WEBVTT 00:00:05.360 --> 00:00:09.760 position:50% align:middle - [Brendan] So, as most of you now know, you've heard my introduction twice. 00:00:09.760 --> 00:00:10.770 position:50% align:middle My name is Brendan Martin. 00:00:10.770 --> 00:00:12.490 position:50% align:middle I'm the director of research here at NCSBN. 00:00:12.490 --> 00:00:17.860 position:50% align:middle And I'm here once again today to discuss the results of one of our workforce subanalyses, 00:00:17.860 --> 00:00:24.200 position:50% align:middle examining the impact of the COVID-19 pandemic on the Advanced Practice Registered Nurse workforce. 00:00:24.200 --> 00:00:28.830 position:50% align:middle Again, if you heard me talk yesterday, you know I try to give credit where credit is due. 00:00:28.830 --> 00:00:32.264 position:50% align:middle So not only did the research team put in a lot of effort on all of these workforce subanalyses, 00:00:32.264 --> 00:00:35.024 position:50% align:middle the overall workforce report, etc. 00:00:35.024 --> 00:00:39.282 position:50% align:middle But for this particular project, we're also indebted to Michelle Buck, 00:00:39.282 --> 00:00:41.834 position:50% align:middle who serves as our APRN senior policy advisor at NCSBN. 00:00:41.834 --> 00:00:46.434 position:50% align:middle Not only did she provide critical insight into the analysis of the results, but as an APRN herself, 00:00:46.434 --> 00:00:50.674 position:50% align:middle she gave us that really crucial perspective when trying to understand the topics as it related to this specific 00:00:50.674 --> 00:00:53.624 position:50% align:middle cohort of providers. 00:00:53.624 --> 00:01:00.651 position:50% align:middle So, for today's presentation, that was really loud, apologies, I'm going to cover a few major points. 00:01:00.651 --> 00:01:06.181 position:50% align:middle So, I'm going to start by providing a bit of background on the APRN subanalysis that we wanted to conduct, 00:01:06.181 --> 00:01:10.291 position:50% align:middle really in particular the context for why we wanted to conduct the study in the first place and what we were 00:01:10.291 --> 00:01:15.481 position:50% align:middle hoping to achieve when we selected this as one of our targeted subanalyses topics, subanalysis topics. 00:01:15.481 --> 00:01:20.241 position:50% align:middle Then I'll provide a brief overview of the study methodology, in particular how we identified and then 00:01:20.241 --> 00:01:25.981 position:50% align:middle isolated APRNs within our general RN respondent pool so that you're clear on how we really identified our 00:01:25.981 --> 00:01:27.611 position:50% align:middle sample because that was really the key piece. 00:01:27.611 --> 00:01:30.812 position:50% align:middle When you're doing a subanalysis, it's how you define your population. 00:01:30.812 --> 00:01:35.432 position:50% align:middle Otherwise, you're just piggybacking off of all the rigorous methodology that the overall study had 00:01:35.432 --> 00:01:37.882 position:50% align:middle as an advantage too. 00:01:37.882 --> 00:01:43.202 position:50% align:middle Then I'm going to get into really the meat of the presentation where I am going to go into a little bit 00:01:43.202 --> 00:01:47.752 position:50% align:middle more detail than my presentation yesterday in terms of the results and then show you how that kind of informs 00:01:47.752 --> 00:01:49.032 position:50% align:middle some key takeaways. 00:01:49.032 --> 00:01:53.592 position:50% align:middle And then as I mentioned today, I'm very, very confident I will have more time for questions 00:01:53.592 --> 00:01:56.452 position:50% align:middle because I think I stopped with like 30 seconds yesterday. 00:01:56.452 --> 00:01:59.162 position:50% align:middle So, I'm not even sure that qualifies as a question-and-answer period. 00:01:59.162 --> 00:02:04.034 position:50% align:middle But I do hope to give you the opportunity to ask any questions or necessary clarification, whatnot. 00:02:04.034 --> 00:02:07.134 position:50% align:middle Or we could just go home, your call. 00:02:07.134 --> 00:02:14.404 position:50% align:middle So to provide context for our discussion today, it's important to note that one of the most critical 00:02:14.404 --> 00:02:18.464 position:50% align:middle studies that we have conducted over the past few years really assessing the impact of the pandemic on the 00:02:18.464 --> 00:02:23.894 position:50% align:middle nursing profession was the 2022 National Nursing Workforce Survey. 00:02:23.894 --> 00:02:27.394 position:50% align:middle So for those of you who are less familiar, and that would likely be the cohort of people who were 00:02:27.394 --> 00:02:30.392 position:50% align:middle at my presentation yesterday, because then by default you missed my colleague 00:02:30.392 --> 00:02:32.362 position:50% align:middle Richard's presentation on these results. 00:02:32.362 --> 00:02:36.422 position:50% align:middle I would highly encourage you when you get the recording for that presentation, 00:02:36.422 --> 00:02:39.142 position:50% align:middle please review it and also download the full report. 00:02:39.142 --> 00:02:42.182 position:50% align:middle It's free for download on the Journal of Nursing Regulation website. 00:02:42.182 --> 00:02:48.142 position:50% align:middle It's chuck full of just such valuable information, and it's super comprehensive across all license types 00:02:48.142 --> 00:02:48.982 position:50% align:middle that we track. 00:02:48.982 --> 00:02:53.172 position:50% align:middle So that's RNs, APRNs, and LPNs, LVNs. 00:02:53.172 --> 00:02:57.802 position:50% align:middle But for the purposes of this talk, I do want to, again, give you a little bit of a crib note for what 00:02:57.802 --> 00:03:00.041 position:50% align:middle this project entails. 00:03:00.041 --> 00:03:06.951 position:50% align:middle So we have partnered with the National Forum of State Nursing Workforce Centers since 2013 to conduct this 00:03:06.951 --> 00:03:10.793 position:50% align:middle survey every two years or so to ensure accurate 00:03:10.793 --> 00:03:14.321 position:50% align:middle tracking of the supply of nurses within the U.S. workforce. 00:03:14.321 --> 00:03:18.241 position:50% align:middle The nurse supply minimum data set constitutes the core of the survey instrument, 00:03:18.241 --> 00:03:22.161 position:50% align:middle so it's about 60% or so of kind of the landscape for the instrument. 00:03:22.161 --> 00:03:25.471 position:50% align:middle And then in addition to that, we layer on a few custom items. 00:03:25.471 --> 00:03:30.487 position:50% align:middle So for the MDS, we're talking about kind of core demographic and practice characteristics. 00:03:30.487 --> 00:03:36.097 position:50% align:middle So we're thinking about age, gender, race, education, years licensed. 00:03:36.097 --> 00:03:39.997 position:50% align:middle We're talking about license type, practice setting, practice specialty, etc. 00:03:39.997 --> 00:03:45.067 position:50% align:middle When we get into the custom questions, while those are kind of specialty topics of interest, 00:03:45.067 --> 00:03:50.477 position:50% align:middle we try to keep those consistent from cycle to cycle for obvious reasons, really to leverage the strength of the 00:03:50.477 --> 00:03:51.987 position:50% align:middle longitudinal data tracking. 00:03:51.987 --> 00:03:57.897 position:50% align:middle However, we do reserve the right to make modifications should special topics of interest emerge that we think 00:03:57.897 --> 00:04:00.169 position:50% align:middle are really relevant to the research at hand. 00:04:00.169 --> 00:04:03.854 position:50% align:middle You'll see 2022 qualified as one of those cycles. 00:04:03.854 --> 00:04:08.444 position:50% align:middle The kind of traditional custom items that we include are pre-tax annual earnings, 00:04:08.444 --> 00:04:15.154 position:50% align:middle specialty topics like the Nurse Licensure Compact, and nurses' use of telehealth practice. 00:04:15.154 --> 00:04:19.744 position:50% align:middle In 2022, we did add a few additional items to the instrument, those related specifically 00:04:19.744 --> 00:04:22.244 position:50% align:middle to travel nursing, I think for obvious reasons. 00:04:22.244 --> 00:04:26.824 position:50% align:middle And then the other point that we added is we added kind of a battery of questions related to nurses' experience 00:04:26.824 --> 00:04:31.065 position:50% align:middle of emotional exhaustion within their role during the COVID-19 pandemic. 00:04:31.065 --> 00:04:35.845 position:50% align:middle So in total, when you look at the MDS and the custom questions, we had a total of 39 questions 00:04:35.845 --> 00:04:38.545 position:50% align:middle for the 2022 survey. 00:04:38.545 --> 00:04:40.305 position:50% align:middle I said this yesterday. 00:04:40.305 --> 00:04:42.495 position:50% align:middle I don't think it could be said enough. 00:04:42.495 --> 00:04:46.185 position:50% align:middle The 2022 National Nursing Workforce Survey really represents the largest, most comprehensive, 00:04:46.185 --> 00:04:50.885 position:50% align:middle and rigorous assessment of the U.S. nursing workforce since the onset of the pandemic. 00:04:50.885 --> 00:04:52.755 position:50% align:middle So hopefully you downloaded it yesterday. 00:04:52.755 --> 00:04:55.715 position:50% align:middle If you haven't, please download it before you get on that plane. 00:04:55.715 --> 00:04:57.055 position:50% align:middle It's well worth a read. 00:04:57.055 --> 00:04:58.475 position:50% align:middle It is robust. 