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Texas Christian University 
“The Science Behind the Art” 
Volume 10 - No.2 2022 

Anesthesia eJournal - Online 
ISSN 2333-2611

Page 1

Barriers and Determinants that Influence Membership in the American Association of 
Nurse Anesthesiology 
David Samons, DNAP, CRNA
Affiliation:
AdventHealth University School of Nurse Anesthesia Graduate, Orlando, Florida 

Jissel Samons, DNAP, CRNA
Affiliation:
AdventHealth University School of Nurse Anesthesia Graduate, Orlando, Florida

Manuel Tolosa, DNAP, CRNA
Affiliation:
Department Vice-Chair and Assistant Program Administrator of AdventHealth University

Grant/Financial Support: 
None 

KEYWORDS: Membership, Nonmembers, AANA, Professional Association, CRNA

Abstract
The American Association of Nurse Anesthesiology (AANA) has a significant role in providing various benefits to 
members and advancing the profession. However, membership percentages have decreased within the last 10 years. A re-
view of the literature discovered Florida was among the states with the highest percentages of nonmembers. A scholarly 
project online survey was developed and sent to all Florida Certified Registered Nurse Anesthetists (CRNAs) with the 
help of the Florida Association of Nurse Anesthesiology (FANA). The results of the survey revealed barriers to 
member-ship included dissatisfaction with the new National Board of Certification and Recertification for Nurse 
Anesthetists (NBCRNA) Continued Professional Certification (CPC) requirements, cost of membership, and a lack of 
education about the AANA. Determinants to membership identified included the benefit of CEUs and tracking, 
professional promotion, and the AANA’s political advocacy. Sufficient information was derived to suggest implications 
and recom-mendations to help improve future research efforts and better understand the issue. 

AEJ



Texas Christian University 
“The Science Behind the Art” 
Volume 10 - No.2 2022 

Anesthesia eJournal - Online 
ISSN 2333-2611

Page 2

Membership in professional associations has a significant role 
in providing various benefits to their members as well as the 
protection and advancement of the profession. Benefits include 
advancing professional knowledge, establishing a code of ethics 
and standards of practice, promoting professional growth and 
development, and providing networking opportunities.1,2 For 
these reasons, professional associations exist in almost every field 
of study.3 In addition, members who are affiliated with a profes-
sional organization feel a sense of belonging and build interper-
sonal relationships with others involved in the group.2 Joining a 
professional association was part of one’s duty and responsibility 
in previous years. Over time, focus has shifted to personal interest 
as a primary reason for joining.2 Currently, there is evidence of a 
widespread decrease in the number of members, member involve-
ment, and retention within professional organizations.1,2,4 One 
organization of particular interest for this scholarly DNAP 
project is the American Association of Nurse Anesthesiology 
(AANA).
PROBLEM DESCRIPTION
AANA national data report,5 the total number of Certified Reg-
istered Nurse Anesthetists (CRNA) has grown by 16,905, repre-
senting a 46.3% increase from 2008 to 2018. However, the total 
number of CRNAs who are AANA members increased by only 
34.6% within that same 10-year period.5 Membership with the 
AANA allows the organization to continue to provide education, 
guidance, and fight to maintain and further the scope of practice 
for CRNAs. Therefore, a professional organization is not only 
beneficial to its members but also helps the profession to evolve. 

The State of Florida is of special interest and is one of the states 
with the most CRNAs but has one of the highest non-member-
ship percentages.1 The national average for nonmembers in 2018 
was around 12%.5 The percentage of nonmembers in Florida was 
20.7% in 2016 and increased to 26% in 2018. 1,5 Understanding 
the factors that determine member participation is crucial to 
ensure satisfied members and professional growth. This can be 
accomplished by using a survey to help gain insight into the ele-
ments that lead to retention and future involvement by CRNAs 
within their professional organization.

PICOT Search Format Questions
Two questions were developed in PICOT format to assist in a 
systematic review of the literature. The first question addressed 
the problem question: P- For licensed Certified Registered 
Nurse Anesthetists (CRNAs), I- what are barriers and 
determinants, 
O- that influence decisions to become or remain involved within
their professional organization, T- post-graduation?
A second PICOT question was developed to address a possible
innovation for FANA: P- For Florida licensed Certified Reg-
istered Nurse Anesthetists (CRNAs), I- what are barriers and
determinates, O- that influence involvement for members and
nonmembers within the American Association of Nurse Anes-
thesiology (AANA), T- post-graduation?
PROJECT AIMS
The purpose of this scholarly project was to examine the factors 
that influenced decision-making regarding professional associ-
ation membership among Florida’s licensed nurse anesthetists 

