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Addressing financial support for nurse anesthesia residents: literature review with policy recommendations

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Content FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS

ADDRESSING FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS:
LITERATURE REVIEW WITH POLICY RECOMMENDATIONS
by
Hope Kassel

A Doctoral Capstone Presented to the
FACULTY OF THE USC KECK SCHOOL OF MEDICINE
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the Requirements for the Degree
DOCTOR OF NURSE ANESTHESIA PRACTICE

May 2023
FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS ii

The following manuscript was contributed to in equal parts by Hope Kassel, Kristina Korte, and
Gary Wei
FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS iii

Dedication
Hope Kassel, SRNA, Kristina Korte, SRNA, and Gary Wei, SRNA, dedicate this project to all
the nurse anesthesia residents currently pursuing education in Nurse Anesthesiology and all those
to come.
FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS iv

Acknowledgments
We would like to extend our gratitude to the Doctor of Nurse Anesthesia Practice at the
University of Southern California’s program directors, Dr. Jeffrey Darna and Dr. Elizabeth
Bamgbose, whose dedication to nurse anesthesiology education has made an immeasurable
impact on the profession. We would also like to thank the faculty members of USC’s DNAP
program, as they have provided indispensable guidance, instruction, and support throughout the
program.
We would like to thank our faculty chair, Dr. Jeffrey Darna, whose expert opinion and
information about financial compensation for nurse anesthesia residents provided pivotal
guidance in creating this project. A special thank you to Drs. Josh Carr and Elizabeth Bamgbose,
who served as readers of this project and provided many essential contributions. The mentorship
and expertise of the faculty chair and readers served as the foundation in the development of this
project, and we sincerely thank them for their many essential contributions. We would also like
to acknowledge professional librarian Hannah Schilperoort for streamlining the extensive
literature search. Lastly, we would like to thank our colleagues in the Class of 2023 for providing
inspiration and support throughout this process.
FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS v

Table of Contents
Dedication ....................................................................................................................................... 2
Acknowledgments........................................................................................................................... 3
Abstract ........................................................................................................................................... 6
Chapter 1 ......................................................................................................................................... 1
Introduction ............................................................................................................................................. 1
Background and Significance ............................................................................................................... 2
Economic Impacts of Nurse Anesthesia Training ................................................................... 7
Research Question ................................................................................................................... 9
Specific Aims .......................................................................................................................... 9
Project Implications ............................................................................................................................... 9
Conclusion ............................................................................................................................................. 10
Chapter 2 ....................................................................................................................................... 11
Methodology ......................................................................................................................................... 11
Chapter 3 ....................................................................................................................................... 14
Literature Review ................................................................................................................................. 14
Trade Organization Funding Resources ................................................................................ 14
Governmental Funding Resources ......................................................................................... 16
Departments of Anesthesiology............................................................................................. 21
Programs of Nurse Anesthesiology ....................................................................................... 24
Additional Funding Sources .................................................................................................. 25
Conclusion ............................................................................................................................................. 26
Chapter 4 ....................................................................................................................................... 28
Results .................................................................................................................................................... 28
Recommendations ................................................................................................................. 28
Conclusion ............................................................................................................................................. 31
Chapter 5 ....................................................................................................................................... 32
Discussion ............................................................................................................................................. 32
Strengths ................................................................................................................................................ 33
FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS v

Limitations ............................................................................................................................................ 34
Final Conclusion ................................................................................................................................... 34
References ..................................................................................................................................... 35
Appendix A ................................................................................................................................... 43

FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS vi

Abstract
Background: Healthcare education in the United States is notoriously expensive, and nurse
anesthesia education is no exception. Educational costs have risen significantly as a result of the
nurse anesthesia education moving from a master’s degree to a doctorate-level degree. Many
nurse anesthesia residents (NARs) are accruing exceptional student debt. Methods: Various
search platforms were accessed to conduct an extensive review of published literature regarding
the effects of student debt, funding sources for NARs, and potential impacts of funding NARs. In
addition to published research, we reviewed government and non-government funding sources
for nurse anesthesia education. The project analyzed education financing for physician anesthesia
residents (PARs) and other graduate learners. Results: The review identified limited funding
available for NAR education. The few funding options are minimal in quantity, limited to a small
percentage of students, or both. A disparity exists between NAR and PAR educational funding.
Conclusion: Based on findings, the authors recommend expanding funding opportunities for
NARs during their training by government and private sector industries. CRNAs are crucial
members of the US healthcare system, and an investment in the future of nurse anesthesiology
will have a significant impact.
Keywords: nurse anesthesia resident, student debt, education funding
FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS 1

Chapter 1
Introduction
In the United States (US), healthcare education is notoriously expensive. Students
enrolled in professional healthcare degree programs often rely on loans to fund most of their
education and accrue significant amounts of debt by the time they complete their training.
Increases in annual tuition and costs of living further exacerbate student debt. In 2017, the
American Association of Colleges of Nursing (AACN) found that most students enrolled in
graduate nursing education had student loan debt between $40,000 and $54,999. Doctoral-
prepared Nurse Anesthesia Residents (NAR) accrue the highest levels of student debt among
graduate nursing students (AACN, 2017).
1
In January 2022, all nurse anesthesia programs
transitioned to a doctoral curriculum, extending traditional nurse anesthesia studies by one to two
years (COA, 2021). At present, 63% of doctoral nursing students, including NARs, accrue more
than $100,000 in student debt (AACN, 2017). The AACN also found 92% of nurse anesthesia
students borrowed loans to fund their education and living expenses, accumulating more than
$150,000 in debt, more than any other advanced practice nursing specialty. Unfortunately, few
financial resources exist, and those available to NARs offer little funding to offset the
exceptional educational debt.
Medical school students and other professional healthcare degree programs experience
mounting education-related debt. Medical school debt increased from $50,000 to $170,000
between 1992 and 2012; significant growth after adjusting for inflation (Rohlfing et al., 2014).
Educational debt can be substantial and burdensome, and some healthcare professionals may

