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Report on the Registered Nursing Workforce in Georgia 2014-2015
Rebecca Wheeler, PhD, RN
Summer 2016 Georgia Nursing Leadership Coalition Atlanta, GA
Support for this project was provided by a grant from the Robert Wood Johnson Foundation’s State Implementation Program.
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Contents Executive Summary.......................................................................................................................iv Introduction.....................................................................................................................................1 Section 1: Registered Nurses..........................................................................................................1 Section 2: Advanced Practice Registered Nurses...........................................................................8 Summary........................................................................................................................................19
Tables Table 1. Age distribution of RNs in Georgia and Budden et al. (2013) ........................................3 Table 2. Age distribution of RNs in Georgia and the HRSA report (2013)...................................4 Table 3. Race/ethnicity of the Georgia RN population compared to national samples..................5 Table 4. Country of entry level nursing education for Georgia RNs educated outside the U.S. Table 5. Hours worked per week in nursing by Georgia RNs........................................................5 Table 6. Primary employment setting of Georgia RNs compared to a national sample (Budden et al., 2013) ........................................................................................................................................6 Table 7. Primary employment specialty of Georgia RNs compared to a national sample (Budden et al., 2013) ....................................................................................................................................6 Table 8. Primary position description of Georgia RNs compared to a national sample (Budden et al., 2013) ........................................................................................................................................7 Table 9. Survey Respondents According to APRN Type..............................................................8 Table 10. APRNs Actively Practicing in Georgia.........................................................................10 Table 11. Gender of Georgia APRNs............................................................................................10 Table 12. Age distribution of Georgia APRNs..............................................................................10 Table 13. Race/ethnicity of Georgia APRNs................................................................................12 Table 14. Country of entry level education in nursing for APRNs in Georgia.............................12 Table 15. Number of positions held in nursing for APRNs in Georgia........................................13 Table 16. Average number of hours worked per week by APRNs in Georgia.............................13 Table 17. Primary employment setting of APRNs in Georgia......................................................13 Table 18. Primary employment specialty of APRNs in Georgia..................................................14 Table 19. Primary position description of APRNs in Georgia......................................................15
Charts Chart 1. Age distribution of RNs in Georgia and Budden et al. (2013) ........................................3 Chart 2. Age distribution of RNs in Georgia and the HRSA report (2013) ..................................4 Chart 3. Age distribution of Georgia APRNs................................................................................11
Maps Map 1. RNs and counties where they practice in Georgia..............................................................2 Map 2. Counties in Georgia where NPs are practicing.................................................................16 Map 3. Counties in Georgia where CNMs are practicing.............................................................17 Map 4. Counties in Georgia where CRNAs are practicing...........................................................18
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Executive Summary The supply of Registered Nurses (RNs) and Advanced Practice Registered Nurses (APRNs) is key for planning healthcare initiatives and provision of quality care. This report presents data on the supply and distribution of RNs and APRNs in Georgia. The data are from surveys completed at the time of online licensure renewal in 2014 and 2015. This report is intended to provide an initial picture of the state of the registered nursing workforce in Georgia.
Highlights RNs • • •
•
•
Georgia has fewer white RNs and more black RNs than the national average, but has fewer Hispanic and Asian RNs. There are more RNs between the ages of 25 and 45 in Georgia compared to national statistics. Like national findings, internationally-educated nurses (IENs) in Georgia come from Canada, India, Nigeria, and the Philippines, but the countries of Georgia and Jamaica are also top sources of GA IENs. More RNs in Georgia work in acute care settings and specialties than the national average, and fewer RNs in GA work in gerontology and assisted living/nursing homes/extended care facilities. A low number of RNs work as faculty/in academic settings.
