PROGRAM DIRECTORS PERCEPTIONS REGARDING THE INITIATIVE TO TRANSITION NURSE ANESTHESIA EDUCATION TO THE CLINICAL DOCTORAL LEVEL. Mary E.

Transcription

1 PROGRAM DIRECTORS PERCEPTIONS REGARDING THE INITIATIVE TO TRANSITION NURSE ANESTHESIA EDUCATION TO THE CLINICAL DOCTORAL LEVEL by Mary E. DeVasher CYNTHIA HOWELL, Ed.D., Faculty Mentor and Chair RUSS MYER, PT, Ph.D., CAS, Committee Member MICHAEL VOLLMAN, R.N., Ph.D., Committee Member Harry McLenighan, Ed.D., Dean, School of Education A Dissertation Presented in Partial Fulfillment Of the Requirements for the Degree Doctor of Philosophy Capella University December 2007

2 UMI Number: Copyright 2008 by DeVasher, Mary E. All rights reserved. UMI Microform Copyright 2008 by ProQuest Information and Learning Company. All rights reserved. This microform edition is protected against unauthorized copying under Title 17, United States Code. ProQuest Information and Learning Company 300 North Zeeb Road P.O. Box 1346 Ann Arbor, MI

3 Abstract Program directors in nurse anesthesia educational programs were surveyed to determine their perceptions regarding the initiative to transition the degree level of nurse anesthesia education from master s to a clinical doctorate. Proponents indicated a desire to move forward with the initiative. Program directors were aware that approximately 50% of schools of anesthesia exist within the university in disciplines other than nursing, and that the American Association of Colleges of Nursing (AACN) had no control over these programs. Concerns ranged from fear of programs closing due to inability to offer the degree, lack of qualified CRNA faculty, the impact on the future applicant pool, and concern that the AACN would supersede the American Association of Nurse Anesthetists/Council on Accreditation of Nurse Anesthesia Educational Programs as the accrediting body for nurse anesthesia education. Concerns included resistance and presumed reaction of other healthcare professionals, including anesthesiologists, toward the initiative.

4 Dedication This dissertation is dedicated first to God, who has been with me every step of the way. Second, it is dedicated to my family. My husband, Bernard DeVasher, has truly been my strongest supporter. He has always encouraged me with any educational venture, even in this most time-consuming effort. I want to thank him for never complaining about the late, sometimes absent, meals, when after a long day of work as Program Director, I would switch gears to work on my doctoral studies. I love him dearly and long for the time when he and I can engage in hobbies again without the pressure of my doctoral studies hobbies such as Bible study, travel, and hiking. Our daughter, Alescia D. Bethea, has taken a journey with me that few daughters would take. She and I enrolled in our doctoral studies together. I would probably choose other fun mother-daughter things to do, but given that doctoral education was necessary for both of us to remain engaged in anesthesia education, I could not have chosen someone I love more to be my educational companion. I am so proud of her. While I am finishing only slightly ahead of her, my research findings are such that her research may possibly answer some of those unanswered questions mine found. May God be with you, Alescia. Our son, Kameron DeVasher, a pastor in the Seventh-day Adventist Church, is engaged in earning his master s degree with a focus in religious studies. He has offered encouragement to me on many occasions, always stating, Mom, I m so proud of you! Son, your area of studies has eternal weight, preparing you to lead others to have eternal life; I love you, am proud of you, and wish God s blessing on your studies and your work in your chosen career. iii

5 Acknowledgments I would like to acknowledge those individuals who have been involved either in helping to code the interviews, edit my work, or have served on my dissertation committee. These are: Dr. Phil Hunt, the President of Middle Tennessee School of Anesthesia, who has been most patient with me; Dr. Michael Vollman, a faculty member at both MTSA and Vanderbilt University School of Nursing, and a committee member who has been a mentor and powerful encourager; Dr. Russ Myer a committee member; and the Chair of the Dissertation Committee, Dr. Cynthia Howell. Two other educators have offered other help and have been general encouragers. Dr. Larry Lancaster, a faculty member at both Middle Tennessee School of Anesthesia and Vanderbilt University School of Nursing, offered editing assistance of some of my early projects in the course room as well as words of encouragement along the way. He was a blessing as he offered suggestions for my power-point presentation for my defense of the dissertation. Dr. C. William McKee, a faculty member at Cumberland University, encouraged me as a shepherd to begin the doctoral studies originally, and without that first encouragement, the degree would likely still be a dream. Finally, I d like to give special acknowledgement to my daughter, Alescia. Having her take this journey with me has made all of the difference. I would likely have given up without believing that her educational future depended on her completing her doctorate, and my desire to be there with her. We have been able to offer strong support to each other. iv