1
The term nurse anesthesia resident is used interchangeably with nurse anesthesiology resident (NAR), nurse anesthesia student,
and student registered nurse anesthetist (SRNA).
FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS 2

carry student debt for several years after graduation. Saley (2019) reported that more than 50
percent of practicing physicians had $100,000 in educational debt four or more years after
medical school. Nearly one-third had more than $250,000 in outstanding student loans. In
addition to a lengthy financial burden, a parallel association exists between increased student
debt and increased stress levels and an inverse relationship with academic performance
(Pisaniello et al., 2019; Ross, 2006). Furthermore, high medical school debt significantly
influenced medical school graduates’ decision to pursue higher-paying employment
opportunities and clinical specialty practice (Grayson et al., 2012; Young et al., 2016). This can
lead to a decrease in access to healthcare in underserved communities.
Background and Significance
Certified Registered Nurse Anesthesiologists (CRNAs) are advanced practice registered
nurses and airway management experts who provide anesthesiology and related services across
the lifespan and in all clinical settings requiring anesthesia and pain management care. Nurses
were among the first professionals to deliver anesthesia more than 150 years ago, with the title of
CRNA being formalized later (American Association of Nurse Anesthesiology [AANA], 2009).
Currently, CRNAs safely administer more than 50 million anesthetics each year. Over several
decades, anesthesia services have developed into a critical component of healthcare, and CRNAs
have become an essential element of the anesthesia workforce (AANA, 2021b). More than
59,000 nurse anesthesiologists (or anesthetists) are board-certified to provide anesthesia services
in the US (AANA, 2021b).
Nurse anesthesiology education has evolved over the last century. Initially, nurse
anesthetists received informal, on-the-job training and obtained a certificate of completion. In
1945, the first certification examination was administered (AANA, n.d.). By 1980, the education
FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS 3

requirement progressed to a four-year bachelor’s degree. A decade later, the Council on
Accreditation Nurse Anesthesia Educational Program (COA) mandated a master’s degree for
entry-to-practice (Horton, 2007). Most recently, the entry-to-practice requirement advanced to
the doctorate level. In 2022, all nurse anesthesia programs in the US transitioned to a doctoral
curriculum that requires a minimum of 36 continuous months of didactic and clinical training
(COA, 2021). To meet program completion requirements, the COA mandates students complete
a minimum of 450 didactic hours and 2,000 clinical hours. The clinical hours are further parsed
out with additional minimum requirements for types of cases and procedures performed by the
student (COA, 2021). Upon graduation, nurse anesthesia students acquire 12,593 mean clinical
training hours, which will likely increase after all programs transition to doctoral programs
(AANA, 2021b).
In addition to rigorous clinical training, NARs incur high tuition and program-related
expenses throughout their graduate education. MacIntyre et al. (2014) estimated the cost of nurse
anesthesia education as high as $118,000; however, the estimation did not account for the recent
transition to a doctoral level, which increases the length of training and associated education
costs. More recently, the tuition for nurse anesthesia educational programs was estimated to be as
high as $60,000 per year resulting in $180,000 in direct student costs (Stanley, 2018).
Many nurse anesthesia programs discourage or, in some cases, prohibit NARs from
participating in outside employment because of the intense coursework and clinical
commitments. For example, the University of Southern California Student Program of Nurse
Anesthesia Handbook (2021) states,
Employment (full-time or part-time) is strongly discouraged because of the academic
rigor and clinical commitment required to complete the program. If a student chooses to
FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS 4

secure employment during their training, the student nurse anesthetist must demonstrate
the ability to maintain an acceptable performance in their academic and clinical training
(p. 21).
Several other CRNA programs, such as Georgetown University and Columbia University, have
similar policies in their student handbooks or websites (Columbia University, n.d.; Georgetown
University, n.d.). These employment policies force NARs to secure additional funding to support
living expenses and tuition.
Despite similar training in anesthesiology and services provided, economic disparities
exist between NARs and PARs. Currently, NARs do not receive guaranteed funding from the
federal government during their three or more years of anesthesia education. However, PARs are
compensated via residency programs funded through Direct Graduate Medical Education
(DGME) (Eden et al., 2014). In 2020, PARs were paid an average of $63,300 (Martin, 2020).
Instead, NARs borrow student loans or apply for available grants or scholarships with nominal
sums of money and no guarantee of an award. In some situations, anesthesia practices that house
a nurse anesthesia residency program provide a small monthly stipend to their NARs. Two such
programs are the Cleveland Clinic Foundation School of Nurse Anesthesia at Case Western
Reserve University and Mayo Clinic College of Medicine and Science (Cleveland Clinic, n.d.;
Mayo Clinic College of Medicine and Science, n.d.). The military and Veterans Administration
also has programs that provide either stipends, tuition payments, or loan repayments in exchange
for years of service.
An income disparity exists in the student debt-to-salary ratio between nurse
anesthesiologists and physician anesthesiologists following their training. A survey was
conducted on graduating medical residents entering the field of anesthesia, and those surveyed
FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS 5

reported a median education debt of $182,000 (Grischkan et al., 2017). In 2019, the median
salary of an anesthesiologist was $392,000, indicating that the ratio of annual pre-tax income to
student debt ratio had a median of more than 2:1 (Kane, 2019). According to a membership
survey by the AANA, the median salary for CRNAs in 2019 was $200,000 (AANA, 2020).
Stanley (2018) found nurse anesthesia students may incur $200,000 or more in debt between
tuition and living expenses, notwithstanding interest rates. Under these financial assumptions, a
CRNA would have an annual pre-tax income to student debt ratio of 1:1. The disparity in income
to student debt results in a more extended repayment period for the CRNA. A prolonged loan
repayment period furthers the financial impact of their education when compared with physician
anesthesiologists. It compounds the effects of the minimal to zero funding that NARs receive
during their education. NARs experience a more significant financial burden than PARs despite
role similarities in their professional and educational models.
Increased student loan debt affects career decisions, increases student stress, and
contributes to poor academic performance. Grayson et al. (2012) found medical students
pursuing higher-paying specialties anticipated a statistically higher debt than students pursuing
primary care (p < .001). Significant medical school debt may negatively affect primary care
physician numbers and recruitment of physicians to underserved communities. Grayson et al.
showed that increasing concerns related to debt significantly affected plans to switch from
pursuing primary care to a higher paying specialty (p < .05) as students progressed through
medical school. The researchers found a statistically significant relationship between first-year
medical students who anticipated greater debt and those who anticipated a higher post-graduation
income (r = .16, p < .001). This relationship does not diminish over time. A statistically
significant correlation was also found between anticipated debt and anticipated income in fourth-
FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS 6

