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U n ive r s i t y o f K e n t u c k yC e n t e r f o r Ru r a l H e a l t hNurse Anesthetists in SoutheasternKentucky: A Survey of SupplyVersus DemandAugust 2005Authored By:Judy Owens, J.D.D ire c to r, Un iv er s ity o f Ke n tu ck yCen ter for Rura l Hea lthDavid A. GrossD ire c to r, Ex te rna l A ffair sPeggy L e wi sCommun ity H ea lth L ia is on750 Morton Boulevard Hazard, Kentucky 41701 (800) 851-7512 www.mc.uky.edu/ruralhealth
Nurse Anesthetists in Southeastern Kentucky: A Survey of Supply Versus DemandTABLE OF CONTENTSPAGEIntroduction . 2Methodology. 3Findings . 3A. Geographic Discrepancy. 3Effect. 6B. Potential Applicant Pool for CRNA Program in Southeastern Kentucky . 7Conclusions . 7Endnote . 9AppendicesA. Education of nurse anesthetists in the United StatesB. Accredited nurse anesthesia programsC. The cost of starting a nurse anesthetist educational programD. An economic analysis of the investment in nurse anesthesia education
Nurse Anesthetists in Southeastern Kentucky: A Survey of Supply Versus DemandINTRODUCTIONOne of the University of Kentucky Center for Rural Health’s missions is to ensure an adequateand well-distributed supply of health care professionals throughout rural portions of the state.To accomplish this goal, the Center offers health professions education programs in a ruralsetting and administers a loan repayment program that targets primary care providers willing topractice in medically underserved areas. The Center also performs periodic rural healthworkforce analyses.It was in regard to the latter objective that the Center was contacted on numerous occasions inlate 2004 and early 2005. Several southeastern Kentucky hospital officials expressed concernabout a shallow applicant pool for certified registered nurse anesthetist vacancies at theirfacilities.CRNAs are registered nurses with advanced training in anesthesiology. They are responsiblefor selecting and administering anesthetic agents, monitoring surgical patients’ responses tothose anesthetics, and selecting and administering – or ordering the administration of – drugsrequired during the recovery from anesthesia. Nurse anesthesia education programs range from24 to 36 months in length, depending on university requirements, and are at the master’sdegree level or higher. The educational costs of preparing a nurse anesthetist are roughly oneeighth those of an anesthesiologist, according to the American Association of NurseAnesthetists – one of the reasons CRNAs serve as the sole providers of anesthetics forsurgeries and other procedures in more than 70 percent of rural hospitals. The average annualsalary for a nurse anesthetist in the Commonwealth is approximately 145,000, according to a2005 Kentucky Hospital Association salary survey.While more than 90 nurse anesthesia educational programs exist in the United States,Kentucky is home to but one – the Trover Foundation/Murray State University Program ofAnesthesia, located about seven hours’ driving distance west of Hazard, the Center’sheadquarters and southeastern Kentucky’s geographic midpoint. Twenty-three states havemultiple CRNA training programs, according to the Council on Accreditation of NurseAnesthesia Educational Programs.In response to the hospital officials’ inquiries and a subsequent request from the KentuckyHospital Association, the Center initiated a project to track the status of nurse anesthetistpositions and vacancies within all southeastern Kentucky hospitals. Among the project’spurposes were to determine whether a geographic imbalance exists in the distribution ofCRNAs in Kentucky and to evaluate the need for a nurse anesthesia training program in thestate’s eastern half.Page 2
Nurse Anesthetists in Southeastern Kentucky: A Survey of Supply Versus DemandMETHODOLOGYA survey was conducted during May 2005 to determine southeastern Kentucky hospitals’ levelof need for nurse anesthetists and their difficulty in filling CRNA vacancies. Telephoneinterviews were conducted with the human resources director or chief executive officer at eachof the 19 hospitals located in the Big Sandy, Cumberland Valley and Kentucky River areadevelopment districts, a 21-county region that encompasses all of southeastern Kentucky. (Fora complete list of the questions asked and results by county, see Table 1 on Page 6).An online search was conducted on April 15, 2005, to track Kentucky Board of Nursingregistrations for nurse anesthetists by county of residence. The nursing board’s electronicrecords also were analyzed to determine the number of bachelor’s- and master’s-level nurses –those eligible for enrollment in a nurse anesthesia training program – residing in southeasternKentucky.Data were collected during one brief time period and therefore provide a snapshot of vacanciesand nurse anesthetist employment trends within the surveyed