00:04:58.475 --> 00:04:59.775 position:50% align:middle It is one of our supplements. 00:04:59.775 --> 00:05:03.037 position:50% align:middle So I think it's over 60 plus pages and whatnot. 00:05:03.037 --> 00:05:08.707 position:50% align:middle But because of how we do this and how rigorously we do this and how often we do this, 00:05:08.707 --> 00:05:13.507 position:50% align:middle I think it provides really critical detail in terms of what it was like before the pandemic and what it's 00:05:13.507 --> 00:05:17.367 position:50% align:middle like now since the onset of the pandemic. 00:05:17.367 --> 00:05:21.917 position:50% align:middle Based on that preamble, though, it will likely come as no surprise to you that the 00:05:21.917 --> 00:05:27.407 position:50% align:middle results of the 2022 National Nursing Workforce Survey really raised a new level of awareness about issues 00:05:27.407 --> 00:05:29.927 position:50% align:middle critical to the nursing workforce. 00:05:29.927 --> 00:05:36.062 position:50% align:middle As a result, for the first time ever, we decided to pursue a number of targeted subtopics 00:05:36.062 --> 00:05:38.732 position:50% align:middle using the 2022 sample. 00:05:38.732 --> 00:05:43.912 position:50% align:middle So this coming April, so just to put it on your radar, this coming April, we are going to be publishing a 00:05:43.912 --> 00:05:46.202 position:50% align:middle paper on all eight of these topics. 00:05:46.202 --> 00:05:49.202 position:50% align:middle If you saw my colleague, Charlie O'Hara's presentation yesterday, 00:05:49.202 --> 00:05:52.182 position:50% align:middle you'll notice that telehealth usage trends is one of them. 00:05:52.182 --> 00:05:55.842 position:50% align:middle The results that I am presenting here today represent the first one. 00:05:55.842 --> 00:05:59.742 position:50% align:middle So chief among these issues, we really felt as though it was imperative to provide 00:05:59.742 --> 00:06:09.611 position:50% align:middle an up-to-date and comprehensive overview of the Advanced Practice Registered Nurse or APRN workforce. 00:06:09.611 --> 00:06:12.921 position:50% align:middle The primary objectives of this study were really twofold. 00:06:12.921 --> 00:06:16.611 position:50% align:middle We wanted that comprehensive descriptive summary of the APRN sample. 00:06:16.611 --> 00:06:20.821 position:50% align:middle We felt that in and of itself represented a contribution to the literature. 00:06:20.821 --> 00:06:25.461 position:50% align:middle But then similar to most of our other studies, since we had that kind of COVID battery of questions, 00:06:25.461 --> 00:06:31.301 position:50% align:middle we wanted to do an in-depth examination of the effects of the COVID-19 pandemic on APRNs' experiences 00:06:31.301 --> 00:06:37.171 position:50% align:middle of burnout and stress during the pandemic, feeling that that provided critical insight into how 00:06:37.171 --> 00:06:45.161 position:50% align:middle that might inform their intent to leave and then workforce planning for future cycles. 00:06:45.161 --> 00:06:47.991 position:50% align:middle So, as I mentioned up front, because this is a subanalysis, 00:06:47.991 --> 00:06:52.771 position:50% align:middle we were largely able to really just rely on the rigorous methodology that underpinned 00:06:52.771 --> 00:06:54.531 position:50% align:middle the overall analysis. 00:06:54.531 --> 00:06:59.881 position:50% align:middle So this was essentially still just a cross-sectional study utilizing a stratified random sampling plan 00:06:59.881 --> 00:07:03.644 position:50% align:middle looking across all 50 states of the District of Columbia and the Northern Mariana Islands 00:07:03.644 --> 00:07:05.364 position:50% align:middle in this particular instance. 00:07:05.364 --> 00:07:10.704 position:50% align:middle In the RN sample, that included proportional representation of APRNs across all the jurisdictions 00:07:10.704 --> 00:07:12.134 position:50% align:middle that we had. 00:07:12.134 --> 00:07:19.954 position:50% align:middle So overall, we were able to identify just over 520,000 APRNs in our sample representing about 11.8% 00:07:19.954 --> 00:07:24.914 position:50% align:middle of the RN total. 00:07:24.914 --> 00:07:26.034 position:50% align:middle Respondents were asked... 00:07:26.034 --> 00:07:30.835 position:50% align:middle So I think as you get into the larger conversation of how do you pursue a subanalysis, 00:07:30.835 --> 00:07:34.445 position:50% align:middle how do you define your population, we really wanted to just give you the nuts 00:07:34.445 --> 00:07:35.525 position:50% align:middle and the bolts. 00:07:35.525 --> 00:07:41.055 position:50% align:middle So for this particular survey instrument, there are two questions that we ask that allow 00:07:41.055 --> 00:07:44.095 position:50% align:middle respondents to identify themselves as an APRN. 00:07:44.095 --> 00:07:46.825 position:50% align:middle So the first one here is, let's see if I can figure out, yeah, there you go, 00:07:46.825 --> 00:07:48.545 position:50% align:middle look, question four. 00:07:48.545 --> 00:07:50.905 position:50% align:middle So we ask what type of license do you hold? 00:07:50.905 --> 00:07:53.905 position:50% align:middle There are four response options, RN, LPN, APRN. 00:07:53.905 --> 00:07:59.735 position:50% align:middle And then there's a second question here, Q9, where we ask how are you credentialed in your state, 00:07:59.735 --> 00:08:01.481 position:50% align:middle basically what is your APRN role? 00:08:01.481 --> 00:08:08.751 position:50% align:middle What we did is we took responses across these two items and combined them to try to make sure that we were 00:08:08.751 --> 00:08:09.981 position:50% align:middle as comprehensive as possible. 00:08:09.981 --> 00:08:11.801 position:50% align:middle So what do I mean by that? 00:08:11.801 --> 00:08:15.721 position:50% align:middle Charlie talked about in his presentation yesterday, kind of visualizing like a Venn diagram. 00:08:15.721 --> 00:08:18.121 position:50% align:middle So that's exactly what you should do here. 00:08:18.121 --> 00:08:22.681 position:50% align:middle Where these two questions intersected, that represented like 98% of the people that we 00:08:22.681 --> 00:08:24.141 position:50% align:middle identified as an APRN. 00:08:24.141 --> 00:08:29.131 position:50% align:middle If you were saying that you had an APRN license, you were also by and large telling us what role you 00:08:29.131 --> 00:08:31.002 position:50% align:middle were certified in, right? 00:08:31.002 --> 00:08:34.322 position:50% align:middle What we did find though, and this is common in any survey research, 00:08:34.322 --> 00:08:38.762 position:50% align:middle is that there were folks who responded to this question and didn't respond to this question. 00:08:38.762 --> 00:08:43.372 position:50% align:middle There were folks who responded to this question and didn't give us information on this one. 00:08:43.372 --> 00:08:47.302 position:50% align:middle In addition, of course, there is variability in how jurisdictions go 00:08:47.302 --> 00:08:49.322 position:50% align:middle about regulating the APRN role. 00:08:49.322 --> 00:08:52.912 position:50% align:middle So taking all of that into account, what we did is we didn't only focus 00:08:52.912 --> 00:08:56.632 position:50% align:middle on that intersection, but we also tried to kind of like herd all the cats. 00:08:56.632 --> 00:09:01.307 position:50% align:middle So we tried to bring the stragglers from question four into the fold, the stragglers from question nine 00:09:01.307 --> 00:09:04.057 position:50% align:middle into the fold, to be as comprehensive as we could. 00:09:04.057 --> 00:09:08.057 position:50% align:middle So if somebody said that they had an APRN license but didn't specify a role, they still counted. 00:09:08.057 --> 00:09:11.537 position:50% align:middle If somebody said that they had a role, but they didn't indicate that they had an APRN license 00:09:11.537 --> 00:09:16.917 position:50% align:middle specifically in their jurisdiction, they still counted for the analysis. 00:09:16.917 --> 00:09:19.697 position:50% align:middle The general timeframe, I always think that this is helpful just for the 00:09:19.697 --> 00:09:20.697 position:50% align:middle sake of transparency. 00:09:20.697 --> 00:09:24.307 position:50% align:middle This is not unique or special for the 2022 cycle. 00:09:24.307 --> 00:09:28.117 position:50% align:middle This really gives you a sense of what it takes to get this survey off the ground, 00:09:28.117 --> 00:09:30.329 position:50% align:middle every single cycle that we go into the fold. 00:09:30.329 --> 00:09:34.209 position:50% align:middle One of the things that I would hasten to mention because I see Richard kind of nodding his head here, 00:09:34.209 --> 00:09:37.279 position:50% align:middle there is a whole bunch of activity that's front-loaded to this process. 00:09:37.279 --> 00:09:40.119 position:50% align:middle There is months of work before we even get to here. 00:09:40.119 --> 00:09:42.279 position:50% align:middle But this is really about how do we get it off the ground? 00:09:42.279 --> 00:09:46.179 position:50% align:middle How do we get nurses in your jurisdictions receiving the survey and providing this critical 00:09:46.179 --> 00:09:47.559 position:50% align:middle information to us? 00:09:47.559 --> 00:09:54.309 position:50% align:middle So in January 2022, we had finalized our distribution plan and you'll see it was a little bit more complex 00:09:54.309 --> 00:09:55.879 position:50% align:middle than it was in prior cycles. 