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Texas Christian University 
“The Science Behind the Art” 
Volume 12 - No.2 2024 

 Anesthesia eJournal - Online
ISSN 2333-2611

Page 9

Occupational Turnover Factors for Certified Registered Nurse Anesthetists:  
A Scoping Review
Michael C. Lambert1, Robyn C. Ward2, and Dru Riddle3   
1.  Harris College of Nursing & Health Sciences PhD Program, Texas Christian University 
2.  School of Nurse Anesthesia, Texas Christian University  
3.  School of Nurse Anesthesia, Texas Christian University
 

Grant/Financial Support: 
None 

KEYWORDS: job satisfaction; occupational stress; organizational climate; organizational commitment; turnover intention

Abstract
The objective of this scoping review is to understand the extent and type of evidence related to occupational turnover 
factors for certified registered nurse anesthetists (CRNA) in the United States.  Demand for anesthesia services is 
increasing dramatically. CRNAs provide a significant number of anesthetics each year and are crucial to accessible 
anesthesia in the U.S. Understanding occupational turnover factors for CRNAs is vital to providing cost effective, 
reliable anesthesia services for Americans. Studies relevant to CRNA turnover in the U.S. were included for this review. 
Due to differences in education, scope of practice, and practice environment, studies involving nurse anesthetists 
outside the U.S. were excluded. Studies with mixed provider populations including physicians, registered nurses, 
other advanced practice providers, and students were also excluded. Five studies were included for data extraction. 
All the studies employed electronic or mailed questionnaires. Common factors associated with occupational turnover 
were compensation, retirement, job satisfaction, and burnout. Findings suggest that occupational turnover factors are 
multifactorial and include broad concepts such as job satisfaction, burnout, and organizational climate. 

AEJ



Introduction
According to the U.S. Bureau of Labor Statistics1, demand for 
advanced practice nurses, including certified registered nurse 
anesthetists (CRNA), is projected to increase by 45% between 
2020 and 2030. In the U.S., CRNAs deliver upwards of 50 
million anesthetics annually and are vital to accessible anesthesia 
services2. In the aftermath of the SARS-CoV-2 (COVID-19) 
pandemic, resignations among healthcare providers have reached 
unprecedented levels3. Given the tremendous cost of occupational 
turnover (hereafter referred to as turnover) in healthcare4, as 
well as evidence that turnover impacts the quality of healthcare 
delivery5, exploring the evidence related to turnover factors for 
CRNAs is important.     
A preliminary search of MEDLINE Complete and Embase 
was conducted and no current or underway systematic reviews 
or scoping reviews on the topic were identified. Results of the 
preliminary search indicated literature on the topic that met 
inclusion criteria and justified conducting a review. Exploring 
the available evidence in a scoping review format was deemed 
appropriate given the body of literature specific to CRNAs. The 
objective of this scoping review is to understand the extent and 
type of evidence in relation to turnover factors for CRNAs in the 
U.S.

Review question
What factors are associated with turnover for CRNAs in the 
U.S.? 

Eligibility criteria

Participants of interest for this scoping review are CRNAs in 
the U.S. No exclusion criteria were set for demographic variables 
such as gender, age, practice type, or geographical location 
within the U.S. If the study focused on practicing CRNAs in 
the US, it was eligible for inclusion. Exclusion criteria in the 
participant realm included studies focusing on a mix of provider 
type. For example, studies were identified that included data 
related to turnover for physicians and CRNAs. To keep within 
the boundaries of the objective for this study, literature including 
physicians, advanced practice providers other than CRNAs, 
registered nurses (RN), and students were excluded. 

Concept
Occupational turnover is the conceptual foundation for this 
review. Hanisch and Hulin6 conceptualized turnover as voluntary 
employee withdrawal from an organization. Turnover intention 
is also included as a concept as it is correlated with turnover 
behavior7. Turnover intention varies from turnover in that the 
latter is defined by the behavior of voluntary organizational 
withdrawal, while the former is a cognitive intention8. Research 
has shown that turnover intention accounts for 9%-25% of 
turnover7,9. Given the correlation between turnover intention and 
turnover, studies addressing turnover and turnover intention for 
CRNAs were eligible for inclusion. 
In the literature, turnover and turnover intention have been 
linked with a variety of factors. Occupational stress, job 
satisfaction, burnout, organizational climate, and workplace 
civility are examples of factors that have been linked to 

