Transcript Statewide

A STUDY OF CERTIFIED
REGISTERED NURSE
ANESTHETIST MANPOWER IN
NEBRASKA: PART IV
Investigator: Matthew D. Petta, BSN
Committee Chairperson: Sharon Hadenfeldt, CRNA, MS
Committee Member: James Cuddeford, CRNA, MA
Committee Member: Carol Elliott, CRNA, MPA
Department Chairperson: Carol Elliott, CRNA, MPA
Problem Statement
The current national shortage of anesthesia providers
has been anticipated for some time. Many factors have
helped sustain the shortage such as: lack of clinical
educators and available clinical sites, increased demand
for surgeries based on an aging population, dilution of
anesthetists to a variety of surgical settings, and the
older demographic age of providers limiting their
production. Nebraska may exhibit a compounded
shortage because rural areas encounter the most
difficulty recruiting anesthetists.
Research Questions







What was the unmet need for CRNAs in Nebraska, including
Ambulatory Surgical Centers?
How was the need projected to change within the next five years as
perceived by hospital administrators and managers of Ambulatory
Surgical Centers?
How many CRNAs currently practicing in Nebraska expected to retire
or relocate out of the state in the next five years?
What was the age distribution of CRNAs in Nebraska?
What was the average length of time required to recruit a CRNA to a
practice setting in Nebraska?
What are the regional differences within Nebraska related to the
above factors?
Where were CRNAs within the state educated?
Literature Review




29,000 CRNAs short by 2010.
Hospital-based operations to increase from 22 million in
1990 to 28 million in 2010, excluding cesarean sections.
Approximately 37 million anesthetics, including
obstetrical and outpatient procedures, are anticipated by
the year 2010.
Ambulatory surgical center surgeries are projected to
rise from 2 million in 1990 to 8 million in 2010. This
corresponds to the greatest operative site increase of all
sites, from 8.6% to 20.1%.
Rosenbach, M.L., Cromwell, J., Pope, G.C., Butricia, B., &Pitcher, J.D. (1991). Study of nurse anesthesia manpower
needs. Journal of the American Association of Nurse Anesthetists,59(3), 233-240.
Cromwell, J., Rosenbach, M.L., Pope, G.C., Butrica, B., & Pitcher, J.D. (1991).CRNA manpower
forecasts:1990-2010. Medical Care, 29(7), 628-644.
Literature Review Continued
There were 105 anesthesia
programs that closed between
1976 and 1996, which contributed
to the decline in the number of
practicing CRNAs. In 1976 there
were 194 nurse anesthetist training
programs. In 1996, there were 89.
Fallacaro, M.D., Obst, T.E., &Manquing, C. (1996).
The national distribution of Certified Registered
Nurse Anesthetists across metropolitan and
nonmetropolitan settings. Journal of the American
Association of Nurse Anesthetists, 64(3), 237242.
In 2004, 15.2% of all nurses
working in advanced practice
roles requiring a master’s degree
were nurse anesthetists. This is a
slight decrease compared to
1996.
Inglis, T. (2004). Nursing the trends: Nurses have
more employment options than ever. American
Journal of Nursing, 104(1), 25-31. Retrieved August
18, 2005, from Ovid database.
Literature Review Continued
Twenty-nine percent of CRNAs who are 55 years of age or older reside in nonmetropolitan counties. Since 18.7% of the total CRNA pool lives in nonmetropolitan areas, it could be reasoned that rural areas would have a higher
percentage of loss due to retirement than metropolitan areas in the next 10
years.
Fallacaro, M.D., Obst, T.E., &Manquing, C. (1996). The national distribution of Certified Registered Nurse
Anesthetists across metropolitan and nonmetropolitan settings. Journal of the American Association of Nurse
Anesthetists, 64(3), 237-242.
The age distribution of currently practicing CRNAs hampers their ability to
alleviate the shortage. Over 49% of nurse anesthetists were fifty years of age or
older in 2003 (Grogono, 2003); and in 2010, 65.9% of nurse anesthetists are
predicted to be fifty years old or greater (Rosenbach, et al. 1990).
Grogono, A.W. (2003). Resident numbers and total graduating from residencies and nurse anesthesia schools in
2003: continuing shortages expected. American Society of Anesthesiologists Newsletter, 67(11), 1-11.
Rosenbach, M.L., Cromwell, J., Pope, G.C., Butricia, B., &Pitcher, J.D. (1991). Study of nurse anesthesia
manpower needs. Journal of the American Association of Nurse Anesthetists,59(3), 233-240.
Methodology
Mailed Questionnaire