00:09:55.879 --> 00:10:02.032 position:50% align:middle And then we collated our final mailing list so that in April of 2022, we were able to administer the survey 00:10:02.032 --> 00:10:05.232 position:50% align:middle in full across all the participating jurisdictions. 00:10:05.232 --> 00:10:09.542 position:50% align:middle That then period of kind of active data collection carried forward through the end of September 2022, 00:10:09.542 --> 00:10:17.102 position:50% align:middle which kind of served as a pivotal inflection point in the study because we pivoted away from active data 00:10:17.102 --> 00:10:21.672 position:50% align:middle collection into the analysis of the responses that we had received across three different modes, 00:10:21.672 --> 00:10:23.392 position:50% align:middle which you'll see in a second. 00:10:23.392 --> 00:10:29.312 position:50% align:middle By the end of December 2022, or thereabouts, kind of bleeding into January 2023, so to speak, 00:10:29.312 --> 00:10:32.295 position:50% align:middle we were able to generate a full report of the study findings. 00:10:32.295 --> 00:10:40.255 position:50% align:middle Those were then published in the April 2023 edition of the Journal of Nursing Regulation as a full supplement. 00:10:40.255 --> 00:10:43.695 position:50% align:middle Regarding the methodology, again, this is just to help those in particular who were not 00:10:43.695 --> 00:10:47.935 position:50% align:middle able to attend Richard's presentation the other day, our stratified random sampling approach, 00:10:47.935 --> 00:10:52.575 position:50% align:middle and this is for the entire survey, really allows us to derive population-weighted national 00:10:52.575 --> 00:10:58.865 position:50% align:middle estimates that project observed trends within our sample of the survey to really all levels of nursing 00:10:58.865 --> 00:11:00.754 position:50% align:middle across the United States. 00:11:00.754 --> 00:11:05.374 position:50% align:middle So the 2022 project in particular took the form of a mixed modes survey. 00:11:05.374 --> 00:11:10.634 position:50% align:middle So we leveraged, as we always do, direct mail and email outreach, 00:11:10.634 --> 00:11:14.664 position:50% align:middle but what was different about the 2022 cycle is that we also, for the first time ever, 00:11:14.664 --> 00:11:20.044 position:50% align:middle integrated data collected systematically through the Nursys e-Notify system. 00:11:20.044 --> 00:11:25.014 position:50% align:middle So Nur Rajwany is here, he might be in the next room, he is the CIO for NCSBN, 00:11:25.014 --> 00:11:29.434 position:50% align:middle so if you really want the full context and detail for Nursys e-Notify, he's your guy. 00:11:29.434 --> 00:11:33.723 position:50% align:middle But what I'm going to do is kind of give you some crib notes so you kind of have a general sense of what it 00:11:33.723 --> 00:11:36.853 position:50% align:middle means that we integrated the Nursys e-Notify data. 00:11:36.853 --> 00:11:43.763 position:50% align:middle So Nursys e-Notify is a free online tool linked to the Nursys licensure database through which a nurse can 00:11:43.763 --> 00:11:50.023 position:50% align:middle self-enroll to receive reminders and updates for their professional licenses or license to keep it up to date. 00:11:50.023 --> 00:11:55.093 position:50% align:middle As part of the registration process, though, it is anticipated and expected that the nurse will 00:11:55.093 --> 00:12:01.960 position:50% align:middle provide information and keep that information up to date on a fairly regular cycle across all MDS items. 00:12:01.960 --> 00:12:05.600 position:50% align:middle So going back to the core of what our survey instrument is. 00:12:05.600 --> 00:12:08.590 position:50% align:middle As a result of that, you have heard, like Charlie, for instance, yesterday, 00:12:08.590 --> 00:12:11.980 position:50% align:middle and you'll see me talk about it, too, there are five jurisdictions, 00:12:11.980 --> 00:12:14.970 position:50% align:middle and we'll get into that on the next slide, where we do not have information 00:12:14.970 --> 00:12:16.600 position:50% align:middle regarding the custom elements. 00:12:16.600 --> 00:12:20.170 position:50% align:middle And that is because five states, we leveraged e-Notify data, 00:12:20.170 --> 00:12:22.290 position:50% align:middle and they are only asking the MDS question. 00:12:22.290 --> 00:12:26.610 position:50% align:middle So that gives you a little bit of, hopefully, clarity as to why those five states are sometimes 00:12:26.610 --> 00:12:29.850 position:50% align:middle removed from certain items on our survey. 00:12:29.850 --> 00:12:35.434 position:50% align:middle In total, though, across the three modes, we were able to leverage for the full report responses 00:12:35.434 --> 00:12:40.204 position:50% align:middle from over 300,000 nurses in the 2022 cycle. 00:12:40.204 --> 00:12:45.584 position:50% align:middle Direct mail outreach was conducted in 43 jurisdictions with our vendor Scantron. 00:12:45.584 --> 00:12:47.394 position:50% align:middle That is kind of our bread and butter. 00:12:47.394 --> 00:12:51.504 position:50% align:middle And then we supplemented that with email outreach, exclusive email outreach 00:12:51.504 --> 00:12:53.524 position:50% align:middle to four additional jurisdictions. 00:12:53.524 --> 00:12:56.304 position:50% align:middle As I have mentioned, there were five jurisdictions where we were able to, 00:12:56.304 --> 00:12:59.664 position:50% align:middle through kind of internal, rigorous testing and analysis, 00:12:59.664 --> 00:13:01.697 position:50% align:middle to determine the e-Notify data. 00:13:01.697 --> 00:13:05.357 position:50% align:middle So the nurse self-enrollment data, when they had provided MDS information, 00:13:05.357 --> 00:13:10.037 position:50% align:middle was of sufficient quality and of a sufficient volume that we could rely on integrating 00:13:10.037 --> 00:13:11.557 position:50% align:middle that information directly. 00:13:11.557 --> 00:13:15.907 position:50% align:middle And that ultimately led to the decision that we didn't need to pursue further survey outreach 00:13:15.907 --> 00:13:17.407 position:50% align:middle in those jurisdictions. 00:13:17.407 --> 00:13:22.787 position:50% align:middle The results I'm about to cover then really focus primarily on kind of a detailed, descriptive summary. 00:13:22.787 --> 00:13:25.337 position:50% align:middle As I mentioned, that really in and of itself constitutes, I think, 00:13:25.337 --> 00:13:30.705 position:50% align:middle a contribution for this particular advanced practice provider role to the literature. 00:13:30.705 --> 00:13:35.455 position:50% align:middle But then we also overlay some inferential statistics, specifically binary, logistic regression, 00:13:35.455 --> 00:13:40.815 position:50% align:middle and natural language processing to give you some additional insight. 00:13:40.815 --> 00:13:46.875 position:50% align:middle So we are using this as an opportunity, obviously, to broadcast this as loud as we can. 00:13:46.875 --> 00:13:50.575 position:50% align:middle We really feel as though, in addition to the overall study findings, 00:13:50.575 --> 00:13:55.785 position:50% align:middle this particular APM breakout represents one of the most comprehensive updates for the APRN workforce, 00:13:55.785 --> 00:14:00.409 position:50% align:middle not only really since the onset of the COVID-19 pandemic, but really dating all the way back to HRSA's 00:14:00.409 --> 00:14:02.439 position:50% align:middle NSSRN in 2018. 00:14:02.439 --> 00:14:06.489 position:50% align:middle We would go a step further, even too, to really call out the fact that, 00:14:06.489 --> 00:14:11.059 position:50% align:middle when you're talking about HRSA's survey approach, they really have a particular focus on nurse 00:14:11.059 --> 00:14:13.599 position:50% align:middle practitioners as a primary role. 00:14:13.599 --> 00:14:18.159 position:50% align:middle And then if you look at other reliable, you know, data sources, such as the Bureau of Labor Statistics 00:14:18.159 --> 00:14:21.499 position:50% align:middle and the way in which they kind of cyclically track labor trends, you know, 00:14:21.499 --> 00:14:25.499 position:50% align:middle they don't include CNSs as part of that track, as part of that tracking. 00:14:25.499 --> 00:14:31.168 position:50% align:middle So what we would actually argue in this instance is this is one of the most comprehensive overviews and 00:14:31.168 --> 00:14:35.978 position:50% align:middle up-to-date analyses for the APRN workforce, kind of over the last decade or so. 00:14:35.978 --> 00:14:41.078 position:50% align:middle So the results of this analysis, as I have mentioned, will be available in April, 2024. 00:14:41.078 --> 00:14:44.598 position:50% align:middle So this dig into the results a little bit. 00:14:44.598 --> 00:14:48.878 position:50% align:middle So overall, certified nurse practitioners account for the bulk of the survey sample, 00:14:48.878 --> 00:14:52.808 position:50% align:middle I think no surprises there, followed by a certified nurse specialist, 00:14:52.808 --> 00:14:56.968 position:50% align:middle certified registered nurse anesthetists, and certified nurse midwives. 00:14:56.968 --> 00:15:04.475 position:50% align:middle On average, APRNs in our survey tended to be about 50 years old, with a majority self-reporting as female, 00:15:04.475 --> 00:15:06.925 position:50% align:middle non-Hispanic, and white. 