1. A STUDY OF CERTIFIED REGISTERED NURSE ANESTHETIST MANPOWER IN NEBRASKA: PART IV

2. 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

3. 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.

4. Research Questions What was the unmet need for CRNAs in Nebraska, including Ambulatory Surgical Centers? 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 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? 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 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 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? What are the regional differences within Nebraska related to the above factors? Where were CRNAs within the state educated? Where were CRNAs within the state educated?

5. 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.

6. 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. 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. 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. 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.

7. Twenty-nine percent of CRNAs who are 55 years of age or older reside in non- metropolitan counties. Since 18.7% of the total CRNA pool lives in non- metropolitan 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. 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). Literature Review Continued 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. 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. 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.

8. Methodology Mailed Questionnaire A response rate of 50% is needed to consider the questionnaire adequate, while 70% or more is considered very adequate A response rate of 50% is needed to consider the questionnaire adequate, while 70% or more is considered very adequate Eliminates interviewer bias Eliminates interviewer bias Eases ability to reach subjects who are difficult to contact per telephone or in person 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 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. 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 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 Large amounts of anonymous data can be obtained with ease

9. 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. 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. 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. 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.

10. 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. 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.

11. Limitations The potential for bias depending on a low response rate. 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. 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. The Veteran Administration hospital in Omaha was not included in this study.

12. Assumptions The respondents would be willing and able to provide accurate information. The respondents would be willing and able to provide accurate information. The respondent interpretation of information was appropriate. The respondent interpretation of information was appropriate. The respondents were honest in answering the questions. The respondents were honest in answering the questions.

13. Procedure The first mailing included cover letters, the respective questionnaires, and an addressed return envelope with postage. 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. 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. 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.

14. Procedure Continued The follow up letters were mailed three weeks from the first mailing. 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 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. A third and final mailed questionnaire was sent to those CRNAs who have not responded to the second mailing.

15. 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 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. 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. 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 All information was transcribed to a spreadsheet computer program

16. Regions

17. 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

18. 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? __________Instruments

19. Year2005200019951991 CRNAs236298212233 Respondents204251174188 Response %86.4 %84 %82 %81 % Statewide CRNA Response Rate

20. RegionRespondents I62 II29 III15 IV34 V49 Non Response7 Not Active8 2005204 Regional CRNA Respondents

21. 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

22. 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 _____Instruments

23. Year2005200019951991 Surveys Mailed90829495 Returns68677085 Response %75.6827489 Statewide Hospital Response Rate

24. RegionRespondents I5 II18 III10 IV19 V16 200568 Regional Hospital Respondents

25. Surveys Mailed 17 Returns9 Response % 52.9 Statewide Ambulatory Outpatient Surgical Center Response Rate

26. Research Question 1 What was the unmet need for CRNAs in Nebraska, including Ambulatory Surgical Centers? What was the unmet need for CRNAs in Nebraska, including Ambulatory Surgical Centers?

27. * Full-time equivalent ** Freestanding Ambulatory Surgical Centers RegionN # of FTEs * % I221.09.5 II226.07.7 III118.05.6 IV563.07.9 V135.02.9 FASCs**110.0 200512173.06.9 200015.5203.58 19954.91773 1991111497 FTE* CRNA Vacancy Rate

28. * Full-time equivalent ** Includes FASCs

29. 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? How was the need projected to change within the next five years as perceived by hospital administrators and managers of Ambulatory Surgical Centers?

30. Regionn I7.0 II*11.0 III6.0 IV10.0 V8.5 Surgical Centers2 200544.5 Number of Administrators or Managers Who Predicted Increase in CRNA Positions Within Five Years Region II reported the only decrease in positions, which is not shown in this table

31. Research Question 3 How many CRNAs currently practicing in Nebraska expected to retire or relocate out of the state in the next five years? How many CRNAs currently practicing in Nebraska expected to retire or relocate out of the state in the next five years?

32. Regionn% I57.9 II310.3 III16.6 IV411.8 V714.3 20052010.6 2000*2513 1995**2113 1991***2415 CRNAs Planning to Retire in the next Five Years * 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

33. Regionn% of CRNAs I69.7 II26.9 III213.3 IV411.8 V612.2 20052010.6 CRNAs Planning to Relocate by the End of 2010

36. Research Question 4 What was the age distribution of CRNAs in Nebraska? What was the age distribution of CRNAs in Nebraska?

37. Agen% 40-4900 50-59630 60-691155 >70315 Age Distribution of Retiring CRNAs

38. * Includes the number of Nebraska CRNAs who live in a state that physically borders Nebraska

39. Research Question 5 What was the average length of time required to recruit a CRNA to a practice setting in Nebraska? What was the average length of time required to recruit a CRNA to a practice setting in Nebraska?