APRNs • • • • • •
• •
Georgia has fewer white APRNs and more black APRNs than the national average, but has fewer Hispanic and Asian APRNs. There are fewer male NPs and more male CRNAs in Georgia compared to national findings. APRNs in Georgia are younger, with more APRNs under the age of 40 and fewer over the age of 55 compared to national findings. Fewer NPs work in nursing homes/extended care/assisted living facilities and home health in Georgia than do nationally. More CNMs in Georgia work in ambulatory care and academic settings and fewer work in hospitals and public and community health settings than do nationally. More Georgia NPs specialize in adult/family health, acute/critical care, and pediatrics and fewer specialize in psychiatric/mental health/substance abuse and women’s health when compared to national findings. More Georgia CNMs specialize primarily in maternal-child health and fewer specialize in medical-surgical and women’s health specialties when compared to national findings. 13.8% of Georgia counties have no practicing APRNs.
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Introduction This report presents an analysis of data obtained from a survey completed by nurses when they renewed their licenses in 2014 and 2015. In 2011, the Georgia Board of Nursing (GBON) revamped a workforce survey that was included in the online re-licensure process. This revision involved two significant changes. First, it adopted the questions in the National Minimum Data (Supply) (NMDS) dataset developed by the National Forum of State Nursing Workforce Centers in an effort to standardize data collected and allow for future comparative analyses. Second, the survey was placed before the final payment screen of the re-licensure process in order to improve participation. Although nurses are not required to fill out the survey, this change has increased the response rate from 14.4% prior to 2011 to 86.7%. The re-licensure process in Georgia takes two years; half the workforce renews in even years and the other half renews in odd years. The data analyzed in this report represents one complete, two-year cycle (2014 and 2015). The National Council of State Boards of Nursing and The Forum of State Nursing Workforce Centers 2013 National Workforce Survey of Registered Nurses (2013), is based on a survey of a national sample of 42,294 registered nurses (RNs) (Budden, Zhong, Moulton, & Cimiotti, 2013). This Budden et al. (2013) report uses the same data covered in the GA re-licensure survey and can be compared to GA data. Two other key reports from the National Center for Health Workforce Analysis of the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services have statistics for the U.S. RN and APRN population. The U.S. Nursing Workforce: Trends in Supply and Education (2013) report analyzed data from the U.S. Census Bureau’s 2000 Long Form and the 2008-2010 American Community Survey (National Center for Health Workforce Analysis, 2013). The Highlights From the 2012 National Sample Survey of Nurse Practitioners (2014) report used data from a survey of a sample of 12,923 NPs across the U.S (National Center for Health Workforce Analysis, 2014). These reports will be referred to throughout this paper as the “HRSA report” from 2013 or 2014. We compared GA data to each of these reports, if applicable.
Section 1: Registered Nurses A total of 101,628 nurses identifying themselves as only holding an RN license renewed their licenses in the 2014-2015 period and 88,152 completed the survey (yielding an 86.7% overall response rate). In Georgia, APRNs also have RN licenses, but these are excluded from the registered nurses analyses. Not every RN answered every question on the survey, yielding missing data for some individual question. Of the 88,152 responses, 75,762 indicated they were actively practicing (85.9%) and 61,271 of these provided a zip code indicating their primary place of employment that was located in Georgia. This means 80.9% of all actively practicing RNs are working in Georgia (see Map 1). Information in this report will be based only on responses from RNs who indicated they are actively practicing in Georgia and whose primary employer’s zip code was located in Georgia.
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Map 1. RNs and counties where they practice in Georgia
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RN DEMOGRAPHICS Gender A total of 43,354 RNs responded to the question asking about gender (70.6%). Of those who answered the question, 7.6% were male, which is similar to the 7% found in the Budden et al. survey (2013) but lower than the 9.1% found by the 2013 HRSA report. Age A total of 46,457 RNs responded to the question asking for age, but 9 were considered invalid (under age 19 or over age 96). The mean age was 45 (median 44, SD 12.3), younger than the findings of Budden et al. (2013) (52 years) but similar to HRSA (2103) findings (44.6 years old). The age profiles are notably different in the two national reports, but the age groupings are also different. As a result, the findings in Georgia will be compared to each report separately. Table 1 and Chart 1 show how the age distribution in Georgia compares to the findings of Budden et al. (2013). Table 2 and Chart 2 show how the age distribution in Georgia compares to the HRSA report (2013). Table 1. Age distribution of RNs in Georgia and Budden et al. (2013) Georgia Budden et al. (2013) Under 30 11.5% 10% 30-34 12.9% 8% 35-39 12.9% 9% 40-44 13.2% 10% 45-49 12.1% 11% 50-54 11.1% 15% 55-59 11.6% 18% 60-64 9.1% 12% 65 and older 5.4% 8%
% of nurses
Chart 1. Age distribution of RNs in Georgia and Budden et al. (2013) 20.0% 18.0% 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0%
Georgia Budden et al.