A response rate of 50% is needed to consider the
questionnaire adequate, while 70% or more is
considered very adequate
Eliminates interviewer bias
Eases ability to reach subjects who are difficult to
contact per telephone or in person
Assures confidentiality, personalizes materials, with
follow up reminders as an effective method to encourage
completion of the mailed questionnaire
Self addressed, stamped return envelopes facilitate
response.
Respondents do not fear the possibility of repercussion
due to their response and are more likely to be honest
Large amounts of anonymous data can be obtained with
ease
Methodology Continued



One questionnaire was mailed to CRNAs licensed to practice in
Nebraska. The purpose was to assess the supply of CRNAs within
the state.
The second questionnaire was mailed to all hospital administrators
and/or department of anesthesia managers within the hospitals in
Nebraska designated acute care hospitals. The purpose of the
second questionnaire was to assess the demand for CRNAs within
the state.
An addition to the previous studies was the inclusion of outpatient
surgical centers within Nebraska. The intent was to derive similar
information related to the demand for CRNAs elicited from hospital
administrators and/or CRNA managers in the past.
Subjects

Subjects of this study included all CRNAs who
have a license to practice within the state of
Nebraska, and who reside in Nebraska. Only
hospital administrators and/or anesthesia
department managers, who belong to the
NAHHS, received the questionnaires, with the
exclusion of the Veteran Administration hospital.
Ambulatory surgical centers also received the
questionnaires addressed to the manager of
anesthesia services.
Limitations



The potential for bias depending on a low
response rate.
Anesthetics that are administered outside of
the hospitals and ambulatory surgical centers
identified would not be included in the
assessment of the demand for CRNAs. For
instance, those procedures performed in
doctor’s offices would not be assessed in this
research.
The Veteran Administration hospital in Omaha
was not included in this study.
Assumptions



The respondents would be willing and
able to provide accurate information.
The respondent interpretation of
information was appropriate.
The respondents were honest in
answering the questions.
Procedure



The first mailing included cover letters, the
respective questionnaires, and an addressed
return envelope with postage.
Mailed questionnaires were returned to the
secure BryanLGH School of Nurse Anesthesia
office.
The respondent’s confidentiality was maintained
by: assigning tracking numbers on the back of
returned envelopes, maintaining a locked office,
keeping the information confidential, and only
reporting group data.
Procedure Continued



The follow up letters were mailed three
weeks from the first mailing.
A three week interval was used between
the second and third mailing.
A third and final mailed questionnaire was
sent to those CRNAs who have not
responded to the second mailing.
Procedure Continued




