From the Operating Room to the Front Lines: Shared Experiences of Nurse Anesthetists During the Coronavirus Pandemic - AANA
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From the Operating Room to the Front Lines:
Shared Experiences of Nurse Anesthetists
During the Coronavirus Pandemic
Marjorie Everson, PhD, CRNA, FNAP
Bryan A. Wilbanks, PhD, DNP, CRNA
Anne Marie Hranchook, DNP, CRNA
Maria Hirsch, DNAP, CRNA
Beth Ann Clayton, DNP, CRNA, FAAN
Lorraine M. Jordan, PhD, CRNA, CAE, FAAN
Vicki Callan, PhD, CRNA, CHSE
Coronavirus disease 2019 (COVID-19) has resulted in the COVID-19 pandemic. Six themes were identified:
severe health, economic, social, political, and cultural (1) CRNAs are part of the solution, (2) doing whatever
consequences while thrusting Certified Registered it takes, (3) CRNAs are valued contributors, (4) removal
Nurse Anesthetists (CRNAs) at the forefront of battling of barriers promotes positive change, (5) trying times,
an often invisible enemy. A mixed-methods study was and (6) expertise revealed. The quantitative compo-
conducted to assess the impact of the COVID-19 pan- nent of the study will be discussed in a separate article.
demic on CRNA practice. The purpose of the qualita-
tive component of the study, a focused ethnography,
was to use personal and group interviews to determine Keywords: Certified Registered Nurse Anesthetist,
the shared experiences of CRNAs who worked during COVID-19, expanded roles, innovation.
T
he World Health Organization designated ment (PPE) needed to care for these critically ill patients.
2020 as the Year of the Nurse.1 Who could In anticipation of the surge of patients entering the
have predicted that a pandemic in this same healthcare system, the Centers for Medicare and Medicaid
year would forever change the lives of so many Services (CMS) announced sweeping regulatory changes
and, in the process, solidify in the minds and on March 30, 2020, to allow healthcare systems better
hearts of American citizens the critical role nurses play flexibility in delivering services during the pandemic. The
in responding to a world health crisis? This is a year in CMS requirement for physician supervision for Certified
which nurses have been called to care for people in ways Registered Nurse Anesthetists (CRNAs) and other ad-
that haven’t been seen since the H1N1 flu pandemic of vanced practice nurses was temporarily waived to ensure
1918 or the yellow fever epidemic experienced in the that these providers could perform the functions for which
United States in 1793.2,3 Like the organisms that caused they are qualified and licensed to carry out.5 Several state
the pandemics and epidemics of the past, the novel coro- governors issued their own executive orders removing bar-
navirus, named severe acute respiratory syndrome coro- riers to CRNA practice by waiving requirements for physi-
navirus type 2 (SARS-CoV-2), has left a powerful mark cian supervision.6 The unique critical care nursing skill
not only on our nation’s historic record but on the lives set, experience, and anesthesia expertise made CRNAs a
of those facing this disease on the front lines. valuable resource during the COVID-19 pandemic.
The novel coronavirus emerged in Wuhan, China, This article aims to present the qualitative findings of
in December 2019 and quickly spread worldwide. The a mixed-methods study that investigated the impact of
World Health Organization (WHO) declared the corona- COVID-19 on CRNA practice. A focused ethnography
virus disease 2019 (COVID-19) epidemic a global pan- was conducted to determine the shared experiences of
demic by March 11, 2020.4 The highly contagious nature CRNAs who worked during the COVID-19 pandemic.
of the virus led to a multitude of infected patients, many Personal interviews and focus group interviews were
with sudden onset of severe interstitial pneumonia with used for the focused ethnography.
the sickest requiring intensive care support. Healthcare
facilities in the United States faced being overwhelmed Materials and Methods
by the sheer volume of infected patients while grappling This focused ethnographic study was deemed exempt
with shortages of appropriate personal protective equip- and was approved by the institutional review board of
www.aana.com/aanajournalonline AANA Journal April 2021 Vol. 89, No. 2 109Webster University, St Louis, Missouri. Traditional eth- the audiorecordings. In qualitative research analysis, in-
nography entails extensive fieldwork and observation by vestigators reduce the data by applying codes to words or
investigators who are unfamiliar with the culture being phrases that have meaning to them. They look for patterns
studied. Focused ethnography entails studying a specific of codes, which lead to themes.10 The team of investigators
issue with a specific culture that is familiar to the inves- independently analyzed the transcripts for codes, patterns,
tigators.7 The investigators of this study were all CRNAs, and emerging themes. They met once a week for 3 weeks
familiar with the CRNA culture, and experienced qualita- via the online meeting platform (GoToMeeting) to discuss
tive researchers. their results and reach a consensus on the final themes.