6 Table of Contents Acknowledgments List of Tables iv viii CHAPTER 1. INTRODUCTION 1 Introduction to the Problem 1 Background of the Study 4 Statement of the Problem 8 Purpose of the Study 9 Rationale 10 Research Questions 11 Significance of the Study 12 Definition of Terms 15 Assumptions and Limitations 17 Organization of the Remainder of the Study 21 CHAPTER 2. LITERATURE REVIEW 22 History of Nurse Anesthesia Education 23 Nursing Initiative for Clinical Doctorates 31 Current Nursing Literature Related to Doctoral Education 32 Nurse Anesthesia Response 35 Regional Accreditation Concerns 38 History of Doctoral Education 40 History of Doctoral Education in Nursing 41 Nursing Doctoral Degree Titles 44 v

7 Drivers and Proponents of the DNP 51 Effects of the DNP 56 Beliefs Related to the DNP and Faculty Preparation 59 Question of Data to Support Doctoral Education 61 Clinical Residencies as a Part of the DNP 61 Perceived Benefits of the DNP 62 Expressions of Concern About the DNP 63 Public Policy and Society Perceptions 69 Summary 72 CHAPTER 3. METHODOLOGY 73 Introduction 73 Methodology 74 Restatement of Research Questions 77 Setting of the Study 77 Instrumentation 78 Data Collection Procedures 84 Data Analysis Procedures 86 Ethical Issues 87 Summary 88 Organization of the Remainder of the Study 88 CHAPTER 4. DATA COLLECTION AND ANALYSIS 89 Introduction 89 Demographic Findings 91 vi

8 Overview of Themes 93 Summary 133 CHAPTER 5. RESULTS, CONCLUSIONS, AND RECOMMENDATIONS 134 Introduction 134 Results 135 Conclusions 137 Summary of Recommendations 166 Summary of Conclusions 172 REFERENCES 175 APPENDIX A. TELEPHONE INTERVIEW QUESTIONS 180 APPENDIX B. CRNA PROGRAM DIRECTORS DOCTORAL FEASIBILITY STUDY 183 APPENDIX C. THEMES 190 vii

9 List of Tables Table 1. Summary of Number of Responses in 6 Questions Related to 11 Themes 94 Table 2. Research Question 1 96 Table 3. Research Question Table 4. Research Question Table 5. Research Question Table 6. Research Question Table 7. Research Question viii

10 CHAPTER 1. INTRODUCTION Introduction to the Problem In an October 2004 position statement, the American Association of Colleges of Nursing (AACN) declared that graduates of advanced practice nurse (APN) educational programs will have earned clinical practice doctorates by 2015 as the entry-to-practice degree. The AACN (2004b) defined advanced practice nurses as certified registered nurse anesthetists (CRNA), certified nurse midwives (CNM), clinical nurse specialists (CNS), and nurse practitioners (NP). The AACN has published drafts of a document, The Essentials of Doctoral Education for Advanced Nursing Practice, which outline the content that should be included in the clinical doctorate. These drafts have been found on the AACN Web site and continue to change as updates occur. For this research, program directors of schools of nurse anesthesia were interviewed in order to determine their perceptions about this dynamic phenomenon. Specifically, it will explore their perceptions of the impact transitioning will have on their programs and on programs nationwide, as well as the benefits and concerns regarding implementing the AACN initiative if the nurse anesthesia professional association the American Association of Nurse Anesthetists (AANA) agreed with the AACN initiative. In the months leading up to this initiative and following it, nurse practitioners and clinical nurse specialists have been actively engaged in open dialog concerning the 1

