UTAH S. A Study on. APRNs. in Utah. Clark. Sri Koduri. Prepared by: Association the. Midwives

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2 UTAH S ADVANCED PRACTICE REGISTERED NURSE WORKFORCE, 2013: A Study on the Supply and Distribution of APRNs in Utah The Utah Medical Education Council State of Utah Prepared by: Clark Ruttinger & Sri Koduri Sponsored by the Utah Medical Education Council, the Utah Nurse Practitioners Association and the Utah Affiliate of the American College of Nurse Midwives

3 Utah s Advanced Practice Registered Nurse Workforce, 2013: A Study of the Supply and Distribution of APRNs in Utah Copyright 2013 by the Utah Medical Education Council All Rights Reserved Printed in the United States of America Internet Address: This publication cannot be reproduced or distributed without permission. Please contact the UMEC at juolson@utah.gov or call (801) for permission to do so. Suggested Citation: Utah Medical Education Council (2013). Utah s Advanced Practice Registered Nurse Workforce, 2013: A Study of the Supply and Distribution of APRNs in Utah. Salt Lake City, UT.

4 THE UTAH MEDICAL EDUCATION COUNCIL The Utah Medical Education Council (UMEC) was created in 1997 by H.B.141 out of a need to secure and stabilize the state s supply of healthcare clinicians. This legislation authorized the UMEC to conduct ongoing healthcare workforce analyses and to assess Utah s training capacity and graduate medical education (GME) financing policies. The UMEC is presided over by an eight member board appointed by the Governor to bridge the gap between public/private health care workforce and education interests. Our Mission: To promote healthcare workforce planning, production, and policy through assessment, innovation, and collaboration with stakeholders Our Vision: The Utah Medical Education Council holds assessment, collaboration, and innovation as its core values and focuses on the interdependency of the three to promote healthcare workforce planning, production, and policy based upon the community's healthcare workforce needs. Core Responsibilities Healthcare Workforce Assess supply and demand Advise/develop policy Seek and disburse Graduate Medical Education (GME) funds Facilitate training in rural locations Products Partnerships public/private Reports healthcare workforce Models workforce and financial Program(s) expansion rural and urban Funds Management Privately funded programs expansion, Medicaid GME and rural training site expansion. Impact/ Accomplishments Economic o $3 million annually to expand GME training from public/private partnership o $6 million annually in Medicaid GME funding statewide

5 Workforce o Increased the number of interns and residents trained in Utah programs by 38%, about 200 positions, over the past ten years o Increased rural health care workforce and education, including establishment of new rural surgery program; rural family medicine fellowship; and rural rotations in dental, emergency medicine, obstetrics/gynecology, pathology, pediatrics, psychiatry, and surgery o Preserved both child and adult psychiatric training programs o Received the only national GME demonstration project awarded by CMS Current Areas of Focus Retention of Utah trained healthcare workforce Facilitate rural training opportunities Strengthen public/private partnerships Members of the UMEC include: CHAIR Vivian Lee, M.D. Dean School of Medicine University of Utah ACTING CHAIR Wayne M. Samuelson M.D. Vice Dean for Education School of Medicine University of Utah VICE-CHAIR Douglas Smith, M.D. Institutional Sponsor Member Associate Chief Medical Officer Intermountain Healthcare John Berneike, M.D. Institutional Sponsor Member Director Family Practice Residency Program Utah Health Care Institute Gar Elison Public Member Former Executive Director, UMEC Larry Reimer, M.D. Institutional Sponsor Member Associate Dean School of Medicine University of Utah Larry V. Staker M.D. Health Insurance Industry Member Chief Medical Officer and Medical Director Deseret Mutual Benefits Administrators Sue Wilkey, DNP Public Member Associate Prof. Rocky Mountain University of Health Professions Mary Williams, PhD, RN Public Member Associate Dean- Graduate Studies Brigham Young University College of Nursing

6 ACKNOWLEDGEMENTS This study of Utah s advanced practice registered nurse workforce is based on a survey completed in 2011 by the Utah Medical Education (UMEC) with assistance from the Utah Division of Occupational and Professional Licensing (DOPL). Special thanks to the Utah Nurse Practitioners Association and the Utah Affiliate of the American College of Nurse Midwives for their co sponsorship of this study. Additional support was provided by the Utah Association of Nurse Anesthetists, the University Of Utah College Of Nursing, Westminster College of Nursing, Brigham Young University College of Nursing and the Utah Organization of Nurse Leaders. The UMEC would like to thank its staff for their assistance and the following members of the advanced practice registered nurse workforce advisory committee, for their time and expertise in developing this report: COMMITTEE CHAIR Deanne Williams, CNM, MS Advanced Practice Clinical Coordinator Intermountain Healthcare Urban Central Region COMMITTEE VICE CHAIR Julie Balk, DNP, APRN, FNP-BC, CNE. Past President Utah Nurse Practitioner Association Kelleen Brown, MSN, APRN, ACNS-BC, OCN Adult Health Clinical Nurse Specialist Intermountain Healthcare- Utah Valley Regional Medical Center Donna Freeborn PhD, FNP-BC, CNM Coordinator, FNP Program Brigham Young University College of Nursing Theresa Garrett RN, MS Division Director, Disease Control and Prevention Utah Department of Health Christine Kapsa, NP Director of Care Management Public Employees Health Plan Maureen Keefe, RN, PhD, FAAN Dean of Nursing University of Utah College of Nursing Sheryl Steadman, PhD, MSN, BSN. Dean- Westminster College School of Nursing and Health Sciences James Stimpson, CRNA, DNP Past President Utah Association of Nurse Anesthetists