using an online survey.  A secondary aim was to delineate the 
barriers and determinants of licensed nurse anesthetists residing 
in the State of Florida to become or remain members of national 
and state professional organizations. Results were disseminated to 
the state organization and recommendations suggested to FANA.
SEARCH STRATEGY
The search strategy included PubMed and Google Scholar 
databases. A total of 917 articles were screened according to 
the title, inclusion, and exclusion criteria. Articles were exclud-
ed from the review if they were over 10 years old, pertained to 
non-professional associations, and if the type of research was not 
described in the article. Of these, 10 research articles pertaining 
to nurses, pharmacy, dentistry, chiropractors, and occupational 
therapists were retained for review. Key Search Terms included: 
“AANA membership,” AND “professional organization member-
ship,” AND “professional association membership.” MeSH terms 
included: professional organization, nurse anesthetist, CRNA, 
membership, students, and professional associations. The search 
limits that were used: within the last 10 years and in the English 
language. 
GRADE Criteria
Grading of recommendations, assessment, development, and 
evaluation (GRADE) criteria were used to rate the literature 
collected. The Working Group developed GRADE in 2000 to 
address the shortcomings of grading systems in healthcare. It has 
been used internationally and considered the standard in guide-
line development.6 The GRADE scale ranges from 1 – 9 where 
the lower numbers represent limited importance for guiding 
decisions.  Higher numbers represent more critical importance 
for guiding decisions. The literature reviewed primarily comprised 
qualitative studies (lower GRADE scores). However, many of the 
studies used quantitative measurements for qualitative data using 
number scales to give partial qualitative answers. This enabled 
statistical analysis and a more thorough understanding of data 
raising the 
GRADE score up to 4. Inconsistent control of duplicate survey 
responses, low survey responses and inconsistent data validation 
downgraded GRADE scoring to 2.  Publication bias was ruled 
out because the studies’ results would not have benefited the 
researchers or publishers. The greatest concern in this literature 
review was the lack of research specific to nurse anesthesia pro-
fessional organizations. Overall, the quality of the data collected 
was low, which further justified the need to conduct the scholarly 
project.  
LITERATURE REVIEW AND SYNTHESIS OF EVI-
DENCE
Review of the literature was performed to identify barriers and 
determinants that influence membership within the AANA. Data 
were limited specific to nurse anesthetist’s professional organiza-
tions, however, common themes and results emerged throughout 
the literature: benefits of professional membership, methods used 
to collect data, reasons why professionals do or do not join their 
professional organization, and involvement within the profession-
al organization. 



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“The Science Behind the Art” 
Volume 10 - No.2 2022 

Anesthesia eJournal - Online 
ISSN 2333-2611

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Benefits of Professional Membership
Being a member of one’s respective professional organization 
were very consistently deemed beneficial.1,4,13-15 Professional 
organizations also were reported to advance development of 
the professional, encourage leadership, advocate for members, 
influence policy, provide continuing education, provide a source 
of networking, and provide members a sense of belonging and 
identity.1,4,13-15 In general, membership was mutually beneficial for 
the individual as well as the profession. Despite the abundance 
of benefits that professional memberships offer, the percentages 
of memberships have been steadily decreasing with the newest 
members least likely to join.1,4,13,14-17

Data Collection Methods
Several common methods were used to collect data in the liter-
ature reviewed: interviews, questionnaires, and online surveys. 
Interviews although thorough and effective (phone or in-person) 
were cited to limit data collection due to time and yielded smaller 
sample sizes limiting generalization of results.1,13 Survey data 
could have offered researchers a feasible option to reach larger 
populations in less time, but also risked individuals complet-
ing more than one survey and offered low response rates.2-4,14-17 
Posting the survey on the professional organization’s webpage or 
social media account did improve response percentages.4,15,18

Reasons to Join Professional Organizations
The most common reasons for joining a professional organization 
were networking opportunities, organizational support, individual 
professional development, professional identity promotion, and 
a sense of belonging. Getting free continuing education credits 
was also a major reason why professionals chose to join or renew 
membership.1,4,13,15. The most common and significant reason for 
not joining was membership cost.1,4,13-15 Other common reasons 
included lack of time, lack of benefits, poor service, inconvenience, 
and poor value for the cost involved.4,14,15  It is also important to 
note that some nonmembers surveyed possessed a poor under-
standing of what professional organizations offer.1,4,15,18 According 
to Farina,1 an individual’s perception of value was the key deter-
minant for membership.