11 necessity of educationally transitioning from the master s level to the clinical doctorate level. Some of the APNs were perceived as either being active proponents of transitioning to a clinical doctorate (Bednash, 2006; Dreher, 2005; Lens, 2005; Marion et al., 2003; Mundinger, 2002; Williams & Hathaway, 2006) or leaning toward the transition, though not necessarily in complete agreement with the actual proposal (Nelson, 2005; O Sullivan, 2005; Wall, Novak, & Wilkerson, 2005). Other APNs were perceived as being active antagonists of the transition (Meleis & Dracup, 2005), or urging caution in it (Baldwin, 2005; Bellack, 2002; Carlson, 2003; Edwardson, 2004; Ellis & Lee, 2005; Fulton & Lyon, 2005; Glazer, 2005; Robb, 2005; Whall, 2005; Wood, 2005). Anderson (2000) suggested that nursing should improve teaching within nursing programs and advance admission standards before it considers doctoral education. These authors are mainly either NP or CNS advanced nurse practitioners. However, in nurse anesthesia-specific literature, by 2005 only three articles had been written addressing doctoral education. Faut-Callahan (1992), a CRNA and educator, was one of the first authors in nurse anesthesia literature to address doctoral education and offer support for a clinical practice doctorate. Jordan (a CRNA) and Shott (1998) surveyed CRNA program directors and practitioners regarding feasibility of doctoral education, and published their findings. One article in nurse anesthesia literature proposed a clinical practice doctorate modeled after the Virginia Commonwealth University Doctor of Physical Therapy (DPT; Clement, 2005). The Council on Accreditation of Nurse Anesthesia Educational Programs (COA) is an autonomous body of the AANA. Prior to 2003 the COA accredited programs at the 2

12 master s level. In the trial version of the 2003 Standards of Accreditation, the COA, under the purview of the U.S. Department of Education s Department of Eligibility and Agency Evaluation s published standards to accredit schools that offer either clinical doctorates or research-oriented doctorates (Nagelhout & Zaglaniczny, 1997). It appeared that members of the COA, even in 2003, were aware of the coming movement for advanced practice nurses to transition from master s- to doctoral-level education. The final version of the Standards of Accreditation is available to those associated with schools of anesthesia, but it is not widely published (COA, 2004, 2006). Thompson, Faut-Callahan, and Beutler (2005) addressed CRNA doctoral education at the 2005 AANA Assembly of School Faculty Meeting. In June 2005 the AANA convened a summit to discuss doctoral preparation as an entry credential for the nurse anesthetist. Participation in this summit included nurse anesthesia educators and leaders, who affirmed the current professional educational program s ability to produce competent practitioners. The participants acknowledged that in the future graduates will need additional knowledge and skills in areas such as technology and research. However, the participants in this summit did not support the 2015 date for doctoral credentials or the title of Doctorate of Nursing Practice (DNP; F. Maziarski, personal communication, June 15, 2005). In the February 2006 AANA Assembly of School Faculty meeting, the DNP was addressed by the president of the AACN, Geraldine Bednash, speaking in favor of the DNP. Another speaker, Alaf Meleis of the University of Pittsburgh, spoke against the DNP, indicating that was not the time. 3

13 The AANA published an interim position statement indicating that the AANA did not as yet support the DNP but was continuing to investigate the initiative. The interim position statement, in part, stated, The AANA cannot, at this time, support the AACN s position on the clinical doctorate as entry into advanced practice since our initial review of the proposal raises serious concerns (2006a, 1). Following the release of this statement, the AANA commissioned a task force to conduct an electronic survey of program directors concerning their perceptions related to the clinical practice doctorate, which appears to indicate the AANA has plans to readdress the interim position statement. Nurse anesthesia program directors will be charged with implementation of the DNP if the AANA does conclude the doctoral preparation as an entry credential to be advantageous to the profession. The focus of this study was to discover the opinions of program directors of schools of nurse anesthesia related to the initiative to move all programs of nurse anesthesia from the current master s level to the doctoral level. Program directors were interviewed and asked to describe how this initiative would impact their educational programs. Background of the Study Program directors in schools of nurse anesthesia are facing the possibility of moving from their current master s-level nurse anesthesia programs to offering a clinical practice doctorate. Those who were in the position of program director in the late 1980s and 1990s were required to move all nurse anesthesia program curricula from the certificate level to a master s degree level. In the mid- to late 1980s, the COA mandated 4