7 TABLE OF CONTENTS LIST OF FIGURES... 5 LIST OF TABLES... 6 EXECUTIVE SUMMARY... 1 POLICY RECOMMENDATIONS... 1 METHODOLOGY... 4 LICENSE DATA... 4 DESIGN OF SURVEY INSTRUMENT... 4 DATA COLLECTION... 4 DATA ENTRY AND ANALYSIS... 5 SURVEY LIMITATIONS... 5 RESTRUCTURE OF 2003 DATA... 6 INTRODUCTION... 7 LICENSED IN UTAH... 8 DECISION TO PRACTICE IN UTAH CERTIFICATION UPBRINGING DEMOGRAPHIC CHARACTERISTICS AGE GENDER PREVIOUS RN EXPERIENCE EDUCATION BACKGROUND NURSING FACULTY RACE INCOME INCOME BY GEOGRAPHY RETIREMENT PRACTICE CHARACTERISTICS GEOGRAPHIC DISTRIBUTION PROVIDER MIX WITH PHYSICIANS AND PAS PRACTICING IN HEALTH PROVIDER SHORTAGE AREAS PRACTICE SETTING... 35

8 PRACTICE SETTING BY SPECIALTY PRIMARY CARE VS. SPECIALTY CARE WORK HOURS PATIENT VISITS AGE RANGES OF PATIENTS PROVIDER ACCESSIBILITY INSURANCE PAYER TYPE UNINSURED PATIENTS SCOPE OF PRACTICE RESTRICTIONS PRACTICE RESTRICTIONS PRACTICE AND REFERRAL PLANS CONSULTATION AND REFERRAL PLANS NATIONAL COMPARISON ON SCOPE OF PRACTICE PRECEPTING WORKFORCE SUPPLY AND DEMAND FACTORS POPULATION GROWTH INCREASED DEMAND DUE TO AGE POLARIZATION UTAH S APRN TRAINING CAPACITY RETENTION OF APRNS WITH UTAH TIES WORKFORCE PROJECTIONS CNS/CRNA PROJECTIONS CNM/NP PROJECTIONS CNM/NP SUPPLY AND DEMAND FACTORS CONCLUSION POLICY RECOMMENDATIONS RECOMMENDATION I. IMPROVE DATA GATHERING AND INFORMATION INFRASTRUCTURE RECOMMENDATION II. STUDY THE INTERPLAY OF APRN & HEALTH REFORM IN THE U.S RECOMMENDATION III. SUPPORT EFFORT TO MAKE APRN WORKFORCE REPRESENTATIVE OF THE POP RECOMMENDATION IV. INCREASE AVAILABILITY OF TRAINING SITES, FACULTY AND PRECEPTORS RECOMMENDATION V. INVEST IN RURAL WORKFORCE DEVELOPMENT APPENDIX A SURVEY INSTRUMENT APPENDIX B ACRONYM AND ABBREVIATION GUIDE APPENDIX C BIBLIOGRAPHY... 90

9 LIST OF FIGURES Figure 1: Total Licensed/ Practicing in State 2003 to Figure 2: All Utah APRN Licenses by Issue Year All vs. Currently Active Figure 3: Certified Nurse Midwifes Licenses Issued, Actively Practicing and National Certification trends 2003 to Figure 4: Certified Registered Nurse Anesthetist Licenses in Utah All vs. Currently Active and National Graduates by Issue Year Figure 5: Nurse Practitioner/ Clinical Nurse Specialist Licenses by Issue Year All vs. Currently Active Figure 6: upbringing setting of APRNs working in Rural areas Figure 7: Utah CNM Age Profiles 2003 to Figure 8: CNS Age Profiles 2003 to Figure 9: CRNA Age Profiles 2003 to Figure 10: NP Age Profiles 2003 to Figure 11: Utah s APRN workforce compared to Utah Population by race Figure 12: FTE Adjusted Annual Gross Income of APRNs in the Utah Workforce Figure 13: Average FTE Adjusted APRN Income by Rural/Urban Primary Practice Setting Figure 14: Number of Years Until Intended Retirement by License Category Figure 15: Number of Years to Intended Retirement by Age Figure 16: Utah HPSA Designated Counties Only Including Primary Care MDs Figure 17: Utah HPSA Designated Counties Including PAs, and APRNs Reimbursed at 100% Figure 18: Utah APRN Work Hours In Comparison to National APRN Work Hours Figure 19: Reported APRN Practice Restrictions Figure 20: CNM Practice and Referral Plans Figure 21: CNM/NP Consultation and Referral Plans Figure 22: 2013 Nurse Practitioner State Practice Environment Figure 23: Preceptor supply of Utah APRNs Figure 24: CNS/CRNA FTE Growth Projection Figure 25: Average Annual CNM Workforce Growth beyond Demand factors Figure 26: Average Annual NP Workforce Growth beyond Demand factors Figure 27: 6.5% of Service Population Visits CNM Figure 28: Most Likely Scenario 11.2% of Service Population Visits CNM Figure 29: 16% of Service Population Visits CNM Figure 30: 22.2% of Population Visits NP Figure 31: Most Likely Scenario 38.4% of Population Visits NP Figure 32: 54.6% of Population Visits NP... 76

