- Email: [email protected]
Retrospective Evaluation of the Advanced Nursing Education Expansion Program
ORIGINAL RESEARCH
Retrospective Evaluation of the Advanced Nursing Education Expansion Program Jamie Mihoko Doyle, PhD, George A. Zangaro, PhD, FAAN, Benjamin A. Howie, MPH, and Mary Beth Bigley, DrPH ABSTRACT
Several interrelated workforce and population trends have intensified the need to increase the number of nurse practitioners (NPs) in primary care. The Advanced Nursing Education Expansion (ANEE) program was created to address health workforce needs by increasing the number of students enrolled full-time in NP and nurse-midwifery programs. Using data from ANEE grant performance measures, we found that nearly 65% of ANEE-supported graduates practice in primary care and 44.8% work in medically underserved communities. Results from this study demonstrate that even short-term federal investments have an impact on the expansion of the primary care health workforce. Keywords: Affordable Care Act, family nurse practitioner, nurse-midwife, primary care, workforce Published by Elsevier Inc.
I
n 2016, the Health Resources and Services Administration (HRSA) National Center for Health Workforce Analysis examined the outputs and outcomes of the Advanced Nursing Education Expansion (ANEE) program. The ANEE program, authorized and appropriated through the Affordable Care Act (ACA), is a $30 million grant program designed to increase the number of students enrolled full-time in accredited primary care nurse practitioner (NP) and nurse midwifery programs, and also accelerate the graduation of part-time students in such programs by encouraging full-time enrollment, thus increasing the production of primary care advanced practice nurses. The program provided support to master’s and postemaster’s degree students so they could complete their education through funding stipends, educational expenses, or other reasonable living expenses at $22,000 per student per year, for a maximum of 2 years per student. BACKGROUND
According to the Institute of Medicine (IOM),1 primary care is the “provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”1(p1) The ANEE program was 488
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developed in response to several interrelated primary care workforce and population trends. First, there has been a decline in the nation’s supply of primary care providers and decreasing interest among medical residents in pursuing careers in primary care.2,3 Studies have also shown that these workforce trends will result in an estimated shortfall in the supply of primary care physicians of approximately 23,640 full-time equivalents by 20254 and 44,340 by 2035.5 These findings are largely consistent with recent projections developed by the Association of American Medical Colleges, which suggest that primary care provider shortfalls may range from 14,900 to 35,600 physicians by 2025.6 Second, the implementation of the ACA was also a contributing factor in the need to increase the national supply of advanced practice NPs.7,8 The Congressional Budget Office estimated that 32 million Americans would be newly insured under the ACA by 2017,9 thus increasing the need for strengthening access to primary care providers. Last, the ANEE program aimed to increase the supply of advanced practice NPs and increase the number of providers who would administer care for a changing demographic population likely to have challenging health care needs. Demographic trends in the United States show that the proportion of older Americans is increasing. Projections by the US Census Bureau estimate that Volume 13, Issue 7, July/August 2017
> 20% of Americans will be > 65 years old by 2030—an increase of 54% from 2010 and a 104% increase from 1970.10 At the same time, the number of children and adolescents is also expected to grow steadily from 74 million to 82 million between 2014 and 2060.11 The trifecta of expanded health care coverage, a shortage of primary care providers, and an aging American population led the HRSA to focus more funding opportunities on increasing the number of primary care NPs. Our focus in this study was on the findings from an internal evaluation by the HRSA of the ANEE program. We restricted our study to family NPs because this group represents the most widely held NP certification,12 which ensures adequate cell sizes for tabulations. The analysis centers on addressing 3 related questions: (1) What are the characteristics of ANEE-supported nurse training programs, particularly with respect to their geographic site and training site location in underserved areas? (2) What are the characteristics of ANEE-funded trainees, particularly with respect to student demographics? Increasing the diversity of NPs is important because the diversity of the health workforce should reflect the diversity of populations they serve, and studies have shown primary care NPs to be predominantly white and female.13 Thus, the diversity of ANEE grantees was also considered. (3) To what extent has the ANEE program increased the supply of family NPs and increased primary care providers in rural and underserved areas? The ANEE program has successfully trained hundreds of primary care providers to support the national goal of improving accessibility and health care for low-income and minority populations.14 The study provided a unique opportunity to detail the processes, outputs, and outcomes of a 5-year investment to increase the number of primary care NPs. The article describes how the HRSA’s Bureau of Health Workforce used a retrospective design to evaluate processes and outputs associated with the ANEE program to help assess the effectiveness of this federal investment.