turnover10,11,12,13. Literature focusing on factors outside of turnover, 
while maintaining some connection to turnover, were excluded to 
maintain fidelity to the objective of this review. 
Context
Contextual inclusion criteria for this literature review were 
limited to the study setting being in the U.S. For this scoping 
review, “CRNAs” refers to nurse anesthetists practicing in 
the U.S., and “nurse anesthetists” refers to nurse anesthetists 
internationally. Preliminary review of the literature identified 
significant differences between CRNAs and nurse anesthetists 
in other countries. Examples of some of those differences are 
degree of training, scope of practice, and role overlap with 
physicians delivering anesthesia. Given that turnover factors for 
nurse anesthetists might not universally apply, studies addressing 
turnover and turnover intention in nurse anesthetist populations 
outside of the U.S. were excluded. Dissemination date was 
considered as an eligibility criterion, but no limitations were set 
on date of publication. Given the relative newness of the nurse 
anesthesia profession, any article related to turnover factors for 
CRNAs was considered for inclusion. 

Types of sources
This scoping review considered both experimental and quasi-
experimental study designs including randomized controlled 
trials, non-randomized controlled trials, before and after studies 
and interrupted time-series studies. In addition, analytical 
observational studies including prospective and retrospective 
cohort studies, case-control studies and analytical cross-sectional 
studies were considered for inclusion. This review also considered 
descriptive observational study designs including case series, 
individual case reports and descriptive cross-sectional studies 
for inclusion.  Qualitative studies were considered that focus 
on qualitative data including, but not limited to, designs such 
as phenomenology, grounded theory, ethnography, qualitative 
description, action research and feminist research. In addition, 
systematic reviews that met the inclusion criteria were also 
considered, depending on the research question. Text and opinion 
papers were not considered for inclusion in this scoping review. 
The rationale here was preliminary review of the literature 
indicated a sufficient research-based body of literature to exclude 
text and opinion papers. 
Methods
The proposed scoping review was conducted in accordance with 
the JBI methodology for scoping reviews14.
Search strategy
The search strategy’s aim was to locate published studies. An 
initial limited search of MEDLINE Complete and Embase 
was undertaken to identify articles on the topic. The text words 
contained in the titles and abstracts of relevant articles, and the 
index terms used to describe the articles were used to develop 
a full search strategy for MEDLINE Complete and Embase. 
Keywords for the search included nurse anesthetist, CRNA, 
burnout, job satisfaction, occupational stress, turnover, turnover 
intention, intent to quit, moral injury, moral distress, job 
retention, and job engagement. The search strategy, including 
all identified keywords and index terms, was adapted for each 

Texas Christian University 
“The Science Behind the Art” 
Volume 12 - No.2 2024 

 Anesthesia eJournal - Online
ISSN 2333-2611

Page 10



included database and information source. The reference list of 
all included sources of evidence were also screened for additional 
studies. Studies published in English were included. No date 
range limitations were set for study inclusion. Databases searched 
include MEDLINE Complete and Embase. 
Study/source of evidence selection
Following the search, all identified citations were collated and 
uploaded into EndNote 20.4.1/2021 (Clarivate Analytics, PA, 
USA) and duplicates removed. Following a pilot test, titles and 
abstracts were then screened independently by each of the authors 
for assessment against the inclusion criteria for the review. 
Potentially relevant sources were retrieved in full. The full text 
of selected citations was assessed in detail against the inclusion 
criteria by each of the authors. Reasons for exclusion of sources of 
evidence at full text that did not meet the inclusion criteria were 
recorded and are reported below. Any disagreements that arose 
between the reviewers at each stage of the selection process was 
resolved through discussion. 
Data extraction
Data was extracted from papers included in the scoping review 
by two independent reviewers using the Joanna Briggs Institute 
( JBI) scoping review data extraction template15. The data extracted 
included specific details about the participants, concept, context, 
study methods and key findings relevant to the review questions. 
Methodological quality or risk of bias was not appraised, 
consistent with guidelines for scoping review conduct16. 
Results 
Initial results of the search returned a total of 508 items. After 
removal of duplicates, 317 articles were screened. 247 articles 
were excluded as not related based on appraisal of title or abstract. 
70 articles were obtained in full for review. Of the 70, 34 articles 
were excluded due to a focus on nurse anesthetists outside of the 
U.S. Of the remaining 36, 22 were excluded after review of the 
full text due to not relating to turnover factors. 9 articles were 
excluded after review, due to either the inclusion of other types 
of providers or focusing on factors loosely related to turnover 
(eg, occupational stress or job satisfaction). In total, five articles 
underwent data extraction for inclusion in this review. 
Characteristics of sources of evidence
Three of the articles were disseminated between 2020 and 
202217,18,19. One was published in 200720, with the final article 
being published in 199021. Four of the five studies were based on 
data obtained from mailed or electronic surveys18,19,20,21, with one 
being secondary analysis of data collected via electronic survey17. 
All the studies were based in the U.S., dealt with turnover and/
or turnover intention, and the studied population was limited 
to practicing CRNAs. Two of the studies included data from 
CRNAs across the U.S.17,19, two were limited to geographical 
regions in the U.S.18,21, with one being limited to CRNAs 
practicing in the Department of Veterans Affairs20. 
Factors associated with turnover and turnover intention
Each article presented factors associated with turnover and or 
turnover intention differently. Factors are presented here in order 
of number of articles associating it with turnover. This order is 