year medical students (r = .17, p < .001). Pursuing a more lucrative medical career may further
contribute to a primary care provider shortage. Morra et al. (2008) explored the relationship
between medical student stress and current or anticipated debt. The researchers found a
statistically significant positive correlation with stress and current debt (r = .303, p < .001) and
anticipated debt (r = .453, p < .001). Andriole & Jeffe (2010) studied medical school
matriculants and found a negative correlation between education debt and academic
performance. Medical students who carried more than $50,000 in educational debt were more
than twice as likely to withdraw from their medical school training (Adjusted OR = 2.33; 95%
CI, [1.57,3.46]). In the same study, the researchers found that medical students with education
debt burden of greater than $50,000 were more likely to fail the United States Medical Licensing
Exam Step 1 and Step 2 clinical knowledge exam (Adjusted OR = 1.68; 95% CI, [1.35, 2.08]).
NARs also report substantial stress related to the financial burdens associated with their
education. Chipas and McKenna (2011) measured stress levels in CRNAs and NARs using an
email survey. The researchers received 7,537 completed surveys out of 28,000 disbursed
surveys, indicating a response rate of 26.9%. CRNAs reported a mean stress level of 4.7 on a
ten-point Likert scale, while SRNAs reported a mean stress level of 7.2, although the researchers
did not publish the inferential data between the two cohorts. The study found that the financial
pressures experienced by participating NARs contributed to their chronic stress levels (Chipas &
McKenna, 2011). The findings suggest that stress has longitudinal effects rather than limited
influence and may persist well beyond completing a NAR’s anesthesia training.
Chipas and colleagues (2012) surveyed NARs on their wellness. The researchers
collected 1,282 responses from 1,374 study invitations, indicating a response rate of 93.3%.
Nearly half (47%) of the student participants reported depressive symptoms. More concerning,
FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS 7

over 20% of respondents expressed thoughts of suicide during their training. The findings
validated previous research by Eisenberg et al. (2007), who showed students who struggle with
financial support during their education have an elevated risk of depression and suicide. Chipas
et al. (2012) noted that long-term stress might contribute to harmful outcomes such as suicidal
ideation or maladaptive coping mechanisms in the form of alcohol or drug abuse.
Davidson et al. (2019) investigated suicide prevalence in registered nurses and found they
were at higher risk when compared to the general population. The incident risk ratio (IRR) was
1.58 (95% CI, [1.34, 1.85], p < .001) for females and 1.41 (95% CI, [1.01, 1.91], p = .028) for
males when compared to the general population. The study further found nurse anesthetists
represented the highest subpopulation of nurses (34.7%) who committed suicide. The previously
stated excessive amount of stress experienced by NARs and CRNAs may explain these higher
suicide rates.
Economic Impacts of Nurse Anesthesia Training
Nurse anesthesiologists contribute significantly to the healthcare system and the
economy. CRNAs and NARs lower anesthesia-related costs due to the economic efficiency of
their services and practice model. The education of CRNAs is also less burdensome to the
overall economy. Providing funding for the training of NARs could have future beneficial
healthcare-related impacts on the economy.
Hogan et al. (2018) compared the effectiveness of different anesthesia delivery models.
The researchers found that the CRNA-only model was the most cost-effective among the four
models studied, including physician-only, medical direction, and medical supervision. They
concluded that allowing CRNAs to practice to the full extent of their training could significantly
decrease anesthesia-related costs by 38 percent and improve access to anesthesia services
FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS 8

compared to other anesthesia care delivery models. Investments in CRNA education similar to
physician anesthesiologist education can alleviate anesthesia shortage issues while decreasing
anesthesia-related costs and maintaining the quality of care. Hogan et al. (2010) analyzed
education costs for physician and nurse anesthesiologists and found that increasing the anesthesia
workforce via investing in CRNA education would have less societal cost.
As stated previously, during nurse anesthesia education, students are generally unable to
continue working as a critical care registered nurse—the loss of work results in the students not
contributing to the national gross domestic product. The median annual critical care registered
nurse salary in the United States is $72,541, which results in a loss of $217,623 in economic
contributions (Schneider, 2021). The loss of income does not consider potential investments,
large purchases (e.g., home buying), and retirement savings from the nursing salary that also
contributes to the economy.
Fagerlund (1998) performed a cost-benefit analysis of nurse anesthesia education
involving four entities: nurse anesthesia students, clinical institutions, academic institutions, and
other affected individuals, e.g., taxpayers. Fagerlund completed the study before the nurse
anesthesia education standard moved from a master’s degree to a doctorate; however, several of
the study’s findings remain applicable. One consideration is the positive societal impact from the
added tax dollars CRNAs pay throughout their professional career as opposed to the amount they
would pay remaining as critical care nurses. Additionally, healthcare organizations and hospital
service lines benefit from training NARs delivering anesthesia care as these entities have reduced
labor and recruitment costs.
FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS 9

Research Question
The project answered the primary research question: What financial resources are
available to NARs to reduce the economic burden associated with nurse anesthesiology
education?
Specific Aims
The project had four separate but related aims.
1. Specific aim number one was to conduct an extensive literature review on public and
private funding resources available to NARs.
2. Specific aim number two was to evaluate the effectiveness of the available funding for
NARs.
3. Specific aim number three was to draft policy recommendations for policymakers and
stakeholders on potential funding sources for NAR education.
4. Specific aim number four was to create a lobbying infographic to promote improved
funding for nurse anesthesiology education.
Project Implications
This project demonstrates the need and benefits of providing financial support to NARs.
Additionally, it outlines all available funding sources for NAR education including potential
sources. Policies are recommended which would allow for financial support to NARs during
their education and thus offset the negative impacts of excessive debt. The reduction in the
financial burden associated with NAR education may also attract a greater number of applicants
which could improve the quality of future CRNAs. This project has limitations due to gaps in
available research, which brings forth an opportunity for future research to address these gaps.
FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS 10

This future research can further examine the effects of education related debt on NARs and
CRNAs as the majority of current data is related to the field of medicine rather than advanced
practice nursing. Additional research on the efficacy of current available funding modalities
would also be beneficial.
Conclusion
Healthcare education has significant associated costs, which results in high amounts of
debt for learners. This debt has been shown to have impacts on academic performance, stress,
and career decision making. This is true for graduate nursing students such as NARs who unlike
their physician counterparts are not financially compensated during their training. The lack of
funding for NARs also has broader economic implications such as loss of tax revenue and
contributions to the gross domestic product. Research has demonstrated that NARs and CRNAs
play a pivotal role in healthcare savings, therefore, investments into nurse anesthesia training can
decrease healthcare related expenses.
FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS 11