that, due to the implementation of improvements in HRSA’s methods for workforce performance measure data collection in 2011, experiential training setting data are not available for the initial 2011-2012 reporting period, but are available thereafter. Thus, data on training settings from the 2012-2013, 20132014, and 2014-2015 performance reporting periods are only used for experiential training settings. Quantitative data were obtained from performance reports submitted electronically by 26 grantee institutions as part of their grant requirements. The annual performance data collected are performance measures specific to ANEE programmatic goals. The analysis incorporates all trainee-level data on demographics, postgraduation employment, training activities, and geographic location of grantees. Because we are using the entire population of ANEE trainees and only reporting on performance measures, no statistical tests were conducted. Descriptive analyses were conducted using R statistical software (version 3.2.3). RESULTS
Table 1 and Figure show the distribution of ANEE grantees by state and the distribution of training settings, respectively. Of the 26 ANEE grantees distributed across the nation, Michigan had the largest number of grantees (n ¼ 4), followed by New York (n ¼ 2), Pennsylvania (n ¼ 2), and Florida (n ¼ 2). Table 1 provides a list of all grantees and current state scope-of-practice laws.15 Figure shows that the ANEE trainees were provided with experiences over a wide range of settings. Given that the ANEE program was intended to expand the number of NPs in primary care, it was foreseeable that almost three quarters of the 1,670 training settings were in primary Figure. Advanced Nursing Education Expansion training settings, 2012-2013 to 2014-2015 (N ¼ 1,700). Primary Care
1239
MUC
681
METHODS
A retrospective design was used for this evaluation to analyze data from 4 academic years (2012-2013, 2013-2014, and 2014-2015). It is important to note www.npjournal.org
Rural
412
0
200
400
600
800
1000
1200
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1400
489
Table 1. Geographic Location of ANEE Grantees by State Practice and Prescriptive Authorities Grantee
State
Practice
Prescriptive
Case Western Reserve University
OH
Full
Reduced
College of St. Scholastica
MN
Full
Full
Daemen College
NY
Full
Full
Duke University
NC
Restricted
Reduced
East Tennessee State University
TN
Restricted
Reduced
Florida State University
FL
Restricted
Reduced
Georgia State University
GA
Restricted
Reduced
Medical University of South Carolina
SC
Restricted
Reduced
Michigan State University
MI
Restricted
Reduced
Oregon Health & Sciences University
OR
Full
Full
Pace University
NY
Full
Full
Pennsylvania State University
PA
Reduced
Reduced
University of Michigan
MI
Restricted
Reduced
Rutgers, The State University of New Jersey
NJ
Reduced
Reduced
Shenandoah University
VA
Restricted
Reduced
University of Pennsylvania
PA
Reduced
Reduced
University of Detroit, Mercy
MI
Restricted
Reduced
University of Illinois
IL
Reduced
Reduced
University of Massachusetts
MA
Restricted
Reduced
University of Miami
FL
Restricted
Reduced
University of Oklahoma
OK
Restricted
Reduced
University of Texas Health Science Center at San Antonio
TX
Restricted
Reduced
University of Utah
UT
Reduced
Reduced
Wayne State University
MI
Restricted
Reduced
continued 490
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Table 1. (continued ) Grantee
State
Practice
Prescriptive
University of West Virginia
WV
Reduced
Reduced
Western University of Health Sciences
CA
Restricted
Reduced
Full practice: State practice and licensure law provides for all nurse practitioners (NPs) to evaluate patients, diagnose, order and interpret diagnostic tests, initiate and manage treatments—including prescribe medications—under the exclusive licensure authority of the state’s Board of Nursing. This is the model recommended by the Institute of Medicine and the National Council of State Boards of Nursing. Reduced practice: State practice and licensure law reduces the ability of NPs to engage in at least 1 element of NP practice. State law requires a regulated collaborative agreement with an outside health discipline in order for the NP to provide patient care or limits the setting or scope of 1 or more elements of NP practice. Restricted practice: State practice and licensure law restricts the ability of NPs to engage in at least 1 element of NP practice. State requires supervision, delegation, or team management by an outside health discipline for the NP to provide patient care.15,24
care (74.2%). The results also show that almost one quarter of the training settings were in rural areas (24.7%), and 40.8% were in medically underserved communities (MUCs). Examples of non‒primary care settings include: urgent care clinics; burn centers; and departments of dermatology, orthopedics, and emergency medicine within medical schools. Table 2 shows the descriptive statistics of ANEE trainees by demographic, enrollment, and degree information, and training hours received by setting. A total of 566 family NP trainees received funding through the ANEE program, with 379 (or 67%) having graduated from their program at the time of this analysis. Of the 379 graduates, postgraduate employment data were available for 172 of the trainees. Among all 566 family NP trainees, 87.8% were female and 11.7% were Hispanic/Latino. Although the majority of trainees were identified as white (71.7%) and < 40 years old, 13% were identified as black or African American and 6.7% were Asian. The majority of trainees were enrolled in campus-based or hybrid programs (29.3% and 43.6%, respectively) and over half pursued master’s of science/master’s of science in nursing degrees. Based on the data reported by grantees, ANEE trainees completed approximately 300 training hours in primary care and 236 training hours in MUCs, on average, while receiving ANEE funding. About 120 hours were spent, on average, in rural areas. It is important to note, however, that these categories were not mutually exclusive and that grantees reported training hours only for the duration of the trainees’ stipend support from the ANEE. For example, if a student received funding www.npjournal.org
for only 2 semesters of their total training semesters, the training hours reported were for only those 2 semesters. Thus, the training hours reported here are conservative and underestimate the total primary care, rural, and MUC training hours a trainee is required to complete in their program of study. The three groups analyzed—all trainees, graduates, and graduates with employment data—were similar with respect to most characteristics considered. However, compared with all trainees and graduates with postemployment data, graduates had a slightly higher percentage of enrollment in campus-only‒ based programs (32.7%) and a slightly higher number of mean hours trained in rural and MUCs (158.4 and 297.9, respectively). Table 3 shows the distribution of trainees by postgraduation career intentions and employment. Grantees were asked to report postgraduation career intentions among ANEE-supported graduates and employment information 1-year after graduation. Of the 566 total trainees, < 5% were lost to attrition during their program. About 73% reported intentions of pursuing primary care careers, over half reported intentions of working in a medically underserved community, and slightly less than one third intended to work in rural areas. However, when graduates with employment data were considered, the distribution of intentions versus employment was dissimilar. Although about 73% of graduates with employment data intended to pursue careers in primary care, only about 65% were actually employed in primary care. Nearly 26% reported intentions of working in a rural area, but only 15% were employed in rural areas after The Journal for Nurse Practitioners - JNP
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Table 2. Distribution of ANEE-supported Trainee Characteristics and Training Experience All
Graduates
Graduates With Employment Data
N
%
N
%
N
%
Total
566
100
379
100
172
100
Female
497
87.8
339
89.4
156
90.7
66
11.7
40
10.6
20
11.6
White
406
71.7
274
72.3
124
72.1
Black
74
13.1
47
12.4
20
11.6
Asian
38
6.7
26
6.9
13
7.6
Other/unknown
48
8.5
32
8.4
15
8.7
20-29 years
214
37.8
142
37.5
65
37.8
30-39 years
219
38.7
149
39.3
66
38.4
40-49 years
101
17.8
64
16.9
31
18.0
32
5.7
24
6.3
10
5.8
166
29.3
124
32.7
48
27.9
31
5.5
28
7.4
10
5.8
247
43.6
172
45.4
91
52.9
2
0.4
2
0.5
2
1.2
120
21.2
53
14.0
21
12.2
DNP
105
18.6
79
20.8
29
16.9
MS/MSN
322
56.9
230
60.7
107
62.2
19
3.4
17
4.5
15
8.7
120
21.2
53
14.0
21
12.2
Ethnicity Hispanic/Latino Race
Age
50þ Enrollee type Campus-based only Distance learning only Hybrid Online only Missing Degree type
Post-master’s certificate Missing Training hours while supported by ANEE (mean) Primary care
299.4
398.7
455.1
Rural
122.5
158.4
141.2
236.0
297.9
268.7
a
MUC
ANEE ¼ Advanced Nursing Education Expansion; DNP ¼ doctor of nursing practice; HPSA ¼ health professions shortage area; MS ¼ master’s of science; MSN ¼ master’s of science in nursing; MUA ¼ medically underserved population; MUC ¼ medically underserved community. a The MUC is a geographic location or population of individuals that is eligible for designation by a state and/or the federal government as an HPSA, MUA, and/or MUP. These communities have limited access to primary health care services. “MUC” is an umbrella term that can be used to describe any location that meets 1 or more of the previously identified designations.