Age
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Table 2. Age distribution of RNs in Georgia and the HRSA report (2013) Georgia HRSA (2013) 25 and younger 2.2% 5.2% 26-30 12.0% 9.6% 31-35 13.1% 11% 36-40 12.7% 12.5% 41-45 13.5% 12.3% 46-50 11.5% 14.5% 51-55 11.2% 15.1% 56-60 11.6% 11.3% 61-65 7.9% 5.9% 66-70 3.0% 1.8% 71 and older 1.4% 0.8%
% of nurses
Chart 2. Age distribution of RNs in Georgia and the HRSA report (2013)
16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0%
Georgia HRSA
Age
Racial and Ethnic Diversity One of the goals of the nursing profession is to increase the diversity of the nursing workforce (see, for example, the Institute of Medicine’s 2010 report The Future of Nursing: Leading Change, Advancing Health). A total of 61,194 GA RNs provided information on their race/ethnicity. Georgia has a lower proportion of White RNs and more Black/African American RNs than reported nationally (see Table 3). However, Georgia has lower representation of Asian and Hispanic nurses than found nationally. Based on population estimates from the U.S. Census (2015), the diversity of RNs in Georgia does not reflect the diversity of the state’s population except in the cases of Asian nurses (3.0% of Georgia RNs compared to 4.0% of the population), American Indian/Alaska Native nurses (0.4% of Georgia RNs compared to 0.5% of the population), and Native Hawaiian/Pacific Islander nurses (0.1% of Georgia RNs compared to 0.1% of the population). RNs are more likely to be White/Caucasian than the general population of the state (70.9% compared to 53.9% of the
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population in Georgia), and there is a distinct lack of Hispanics (1.3% of RNs compared to 9.4% of the population in Georgia). Georgia has a higher proportion of Black/African American RNs than reported nationally (21.6%), but it is still below the proportion of Black/African Americans in the state (31.7%). Table 3. Race/ethnicity of the Georgia RN population compared to national samples Georgia % (n) Georgia Census Budden et HRSA (2015 est.) al. (2013) (2013) American Indian/ 0.4% (251) 0.5% 1% 0.4% Alaska Native Asian 3.0% (1,832) 4.0% 6% 8.3% Black/African 21.6% (13,200) 31.7% 6% 9.9% American Hispanic 1.3% (768) 9.4% 3% 4.8% Native Hawaiian/ 0.1% (75) 0.1% 1% -Pacific Islander White 70.9% (43,362) 53.9% 83% 75.4% Other 1.4% (829) -3% -Multiple 1.4% (877) 2.0% --INTERNATIONALLY EDUCATED NURSES A total of 60,631 nurses provided information about where they received their “entry-level� nursing education (the first degree that led them to licensure). Of the respondents, 95.2% (n=57,730) were educated in the United States. Of nurses initially educated in other countries, the top six countries are listed in Table 4. Table 4. Country of entry level nursing education for Georgia RNs educated outside the U.S. Country Philippines India Georgia Jamaica Nigeria Canada % 18.9% 10.1% 8.5% 8.5% 8.2% 7.6% n 548 294 247 247 239 221 WORK A total of 61,280 RNs responded to the question on how many positions in nursing they hold. The majority hold only one position (85.3%, n=52,273) and 13% (n=7,995) hold 2 positions. This finding is similar to that reported by Budden et al. (2013). A total of 61,137 nurses provided information on how many hours per week they work in nursing. The majority work between 35 and 45 hours per week (Table 5). Table 5. Hours worked per week in nursing by Georgia RNs Hours/week 50 45 35 25 15 5 % 5.3% 32.5% 47.0% 8.2% 4.1% 2.9% n 3,214 19,898 28,753 5,011 2,496 1,765 A total of 61,327 RNs responded to the question about their primary employment setting. The majority work in hospitals (64.9%, n=39,787) which is higher than the 56% reported by Budden 5
