CRNA Supervision Requirements by State

More than 80% of anesthesia providers in rural communities are certified registered nurse anesthetists (CRNAs), according to the American Association of Nurse Anesthesiology (AANA) in November 2022. Many rural hospitals provide CRNA-only anesthesia care to cut down on commute times and keep their general surgery and obstetrics departments open.

Yet, 23 states don’t allow CRNAs to practice independently. Even in states where CRNAs can practice independently, supervision requirements remain complicated. Learn about CRNA supervision requirements by state, care model, and practice setting, and what they mean for CRNAs.

CRNA supervision requirements vary by care model. Whether you live in a state that allows CRNAs to work independently may not matter as much as the amount of independence your employer gives you.

For example, CRNAs in Maryland are not allowed to work independently, but Johns Hopkins uses collaborative care. CRNAs in Minnesota are allowed to work independently, but Mayo Clinic uses the anesthesia care model.

Anesthesia care follows one of four main care models: physician only, anesthesia care, collaborative care, and CRNA only.The main difference between collaborative care and anesthesia care is anesthesiologists are more involved in anesthesia care and bill patients for their involvement.

In larger hospital systems and teaching hospitals, anesthesiologists may not meet all seven requirements for every procedure they supervise. CRNAs working in those settings may experience a combination of the collaborative care and anesthesia care models even if the anesthesia team prefers the ACT model. The amount of supervision CRNAs will experience for each case depends on the resources, workload, and staffing ratios in their work setting.

The practice setting you choose will also affect your supervision requirements as a CRNA. As a rule, the larger the practice setting, the larger the anesthesia team and the more supervision you will experience.

CRNAs in large healthcare systems or teaching hospitals will usually be part of an anesthesia care team that follows the ACT model. Their services will often be billed through medical direction billing.

Outpatient care centers make up 23% of CRNAs’ industry employment compared to 3% of anesthesiologists’ industry employment, according to the U.S. Bureau of Labor Statistics data from May 2021.

CRNAs usually work independently and often they’re the only anesthesia care provider available on their shift in outpatient care centers, such as:

If CRNAs work in outpatient care centers in states where they do not have full-practice authority, the surgeon may fill the role of supervising physician. Many CRNAs point out that it doesn’t make sense to be supervised by a physician that has less anesthesia experience and expertise than they do just to meet a physician supervision requirement.

Community hospitals and rural hospitals may use collaborative care or CRNA-only care depending on where they are, how big the team is, and how much work the anesthesia team does. Rural hospitals have moved toward CRNA-only models in recent years. In these hospitals, CRNAs usually handle routine cases in:

According to the American Association of Nurse Anesthesiology in 2022, half of the rural hospitals in the U.S. exclusively use CRNAs for their obstetrics care. CRNAs allow these hospitals to keep their departments open and cut down on commute times for patients who need straightforward procedures.

All these supervision requirements can be complicated for CRNAs looking for their next job or new to the job market. The American Society of Anesthesiologists and AANA created a lot of contention around the topic of CRNA supervision.

CRNAs who have experience working in one or more of the care models will be able to give you a more informed opinion based on their experiences. You should network with CRNAs with experiences in different care settings and models, so you have an honest and clear picture of the benefits and disadvantages of different supervision levels for CRNAs. Then, you can try different settings and make a decision based on what works best for you.

As you apply for jobs, try to find current employees in different departments who will talk to you about the anesthesia team you’ll join because your employer has the most say in how much independence you have as a CRNA. Consider asking these questions of your potential boss, recruiter, or other members of the care team before you sign the contract:

CRNA supervision happens when an anesthesiologist supervises one or more CRNAs on the anesthesia team. They can medically direct the CRNAs if they meet the billing requirements, or they can loosely supervise the patient’s anesthesia care depending on the workload and resources of the anesthesia team.

As of July 2023, Wisconsin, Washington, West Virginia, Montana, Massachusetts, Vermont, Utah, South Dakota, Oregon, Oklahoma, North Dakota, New Mexico, New Jersey, New Hampshire, Minnesota, Michigan, Kansas, Iowa, Kentucky, Idaho, Alaska, Arizona, Delaware, California, Colorado, Arkansas, and Washington D.C. opted out of CRNA supervision.

CRNAs can practice independently as soon as they get their licenses in 23 states, Washington D.C., and Guam. Massachusetts, West Virginia, Vermont, and Colorado have transition-to practice laws that require newly licensed CRNAs to complete a certain number of hours of supervised practice before they can apply to practice independently.

CRNAs can work independently in the military, Guam, Washington D.C., and the 27 states that opted out of CRNA supervision.

Page last reviewed December 18, 2022