The third attempt for the ambulatory surgical centers
and hospitals included a phone call to the facility. The
phone numbers were found in phone registries.
The questionnaires were completed on the phone by the
researcher, who asked all the questions verbatim from
the questionnaire.
After several attempts to contact persons able to
accurately and willingly complete the survey over the
phone were unsuccessful, the author halted further
attempts.
All information was transcribed to a spreadsheet
computer program
Regions
Instruments
School of Nurse Anesthesia
March 1, 2005
Dear CRNA:
I am a senior in the BryanLGH Medical Center School of Nurse Anesthesia program. I
am researching nurse anesthesia manpower in the state of Nebraska with the aid of the Nebraska
Association of Nurse Anesthetists (NANA). This is my master’s degree thesis project.
Participation in the survey is voluntary. Please complete the enclosed questionnaire and
return it in the envelope provided within the next two weeks if you wish to participate. If you did not
administer anesthesia in the state of Nebraska in 2004, please answer question #1 accordingly.
Then, return the questionnaire with the envelope provided.
The current research will allow me to determine supply and demand of nurse anesthetists
in Nebraska. The research will be compared to studies performed in 1991, 1995, and 2000; so
manpower trends over the past fifteen years will be determined. Compiled results will be shared
with the NANA. A copy of the complete results of the survey can be obtained through the
BryanLGH Medical Center School of Anesthesia. All information will be kept confidential.
Thank you for completing the questionnaire. Your assistance is greatly appreciated.
Sincerely,
Matthew D. Petta, RN, BSN
Instruments
CRNA MANPOWER STUDY
NURSE ANESTHETIST SURVEY
1. Did you administer anesthesia in Nebraska in 2004? Yes _____ No _____
If you answered “no,” please return the questionnaire with the remaining questions unanswered.
2. Approximately how many anesthetics did you administer in 2004? __________
3. Approximately how many hours per week do you average for direct anesthesia care, including in-house call, department
management, and nurse anesthesia education? __________
4. In what type of practice setting do you work?
Hospital employed ______
CRNA group _____
Anesthesiologist group _____
Self employed
______
Other _____
5. During your TYPICAL workweek, at how many facilities do you administer anesthesia?
__________
6. If you typically deliver anesthesia at more than one facility, please estimate the number of hours you spend at each:
FACILITY #1 _____
FACILITY #2 _____
FACILITY #3 _____
FACILITY #4 _____
7. Are any of these facilities freestanding outpatient surgical centers? Yes _____ No _____
8. Do you anticipate increasing your work commitment in the next five years? (For example,
changing from part-time to full-time, or adding another facility to your present area of practice)
Yes _____ No _____
9. Do you anticipate decreasing your work commitment in the next five years?
Yes _____ No _____
10. Do you expect to relocate out-of-state in the next five years? Yes _____ No _____
11. Do you expect to retire from delivering anesthesia services in the next five years?
Yes _____ No _____
12. Please state your county of residence. __________
13. Please state your county or counties of anesthesia service delivery: ____________________
14. Please check your age in years:
< 30 _____
50-59 _____
30-39 _____
60-69 _____
40-49 _____
> 70 _____
15. What is the name of the Nurse Anesthesia program where you were educated? __________
Statewide CRNA Response Rate
Year
2005
2000
1995
1991
CRNAs
236
298
212
233
Respondents
204
251
174
188
Response %
86.4 %
84 %
82 %
81 %
Regional CRNA Respondents
Region
Respondents
I
62
II
29
III
15
IV
34
V
49
Non Response
7
Not Active
8
2005
204
Instruments
School of Nurse Anesthesia
March 1, 2005
Dear Hospital Administrator,
I am a senior in the BryanLGH Medical Center School of Nurse Anesthesia program. I am researching nurse
anesthesia manpower within the state of Nebraska with the aid of the Nebraska Association of Hospitals and Health Systems
(NAHHS). This is my master’s degree thesis project.
The enclosed questionnaire is to be completed by the head of the anesthesia department, or the head of the group or
person that provides anesthesia at your hospital. Participation in the survey is voluntary. Please have the questionnaire completed
and returned in the envelope provided within the next two weeks if you wish to participate.
The research will allow me to determine current supply and demand of nurse anesthetists in Nebraska. The research
will be compared to studies performed in 1991, 1995, and 2000, so manpower trends over the last fifteen years will be determined.
Compiled results will be shared with the NAHHS. A copy of the complete results of the survey can be obtained through the
BryanLGH Medical Center School of Nurse Anesthesia. All questionnaires will be kept confidential.
Thank you for completing the questionnaire. Your assistance is greatly appreciated.
Sincerely,
Matthew D. Petta, RN, BSN
Instruments
HOSPITAL SURVEY
Please state the county in which your hospital is located. _______________________________
How many acute care beds does your hospital currently have? ___________________________
Around how many procedures in 2004 required anesthesia services? ______________________
How many anesthesiologists provide anesthesia services? ______________________________
Does your hospital employ CRNA’s directly? Yes _____ No _____
If you answered “yes”:
How many full-time equivalents for CRNA’s are in the present budget? ________
How many equivalents are filled? ___________
How many equivalents are vacant? __________
Are anesthesia services provided in your hospital by CRNAs who are not hospital employees?
Yes _____ No _____
If “yes,” please state the arrangement by which these services are provided. (For example, self-employed CRNA,
anesthesiologist-employed CRNA, CRNA group, locum tenens, etc.)
______________________________________________________________
How many full-time equivalent positions for CRNA’s are in the group? _____
How many equivalents are filled? _____
How many equivalents are vacant? _____
Have CRNA’s been actively recruited (with advertisement or an agency for example) in the past two years?
Yes _____
If “yes,” how many months did it take to fill a CRNA position? ______________
If you are still looking to fill a CRNA position, how many months have you been
recruiting? ___________________
No _____
Do you anticipate increasing CRNA positions in the next five years?
Yes _____, and by how many? __________
No _____
Do you anticipate decreasing CRNA positions in the next five years?
Yes _____ , and by how many? __________
No _____
Will you or have you recruited an anesthesiologist because of difficulty in recruiting a CRNA? Yes _____ No _____
Statewide Hospital Response Rate
Year
2005
2000
1995
1991
Surveys Mailed
90
82
94
95
Returns
68
67
70
85
Response %
75.6
82
74
89
Regional Hospital Respondents
Region
Respondents
I
5
II
18
III
10
IV
19
V
16
2005
68
Statewide Ambulatory Outpatient
Surgical Center Response Rate
Surveys Mailed
17
Returns
9
Response %
52.9
Research Question 1