Professional Organization Involvement
The literature indicated membership and involvement within the 
professional organization have declined.16,17 Professional involve-
ment included mentoring colleagues, advocating for the profes-
sion, e-mailing senators, attending state and national conferences, 
and becoming politically active. 2,16,17 If the trend continues, fewer 
professionals will be involved in advocating for the profession. 
The potential reasoning behind the declining number of profes-
sionals involved within their professional organization or being 
politically active was education about impact of involvement and 
what the organization gives to members.2,17

Plan, Do, Study, Act (PDSA) Cycle
Understanding the factors that can improve membership per-
centages within the AANA is crucial to reverse the downward 
trend. Theoretical frameworks and conceptual models help guide 
and organize projects to successful completion. One model is 

the Plan, Do, Study, Act (PDSA) Cycle. This model provides 
a framework with 4 stages to help lead to improvement.19 The 
“Plan” stage involves identifying the problem to be improved, cre-
ation of PICOT questions, review of literature, assembling a proj-
ect committee, and developing the implementation tool. The “Do” 
stage is the implementation phase depicted by FANA deploying 
an online survey. The “Study” stage involves analyzing the data to 
identify key findings to meet the scholarly project’s objectives. The 
last stage is “Act.” During this stage, recommendations are made 
and disseminated based on the findings of the scholarly project.
METHODS
The scholarly project design was a mixed-methods design that 
used descriptive statistics to describe qualitative and quantitative 
data. The sample methodology was a purposive sampling method 
directed to Florida’s licensed nurse anesthetists. A survey was the 
most logical and feasible method to collect data from a large pop-
ulation for this scholarly project; it was also the most frequently 
used method found in the literature reviewed. The project’s data 
collection tool was a survey that used Likert scale questions 
to capture quantitative data. The survey also had open-ended 
fill-in-the-blank options to capture qualitative data. A validated 
survey for the data collection tool was the original goal. However, 
there was a problem finding a validated survey that was unique 
and specific to the topic’s population; after further review and 
contacting the AANA and FANA’s research department, creating 
an online survey specific to this target population that stems from 
current validated surveys was deemed the best and most reliable 
way to achieve desired results. A survey was created and face-val-
idated by three AdventHealth University (AHU) doctorate nurse 
anesthesia program (DNAP) students, one end-user CRNA, two 
DNAP faculty members, one AHU faculty member outside of 
the DNAP department, and the President of FANA.
The survey underwent pilot testing through SurveyMonkey® to 
ensure all aspects of the survey were working. Once the Insti-
tutional Review Board (IRB) of AHU approved the scholarly 
project, FANA dispersed the survey link in a recruitment e-mail. 
The survey was sent out on April 1st, 2020 and was open for 30 
days. Completion of the online survey would take approximate-
ly 15 minutes using a mix of Likert-type scale questions and 
short open-ended questions. The survey included demographic 
questions to assist in identifying members versus nonmembers. 
Inclusion criteria included all CRNAs who lived in the State of 
Florida and had a valid e-mail on file with the National Board 
of Certification and Recertification for Nurse Anesthetists 
(NBCRNA) who were willing to agree to the terms of the survey. 
Original population size was 4,180 Florida CRNAs, according 
to the most recent data received by FANA. However, FANA 
sent the survey out to 4,500 members and 1,700 nonmembers. 
Exclusion criteria included CRNAs under 18, people who were 
not Florida licensed nurse anesthetists, and CRNAs who did not 
have a valid e-mail on file.
Consent was obtained and approved by the Institutional Review 
Board of AdventHealth University. Participants were not com-
pensated individually but were given a chance to win one of 10 
Amazon $50 gift cards by entering their e-mail at the end of 
the survey. Demographic data were summarized using frequency 
counts and percentages. Descriptive analysis was used to compare 



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“The Science Behind the Art” 
Volume 10 - No.2 2022 

Anesthesia eJournal - Online 
ISSN 2333-2611

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group summaries and trends. For open-ended responses, an iter-
ative narrative review seeking keywords, concepts, and emergent 
themes was used. Originally, Chi-square tests would be used to 
compare distributions of responses between members and non-
members. However, this was not possible due to the low response 
rate from nonmembers. The sample size was determined at n=73 
with values of power at .90 and alpha at .05 level of confidence 
(XLSTAT v. 2017).

RESULTS
FANA sent out the survey to 6,200 recipients, and a total of 
237 participants submitted a survey for a response rate of 3.82%. 
There were 11 (4.64%) incomplete responses that were removed 
from the data set. An additional 13 (5.48%) responses were also 
removed because FANA identified them as a student registered 
nurse anesthetist (SRNA), or the respondent could not be identi-
fied. This cull left a final sample size of 213 responses. Out of the 
213 respondents, 88.7% (n=189) were members, 10.3% (n=22) 
were nonmember, and 0.09% (n=2) did not answer the question. 