et al. (2013) but similar to the 63.2% found by HRSA (2013). Table 6 contains the other settings and compares Georgia numbers to findings of Budden et al. (2013). The setting categories used by HRSA (2013) were too different to compare to GA data or Budden et al. (2013). Table 6. Primary employment setting of Georgia RNs compared to a national sample (Budden et al., 2013) Georgia Hospital Ambulatory Care Public Health Occupational Health Insurance Claims/Benefits Nursing Home/ Extended Care/ Assisted Living Home Health Academic Correctional Facility School Health Service Other Community Health Policy/Planning/ Regulatory/ Licensing Agency
% 64.9% 6.8% 1.7% 0.6% 1.9% 3.9% 5.6% 1.7% 0.9% 1.8% 8.2% 1.7% 0.2%
n 39,787 4,158 1,043 370 1,189 2,392 3,431 1,070 549 1,111 5,018 1,069 140
Budden et al. (2013) % 56% 9% 2% 1% 1% 6% 6% 3% 1% 3% 9% 2% <1%
A total of 58,507 nurses responded to the question about their primary specialty area. 23.3% (n=13,647) work in acute/critical care, which is higher than the 17% reported by Budden et al. (2013). Table 7. Primary employment specialty of Georgia RNs compared to a national sample (Budden et al., 2013) Georgia Acute/Critical Care Adult/Family Health Anesthesia Community Geriatric/ Gerontology Home Health Maternal-Child Health Medical Surgical Occupational Health Oncology Palliative Care Pediatrics/ Neonatal Public Health Psychiatric/ Mental Health/ Substance Abuse Rehabilitation School Health
% 23.3% 3.4% 0.7% 1.3% 4.0% 4.2% 4.9% 15.2% 0.8% 3.4% 2.1% 6.9% 1.6% 3.5% 1.7% 1.8%
n 13,647 1,982 395 786 2,325 2,437 2,843 8,917 472 1,969 1,213 4,018 918 2,043 989 1,036
Budden et al. (2013) % 17% 3% 2% 1% 6% 5% 5% 13% 1% 3% 1% 6% 2% 4% 2% 3%
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Trauma Women’s Health Other
2.3% 0% 19.1%
1,319 0 11,198
2% 2% 20%
* Budden et al. (2013) include two more categories: primary care (3%) and tele-health (1%) A total of 61,091 RNs responded to the question about the description of their primary position. The majority are staff nurses (70.6%), which is somewhat higher than the 64% found by Budden et al. (2013). Table 8 presents the primary position descriptions. Although no nurse selected “nursing consultant” as a primary position description, it was selected by 8.6% of those who provided information regarding a secondary position description. Table 8. Primary position description of Georgia RNs compared to a national sample (Budden et al., 2013) Georgia
Staff Nurse Nurse Manager Nurse Researcher Nurse Faculty Nurse Executive Nursing Consultant Advanced Practice Nurse Other: health-related Other: not health-related
% 70.6% 13.6% 1.9% 2.2% 2.5% 0 0.5% 8.2% 0.4%
n 43,156 8,2871 1,169 1,369 1,548 0 319 5,006 241
Budden et al. (2013) % 4% 1% 1% 3% 2% 2% 7% 9% <1%
Discussion Some aspects of the demographics of Georgia RNs are promising when compared to the national picture. More GA RNs are between the ages of 25 and 45 when compared to both the Budden et al. (2013) and HRSA report (2013). There is also a higher percentage of Black/African American RNs in Georgia, but less Asian and Hispanic RNs. Given population estimates of the numbers of Blacks/African Americans and Hispanics in Georgia, it is clear that efforts are needed to recruit more of both groups into nursing in GA. While the proportion of males in the RN population in GA is similar to the national average, there is room for growth in the recruitment of males to nursing. The number of internationally-educated nurses (IENs) in Georgia is similar to national findings, but the countries where they come from differ. The Budden et al. (2013) report specifically includes numbers of nurses from Canada the Philippines, and India. The HRSA (2013) report includes the Philippines, South Korea, India, Canada and Nigeria as the countries with the most nurses passing the NCLEX in 2010. IENs in Georgia are primarily from the Philippines, India and Canada as well, but also Jamaica and the European nation of Georgia. Given Georgia’s proximity to the Caribbean, it is not surprising to see the higher proportion of Jamaican nurses. The high proportion of nurses from the nation of Georgia is more surprising. According to the Migration Policy Institute (2016), here were 27,321 people in Georgia in 2014 who were born in