00:15:06.925 --> 00:15:13.445 position:50% align:middle Not included in this table, but of relevance, about one in two APRNs reported that their first, 00:15:13.445 --> 00:15:18.235 position:50% align:middle a baccalaureate as their first nursing degree or credential, followed by associates or masters, 00:15:18.235 --> 00:15:24.905 position:50% align:middle and about three-quarters of APRNs identified a masters as their highest order of nursing degree or credential, 00:15:24.905 --> 00:15:29.055 position:50% align:middle followed by DMP at about 10%. 00:15:29.055 --> 00:15:34.313 position:50% align:middle Most APRNs indicate that they are actively employed within nursing itself, 00:15:34.313 --> 00:15:37.623 position:50% align:middle and work in a direct patient care setting. 00:15:37.623 --> 00:15:42.013 position:50% align:middle Furthermore, on average, APRNs across all four roles reported being licensed 00:15:42.013 --> 00:15:47.933 position:50% align:middle approximately 24 years and working on average about 40 hours a week. 00:15:47.933 --> 00:15:53.843 position:50% align:middle Family health and acute/critical care were two of the most commonly reported clinical practice 00:15:53.843 --> 00:15:58.033 position:50% align:middle specialty areas, and a plurality of APRNs, so not exactly a majority, 00:15:58.033 --> 00:16:04.074 position:50% align:middle but about 40% of APRNs reported working in a hospital setting, followed by about a quarter of the APRN 00:16:04.074 --> 00:16:07.694 position:50% align:middle workforce indicating an ambulatory care setting. 00:16:07.694 --> 00:16:10.934 position:50% align:middle Again, I don't think this necessarily constitutes any great surprise. 00:16:10.934 --> 00:16:19.148 position:50% align:middle The median pay for CRNAs was highest at about $193,000, followed by CMPs at about $109,000, 00:16:19.148 --> 00:16:24.314 position:50% align:middle CNMs at about $104,000, and then CNSs at $90,000. 00:16:24.314 --> 00:16:31.532 position:50% align:middle Interesting, this dovetails a lot if you were present for Charlie's presentation the other day. 00:16:31.532 --> 00:16:36.132 position:50% align:middle When we get into the topic of telehealth, about two-thirds of APRNs indicate that they practice, 00:16:36.132 --> 00:16:40.542 position:50% align:middle actively practice telehealth in their role, and two in three APRNs report, in fact, 00:16:40.542 --> 00:16:44.302 position:50% align:middle that they use two or more telehealth modalities quite regularly. 00:16:44.302 --> 00:16:48.552 position:50% align:middle While most employed video calls, which is exactly in line with your profile analysis the 00:16:48.552 --> 00:16:54.732 position:50% align:middle other day, notable proportions did use electronic messaging, email, and phone. 00:16:54.732 --> 00:17:02.910 position:50% align:middle In addition, APRNs estimate that about 22% of their APRN practice goes to facilitate remote patient care 00:17:02.910 --> 00:17:10.160 position:50% align:middle within their single jurisdiction, and about 10% goes to promote cross-border care. 00:17:10.160 --> 00:17:18.070 position:50% align:middle The cross-border care was facilitated by APRNs' use of their RN multi-state license. 00:17:18.070 --> 00:17:25.510 position:50% align:middle So roughly a quarter of the APRNs in this analysis hold an MSL, and about 14% of that cohort indicate that they 00:17:25.510 --> 00:17:32.173 position:50% align:middle use their MSL to support telehealth or other means of communication across state borders. 00:17:32.173 --> 00:17:38.833 position:50% align:middle Approximately 6% of the APRN sample with that MSL also use it to facilitate distance education. 00:17:38.833 --> 00:17:44.083 position:50% align:middle That's another thing that we know that this population often does, and a much smaller proportion used it 00:17:44.083 --> 00:17:47.273 position:50% align:middle to promote disaster support, which was kind of interesting, 00:17:47.273 --> 00:17:52.913 position:50% align:middle given the context for 2020 to 2022 in this sample. 00:17:52.913 --> 00:18:00.503 position:50% align:middle Getting into the COVID-specific questions, a majority of APRNs, about 55%, 00:18:00.503 --> 00:18:05.529 position:50% align:middle indicated that their workload increased as a direct result of the COVID-19 pandemic. 00:18:05.529 --> 00:18:08.939 position:50% align:middle Again, I think that this dovetails with our own experience. 00:18:08.939 --> 00:18:16.289 position:50% align:middle Similarly, high proportions of APRNs reported feeling emotionally drained, used up, fatigued, burned out, 00:18:16.289 --> 00:18:19.359 position:50% align:middle or at the end of the rope, a few times a week to every day. 00:18:19.359 --> 00:18:20.829 position:50% align:middle And I think that that's really critical. 00:18:20.829 --> 00:18:25.179 position:50% align:middle When I presented the overall results at the annual meeting last August, 00:18:25.179 --> 00:18:29.269 position:50% align:middle I tried to take a step back and just let that sink in a little bit, because this isn't, 00:18:29.269 --> 00:18:34.344 position:50% align:middle when you think about the frequency and the high level of these sentiments being expressed here, 00:18:34.344 --> 00:18:37.524 position:50% align:middle this isn't just like occasionally, I feel a little worn out. 00:18:37.524 --> 00:18:42.244 position:50% align:middle This is extreme levels of emotional exhaustion rising up to the level of burnout, 00:18:42.244 --> 00:18:47.074 position:50% align:middle experienced at a minimum multiple times a week, if not every single day. 00:18:47.074 --> 00:18:51.964 position:50% align:middle So I think it bears very serious consideration when thinking about workforce policy and 00:18:51.964 --> 00:18:53.774 position:50% align:middle planning moving forward. 00:18:53.774 --> 00:18:57.384 position:50% align:middle APRNs with the least experience, so those are defined in our sample, 00:18:57.384 --> 00:19:04.641 position:50% align:middle as you can see on the table here as those licensed 12 or fewer years, consistently reported heightened 00:19:04.641 --> 00:19:08.741 position:50% align:middle emotional exhaustion, vis-à-vis every other strata of the experience. 00:19:08.741 --> 00:19:14.821 position:50% align:middle So you can see we've bent number of years licensed into quartiles, so we let the data speak for itself. 00:19:14.821 --> 00:19:19.631 position:50% align:middle We didn't just pick these as like cutoffs based on like subjective reasoning or because of the literature, etc. 00:19:19.631 --> 00:19:21.681 position:50% align:middle This is how the data was born out. 00:19:21.681 --> 00:19:26.761 position:50% align:middle When you look at these groups of individuals, and you can kind of see it in all these columns, 00:19:26.761 --> 00:19:32.272 position:50% align:middle very consistently across this kind of youngest, least experienced cohort of nurses compared to all the 00:19:32.272 --> 00:19:39.102 position:50% align:middle other strata, we are seeing heightened levels and often very statistically significant levels of heightened 00:19:39.102 --> 00:19:42.632 position:50% align:middle emotional distress and burnout among that young cohort. 00:19:42.632 --> 00:19:45.832 position:50% align:middle Similarly, and again, I don't think that this comes as too great a surprise. 00:19:45.832 --> 00:19:48.692 position:50% align:middle Here, let's see if I can highlight that, sorry. 00:19:48.692 --> 00:19:55.012 position:50% align:middle Those APRNs who reported increased workloads during the same period of time presented similar patterns in terms 00:19:55.012 --> 00:20:00.982 position:50% align:middle of significant increases in their experience of emotional distress. 00:20:00.982 --> 00:20:06.432 position:50% align:middle So then, because we had such a robust sample, because our survey instrument is so comprehensive 00:20:06.432 --> 00:20:13.752 position:50% align:middle with employing both MDS items and the custom survey elements, we were able to pursue kind of a more robust 00:20:13.752 --> 00:20:15.792 position:50% align:middle approach to the analysis, so to speak. 00:20:15.792 --> 00:20:20.832 position:50% align:middle So that prior analysis was looking independently at each of these individual characteristics and how does 00:20:20.832 --> 00:20:26.702 position:50% align:middle it align with nurses, self-reported, emotional exhaustion, burnout, stress, etc. 00:20:26.702 --> 00:20:32.776 position:50% align:middle In this particular instance in the multivariable setting, we were able to adjust for respondents' other 00:20:32.776 --> 00:20:35.106 position:50% align:middle known and very important covariants. 00:20:35.106 --> 00:20:39.676 position:50% align:middle So when we are looking at these model results here, these adjusted odds ratios, that's what this, 00:20:39.676 --> 00:20:41.296 position:50% align:middle you can kind of see it's defined here. 00:20:41.296 --> 00:20:46.346 position:50% align:middle So the adjusted odds ratios, this model is controlling for respondents' 00:20:46.346 --> 00:20:54.046 position:50% align:middle self-reported sex, ethnicity, race, salary, role, indicators for full-time nursing employment, 00:20:54.046 --> 00:20:55.786 position:50% align:middle and direct patient care. 00:20:55.786 --> 00:21:01.256 position:50% align:middle So all of that is packaged into this model, and the idea in doing that is essentially you are kind 00:21:01.256 --> 00:21:04.036 position:50% align:middle of further isolating the variable of interest. 