graduation. Finally, slightly higher percentages of trainees reported MUC employment intentions than actually employed in these areas (48.3% and 44.8%, respectively). 492
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Limitations
Despite the extensive, cross-cutting information collected from the grantees, the data had some limitations. Demographic information on trainees was Volume 13, Issue 7, July/August 2017
Table 3. Distribution of ANEE-supported Trainee Career Intentions and Career Outcomes All N Total Lost to attrition
566 26
Graduates % 100
N
Graduates With Employment Data
%
N
%
379
100
172
100
0
0
0
0
4.6
Postgraduate intentions Primary care
275
72.6
125
72.7
Rural
119
31.4
45
26.2
MUC
203
53.6
83
48.3
112
65.1
Rural
26
15.1
MUC
77
44.8
Postgraduate employment Primary care
ANEE ¼ Advanced Nursing Education Expansion; MUA ¼ medically underserved population.
reported by grantees and not the individual recipient of the stipend. Grantees were provided with a uniform data collection instrument to collect individuallevel information, but we had no way of validating the grantee responses with the individual recipients. One-year postgraduation employment data were only available for about 45% of graduates (or 172 of the 329 total graduates). It could not be determined whether NPs remained in rural and medically underserved areas—or even in primary care—in the long term. However, future opportunities to collect longitudinal data are being explored to allow tracking of students for several years beyond graduation, which will enhance our ability to report on practice locations and diversity in the NP workforce. DISCUSSION
In this study, the use of a retrospective design proved useful given that the Bureau of Health Workforce was able to use existing performance data from the ANEE program to comprehensively assess the programmatic outputs over a period of academic years. Using this specific evaluation design had the advantage of allowing for the examination of the program’s accomplishments without an additional significant investment in resources to collect new data. Budd and colleagues conducted a survey assessing NPs’ future work plans after graduation and found that 48% reported plans to work in primary care.16 One of www.npjournal.org
the top five factors influencing the students’ decision to work in primary care was clinical experience as an NP student. These findings were consistent with the National Center for Health Workforce Analysis 2012 National Sample Survey of Nurse Practitioners,12 which indicated that 48% of NPs intended to work in primary care settings after graduation. In the current study, 73% of students reported plans to work in primary care and, of those graduates with employment data available, about 65% are working in primary care settings. Students in the ANEE program spend at least 50% of their required training hours in primary care and community-based settings, suggesting that increased clinical hours may result in a greater likelihood of students choosing primary care practice settings after graduation. The ANEE program trained NPs who can provide primary care services. Recent Association of American Medical Colleges and HRSA reports have documented a shortage of primary care physicians in rural and underserved areas.4,6 Initiatives such as the ANEE program serve to mitigate the shortage of primary care providers, which is anticipated to worsen over time due to demographic trends and the ACA’s enrollment of > 20 million newly insured individuals. This provider shortage is not new to the US as it was identified in the mid-1960s with the passage of Medicare and Medicaid, which created a need for more primary care providers. This sentinel The Journal for Nurse Practitioners - JNP
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event launched the NP professions. In the 1960s, the role of the NP expanded to that of a primary care provider with the ability to independently diagnose, treat, and prescribe medications to patients who were newly enrolled in Medicare and Medicaid.17 NPs continue to fill the gap where access to primary care physicians is limited. A Kaiser Permanente study showed that NPs are positioned to ameliorate the shortage of primary care physicians in rural and underserved areas.18 Consistent with 2015 American Association of Colleges of Nursing data, the ANEE program student characteristics generally represent the national enrollment data of primary care NP students with the only noticeable difference being a higher percent of Hispanic/Latino students.19 According to the IOM, increasing the diversity of students will create a workforce prepared to meet the demands of diverse populations across the lifespan.7 The HRSA’s mission is in part to provide health care to people who are geographically isolated and economically or medically vulnerable. In line with this, our study has shown that the ANEE program helps to generate graduates whose career pathways lead them to serve rural and medically underserved communities (15.1% and 44.8%, respectively). The increase in the number of NPs practicing in rural and underserved areas is a signal that the field of nursing is responding to the shortage of primary care physicians in these areas and increasing access for patients. Implications
As noted in Table 1, the NPs’ scope of practice and regulations is varied across the US. Although an NP’s educational preparation is guided by accreditation agencies and national certification exams, the scope of practice laws are governed by state-based agencies and remain inconsistent.20 These variations across states limit the NP’s ability to be fully integrated into the evolving health care delivery system and practice to the full extent of their training. Studies have reported that more potential benefit could be gained in addressing workforce shortages with regard to access to health care services by expanding the advanced practice nursing workforce if there was more consistent authority nationwide to 494
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independently practice and prescribe. There are limitations to this ability at the federal, state, and local levels.21-23 Allowing NPs to deliver a greater proportion of the services than they do now may expand access to care for all Americans. The IOM report, “The Future of Nursing: Leading Change, Advancing Health,” recommends the removal of scope-of-practice barriers to allow NPs to practice to the full extent of their education and training.7 In addition, the IOM, now called the National Academies of Sciences, Engineering, and Medicine, notes that these barriers are particularly prevalent in primary care practices and present implications for reducing access to care for Americans. Further, the IOM has urged states with unduly restrictive regulations on NPs to amend them and permit NPs to practice to the full scope of their abilities. The IOM’s report also recommend that emphasis be placed on increasing the diversity of the workforce.7 Future HRSA investments may consider requiring awardees to use funds to increase the diversity of the workforce and connect with the Center to Champion Nursing in America, which works nationally and through state action coalitions to advance its goal of a diverse workforce. The results of the present study highlight how even short-term federal investments can contribute to the expansion of the health workforce, particularly in primary care. Programs such as ANEE are critical for increasing access to health care by supporting and encouraging NPs to enter primary care careers and to practice in geographic areas with workforce shortages. Targeted investments in the primary care workforce will become increasingly important as provider shortages are projected to intensify in coming years, and NPs are essential providers who could fulfill existing and future primary care needs. References 1. Institute of Medicine. Primary Care: America’s Health in a New Era. Washington, DC: National Academies Press; 1996. 2. Ebell M. Future salary and US residency fill rate revisited. JAMA. 2008;300(10):1131-1132. 3. Klink K. Incentives for physicians to pursue primary care in the ACA era. AMA J Ethics. 2015;17(37):637-646. 4. Health Resources and Services Administration. Projecting the supply and demand for primary care practitioners through 2020. November 2013. https:// bhw.hrsa.gov/sites/default/files/bhw/nchwa/projectingprimarycare.pdf. Accessed November 10, 2016.