What was the unmet need for CRNAs in
Nebraska, including Ambulatory Surgical
Centers?
FTE* CRNA Vacancy Rate
Region
N
# of
FTEs *
%
I
2
21.0
9.5
II
2
26.0
7.7
III
1
18.0
5.6
IV
5
63.0
7.9
V
1
35.0
2.9
FASCs**
1
10.0
10.0
2005
12
173.0
6.9
2000
15.5
203.5
8
1995
4.9
177
3
1991
11
149
7
* Full-time equivalent
** Freestanding Ambulatory Surgical Centers
NUMBER OF FTE* CRNAs
250
200
150
100
50
REGION
* Full-time equivalent
** Includes FASCs
91
19
95
19
00
20
20
05
**
s*
A
SC
V
IV
III
II
I
0
Research Question 2

How was the need projected to change
within the next five years as perceived by
hospital administrators and managers of
Ambulatory Surgical Centers?
Number of Administrators or Managers Who Predicted
Increase in CRNA Positions Within Five Years
Region
n
I
7.0
II*
11.0
III
6.0
IV
10.0
V
8.5
Surgical Centers
2
2005
44.5
•Region II reported the only decrease in positions,
which is not shown in this table
Research Question 3

How many CRNAs currently practicing in
Nebraska expected to retire or relocate
out of the state in the next five years?
CRNAs Planning to Retire in the next Five Years
Region
n
%
I
5
7.9
II
3
10.3
III
1
6.6
IV
4
11.8
V
7
14.3
2005
20
10.6
2000*
25
13
1995**
21
13
1991***
24
15
* Includes the number of Nebraska CRNAs who live in a state that
physically borders Nebraska
** Those Planning to retire by the end of 1999
*** Those planning to retire by the end of 1995
CRNAs Planning to Relocate by the
End of 2010
Region
n
% of CRNAs
I
6
9.7
II
2
6.9
III
2
13.3
IV
4
11.8
V
6
12.2
2005
20
10.6
RETIRING/RELOCATING CRNAs - NUMBER OF ANESTHEICS
35
30
% OF CRNAs
25
20
%
15
10
5
0
<200
200-399
400-599
600-799
NUMBER OF ANESTHETICS
800-899
>900
RETIRING/RELOCATING CRNAs - NUMBER OF HOURS PER WEEK
60
50
40
30
20
10
0
<20
20-29 30-39 40-49 50-59
NUMBER OF HOURS
%
>59
Research Question 4