hospitals. The findings did,however, concur with a January 2001 “CRNA Needs Assessment Survey” conducted by theCenter and therefore suggest a persistent health workforce problem for this region. Though a2004 Kentucky Hospital Association evaluation found a much smaller nurse anesthetistvacancy rate than the Center’s more recent survey (16 vacancies statewide to 44.5 withinsoutheastern Kentucky alone), it is believed that the KHA estimate of need was substantiallylow because of employment arrangements that KHA’s survey instrument did not measure,such as contracted nurse anesthetists not being considered hospital employees.FINDINGSA. GEOGRAPHIC DISCREPANCYKentucky has a significantly lower per-capita ratio of nurse anesthetists as residents than twoof its similarly rural border states – West Virginia, with 18.3 CRNAs per 100,000 residents,and Tennessee, with 17.7. With 476 resident nurse anesthetists as of mid-April and a totalpopulation in excess of 4.1 million, Kentucky had nearly 11.5 CRNAs per 100,000 residents,still higher than the national rate of 9.3, according to federal Health Resources and ServicesAdministration workforce profiles. Yet, while Kentucky as a whole exceeds the national rate,southeastern Kentucky lags far behind, with fewer than six nurse anesthetists per every100,000 residents.On April 15, the state nursing board’s online database showed 31 nurse anesthetists registeredas living within the Big Sandy, Cumberland Valley and Kentucky River area developmentdistricts. Pike County had six resident nurse anesthetists, the most of any southeasternPage 3
Nurse Anesthetists in Southeastern Kentucky: A Survey of Supply Versus DemandFIGURE 1Number of CRNAs by county of residencegrouped by Kentucky Area Development aryWhitleyBellCallowayFultonPurchaseKIPDANorthern KentuckyBuffalo TraceFIVCOPennyrileLincoln TrailBluegrassGatewayBig SandyGreen RiverBarren RiverLake CumberlandCumberland ValleyKentucky RiverSource: Kentucky Board of Nursing, 2005Kentucky county. By contrast, the entire eight-county Kentucky River district had just oneresident nurse anesthetist. Of the state’s 15 area development districts, southeastern Kentuckyhad the lowest (Kentucky River, with one), fifth-lowest (Big Sandy, with 13) and seventhlowest (Cumberland Valley, with 17) totals for nurse anesthetist residency. In fact, fiveindividual area development districts – representing nearly every other region of Kentucky –had more resident nurse anesthetists than the three southeastern Kentucky districts combined(Figure 1).For further comparison, consider that southeastern Kentucky’s cumulative total of residentnurse anesthetists was less than one-third that of Jefferson County’s alone (94). Yet, whileJefferson County had over 300 percent more resident nurse anesthetists than southeasternKentucky, its overall population was just 26 percent greater than the 21 southeastern counties’combined total, according to the Census Bureau’s July 15, 2005, estimate.Southeastern Kentucky’s number of resident nurse anesthetists also was considerably less thanFayette County’s total of 42. While southeastern Kentucky had 11 fewer resident nurseanesthetists than Fayette County, it is home to nearly twice as many total residents, accordingto the Census estimate (520,408 to 266,358).Finally, southeastern Kentucky’s total of 31 resident nurse anesthetists was just two more thanthat of McCracken County. Although home to just two hospitals, McCracken’s abundance ofPage 4
Nurse Anesthetists in Southeastern Kentucky: A Survey of Supply Versus Demandresident CRNAs could be explained by its location – Paducah, the county seat, is less than 90miles away from Madisonville’s Trover Regional Medical Center, the primary clinical site forKentucky’s lone nurse anesthesia training program. With 29 nurse anesthetists as residentsamong a total population of 64,700, McCracken County’s CRNA-to-general population ratio is1-to-2,231; southeastern Kentucky’s was nearly eight times that, at 1-to-16,787.Another method of demonstrating the maldistribution of nurse anesthetists in Kentucky isthrough per-surgical operation ratios. Below are relevant data for southeastern Kentucky, theBluegrass Area Development District and the Kentuckiana Area Development District, with2004 surgical operations totals accessed from the state Department for Public Health’s onlineData Warehouse:ResidentCRNAsSoutheastern KentuckyBluegrass Area Development District(Fayette and surrounding counties)Kentuckiana Area Development District(Jefferson and surrounding 713,93994,846127895,634133,307While it should be noted that the large medical centers in Fayette and Jefferson countiesperform a much higher number of intricate surgeries, such as open-heart operations, from alook at just these raw numbers consider that:Southeastern Kentucky’s hospitals performed an average of 1,976 surgeries per residentCRNA, more than