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5. Petterson SM, Liaw WR, Tran C, Bazemore AW. Estimating the residency expansion required to avoid projected primary care physician shortages by 2035. Ann Fam Med. 2015;13(2):107-114. 6. HIS, Inc. The complexities of physician supply and demand: projections from 2014 to 2025. 2016. https://www.aamc.org/download/458082/data/2016_ complexities_of_supply_and_demand_projections.pdf/. Accessed October 5, 2016. 7. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2010. 8. Medicare Payment Advisory Commission. Report to Congress: Reforming the Delivery System. Washington, DC: National Academies Press; 2008. 9. Congressional Budget Office. HR 4872, Reconciliation Act of 2010 (Final Health Care Legislation) Cost Estimate; 2010. 10. Ortman JM, Velkoff VA, Hogan H. An Aging Nation: the Older Population in the United States. Washington, DC: US Census Bureau; May 2014. 11. Colby SL, Ortman JM. Projections of the Size and Composition of the U.S. Population: 2014 to 2060. Washington, DC: US Census Bureau; 2015. 12. Chattopadhyay A, Zangaro GA, White KM. Practice patterns and characteristics of nurse practitioners in the United States: results from the 2012 national sample survey of nurse practitioners. J Nurse Pract. 2015;11(2):170-177. 13. Buerhaus PI, DesRoches CM, Dittus R, Donelan K. Practice characteristics of primary care nurse practitioners and physicians. Nurs Outlook. 2015;63(2):144-153. 14. Health Resources and Services Administration (HRSA). FY 2017 Annual Performance Report. 2016. https://www.hhs.gov/about/budget/fy2017/ performance/index.html. Accessed November 16, 2016. 15. American Association of Nurse Practitioners. State practice environment. 2016. https://www.aanp.org/legislation-regulation/state-legislation/state -practice-environment/. Accessed November 16, 2016. 16. Budd G, Wolf A, Haas R. Addressing the primary care workforce: a study of nurse practitioner students’ plans after graduation. J Nurs Educ. 2015;4(3):130-136. 17. American Association of Nurse Practitioners. Historical timeline. 2016. https:// www.aanp.org/all-about-nps/historical-timeline. Accessed November 17, 2016. 18. Van Vleet A, Paradise J. Tapping nurse practitioners to meet rising demand for primary care. Issue Brief Jan 20. 2015. http://kff.org/medicaid/issue-brief/ tapping-nurse-practitioners-to-meet-rising-demand-for-primary-care/. Accessed November 17, 2016. 19. American Association of Colleges of Nursing. 34th annual survey of institutions with baccalaureate and higher degree nursing programs. 2015. http://www.aacn.nche.edu/news/articles/2015/enrollment/. Accessed November 17, 2016. 20. Poghosyan L, Doyd D, Clarke S. Optimizing full scope of practice for nurse practitioners in primary care: A proposed conceptual model. Nurs Outlook. 2016;64(2):146-155. 21. Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ. 2002;324:819-823.
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22. Mundinger M. Advanced-practice nursing—good medicine for physicians? N Engl J Med. 1994;330(3):211-214. 23. Rohrer J, Angstman K, Garrison G, Pecina J, Maxson J. Nurse practitioners and physician assistants are complements to family medicine physicians. Popul Health Manag. 2013;16(4):242-245. 24. Phillips S. 27th Annual APRN legislative update: advancements continue for APRN practice. Nurse Pract. 2015;40(1):16-42.
Jamie Mihoko Doyle, PhD, is a health science policy analyst team lead in the Office of Extramural Research, Statistical Analysis and Reporting Branch, at the National Institutes of Health in Bethesda, MD, and was formerly a social scientist at the National Center for Health Workforce Analysis of the Health Resources and Services Administration in Rockville, MD. He can be reached at [email protected]. George A. Zangaro, PhD, RN, FAAN, is the director of the National Center for Health Workforce Analysis of the Health Resources and Services Administration. Benjamin A. Howie, MPH, is a medical student at Northeast Ohio Medical University in Rootstown, OH. Mary Beth Bigley, DrPH, ANP, is the former director of the Division of Nursing and Public Health of the Health Resources and Serves Administration and is currently the chief executive officer of the National Organization of Nurse Practitioner Faculties. The views expressed in this study are those of the authors and do not necessarily represent those of the Health Resources and Services Administration, the National Institutes of Health, or the United States Department of Health and Human Services. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. 1555-4155/17/$ see front matter Published by Elsevier Inc. http://dx.doi.org/10.1016/j.nurpra.2017.04.019
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Retrospective Evaluation of the Advanced Nursing Education Expansion Program Jamie Mihoko Doyle, PhD, George A. Zangaro, PhD, FAAN, Benjamin A. Howie, MPH, and Mary Beth Bigley, DrPH ABSTRACT
Several interrelated workforce and population trends have intensified the need to increase the number of nurse practitioners (NPs) in primary care. The Advanced Nursing Education Expansion (ANEE) program was created to address health workforce needs by increasing the number of students enrolled full-time in NP and nurse-midwifery programs. Using data from ANEE grant performance measures, we found that nearly 65% of ANEE-supported graduates practice in primary care and 44.8% work in medically underserved communities. Results from this study demonstrate that even short-term federal investments have an impact on the expansion of the primary care health workforce. Keywords: Affordable Care Act, family nurse practitioner, nurse-midwife, primary care, workforce Published by Elsevier Inc.