40. * Ambulatory Surgical Centers AVERAGE CRNA RECRUITMENT TIME

41. * Includes Freestanding Ambulatory Surgical Centers

42. Research Question 6 What are the regional differences within Nebraska related to the above factors? What are the regional differences within Nebraska related to the above factors?

43. Regionn% I00.0 II1482.4 III880.0 IV1473.7 V1280.0 20054872.7 20004060 19954463 19915872 Hospitals With CRNAs as Only Anesthesia Providers

44. Yes 35% 31% 22% 13% 3% Percentage of CRNAs that Work at FASCs with Regional Breakdown

45. * 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. CRNA Practice Settings Practice Setting IIIIIIIVV20052000*19951991 Hospital21.0%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-employed6.5%17.2%0.0%26.5%12.2%12.7%21%10%2%** CRNA Group0.0%13.8%0.0%52.9%2.0%12.2%15% 10% Agency/Other21.0%3.4%6.7%2.9%2.0%9.0%2% Multiple6.5%0.0%13.3%0.0%14.3%6.9%

46. * 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

47. * Includes the number of Nebraska CRNAs who live in a state that physically borders Nebraska

48. * Includes the number of Nebraska CRNAs who live in a state that physically borders Nebraska

49. Regionn% by Region I58.0 II517.2 III320.0 IV1441.2 V36.1 20053015.9 2000*4020 1995**2214 1991***2314 * 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 Increase Work by the End of 2010

50. Regionn% by Region I1524.2 II724.1 III320.0 IV926.5 V1224.5 20054624.3 2000*5428 1995**3321 1991***3421 * 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

51. Research Question 7 Where were CRNAs within the state educated? Where were CRNAs within the state educated?

52. ProgramnProgramn Mount Marty 52 St. Raphael 1 Bryan44 St. Joe’s (PA) 1 Creighton/St. Joe’s 22 St. Luke’s 1 University of Nebraska Med Center 7Georgetown1 Mayo4 Wayne State 1 St. Mary’s (MN) 4 George Washington 1 Truman4 Case Western 1 Texas Wesleyan 3Drake1 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 Mercy2 St. Mary’s (NY) 1 Wesley2 Middle Tennessee 1 Friends2Charity1 Northwestern-MN2 St. John’s 1 University of Missouri @ K.C. 1 Murray State University 1 Tripler1 University of NY at Buffalo 1 NEBRASKA CRNA TRAINING PROGRAM REPRESENTATION

53. NEBRASKA PROGRAMS 61%39 % 24% 12 % 4% NEBRASKA CRNA TRAINING PROGRAM DISTRIBUTION Mount Marty trains 28.1% of all Nebraska CRNAs, thus having the most overall representation of any program

54. Manpower Forecast & Additional Findings

55. CategoryActual Response Projected Number with 100% Response Retirees2023 Vacancies12*16* New Positions42.5*57* Relocate17**19 200591.5*115* 20007490 1995***57***68*** 1991****58****68**** Number of Positions to be Filled in Nebraska Between 2005 and 2010 * 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

56. Region I Characteristics Zero hospitals with CRNAs as sole providers reported Zero hospitals with CRNAs as sole providers reported 76.2% of CRNAs work at one facility 76.2% of CRNAs work at one facility Most procedures per hospital (5600) Most procedures per hospital (5600)

57. Region II Characteristics Most anticipated new positions (11) Most anticipated new positions (11) Fewest relocating within five years (6.9%) Fewest relocating within five years (6.9%) Least # of cases per year per CRNA (689) Least # of cases per year per CRNA (689)

58. Region III Characteristics Lowest retirement rate (6.6%) Lowest retirement rate (6.6%) Highest relocation rate (13.3%) Highest relocation rate (13.3%)

59. Region IV Characteristics CRNA group most popular arrangement (52.9%), and only region not primarily anesthesiologist group employed CRNA group most popular arrangement (52.9%), and only region not primarily anesthesiologist group employed Only 26.5% work at one facility Only 26.5% work at one facility Highest hours worked per week (43.9) Highest hours worked per week (43.9) CRNAs to increase work commitment within five years (42.4%) CRNAs to increase work commitment within five years (42.4%) 31% of CRNAs work at an ambulatory surgical center 31% of CRNAs work at an ambulatory surgical center

60. Region V Characteristics Lowest vacancy rate (2.9%) Lowest vacancy rate (2.9%) Highest retirement rate (14.3%) Highest retirement rate (14.3%) Most CRNAs >49 years of age (56.2%) Most CRNAs >49 years of age (56.2%) Lowest hours worked per week (39.4) Lowest hours worked per week (39.4) Most cases on average per year (860) Most cases on average per year (860) Increasing their work commitment within five years (6.1%) Increasing their work commitment within five years (6.1%) 31% of CRNAs work at an ambulatory surgical center 31% of CRNAs work at an ambulatory surgical center

61. Questions?