The relatively small sample size of the focused ethnog- Once the final themes were established, the data and analy-
raphy was offset by the in-depth information provided sis were sent to an independent expert qualitative investiga-
during focus group and personal interviews regarding tor who validated the themes.
the phenomenon under study.8,9 Focus group interviews
allow the collection of high-quality data in a social Results
context, which helps the researcher understand a specific • Descriptive Analysis. A total of 29 CRNAs agreed to par-
problem from the viewpoint of the research participants.8 ticipate in the study. The demographic questionnaire was
Focus groups provide a rich and detailed set of data completed by 27 of the 29 focus group members. Some
about perceptions, thoughts, feelings, and impressions of questions allowed the selection of more than 1 answer.
people in their own words. Most study participants (70%, 19/27) had been practicing
Purposive and snowball sampling were used to recruit for more than 16 years. The highest educational prepara-
participants. Purposive sampling consists of nonrandomly tion of participants included 15 doctoral degrees (58%),
selecting participants on purpose, in this case chief CRNAs 9 master’s degrees (35%), and 2 bachelor’s degrees (7%).
and CRNAs.10 Snowball sampling (also known as network Sixteen states and all US geographic regions were repre-
sampling) consists of using the network of potential par- sented, with most CRNAs practicing in urban (34%, n =
ticipants to recruit additional participants.10 A recruitment 14) and suburban (34%, n = 14) settings; only 5 practiced
email was sent to 63 chief CRNAs and CRNAs (purposeful in a rural setting (13%). Other practice settings included
sampling) who were encouraged to share the recruitment Veterans Affairs hospitals (10%, n = 4), critical access
email with colleagues (snowball sampling). hospitals (7%, n = 3), and a military facility (2%, n = 1).
For the CRNAs who responded to the recruitment • Qualitative Analysis. The purpose of this study was
emails and agreed to participate in the study, focus to describe the shared experiences of CRNAs during
groups and personal interviews were scheduled. Personal the COVID-19 pandemic. Six focus groups and 3 per-
interviews were scheduled for those who preferred not to sonal interviews were held to obtain this information.
participate in focus groups. The plan was to recruit ad- Although data saturation occurred after 20 CRNAs (4
ditional participants if data saturation did not occur after focus groups) were interviewed, all scheduled interviews
the scheduled interviews. Data saturation occurs when were completed. Qualitative analysis of more than 100
information is being repeated, or no new information is pages of interview transcripts revealed 6 themes. These
revealed during interviews.10 themes are as follows: (1) CRNAs are part of the solu-
Before the interviews, participants were asked to com- tion, (2) doing whatever it takes, (3) CRNAs are valued
plete a demographic questionnaire. The questionnaire contributors, (4) removal of barriers promotes positive
asked how long they had been practicing as a CRNA, change, (5) trying times, and (6) expertise revealed. The
their highest academic degree, the state in which they themes and descriptions are summarized in Table 2.
practiced during the COVID-19 pandemic, the type of What follows are the themes and excerpts from the focus
healthcare facility in which they practiced, the designa- group interviews that best illustrate them.
tion of the practice facility, and their primary practice • Theme 1: CRNAs Are Part of the Solution. The first
model before and during the COVID-19 pandemic. theme captures the many essential roles CRNAs fulfilled
Descriptive statistics were calculated using IBM SPSS in caring for patients with COVID-19. CRNAs were
version 25 (IBM Corp). utilized in what some focus group participants called
The interviews took place using an online meeting plat- “right-sized” roles, which varied depending on the need.