10 LIST OF TABLES TABLE 1: PERCENT OF WORKFORCE PRACTICING IN STATE 2003 TO Table 2: Percent Change in Workforce 2003 to Table 3: Factors Influencing Decision to Practice in Utah Table 4: Utah CNM Certifications Table 5: Utah CNS Certifications Table 6: National NP Cert. Breakdown Table 7: Utah NP Certifications Table 8: Average Ages of APRNs 2003 to Table 9: APRN Workforce by Age 2003 to Table 10: APRNs in Utah by Gender and License Category 2003 to Table 11: Average Number of Years of RN Experience Before Beginning an Advanced Practice Training Program by License Category and Gender Table 12: Age of APRNs at Graduation Table 13: Highest Degree achieved by Utah APRNs Table 14: Utah Nursing Faculty Table 15: Faculty/ teaching status of Utah APRNs Table 16: Av. Median FTE Adjusted Income for APRNs in Utah 2003 to Table 17: Average Age at Retirement 2003 to Table 18: Reported Weekly Hours Worked in 2011 for APRNs retire in 5 years or less in Table 19: Percent of 2003 Survey Respondents Who Reported Intention to Retire in 5 years and within 5 10 years and Percent of those that actually Retired Table 20: Number and Percent of 2011 Survey Resp. Intending to Retire Within 10 Years Table 21: APRNs By Rural/ Urban Primary Practice Setting Table 22: Male APRNs in the Rural workforce 2003 to Table 23: APRN Primary Practice Location By County Table 24: Change in Utah APRNs by County 2003 to Table 25: Physician, PA and Population to APRN ratios by rural/urban setting Table 26: Physician, PA and population to APRN Ratios in Rural and Urban Counties Table 27: Primary Work Settings for APRNs in Table 28: Secondary Work Settings for APRNs Table 29: Changes in Primary Work Settings for APRNs 2003 to Table 30: Median FTE Adjusted Income by work setting Table 31: Hourly Wage Ranges by Work Setting Table 32: CNM Specialties by work setting Table 33: CRNA Specialties by Work Setting Table 34: CNS Specialties by Work setting Table 35: NP Specialties by Work Setting... 44

11 Table 36: NP Specialty changes 2003 to Table 37: Utah NPs working in core physician primary care specialties Table 38: NP Primary Care/ Specialty Care by work setting Table 39: Average (Mean) hours worked per week by Activity Table 40: Hours worked per week Table 41: Average Patient Visits per Week per APRN FTE Table 42: Average Patient Visits per week per APRN FTE Table 43: Change in Average Patient Visits per APRN FTE 2003 to Table 44: FTE Adjusted In/Out Patients visits per week by Primary and Specialty Care APRNs.. 50 Table 45: FTE adjusted In/Out Patients seen per week by Specialty Table 46: Age ranges of in/out patients for Utah APRNs Table 47: Average Patient Wait time to first appointment/ Follow up care for CNMs and NPs. 53 Table 48: Average NP Patients Wait Time for Primary and Specialty Care Providers Table 49: Accepting new patients by payer type Table 50: Insurance Payer Type by Primary and Secondary Practice Setting Table 51: Services offered to uninsured patients by CNMs and NPs Table 52: Provider to 100,000 Population Ratios from 2003 to Table 53: Utah BRFSS Annual visit Rates to A medical Provider Table 54: Utah APRN Training Program Graduates per Year Table 55: Location of APRN Training for Utah APRNs Table 56: Location of Training by Utah Ties for Utah APRNs Table 57: CNS/CRNA workforce Projection Factors Table 58: CNM/NP Workforce Projection Factors Table 59: CNM/NP Annual Supply and Demand Factors... 69

12 EXECUTIVE SUMMARY Utah s APRN workforce has grown since 2003 when the last UMEC survey of the workforce was conducted. As of December 2010 there were a total of 1,692 APRNs licensed in the state of Utah. This number consists of 151 (8.9%) APRNs licensed as CNMs, 231 (13.6%) licensed as CRNAs and 1,310 licensed as APRNs. Of those licensed as APRNs our survey estimates that 1,229 (72.6%) are working as NPs and approximately 81 (4.8%) are working as Clinical Nurse Specialists (CNSs), Of all the APRNs licensed in Utah, 84.7% (1433) provide health care services in the state (pg. 8). The 2011 advanced practice nurse survey received 1,159 responses, (a 68.5% response rate). Such a high response rate allows the analysis of this survey to be highly accurate. The accuracy has a confidence interval of 95% +/ 2%. Survey responses were weighted with a factor of 1.45 to account for non respondents (pg. 4). Overall, the APRN workforce has grown slightly older since The average overall age for an APRN practicing in Utah in 2011 is 47. However, when broken down by license type CNM, CNS and NP average ages have increased (4%, 6% and 2% respectively) and CRNA average age has decreased ( 4%) since 2003 (pg. 15). Adjusted for inflation and FTEs, overall APRN incomes have declined by 5% over time from 2003 to 2011 (pg. 23). Practice location has an effect on income of CNMs and CRNAs but not of NPs and CNSs. Differences in income based on practice location may be caused by a wide variety of factors such as differing demand for primary care providers, the use of midwives and anesthetists over OB/GYNs and anesthesiologists in rural areas, and differences in how insurance pays providers in rural vs. urban areas. There are 9% (12) of CNMs in comparison to 8% (23) of OB/GYNs practicing in rural Utah. There are 27% (49) of CRNAs in comparison to 4% (16) of anesthesiologists (UMEC Physician Workforce Report, 2012) practicing in rural Utah. In addition, 75% (54) of NPs work in primary care in rural areas of the state whereas in urban areas, 47% (295) of NPs work in primary care (pg. 25). In 2003 the average self reported age of an APRN practicing in Utah at retirement was 61 years old. In 2011 it has risen 11.4% to 68 years old (pg. 26). In 2003, 11% (103) of the APRN workforce reported a rural primary practice site. In 2011, 10% (143) of the Utah APRN workforce reported their primary practice site in a rural county. In comparison, 15% of Utah s population lives in a rural county (pg. 28). 1