Chapter 2
Methodology
Several approaches were used for the literature review to identify government and non-
government funding sources for nurse anesthesia education. The peer-reviewed literature was
accessed utilizing traditional research databases. Government, non-government, and educational
institution websites were reviewed for policies and regulations relevant to nurse anesthesia
education funding. Research article inclusion and exclusion criteria were established ahead of the
search. Inclusion criteria included articles published in the English language, publications within
the last 25 years, and research containing relevant information on anesthesia learners, student
debt, or the financial impacts of education. Exclusion criteria consisted of articles older than 25
years and research on stressors unrelated to educational, financial burdens. Before the literature
search, the authors consulted a medical school librarian to optimize the search strategy and data
sources.
The peer-reviewed literature was searched using PubMed, Cumulative Index to Nurse
and Health Allied Literature (CINAHL), and Google Scholar databases. The following search
terms were entered into each database: “medical student” AND “debt” OR “educational debt,”
“nurse anesthesia” AND “student,” and “anesthesia education” AND “cost.” A search was also
conducted to examine the consequences of financial stress on individuals in the field of nurse
anesthesiology using the search terms “nurse” AND “stress.” These terms were later adapted to
“nurse anesthetist” AND “suicide” following the initial review, which revealed significant
mental health impacts experienced by anesthesia learners.
A snowballing technique was utilized to obtain additional articles of interest based on
titles that suggested applicable content or referenced by previous researchers. Each article
FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS 12

abstract was reviewed for relevance. The research team critically appraised the pertinent studies
using the JBI Checklists for Systematic Reviews and Qualitative Research. The authors settled
disagreements through consensus.
The authors explored the published research for most of the literature review; however, to
identify supplemental sources, the authors explored professional trade organizations (e.g.,
AANA and ASA) for policies on education funding. The authors also searched for trade
organization scholarships available for both NARs and medical residents. Finally, the authors
resourced the COA to ensure each recommendation adhered to educational standards.
The researchers investigated government funding resources available to NARs and
medical residents. The funding sources included the Centers for Medicare and Medicaid Services
(CMS), the Health Resources and Services Administration (HRSA), the Nurse Corps Loan
Repayment Program (LRP), as well as both military and Veterans Affairs (VA) funding
resources. The DGME system was reviewed to determine the current funding sources for
medical resident compensation. The HRSA’s Nurse Anesthetist Traineeship (NAT) program was
evaluated for government funding available for nurse anesthesia programs. The Nurse Corps
LRP was explored for potential loan repayment opportunities available to NARs upon program
completion and a commitment to work in a Critical Shortage Facility upon graduation. The
authors examined the military service opportunities with the US Army and Navy, which would
provide compensation during nurse anesthesia training in exchange for years of service. Finally,
the authors surveyed the programs available through the VA for individuals who commit to a
designated number of years of service at a VA facility.
The authors reviewed non-governmental sources to understand American Council on
Graduate Medical Education (ACGME) and COA training requirements, additional non-
FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS 13

monetary benefits, and program-specific benefits for NARs. The ACGME standards were
evaluated to describe the structure of medical resident training in anesthesiology. Departments of
anesthesiology websites were assessed for anesthesia trainee compensation data and resources
available to medical residents at various residency programs. The COA Standards for Nurse
Anesthesia Education were referenced to outline the level of commitment and responsibility that
NARs carry during their anesthesia education. Nurse anesthesia program websites were searched
to identify available supplemental resources to fund education. The authors provided several
examples of nurse anesthesia programs and the financial resources they provide to their students
to support their education.
Lastly, the authors examined other potential outside funding resources for NARs to
exhaust all funding resources and display the available funding options for NARs. The results
were used to develop policy recommendations for government and non-government entities,
future research, and programs of nurse anesthesiology. A lobbying infographic was produced for
stakeholder advocacy efforts.

FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS 14

Chapter 3
Literature Review
The literature review focused on available funding sources for NAR and PARs, and
government and non-government funding sources were explored. The AANA and the American
Society of Anesthesiologists (ASA) are two professional trade organizations for anesthesia
professionals, CRNAs and physician anesthesiologists. Each trade association offers select
funding and resources for learners in each respected profession. Also included in this literature
review are scholarship opportunities, current program-specific funding, and accreditation
standards for both medical and nurse anesthesia residents. All funding options for nurse
anesthesia training must comply with the COA Standards for Nurse Anesthesia Education.
Funding sources that did not adhere to these standards or were non-specific to nurse anesthesia
education were omitted from consideration.
Trade Organization Funding Resources
American Association of Nurse Anesthesiology
The AANA provides a list of available scholarships for NARs on their website.
Scholarships are awarded annually and have various requirements, including the current year in
the program, demonstrated financial need, and GPA stipulations. Many scholarships are state-
based and available exclusively to in-state residents, while others are designated for ethnic and
cultural minorities or individuals demonstrating significant financial need (AANA, 2021a). In
the fiscal year of 2021, 73 scholarships were awarded to students chosen from among 2,111
applications. Awards are determined based upon scholarship-specific criteria such as merit and
financial hardship. These scholarships averaged just under $3,000 each (AANA, 2021a).
FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS 15

Additionally, scholarships are awarded preferentially to those who have not been
recipients in the past. More than 8,500 NARs are enrolled in graduate nurse anesthesia programs
(AANA, 2021c). Statistically, even if every student were eligible to apply to each scholarship,
students would have less than a one percent chance of receiving an award through the AANA.
Interestingly, Stanley (2018) estimated the average AANA scholarship would only cover five
percent of direct educational costs per year.
American Society of Anesthesiologists
The ASA does not offer any substantial scholarships or funding to medical residents. A
$500 stipend is available for PARs and medical students in clerkships at rural hospitals to
encourage postgraduate practice in underserved communities (ASA, n.d.). Rather than offer
scholarships, the ASA lobbied the federal government for student loan relief. The ASA urged
Congress to introduce H.R. 1554 in 2019, known as the “Resident Education Deferred Interest
Act” or “REDI Act.” The legislation would pause interest during residency programs so that
medical school loans do not continue to accrue interest while in forbearance (Cate, 2021). While
the bill received several endorsements in the US House of Representatives, it remains in the
Education and Labor Committee in the House of Representatives (H.R. 1554, 2019).
The ASA provides funding for PARs to participate in organizational events and research.
The Foundation for Anesthesia Education and Research’s (FAER) Resident Scholar Program
provides funding to 60 residents annually to attend the ASA conference and disseminate research
to anesthesiology colleagues. Additionally, the FAER provides several research grants each year
to PARs interested in research related to anesthesiology. The Research Fellowship Grant is
available to PARs following their first year of anesthesia residency and amounts to $75,000
towards a designated research opportunity (FAER, 2021).
FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS 16