Figure 1. Percentage of Florida CRNA Members and Nonmembers by Years of Experience.



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“The Science Behind the Art” 
Volume 10 - No.2 2022 

Anesthesia eJournal - Online 
ISSN 2333-2611

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Figure 2. Level of Education Completed by Florida CRNAs.



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“The Science Behind the Art” 
Volume 10 - No.2 2022 

Anesthesia eJournal - Online 
ISSN 2333-2611

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Quantitative Data
Due to the great discrepancy between the member and nonmember group sizes, statistical tests comparing the 2 groups were not 
plausible. The quantitative data received was used for descriptive analysis to compare group summaries and trends among members and 
nonmembers.

Figure 3. Factors Influencing Florida CRNAs to Join AANA

Nonmembers were asked about top 3 factors that influenced their decision not to join. The most frequently chosen answers were the 
cost of membership (n=14), poor value for the cost of membership (n=11), and disagreement with AANA policies and positions 
(n=8). This is shown in Figure 4.



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“The Science Behind the Art” 
Volume 10 - No.2 2022 

Anesthesia eJournal - Online 
ISSN 2333-2611

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Figure 4. Factors Influencing Florida CRNAs NOT to Join AANA.

Data also showed 12.2% (n=26) of members were not aware that being a member of the AANA made them a member of FANA. For 
the participants that were aware, the data did not show any outliers for potential barriers or determinants that influence membership.  
Participants were also given the opportunity the choose the main source of where they received information and education about the 
AANA (Figure 5). The most frequent choices were AANA Journal with 39.3% (n=83) and social media platforms with 31.8% (n=67)



Figure 5. Source of Information Regarding the AANA 

Each member (N=189) was asked to rate how satisfied they were with their AANA membership on a 4-point Likert Scale 
(4=strongly agree, 1=strongly disagree). The results yielded an average of 3.09. This is displayed in Figure 6. When asked about if they 
were planning to renew their membership, 89.2% (n=165) selected yes, 2.2% (n=4) selected no, and 8.6% (n=16) selected undecided. 

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Volume 10 - No.2 2022 

Anesthesia eJournal - Online 
ISSN 2333-2611

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Figure 6. Florida CRNAs Membership Satisfaction. 

Membership Satisfication 

I am aware of how my AANA membership dues are divided 

I feel valued by my professional organization (AANA) 

The cost of AANA dues for membership is worth the investment 

My nurse anesthesia educational program educated me on the function, 
role, purpose and benefits of being a member of the AANA. 

I am satisfied with how the AANA advocates at the federal level 

I am satisfied with the educational opportunities provided by the AANA 

The AANA is dedicated to my professional development 

I am aware of what the AANA does for Nurse Anesthesia profession 

0 0.5 1 1.5 2 2.5 3 3.5 4 

3.02 

3.04 

3.04 

3.12 

3.24 

2.97 

3.28 

3.45 

Qualitative analysis
A total of 5 open-ended survey questions enabled an iterative 
narrative review to be conducted. These questions allowed the 
participants to choose the answers listed or fill in additional an-
swers to the questions. The themes that were identified included 
benefits that members are dissatisfied with, additional factors that 
influence Florida CRNAs to join the AANA, and factors that 
influence Florida CRNAs not to join the AANA.

Benefits that dissatisfied members. The first theme that emerged 
frequently was issues surrounding the National Board of Certi-
fication & Recertification for Nurse Anesthetists (NBCRNA). 
Participants received the option to type in additional dissatisfac-
tions. The most frequent response was that most members were 
not dissatisfied with any of the benefits. Other responses included 
continuing education units (CEU) tracking, and insurance. 

A subtheme that emerged quite frequently were issues with the 
NBCRNA. While it is not a benefit, several members identi-
fied dissatisfaction with the NBCRNA Continued Professional 
Certification (CPC) program for continued certification. Some 

of the quotes included “recertification changes,” “having to retake 
boards,” “allowing NBCRNA to take over certification,” “CPC 
exam,” and “keeping informed about retaking boards & re-edu-
cation to prepare.” Some responses showed dissatisfaction with 
support from AANA about the NBCRNA. This was identified 
by comments such as “disagree with NBCRNA. No support by 
AANA” and “the AANA/FANA has not stood up for CRNAs 
against the draconian NBCRNA CPC requirements.”
Additional factors that influenced Florida CRNAs to join 
AANA. The most frequent was continuing education units 
(CEUs). The theme of political advocacy was identified as a 
re-occurring response by members. Some of the comments in-
cluded “political advocacy,” “to support our voice as CRNAs,” and 
“most importantly by far, I’m a contributing donor to the AANA 
& FANA PAC.” It was also very intriguing to see this answer 
several times, considering the other option choices. For example, 
members had the option to choose personal professional devel-
opment and promotion of the profession. These were two of the 
top three answers chosen and could be associated with political 
advocacy. However, members purposely decided to take the time 
to type in those additional responses. 