form (GoToMeeting, LogMeIn). Video conference use is an These roles included but were not limited to working
acceptable alternative to face-to-face focus groups.11 The as intensivists, innovators, educators, leaders, and ICU
lead investigator used an interview guide, which was pilot nurses. Their education, training, experience, and skill
tested on CRNAs who were not included in this study, con- sets provided a seamless transition into these roles.
sisting of predetermined semistructured and probe ques- Most CRNAs discussed being called on to serve inten-
tions to facilitate the interviews (Table 1). The interviews sive care unit (ICU) patients by partnering with intensiv-
were audiorecorded, transcribed verbatim, and checked ists to oversee patient care or stepping into the intensivist
for accuracy by reading the transcripts while listening to role themselves. As intensivists, these CRNAs managed
110 AANA Journal April 2021 Vol. 89, No. 2 www.aana.com/aanajournalonlineInterview question Probes
Describe how your role as a CRNA changed • How was your expertise as a CRNA expanded/utilized during the pandemic?
during the COVID-19 pandemic and whether • Tell us about your patient care experience. What, if any, patient care innovations
you work in an urban, suburban, or rural did you apply/develop (ie, equipment, patient care) during COVID-19 (eg, using
setting, or a military, VA, etc, setting. anesthesia gas machines as ventilators, protective wear)?
• In what ways did your interdisciplinary team role change? How did
interdisciplinary team members’ perceptions of CRNAs change as a result?
• What was your role in educating others?
• What was your role in writing protocols/developing or managing resources?
How did executive orders (federal and/or • Who were the stakeholders involved in executing changes to expand your scope?
state) expand your scope of practice? • How long did it take for the barriers to be removed?
•D
escribe the activities/procedures you were able to do that you were not allowed
to do before.
• How did it improve patient care?
If barriers to practice were not removed • What opportunities were missed or what problems with emergency resource
during the pandemic, can you describe management could have been solved if the institution would have allowed
patient scenarios that would have been removal of barriers?
better managed by a CRNA with full-scope • What can be done to remove scope-of-practice barriers considering COVID-19?
privileges if allowed?
Describe any perceived changes in your
physician anesthesiologist colleagues’
practice during the COVID-19 pandemic.
What does future CRNA practice look like?
What COVID-19 impact haven’t we talked
about?
How did the COVID-19 pandemic personally
impact you?
Table 1. Qualitative Interview Guide and Probes
Abbreviations: COVID-19, coronavirus disease 2019; CRNA, Certified Registered Nurse Anesthetists; VA, Veterans Affairs.
airways, ventilators, vasoactive intravenous infusions, and the availability of supplies and solutions for providing
proning (prone-position ventilation) teams, and numer- care. These gaps inspired many CRNAs to become inno-
ous other duties. Of the many statements recorded, one vators in the face of the unknown. For example, several
CRNA’s account was particularly profound: CRNAs reported using 3-dimensional printers to produce
disposable laryngoscope blades and PPE to overcome
There’s one hospital … the intensivist left. He had 70 people on
a ventilator; he just left the building and never came back. So, it shortages. Other innovations included converting anes-
was actually CRNAs who came in and completely took over the thesia machines to ventilators and developing intubation
care of the ICU there. That would have been impossible without boxes, emergency intubation kits, and other devices to
the [scope-of-practice] restrictions being removed.
protect healthcare personnel during intubations.
Some CRNAs functioned as intensive care nurses but A few CRNAs who own anesthesia service companies
with expanded roles. They were expected to use their established innovative ways to provide services to hospi-
advanced practice skills such as intubation, central line tals. The following quotation reflected this: “We developed
placement, medication management, and provision of re- a product line specifically for COVID, and that was our
gional anesthesia, and to act as a resource person for the consulting product line.… Each one of our CRNAs took [a]
management of ICU patients. different hospital and became the advisory CRNA for the
Quite a few of the participating CRNAs stepped into hospital. Eventually, the hospital just turned over all COVID
leadership roles. They were part of hospital task forces, de- preparation to us.”