00:21:04.036 --> 00:21:07.516 position:50% align:middle So what we're doing in this context is we're saying it's not about race anymore, 00:21:07.516 --> 00:21:09.906 position:50% align:middle it's not about ethnicity anymore, it's not about how much you earn, 00:21:09.906 --> 00:21:12.396 position:50% align:middle it's not about whether or not you're in a direct patient care setting, etc. 00:21:12.396 --> 00:21:13.926 position:50% align:middle That's all to the side. 00:21:13.926 --> 00:21:16.576 position:50% align:middle We've controlled for that, so to speak, within this context. 00:21:16.576 --> 00:21:22.456 position:50% align:middle And now we're looking, does that relationship between emotional exhaustion and 00:21:22.456 --> 00:21:29.356 position:50% align:middle the provider type, does that experience of emotional exhaustion and increased workload still hold? 00:21:29.356 --> 00:21:33.393 position:50% align:middle In this particular instance, we found that the results were very, very durable. 00:21:33.393 --> 00:21:37.623 position:50% align:middle So consistent with kind of our independent results that we just looked at at the prior slide. 00:21:37.623 --> 00:21:41.543 position:50% align:middle We looked at essentially APRNs with the least experience, once again, 00:21:41.543 --> 00:21:47.833 position:50% align:middle reporting elevated levels of emotional exhaustion and burnout vis-a-vis all of their other counterparts. 00:21:47.833 --> 00:21:52.383 position:50% align:middle For context, these adjusted odds ratio, for those of you who are familiar with statistics 00:21:52.383 --> 00:21:54.823 position:50% align:middle and research, there's always a comparison group, right? 00:21:54.823 --> 00:21:57.583 position:50% align:middle Like, so an adjusted odds ratio needs context. 00:21:57.583 --> 00:22:01.039 position:50% align:middle So in this instance, what we highlighted here are the effect sizes 00:22:01.039 --> 00:22:05.779 position:50% align:middle associated with the least experienced cohort of APRNs compared to the most experienced kind of group 00:22:05.779 --> 00:22:11.229 position:50% align:middle of APRNs, anticipating that that would, where we would see the most severe divergence, 00:22:11.229 --> 00:22:12.529 position:50% align:middle which was what we saw. 00:22:12.529 --> 00:22:15.819 position:50% align:middle So in this instance, I've already defined what constitutes kind of the 00:22:15.819 --> 00:22:18.109 position:50% align:middle youngest least experienced group at 12 years. 00:22:18.109 --> 00:22:22.759 position:50% align:middle The most experienced group was 36 or more years experience in this sample. 00:22:22.759 --> 00:22:25.199 position:50% align:middle Important, yeah, so there you go. 00:22:25.199 --> 00:22:27.609 position:50% align:middle On this slide then, we looked at increased workload. 00:22:27.609 --> 00:22:28.879 position:50% align:middle So we did the exact same thing. 00:22:28.879 --> 00:22:33.783 position:50% align:middle So the exact same adjustments as we did for a year's experience. 00:22:33.783 --> 00:22:37.033 position:50% align:middle And what we found was that the results were very, very consistent. 00:22:37.033 --> 00:22:40.583 position:50% align:middle You can see that the odds ratio here were even higher. 00:22:40.583 --> 00:22:46.243 position:50% align:middle I mean, if you're familiar with odds ratios, you know, this is three times the likelihood that you're going 00:22:46.243 --> 00:22:49.353 position:50% align:middle to report heightened emotional exhaustion into stress. 00:22:49.353 --> 00:22:53.373 position:50% align:middle So I mean, this almost, this absolutely qualifies as not needing a P-value when 00:22:53.373 --> 00:22:54.863 position:50% align:middle you see something that high. 00:22:54.863 --> 00:22:58.063 position:50% align:middle In this instance, I think it kind of goes without saying we're looking at increased workloads. 00:22:58.063 --> 00:23:02.496 position:50% align:middle So the comparison group here are those APRNs who indicated that they had not experienced an increase 00:23:02.496 --> 00:23:06.416 position:50% align:middle to their workload during the pandemic. 00:23:06.416 --> 00:23:11.396 position:50% align:middle So what are the key takeaways for this whole analysis? 00:23:11.396 --> 00:23:17.246 position:50% align:middle So acute experiences of stress and burnout during the COVID-19 pandemic were felt disproportionately 00:23:17.246 --> 00:23:19.946 position:50% align:middle by younger, less experienced APRNs. 00:23:19.946 --> 00:23:24.256 position:50% align:middle But unlike, here's the silver lining, unlike the overall analysis that we did for the 00:23:24.256 --> 00:23:31.525 position:50% align:middle RN and LPN, LVN workforce analysis that we published in April of 2023, we did not find a correlative effect or 00:23:31.525 --> 00:23:36.765 position:50% align:middle an association between those heightened levels of emotional distress and exhaustion and their intent 00:23:36.765 --> 00:23:38.375 position:50% align:middle to leave in the next five years. 00:23:38.375 --> 00:23:40.135 position:50% align:middle So that's a little bit of a silver lining. 00:23:40.135 --> 00:23:43.615 position:50% align:middle But it does, I still think, kind of constitute a shot across the bow, right? 00:23:43.615 --> 00:23:48.165 position:50% align:middle So at this moment in time, we have those APRNs who are consistently reporting 00:23:48.165 --> 00:23:53.465 position:50% align:middle higher levels of burnout, higher levels of stress, telling us that in the near and intermediate term, 00:23:53.465 --> 00:23:57.055 position:50% align:middle they do not plan to exit the workforce, which is, I think, a tremendous boon. 00:23:57.055 --> 00:23:59.345 position:50% align:middle The flipside is they're still experiencing those things. 00:23:59.345 --> 00:24:02.820 position:50% align:middle And I think we need to be intentional with workforce planning moving forward to make sure that 00:24:02.820 --> 00:24:05.350 position:50% align:middle dial doesn't change. 00:24:05.350 --> 00:24:10.740 position:50% align:middle However, this report, I think, does highlight kind of a parallel concern. 00:24:10.740 --> 00:24:16.900 position:50% align:middle And that is the potential loss of kind of the diverse educational training and education of a more 00:24:16.900 --> 00:24:19.300 position:50% align:middle experienced generation of APRNs. 00:24:19.300 --> 00:24:24.000 position:50% align:middle So unlike the younger kind of less experienced cohort, that most experienced cohort of APRNs in this, 00:24:24.000 --> 00:24:30.833 position:50% align:middle so those were 36 or more years' experience, at a clip of 75% indicated that they were likely 00:24:30.833 --> 00:24:34.833 position:50% align:middle to leave the profession or retire in the next five years. 00:24:34.833 --> 00:24:38.383 position:50% align:middle So that's not necessarily earth-shattering, right? 00:24:38.383 --> 00:24:43.473 position:50% align:middle We would anticipate as you advance in your career at a certain point, you might consider retiring. 00:24:43.473 --> 00:24:46.611 position:50% align:middle What was a little bit striking to us is the 75%. 00:24:46.611 --> 00:24:51.203 position:50% align:middle When we did the same thing and cut the RN population, it was more in the order of 50% to 60%. 00:24:51.203 --> 00:24:56.643 position:50% align:middle So when you're talking about an order of increase of 15% to possibly 20% in the advanced provider role, 00:24:56.643 --> 00:24:59.733 position:50% align:middle I think that that also bears further consideration. 00:24:59.733 --> 00:25:03.563 position:50% align:middle But the thing that we really highlighted in the full report, so I would ask that you keep that 00:25:03.563 --> 00:25:08.263 position:50% align:middle on your radar, download it when you get the opportunity, is that what we were able to document is 00:25:08.263 --> 00:25:12.523 position:50% align:middle that the projected attrition, also the past, but really the projected attrition, 00:25:12.523 --> 00:25:17.643 position:50% align:middle is not going to be felt proportionally with that older generation across all four roles. 00:25:17.643 --> 00:25:24.243 position:50% align:middle What we were able to identify in our full analysis is that this projected attrition is going to be likely 00:25:24.243 --> 00:25:30.797 position:50% align:middle more pronounced among APRNs in the CNS role and to a lesser extent the CNN role. 00:25:30.797 --> 00:25:36.967 position:50% align:middle At a time, we would argue when more nurses are needed than ever to really care for the increased inpatient 00:25:36.967 --> 00:25:44.037 position:50% align:middle demand associated with COVID-19 and an aging population, how nurses are trained and in particular 00:25:44.037 --> 00:25:48.687 position:50% align:middle the risk of being lost, I think really bear attention. 00:25:48.687 --> 00:25:53.357 position:50% align:middle And I think that they have potential ramifications when we think about future patient access and provider 00:25:53.357 --> 00:25:56.387 position:50% align:middle choice down the road. 00:25:56.387 --> 00:26:01.227 position:50% align:middle And then finally, I don't think it will be very surprising in an NCSBN context to hear me say this. 00:26:01.227 --> 00:26:06.067 position:50% align:middle As the APRN consensus model really confirms, there is value and unique contributions across all 00:26:06.067 --> 00:26:07.877 position:50% align:middle four APRN roles. 