USAGPAN
.jpg)
U.S. ARMY NURSING ANESTHESIA PROGRAM RECEIVES HIGH MARKS.
In April 2007, U.S. News and World Report magazine ranked the U.S. Army Graduate Program in Anesthesia Nursing (USAGPAN) the second highest graduate institution in the nation for its nursing anesthesia category. USAGPAN received four points out of five—up from the 3.8 points it received when it was last ranked in 2003—based on the ratings of 106 nursing anesthesia schools by peer educators and deans.
This is not surprising, considering that USAGPAN has been educating certified registered nurse anesthetists (CRNAs) for over 45 years and is the biggest producer of Army anesthetists—about 90 percent have been trained at the Fort Sam Houston-based institution. In addition, the program also trains CRNAs that ultimately will practice in the Air Force or for the U.S. Department of Veterans Affairs (VA).
“I really think that the reason we’re number two is obviously the product we produce, which is the certified nurse anesthetists and their ability to perform anesthetics independently or autonomously,” said USAGPAN’s program director Army Lieutenant Colonel Thomas Ceremuga. “Also, the reputation of an Army CRNA is probably the best reputation a nurse anesthetist can have. When you look at Army nurse anesthetists and they go out into the civilian market for employment, there’s a raised eyebrow and a large amount of respect associated with that.”
The raised eyebrows and respect that Army CRNAs receive within the profession are earned thanks to the high standards and thorough training of USAGPAN. Before students even step foot on campus, they are expected to be the best in the nursing profession, as evidenced by the stringent admissions requirements of the program. First prospective students—who must already be practicing registered nurses when they apply— must meet the admission standards of Northeastern University in Boston, which is the institution that grants USAGPAN’s nursing degrees. Students are evaluated based on the submission of transcripts from their alma maters, letters of recommendation from nursing supervisors, and Graduate Record Examination (GRE) scores.
Once students are admitted to Northeastern University, their applications receive a second round of review by the education board of the Army, Air Force or VA for admission into USAGPAN. These admission prerequisites include a minimum GPA of 3.0 and a score of over 1,000 on the GRE, in addition to submission of an Officer Record Brief (ORB) and an Officer Evaluation Record (OER).
But the high expectations of USAGPAN do not end when the students are admitted into the program. The 30-month curriculum—which is divided into a 12-month didactic, classroom phase (known as Phase 1) and an 18- month, hands-on clinical residency phase (Phase 2)—is designed for students to achieve excellence in the field. Throughout the program, students are continuously being evaluated to ensure that they meet USAGPAN’s standards—which include not failing more than 50 percent of the exams in specific classes and maintaining an overall average of at least 80 percent. As a result of these strict requirements, the program loses an average of 25 percent of its students each year to attrition—which is sometimes academic in nature, and other times the result of personal issues that arose during the students’ tenure in the program.
“We’re pretty stringent in our academic standards because when students graduate, they may be at the war zone within six months, and so they have to be proficient, independent practitioners. There’s not a lot of room for mediocrity,” said Ceremuga.
And the program is designed specifically to avoid mediocrity in its students. During Phase 1 at USAGPAN, students spend eight hours daily in the classroom to complete the required courses for that portion of the program. During this time, students take courses to prepare them to work on patients, which include statistics in nursing, biochemistry for nurse anesthesia, pharmacology for nurse anesthesia and physical examination and differential diagnosis.
But what really prepares USAGPAN students for the rigors of the nursing anesthesia field is its extensive use of simulators, which students practice on before they are able to work with actual live patients. This practice is becoming more and more common in nursing programs, not only because of the effectiveness of simulators as teaching tools, but because of the standards of the medical field.
“The reason why simulation, especially high-fidelity simulation, has become so critical now to medical education is because of the ethics of when you’re educating a nurse anesthetist who is in the novice stage of learning very critical skills, and trying your skills for the first time on a human being leads to a lot of concern,” said Jo Ann Ramos-Alarilla, a veteran nurse anesthetist and assistant director of USAGPAN’s simulation program. “Whereas, if students are able to practice and get over some of those mistakes on the simulator, and develop a level of competency and lessen their anxiety, by the time they do get to the patients, they’re either an advanced novice or ready to move into an intermediate state. The ethical issue is what is making high-fidelity simulation so popular among the medical and nursing community.”
USAGPAN uses three kinds of simulators to train its CRNAs. The haptic virtual reality simulator is a program that allows students to look through an orifice on a computer screen while they navigate around it with a device that performs the procedure they are practicing. The partial test simulator is a replica of a specific part of the body, such as a neck or back, which allows students to practice using instruments—like needles or scalpels—on one region of the body. The most advanced simulator used by USAGPAN’s students is the human patient simulator, a full-body teaching device that is programmed to mimic the responses of live patients receiving treatment.
“The program for our human patient simulator comes with over 50 scenarios ranging from a standard man—which is just an average, healthy gentleman who comes in and might need his hernia repaired—to a soldier with gunshot wounds to the abdomen or a granny who needs a hip fixed,” said Ramos-Alarilla. “So, we have various scenarios that once we activate them, it’s up to the student to be able to assess them based on the information from their pre-evaluation.”
These simulators are not only an important tool for preparing students for the physiological aspects of anesthesia nursing—they also help students experience the emotional and psychological responses associated with treating patients. Because of this, students become personally attached to the outcomes of the simulators—just as they would with actual live patients.
“It is a very short period of time where the student goes from ‘oh, this is just a plastic person,’ to really believing that the simulator is a person undergoing trouble during anesthesia and they need to intervene. And some of them get appropriately upset when they kill ‘Harry,’” Ramos-Alarilla said.
Once students have completed the required coursework and simulations of Phase 1, they move on to Phase 2, where they work one-on-one with a faculty member on real patients. During this phase, students are required to work on at least 550 clinical cases in order to take their boards for accreditation by the American Association of Nurse Anesthetists. Although this is a large number of cases, USAGPAN students have no problem meeting this requirement—in fact, they often work on about 800 cases by the time they are ready to be certified. In addition, USAGPAN also requires students to complete a certain number of specific cases, such as open heart surgery and working with children, in order to complete Phase 2 of the program.
A large amount of the skills being taught during Phase 2 of the program— which is divided into six three-month long terms—have been tailored based on a data call that USAGPAN made to military personnel in order to ascertain what skills are most important for the graduating CRNAs to have to prepare them for deployment. Among the feedback the program received was the need for its graduates to have superior skills in a trauma center, which will prepare them for the realities of working in Afghanistan or Iraq.
Thanks to the rigorous training that USAGPAN provides, its reputation has preceded it among members of the nursing community. Although applicants know that they will most likely be deployed within months of completing the program, and they face a military obligation of about four years, the number of applications coming in grows every year. Last year, the program received a record number of 117 applicants, 51 of which will begin the program this year. And Ceremuga said he expects these numbers to continue to increase as the program mints more and more CRNAs with superior skills. ♦