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Eastern European countries other than Poland and Russia (Migration Policy Institute, 2016). This suggests there could be a sizeable population of people from the nation of Georgia. In terms of primary employment setting and specialty, more Georgia RNs seem to practice in acute care and fewer in gerontology and assisted living/nursing homes. This may reflect something about the employment options available in the state; an analysis of the state’s health care industry might provide further insight. There is clearly a need for more nurses to work with older patients. The US Census estimated the population of Georgia residents over the age of 65 was 10.7% in 2010 and 12.8% in 2015, indicating faster growth of this population in the state than nationally (national estimates for this population were 13.0% in 2010 and 14.9% in 2015) (U.S. Census Bureau, 2015). It is unclear why no nurse in Georgia selected “women’s health” as a specialty area. It is possible that nurses who work with women also work with their children and therefore choose “adult/family health” or “maternal-child health”. Another area of potential concern is the low numbers of nurses working as faculty and in academic settings. Universities generally require nurse faculty to have at least Master’s degrees, and possibly also a doctorate. Unfortunately, due to a glitch in data collection for this dataset, educational level of nurses was not collected correctly. Future datasets will contain this information and will help determine the potential pool of nurse faculty available in Georgia so strategies can be developed to recruit nurses to academia.
Section 2: Advanced Practice Registered Nurses According to the Consensus Model for APRN Education (APRN Consensus Work Group and National Council of State Boards of Nursing APRN Advisory Committee, 2008), there are four categories of Advanced Practice Registered Nurses (APRNs): Nurse Practitioners (NPs), Certified Nurse Midwives (CNMs), Certified Registered Nurse Anesthetists (CRNAs) and Clinical Nurse Specialists (CNSs). The Georgia survey asked respondents if they were “currently licensed/certified as a…” and listed these four options. There was also an option to select “not licensed/certified as any of the above”. We compared the number of nurses responding affirmatively to the question of being currently licensed/certified to the Georgia Board of Nursing’s total numbers of nurses who renewed their licenses to practice in these four categories in 2014-2015 (Table 9). Table 9. Survey Respondents According to APRN Type APRN type
Total number of APRN type reported by Percent of total APRN APRN renewals survey respondents respondents reported by GBON NP 5,778 5,261 62.7% CNM 430 441 5.3% CRNA 1,614 1,403 16.7% CNS 350 1,465 17.4% total 8,172 8,570 -Note: totals add up to more than 8,399/100% because some respondents selected licenses/certifications in more than one APRN category * more individuals identified themselves as CNM and CNS than are considered licensed by the Georgia Board of Nursing