00:26:07.877 --> 00:26:12.587 position:50% align:middle So to ensure that current models of care remain fit for the future and sufficiently flexible to meet 00:26:12.587 --> 00:26:18.947 position:50% align:middle the demands, the diverse demands really of tomorrow's patients, we really encourage policymakers, employers, 00:26:18.947 --> 00:26:24.557 position:50% align:middle educators, whatnot to be intentional in how they recruit, train, and support both the current and the 00:26:24.557 --> 00:26:26.357 position:50% align:middle future APRN workforce. 00:26:26.357 --> 00:26:31.182 position:50% align:middle I think efforts need to continue to be made to diversify the APRN workforce, 00:26:31.182 --> 00:26:36.072 position:50% align:middle but that's usually within the context of kind of the demographic profile, which is incredibly important. 00:26:36.072 --> 00:26:39.912 position:50% align:middle But in addition to that for the APRN workforce, I think we need to think about the diversity in the 00:26:39.912 --> 00:26:44.802 position:50% align:middle professional training and the education of tomorrow's workforce to make sure that we're really adequately 00:26:44.802 --> 00:26:49.682 position:50% align:middle prepared to address a range of patient needs. 00:26:49.682 --> 00:26:51.652 position:50% align:middle So with that, let's see, how did I do? 00:26:51.652 --> 00:26:53.752 position:50% align:middle So we have 17...we're 17 minutes early here. 00:26:53.752 --> 00:26:55.882 position:50% align:middle So we have plenty of time for questions. 00:26:55.882 --> 00:27:00.540 position:50% align:middle But as I mentioned, if nothing occurs to you now and you want to follow up with me, please do so. 00:27:00.540 --> 00:27:03.240 position:50% align:middle But I hope you found this interesting. 00:27:03.240 --> 00:27:05.700 position:50% align:middle You have had the opportunity to hear about the telehealth results. 00:27:05.700 --> 00:27:07.870 position:50% align:middle You've had the opportunity now to hear about the APRN results. 00:27:07.870 --> 00:27:12.330 position:50% align:middle There are six additional sub-analyses that we spearheaded and that we are moving towards kind 00:27:12.330 --> 00:27:13.200 position:50% align:middle of the publication. 00:27:13.200 --> 00:27:15.990 position:50% align:middle We're under peer review for the April edition of the JNR. 00:27:15.990 --> 00:27:17.670 position:50% align:middle So please be on the lookout for those. 00:27:17.670 --> 00:27:21.120 position:50% align:middle If you don't see them or you run into any kind of firewalls or barriers for access, 00:27:21.120 --> 00:27:23.030 position:50% align:middle just reach out to us and we'll make sure you get a copy. 00:27:23.030 --> 00:27:25.946 position:50% align:middle But thank you guys for your attention and for attending. 00:27:34.454 --> 00:27:38.794 position:50% align:middle - [Woman 1] I don't know if you're from the Midwest, but you talk super fast. 00:27:38.794 --> 00:27:43.294 position:50% align:middle So I might have missed it, but you were talking about multi-state 00:27:43.294 --> 00:27:46.034 position:50% align:middle licenses for APRNs. 00:27:46.034 --> 00:27:49.014 position:50% align:middle So how does that work? 00:27:49.014 --> 00:27:50.274 position:50% align:middle Are the compact... 00:27:50.274 --> 00:27:50.674 position:50% align:middle - Yeah. 00:27:50.674 --> 00:27:55.034 position:50% align:middle So what they were piggybacking off of is their RN-level multi-state license. 00:27:55.034 --> 00:27:59.254 position:50% align:middle So they were using that within kind of the confines of what that is permitted, 00:27:59.254 --> 00:28:02.431 position:50% align:middle the care that they can provide within that particular context. 00:28:02.431 --> 00:28:04.241 position:50% align:middle But this isn't the APRN compact. This is the NLC. 00:28:04.241 --> 00:28:05.151 position:50% align:middle - Yes. Okay. 00:28:05.151 --> 00:28:10.291 position:50% align:middle So I heard you mention in that same sort of sentence around that time there was some education stuff. 00:28:10.291 --> 00:28:15.591 position:50% align:middle So they're basically functioning off their RN multi-state license, 00:28:15.591 --> 00:28:23.071 position:50% align:middle even though they hold an APRN license and they function as an APRN, but they use what they learned and 00:28:23.071 --> 00:28:23.531 position:50% align:middle what they know. 00:28:23.531 --> 00:28:28.871 position:50% align:middle - So what we saw in our analysis is that by and large what they use the RN multi-state license to do is 00:28:28.871 --> 00:28:31.082 position:50% align:middle to facilitate communication. 00:28:31.082 --> 00:28:34.112 position:50% align:middle So it was to follow up with patients who were potentially outside of the borders, 00:28:34.112 --> 00:28:39.822 position:50% align:middle either temporarily or permanently for whatever reason, for the patient care side of things. 00:28:39.822 --> 00:28:43.782 position:50% align:middle And then for the distance education, yes, to facilitate in other compact states, 00:28:43.782 --> 00:28:45.702 position:50% align:middle distance or remote education. 00:28:45.702 --> 00:28:47.812 position:50% align:middle There was a certain proportion, but I think it was about 2%. 00:28:47.812 --> 00:28:50.762 position:50% align:middle It was very, very minimal, which was a little surprising, 00:28:50.762 --> 00:28:56.982 position:50% align:middle just given the context with the pandemic in the interim two years that provided disaster support as well. 00:28:56.982 --> 00:28:59.782 position:50% align:middle But that just didn't kind of come to the fore in this analysis. 00:28:59.782 --> 00:29:00.359 position:50% align:middle - Yeah. 00:29:00.359 --> 00:29:01.379 position:50% align:middle I think it's really interesting. 00:29:01.379 --> 00:29:04.329 position:50% align:middle I mean, it's a fine, I think in some ways it would be a fine line for a 00:29:04.329 --> 00:29:09.629 position:50% align:middle nurse to remember when they're wearing their RN hat and when they're wearing their APRN hat and what they're 00:29:09.629 --> 00:29:12.169 position:50% align:middle doing across these state lines. 00:29:12.169 --> 00:29:16.219 position:50% align:middle And, you know, certainly during the pandemic, probably all hands on deck. 00:29:16.219 --> 00:29:19.189 position:50% align:middle We needed all the help we could get every single place in the United States. 00:29:19.189 --> 00:29:23.979 position:50% align:middle So maybe we looked past those things, but that's interesting. 00:29:23.979 --> 00:29:28.589 position:50% align:middle I hadn't thought of that before, but that would, I think, lead to some creep so... 00:29:28.589 --> 00:29:31.082 position:50% align:middle - True. 00:29:31.082 --> 00:29:34.062 position:50% align:middle Karen. 00:29:34.062 --> 00:29:34.292 position:50% align:middle It's hard to get off. 00:29:34.292 --> 00:29:34.932 position:50% align:middle - [Karen] I have no idea. 00:29:34.932 --> 00:29:36.262 position:50% align:middle - It's hard to get off. 00:29:36.262 --> 00:29:38.562 position:50% align:middle - If I wasn't sure it would turn. 00:29:38.562 --> 00:29:41.052 position:50% align:middle Karen Lyon, Louisiana. 00:29:41.052 --> 00:29:44.502 position:50% align:middle So well, one of the things, because it was during COVID. 00:29:44.502 --> 00:29:50.342 position:50% align:middle And almost all jurisdictions passed, their governors passed health. 00:29:50.342 --> 00:29:53.032 position:50% align:middle So you all APRNs could practice. 00:29:53.032 --> 00:29:55.472 position:50% align:middle We let APRNs from all over. 00:29:55.472 --> 00:29:57.382 position:50% align:middle They didn't have to get licensed. 00:29:57.382 --> 00:30:04.405 position:50% align:middle The other thing is, I'm not sure if this picked up was even if they needed to get a license to practice 00:30:04.405 --> 00:30:09.265 position:50% align:middle across state lines doing telehealth, they could have gotten a single state license in the 00:30:09.265 --> 00:30:15.305 position:50% align:middle other states, but almost all jurisdictions had health emergency declarations by their governors, 00:30:15.305 --> 00:30:18.575 position:50% align:middle which didn't, I mean, we worked with the governor's office and all of that. 00:30:18.575 --> 00:30:25.695 position:50% align:middle We welcomed any APRN that was licensed and had no discipline against their license. 00:30:25.695 --> 00:30:32.949 position:50% align:middle So I don't know that we asked those kind of, I mean, that we could pick that up within this context. 00:30:32.949 --> 00:30:34.319 position:50% align:middle - No, it's an excellent point. 00:30:34.319 --> 00:30:37.119 position:50% align:middle So, and I think it relates to the first question quite nicely. 00:30:37.119 --> 00:30:40.319 position:50% align:middle You know, there were other things going on at this time. 00:30:40.319 --> 00:30:44.879 position:50% align:middle And so when we kind of counseled together and thought about like how we were analyzing the responses 00:30:44.879 --> 00:30:50.539 position:50% align:middle and whatnot, one of the things that we tried to keep in mind is even the rate of multi-state licensure usage 00:30:50.539 --> 00:30:52.979 position:50% align:middle reported here, sometimes it's difficult, right? 00:30:52.979 --> 00:30:58.239 position:50% align:middle Nurses don't know necessarily if what they're doing constitutes, well, I can do this because 00:30:58.239 --> 00:30:59.239 position:50% align:middle of the compact license. 