14 that by 1998 the master s degree would become the only recognized terminal degree in the discipline (Frels, 1992). According to Mastropietro, Horton, Ouellette, and Faut-Callahan (2001a), between 1980 and 2000 the number of nurse anesthesia programs declined from 110 to 83, with 14 programs closing in The cause of these closures remains controversial. However, CRNAs believed the primary causes included a lack of administrative and anesthesiologists support, reduced program funding, strained relations between the AANA and the American Society of Anesthesiologists (ASA), and the trend toward development of master s-level nurse anesthesia education. Anesthesiologists believed the causes of the closures related to the closure of hospital-based programs as a result of the mandated master s degree, fewer resources in academic medical centers to support both nursing and physician programs, and a generalized shortage of nurses, especially critical care nurses (Mastropietro et al.). Given the shortage of nurses and nurse anesthetists at present, nurse anesthesia program directors are directing energies toward educating nurses to become nurse anesthetists in order to help fill the vacancies of anesthesia providers in the nation s operating rooms. Faculty members in those schools have met regional and professional eligibility criteria to educate students seeking master s degrees. However, it is perceived that due to regional accreditation standards (Southern Association of Colleges and Schools [SACS], 2004), the educational level of these faculty members may not be adequate for them to teach at the doctoral level. The AANA (2006b) Web site revealed that the master s degree is the highest degree of 62% of CRNAs directing schools of nurse anesthesia. Additionally, faculty members often do not have resources of time and 5

15 finances to be able to reengage in academic pursuit of personal doctoral education in order to meet the increased academic eligibility criteria. It is perceived that many nurse anesthesia faculty members do not have geographic access to doctoral programs, and if they were located where programs are available, it is likely that the clinical schedules associated with their clinical and teaching load would make attendance at regularly scheduled classes difficult, if not impossible. While not widespread, anesthesiologists are responding to the shortage of anesthesia providers by increasing the number of anesthesiologist-led Anesthesiologist Assistant (AA) programs. Within the past 5 years, the number of these programs has increased from two to four. Most AA anesthesia providers have no previous healthcare background (ASA, 2005). AAs are legal anesthesia providers under the supervision of anesthesiologists in a few states. In at least one other state, anesthesiologists have attempted, through the legislature, to mandate that they supervise all CRNAs, and that AAs become recognized anesthesia providers in that state (General Assembly of North Carolina, 2005). How the move from master s-level entry to doctoral-level entry will affect the current relatively harmonious relationships between nurse anesthetists and anesthesiologists is unknown. In the past, one cause of disharmony between these groups involved education of nurse anesthetists. Historically, as nurse anesthesia educational programs continued to increase educational requirements and moved from being hospitalbased to being university-based, nurse anesthesia educational programs were enveloped by schools of nursing in universities. 6

16 The genesis of this move appears to have been initiated when the ASA obtained a federally funded grant to perform a demographic study of anesthesia providers, to include both anesthesiologists and CRNAs. Nagelhout and Zaglaniczny (1997) stated that the study was reported to have been done in cooperation with the AANA, when in reality the only part the AANA had was supplying the researchers with a list of members. This was significant in that one of the recommendations was for anesthesiologists to become more involved in the education and credentialing of nurse anesthetists (Nagelhout & Zaglaniczny, p. 11). The first time the AANA was aware of this recommendation was when the U.S. Department of Education s Department of Eligibility and Agency Evaluation, which had oversight of accrediting agencies, communicated with the AANA to determine how to fulfill the recommendation. According to Nagelhout and Zaglaniczny (1997), This set the stage for a major confrontation between the ASA and AANA in the mid-1970s concerning which of the groups was going to control the education and credentialing of nurse anesthesia educational programs and their graduates (p. 11). Ultimately, this led to incorporating nurse anesthesia education into the university framework and redesigning the AANA to form an autonomous council, the COA, to accredit schools of nurse anesthesia. The displeasure of many ASA leaders with the AANA s federal funding initiatives, along with concerns by some anesthesiologists that they were, in fact, participating in preparing their future competitors, led a sizable number of anesthesiologists who were academic chairmen in institutions where nurse anesthesia educational programs were located to convert the nurse anesthesia training slots into medical residency training spaces and to close the nurse anesthesia programs (Nagelhout 7

17 & Zaglaniczny, 1997, p. 18). How anesthesiologists today will respond to offering clinical doctoral education to nurse anesthesia students is unknown, although it is anticipated that the ASA will resist such a move. Nurse anesthesia program directors have established relationships with anesthesiologists, the gatekeepers to clinical experience. Often the relationship is symbiotic. Anesthesiologists offer clinical experience as an avenue to graduates for employment, and program directors receive clinical experience for their students. These program directors are the most likely individuals to understand how anesthesiologists will respond to transitioning nurse anesthesia education from the master s level to the clinical doctoral level. They will also be the ones who understand there may be attempts by anesthesiologists to close clinical sites for nurse anesthesia students. Their collective voice has not yet been heard. Statement of the Problem It is anticipated that any forced transition from the master s level to the doctoral level will present problems to program directors, who will be responsible for transitioning master s-level nurse anesthesia educational programs to the clinical doctoral degree level. Among these concerns are academic qualifications of faculty, resources to transition the program to a higher level, institutional and governmental hurdles, timing of such a move, title of the degree, and loss of clinical sites due to anesthesiologists concerns regarding offering clinical education to nurse anesthesia students who will earn clinical doctorates. 8