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Overall, 8,399 nurses identified themselves as currently licensed/certified as APRNs in Georgia. As this report relies on survey responses, it is important to keep in mind that this information is self-reported and may have some inherent inaccuracies due to misunderstanding of a given question and erroneous selections. The numbers of self-reported NP and CRNAs are similar to the numbers reported by the GBON as licensed in the state (see Table 9). (GBON numbers were obtained directly from the Chief Executive Officer of the organization.) However, more survey respondents selected “CNS” than are actually authorized to practice as a CNS advanced practice provider in Georgia by the Board of Nursing. The CNS role is long standing and for many years did not require licensing, nor was it considered to be an APRN role. It is likely that nurses who completed this degree years ago marked this category even though they do not actually have authorization to practice as an APRN in Georgia. Due to the large discrepancy between survey responses and actual CNSs authorized by the GBON, data about this group will not be presented. Although there are also more respondents who selected “CNM” than who are authorized to practice as CNMs in Georgia, likely for the same reason, the discrepancy is much smaller so these data will be included in this report. As mentioned in the introduction of this report, only two national reports provide findings specifically related to APRNs; Highlights From the 2012 National Sample Survey of Nurse Practitioners from HRSA (2014) and The National Council of State Boards of Nursing (NCSBN) and The Forum of State Nursing Workforce Centers 2013 National Workforce Survey of Registered Nurses (Budden et al., 2013). Findings are difficult to compare between these two reports because their data comes from different national surveys, thus categories and definitions are not always the same. The survey used in Georgia is very similar to the survey published by Budden et. al. (2013), so these findings will be most frequently used for comparison. The percentages of APRN types in GA are similar to national findings where 67% of respondents were NPs (62.7% in GA), 5% were CNMs (5.3% in GA), 15% were CRNAs (16.7% in GA), and 14% were CNSs (17.4% in GA) (Budden et al., 2013). The demographic and work data were only analyzed for APRNs who indicated they are actively practicing and whose primary employer’s zip code was located in Georgia are presented in this report (see Table 10). Nurses were determined to be actively practicing if they responded that they were employed or volunteered in a position requiring a nursing license. However, due to an error in the online survey, options for part-time work were not made available. (This has been corrected for future surveys.) Nurses responding they worked part-time in a position requiring a nursing license would have also been included as actively practicing, so numbers reported here may be lower than in actuality. It is also important to note that no one provided an employer zip code who was not actively employed. The different APRN types (excluding CNS) have been analyzed separately for purposes of comparison among specialties. For each question, the response rates are reported as well as responses from all APRNs and from nurses in each APRN sub-group.
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Table 10. APRNs Actively Practicing in Georgia* APRN type
Total number of responses to survey
Percent actively practicing (n)
All APRNs† NP CNM CRNA
7,028 5,261 441 1,403
90.4% (6,356) 90.8% (4,776) 81.4% (380) 90.6% (1,271)
Number actively practicing who provided an employer zip code 5896 4503 359 1179
Percent of employer zip codes located in Georgia (n) 83.1% (4,898) 86.1% (3,877) 88.3% (317) 69.9% (824)