Governmental Funding Resources
Medicare
According to the Medicare Claims Processing Manual (2021), physician anesthesiologist
remuneration is limited when supervising and clinically instructing a NAR. Physician
anesthesiologists may supervise two NARs concurrently but only collect 50% payment for each
concurrent anesthesia case. To collect 100% of the fees for an anesthesia case, the physician
must supervise the NAR in a 1:1 ratio. However, physician anesthesiologists may collect 100%
of each case when they supervise and clinically instruct two PARs. A teaching rule exists that
allows a CRNA to supervise two NARs and claim 100% remuneration for each case, provided
the physician anesthesiologist does not supervise the CRNA. Under a split teaching model, one
physician anesthesiologist may supervise a NAR and a PAR concurrently. The physician
anesthesiologist can collect 50% for the NAR case and 100% for the PAR case (AANA, 2011).
A change to the Medicare Teaching rules could allow physician anesthesiologists to collect
100% for two concurrent anesthesia cases with NARs. The additional remuneration could be
redirected to support NARs for providing anesthesia services.
Graduate Nurse Education Demonstration
The Graduate Nurse Education (GNE) Demonstration was part of the Affordable Care
Act that authorized the CMS to invest $200 million in APRN training to increase the number of
primary care providers. Nineteen schools of nursing were chosen to receive funding to increase
enrollment and graduation of primary care nurse practitioners. Porat-Dahlerbruch et al. (2022)
determined the effectiveness of the GNE Demonstration. They concluded that schools that were
part of the GNE Demonstration were successful in increasing the number of primary care
providers they graduated in comparison to the years prior the GNE Demonstration and in
FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS 17

comparison, non-GNE Demonstration schools of nursing. Furthermore, the study showed that
graduation and enrollment numbers decreased in the year following the end of the project. The
program illustrated that monetary investments into graduate nurse education improve access to
healthcare. Additionally, evidence has shown that nurse practitioners are a cost-effective
provider (Morgan et. al., 2019). Therefore, the increased availability and thus utilization of nurse
practitioners as a result of the GNE Demonstration can reduce healthcare associated costs. A
similar program specified for schools of nurse anesthesia could increase the number of
anesthesia providers to meet the demands of the population while simultaneously decreasing
healthcare expenditures.
Health Resources and Services Administration
The Health Resources and Services Administration (HRSA), provides a source of funding
to nurse anesthesia programs across the country called the Nurse Anesthesia Traineeship (NAT)
Program. According to the HRSA website, the program “aims to increase the number of
[CRNAs] providing care, especially to rural and underserved populations” (HRSA, n.d.). At
present, CRNAs are the primary providers of anesthesia care to rural communities, and over
1,500 rural hospitals rely exclusively on CRNAs for their anesthesia and pain management
services (Martsolf et al., 2019). Although HRSA’s goal is to increase access to anesthesia care in
underserved areas by supporting nurse anesthesia training, the financial support does not
meaningfully contribute to a more robust healthcare workforce for underserved communities.
The FY2020 HRSA grant provided $2,250,000 annually to 80 nurse anesthesia programs
in the US, or $28,125 per program if funds were equally distributed. However, funds are not
currently designated this way, resulting in an even lower dollar amount for some programs.
Additionally, there are 128 nurse anesthesia programs in the US, which means that 48 programs
FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS 18

and their students do not receive any funding from this source. For 2020, the disbursement
amount ranged from $1,000 to $117,582 per program, divided amongst NARs in the program
(HRSA, 2020). While the number of NARs in each program varies from less than ten per
graduation cohort to more than a hundred, this amount of funding does not significantly reduce
the educational debt burden. When divided by the total number of NARs across the country, the
NAT program provides approximately $264 per student, equating to a meager portion of annual
tuition.
The HRSA grant also requires each student to be awarded a sum of a minimum of $1,000
to a maximum of $22,000 (HRSA, n.d.). Financial support inequity may occur if programs
cannot evenly disperse the required minimum $1000 per NAR. Some programs may supplement
the support, so all NARs receive financial equity. Given these restrictions and the number of
nurse anesthesia programs/students in this country, the HRSA grant provides limited funding to
NARs.
Nurse Corps
The Nurse Corps LRP offers to fund Advanced Practice Registered Nurses, including
CRNAs, provided they commit to working in a Critical Shortage Facility for a designated period
upon graduation. The program forgives up to 60% of an outstanding balance on student loan
payments in exchange for a two-year commitment at an eligible healthcare facility with a critical
shortage of nurses. The program offers an additional 25% student debt forgiveness for the third
year of commitment (Nurse Corps, 2021). Approximately 252 awards were available for the
2021-2022 academic year, and the program requires applicants to sign a commitment agreement.
The scholarship program divides applicants into three tiers. Tier 1 consists of full-time
undergraduate nursing, nurse practitioner, and nurse midwife students. Tier 2 is for full-time
FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS 19

nurse anesthesia students and clinical nurse specialist students. Tier 3 is for all part-time students
in any undergraduate or graduate nursing specialty. It is unclear in the program guidelines how
the tier system was determined. Because of the competitive nature of the program and a high
volume of qualified applicants, the program only accepts applicants in Tier 1, rendering NARs
ineligible (Nurse Corps, 2021).
US Army Health Professional Scholarship Program
The US Army Health Professional Scholarship Program (HPSP) grants several financial
incentives to NAR. This program provides a monthly stipend and sign-on bonus for NARs who
are willing and able to commit to serving in the reserves during their education. Following their
program graduation, the CRNA serves in the military for a designated period. Upon graduation,
these residents can also qualify for the Healthcare Professionals Loan Repayment Program,
which offers $50,000 in loan repayment throughout three years (US Army, 2011). There is no
current data on the number of program applications or evaluation data on the success of the
HPSP.
US Air Force Scholarship Program
The US Air Force offers multiple scholarships to suit the student’s degree; among these
are two- and three-year scholarships for Nurse Corps specialties, including NARs. “The
scholarship covers all tuition and required fees, including textbooks, small equipment items, and
supplies needed for study” (Health Professions Scholarship Program, 2021). NARs also receive a
monthly allowance for living expenses. The program requires 45 days of active duty in the Air
Force while on scholarship, followed by serving one year of active duty for each scholarship
year. NAR recipients must do a minimum of three years of active duty.
The US Air Force also offers a Financial Assistance Program for medical and dental
FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS 20

residents during their training. Participants receive more than $45,000 for every year of the
program and a stipend of $2,000 a month to cover living expenses. Like the Nurse Corps
funding, this program requires a one-year obligation to active duty for each year of participation
plus one extra year. Additional graduate medical education offers residencies and fellowship
programs with various specialties that are nearly all integrated or affiliated with civilian
universities (US Air Force).
While these military funding sources cover a more significant portion of educational
costs than other sources, substantial commitments are required from the recipients. There is also
no current evaluation data on the program or those who have utilized this funding source.
Department of Veterans Affairs
The US Department of Veteran Affairs (VA) and the US Department of the Army jointly
administer the Nurse Anesthetist Education Program to educate interested and qualified VA
nurses in the field of nurse anesthesia. The program is affiliated with Baylor University and is
funded through the VA’s Employee Incentive Scholarship Program (EISP). It consists of a 36-
month timeline divided into one year-long didactic phase completed at US Army Medical
Department Center & School in San Antonio, Texas, followed by a two-year clinical phase at the
VA Medical Center in Memphis, Tennessee. Admission criteria are similar to other academic
programs with prerequisites for science and critical care nursing experience. In addition,
applicants must have an overall evaluation rating of satisfactory on their most recent VA
proficiency report, have been continuously employed by the VA in a permanent full-time or part-
time position for a minimum of one year, and provide a letter of recommendation from their
faculty’s Nurse Executive supporting upward mobility within the VA System (US Department of
Veterans Affairs, n.d.).
FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS 21