13 There are an average of.20 APRNs per physician and.91 APRNs per PA in rural counties of the state. There are 426 physicians, 157 PAs and 143 APRNs working in rural areas of the state. In urban areas of the state there are.21 APRNs per physician and 2.35 APRNs to every PA. There are 5,570 physicians, 267 PAs and 1,219 APRNs working in urban areas of the state. (pg. 32). Utah currently has 15 counties designated as Health Provider Shortage Areas (HPSAs) by the federal government. This means that there is less than 1 Physician FTE per 3,000 people in the county. If HPSA calculations included PA and APRN clinicians who are practicing in these counties and that are reimbursed by Medicaid at a 100% rate, the number of counties having less than 1 clinician FTE per 3,000 people would fall to six (pg. 33). An average of 36% (513) of APRNs work in hospitals in Utah. This is the most common work setting for APRNs across the board. The next most common settings vary by license type. For CNMs it is in a physician practice group (16.9%, 22), for CNSs, there is a tie (21.8%, 18) between being self employed and working in a non hospital based outpatient clinic (NHBOC). For CRNAs it is at a free standing surgery center (14.5%, 26). Like CNMs, a physician practice group is also the next most common place (23.6%, 245) for NPs to work (pg. 36). Thirty five percent of Utah s NPs (364) work in primary care compared to 44.2% (280) of Utah PAs and 36% (2,136) of Utah physicians, according to data from the most recent UMEC studies on these workforces. Primary care is defined as providers whose specialty is in family practice, internal medicine, pediatrics and obstetrics/gynecology. According to the American Journal for Nurse Practitioners 2011 Pearson report, an estimated 30 to 35% of NPs in the country work in primary care (pg. 46). APRNs in Utah work an average of 37.9 hours a week. CNMs average the largest number of hours working in primary care (28.9). CNSs average the largest number of teaching hours (5.1). NPs average equal time (16.2 hours per week in each) between primary and specialty care (pg. 47). APRNs tend to see more outpatient visits than inpatient visits. Overall, APRNs in Utah average 20 inpatient visits and 54 outpatient visits per FTE per week. NPs report the most in and out patient visits per FTE per week (26 inpatients and 62 outpatients). CRNAs report the fewest (30) outpatient visits per FTE per week and CNMs report fewest (7) inpatient visits per FTE per week (pg. 49). An overall average of 34% of APRN patients are covered by private insurance as the option that covers the largest percent of APRN patients. For CNMs, the next largest portion of patients is covered by Medicaid (31%). CNSs are tied with self pay/ uninsured and Medicaid as the second largest insurer of their patients (19%). For CRNAs, the second largest portion of their patients is 2

14 covered by Medicare (23%). NPs are also nearly tied with 20% and 19% of their patients having Medicare and Medicaid respectively (pg. 55). It is estimated that the CNM workforce will possibly increase by up to two CNMs per year beyond what is needed to account for annual average demand factors or it will fall below what is needed to account for demand factors by up to an average of three CNMs per year depending on variability in the factors of population utilization and provider productivity (pg. 71). It is estimated that the NP workforce will possibly increase by between seven and thirty nine NPs per year beyond what is needed to account for annual average demand factors depending on variability in the factors of population utilization and provider productivity (pg. 71). 3

15 POLICY RECOMMENDATIONS RECOMMENDATION I. IMPROVE DATA GATHERING AND INFORMATION INFRASTRUCTURE. UMEC data is primarily supply side information. To provide an accurate picture of the need for APRNs, there is a palpable need for demand side data. To rectify this: a) The UMEC should collaborate or facilitate with state and national entities that collect and house data to obtain and improve necessary workforce data. Some of these data sources are: Utah Department of Health Office of Health Care Statistics All Payer Claims Database. U.S. Department of Health and Human Services Agency for Healthcare Research and Quality Medical Expenditure Panel Survey. National State Boards of Nursing Council/ National Forum of State Nursing Workforce Centers Minimum, supply, demand and education datasets. Utah Department of Workforce Services Employment and wage data. b) Understand the demand forces in the market for APRNs. This can be achieved through conducting employer surveys to gather data on team composition, patient panel sizes, new employment, and vacancy rates. c) Develop infrastructure to facilitate speed and accuracy of data collection by working with the Utah Division of Occupational & Professional Licensing to develop an online survey comprising of core questions that can be collected with each APRN license renewal cycle. For example: The lack of data on APRN certification (as an FNP, PNP, PMHCNS etc.) is a handicap to better projecting workforce needs. This could easily be remedied with a question on what certification an APRN holds added to their license renewal. RECOMMENDATION II. STUDY THE INTERPLAY OF ADVANCED PRACTICE NURSING & HEALTH REFORM IN THE U.S. The Patient Protection and Affordable Care Act (PPACA) provides funding for an array of APRN services including nurse managed health centers, as well as grants for graduate education in nurse midwifery and geriatric nursing. The law also establishes a demonstration program to reimburse eligible hospitals through Medicare for their graduate education costs in training APRNs to provide primary and preventive care, transitional care, chronic care, and other 1

16 services for Medicare patients. In January 2011, the law increased Medicare reimbursement for certified nurse midwives from 65 percent of the rate paid to physicians to the full rate. Nursing workforce dynamics can be studied in the following ways: a) Tracking State and National Supply/Demand for APRNs. b) Focusing future surveys on how APRNs work in inter professional teams. c) Encouraging efforts to bring scope of practice regulations into parity with surrounding states in order to support Institute of Medicine Future of Nursing report recommendations that APRNs practice to the full extent of their education and training will increase retention of APRN providers in the state and attract new providers to the state. d) Assessing APRN roles and participation in Medicaid/Medicare as those programs change. e) Understanding how involvement of APRNs in team care can keep costs down for patient centered care and accountable care organization service models. RECOMMENDATION III. SUPPORT EFFORTS TO MAKE THE APRN WORKFORCE MORE REPRESENTATIVE OF THE POPULATION The Utah APRN workforce as a whole is made up of 16% minorities. The state population is 20% minority. In general, APRNs seem to have a better representation of minorities than other medical professions (physicians, PAs, dentists etc.) in the state. However, UMEC recommends continued support for efforts to preserve and perpetuate diversity in the APRN workforce. a) Make collaborative efforts with AHEC, local high schools, DOH, United Way (Cradle to Career Program etc.) etc. to encourage minority youth and college students to look at nursing as a profession. RECOMMENDATION IV. INCREASE AVAILABILITY OF TRAINING SITES, FACULTY AND PRECEPTORS. Competition for clinical training sites has been on the rise and will continue to grow with new clinical education programs opening in the state. The Utah Governor s Health Innovations Report, 2011 recommends that the state create a clinical rotation coordination group in order to identify areas where students from multiple disciplines could train together and coordinate clinical rotations in Utah s workforce shortage areas. 2