* Note: Many APRNs have licenses in more than one category † Excluding CNS
APRN DEMOGRAPHICS Gender Georgia has a relatively high percentage (10.5%) of male APRNs overall (see Table 11) although fewer Georgia NPs are male compared to findings from the HRSA report (2014) (7% male). This is primarily due to the high number of male CRNAs. Table 11. Gender of Georgia APRNs Female Male
All APRNs† % (n) 89.2% (3,747) 10.8% (455)
NP % (n) 93.4% (3,103) 6.6% (221)
CNM % (n) 98.2% (268) 1.8% (5)
CRNA % (n) 64.5% (423) 35.5% (233)
† Excluding CNS
Age The average age and the age profile of APRNs are important to know as employers develop strategies around recruitment and retirements. APRNs in Georgia are somewhat younger than the average age of RNs (50 years old) (Budden et al., 2013) and specifically for NPs (48 years old) (National Center for Health Workforce Analysis, 2014)(see Table 12 and Chart 3). Georgia also has fewer NPs over the age of 55 (25.5% compared to 40%) and more NPs under the age of 40 (34.3% compared to 25%) (Budden et al., 2013). Georgia’s CNMs are also younger, with more CNMs under the age of 40 (30.3% compared to 20%) and fewer over the age of 65 (5.8% compared to 31%) (Budden et al., 2013). The CRNAs show similar patterns; more are under the age of 40 (31.5% compared to 26%) and fewer over the age of 65 (8% compared to 9%) (Budden et al., 2013). Table 12. Age distribution of Georgia APRNs All APRNs†
NP
CNM
CRNA
Mean age
46.9
45.7
47.1
47.0
SD
11.2
11.1
11.3
11.7
Median
45
45
46
45
Age range Under 30 30-34 35-39 40-44
n 158 634 614 660
% 3.8% 15.1% 14.6% 15.7%
n 131 522 491 516
% 3.9% 15.7% 14.7% 15.5%
n 9 28 41 38
% 3.5% 10.9% 15.9% 14.7%
n 20 91 97 111
% 3.0% 13.8% 14.7% 16.8%
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45-49 50-54 55-59 60-64 65-69 Over 69
540 473 487 419 157 57
12.9% 11.3% 11.6% 10.0% 3.7% 1.4%
433 388 393 310 104 43
13.0% 11.6% 11.8% 9.3% 3.1% 1.3%
52 28 33 34 13 2
12.4% 10.9% 12.8% 13.2% 5.0% 0.8%
80 62 67 79 41 12
12.1% 9.4% 10.2% 12.0% 6.2% 1.8%
† Excluding CNS
Chart 3. Age distribution of Georgia APRNs 18.0% 16.0% 14.0%
% of APRNs
12.0%
NP
10.0%
CNM
8.0%
CRNA
6.0% 4.0% 2.0% 0.0%
Age
Racial and Ethnic Diversity One of the goals of the nursing profession is to increase the diversity of the nursing workforce (e.g. see the Institute of Medicine’s 2010 report The Future of Nursing: Leading Change, Advancing Health). Georgia is less diverse than the national average for all racial/ethnic categories (see Table 13) except Black/African American, where the percent is much higher than the national average (12.0-17.1% in Georgia compared to 4-10% nationally, depending on APRN type) (Budden et al., 2013). This is also true when looking only at Black/African American NPs (16% in Georgia compared to 5% nationally) (National Center for Health Workforce Analysis, 2014). Overall, Georgia also has fewer White/Caucasians for all APRN types (76.5% compared to 83% nationally) (Budden et al., 2013) and for White/Caucasian NPs specifically (75.2% in Georgia compared to 86% nationally) (National Center for Health Workforce Analysis, 2014). Also, the numbers in Georgia do not reflect the national distribution of diversity within specific APRN types; for example, according to Budden et al. (2013), nationally CNMs have the highest percentage of Black/African American nurses (10%) nationally, but in Georgia, NP’s have the highest percentage of Black/African American nurses (17.1%). Based on population estimates from the US Census (2015 estimate) (U.S. Census Bureau, 2015), the diversity of APRNs in Georgia does not reflect the diversity of the state’s 11