not intended to indicate ranking or level of importance as not 
each article ranked factors in terms of impact on turnover or 
turnover intention. Turnover factors for CRNAs most frequently 
cited in the literature included for this review were compensation, 
retirement, job satisfaction, and burnout.
Compensation was a factor associated with turnover or 
turnover intention in each of the articles17,18,19,20,21. “Better pay” 
was the terminology used in three of the studies17,18,19, with “pay 
satisfaction”21 and “non-competitive salaries”20 being other terms 
used. Compensation was the only factor identified in each of the 
articles.
Retirement as a factor for turnover or turnover intention 
was identified in four of the articles17,18,19,20. Job satisfaction was 
associated with turnover in three of the articles18,19,21. Burnout was 
identified as a factor in turnover, or turnover intention, in three of 
the articles17,18,19. Career advancement as a factor for turnover was 
identified in three of the articles17,19,21. The terminology associated 
with career advancement varied, with the following terms being 
represented in the studies included in this review: “promotion” 
and “career advancement”17, “advance position”19 (as a reason for 
leaving), and “promotion satisfaction”21. Better working conditions 
was identified as a factor for turnover in two of the articles18,19. 
Finally, geographic relocation was listed as a factor for turnover in 
two articles17,19. 
Other factors associated with turnover and/or turnover intention 
were more specific and did not share categorization similarities 
between studies. The list of all these factors is too broad to 
incorporate here, but examples are role ambiguity and role 
restraints, incompetent leadership, limited scope of practice, 
dissatisfaction with schedule, stressful work environment, and 
inadequate staffing17,19. Broader concepts like job satisfaction and 
burnout were also associated with turnover19.       
Discussion
The major finding of this scoping review is that turnover factors 
for CRNAs are multifactorial. Compensation, retirement, job 
satisfaction, burnout, career advancement, and geographic 
relocation were cited across the literature as turnover factors for 
CRNAs in the U.S. However, this evidence indicates that not 
just one of the above factors alone is responsible for turnover 
or turnover intention in CRNAs. For example, Dexter et al17(p487) 
found that CRNAs who had left their position provided 2.5 
“primary” reasons for quitting, and CRNAs who had considered 
leaving their positions had an average of 3.7 primary reasons.
Another finding of this scoping review is that the broad concepts 
of job satisfaction and burnout have a multitude of indicators 
that impact turnover and turnover intention. Mahoney et al19 
found that burnout and job satisfaction were determined by 
job and personality characteristics. Examples of some of those 
characteristics were autonomy, skill variety, agreeableness, age, 
and hours worked per week. Lea et al18 reported that burnout 
was associated with a decrease in job satisfaction, which 
contributed to turnover intention. Factors identified by Lea et 
al18 as contributing to burnout were job feedback (more feedback 
decreasing burnout), CRNA and administration relations 
(better relations decreasing burnout), and work and personal 
responsibility conflicts (conflicts resolved in favor of work 
increasing burnout).   