17 Utah APRN training programs and the UMEC as the state s nursing workforce information center should collaborate to: a) Develop information on potential untapped preceptors. b) Recognize and leverage training site capacity. c) Work with other medical training programs in the state to optimizing training sites for inter professional team based training. RECOMMENDATION V. INVEST IN RURAL WORKFORCE DEVELOPMENT Currently, some APRN specialties are represented at a higher percentage in rural areas than are physicians in analogous specialties. For example, 27% (49) of CRNAs in comparison to 4% (16) of anesthesiologists work in rural areas of the state. Reform that encourages APRN providers to practice in geographic, demographic and institutional Health Provider Shortage Areas (HPSAs) can be a means to improve access to medical services for people living in those HPSAs. While APRNs who practice in a rural area earn more that their urban counterparts in general, an APRN costs less to employ than a physician in a rural area. Rural practice can be encouraged in the following ways: a) Support insurance payment/reimbursement reform for APRNs, both public and private. b) Support loan reimbursement programs for APRNs through private, non profit, state and federal government programs. c) Support clinical rotations for APRNs in rural areas through UMEC s continued partnership with the Area Health Education Center. d) Support the state of Utah opting out of federal regulation on ambulatory surgical services (42 CFR ) which requires that CRNAs be supervised by a physician when the CRNA is administering anesthesia. The Utah Nurse Practice Act allows CRNAs to practice without being supervised by a physician. This supports Institute of Medicine Future of Nursing report recommendations that APRNs practice to the full extent of their education and training. 3

18 METHODOLOGY LICENSE DATA The Utah Department of Commerce s Division of Occupational and Professional Licensing (DOPL) provided the UMEC with license information for every nurse in the state of Utah licensed as a CRNA, CNM APRN or APRN (Utah classifies NPs and CNSs the same). As of December 2010, there were 1,692 nurses in Utah holding one of these licenses. The ability to send a survey to every licensed advanced practice nurse in the state eliminated the need to establish selection criteria and remove errors associated with sampling a population. DESIGN OF SURVEY INSTRUMENT The design of the 2011 APRN workforce survey was influenced by a number of factors. The previous surveys administered by the UMEC in 1998 and 2003 were critically analyzed for their strengths and weaknesses. The 2011 survey was redesigned to be more comprehensive. Questions asked in 1998 and 2003 were incorporated into the 2011 survey in order to provide trend analysis and comparative measures over time. An expanded number of specialty options for respondents to choose from were added to the 2011 survey. An additional section was added to the survey to collect information specific to each license type. The advisory committee for the project provided input as to what specific questions would be important to each license type. Respondents were asked only to answer the questions that pertained to their license type. The survey instrument is included as an appendix to this report. Advisory committee members presented a draft version of the survey to colleagues for field testing to ensure optimum survey design so that the data gathered would be of a high quality with minimal errors. Feedback from these tests was incorporated into the survey instrument. DATA COLLECTION The first mailing of the survey was done in December of Respondents to the survey were tracked and a second mailing was sent to those who had yet to respond in March of After the second mailing, an analysis was done to determine if there were any geographic areas of the state that were responding at a lower rate. There were none found. A third mailing was sent out to those who had yet to respond in May of Data collection was completed at the end of June The survey received 1,159 responses, (a 68.5% response rate). Such a high response rate allows the analysis of this survey to be highly accurate. The accuracy has a confidence interval of 95% +/ 2%. Survey responses were weighted with a factor of 1.45 to account for non respondents. 4

19 DATA ENTRY AND ANALYSIS The 2011 Utah APRN Workforce Survey was processed using forms and databases created in Microsoft Access. Data entry and cleanup were done in house by UMEC staff. Once data entry and clean up were complete, the information was imported into Statistical Package for the Social Sciences (SPSS) for statistical analysis. Analysis began in July of SURVEY LIMITATIONS The survey asked for respondents to provide information about the number and ages of patients seen in a week. Although the wording of the survey specifically asks for information on patients, it is unclear if the reported numbers are for patients seen by a provider or for patient visits to a provider. This information is used as part of the projection models in the report. Questions regarding the number of patients should be specifically clarified for respondents to future surveys. The survey asked respondents about their work setting including options such as self employed, group APRN practice, hospital, physician practice etc. Self employed is not actually a setting. Self employed providers could be working in their own clinic or contracting in different types of work settings such as a hospital or clinic. This may have resulted in some ambiguity to the work setting responses. There are 33 APRNs in the state that are dual licensed as CNMs as well as NPs. There are no dual licensed CRNAs and licensing other than as an NP is not applicable to CNSs. Of these 33 dual licensed CNM/NPs, 81% (27) indicated that they were practicing both as an NP and a CNM. While these APRNs could be considered NPs, it seems, based on their characteristics, that they are more similar in profile to the state s CNMs. For ease of reporting, these dual licensed APRNs are included in the CNM counts and excluded from the NP counts throughout the entire report. Including them in NP counts would not materially change the numbers for NPs within this report, but excluding them from CNM numbers would definitely change the situation for CNMs. Including them in both CNM and NP counts only complicates reporting and does not accurately reflect how these 33 CNM/NPs are practicing. While CNS is nationally recognized as one of the four types of APRNs, the state of Utah has separate licenses specifically for CNMs and CRNAs but licenses both NPs and CNSs together with no distinction between the two. The survey asked respondents to specifically indicate which type of APRN they are currently practicing as. While the exact number of CNMs and CRNAs in the state could be determined by license data, the number of CNSs was determined by the number of survey respondents who indicated that they are currently practicing as a CNS. The survey also asked respondents about what certifications they hold. Of those respondents 5