veloped protocols for caring for patients who tested posi- Several CRNAs described being the only anesthe-
tive for SARS-CoV2 (COVID-19), and became essential sia providers providing anesthesia in the operating
advisors in educating healthcare personnel on issues such room (OR) or intubating and inserting central lines for
as proper donning and doffing of PPE. Some even cited COVID-19–positive patients in the hospital. One of the
serving as leaders on hospital incident command teams. participants noted:
The novel coronavirus brought to light many gaps in I think this crisis gave us a unique opportunity to demonstrate
knowledge of how to care for and treat infected patients to administration, to those in the decision-making chain. We
www.aana.com/aanajournalonline AANA Journal April 2021 Vol. 89, No. 2 111crawled out of the OR and took over the hospitals. If there was
a hole in any part of the dam, it seemed like there was a CRNA Theme Descriptors
who would be standing there with their finger in and figuring CRNAs are part of Right-sized and expanded roles:
out how to stop the flow and manage the problem.
the solution • Leadership
• Theme 2: Doing Whatever it Takes. The second • Education
theme represents the willingness of CRNAs to extend • Task force
their patient care activities into settings outside the OR, • Hospital incident command
taking care of COVID-19–positive patients while simul- • Innovators
taneously increasing their personal and family’s risk of • Protocol development
catching COVID-19 by using or reusing inadequate PPE. • Consultants
One CRNA recalled an ICU in which every patient was Doing whatever it takes • Working despite PPE
intubated: “[T]he doctors didn’t even want to go up there. shortages
And so … the CRNAs started going up there. And slowly, • Working in unfamiliar
settings
they kind of took charge of pretty much everything.”
• Crossing state lines
A few CRNAs mentioned they helped set up and/or
• Running into the “storm”
work in temporary COVID-19 field hospitals. There was • Caring for not only COVID-
a shortage of PPE, and CRNAs took care of COVID-19– 19–positive patients but
positive patients despite the shortage. One CRNA report- also their families, fellow
ed working despite safety concerns: “It felt very unsafe. It healthcare workers, and the
was scary. I was afraid of contaminating my family.” community
Several CRNAs left their homes and families to travel to CRNAs are valued Heightened awareness and
contributors appreciation by
cities with high COVID-19 positivity rates to work. One
• State leaders
CRNA who worked in New York City expressed a sense of
• C-suite: Hospital presidents,
patriotism and duty: “[W]e need to keep this going for our CNOs
country. We can’t let this disease kill our country; we need to • Interdisciplinary team
boot up like we did post 9/11. It was challenging at times.” members
The lack of proper PPE led CRNAs to develop innova- • Intensivists
tive techniques to intubate COVID-19–positive patients. • ICU nurses
Specifically, CRNAs reported using trash bags to cover Removal of barriers Full-scope privileges granted:
their chest and being forced to reuse single-use PPE. One promotes positive change • Prescriptive authority
CRNA reported adapting scuba diving face masks with an • Central line insertion
air filter positioned where the snorkel was located. These • Regional administration
examples demonstrate how unmet patient care needs led • Removal of supervision
to innovations in patient care. • Removal of unnecessary
layers
• Theme 3: CRNAs are Valued Contributors. The third
• Increased access to care for
theme represents how the pandemic revealed the exper- patients
tise of CRNAs and their ability to meet the needs of many Trying times • Anxiety
hospitals and facilities for value-based care. As advanced • Sleep disturbances
practice nurses, numerous CRNAs led expert care and • Financial strain
filled various professional roles during the COVID-19 • Furloughs, loss of job
pandemic. One team of CRNAs helped transform a security
nursing home into a COVID-19–dedicated hospital and • Physical stress
supported it through airway management, arterial and • PTSD
venous line placements, and COVID-19 management. • Burnout
Other CRNAs proactively recognized the need to be seen • Substance use disorders
as a value-added service and not as a cost line item, as • Inability to exercise
reflected by one CRNA’s comment: “You have to become Expertise revealed • People were unaware of
what CRNAs could do
invaluable in the crisis, and you have to find out where the
• CRNAs are normally
weak points are.” “hidden” in the OR
As mentioned before, a group of CRNAs developed • CRNAs’ role as an
a consulting product line, including hospital resource intensivist was a good fit
planning, COVID-19 patient care management, and criti-
cal care patient management. CRNA teams also added Table 2. Themes of Survey Results
value by assessing medication availability and distribu- Abbreviations: CNO, chief nurse officer; COVID-19, coronavirus
disease 2019; CRNA, Certified Registered Nurse Anesthetists;
tion, evaluating equipment utilization and resourcing, ICU, intensive care unit; OR, operating room; PPE, personal
developing and implementing care protocols, and creat- protective equipment; PTSD, posttraumatic stress disorder.