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“The Science Behind the Art” 
Volume 10 - No.2 2022 

Anesthesia eJournal - Online 
ISSN 2333-2611

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Factors that influenced Florida CRNAs not to join AANA. 
Out of the 22 nonmember participants, 5 typed in additional 
responses. Three of those responses addressed dissatisfaction 
with support from AANA and/or with the NBCRNA. This was 
identified with comments such as “disagree with NBCRNA. No 
support by AANA” and “the AANA/FANA has not stood up for 
CRNAs against the draconian NBCRNA CPC requirements.” 
One nonmember wrote, “Not standing up for [the] membership, 
delving into politics, ignoring opinions of membership.” The other 
responses were issues related to retirement and CEUs.

DISCUSSION AND IMPLICATIONS
The AANA is the largest professional organization for the nurse 
anesthesia profession that provides many benefits to its members 
and is very influential in the profession’s growth by providing a 
collective voice for CRNAs. The AANA national data shows that 
membership percentages within the AANA have decreased over 
the last ten years.5 This is very concerning because membership 
within the AANA is what helps sustain the professional organi-
zation.

Key Findings 

• Concern by members and nonmembers with NBCRNA and new CPC requirements
• Florida CRNAs with < 10 years’ experience less likely to be members AANA/FANA
• Higher degree obtained positively influenced membership within AANA/FANA
• Non-members unaware of full scope of AANA benefits
• AANA information gleaned most from AANA Journal and social media
• “Promotion of Profession” #1 reason to join AANA by members
• “Cost of Membership” #1 reason not to join AANA by non-members

RESEARCH & EDUCATIONAL IMPLICATIONS
Declining AANA membership is an important matter requir-
ing further exploration with a larger number of nonmembers 
participants. Incorporating phone interviews and social media 
recruitment strategies as part of the methodology could increase 
the number of nonmembers’ responses.  Dissatisfaction with the 
new NBCRNA CPC recertification requirements, cost of mem-
bership, and education were identified as membership barriers. 
Further research into benefits of CPC recertification and its 
contribution to professional growth and promotion would help 
educate all CRNAs. 
Lack of education about the AANA contributes to dissatisfaction 
about membership and could also be leading to higher nonmem-
ber percentages. Anesthesia schools provided the least amount 
of education regarding the AANA compared to other avenues, 
including social media and AANA Journal. A recommendation to 
increase AANA education and participation in schools is suggest-
ed. A recommendation to FANA leadership is to develop some 
type of education module or program and work with anesthesia 
programs to identify a good time and way to incorporate that 
education early on throughout an SRNAs educational journey. 
Considering SRNAs in the State of Florida are required to be 
members, this would allow them to understand better where their 
money is going and gain an education about the AANA from a 
reputable source.

LIMITATIONS 
A low response rate was an anticipated limitation, and several 
methods were developed to increase response rates (eg, recruit-
ment email, email reminders). Non-members were primarily 
the unresponsive cohort.  The survey was intended for CRNAs 
only. However, student registered nurse anesthetists (SRNAs) 
also received the link to the survey to submit a response. The 
COVID-19 pandemic was also an unexpected limitation. The 
survey was released in April, which was very early during the 
pandemic when there was so much uncertainty and fear circu-
lating about the virus. One noticeable effect it had was that it 
slowed down communication between everyone involved with the 
project. However, it is almost impossible to understand how this 
may have truly impacted the scholarly project.
The AANA is crucial for CRNAs and professional advancement. 
Understanding why membership percentages are declining is im-
portant. Major determinants that influence membership included 
benefits such as CEUs, political advocacy, and professional devel-
opment. The significant barriers to membership identified includ-
ed the cost of membership, issues surrounding NBCRNA CPC 
requirements, and overall lack of education about the AANA. 

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“The Science Behind the Art” 
Volume 10 - No.2 2022 

Anesthesia eJournal - Online 
ISSN 2333-2611

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Anesthesia eJournal - Online 
ISSN 2333-2611

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