twice as many as Bluegrass hospitals (968 per) and nearly doubleKentuckiana hospitals (1,050 per).Kentuckiana has more than 400 percent as many resident nurse anesthetists as southeasternKentucky, but its hospitals only performed 218 percent more surgeries during 2004. The ratiowas nearly identical for hospitals in the Bluegrass region, which has over 300 percent moreresident CRNAs than southeastern Kentucky but performed only 155 percent more surgeries.While Kentuckiana and Bluegrass hospitals performed substantially more surgeries thantheir southeastern Kentucky counterparts, the ratio of operations per population was not overlydisparate. During 2004, Kentuckiana and Bluegrass hospitals performed an average of onesurgery for every 6.7 residents and 7.5 residents, respectively. In southeastern Kentucky, theratio was one surgery per 8.5 residents.Page 5
Nurse Anesthetists in Southeastern Kentucky: A Survey of Supply Versus DemandSo, a combined analysis of nurse anesthetist perpopulation and per-surgical operation data reveals this:Southeastern Kentucky has 12.5 percent of Kentucky’stotal population and performs 11.5 percent of thestate’s total surgeries – but has only 6.5 percent of thestate’s total resident CRNAs.EFFECTSoutheastern Kentucky has12.5 percent of Kentucky’stotal population andperforms 11.5 percent of thestate’s total surgeries – buthas only 6.5 percent of thestate’s total resident CRNAs.The above analysis provides strong evidence of the shallowness of the nurse anesthetistapplicant pool available to southeastern Kentucky hospitals. Surveyed hospital officials alsocited difficulty in recruiting those who live elsewhere to relocate to the region for permanentemployment. On a five-point scale, those officials rated nurse anesthetist as the second-mostdifficult position to recruit, behind only physicians (Table 1).This set of circumstances has forced most southeastern Kentucky hospitals to contract theiranesthesia services to companies that, in many instances, are based outside the state. In thosecases, transient nurse anesthetists employed by the contracted companies work for a period oftime at one of the region’s hospitals,TABLE 1then transfer elsewhere and may beComparison of CRNAs employed/contracted incounties with hospitals located in study areareplaced by another of the1. How many full-time nurse anesthetists are employed by your facility?company’s mobile nurse2. How many part-time nurse anesthetists are employed by your facility?3. How many full-time nurse anesthetists are contracted by your facility?anesthetists. In fact, less than half of4. How many part-time nurse anesthetists are contracted by your facility?5. How many nurse anesthetist vacancies does your facility expect within the nextthe hospitals within the surveyyear?region – nine out of 19 – had at least6. Rank the level of difficulty your facility has experienced in recruiting nurseanesthetists, in comparison to other health professionals.one full-time CRNA on staff as anVacancyemployee (Table 1).FTEsPart TimeFTEsPart tractedcontractedone 21344.54Study area contains counties in three southeast Kentucky Area Development Districts: Big Sandy,Cumberland Valley, and Kentucky River.Of the 50 full-time nurse anesthetistpositions reported at the surveyedhospitals, nurses who were notactual employees of the facilityoccupied 32 slots. Another 13 parttime nurse anesthetist positionswere filled on a contracted basis,meaning that of 63 full- and parttime CRNA positions atsoutheastern Kentucky hospitals, 45– or 71.5 percent – were held bynon-employees.*Range for degree of recruiting difficulty is 1-5 with 5 the hardest and 1 the easiest. The totaldisplayed for this column is an average.Page 6
Nurse Anesthetists in Southeastern Kentucky: A Survey of Supply Versus DemandSeveral hospital representatives expressed satisfaction with the use of contract nurseanesthetist companies. In particular, a Baptist Regional Medical Center official said theCorbin-based facility was so pleased with its contract company that it is unclear whether thehospital would hire local nurse anesthetists even if they were available.Hospital officialsestimated a potential44.5 CRNA vacancieswithin the next year –assuming therewould be localapplicants for thepositions now largelyheld by contractedworkers.For the most part, however, surveyed hospital officials said theywould prefer to hire nurse anesthetists as full-time employees oftheir facility, citing increased local control and other benefits. Ahigher percentage of on-staff CRNAs within southeasternKentucky could result in better access to care and less travel timefor patients, as well as improved quality of care because of timelysurgical intervention for required procedures. Nurse anesthetistswho are full-time employees also could be better incorporated intohospitals’ surgical teams. As a result, southeastern Kentuckyhospital