112 AANA Journal April 2021 Vol. 89, No. 2 www.aana.com/aanajournalonlineing and educating response teams. Hospital administra- distress. The impact of this stress on one CRNA occurred to
tion and clinical leadership recognized the value and him after his assignment was completed. He stated:
appreciated the CRNA efforts to optimize care, as evi- I didn’t think I was that upset about very many things. But 3
denced by the following comment: “We were highlighted days after I got back, I got a kidney stone, and then 8 days after
I got back, one of my coworkers died suddenly of a heart attack.
and appreciated by the president of the health system and by She felt sick, stayed home from work, took a nap, and died. A
the CNO [chief nurse officer]. The CRNAs as a group were lot of stuff built up, and it was really worth it to talk to that
always coming up in the [hospital’s] town hall meetings … counselor.... I didn’t think I was that upset about it, and then
I’m crying on the phone with this counselor.
all the work that we were doing.”
CRNAs demonstrated their value to executive hospital The lack of appropriate PPE or the performance of
leaders when they took over and managed the ICUs. One aerosol-generating procedures on infected patients placed
CRNA stated: “We really got the spotlight of our adminis- CRNAs at a higher risk of contracting COVID-19. Many
trators. They knew how cost-effective we are.” voiced fears of infecting their family members and, in
• Theme 4: Removal of Barriers Promotes Positive turn, isolated themselves from others.
Change. Theme 4 reflects the experiences of CRNAs fol- I’m scared for my family members. I haven’t seen my parents
lowing unprecedented regulatory changes enacted by in 8 months.
CMS and many state governors. These included execu- [O]ne of the biggest things we had was one of my coworkers,
tive orders that relaxed barriers to full-scope practice for she tested positive. But after she was negative, her partner lost
his mother and father 8 hours apart, both from COVID in sepa-
CRNAs and many other advanced practice professionals rate hospitals.
throughout the United States. Although not all states had
So we did end up having an outbreak on our [military] ship,
governors that enacted executive orders resulting in the which meant we went into quarantine for about a month and a
removal of scope-of-practice barriers, many did.12 Some half. The only way we got out of our hotel rooms was if we were
CRNAs who experienced removal of full scope-of-prac- going to the ship to work.
tice barriers during the pandemic commented on their For CRNAs, the high morbidity and mortality seen with
ability to practice independently: COVID-19–affected patients were outside their typical an-
We were working independently, and we were empowered to esthesia practice, where patients rarely die. Some CRNAs
make decisions.... [W]e would have collegial discussions when expressed experiencing situations that were surreal.
it was necessary, but they [intensive care physicians] gave us a
free run, and we had an executive order from the governor that We don’t routinely have people die on us in the OR; that’s just
gave us a full scope of practice. not our norm anymore. So 10, 11 years removed from ICU, it
hit me differently.
Given the circumstance, there was real latitude in practice com-
ing from where I normally practice. I went into work one morning, and I had about 9 dead bodies
in front of my office.… I had to move the bodies, because they
What surprised me with the computer systems when we got were loading the morgue trucks, to get into my own office.
there, we have full signing rights on the computers as if we were
physicians. We didn’t need co-signers, we didn’t need an extra Another CRNA described a situation of intubating
person, an extra step.
an ICU patient for respiratory distress, managing the
For some CRNAs in the focus groups, the effect of re- patient’s sedation for 5 days, and then guiding the car-
moving barriers allowed CRNAs to demonstrate what the diopulmonary resuscitation until the patient’s death.
profession and our national organization, the American The CRNA stated: “[I]t was quite a shock for me to have
Association of Nurse Anesthetists (AANA), has been to make the decision to stop cardiopulmonary resuscitation
advocating for years: CRNAs provide high-quality, safe and for me to have the knowledge that I am the last person
anesthesia care. The following quotes reflect this reaction that patient saw before they died.”