18 It was felt that there likely were concerns that were not anticipated when this study was proposed. Since this was a qualitative study with open-ended questions, it was believed these might be discovered as interviews of program directors were conducted. Therefore, this study attempted to discover the evolving perceptions of current CRNA program directors regarding the AACN initiative to transition nurse anesthesia educational programs from the master s level to a clinical doctorate level. It should be noted that there are positive issues that surfaced as well, such as allowing CRNA practitioners to have parity with other healthcare providers, such as podiatrists and chiropractors, who have equal or fewer academic hours in their background compared to CRNAs yet have earned clinical doctorates. Another positive issue is that creating a clinical doctorate would allow the advanced practice nurse, whose academic hours have expanded over time to far exceed those of master s-prepared graduates in other academic fields, to have a degree that more fairly represents the time spent in education. Purpose of the Study This study had two purposes. The first purpose was to determine if the nurse anesthesia program directors perceptions regarding perceived benefits or concerns with moving from the master s degree as the entry-level preparation to the doctoral degree as the entry level to practice are similar to responses in the literature published by nurses of other advanced nursing specialists. The second purpose was to determine if the responses of those program directors whose schools of nurse anesthesia exist within the discipline of nursing are similar to the responses of program directors from schools of anesthesia 9

19 that exist in disciplines other than nursing, showing whether or not they have similar concerns and/or perceive similar benefits. Rationale The primary concerns that program directors have to implementing doctoral education in their own programs of nurse anesthesia need to be explored. Such exploration by personal interviews will add value to the current online survey of program directors being performed by the AANA doctoral task force. The AANA has not yet agreed to comply with the AACN initiative. Having additional information related to program directors concerns for transition to a doctoral level will assist the AANA in this decision making, as well as initiate groundwork for assisting programs to move in the direction of doctoral education should the profession decide to follow the AACN doctoral initiative. Providing information related to CRNA program directors opinions about which curricular additions would benefit the nurse anesthesia profession and who should design the curricular additions seems prudent, if such information is revealed in the responses. In addition, while the AACN has mandated the DNP title for the degree, program directors opinions related to this title should be solicited. Also, program directors should be offered a venue to express why they prefer a given title. Suggestions related to the title of the degree would be important information for the AANA to have as they make decisions regarding whether to comply with the AACN mandate. This information could persuade the AANA to create clinical doctorate curricular inclusions and a degree title proposal exclusive of the AACN mandate. 10

20 Research Questions The primary research focus was to determine what the initiative to have a clinical doctoral degree as the entry-to-practice credential for nurse anesthetists actually means to program directors. Given that the most recent Assembly of School Faculty meeting (February 2006) had one full day devoted to presenting topics both for and against this transition with speakers such as Bednash (2006) and Meleis and Dracup (2005) representing the pro and con, respectively it is likely that many of the responses of program directors will be repeats of those arguments. However, program directors may express opinions related to issues that have as yet been unaddressed. The questions in the telephonic interview sought demographic information prior to examining the actual focus of the research, and was followed by six questions related to the topic. As a preamble to these six questions, the following statement was read to all participants: There may or may not be barriers or concerns you have about being able to implement the AACN initiative in your program. This study is interested in exploring these. There may or may not be benefits you perceive would occur by implementing the AACN initiative in your program, this study is interested in exploring these as well. Please respond to the following: If the AANA determines to support the AACN position statement that the degree for entry-to-practice of nurse anesthetists will be the doctor of nursing practice, and programs will be required to implement it by 2015: 1. What impact do you believe implementing the AACN initiatives will have on your program of nurse anesthesia? 2. What impact do you believe implementing the AACN initiative would have on nurse anesthesia education nationwide? 3. What are your general impressions of moving toward doctoral education as the degree for entry-to-practice? 4. Would you be satisfied with the title of the degree of nurse anesthesia graduates from a doctoral program being the DNP? 5. What benefits do you believe would occur by transitioning master s programs in nurse anesthesia to doctoral programs? 11

