Presidents from 5 advanced practice provider (APP) associations shined a light on strategies to increase the health care workforce, key bills that may change the practice landscape, how to create greater diversity among practitioners, and what keeps them up at night at an online panel discussion held in honor of the second annual National APP Week.
The presidents all noted access to care issues, with 96 million Americans lacking adequate primary care access and 155 million lacking mental health access. They also discussed the high levels of burnout among all APPs and the need for changes in educational programs to help build resiliency and recruit a more diverse student body and faculty. The 5 associations included the American Association of Nurse Anesthesiology (AANA), American Association of Nurse Practitioners (AANP), American Academy of Physician Associates (AAPA), American College of Nurse-Midwives (ACNM), and the National Association of Clinical Nurse Specialists (NACNS).
Access to Care Issues for Clinical Nurse Specialists and Midwives
Clinical nurse specialists (CNS) are trained to diagnose, treat, and prescribe but their ability to practice is severely restricted in many states, including a few states where these APPs do not have prescriptive authority. “This impacts access to care for some of the most vulnerable patients including mental health and women’s health such as perinatal care,” said Phyllis Whitehead, PhD, APRN/CNS, ACHPN, PMGT-BC, FNAP, FAAN, president of NACNS. Some states also do not provide title protection, meaning that the CNS title cannot be used by anyone who does not meet the criteria for this title.
Access to care issues were echoed by the other panelists. Access to certified nurse-midwives (CNMs) and certified midwives (CMs) is particularly lacking, with only 13,000 of these clinicians currently in practice, explained Heather Clarke, DNP, CNM, LM, APRN, FACNM, president of ACNM. Data show that CNMs/CMs attended approximately 10% of births in the US in 2020.
Studies show an inverse relationship between midwifery and birth outcomes with countries that have a high proportion of midwives per birth consistently showing lower mortality rates; in contrast, the US has one of the lowest rates of midwifery utilization and has one of the highest rates of maternal mortality compared with other developed countries. Additionally, many urban areas with a high proportion of Black, Hispanic, and other marginalized patients lack access to racially concordant midwifery care.
“As a result, we see unacceptable disparities in maternal mortality and morbidity,” Dr Clarke said. In rural settings, such as those in Georgia and Alabama, which have the highest rates of maternal morbidity and mortality, many counties have no obstetric providers and midwives cannot provide needed care because they are restricted from full practice authority unless they are working with a supervising obstetrician.
ACNM supports 2 bills that will help address these access issues:
- Midwives for MOMS Act (HR 3352/S 1697): will establish 2 new funding streams for accredited midwifery education, one in Title VII Health Professions Training Programs, and one in the Title VIII Nursing Workforce Development Programs. Additionally, the bill will address the significant lack of diversity in the maternity care workforce by prioritizing racial and ethnic students and students from disadvantaged backgrounds.
- Birth Access Benefiting Improved Essential Facility Services (BABIES) Act (HR 3337/S 1716): will provide grant funding to states to develop and advance innovative payment models for freestanding birth centers
Greater Diversity Needed in APP Professions
The NACNS is also working to create a more diverse and equitable workforce, Dr Whitehead said. The organization established a committee to integrate diversity, equity, and inclusion (DEI) principles throughout NACNS government structure and membership and to understand the role of CNS in diverse communities.
Other associations have also established DEI initiatives. “We know that patients of color who see a provider of color do better. There is proven research. But we have to work on that in our PA and APRN professions,” said Jennifer M. Orozco, DMSc, PA-C, DFAAPA, president of AAPA. Greater diversity among clinicians will drive some of the necessary changes needed in health care and patient outcomes, she said.
Building Resiliency Among Certified Registered Nurse Anesthetists
Angela Mund, DNP, CRNA, president of AANA, noted that the COVID-19 pandemic has had a marked effect on the mental health of current nurse anesthesia residents, many of whom were intensive care nurses and witnessed the devastation that occurred in intensive care units during the initial COVID-19 wave.
“We as APPs have dealt with COVID-19, but our students coming into CRNA [Certified Registered Nurse Anesthetists] programs, they lived it. And we need to be mindful of developing resiliency in our programs to make sure these students have access to mental health resources because they will be the providers of the future,” Dr Mund said.
Another lesson learned from the COVID-19 pandemic is that the federal temporary removal of supervision requirement for CRNAs allowed advocacy groups to demonstrate what APPs can do if barriers to practice are removed, Dr Mund noted.
What Keeps You Up at Night?
The nurse practitioner (NP) profession is expected to grow by 46% between 2021 and 2031, and April N. Kapu, DNP, APRN, ACNP-BC, FAANP, FCCM, FAAN, president of AANP, said that what keeps her up at night is thinking about how to support education for NPs and educators.
“How do we support our preceptors and give them time so that they can teach and train our next generation of NPs and APPs?,” Dr Kapu said. “And how do we reach into the pipeline of all of those future students?” Also, “With 91 million people living in health care deserts, I’m concerned about ensuring patients have adequate access to health care delivered by the provider of their choice,” she noted.
“One of the greatest concerns that I have is trying to engage the 159,000 PAs as well as our senators, representatives, and other legislators to help everyone understand the urgency that we have right now in this perfect storm,” said Dr Orozco said. “We’re really at this, this tipping point in health care.”
Dr Mund called for APPs to take on leadership positions. “The only way that we can impact what’s happening at our local, state, and national level is having practitioners who are willing, in our case, to leave the operating room and step into roles in academic leadership, C-suites, and national and state elected offices,” Dr Mund said. She thinks about how to best prepare APP students to take on those roles.
The full National APP Week panel discussion can be viewed here. The event was moderated by Tamekia Hayes, MBA, PA-C, of Huntsville Hospital, and was hosted by Stanford Health Care.