Texas Christian University 
“The Science Behind the Art” 
Volume 12 - No.2 2024 

 Anesthesia eJournal - Online
ISSN 2333-2611

Page 11



Organizational climate is another concept that deserves mention. 
Lea et al18 and Szigeti et al21 both mention organizational 
conditions or climate as a factor in turnover. Sein Myint et al22(p175) 
define organizational climate as, “a shared perception about an 
organization by its workforce”. Lea et al18(p145) tie this concept 
into turnover in the following statement, “The degree to which 
an organizational climate values, supports, communicates, and 
collaborates with CRNAs was a significant predictor of burnout 
and resultant changes in job satisfaction and turnover intention”. 
Szigeti et al21(p324) state, “The organizational or work conditions 
variables—i.e., role ambiguity, opportunity to participate, and 
performance constraints—were moderately related to intention 
to quit”. What these statements suggest is that the concept of 
organizational climate, with its varied indicators, plays a role in 
turnover intention. These findings have implications for practice.
Perhaps the biggest implication for practice is that preventing 
turnover requires a multifaceted approach from organizations. To 
synthesize the findings into practice implications, categorization 
of the myriad factors might be useful. For example, retirement 
and geographical relocation could be categorized as personal 
factors. Factors such as better pay, career advancement, job 
satisfaction, and burnout could be categorized under the 
umbrella concept of organizational climate. Even though 
organizations might not ultimately be able to prevent attrition 
secondary to personal factors (i.e., retirement or employees 
choosing to relocate), this evidence suggests that efforts to ensure 
competitive compensation, and an organizational climate that 
minimizes burnout and maximizes job satisfaction, are valuable 
considerations to mitigate turnover. 
These findings are also useful as they suggest future directions 
for research. Exploring the overlap between the concepts of job 
satisfaction, burnout, and organizational climate would help 
define conceptual boundaries and areas of overlap, as well as 

elucidate their relationship with turnover. To our knowledge, no 
qualitative studies have been conducted on turnover and turnover 
intention for CRNAs in the U.S. Qualitative research, with its 
exploration of the lived experience of participants, may be useful 
in providing a more textured understanding in this area.  
This scoping review is not without limitations. First, the studies 
included in this review used disparate approaches to address 
factors associated with turnover, thus, the findings are not 
generalizable beyond the scope of the initial study. Second, 
CRNA populations studied in this body of literature varied, 
resulting in findings that may not apply to CRNAs in the U.S. 
at large. Finally, all but one of the studies18, was based on data 
collected prior to the COVID-19 pandemic, the impact of which 
on turnover in healthcare is still an area of active research, and 
thus may not reflect COVID-19 associated factors involved in the 
unprecedented turnover currently being experienced in healthcare. 
Conclusion
The objective of this study was to explore the extent and type of 
literature related to turnover factors for CRNAs in the U.S. To that 
end, this scoping review found that turnover factors for CRNAs 
are myriad, with compensation, retirement, job satisfaction, and 
burnout being the most frequently mentioned factors in the 
literature included for this review. Broad concepts such as burnout, 
job satisfaction, and organizational climate were also associated 
with turnover in this body of literature. The broad nature of these 
concepts, with overlap between them, suggest the value of future 
research in this area. Qualitative research in this area might also 
be of value in addressing gaps in the qualitative body of literature. 
Finally, practice implications from this scoping review indicate that 
organizational efforts in the areas of competitive compensation and 
a positive organizational climate may be rewarded with a decrease 
in turnover for CRNAs they employ.

Texas Christian University 
“The Science Behind the Art” 
Volume 12 - No.2 2024 

 Anesthesia eJournal - Online
ISSN 2333-2611

Page 12



References
1. Bureau of Labor Statistics, U. S. Department of Labor. Nurse anesthetists, nurse midwives, and nurse practitioners. Occupational 

Outlook Handbook Web site. https://www.bls.gov/ooh/healthcare/nurse-anesthetists-nurse-midwives-and-nurse-practitioners.
htm. Accessed August 18, 2022.

2. American Association of Nurse Anesthesiology. Certified registered nurse anesthetists fact sheet. https://www-aana-com.
ezproxy.tcu.edu/membership/become-a-crna/crna-fact-sheet#:~:text=Prolific%20Providers%3A%20CRNAs%20are%20
anesthesia,trusted%20professions%20according%20to%20Gallup. Updated 2022. Accessed August 18, 2022.

3. Bureau of Labor Statistics, U. S. Department of Labor. Number of quits at all-time high in November, 2021. The Economics 
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18, 2022.

4. Waldman JD, Kelly F, Arora S, Smith HL. The Shocking Cost of Turnover in Health Care. Health care management review. 
2004;29:2-7.

5. Zaheer S, Ginsburg L, Wong HJ, Thomson K, Bain L, Wulffhart Z. Acute care nurses’ perceptions of leadership, teamwork, 
turnover intention and patient safety - a mixed methods study. BMC nursing. 2021;20(1):1-134.

6. Hanisch KA, Hulin CL. General attitudes and organizational withdrawal: An evaluation of a causal model. J Vocat Behav. 
1991;39(1):110-128.

7. Cho YJ, Lewis GB. Turnover intention and turnover behavior: Implications for retaining federal employees. Review of public 
personnel administration. 2012;32(1):4-23.