Once selected, the applicant’s funding is sourced from the EISP, which covers tuition and
education-related expenses (e.g., registration, fees, books, materials, and supplies). A maximum
amount is authorized as the equivalent of 36 months of full-time employment coursework. This
funding is provided by the government funding dispersed to the VA System and allocated
directly to the program. Outside of this funding, the learner is responsible for their living
expenses throughout the program. Although this program offers significant benefits to the
learner, there is a required service obligation upon graduation. The EISP funding requires a
three-year full-time employment commitment at a VA healthcare system with a need for CRNA
services. The Under Secretary for the Department of Veterans Affairs conducts the needs
assessment and determines CRNA assignment, although location requests can be made (US
Department of Veterans Affairs, n.d.). Similar to other military funding programs, there are no
available data on applicant statistics or the program’s effectiveness.
Departments of Anesthesiology
American Council on Graduate Medical Education Structure and Standards
Following completion of a Doctor of Medicine degree, physicians pursuing
anesthesiology complete a one-year non-anesthesia medical internship followed by a three-year
anesthesia residency where they receive clinical training under physician supervision. PARs
receive didactic education related to perioperative anesthesia care during their training. After
four years of internship and residency are complete, physicians may complete the American
Board of Anesthesiology board certification examinations. The three-year physician anesthesia
residency has the same duration as the nurse anesthesia curriculum; both run 36 continuous
months.
FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS 22

The ACGME sets standards for clinical and educational requirements for physician
resident training. Among these standards is a maximum of 80 clinical and academic work hours
per week, averaged over four weeks, inclusive of all in-house clinical and educational activities,
clinical work done from home, and all moonlighting (ACGME, 2017). Clinical and academic
work periods must also not exceed 24 hours of continuous, scheduled clinical assignments. In
addition, residents are to be off eight hours between scheduled clinical work and education
periods and 14 hours free of clinical work and education following a 24-hour in-house call shift
(ACGME). Residents must be scheduled for in-house call no more frequently than every third
night, and time spent on patient care during at-home call must be counted towards the 80-hour
maximum weekly limit. PARs are compensated throughout their residency through DGME
funding allocated to hospitals that have residency programs.
Since 1965, the Medicare program has funded Graduate Medical Education (GME)
payments to ensure Medicare beneficiaries access the highest quality hospitals (Iglehart, 1999).
With the start of the Medicare Prospective Payment System (PPS) for acute care hospitals in
1983, two separate GME funding streams were established for teaching hospitals: DGME
funding to cover direct expenses associated with residency training (salaries, benefits, and
administrative and overhead costs); and Indirect Medical Education (IME) funding, an
adjustment for hospitals’ additional costs thought to be associated with sponsoring residency
programs (Wynn et al., 2013). The total DGME amount for an individual institution is calculated
by multiplying three factors: weighted resident count, which is a 3-year rolling average of full-
time equivalent residents, per-resident amount, which is a dollar amount calculated by dividing
the hospital’s base year DGME costs by weighted resident count, and a Medicare day ratio,
FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS 23

which is a ratio of the hospital’s Medicare inpatient days to total inpatient days (Wynn et al.,
2006).
Keck School of Medicine Resident Compensation
One example of resident compensation and benefits is USC’s Keck School of Medicine.
PARs receive upwards of $56,000 per year and other benefits described below. Anesthesia
residents at USC are provided a monthly salary of between $4,735.90 and $6,006.20 (increasing
each year) throughout their residency in addition to an annual housing allowance of $4,000 per
intern/resident (Committee of Interns and Residents 2019). They also receive life insurance,
health insurance, dental insurance, sick leave, workers’ compensation, jury duty leave, and
witness leave. Furthermore, three fresh meals are provided each day a resident participates in
patient care, and a reimbursement of $25.00 per day is followed for rotations outside of Los
Angeles County facilities. Residents are allowed 192 hours (24 eight-hour workdays) per
residency year for time off from patient care. The remaining available time off hours will be
reimbursed to the resident for up to 80 hours or carried over to the next year for use (Committee
of Interns and Residents, 2019).
University of California Irvine Resident Compensation
Another example is that of Anesthesiology residents at the University of California,
Irvine, receive stipends of $62,486 and $67,094 annually. This program includes four weeks of
annual vacation time and insurance coverage for medical, dental, vision, and long-term
disability. Additionally, residents receive stipends for continuing education, licensure exams,
housing, and meal stipends that cover three daily meals on weekdays and an additional $960
annually for additional food at the UCI hospital cafeteria (University of California, Irvine:
Residency Program, 2020).
FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS 24

Programs of Nurse Anesthesiology
Council on Accreditation of Nurse Anesthesia Educational Programs Standards
The COA delineates the academic and professional standards for nurse anesthesia
programs, faculty, NARs, and graduates. NARs may spend up to 64 hours per week, averaged
over four weeks, dedicated to their education and training. These hours are divided between both
didactic and clinical training. NARs must demonstrate exceptional communication, critical
thinking, vigilance, professionalism, and leadership skills, in addition to a sound knowledge of
perianesthesia management (COA, 2021). The expectations indicate the level of performance
required from all NARs while in training. Notably, while NAR and PAR professional abilities
are comparable, no comparison exists between the amount of compensation each anesthesia
trainee receives. Interestingly, COA Standard G8 forbids NARs from being employed as a
CRNA in title or function (COA, 2021); however, this does not preclude NARs from receiving
financial support from the department in the form of a stipend or monthly housing allowance.
Several nurse anesthesia programs offer financial support to their NARs during their training.
Unlike PARs, NARs are not compensated by DGME funding. Most nurse anesthesia
programs do not have the resources to provide students with financial compensation for the
clinical hours spent giving anesthesia. With rising education costs, nurse anesthesia programs
recognize the educational debt burden students face and aim to offset this with assistance
covering program costs, such as stipends, health insurance, and housing during distance clinical
placements. Several nurse anesthesia programs offer free housing during clinical rotations or
provide meals when involved in direct patient care. For example, a Southern California program
offers free housing accommodations when students are placed at clinical sites outside of a
FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS 25