I
n 2016, the Health Resources and Services Administration (HRSA) National Center for Health Workforce Analysis examined the outputs and outcomes of the Advanced Nursing Education Expansion (ANEE) program. The ANEE program, authorized and appropriated through the Affordable Care Act (ACA), is a $30 million grant program designed to increase the number of students enrolled full-time in accredited primary care nurse practitioner (NP) and nurse midwifery programs, and also accelerate the graduation of part-time students in such programs by encouraging full-time enrollment, thus increasing the production of primary care advanced practice nurses. The program provided support to master’s and postemaster’s degree students so they could complete their education through funding stipends, educational expenses, or other reasonable living expenses at $22,000 per student per year, for a maximum of 2 years per student. BACKGROUND
According to the Institute of Medicine (IOM),1 primary care is the “provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”1(p1) The ANEE program was 488
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developed in response to several interrelated primary care workforce and population trends. First, there has been a decline in the nation’s supply of primary care providers and decreasing interest among medical residents in pursuing careers in primary care.2,3 Studies have also shown that these workforce trends will result in an estimated shortfall in the supply of primary care physicians of approximately 23,640 full-time equivalents by 20254 and 44,340 by 2035.5 These findings are largely consistent with recent projections developed by the Association of American Medical Colleges, which suggest that primary care provider shortfalls may range from 14,900 to 35,600 physicians by 2025.6 Second, the implementation of the ACA was also a contributing factor in the need to increase the national supply of advanced practice NPs.7,8 The Congressional Budget Office estimated that 32 million Americans would be newly insured under the ACA by 2017,9 thus increasing the need for strengthening access to primary care providers. Last, the ANEE program aimed to increase the supply of advanced practice NPs and increase the number of providers who would administer care for a changing demographic population likely to have challenging health care needs. Demographic trends in the United States show that the proportion of older Americans is increasing. Projections by the US Census Bureau estimate that Volume 13, Issue 7, July/August 2017
> 20% of Americans will be > 65 years old by 2030—an increase of 54% from 2010 and a 104% increase from 1970.10 At the same time, the number of children and adolescents is also expected to grow steadily from 74 million to 82 million between 2014 and 2060.11 The trifecta of expanded health care coverage, a shortage of primary care providers, and an aging American population led the HRSA to focus more funding opportunities on increasing the number of primary care NPs. Our focus in this study was on the findings from an internal evaluation by the HRSA of the ANEE program. We restricted our study to family NPs because this group represents the most widely held NP certification,12 which ensures adequate cell sizes for tabulations. The analysis centers on addressing 3 related questions: (1) What are the characteristics of ANEE-supported nurse training programs, particularly with respect to their geographic site and training site location in underserved areas? (2) What are the characteristics of ANEE-funded trainees, particularly with respect to student demographics? Increasing the diversity of NPs is important because the diversity of the health workforce should reflect the diversity of populations they serve, and studies have shown primary care NPs to be predominantly white and female.13 Thus, the diversity of ANEE grantees was also considered. (3) To what extent has the ANEE program increased the supply of family NPs and increased primary care providers in rural and underserved areas? The ANEE program has successfully trained hundreds of primary care providers to support the national goal of improving accessibility and health care for low-income and minority populations.14 The study provided a unique opportunity to detail the processes, outputs, and outcomes of a 5-year investment to increase the number of primary care NPs. The article describes how the HRSA’s Bureau of Health Workforce used a retrospective design to evaluate processes and outputs associated with the ANEE program to help assess the effectiveness of this federal investment.