00:30:59.239 --> 00:31:04.047 position:50% align:middle So there's often kinds of deflating of trying to understand that self-report trend. 00:31:04.047 --> 00:31:08.647 position:50% align:middle But to your very point at this exact same period of time, in many respects, you know, 00:31:08.647 --> 00:31:12.847 position:50% align:middle there were still lots of emergency orders and variation across the state landscape. 00:31:12.847 --> 00:31:18.197 position:50% align:middle And so there were multiple things kind of working in concert to allow this type of practice, yeah. 00:31:18.197 --> 00:31:22.017 position:50% align:middle - The other thing I wanted to say, as a, so I'm a clinical nurse specialist, 00:31:22.017 --> 00:31:28.227 position:50% align:middle I'm not currently clinically practicing because I'm in regulation now, but I appreciated what you said 00:31:28.227 --> 00:31:32.676 position:50% align:middle at the end, you know, the takeaway about all four roles being important 00:31:32.676 --> 00:31:34.066 position:50% align:middle and they are. 00:31:34.066 --> 00:31:40.316 position:50% align:middle However, what we're seeing again in Louisiana, our enrollment in our clinical nurse specialist and our 00:31:40.316 --> 00:31:43.436 position:50% align:middle certified nurse midwives programs is very low. 00:31:43.436 --> 00:31:46.196 position:50% align:middle They all want to be nurse practitioners. 00:31:46.196 --> 00:31:50.516 position:50% align:middle They all think they're going to go out and start their own clinics, even though we're not a full practice 00:31:50.516 --> 00:31:54.066 position:50% align:middle authority state, you'd still have to have collaborative practice agreements. 00:31:54.066 --> 00:32:03.213 position:50% align:middle So I worry, I truly worry that there, you know, everyone that's interested in advanced practices going 00:32:03.213 --> 00:32:10.443 position:50% align:middle towards that nurse practitioner role, and that's great, but we have three other very important roles that need 00:32:10.443 --> 00:32:12.253 position:50% align:middle to be, we need people in as well. 00:32:12.253 --> 00:32:14.813 position:50% align:middle - And that is very much what we saw. 00:32:14.813 --> 00:32:21.733 position:50% align:middle Like among that least experienced cohort of APRNs, we saw, you know, 40 to 50% in that kind of CMP role. 00:32:21.733 --> 00:32:26.793 position:50% align:middle And then in that most experienced cohort, we saw over 30% CNS and they were telling us, you know, 00:32:26.793 --> 00:32:27.793 position:50% align:middle they're likely to retire. 00:32:27.793 --> 00:32:33.049 position:50% align:middle And this dovetails with the, you know, the kind of CNS provider association 00:32:33.049 --> 00:32:34.389 position:50% align:middle projections as well. 00:32:34.389 --> 00:32:38.119 position:50% align:middle And so that was one of the reasons why we brought up the consensus model and kind of linked it to that. 00:32:38.119 --> 00:32:42.609 position:50% align:middle I think the literature attests to the fact that for CMPs, there is overlap in that education and training 00:32:42.609 --> 00:32:46.689 position:50% align:middle to some extent, but there's a reason why there is a unique role. 00:32:46.689 --> 00:32:49.949 position:50% align:middle And so when we looked at this, it's not necessary, it was a very different story. 00:32:49.949 --> 00:32:51.509 position:50% align:middle It was kind of a nuanced story, right? 00:32:51.509 --> 00:32:57.979 position:50% align:middle For the RN population, there were, we were able to project the potential if barring no 00:32:57.979 --> 00:33:02.959 position:50% align:middle policy interventions and intentional solutions being brought to bear for the workforce, 00:33:02.959 --> 00:33:07.169 position:50% align:middle the possibility that there could be significant attrition that could lead to a staffing crisis based 00:33:07.169 --> 00:33:11.689 position:50% align:middle on their experiences during the COVID and prior, all leading and kind of aggregating 00:33:11.689 --> 00:33:12.909 position:50% align:middle to stress and burnout. 00:33:12.909 --> 00:33:14.749 position:50% align:middle For the APRN workforce, it was a little different. 00:33:14.749 --> 00:33:17.609 position:50% align:middle Those younger providers weren't telling us that they were going to leave. 00:33:17.609 --> 00:33:22.629 position:50% align:middle But what we recognized was that that older cohort, that more kind of with a diverse educational and 00:33:22.629 --> 00:33:26.469 position:50% align:middle professional training background, you know, if those folks exit at the rate that they're 00:33:26.469 --> 00:33:32.119 position:50% align:middle talking about, that has real implications for what we see in that distributional shift across the roles. 00:33:32.119 --> 00:33:36.809 position:50% align:middle And we do think if you look at the literature, that does tie to issues of patient access and 00:33:36.809 --> 00:33:38.179 position:50% align:middle ultimately really provider choice. 00:33:38.179 --> 00:33:41.239 position:50% align:middle And so we felt like that was important to bring to the fore. 00:33:41.239 --> 00:33:42.489 position:50% align:middle Please, Susan. 00:33:42.489 --> 00:33:43.289 position:50% align:middle - [Susan] Thank you. 00:33:43.289 --> 00:33:44.269 position:50% align:middle Really interesting data. 00:33:44.269 --> 00:33:45.829 position:50% align:middle I can't wait to see the article come out. 00:33:45.829 --> 00:33:51.059 position:50% align:middle But I wanted to follow up on something that Dr. Lyon said, you know, so we had a lot of changes in, 00:33:51.059 --> 00:33:54.669 position:50% align:middle you know, people could go across state lines and licensure all over the place, 00:33:54.669 --> 00:33:58.949 position:50% align:middle but also the changes that happened in the APRN role with CMS, right? 00:33:58.949 --> 00:34:04.322 position:50% align:middle So you have, there was an expansion of scope that was never seen, right? 00:34:04.322 --> 00:34:10.782 position:50% align:middle And so you had these younger providers who had never had that kind of scope depending on where they were at. 00:34:10.782 --> 00:34:17.062 position:50% align:middle You know, we had different prescribing and different ability to do our jobs to the fullest extent of our 00:34:17.062 --> 00:34:18.482 position:50% align:middle education and training. 00:34:18.482 --> 00:34:22.792 position:50% align:middle And I think that that could be one of those contributing factors to adding to some of that stress 00:34:22.792 --> 00:34:26.432 position:50% align:middle because some of them were not prepared for any of those changes. 00:34:26.432 --> 00:34:30.457 position:50% align:middle All of a sudden it was like, boom, you're doing this, but yet you'd never, 00:34:30.457 --> 00:34:32.097 position:50% align:middle that had never been part of your practice. 00:34:32.097 --> 00:34:33.977 position:50% align:middle So that kind of was a light bulb for me as well. 00:34:33.977 --> 00:34:40.847 position:50% align:middle The other thing is too, as being one of those older nurse practitioners, 00:34:40.847 --> 00:34:47.027 position:50% align:middle not 36 years, but I'm 31 here, years in practice as a nurse and nurse practitioner. 00:34:47.027 --> 00:34:54.107 position:50% align:middle I can see in my contemporary cohort of colleagues that that burnout is a million percent real. 00:34:54.107 --> 00:35:02.725 position:50% align:middle And I think that your numbers really do reflect what's going to happen because I can see that in my own kind 00:35:02.725 --> 00:35:11.715 position:50% align:middle of peer group that I think that we are going to see a huge exodus of people in the next few years. 00:35:11.715 --> 00:35:15.125 position:50% align:middle I predict that to be true. 00:35:15.125 --> 00:35:19.775 position:50% align:middle - And I think you're hitting on something that's important that potentially my talking points kind 00:35:19.775 --> 00:35:21.825 position:50% align:middle of overlooked so to speak. 00:35:21.825 --> 00:35:26.145 position:50% align:middle I focused on the comparisons across the experience strata, but if you look at that most 00:35:26.145 --> 00:35:30.799 position:50% align:middle experienced cohort, we're talking 30%, 40% experience of this emotional distress, 00:35:30.799 --> 00:35:32.299 position:50% align:middle heightened emotional exhaustion. 00:35:32.299 --> 00:35:33.859 position:50% align:middle So nobody was spared, really. 00:35:33.859 --> 00:35:40.319 position:50% align:middle And I mean, that's what we see consistently time and time again across license type in the entire survey. 00:35:40.319 --> 00:35:40.949 position:50% align:middle Nicole. 00:35:40.949 --> 00:35:41.639 position:50% align:middle - Thanks, Brendan. 00:35:41.639 --> 00:35:44.219 position:50% align:middle I'm Nicole Williams, NCSBN and staff. 00:35:44.219 --> 00:35:50.569 position:50% align:middle The two speakers certainly just kind of segued into a lot of things that I'm interested in. 00:35:50.569 --> 00:35:58.079 position:50% align:middle When I heard your presentation, great presentation, by the way, one of the things that interests me is kind 00:35:58.079 --> 00:36:01.840 position:50% align:middle of that younger and less experienced cohort. 00:36:01.840 --> 00:36:06.760 position:50% align:middle A lot of those things that you mentioned essentially mirror a lot of those inter-level characteristics 00:36:06.760 --> 00:36:08.880 position:50% align:middle in initial licensure. 