21 6. Do you have any concerns (academic, clinical or other) about implementing the AACN initiative that these questions may not have addressed that you wish to share? Significance to Society Significance of the Study Nurse anesthetists administer approximately 65% of the anesthetics given in the United States, are the sole providers in approximately two thirds of rural hospitals in the United States, and are providing anesthesia in military institutions both in the United States and abroad (AANA, 2006a). Currently, there is a shortage of nurse anesthesia providers. The following is a statement released by Rodney Lester, then-president of the AANA, in response to proposed cuts to funding for nurse anesthesia educational programs: There s a severe and growing national shortage of nurse anesthetists, who provide two-thirds of U.S. anesthetics and the lion s share in rural and medically underserved America and the U.S. Armed Forces... the average number of nurse anesthetist job vacancies increased 250 percent from 1998 to (2003, p. 1) If moving nurse anesthesia education from the master s level to the clinical doctorate causes a decrease in the number of graduates for any reason, whether due to increased cost, decreased faculty to teach at the doctoral level, or closure of clinical sites, society will be impacted due to the potential of closing operating rooms and reduced access to surgery. This is likely to be more pronounced in rural and underserved areas where CRNAs administer a significant percentage of anesthetics. Further, at least one state s society of anesthesiologists has quoted the documented shortages, and has responded to the shortage by suggesting an increase in licensure of AAs, as evidenced by 12

22 the North Carolina Society of Anesthesiologists (2006) suggesting that AA licensure will help to alleviate shortages of nurse anesthetists in North Carolina. Significance to Healthcare CRNAs provide anesthesia for hospital surgical patients, outpatient services, obstetrical services, podiatry clinics, dental offices, eye clinics, plastic surgery suites, and pain management clinics. In addition, they provide anesthesia for the U.S. military and the Department of Veterans Affairs. CRNAs provide these anesthesia services safely and at reduced costs to patients and insurance companies, which helps control cost of healthcare (AANA, 2006a). Should the already short supply of CRNAs be compounded by lengthening educational programs, increasing cost of educational programs, or closure of nurse anesthesia clinical educational sites, healthcare will be negatively impacted. Significance to the Profession Historically, the nurse anesthesia profession has fought political battles to have state nurse practice acts provide a certain amount of autonomy to nurse anesthetists. However, to revisit the nurse practice acts to include doctoral-level education as the entry credential for CRNAs to practice would cause these acts to once again become vulnerable to those who originally opposed the status these acts provided for advanced practice nurses. If these nurse practice acts are reopened, it is a concern that anesthesiologists will attempt to institute direct supervision of CRNAs or will attempt to legalize the services of AAs in various states. Currently the number of PhD-prepared nurse anesthesia providers is unknown. The April 2005 White Paper on Nursing Practice Doctorates indicated that an 13

23 unanticipated side effect of developing the practice doctorate in pharmacology (PharmD) was that the numbers of PhD prepared pharmacists decreased (National Association of Clinical Nurse Specialists [NACNS]). The same article noted that moving advanced practice nurse programs to the clinical doctoral level may also inhibit the number of traditional PhD-prepared nurse scientists. This could lead to a decrease in the number of researchers and educators in nursing, thus further decreasing the evidence base for advanced nursing practice and nursing faculty. While practice doctorates are touted to increase safety in nursing practice, it could actually lead to a diminished evidenced base for sound advanced nursing practice, thus having a negative impact on the profession. In order to continue as a profession, the profession must have accredited schools of anesthesia, and in order to meet accreditation standards, schools of anesthesia must have qualified faculty. Since some regional accreditation entities require academic degrees for teaching faculty, any decrease in PhD programs has the potential to further decrease numbers of appropriately qualified faculty. In February 2005, approximately 54% of the nurse anesthesia programs existed within schools of nursing in the university. The other 46% existed in programs outside of nursing, in disciplines such as allied health, or as independent, anesthesia-specific schools. The clinical doctorate initiative had its genesis within the accrediting entities for schools of nursing, not within those schools of anesthesia existing in other related disciplines. For the AANA to follow a nursing accreditation mandate, without significant input from all program directors, would seem to be out of character for the AANA, which has celebrated its diversity. Choosing to make all schools of nurse anesthesia follow a 14