that, due to the implementation of improvements in HRSA’s methods for workforce performance measure data collection in 2011, experiential training setting data are not available for the initial 2011-2012 reporting period, but are available thereafter. Thus, data on training settings from the 2012-2013, 20132014, and 2014-2015 performance reporting periods are only used for experiential training settings. Quantitative data were obtained from performance reports submitted electronically by 26 grantee institutions as part of their grant requirements. The annual performance data collected are performance measures specific to ANEE programmatic goals. The analysis incorporates all trainee-level data on demographics, postgraduation employment, training activities, and geographic location of grantees. Because we are using the entire population of ANEE trainees and only reporting on performance measures, no statistical tests were conducted. Descriptive analyses were conducted using R statistical software (version 3.2.3). RESULTS
Table 1 and Figure show the distribution of ANEE grantees by state and the distribution of training settings, respectively. Of the 26 ANEE grantees distributed across the nation, Michigan had the largest number of grantees (n ¼ 4), followed by New York (n ¼ 2), Pennsylvania (n ¼ 2), and Florida (n ¼ 2). Table 1 provides a list of all grantees and current state scope-of-practice laws.15 Figure shows that the ANEE trainees were provided with experiences over a wide range of settings. Given that the ANEE program was intended to expand the number of NPs in primary care, it was foreseeable that almost three quarters of the 1,670 training settings were in primary Figure. Advanced Nursing Education Expansion training settings, 2012-2013 to 2014-2015 (N ¼ 1,700). Primary Care
1239
MUC
681
METHODS
A retrospective design was used for this evaluation to analyze data from 4 academic years (2012-2013, 2013-2014, and 2014-2015). It is important to note www.npjournal.org
Rural
412
0
200
400
600
800
1000
1200
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Table 1. Geographic Location of ANEE Grantees by State Practice and Prescriptive Authorities Grantee
State
Practice
Prescriptive
Case Western Reserve University
OH
Full
Reduced
College of St. Scholastica
MN
Full
Full
Daemen College
NY
Full
Full
Duke University
NC
Restricted
Reduced
East Tennessee State University
TN
Restricted
Reduced
Florida State University
FL
Restricted
Reduced
Georgia State University
GA
Restricted
Reduced
Medical University of South Carolina
SC
Restricted
Reduced
Michigan State University
MI
Restricted
Reduced
Oregon Health & Sciences University
OR
Full
Full
Pace University
NY
Full
Full
Pennsylvania State University
PA
Reduced
Reduced
University of Michigan
MI
Restricted
Reduced
Rutgers, The State University of New Jersey
NJ
Reduced
Reduced
Shenandoah University
VA
Restricted
Reduced
University of Pennsylvania
PA
Reduced
Reduced
University of Detroit, Mercy
MI
Restricted
Reduced
University of Illinois
IL
Reduced
Reduced
University of Massachusetts
MA
Restricted
Reduced
University of Miami
FL
Restricted
Reduced
University of Oklahoma
OK
Restricted
Reduced
University of Texas Health Science Center at San Antonio
TX
Restricted
Reduced
University of Utah
UT
Reduced
Reduced
Wayne State University
MI
Restricted
Reduced
continued 490
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Table 1. (continued ) Grantee
State
Practice
Prescriptive
University of West Virginia
WV
Reduced
Reduced
Western University of Health Sciences
CA
Restricted
Reduced
Full practice: State practice and licensure law provides for all nurse practitioners (NPs) to evaluate patients, diagnose, order and interpret diagnostic tests, initiate and manage treatments—including prescribe medications—under the exclusive licensure authority of the state’s Board of Nursing. This is the model recommended by the Institute of Medicine and the National Council of State Boards of Nursing. Reduced practice: State practice and licensure law reduces the ability of NPs to engage in at least 1 element of NP practice. State law requires a regulated collaborative agreement with an outside health discipline in order for the NP to provide patient care or limits the setting or scope of 1 or more elements of NP practice. Restricted practice: State practice and licensure law restricts the ability of NPs to engage in at least 1 element of NP practice. State requires supervision, delegation, or team management by an outside health discipline for the NP to provide patient care.15,24
care (74.2%). The results also show that almost one quarter of the training settings were in rural areas (24.7%), and 40.8% were in medically underserved communities (MUCs). Examples of non‒primary care settings include: urgent care clinics; burn centers; and departments of dermatology, orthopedics, and emergency medicine within medical schools. Table 2 shows the descriptive statistics of ANEE trainees by demographic, enrollment, and degree information, and training hours received by setting. A total of 566 family NP trainees received funding through the ANEE program, with 379 (or 67%) having graduated from their program at the time of this analysis. Of the 379 graduates, postgraduate employment data were available for 172 of the trainees. Among all 566 family NP trainees, 87.8% were female and 11.7% were Hispanic/Latino. Although the majority of trainees were identified as white (71.7%) and < 40 years old, 13% were identified as black or African American and 6.7% were Asian. The majority of trainees were enrolled in campus-based or hybrid programs (29.3% and 43.6%, respectively) and over half pursued master’s of science/master’s of science in nursing degrees. Based on the data reported by grantees, ANEE trainees completed approximately 300 training hours in primary care and 236 training hours in MUCs, on average, while receiving ANEE funding. About 120 hours were spent, on average, in rural areas. It is important to note, however, that these categories were not mutually exclusive and that grantees reported training hours only for the duration of the trainees’ stipend support from the ANEE. For example, if a student received funding www.npjournal.org
for only 2 semesters of their total training semesters, the training hours reported were for only those 2 semesters. Thus, the training hours reported here are conservative and underestimate the total primary care, rural, and MUC training hours a trainee is required to complete in their program of study. The three groups analyzed—all trainees, graduates, and graduates with employment data—were similar with respect to most characteristics considered. However, compared with all trainees and graduates with postemployment data, graduates had a slightly higher percentage of enrollment in campus-only‒ based programs (32.7%) and a slightly higher number of mean hours trained in rural and MUCs (158.4 and 297.9, respectively). Table 3 shows the distribution of trainees by postgraduation career intentions and employment. Grantees were asked to report postgraduation career intentions among ANEE-supported graduates and employment information 1-year after graduation. Of the 566 total trainees, < 5% were lost to attrition during their program. About 73% reported intentions of pursuing primary care careers, over half reported intentions of working in a medically underserved community, and slightly less than one third intended to work in rural areas. However, when graduates with employment data were considered, the distribution of intentions versus employment was dissimilar. Although about 73% of graduates with employment data intended to pursue careers in primary care, only about 65% were actually employed in primary care. Nearly 26% reported intentions of working in a rural area, but only 15% were employed in rural areas after The Journal for Nurse Practitioners - JNP
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Table 2. Distribution of ANEE-supported Trainee Characteristics and Training Experience All
Graduates
Graduates With Employment Data
N
%
N
%
N
%
Total
566
100
379
100
172
100
Female
497
87.8
339
89.4
156
90.7
66
11.7
40
10.6
20
11.6
White
406
71.7
274
72.3
124
72.1
Black
74
13.1
47
12.4
20
11.6
Asian
38
6.7
26
6.9
13
7.6
Other/unknown
48
8.5
32
8.4
15
8.7
20-29 years
214
37.8
142
37.5
65
37.8
30-39 years
219
38.7
149
39.3
66
38.4
40-49 years
101
17.8
64
16.9
31
18.0
32
5.7
24
6.3
10
5.8
166
29.3
124
32.7
48
27.9
31
5.5
28
7.4
10
5.8
247
43.6
172
45.4
91
52.9
2
0.4
2
0.5
2
1.2
120
21.2
53
14.0
21
12.2
DNP
105
18.6
79
20.8
29
16.9
MS/MSN
322
56.9
230
60.7
107
62.2
19
3.4
17
4.5
15
8.7
120
21.2
53
14.0
21
12.2
Ethnicity Hispanic/Latino Race
Age
50þ Enrollee type Campus-based only Distance learning only Hybrid Online only Missing Degree type
Post-master’s certificate Missing Training hours while supported by ANEE (mean) Primary care
299.4
398.7
455.1
Rural
122.5
158.4
141.2
236.0
297.9
268.7
a
MUC
ANEE ¼ Advanced Nursing Education Expansion; DNP ¼ doctor of nursing practice; HPSA ¼ health professions shortage area; MS ¼ master’s of science; MSN ¼ master’s of science in nursing; MUA ¼ medically underserved population; MUC ¼ medically underserved community. a The MUC is a geographic location or population of individuals that is eligible for designation by a state and/or the federal government as an HPSA, MUA, and/or MUP. These communities have limited access to primary health care services. “MUC” is an umbrella term that can be used to describe any location that meets 1 or more of the previously identified designations.