8. Tett RP, Meyer JP. Job-satisfaction, organizational commitment, turnover intention, and turnover - path analyses based on meta-
analytic findings. Person Psychol. 1993;46(2):259-293.

9. Dalton DR, Johnson JL, Daily CM. On the use of “intent to...” variables in organizational research: An empirical and cautionary 
assessment. Human relations (New York). 1999;52(10):1337-1350.

10. Alves SL. A study of occupational stress, scope of practice, and collaboration in nurse anesthetists practicing in anesthesia care 
team settings. AANA J. 2005;73(6):443-452.

11. Boyd D, Poghosyan L. Measuring certified registered nurse anesthetist organizational climate: Instrument adaptation. J Nurs 
Meas. 2017;25(2):224-237.

12. Elmblad R, Kodjebacheva G, Lebeck L. Workplace incivility affecting CRNAs: A study of prevalence, severity, and consequences 
with proposed interventions. AANA J. 2014;82(6):437-445.

13. Thompson L. Job satisfaction of nurse anesthetists. AANA J. 1981;49(1):43-51.

14. Tricco AC, Lillie E, Zarin W, et al. PRISMA extension for scoping reviews (PRISMA-ScR): Checklist and explanation. Ann 
Intern Med. 2018;169(7):467-473.

15. Joanna Briggs Institute. JBI manual for evidence synthesis. JBI Web site. https://synthesismanual.jbi.global/. Updated 2022. 
Accessed August 26, 2022.

16. Peters MDJ, Marnie C, Tricco AC, et al. Updated methodological guidance for the conduct of scoping reviews. JBI evidence 
synthesis. 2020;18(10):2119-2126.

17. Dexter F, Epstein R, Elhakim M, O’Sullivan C. US survey of incidence of and reasons for nurse anesthetists leaving or having 
considered leaving their jobs. AANA J. 2021;89(6):484-490.

18. Lea J, Doherty I, Reede L, Mahoney CB. Predictors of burnout, job satisfaction, and turnover among CRNAs during COVID-
19 surging. AANA J. 2022;90(2):141-147.

19. Mahoney CB, Lea J, Schumann PL, Jillson IA. Turnover, burnout, and job satisfaction of certified registered nurse anesthetists in 
the united states: Role of job characteristics and personality. AANA J. 2020;88(1):39-48.

20. United States. Government Accountability Office. VA health care: Many medical facilities have challenges in recruiting and 
retaining nurse anesthetists : Report to congressional requesters. 2007. https://go.exlibris.link/wgCrcPrG.

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“The Science Behind the Art” 
Volume 12 - No.2 2024 

 Anesthesia eJournal - Online
ISSN 2333-2611

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21. Szigeti E, Largent RN, Eberhardt BJ. An exploratory study of the correlates of intent to quit among certified registered nurse 
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Appendices

Figure 1: Prisma Diagram

From:  Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated 
guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71

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Texas Christian University 
“The Science Behind the Art” 
Volume 12 - No.2 2024 

Records identified from:

Databases (n = 508)

Registers (n = 0)

Records removed before screening:
Duplicate records removed  (n = 
191)

Records screened
(n = 317)

Records excluded based on abstract 
or title relevance
(n = 247)

Reports sought for retrieval
(n = 70)

Reports not retrieved
(n = 0)

Reports assessed for eligibility
(n = 70)

Reports excluded (n = 65)

Specific to international nurse 
anesthetists (n = 34) 

Not related to occupational 
turnover factors (n = 22)

Mixed provider studies or related 
to loosely related factors (n = 9)

Studies included in review
(n = 5)



Appendix 2

Table 1.
Factors Associated with CRNA Occupational Turnover 
Study Factors
Dexter et al, 202117 Better pay/benefits, burnout, lack of good management/

leadership, inability to practice to the full extent of my 
license, retirement, scheduling, interpersonal differences, 
stressful work environment, promotion, inadequate staffing, 
geographic relocation, lack of advancement opportunities, 
career change, physical demands of the job

Leah et al, 202218 Burnout, job satisfaction, better working conditions, better 
pay, retirement

Mahoney et al, 202019 Better working conditions, retirement, better pay, geographic 
relocation, promotion, job satisfaction, burnout

United States, Government 
Accountability Office, 200720

Salaries not competitive

Szigeti et al, 199021 Overall satisfaction, pay, promotion, role ambiguity, role 
constraints

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“The Science Behind the Art” 
Volume 12 - No.2 2024 


