The certified registered nurse anesthetist is the oldest of the four advanced practice roles — nurses were giving anesthesia in American operating rooms decades before anesthesiology existed as a medical specialty — and the best paid occupation in nursing by a wide margin. About 54,500 people held nurse anesthetist jobs in 2025, with a median wage of $236,590.
The work is administering anesthesia and managing the patient through it: pre-anesthetic assessment, choosing and delivering the anesthetic, airway management, monitoring and physiological control during the procedure, and recovery. In much of rural America the nurse anesthetist is the only anesthesia provider in the building.
An unusually old role
Nurse anesthesia dates to the 1870s, when hospitals began assigning the ether can to nurses rather than to medical students. Alice Magaw, who gave anesthetics for the Mayo brothers in Rochester, published a series of case reports beginning in 1899 describing thousands of administrations, and Charles Mayo called her the mother of anesthesia. Agatha Hodgins formalized the training, running instruction at Lakeside Hospital in Cleveland from 1911 and establishing a school of anesthesia there in 1915.
Hodgins also built the profession's institutions. She proposed a national organization at the 1930 American Nurses Association convention, and the National Association of Nurse Anesthetists was founded in Cleveland the following June. It became the American Association of Nurse Anesthetists, later the American Association of Nurse Anesthesiology. Certification followed in 1945, and mandatory continuing education in 1978 — both well ahead of the rest of nursing.
That history is the reason the role sits slightly awkwardly inside the advanced practice tier. It was organized, credentialed, and regulated on its own terms for seventy years before the Consensus Model arrived to describe all four roles at once.
Getting in
Entry requires a registered nurse licence and, in practice, at least a year of critical care experience — most programmes want more, and most successful applicants come from intensive care rather than from the operating room. See critical care nursing.
Since 2022 every student entering a programme accredited by the Council on Accreditation of Nurse Anesthesia Educational Programs must enrol in a doctoral programme, either a doctor of nursing practice or a doctor of nurse anesthesia practice, and by 2025 all accredited programmes award a doctorate. The transition was decided in 2009 and applies at the point of admission: nurse anesthetists certified under the earlier master's standard were not required to return for a doctorate.
Programmes run about three years, are full-time, and generally forbid outside employment. Graduates sit the National Certification Examination administered by the National Board of Certification and Recertification of Nurse Anesthetists.
Keeping the credential is a structured, ongoing obligation rather than a box to tick. Certification renews on a four-year cycle with a check-in at the two-year mark, and renewal in the 2026–2027 window requires 60 continuing education credits and 40 professional development credits, alongside a periodic assessment of core knowledge.
Supervision, and the opt-out
Whether a nurse anesthetist may practise without physician supervision is governed by two separate rules that are constantly confused.
The first is state law — the practice act and the board of nursing, which in many states have never required anesthesiologist supervision at all.
The second is federal payment law. Medicare's conditions of participation for hospitals, critical access hospitals, and ambulatory surgical centres have long required that anesthesia be administered under physician supervision. In 2001 the Centers for Medicare and Medicaid Services kept that requirement but allowed a state's governor to opt out of it, after consulting the state boards of nursing and medicine and attesting that the exemption is consistent with state law and in the public interest. Iowa went first, in 2001, and more than half the states have since followed; Ohio was reported as the twenty-seventh in July 2025.
The opt-out is why a nurse anesthetist can practise independently in one state and be required to work under an anesthesiologist's direction next door despite identical certification. The argument over it — access and cost on one side, training length and safety on the other — closely resembles the argument over nurse practitioner practice authority, and turns on similarly contested research. Hodgins spent years of her own career defending nurse anesthetists in court against the claim that giving an anesthetic was practising medicine without a licence, which is the same argument in its original form.
Rural hospitals have the largest stake. Where a facility cannot recruit or afford an anesthesiologist, a supervision requirement determines whether surgery, obstetrics, and endoscopy can be offered at all. See critical access hospitals and rural and frontier nursing.
The economics
The pay is the highest in nursing and is not evenly distributed. Anesthesia is a high-revenue service, the supply of providers is constrained by a small number of demanding programmes, and hospitals in places anesthesiologists do not want to live pay a premium on top of that. Locum and independent contract work is common and pays higher still.
The costs on the other side are real: three years of full-time doctoral study without income, substantial debt, call obligations, and liability exposure in a specialty where errors are immediate and severe.
Related
- Levels of nursing
- Nurse practitioners
- Critical care nursing
- Perioperative nursing
- Critical access hospitals
- Alice Magaw
- Agatha Hodgins
Sources
- Occupational Outlook Handbook: Nurse Anesthetists, Nurse Midwives, and Nurse Practitioners — U.S. Bureau of Labor Statistics, May 2025 data. Accessed September 9, 2026.
- History of AANA — American Association of Nurse Anesthesiology, on Alice Magaw, Agatha Hodgins, the 1931 founding, and the 1945 certification examination. Accessed September 9, 2026.
- Requirements to Practice as a Nurse Anesthetist in the United States — Council on Accreditation of Nurse Anesthesia Educational Programs, on the doctoral requirement. Accessed September 9, 2026.
- Continued Professional Certification Program — National Board of Certification and Recertification of Nurse Anesthetists, on the four-year cycle and credit requirements. Accessed September 9, 2026.
- More states are changing up CRNA supervision laws — Becker's ASC Review, on Ohio as the twenty-seventh opt-out state, July 2025. Accessed September 9, 2026.
- Effects of opting out from federal nurse anesthetists' supervision requirements on anesthesiologist work patterns — Health Services Research, on the 2001 CMS opt-out rule. Accessed September 9, 2026.