mileage range from campus. Some clinical sites provide meal vouchers during call shifts.
Additionally, some nurse anesthesia programs offer some compensation or benefits to their
residents to alleviate some financial burden during their training.
Mayo Clinic College of Medicine and Science. The Mayo Clinic College of Medicine
and Science provides accommodations during the eight-week senior off-campus rotation. Still,
the student is responsible for housing and transportation for the remainder of the three-year
program. NARs also receive an annual stipend of approximately $5,600 during the last 24
months of the program, for a total of $11,200. Students are offered low-cost health and dental
insurance for the duration of the program. Still, they are responsible for funding this insurance
every year (Mayo Clinic College of Medicine and Science, n.d.).
Cleveland Clinic Foundation School of Nurse Anesthesia. Another nurse anesthesia
program that provides financial compensation to students is the Cleveland Clinic Foundation
School of Nurse Anesthesia at Case Western Reserve University. This program guarantees
students receive 20% of their tuition in scholarships and grants (Cleveland Clinic, n.d.). They
provide a $300 monthly stipend without an associated work commitment or contract.
Additionally, the program offers health insurance and malpractice insurance at no additional cost
to the student.
Baylor University Program of Nurse Anesthesia. Nurse anesthesia residents in the
Baylor University program receive a monthly $1,000 stipend during their clinical rotation at Ben
Taub Hospital. This stipend is sponsored by the Harris Health System (Baylor College of
Medicine, n.d.).
Additional Funding Sources
Anesthesia Patient Safety Foundation
FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS 26

The ASA and the Anesthesia Patient Safety Foundation provide scholarships to three
anesthesia trainees annually (available to NARs, PARs, and anesthesiologist assistant students).
These scholarships range from $250 to $1,000 and are awarded based upon participation in
Quality Improvement projects, which ultimately are presented at the ASA annual meeting
(Anesthesia Patient Safety Foundation, 2020). Although available to anesthesia learners in
different training programs, most of the scholarships in the past several years have been awarded
directly to PARs.
Other Graduate Degree Programs
Many Ph.D. programs offer a stipend to their students to cover living expenses. The
amount of the stipend varies depending on the school and department. In 2017, the stipend for a
Ph.D. student in the sciences ranged from $20,000 to $30,000. These stipends usually come from
a grant or the school in exchange for teaching courses. Additionally, the Ph.D. students typically
have their tuition covered by the school (Ruben, 2017). If similar monetary benefits could be
made available for NARs, it could significantly reduce the financial burden and the associated
hardship frequently encountered by NARs.
Conclusion
The literature review outlined various funding sources for NARs, including trade
organization scholarships, military, government, nurse anesthesiology program, and anesthesia
department. Funding sources for PARs were also included for purposes of comparison and
possible duplication. The NAR funding sources are limited, cumbersome to obtain, and generally
inadequate to provide substantial support. Gaps in the data such as efficacy of current funding
modalities and source of program sponsored benefits were addressed. Areas for improvement
FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS 27

such as expanding HRSA funding and improving access to Nurse Corps LRP for NARs were
also outlined.

FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS 28

Chapter 4
Results
This project identified all available funding sources for NARs from the government, trade
organizations, programs of nurse anesthesiology, and others. The review found few funding
sources available or specific for NARs. The authors noted the financial support during nurse
anesthesia training is challenging to attain. Economic aid is often inadequate to compensate
NARs for their extensive work hours, contributions to healthcare organizations, or reducing their
debt meaningfully. The financial hardships experienced by NARs and resultant amounts of debt
are significant, and the long-term consequences associated with educational debt can be
substantial and deleterious. Funding sources for PAR compensation were included for
comparison and potential replication for NARs.
Recommendations
Based on the findings from this project, we propose several recommendations to improve
the financial support for NAR education and training. The recommendations are delineated into
policy, research, and practice. We believe the following recommendations will improve funding
for nurse anesthesia education, reduce NAR hardship, and encourage equitable learning
opportunities in anesthesiology.
Policy Recommendations
This study identified potential legislative modalities that would allow for financial
compensation to NARs for their work contribution in healthcare.
● Establish a Congressional oversight committee that reports annually the funding sources,
money distribution, and program utilization for advanced practice nursing education and
residencies.
FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS 29

● Expand Medicare graduate education funding to include compensation for NARs and
other advanced practice specialties, similar to PARs.
● Modernize the Medicare reimbursement regulations and rules to allow physicians
anesthesiologists to collect 100 percent of each concurrent anesthesia case while
supervising two NARs, identical to PAR cases.
● Create federal legislation to pause interest on student loans utilized by NARs. This would
significantly reduce the debt burden from nurse anesthesia education.
● Increase annual HRSA Nurse Anesthetist Traineeship Program funding so all qualified
NARs can receive financial support.
● Amend the Nurse Corps LRP rules to allow nurse anesthetists access to Tier 1
consideration.
● Incorporate recommendations within the COA Standards for Nurse Anesthesia Education
for nurse anesthesia schools to implement various avenues of providing financial support
to NARs.
Research Recommendations
There is little research on financial stress's immediate and longitudinal effects on NARs.
The literature review identified additional research gaps, including efficacy of current funding
modalities, source of program sponsored benefits, and long-term effects of debt on
NARs/CRNAs. We recommend future studies concentrate on the following areas to advance
knowledge and research on higher education cost disparities and its impact on building a more
robust healthcare workforce.
● Identify the impact of the rising costs of nurse anesthesia education that may influence a
nurse’s decisions to pursue education in nurse anesthesia.
FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS 30

● Describe the immediate and long-term effects of financial support on NAR wellbeing,
academic performance, and learning opportunities.
● Explore the relationship between fully sponsored programs and financial stress on
academic performance and future employment interests.
● Examine the long-term effects of educational debt carried by NARs following program
completion to elucidate the heavy debt burden's emotional, financial, and wellness
consequences.
● Evaluate the economic impact of government-sponsored education on nurse anesthesia
educational programs and departments of anesthesiology.
● Measure the cost and financial support variances between NAR and PAR anesthesiology
education.
Educational Programs and Departments of Anesthesiology Recommendations
This project showed there is no universal compensation or benefits standard for NARs.
While it may not be possible to create a genuinely standardized system, there are certain areas in
which hospitals and nurse anesthesia programs could provide more resources to NARs to
decrease the financial and stress burden. We recommend nurse anesthesia educational programs
and departments of anesthesiology consider the following recommendations:
● Provide meal coverage for NARs during their clinical days, thereby ensuring that NARs
are nourished during their clinical shifts and allocate less of their time and financial
resources towards planning meals on clinical days.
● Offer housing for distant clinical rotations.
● Provide monthly living expense stipends for NARs delivering clinical anesthesia services
at program-affiliated academic medical centers.
FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS 31