graduation. Finally, slightly higher percentages of trainees reported MUC employment intentions than actually employed in these areas (48.3% and 44.8%, respectively). 492
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Limitations
Despite the extensive, cross-cutting information collected from the grantees, the data had some limitations. Demographic information on trainees was Volume 13, Issue 7, July/August 2017
Table 3. Distribution of ANEE-supported Trainee Career Intentions and Career Outcomes All N Total Lost to attrition
566 26
Graduates % 100
N
Graduates With Employment Data
%
N
%
379
100
172
100
0
0
0
0
4.6
Postgraduate intentions Primary care
275
72.6
125
72.7
Rural
119
31.4
45
26.2
MUC
203
53.6
83
48.3
112
65.1
Rural
26
15.1
MUC
77
44.8
Postgraduate employment Primary care
ANEE ¼ Advanced Nursing Education Expansion; MUA ¼ medically underserved population.
reported by grantees and not the individual recipient of the stipend. Grantees were provided with a uniform data collection instrument to collect individuallevel information, but we had no way of validating the grantee responses with the individual recipients. One-year postgraduation employment data were only available for about 45% of graduates (or 172 of the 329 total graduates). It could not be determined whether NPs remained in rural and medically underserved areas—or even in primary care—in the long term. However, future opportunities to collect longitudinal data are being explored to allow tracking of students for several years beyond graduation, which will enhance our ability to report on practice locations and diversity in the NP workforce. DISCUSSION
In this study, the use of a retrospective design proved useful given that the Bureau of Health Workforce was able to use existing performance data from the ANEE program to comprehensively assess the programmatic outputs over a period of academic years. Using this specific evaluation design had the advantage of allowing for the examination of the program’s accomplishments without an additional significant investment in resources to collect new data. Budd and colleagues conducted a survey assessing NPs’ future work plans after graduation and found that 48% reported plans to work in primary care.16 One of www.npjournal.org
the top five factors influencing the students’ decision to work in primary care was clinical experience as an NP student. These findings were consistent with the National Center for Health Workforce Analysis 2012 National Sample Survey of Nurse Practitioners,12 which indicated that 48% of NPs intended to work in primary care settings after graduation. In the current study, 73% of students reported plans to work in primary care and, of those graduates with employment data available, about 65% are working in primary care settings. Students in the ANEE program spend at least 50% of their required training hours in primary care and community-based settings, suggesting that increased clinical hours may result in a greater likelihood of students choosing primary care practice settings after graduation. The ANEE program trained NPs who can provide primary care services. Recent Association of American Medical Colleges and HRSA reports have documented a shortage of primary care physicians in rural and underserved areas.4,6 Initiatives such as the ANEE program serve to mitigate the shortage of primary care providers, which is anticipated to worsen over time due to demographic trends and the ACA’s enrollment of > 20 million newly insured individuals. This provider shortage is not new to the US as it was identified in the mid-1960s with the passage of Medicare and Medicaid, which created a need for more primary care providers. This sentinel The Journal for Nurse Practitioners - JNP
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event launched the NP professions. In the 1960s, the role of the NP expanded to that of a primary care provider with the ability to independently diagnose, treat, and prescribe medications to patients who were newly enrolled in Medicare and Medicaid.17 NPs continue to fill the gap where access to primary care physicians is limited. A Kaiser Permanente study showed that NPs are positioned to ameliorate the shortage of primary care physicians in rural and underserved areas.18 Consistent with 2015 American Association of Colleges of Nursing data, the ANEE program student characteristics generally represent the national enrollment data of primary care NP students with the only noticeable difference being a higher percent of Hispanic/Latino students.19 According to the IOM, increasing the diversity of students will create a workforce prepared to meet the demands of diverse populations across the lifespan.7 The HRSA’s mission is in part to provide health care to people who are geographically isolated and economically or medically vulnerable. In line with this, our study has shown that the ANEE program helps to generate graduates whose career pathways lead them to serve rural and medically underserved communities (15.1% and 44.8%, respectively). The increase in the number of NPs practicing in rural and underserved areas is a signal that the field of nursing is responding to the shortage of primary care physicians in these areas and increasing access for patients. Implications
As noted in Table 1, the NPs’ scope of practice and regulations is varied across the US. Although an NP’s educational preparation is guided by accreditation agencies and national certification exams, the scope of practice laws are governed by state-based agencies and remain inconsistent.20 These variations across states limit the NP’s ability to be fully integrated into the evolving health care delivery system and practice to the full extent of their training. Studies have reported that more potential benefit could be gained in addressing workforce shortages with regard to access to health care services by expanding the advanced practice nursing workforce if there was more consistent authority nationwide to 494
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independently practice and prescribe. There are limitations to this ability at the federal, state, and local levels.21-23 Allowing NPs to deliver a greater proportion of the services than they do now may expand access to care for all Americans. The IOM report, “The Future of Nursing: Leading Change, Advancing Health,” recommends the removal of scope-of-practice barriers to allow NPs to practice to the full extent of their education and training.7 In addition, the IOM, now called the National Academies of Sciences, Engineering, and Medicine, notes that these barriers are particularly prevalent in primary care practices and present implications for reducing access to care for Americans. Further, the IOM has urged states with unduly restrictive regulations on NPs to amend them and permit NPs to practice to the full scope of their abilities. The IOM’s report also recommend that emphasis be placed on increasing the diversity of the workforce.7 Future HRSA investments may consider requiring awardees to use funds to increase the diversity of the workforce and connect with the Center to Champion Nursing in America, which works nationally and through state action coalitions to advance its goal of a diverse workforce. The results of the present study highlight how even short-term federal investments can contribute to the expansion of the health workforce, particularly in primary care. Programs such as ANEE are critical for increasing access to health care by supporting and encouraging NPs to enter primary care careers and to practice in geographic areas with workforce shortages. Targeted investments in the primary care workforce will become increasingly important as provider shortages are projected to intensify in coming years, and NPs are essential providers who could fulfill existing and future primary care needs. References 1. Institute of Medicine. Primary Care: America’s Health in a New Era. Washington, DC: National Academies Press; 1996. 2. Ebell M. Future salary and US residency fill rate revisited. JAMA. 2008;300(10):1131-1132. 3. Klink K. Incentives for physicians to pursue primary care in the ACA era. AMA J Ethics. 2015;17(37):637-646. 4. Health Resources and Services Administration. Projecting the supply and demand for primary care practitioners through 2020. November 2013. https:// bhw.hrsa.gov/sites/default/files/bhw/nchwa/projectingprimarycare.pdf. Accessed November 10, 2016.