20 who indicated they are currently practicing as a CNS, 69% indicated that they hold a CNS certification. Only 4% of respondents that were classified as NPs indicated that they had a certification as a CNS. RESTRUCTURE OF 2003 DATA In much of the 2003 APRN workforce report, numbers were reported for the overall APRN population. While each of the four APRN types are all considered nurses, they can be very different in many characteristics such as work setting, age ranges, income and specialty to name a few. Effort was made in the 2011 report to provide all information where applicable and relevant in both numbers for all APRNs as a group and by each license type. In many instances the 2003 report did not include the information needed to make a comparison over time. To address this problem, the raw data from the 2003 survey was organized and categorized in the same way as the 2011 survey data. Comparative analysis and numbers provided in this report are based on that raw dataset organized to match the 2011 dataset rather than quoting numbers from the 2003 report. For this reason, many of the 2003 numbers included in the 2011 report are not reported in the 2003 survey and some numbers in the 2003 report do not match with the numbers reported in the 2011 report for 2003 data. 6

21 INTRODUCTION An advanced practice registered nurse (APRN) is a registered nurse (RN) prepared at the postgraduate level and hold a specialized certificate. APRNs may work in either a specialist or generalist capacity. APRNs are prepared with advanced didactic and clinical education, knowledge and skills. The APRN profession is divided into four basic categories: Certified Nurse Midwives (CNMs), Clinical Nurse Specialists (CNSs), Certified Registered Nurse Anesthetists (CRNAs), and Nurse Practitioners (NPs). National Healthcare reform passed in 2010 is likely to provide insurance coverage for an estimated 32 million more Americans. Accommodations need to be made for increased demand in addition to improving quality and reducing the cost of health care services provided. These goals will be accomplished through management of chronic conditions, increased access to primary care, prevention and wellness education and improved provision of mental health, school health, longterm care and palliative services. Advanced Practice nursing is a profession expertly prepared in providing these services. In order to decide how best to utilize the APRN workforce as the healthcare system in the United States changes, policy makers must address questions such as: How many APRNs are there and what type of work they are doing? What should be done to ensure there is an adequate supply of APRNs to meet anticipated increases in demand? Who will train these APRNs? To what extent should APRNs be allowed to practice? How are APRNs involved with physicians, physician assistants, pharmacists, dentists and other health care professionals in providing cost effective and quality patient care? This report provides information that is useful in addressing these questions. 7

22 LICENSED IN UTAH As of December 2010 there were a total of 1,692 APRNs licensed in the state of Utah. This number consists of 151 (8.9%) APRNs licensed as CNMs, 231 (13.6%) licensed as CRNAs and 1,310 licensed as APRNs. Of those licensed as APRNs our survey estimates that 1,229 (72.6%) are working as NPs and approximately 81 (4.8%) are working as Clinical Nurse Specialists (CNSs), although there is no way to determine the actual number of CNSs because there is not a separate license for CNSs in Utah 1. Utah s APRN workforce has grown since 2003 when the last UMEC survey of the workforce was conducted. Overall the APRN workforce has grown from 1,110 active Utah licenses in 2003 to 1,692 active licenses in This equates to an overall 52.4% (582) increase or a compound annual growth rate of 5.41%. Of APRNs with an active Utah license, a small percentage do not actually work in Utah. In 2011, of the 1,692 active Utah APRN licenses, 1,433 (84.7%) reported working some hours in Utah each week. This is a 4% increase from 2003 where 896 of the total 1,110 active Utah APRNs practiced in Utah. There are a variety of reasons that APRNs choose not to practice in Utah and yet maintain a Utah license. There are so few Utah licensed CNMs that do not work in the state (only about 20 or 13% of the total) that no specific reason for not practicing in Utah stands prominent among all that were given. For Utah licensed NPs, the primary reason they did not practice in Utah is simply that they have moved (45 or 24% of those NPs licensed in Utah but not working in the state). It is likely that these NPs will allow their licenses to expire when it comes time to renew. For CRNAs the primary reason for not working in Utah was that they could not find jobs (15 or 30% of CRNAs licensed in Utah but not working here). As for the reason that these APRNs maintain a Utah license despite not practicing in the state, the most prevalent reason across all three APRN license types was that they intend to return to practice in Utah eventually. The rest of this report refers only to the 1,433 APRNs currently practicing in Utah unless otherwise indicated. 1 Nationally, CNSs and NPs have separate and distinctly defined roles. The Consensus Model for APRN Regulation defines the CNS role as to integrate care across the continuum and through three spheres of influence: patient, nurse, and system The NP role is defined as to provided initial, ongoing and comprehensive care. For more specifics about these roles see the full report at the National State Boards of Nursing website. ( The number of CNSs in Utah was estimated from a survey question asking Are you currently practicing as a CNS? Those that responded in the affirmative to this question were included in the CNS cohort. As this question was only asked of survey respondents actually working in Utah, there is no way to determine if there are any APRNs licensed as NPs in Utah but not practicing here that are certified or working as CNSs in other states. It is assumed that there would be very few CNSs in the group of APRNs licensed as NPs in Utah that are not working in the state. Of the number of APRNs licensed as NPs who are working in state only about 7% reported working as CNSs. If the same percent were to be applied to the licenses not working in Utah, there might be about 14 NPs that are not working in Utah that are possibly certified or working as CNSs. 8