00:36:08.880 --> 00:36:16.700 position:50% align:middle What I wanted to note is was there any thought behind the demarcation with the number of years of experience, 00:36:16.700 --> 00:36:18.780 position:50% align:middle you mentioned 12 or less. 00:36:18.780 --> 00:36:23.150 position:50% align:middle Was there any other levels besides 12? 00:36:23.150 --> 00:36:30.017 position:50% align:middle - So we didn't go into like really a finer level of granularity there. 00:36:30.017 --> 00:36:33.647 position:50% align:middle We wanted to kind of first pass, understand, and it was mirroring what we had done 00:36:33.647 --> 00:36:34.627 position:50% align:middle with the RN analysis. 00:36:34.627 --> 00:36:38.167 position:50% align:middle So there was some intention in that, in that when we isolated this group of providers and 00:36:38.167 --> 00:36:43.587 position:50% align:middle that really constituted our population of interest, so to speak, we just bended into quartiles. 00:36:43.587 --> 00:36:47.197 position:50% align:middle We didn't look further on that, and we also didn't use years experience or years 00:36:47.197 --> 00:36:52.217 position:50% align:middle licensed as a continuous variable at any point, but it is certainly something we could do. 00:36:52.217 --> 00:36:54.767 position:50% align:middle So if this is of interest to you, we could pursue it. 00:36:54.767 --> 00:36:55.567 position:50% align:middle We could pursue it. 00:36:55.567 --> 00:37:00.667 position:50% align:middle - Absolutely, certainly, tagging off of Susan [inaudible] We were 00:37:00.667 --> 00:37:05.007 position:50% align:middle having a discussion yesterday, and one of the things I'm really interested in is, 00:37:05.007 --> 00:37:10.827 position:50% align:middle as you know, we have many entry-level nurses that are entering into practice with an immediate interest 00:37:10.827 --> 00:37:13.287 position:50% align:middle in progressing to APRN. 00:37:13.287 --> 00:37:17.717 position:50% align:middle And my interest is, you know, what does that look like? 00:37:17.717 --> 00:37:24.667 position:50% align:middle How many years is a nurse in actual entry-level practice prior to entering into an APRN role and what 00:37:24.667 --> 00:37:26.097 position:50% align:middle does that look like? 00:37:26.097 --> 00:37:27.937 position:50% align:middle So yes, absolutely. 00:37:27.937 --> 00:37:29.057 position:50% align:middle - Yeah, we can easily break that down. 00:37:29.057 --> 00:37:32.234 position:50% align:middle I mean, it's one of the things that I think in clinical research, in all research, right, 00:37:32.234 --> 00:37:33.454 position:50% align:middle like you can kind of be guilty of. 00:37:33.454 --> 00:37:37.214 position:50% align:middle Like when you have a continuous variable, you start to bend it, information is lost. 00:37:37.214 --> 00:37:42.964 position:50% align:middle The truth, which is wonderful in this context, is if you track it as a continuous variable, 00:37:42.964 --> 00:37:44.264 position:50% align:middle then you can look at it however you want. 00:37:44.264 --> 00:37:48.984 position:50% align:middle We did track this as a continuous variable to ease and kind of facilitate reader interpretation. 00:37:48.984 --> 00:37:53.924 position:50% align:middle We bend it, because we thought that that might be an easier conceptual way to understand the results. 00:37:53.924 --> 00:37:55.924 position:50% align:middle But we can definitely dig into it. 00:37:55.924 --> 00:37:59.564 position:50% align:middle And Susan, to follow up, one of the things, actually, you kind of gave me, you teed it up for me, 00:37:59.564 --> 00:38:02.133 position:50% align:middle and I missed my swing. 00:38:02.133 --> 00:38:07.183 position:50% align:middle But you were talking about the effects, those really early effects of the pandemic and kind 00:38:07.183 --> 00:38:10.143 position:50% align:middle of the expansion to scope of practice. 00:38:10.143 --> 00:38:15.583 position:50% align:middle We did actually publish another study in April 2023 when we looked at our kind of our COVID 00:38:15.583 --> 00:38:21.073 position:50% align:middle special edition, looking at the effects of the emergency waivers, lifting restrictions 00:38:21.073 --> 00:38:22.013 position:50% align:middle on APRN and practice. 00:38:22.013 --> 00:38:25.703 position:50% align:middle And in many instances, we were able to actually highlight particular 00:38:25.703 --> 00:38:29.043 position:50% align:middle jurisdictions where prior, they had been among the most restrictive 00:38:29.043 --> 00:38:29.653 position:50% align:middle in the country. 00:38:29.653 --> 00:38:33.317 position:50% align:middle And then they basically had a proxy for full practice authority for a temporary period of time. 00:38:33.317 --> 00:38:38.217 position:50% align:middle And one of the critical things that I would highlight here, again, please, it's free for download. 00:38:38.217 --> 00:38:39.537 position:50% align:middle I can't say that enough. 00:38:39.537 --> 00:38:42.367 position:50% align:middle But one of the things that I would highlight here is one of the things that we thought was critical 00:38:42.367 --> 00:38:47.457 position:50% align:middle with that piece, just from the start, was to look at the safety profile 00:38:47.457 --> 00:38:48.387 position:50% align:middle of those practitioners. 00:38:48.387 --> 00:38:50.127 position:50% align:middle And we found absolutely no increase. 00:38:50.127 --> 00:38:55.157 position:50% align:middle And we're talking two to three years follow up following the implementation of that emergency order. 00:38:55.157 --> 00:38:57.737 position:50% align:middle So this wasn't like within the next month, we didn't see anything happen, right? 00:38:57.737 --> 00:39:02.664 position:50% align:middle There's a delay in the discipline process, the administrative process of the boards, etc., 00:39:02.664 --> 00:39:06.334 position:50% align:middle just as an artifact of how serious these investigations need to be. 00:39:06.334 --> 00:39:08.554 position:50% align:middle We looked three years out, we continue to track it. 00:39:08.554 --> 00:39:11.504 position:50% align:middle We see no spike associated with that in those jurisdictions. 00:39:11.504 --> 00:39:13.864 position:50% align:middle And so it is, I think, an excellent point. 00:39:13.864 --> 00:39:17.364 position:50% align:middle I think the context, in a way, is that they were incredibly safe, 00:39:17.364 --> 00:39:22.844 position:50% align:middle but the flip side is the immense pressure, in particular the acuity that these patients were 00:39:22.844 --> 00:39:29.454 position:50% align:middle presented with, you take yourself back to 2020, 2021, etc., the stress that would have been on any of these 00:39:29.454 --> 00:39:31.162 position:50% align:middle providers was very real. 00:39:31.162 --> 00:39:35.222 position:50% align:middle And I absolutely think you're correct, likely contributed to some of their sentiments 00:39:35.222 --> 00:39:36.132 position:50% align:middle for emotional exhaustion. 00:39:36.132 --> 00:39:43.422 position:50% align:middle - And I think that article, which I did read, and see that along with data, lots of data, 00:39:43.422 --> 00:39:49.632 position:50% align:middle can be one of those foundations for states that are looking for full practice authority to say, the sky, 00:39:49.632 --> 00:39:51.562 position:50% align:middle in fact, did not fall. 00:39:51.562 --> 00:39:54.882 position:50% align:middle And that we were okay, and the outcomes were actually positive. 00:39:54.882 --> 00:39:59.432 position:50% align:middle And then build on some of the other data that's already out there about states who have gone 00:39:59.432 --> 00:40:01.456 position:50% align:middle through full practice authority. 00:40:01.456 --> 00:40:05.246 position:50% align:middle Unfortunately, we had to go through COVID to get the data, but it's there. 00:40:05.246 --> 00:40:12.554 position:50% align:middle And I think that it makes a strong foundation for that safety of the nurse practitioner role in practice 00:40:12.554 --> 00:40:13.416 position:50% align:middle at the end. Thank you. 00:40:13.416 --> 00:40:17.446 position:50% align:middle - Yeah, and we concluded that report with a call for full practice authority for APRNs. 00:40:17.446 --> 00:40:23.496 position:50% align:middle I just think that the data consistently decade after decade, now attests to their safety profile. 00:40:23.496 --> 00:40:28.636 position:50% align:middle And I think when you look at the need and the way in which states reacted to really those acute early stages 00:40:28.636 --> 00:40:34.279 position:50% align:middle of the pandemic, everybody who was in a position of power saw what should happen, and they did it. 00:40:34.279 --> 00:40:36.509 position:50% align:middle But there's also a permanent solution to that. 00:40:36.509 --> 00:40:41.019 position:50% align:middle And that's being proactive in changing the scope of practice and making sure that they're able to practice 00:40:41.019 --> 00:40:42.999 position:50% align:middle at the top of their license and education. 00:40:42.999 --> 00:40:48.029 position:50% align:middle So I think we, three minutes left, any other questions? 00:40:48.029 --> 00:40:49.479 position:50% align:middle Or I think we're good. 00:40:49.479 --> 00:40:50.759 position:50% align:middle All right, well, thank you, everyone. 00:40:50.759 --> 00:40:52.566 position:50% align:middle I hope you enjoyed the conference.