officials estimated a potential 44.5 CRNA vacancieswithin the next year – assuming there would be local applicantsfor the positions now largely held by contracted workers (Table 1).B. POTENTIAL APPLICANT POOL FOR CRNA PROGRAM IN SOUTHEASTERN KENTUCKYAs of April 15, the state nursing board listed 608 bachelor’s-level and 248 master’s-levelnurses as residents of the three southeastern Kentucky area development districts. That meansthere would be more than 800 potential applicants should a nurse anesthetist program be madeavailable within the region. (Note: Not all of the BSN/MSN nurses would be candidates, asmost nurse anesthesia programs require at least one year of critical-care experience as aprerequisite for enrollment. Also, the potential applicants have not been surveyed to gaugetheir interest in attending a nurse anesthesia training program.). Online records showed therewere 1,545 bachelor’s- and master’s-level nurses within Kentucky’s three westernmost areadevelopment districts, which are home to Murray State University and its nurse anesthesiaclinical site at Madisonville.Though the western region’s applicant pool is nearly twice as large, so is the number ofstudents to be served. Murray State’s nurse anesthesia program admits 12 students each year,while a program operating in southeastern Kentucky likely would be designed for no morethan six students and perhaps as few as four.CONCLUSIONSFrom the perspective of the entire state of Kentucky, the current workforce supply of nurseanesthetists falls short of crisis designation. In fact, Kentucky as a whole exceeds the nationalCRNA-to-population ratio. And where a shortage does exist, hospitals have managed toPage 7
Nurse Anesthetists in Southeastern Kentucky: A Survey of Supply Versus Demandcontinue surgery services – although largely with CRNAs provided by out-of-state contractcompanies.Yet, whether examined for per-population or per-surgical operation ratios, the data containedin this workforce survey report definitively confirm what southeastern Kentucky hospitalofficials already knew to be true: There indeed is a serious maldistribution of nurse anesthetistsin the state – a discrepancy that has the potential to impact the availability and quality ofsurgical care in Eastern Kentucky. Perhaps the most telling numerical evidence is this: 127-to1. That is the ratio of nurse anesthetists living in the greater Louisville area compared to theentire Kentucky River Area Development District. There seem to be two main reasons for thediscrepancy:Metropolitan areas such as Jefferson and Fayette counties are home to large medical centersthat perform high volumes of surgical procedures, so it stands to reason that is where mostnurse anesthetists would settle.The state’s only nurse anesthesia training program is located in western Kentucky, too farfor many southeastern Kentucky-based nurses – particularly those who are in mid-career orhave started a family – to travel in search of an advanced degree, even one as financiallyrewarding as CRNA.The latter item leads to the consideration that nurses are likely to work near the geographicarea in which they were educated, according to workforce profiles. This validates a long-heldpremise of the Center for Rural Health that health care professionals tend to practice in thearea in which they receive their terminal training. For instance, more than 75 percent ofgraduates from the family medicine residency based at the Center – and nearly 90 percent ofits physical therapy graduates – currently practice in rural Kentucky. Other rural medicinetraining programs, such as the Pikeville College School of Osteopathic Medicine, are based onthe same rationale.Therefore, one potential solution would be to train nurse anesthetists within southeasternKentucky, whether through the extension of an existing program or, however less likely, thecreation of a new one. State nursing board records indicate there is an adequate applicant poolwithin the region for annual classes of four to six students. After repeated inquiries, the Centerfor Rural Health has begun exploring the possibility of recruiting a nurse anesthesia educationprogram to Hazard. That would be a significant first step toward easing southeasternKentucky’s nurse anesthetist shortage.In the interim, southeastern Kentucky’s deficiency of resident nurse anesthetists leaves most ofthe region’s hospitals no viable option but to rely on contracted companies for the provision ofanesthesia services. This circumstance could subject a hospital to the mercy of an out-of-statePage 8