23 The following tables break down Utah licensed and practicing APRNs into their respective license categories and show percentage change for each license category from 2003 to Notice there has been significant growth in the workforce by license category in both overall APRNs licensed in the state and APRNs practicing in the state. The largest growth has been in the NP workforce. The CNS workforce is actually shrinking. The percent change increases across all certification categories (except CNSs) is in large part due simply to the growth in the APRN workforce in general over time. FIGURE 1: TOTAL LICENSED/ PRACTICING IN STATE 2003 TO Total 3 Licensed ,110 / ,692 1,229 Practicing in State / , CNM CNS CRNA NP 680 1,039 In State Out of State TABLE 1: PERCENT OF WORKFORCE PRACTICING IN STATE 2003 TO 2011 All APRNs CNM CNS CRNA NP % 86% 98% 65% 79% % 87% 100% 79% 85% TABLE 2: PERCENT CHANGE IN WORKFORCE 2003 TO 2011 All APRNs CNM CNS CRNA NP All Utah Licenses 52% 43% 51% 45% 81% Practicing in State 60% 45% 50% 75% 93% Figures below show the number of new APRN licenses overall and by license type issued each year in Utah from 2001 through 2011 along with the licenses that are currently active from the same issue years. Figures for specific license types also show the national numbers for each license type over the same time period. An average of 121 total licenses for APRNs were issued per year from 2003 to Overall, Utah s APRN workforce has seen steady growth over many years. 9

24 FIGURE 2: ALL UTAH APRN LICENSES BY ISSUE YEAR ALL VS. CURRENTLY ACTIVE Number of Licenses Issue Year Number of New Licenses Issued Currently Active Licenses Looking at each license type individually, CNMs went through a period of slow decline from 2001 to 2007 with a 7% annual decline in licenses issued annually (an average of 7 new licenses being issued per year). CNMs now seem to be experiencing a more rapid increase with an average of over 9 new licenses being issued per year from 2008 through 2011 (no annual rate of decline). For comparison to national trends, the number of national CNM certifications per year has been included with the state license numbers. Nationally, newly certified CNMs saw a decline of 5% per year (averaging 338 CNMs certified per year) from 2001 to 2007 and then began to rise again in 2007 at a rate of 6% annually (averaging 343 CNMs certified nationally per year). The American College of Nurse Midwives has two primary workforce goals: That CNMs will attend twenty percent of births in the U.S. by the year 2020 and that there will be 1,000 newly certified midwives per year in the U.S. by the year 2015 (ACNM, 2011). 10

25 Utah Number of Licenses FIGURE 3: CERTIFIED NURSE MIDWIFES LICENSES ISSUED, ACTIVELY PRACTICING AND NATIONAL CERTIFICATION TRENDS 2003 TO Issue Year Number of New Licenses Issued Currently Active Licenses National Certifications National Number of Certifications From 2001 to 2007 there was a slight decrease in the number of CRNA licenses issued in Utah of about 8% annually (averaging about 15 licenses issued per year) and then a recovery back to 2011 with an average of 16 licenses issued per year (27% annual increase). Considering the creation of a CRNA training program in the state that began in 2005, the number of CRNA licenses issued in Utah is likely to continue to increase. On a national level, CRNAs have seen 111% growth from 2001 to 2011 from 1,159 national graduates in 2001 to 2,447 national graduates in This is an annual growth rate of 10.1% per year. FIGURE 4: CERTIFIED REGISTERED NURSE ANESTHETIST LICENSES IN UTAH ALL VS. CURRENTLY ACTIVE AND NATIONAL GRADUATES BY ISSUE YEAR Utah Number of Licenses ,375 2,447 2,500 2, ,158 2, , , ,900 1, , , , ,500 1, ,159 1,300 1,333 1, Issue Year Number of New Licenses Issued Currently Active Licenses National Graduates National Number of Graduates 11

26 Growth in Utah s NPs has been very similar to national trends. There was 5.3% (averaging 87 licenses issued per year) annual growth from 2001 to Nationally there was 6.9% annual growth over the same time period. FIGURE 5: NURSE PRACTITIONER/ CLINICAL NURSE SPECIALIST LICENSES BY ISSUE YEAR ALL VS. CURRENTLY ACTIVE Utah Number of Licenses , , ,865 9, ,611 6,526 7,261 6,979 6,900 7,583 8, Issue Year 13,000 12,000 11,000 10,000 9,000 8,000 7,000 6,000 National Number of Graduates Number of New Licenses Issued Currently Active Licenses National Nurse Practitioner Graduates DECISION TO PRACTICE IN UTAH The state continues to have a high percentage of licensed APRNs who practice in Utah. As of 2011, out of the total 1,692 APRNs with a Utah license, 1,433 (84.7%) actually practice in Utah. This is a 4% increase from 2003 when 80.7% of APRNs licensed in Utah also practiced here. Having family in Utah is the primary reason cited by many (65%) who practice here. Other factors by rank are present in the table below. TABLE 3: FACTORS INFLUENCING DECISION TO PRACTICE IN UTAH Rank Factor 1 Family in Utah 2 Raised in Utah 3 Recreation Opportunities 4 Spouse Emp. in UT 5 Career Opportunities 6 UT Graduate 7 Cost of Living 12