to the policy changes made during the pandemic: Even in areas where COVID-19 cases were not preva-
Well, I know it hasn’t been a very good time for the country. But lent, CRNAs described increased stress and anxiety often
as far as CRNA practice goes, at least, we’ve proved what we’ve related to job security. Many CRNAs voiced concerns
been espousing for the last 30 years.
regarding a lack of work due to cancellation of elective
The executive orders eliminated a tremendous amount of paper- surgical cases. Outpatient surgical centers, in particu-
work burden. We actually increased access, and we optimized
patient care, which is completely aligned with [CMS’] patients lar, were without a need for anesthesia services. Some
over paperwork.” CRNAs were furloughed from their jobs or received pay
reductions. Those who were also business owners were
“The proof’s in the pudding. This pandemic has truly proven our
safety and quality of care, especially with our prescriptive authority.” concerned about their ability to pay employees and them-
selves. One business owner stated: “We’ve always thought
• Theme 5: Trying Times. Theme 5 represents the nega- we had a way to earn income, and suddenly you were faced
tive impact on mental and/or physical well-being universally with this ordeal of where is money going to come from at this
expressed by the CRNAs interviewed. The fear and uncer- point? I have people counting on me to actually pay them. So
tainty caused by caring for patients with an unfamiliar virus, that was very stressful.”
combined with a change in usual professional roles, created • Theme 6: Expertise Revealed. The final theme identi-
www.aana.com/aanajournalonline AANA Journal April 2021 Vol. 89, No. 2 113fied represents what respondents perceived as the rev- challenges and leading during a crisis.
elation on the part of many hospital administrators and Another finding of this study was the impact COVID-
other healthcare providers of the expertise and scope-of- 19 had on healthcare systems and providers because of
practice capabilities possessed by CRNAs. One CRNA in- reliance on fee-for-service payment models. Hospitals
terviewed stated: “Often, we’re hidden away because we’re and private practices across the nation saw a dramatic
not spoken of, we’re not seen. We give the medications and decline in revenue as the population they care for pivoted
disappear.” from revenue-generating procedures to the long-term
Another member of the focus group recalled the fol- care of the critically ill.15 The COVID-19 pandemic
lowing after scope-of practice barriers were removed by prompted rapid, dramatic care delivery changes that em-
the state governor: phasized the need for conversion to value-based services.
[I]ntensivists were surprised at what we brought to the table in Even before the uncertainty caused by the COVID-19
terms of our skill sets and our ability to multitask and to take pandemic, there was a need for effective leadership to
on challenging patients and challenging assignments. We would determine how to deliver value-based care while ensuring
have collegial discussions when it was necessary, but they gave
us a free run. quality, efficiency, and safety.1
While hospitals experienced financial strains, the
CRNAs were seen as experts in several areas. One CRNAs interviewed experienced many stresses resulting
CRNA noted: from their work during the pandemic. Some faced job
[T]he lines of communication opened instantly between the insecurity while many feared being exposed or exposing
CRNAs, who all of a sudden … were experts at airway and others to the coronavirus. They also cited shortages of
experts in lines, and also we were going to do all the airways and
do all the lines, and so instantly, the leadership and the physi- PPE, long shifts, and isolation as sources of stress. Some
cians within the ICU, who we’ve always had strong relationships shared feeling depressed and/or anxious. This study’s
with, the communications just opened. And they wanted us to findings are similar to other studies examining health-
assist with everything. So, we developed all the policies, all the
protocols, did all the PPE training, went in, taught everybody care workers during the pandemic.16,17 High levels of
what we should do for, what the intubation protocol is, what the anxiety, depression, distress, and sleep disturbances are
policy should be for everything. common experiences among the COVID-19 healthcare
CRNAs noted that the pandemic allowed their hospi- workforce.16,17
tal administrators to realize that CRNA expertise is not State lockdowns and the need for many of the CRNAs
limited to clinical expertise; they also possess policy, to self-quarantine led to long periods of isolation. Some
management, and leadership expertise. reported that the lack of availability of the usual outlets
for maintaining mental and physical health, such as
Discussion gyms or social gatherings with friends or family, led to
The aim of this qualitative study was to describe the further isolation—a known contributor to psychologi-
shared experiences of CRNAs during the COVID-19 pan- cal distress.16 Although some CRNAs reported seeing an
demic. Six themes were identified: (1) CRNAs are part of increase reliance on unhealthy coping behaviors, such as
the solution, (2) doing whatever it takes, (3) CRNAs are alcohol intake, during the pandemic, others made a con-
valued contributors, (4) removal of barriers promotes pos- certed effort to exercise more at home as a positive way
itive change, (5) trying times, and (6) expertise revealed. to manage stress.
