNA school. 

The First transition: From Trauma ICU RN to SRNA 

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I began CRNA school in May 2020 as a full-time student. This is the moment when I became a Student Registered Nurse Anesthetist (SRNA). After discussion and guidance from mentors and others who completed this rigorous journey before me, I opted to leave work and committed myself to this undertaking in its entirety. Although it is possible to work while in school, ultimately the decision comes down to understanding and appreciating one’s own abilities, circumstances, and stressors of life. For me, this was an investment of a lifetime, for my family and my future. I wanted nothing to jeopardize my chances of success and thus I chose to take out loans, utilize my savings, and commit to the full-time studentship. 

CRNA school curricula are of two kinds: front-loaded or integrated/hybrid. My program is a 36-month front-loaded program divided into 12 quarters (12weeks), which means that it is structured in a way where you take all (or a majority) of your didactic coursework up-front over the course of the first eighteen months and subsequently complete an eighteen-month clinical residency leading up to graduation. 

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Throughout the previous eighteen months, most if not all, of my time was spent completing didactic coursework consisting of 

• Advanced science courses, 
• Anesthesia-specific courses, 
• Advanced nursing practice courses, 
• An abundance of leadership, research, and writing courses is required for a DNP degree. 

Given the fact that I was a victim of the zoom era of education, the graduate school looked and felt very different and significantly more difficult than I anticipated. It was different because classes were taught with asynchronous methods of delivery, mostly pre-recorded and seldom in person if any. It was difficult because my place of comfort and leisure, my home, was forced to be transformed into my classroom, campus, library, and office overnight. This change required an exceptionally high level of self-motivation, discipline, and consistency. Attending classes in a business casual top and pajamas became the normative day at “school”. My classmates and I relied heavily on our collective zoom study sessions to persevere past the monotony of studying at home and alone. This new challenge on top of the existing one brought forth by the rigorous nature of the program forced me to renew my intentions and realign my purpose for why I chose this path on a daily basis. Because there are only so many 14–15-hour study days you can complete on your own in your “office”. This is when you must remind yourself of your “Why(s)” and the reason for your conviction.

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In addition to the aforementioned classes, we also began research and development of our doctoral project/thesis which continues to be developed throughout the program and is ultimately presented before the end of the program. 

The start of the 4th quarter served as a segue into high fidelity simulation which introduced concepts of the clinical anesthesia skills and combined the classroom knowledge with clinical practice. The simulation days are designed to foster clinical proprioception, emotional intelligence, and guide student registered nurse anesthetists (SRNAs) to be able to create holistic anesthetic plans for a variety of surgical cases, complex scenarios, and patient populations. 

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During our second year, we continued building upon our anesthesia knowledge with classes each semester leading up to the seventh quarter (18-month mark) of the program. Upon completion and successful passing of all didactic classes and the anesthesia pharmacology oral boards examinations, we embark on our clinical journey. This is where we learn to fuse science and skill and learn the art of anesthesia. This momentous milestone is the transition from an SRNA to a Registered Resident Nurse Anesthetist (RRNA). 

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The Second Transition: From SRNA to RRNA

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This past November (2021) was the start of the 7th quarter, which marked the beginning of clinical residency for me. We began clinical work in the operating room alongside a CRNA, a physician anesthesiologist, or both if in a team model setting. 

My program has over 52 credentialed hospital and surgical sites where students experience the nuances of clinical practice between rural and urban hospital settings and create a multifaceted repertoire of anesthesia skills to employ once independently practicing. 

In my first three months alone, I clocked in over 650 hours of clinical anesthesia time. The advantage of attending my respective program is that by the end of our clinical residency, we considerably exceed the 2,000 clinical hour requirement set forth by the council on accreditation to sit for the board examination. The time spent at each clinical site is respectively three months and then it is off to a new clinical site. We rotate through approximately seven different sites when all is said and done. 

Currently, I am on my second rotation at a large academic level one trauma center. There are many challenges and subtleties that come with clinical residency. In addition to the clinical skills, each site is full of new faces, new personalities, new charting systems, new anesthesia equipment (especially anesthesia machines) and we must learn it all and then do it all over again once the rotation is complete. But these, as many have said, are the expected growing pains of a nurse anesthesia resident. The most frequent advice and pearl of wisdom said by core faculty is, “embrace the suck”. As unhelpful as it may seem, it's a delightful and humorous truth understood by those experiencing "the suck".

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The beginning of each clinical day begins the night before with preparation for cases I will complete the following day. 

• Depending on the clinical site you are at, you may or may not have access to patient information from home and thus a tentative care plan is created for each surgical case and reviewed with the assigned preceptor for that day. 
• Once more, depending on the clinical site, operating room, or cases assigned, the day can range from one surgical procedure such as a 10-hour long neuro skeletal multi-level spinal fusion or 7-10 shorter duration cases such as colonoscopies, endoscopies, cystoscopies, or a potpourri of everything in-between. 
• Each morning begins with completing a full anesthesia machine check that follows a systematic pattern. Following the machine check, the room is prepared and case appropriate supplies are gathered to ensure a safe and efficacious anesthetic. One of the most commonly used mnemonics for setting up a surgical case is “MSMAIDS” (see attached video/REEL).  
• Once the operating room (OR) has been prepared and applicable medications have been drawn, I go and see my patient(s) for a preoperative assessment, complete the required charting, review the plan once more with my preceptor and make sure that all consents have been signed by the patient and all appropriate members of the surgical team before we head to the operating room for the scheduled procedure. 
• The patient is then brought back to the OR, connected to the monitors for a baseline assessment, and off to sleep they go! 

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To recap, at this point in my professional and academic journey, I am considered an RRNA (Resident Registered Nurse Anesthetist). I have completed my didactic coursework and am currently in the fourth month of my clinical residency while simultaneously completing my doctoral project and preparing for the national certification board exam (NCE) that we take upon graduation. 

The last nineteen months have tested me beyond what I thought my perceived limitations were, mentally, emotionally, and physically. Some days, it feels as if time has frozen over, and yet somehow that sentiment is easily replaced with overwhelming joy and appreciation at just how much knowledge I have gained in just this short span of time and the growth that has occurred. Irrespective of the emotions that come forth, with each passing day, I am reminded of just how blessed I am to be in this disposition and continue to strive to be the best I can be, for myself and my patients.