27 CERTIFICATION While CNMs and CRNAs are by definition certified in a specific area of advanced practice nursing, NPs and CNSs certify in a specific field or patient population. NPs can certify in the following areas: Acute Care (ACNP), Adult (ANP), Family Practice (FNP), Geriatric (GNP), Neonatal (NNP), Oncology (ONP), Pediatric (PNP), Psychiatric/Mental Health (PMHNP), and Women s Health (WHNP). CNSs can certify in these same areas and are abbreviated with CNS instead of NP. None of the state s CRNAs hold other types of certifications. CNMs holding dual licenses as NPs also certify as NPs. The tables below show how CNMs, CNSs, and NPs in Utah are certified along with national certification breakdowns for NPs. TABLE 4: UTAH CNM CERTIFICATIONS Certifications Count % CNM 96 73% CNM-FNP 10 8% CNM-WHNP 21 16% Total % Less than 5: FNP, WHNP TABLE 6: NATIONAL NP CERT. BREAKDOWN 2 Specialty Percent Specialty Percent ACNP 5.6% NNP 2.0% ANP 19.3% ONP 1.0% FNP 48.3% PNP 8.5% GNP 3.2% PMHNP 3.0% WHNP 9.0% TABLE 7: UTAH NP CERTIFICATIONS Certifications Count % ACNP 56 5% ACNP-FNP 6 1% FNP % FNP-ANP 7 1% GNP 25 2% GNP-ANP 9 1% NNP 87 8% ANP 49 5% PNP 74 7% WHNP 34 3% PMHNP 35 3% PMHCNS 12 1% Not Reported 9 1% Total % Less than 5: CNM-FNP, ACNP-ANP, ACNP-PNP, FNP-GNP, FNP-NNP, FNP-PNP, FNP-WHNP, FNP- PMHNP, FNP-AHCNS, NNP-PNP, ANP-WHNP, ANP-ACCNS, ACCNS, ADMCNS, PCNS TABLE 5: UTAH CNS CERTIFICATIONS Certifications Count % PMHNP 7 9% PMHCNS 49 60% Total % Less than 5: FNP, NNP,PNP, WHNP, ACCNS, AHCNS, PCNS, Not Reported All APRNs licensed as CNMs and CRNAs are also certified as such. There are no CRNAs holding dual certifications. However, 18% (24) CNMs report also being certified as WHNPs and 9% (12) report being certified as FNPs. The majority of CNSs are certified as PMHCNSs (60% (49). The majority of NPs in Utah are certified as FNPs 61% (637). This is compared nationally to 48.3% of NPs being certified as FNPs and 19.3% as ANPs according to the American Association of Nurse Practitioners 2012 membership survey (AANP, 2012). 2 Source: American Association of Nurse Practitioners 2012 membership survey. 13

28 UPBRINGING Overall, 26% (369) of APRNs in Utah report the majority of their upbringing was in a rural area. Forty five percent (639) report the majority of their upbringing in a suburban area, and 28% (406) report the majority of their upbringing was in an urban area. Twenty four percent (268) of female APRNs and 31% (101) of male APRNs reported that the majority of their upbringing was in a rural area. A slightly larger percentage (30%, 329) of female APRNs reported a majority urban area upbringing compared to male APRNs (24%, 76). However, 31% (101) of male APRNs report their upbringing in a rural area in comparison to 24% (268) female APRNs. FIGURE 6: UPBRINGING SETTING OF APRNS WORKING IN RURAL AREAS 18% 36% 10% 36% 15% 46% 9% 35% Area of Upbringing Urban 73% 45% 55% 39% 55% Suburban Rural 19% CNM (12%, 16) CNS (20%, 16) CRNA (34%, 62) NP (12%, 128) Overall (10%, 142) (Rural % of Workforce) Overall, 10% (142) of Utah s APRN workforce works in a rural primary practice setting. Of that rural workforce, 55% (78) come from a rural area upbringing. By license type, while a small group, it is notable that 73% (12) of Utah s rural CNM workforce comes from a rural area upbringing. 14

29 DEMOGRAPHIC CHARACTERISTICS AGE Overall, the APRN workforce has grown slightly older since The average overall age for an APRN practicing in Utah in 2011 is 47. However, when broken down by license type CNM, CNS and NP average ages have increased (4%, 6% and 2% respectively) and CRNA average age has decreased ( 4%) since Table 8 shows average age by license category for 2003 and 2011 along with a percent change for each group TABLE 8: AVERAGE AGES OF APRNS 2003 TO % Change CNM % CNS % CRNA % NP % Table 9: APRN Workforce by Age 2003 to 2011 Age Cohorts < Total CNM % 30% 54% 4% 4% 100% % 24% 28% 31% 2% 100% CNS % 17% 54% 22% 6% 100% % 13% 33% 42% 13% 100% CRNA % 32% 34% 22% 1% 100% % 40% 31% 17% 3% 100% NP % 30% 45% 9% 2% 100% % 25% 32% 24% 2% 100% 15

30 Looking at age cohorts by APRN license category shows that while average age has changed very little over time there have been changes in the age distributions. In 2003, the majority of CNMs (47 or 54%) were between the ages of 45 to 54. This same group of CNMs continues in the majority in 2011 just moving forward to the next age cohort of 55 to 64 years of age. This means that the majority of the state s CNM workforce is moving closer to retirement. However there has been an almost threefold increase in the number of CNMs under 35 years of age from 7 CNMs in 2003 to 19 CNMs in It appears that despite the large group of CNMs moving toward retirement, there is a growing group of young CNMs to replace them. According to the most recent age data available, provided by the 2008 federal Bureau of Health Professions (BHPr) national sample survey of registered nurses, published in 2010, more than 54% of CNMs were 50 years of age or older (BHPr, 2010). 60 FIGURE 7: UTAH CNM Age Profiles 2003 to 2011 Number of CNMS <5 7 < 5 < 5 <

31 The distribution of CNSs practicing in Utah shows a distinct aging and decline in number of those in the workforce. In 2003, the majority (81 or 50%) of the workforce was between the ages of 45 to 54. In 2011 the age cohort with the largest number of CNSs has moved forward with time as expected so that in 2011, the majority of CNSs (34, 42% of the CNS workforce) are within the age cohort of 55 to 64 years of age. According to the BHPr survey, CNSs were older than any other APRN group in 2008, with 63.6% over 50 years old and only 18.2 percent under 45 years. Few CNSs, only 10.2 percent, are under the age of 40. FIGURE 8: CNS AGE PROFILES 2003 TO 2011 Number of CNSs < <