● Assist NARs with grants and scholarships applications. Many application processes can
be confusing and time-consuming. Aid in this process may increase applications and
acceptance of these awards.
● Disseminate the program or department's financial support model to support NAR
education replication by other educational programs.
● Establish an AANA-sponsored educational funding resource center for current and
prospective NARs that details the varied financial options with a rating system to
promote user understanding.
Conclusion
Several potential modalities for improving the financial situation of NARs during their
education have been listed in this project. These modalities are further categorized into policy,
research, and program/departmental recommendations with some having more potential for
immediate impact than others. Implementing some or all of these recommendations could
significantly reduce the financial burdens experienced by NARs and may also create improved
educational parity between NARs and PARs. While this could have a significant beneficial
impact for NARs, it could furthermore impact the healthcare system as a whole due to the role of
NARs and CRNAs in the system. An evaluation process should also accompany the
implementation of any of these recommendations to determine the effectiveness of these
changes. It will assist in identifying the adequacy of the recommendation and any adjustments
that need to be made.

FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS 32

Chapter 5
Discussion
This review contends that improved financial support for NAR training is needed to
reduce educational debt-related burdens. The report outlined the importance of strengthening
financial support for NARs and described the financial resources currently available to NARs.
Based on the literature review, the authors recommend policymakers and stakeholders address
the policy gaps and disparities in anesthesia educational support between NARs and PARs. The
final component of the project consisted of a toolkit which highlighted the major components of
the project and provided actionable steps towards providing financial resources for NARs.
The authors presented the current economic situation for NARs and advocated for
monetary compensation for work completed during their residency. Nurse anesthetists make a
significant contribution to the healthcare system and workforce during their training as NARs
and, later, as board-certified anesthesia professionals. The healthcare system would benefit from
NAR financial support, as it would attract and support learners who will go on to illustrious
careers in anesthesia. This would ensure that the anesthesia needs of the population are met while
decreasing healthcare related expenses. The GNE Demonstration has already illustrated the
societal benefits of investing in graduate nurse education. The authors hope that others will see
the value in pursuing this goal and build upon this project to strengthen the argument and
develop policy to achieve this goal.
Along with the research done in this project, a lobbying infographic (see Appendix A)
has been developed to assist with lobbying and educating stakeholders. Ultimately, the goal is for
a policy that would provide financial compensation to NARs for their hours providing anesthesia
FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS 33

services to be developed, introduced, and passed. Such implementation would go far beyond the
NAR; affecting anesthesia programs, healthcare systems, and even other healthcare professions
that may adopt similar policies to support their students. The substantial debt NARs accrue is
only one portion of the debt of healthcare professionals. The problem of debt for healthcare
learners is vast, and this project proposed actionable steps towards alleviating some of the burden
for those pursuing nurse anesthesiology specifically.
Monumental change in financial resources for NARs will not come simply by a paper
being published. The authors hope that others in the future will recognize the validity of the
argument for increased financial resources and agree that there is a need that deserves more
attention. This project presented the current financial situation for those entering the field of
nurse anesthesiology and encouraged others to pursue research and efforts to expand the
financial support for NARs.
Strengths
The authors recognize this review as a foundational culmination of literature relating to
the financial constraints of nurse anesthesia training and compensation for NARs throughout
their training. In addition to a review of current compensation available for NARs, there is
evidence of significant financial and educational disparity between NARs and PARs. Viable
options for closing this gap have been presented above using current compensation policies and
procedures for PARs as a structured guide.

FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS 34

Limitations
There are several limitations to this review. Many of the adverse effects of healthcare
education-related debt, such as academic performance, stress levels, and employment decisions,
were extrapolated from studies on medical students. The same findings may not necessarily
apply to NARs. Additionally, several pieces of literature used in this review were older than five
years and potentially have outdated numbers and applications. There are several gaps in current
research, especially around funding which limited the ability of this review to determine the
effectiveness of the funding source or even modality by which funding was provided. This also
limits the study’s ability to determine the adequacy of funding. Lastly, some recommendations
may not be easily implemented or even feasible because of timing, organizational structure, or
other barriers that preclude full operation.
Final Conclusion
Financial constraints placed on NARs throughout their education and training can distress
their emotional and physical wellbeing. These effects can be seen in the individual and the
community they serve in career choices solely based on income opportunity. It is crucial for
policymakers and stakeholders to address financial support for NARs. A means of doing so has
been presented in the current practices for compensation of PARs, which have recently proven to
be comparable to NARs in practice. This review of available NAR and PAR financial support
options demonstrates a gap in provider support and highlights an opportunity for improvement in
NAR compensation policies. The authors hope these recommendations serve as a framework for
future refinement and success in supporting all anesthesiology residents, nurse or physician,
during their clinical training.

FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS 35

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FINANCIAL SUPPORT FOR NURSE ANESTHESIA RESIDENTS 43

Appendix A

Abstract (if available)

Abstract Background: Healthcare education in the United States is notoriously expensive, and nurse anesthesia education is no exception. Educational costs have risen significantly as a result of the nurse anesthesia education moving from a master’s degree to a doctorate-level degree. Many nurse anesthesia residents (NARs) are accruing exceptional student debt. Methods: Various search platforms were accessed to conduct an extensive review of published literature regarding the effects of student debt, funding sources for NARs, and potential impacts of funding NARs. In addition to published research, we reviewed government and non-government funding sources for nurse anesthesia education. The project analyzed education financing for physician anesthesia residents (PARs) and other graduate learners. Results: The review identified limited funding available for NAR education. The few funding options are minimal in quantity, limited to a small percentage of students, or both. A disparity exists between NAR and PAR educational funding. Conclusion: Based on findings, the authors recommend expanding funding opportunities for NARs during their training by government and private sector industries. CRNAs are crucial members of the US healthcare system, and an investment in the future of nurse anesthesiology will have a significant impact.

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Creator Wei, Gary (author)

Core Title Addressing financial support for nurse anesthesia residents: literature review with policy recommendations

School Keck School of Medicine

Degree Doctor of Nurse Anesthesia Practice

Degree Program Nurse Anesthesiology

Degree Conferral Date 2023-05

Publication Date 10/25/2022

Defense Date 10/24/2022

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Tag education funding,nurse anesthesia resident,OAI-PMH Harvest,student debt

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Advisor Darna, Jeffery (committee chair), Bamgbose, Elizabeth (committee member), Carr, Josh (committee member)

Creator Email garywei@usc.edu,hkassel@usc.edu

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