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5. Petterson SM, Liaw WR, Tran C, Bazemore AW. Estimating the residency expansion required to avoid projected primary care physician shortages by 2035. Ann Fam Med. 2015;13(2):107-114. 6. HIS, Inc. The complexities of physician supply and demand: projections from 2014 to 2025. 2016. https://www.aamc.org/download/458082/data/2016_ complexities_of_supply_and_demand_projections.pdf/. Accessed October 5, 2016. 7. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2010. 8. Medicare Payment Advisory Commission. Report to Congress: Reforming the Delivery System. Washington, DC: National Academies Press; 2008. 9. Congressional Budget Office. HR 4872, Reconciliation Act of 2010 (Final Health Care Legislation) Cost Estimate; 2010. 10. Ortman JM, Velkoff VA, Hogan H. An Aging Nation: the Older Population in the United States. Washington, DC: US Census Bureau; May 2014. 11. Colby SL, Ortman JM. Projections of the Size and Composition of the U.S. Population: 2014 to 2060. Washington, DC: US Census Bureau; 2015. 12. Chattopadhyay A, Zangaro GA, White KM. Practice patterns and characteristics of nurse practitioners in the United States: results from the 2012 national sample survey of nurse practitioners. J Nurse Pract. 2015;11(2):170-177. 13. Buerhaus PI, DesRoches CM, Dittus R, Donelan K. Practice characteristics of primary care nurse practitioners and physicians. Nurs Outlook. 2015;63(2):144-153. 14. Health Resources and Services Administration (HRSA). FY 2017 Annual Performance Report. 2016. https://www.hhs.gov/about/budget/fy2017/ performance/index.html. Accessed November 16, 2016. 15. American Association of Nurse Practitioners. State practice environment. 2016. https://www.aanp.org/legislation-regulation/state-legislation/state -practice-environment/. Accessed November 16, 2016. 16. Budd G, Wolf A, Haas R. Addressing the primary care workforce: a study of nurse practitioner students’ plans after graduation. J Nurs Educ. 2015;4(3):130-136. 17. American Association of Nurse Practitioners. Historical timeline. 2016. https:// www.aanp.org/all-about-nps/historical-timeline. Accessed November 17, 2016. 18. Van Vleet A, Paradise J. Tapping nurse practitioners to meet rising demand for primary care. Issue Brief Jan 20. 2015. http://kff.org/medicaid/issue-brief/ tapping-nurse-practitioners-to-meet-rising-demand-for-primary-care/. Accessed November 17, 2016. 19. American Association of Colleges of Nursing. 34th annual survey of institutions with baccalaureate and higher degree nursing programs. 2015. http://www.aacn.nche.edu/news/articles/2015/enrollment/. Accessed November 17, 2016. 20. Poghosyan L, Doyd D, Clarke S. Optimizing full scope of practice for nurse practitioners in primary care: A proposed conceptual model. Nurs Outlook. 2016;64(2):146-155. 21. Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ. 2002;324:819-823.
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22. Mundinger M. Advanced-practice nursing—good medicine for physicians? N Engl J Med. 1994;330(3):211-214. 23. Rohrer J, Angstman K, Garrison G, Pecina J, Maxson J. Nurse practitioners and physician assistants are complements to family medicine physicians. Popul Health Manag. 2013;16(4):242-245. 24. Phillips S. 27th Annual APRN legislative update: advancements continue for APRN practice. Nurse Pract. 2015;40(1):16-42.
Jamie Mihoko Doyle, PhD, is a health science policy analyst team lead in the Office of Extramural Research, Statistical Analysis and Reporting Branch, at the National Institutes of Health in Bethesda, MD, and was formerly a social scientist at the National Center for Health Workforce Analysis of the Health Resources and Services Administration in Rockville, MD. He can be reached at [email protected]. George A. Zangaro, PhD, RN, FAAN, is the director of the National Center for Health Workforce Analysis of the Health Resources and Services Administration. Benjamin A. Howie, MPH, is a medical student at Northeast Ohio Medical University in Rootstown, OH. Mary Beth Bigley, DrPH, ANP, is the former director of the Division of Nursing and Public Health of the Health Resources and Serves Administration and is currently the chief executive officer of the National Organization of Nurse Practitioner Faculties. The views expressed in this study are those of the authors and do not necessarily represent those of the Health Resources and Services Administration, the National Institutes of Health, or the United States Department of Health and Human Services. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. 1555-4155/17/$ see front matter Published by Elsevier Inc. http://dx.doi.org/10.1016/j.nurpra.2017.04.019
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