What was the age distribution of CRNAs in
Nebraska?
Age Distribution of Retiring CRNAs
Age
n
%
40-49
0
0
50-59
6
30
60-69
11
55
>70
3
15
AGE DISTRIBUTION OF CRNAs
100%
80%
>59
50-59
40-49
<40
60%
40%
20%
0%
I
II
III
IV
V
2005 2000* 1995 1991
REGION
* Includes the number of Nebraska CRNAs who live in a
state that physically borders Nebraska
Research Question 5

What was the average length of time
required to recruit a CRNA to a practice
setting in Nebraska?
AVERAGE CRNA
RECRUITMENT TIME
9
8
6
5
4
3
2
1
Mean
* Ambulatory Surgical Centers
199
1
199
5
200
0
200
5
s*
AS
C
V
IV
III
II
0
I
MONTHS
7
% of
Hospitals
RECRUIT ANESTHESIOLOGIST
DUE TO DIFFICULTY IN CRNA
RECRUITMENT*
80
60
40
20
0
%
Yes
No
N/R
RESPONSE
* Includes Freestanding Ambulatory Surgical Centers
Research Question 6

What are the regional differences within
Nebraska related to the above factors?
Hospitals With CRNAs as Only Anesthesia Providers
Region
n
%
I
0
0.0
II
14
82.4
III
8
80.0
IV
14
73.7
V
12
80.0
2005
48
72.7
2000
40
60
1995
44
63
1991
58
72
Percentage of CRNAs that Work at FASCs
with Regional Breakdown
31%
3%
Yes
35%
31%
13%
22%
No
I
II
III
IV
V
CRNA Practice Settings
Practice
Setting
I
II
III
IV
V
2005
2000*
1995
1991
Hospital
21.0%
27.6%
26.7%
2.9%
12.2%
16.9%
21%
46%
55%
Anesthesiologist
Group
46.8%
35.5%
53.3%
14.7%
57.1%
42.3%
42%
29%
23%
Self-employed
6.5%
17.2%
0.0%
26.5%
12.2%
12.7%
21%
10%
2%**
CRNA Group
0.0%
13.8%
0.0%
52.9%
2.0%
12.2%
15%
15%
10%
Agency/Other
21.0%
3.4%
6.7%
2.9%
2.0%
9.0%
2%
Multiple
6.5%
0.0%
13.3%
0.0%
14.3%
6.9%
* Includes the number of Nebraska CRNAs who live in a state that physically borders Nebraska
** This was referred to as “staff relief” in the 1991 study. This was defined as not having primary
employment in Nebraska, but provides occasional coverage in Nebraska.
NUMBER OF
FACILITIES PER
MONTH*
% OF CRNAs
10 0 %
90%
80%
70%
60%
50%
40%
30%
20%
10 %
91
19
00
**
19
95
20
05
20
V
IV
III
II
I
0%
REGION
1 Facility
2 Facilities
3 or >
* Must have provided at least 8 hours per month to be included
** Includes the number of Nebraska CRNAs who live in a state that physically borders Nebraska
AVERAGE NUMBER OF HOURS
WORKED PER CRNA WORK WEEK
44.0
# OF HOURS / WEEK
43.0
42.0
41.0
40.0
39.0
38.0
37.0
REGION
* Includes the number of Nebraska CRNAs who live in a state that
physically borders Nebraska
91
19
95
19
*
00
20
05
20
V
IV
III
II
I
36.0
20
05
20
00
*
19
95
19
91
V
IV
III
II
900
800
700
600
500
400
300
200
100
0
I
# OF CASES / YEAR
AVERAGE NUMBER OF
ANESTHETICS PER CRNA
REGION
* Includes the number of Nebraska CRNAs who live in a state that physically borders Nebraska
CRNAs Planning to Increase Work by the End of 2010
Region
n
% by Region
I
5
8.0
II
5
17.2
III
3
20.0
IV
14
41.2
V
3
6.1
2005
30
15.9
2000*
40
20
1995**
22
14
1991***
23
14
* Includes the number of Nebraska CRNAs who live in a state that physically borders Nebraska
** Those planning to increase work by the end of 1999
*** Those planning to increase work by the end of 1995
CRNAs Planning to Decrease Work by the End of 2010
Region
n
% by Region
I
15
24.2
II
7
24.1
III
3
20.0
IV
9
26.5
V
12
24.5
2005
46
24.3
2000*
54
28
1995**
33
21
1991***
34
21
* Includes the number of Nebraska CRNAs who live in a state that physically borders Nebraska
** Those planning to increase work by the end of 1999
*** Those planning to increase work by the end of 1995
Research Question 7