Studies have demonstrated nurses are essential in times Some of the CRNAs expressed psychological distress
of crisis because of their education and experience in after seeing many patients decline rapidly or die despite
triage, assessment, emergency care, ground and air patient their best efforts. This led to a type of suffering known as
evacuation, physical and psychosocial support and recov- moral injury, which results when a decision conflicts with
ery, disaster management, and disease prevention.13,14 Our what we intrinsically believe is right.18 Moral injury expe-
study revealed similar findings. The focused interviews rienced by CRNAs and other healthcare workers is often
demonstrated that CRNAs have the requisite knowledge the result of the inability to save critically ill patients’ lives
and skills to provide expert clinical care and leadership due to a lack of effective treatments or resources despite
both inside and outside the OR to meet the global pan- doing everything possible. These highly challenging and
demic’s demands. A key finding was the remarkable in- tragic situations can contribute to the development of
novation, leadership, and courage exhibited by CRNAs posttraumatic stress disorder or depression.19
during the pandemic. The majority found themselves front Although COVID-19 has resulted in the tragic loss of
and center of the crisis educating, developing protocols, life, the pandemic caused people to work in ways and
acting as consultants and intensivists, leading incident adopt solutions that were thought impossible. The focus
command centers, and innovatively solving problems. group interviews revealed that CRNAs skillfully met hos-
They adapted to every situation they were confronted with, pitals and facilities’ needs in delivering high-quality care.
which one CRNA identified as fulfilling “right-size roles.” As a result, CRNAs found themselves receiving recogni-
Our findings confirmed that CRNAs are adept at meeting tion for their work both in and outside the OR. The pan-
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hlthaff.2020.00426
was common for the CRNAs interviewed to experience
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of patients infected with COVID-19, they simultaneously tions to help them: a rapid systematic review. Psychiatry Res.
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in a multitude of settings both in and out of the OR. In doi:10.1016/j.bbi.2020.05.026
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www.aana.com/aanajournalonline AANA Journal April 2021 Vol. 89, No. 2 115fessor and Roanoke Campus manager, Virginia Commonwealth University DISCLOSURES
Department of Nurse Anesthesia. Email: mthirsch@carilionclinic.org. The authors have declared no financial relationship with any commercial
Beth Ann Clayton, DNP, CRNA, FAAN, is a professor of clinical nurs- entity related to the content of this article. The authors did not discuss
ing and director, Nurse Anesthesia major, University of Cincinnati College off-label use within the article. Disclosure statements are available for
of Nursing, Cincinnati, Ohio. Email: claytoba@ucmail.uc.edu. review upon request.
Lorraine M. Jordan, PhD, CRNA, CAE, FAAN, is the AANA Founda-
tion chief executive officer and the AANA chief advocacy officer. Email:
ljordan@aana.com. ACKNOWLEDGMENTS
Vicki Callan, PhD, CRNA, CHSE, is an associate professor at Webster The authors would like to thank the AANA Foundation for funding this
University in St Louis, Missouri, and is the director of clinical education study. We also wish to thank Trinidad Legaspi for her valuable contribu-
for the university’s Department of Nurse Anesthesia. Email: Vickicoop- tion to this project. Finally, we thank Rayna Scott and Ruby Hoyem for
mans20@webster.edu. their contributions to this project.
116 AANA Journal April 2021 Vol. 89, No. 2 www.aana.com/aanajournalonlineYou can also read