Nurse Anesthetists in Southeastern Kentucky: A Survey of Supply Versus Demandinterest. For instance, a gap in the administration of anesthesia services could force a ruralhospital to refer a surgical patient to another – likely urban – facility. It also has anothernegative financial impact: Money spent on contracted services is not reinvested in localeconomies.Other factors that should be considered in future research, but which were outside the scope ofthe Center’s survey, include:As was mentioned in the Center’s report, bachelors- and masters-level nurses living withinsoutheastern Kentucky were not polled as to their interest in applying to a nurse anesthesiaprogram. It seems at least a random sampling of this group would be necessary beforesubstantial movement was made toward establishing a CRNA training program in the region.The survey process revealed that 31 nurse anesthetists live within southeastern Kentucky,yet the region’s hospitals employ just 18 full-time CRNAs out of 50 such positions, with theremainder filled by outsourced contract workers. The region’s resident CRNAs could besurveyed to discern their work status. This information could be especially useful in projectingretention rates for prospective CRNAs trained within the region.ENDNOTEThe authors wish to recognize the contributions of those who helped make this report possible.Lola M. Dixon, the Center’s director of internal affairs, compiled data for the appendixsection. Tena R. Smith, a staff support associate with the State Office of Rural Health,designed the report and its graphical elements. Editorial consultants included Elmer T. Whitler,the Center’s director of research; Emery A. Wilson, director of UK’s Office of HealthResearch and Development; Joseph E. Smith, executive director of the Kentucky Primary CareAssociation; David Bolt, chief operating officer of the Lewis County Primary Care System andpresident-elect of the Kentucky Rural Health Association; and Carol Blevins Ormay and JoyKnight, representatives of the Kentucky Hospital Association.Page 9
Nurse Anesthetists in Southeastern Kentucky: A Survey of Supply Versus DemandAPPENDICESA. Education of nurse anesthetists in the UnitedStatesB. Accredited nurse anesthesia programsC. The cost of starting a nurse anesthetisteducational programD. An economic analysis of the investment in nurseanesthesia education
Nurse Anesthetists in Southeastern Kentucky: A Survey of Supply Versus DemandAPPENDIX AEducation of nurse anesthetists in theUnited States
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Kentucky’s lone nurse anesthesia training program. With 29 nurse anesthetists as residents among a total population of 64,700, McCracken County’s CRNA-to-general population ratio is 1-to-2,231; southeaster
§ Provide opportunities for continuing education in anesthesia. § Assist nurse anesthetists' associations to improve the standards of nurse anesthesia . Congress for Nurse Anesthetists, Glasgow, Scotland, 2016, and the competencies that lead to their fulfillment. As the scope of practice can vary among IFNA's member countries in
176 Raymond Building Lexington KY 40506 859.257.6898 www.ktc.uky.edu KENTUCKY Kentucky Kentucky Transportation Center College of Engineering, University of Kentucky Lexington, Kentucky in cooperation with Kentucky Transportation Cabinet Commonwealth of Kentucky The Kentucky Transportation Center is committed to a policy of providing .Author: Victoria Lasley, Steven Waddle, Tim Taylor, Roy E. Sturgill
176 Raymond Building Lexington KY 40506 859.257.6898 www.ktc.uky.edu KENTUCKY Kentucky Kentucky Transportation Center College of Engineering, University of Kentucky Lexington, Kentucky in cooperation with Kentucky Transportation Cabinet Commonwealth of Kentucky The Kentucky Transp
2. Continuing Education: Continuing education in this study is defined based on the requirements for CRNA certification and recertification released by the National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA) in conjunction with the American Association of Nurse Anesthetists (AANA).
The Doctorate of Nursing Practice (DNP) program was established in Fall 2016. This program initiated as a Post -Advanced Practice Registered Nurse (APRN) program only, admitted nurse practitioners (NP) of all specialties, clinical nurse specialists (CNS), certified registered nurse anesthetists (CRNA), and nurse mid-wives. Beginning in Fall
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Clinical Nurse Specialists34 . Nurse Practitioners and Clinical Nurse Specialists35 . Nurse Anesthetists35 . Nurse Midwives36 . Nurse Practitioners and Nurse Midwives36 . Non-White, Hispanic, or Latino Advanced Practice Nurses37 . REGISTERED NURSES IN THE WORKFORCE37 . Characteristics within Employment Setting39 . Registered Nurses in Nursing .
Centre for Comparative and Clinical Anatomy, University of Bristol, Southwell Street, Bristol, BS2 8EJ. Receipt of these documents is a condition of our acceptance. If we do not receive these documents within 14 days of registration of the death we will be required to decline the bequest. At the time of donation the next of kin or executor will be asked to complete form ‘Instructions for the .