Where were CRNAs within the state
educated?
NEBRASKA CRNA TRAINING PROGRAM REPRESENTATION
Program
n
Program
n
Mount Marty
52
St. Raphael
1
Bryan
44
St. Joe’s (PA)
1
Creighton/St. Joe’s
22
St. Luke’s
1
University of Nebraska Med Center
7
Georgetown
1
Mayo
4
Wayne State
1
St. Mary’s (MN)
4
George Washington
1
Truman
4
Case Western
1
Texas Wesleyan
3
Drake
1
Minneapolis School of Anesthesia
3
St. Frances
1
United States Air Force
3
Medical College of Virginia
1
University of Kansas
3
United States Navy
1
University of Iowa
3
Colorado University
1
University of Texas
3
University South Carolina
1
Mercy
2
St. Mary’s (NY)
1
Wesley
2
Middle Tennessee
1
Friends
2
Charity
1
Northwestern-MN
2
St. John’s
1
University of Missouri @ K.C.
1
Murray State University
1
Tripler
1
University of NY at Buffalo
1
NEBRASKA CRNA TRAINING
PROGRAM DISTRIBUTION
24%
61%
39%
NEBRASKA
PROGRAMS
12%
4%
•Mount Marty trains 28.1% of all Nebraska CRNAs, thus
having the most overall representation of any program
Outstate
Programs*
Bryan
Creighton / St.
Joe's
UNMC
Manpower Forecast
&
Additional Findings
Number of Positions to be Filled in Nebraska Between
2005 and 2010
Category
Actual Response
Projected Number with
100% Response
Retirees
20
23
Vacancies
12*
16*
New Positions
42.5*
57*
Relocate
17**
19
2005
91.5*
115*
2000
74
90
1995***
57***
68***
1991****
58****
68****
* Includes Ambulatory Surgical Centers
** Reduced by three to account for those who were both retiring and relocating
*** By 1999
**** By 1995 and did not include CRNAs relocating out of Nebraska
Region I Characteristics

Zero hospitals with CRNAs as sole
providers reported

76.2% of CRNAs work at one facility

Most procedures per hospital (5600)
Region II Characteristics

Most anticipated new positions (11)

Fewest relocating within five years (6.9%)

Least # of cases per year per CRNA (689)
Region III Characteristics

Lowest retirement rate (6.6%)

Highest relocation rate (13.3%)
Region IV Characteristics





CRNA group most popular arrangement
(52.9%), and only region not primarily
anesthesiologist group employed
Only 26.5% work at one facility
Highest hours worked per week (43.9)
CRNAs to increase work commitment within five
years (42.4%)
31% of CRNAs work at an ambulatory surgical
center
Region V Characteristics







Lowest vacancy rate (2.9%)
Highest retirement rate (14.3%)
Most CRNAs >49 years of age (56.2%)
Lowest hours worked per week (39.4)
Most cases on average per year (860)
Increasing their work commitment within five
years (6.1%)
31% of CRNAs work at an ambulatory surgical
center
Questions?