population (except for American Indian/Alaska Native and Native Hawaiian/Pacific Islander). APRNs are more White/Caucasian than the general population of the state (76.5% compared to 53.9% of the population in Georgia), and there is a distinct lack of Hispanics (1.4% of APRNs compared to 9.4% of the population in Georgia). 2.6% of APRNs are Asian compared to 4.0% of the population in Georgia and 16% of APRNs are Black/African American compared to 31.7% of the population. Table 13. Race/ethnicity of Georgia APRNs American Indian/ Alaska Native Asian Black/African American Hispanic Native Hawaiian/ Pacific Islander White Other Multiple † Excluding CNS
Georgia Census (2015 est.) 0.5%
All APRNs† % (n)
NP % (n)
CNM % (n)
CRNA % (n)
0.3% (16)
0.4% (15)
0
0.1% (1)
4.0% 31.7%
2.6% (126) 16.0% (787)
2.6% (99) 17.1% (661)
5.0% (16) 12.6% (40)
1.6% (13) 12.0% (98)
9.4% 0.1%
1.4% (71) 0.1% (7)
1.6% (60) 0.1% (4)
1.9% (6) 0
0.7% (6) 0.4% (3)
53.9% -2.0%
76.6% (3,777) 1.3% (65) 1.7% (85)
75.2% (2,899) 1.3% (51) 1.7% (67)
77.9% (247) 2.2% (7) 0.3% (1)
81.9% (671) 1.2% (10) 2.1% (17)
INTERNATIONALLY EDUCATED NURSES Overall, 4,899 APRNs responded to the question about where they received their “entry-level” nursing education (the first degree that led them to licensure). Of all nurses educated outside the U.S., 46 countries are represented. The top eight of these countries are included in Table 14. Table 14. Country of entry level education in nursing for APRNs in Georgia U.S. educated
All APRNs† % (n) (n = 4,899) 96.9% (4,746)
NP % (n) (n = 3,832) 97.3% (3,730)
CNM % (n) (n=315) 90.5% (285)
CRNA % (n) (n=810) 97.3% (788)
8.5% (13) 5.2% (8) 11.8% (18) 15.7% (24) 11.1% (17) 2.6% (4) 8.5% (13) 7.2% (11)
11.8% (12) 4.9% (5) 14.7% (15) 10.8% (11) 11.8% (12) 2.9% (3) 6.9% (7) 8.8% (9)
3.3% (1) 13.3% (4) 3.3% (1) 33.3% (10) 13.3% (4) 0 13.3% (4) 0
0 0 9.1% (2) 13.6% (3) 4.5% (1) 4.5% (1) 9.1% (2) 9.1% (2)
Top 8 countries Canada United Kingdom Georgia India Jamaica Korea (Republic of) Nigeria Philippines † Excluding CNS
WORK The majority of APRNs in Georgia hold only one position in nursing (see Table 15). NPs are the most likely to have a second position. The majority also works approximately 45 hours per week, although more CNMs may work 50 hours or more (see Table 16).
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Table 15. Number of positions held in nursing for APRNs in Georgia 1 position 2 positions 3 positions
All APRNs† % (n) 79.0% (3,909) 17.6% (869) 3.4% (167)
NP % (n) 77.5% (2,998) 19.1% (739) 3.4% (130)
CNM % (n) 83.5% (264) 13.3% (42) 3.4% (10)
CRNA % (n) 84.9% (696) 11.2% (92) 3.9% (32)
† Excluding CNS
Table 16. Average number of hours worked per week by APRNs in Georgia 5 hours 15 hours 25 hours 35 hours 45 hours 50 hours
All APRNs† % (n) 2.0% (99) 3.3% (164) 7.7% 379 33.7% (1,664) 42.7% (2,104) 10.6% (523)
NP % (n) 2.1% (82) 3.7% (143) 7.9% (305) 33.0% (1,274) 43.0% (1,657) 10.3% (396)
CNM % (n) 0.6% (2) 1.3% (4) 6.0% (19) 23.7% (75) 41.1% (130) 27.2% (86)
CRNA % (n) 2.0% (16) 2.3% (19) 7.0% (57) 40.7% (333) 41.7% (341) 6.4% (52)
† Excluding CNS
Hospitals are the most common primary employment setting, although more so for CRNAs and CNMs and less so for NPs, who also work in ambulatory care (see Table 17). In Georgia, similar to some national findings, NPs are almost evenly divided between hospital and ambulatory care settings (Budden et al., 2013). In Georgia, it also seems fewer NPs work in nursing homes/extended care/assisted living facilities and home health as do nationally (4% compared to 8% nationally) (Budden et al., 2013). More CNMs in Georgia work in ambulatory care than nationally (18.3% compared to 9%) and fewer work in hospitals (46.7% in Georgia compared to 53% nationally) (Budden et al., 2013). There is also a considerably higher percentage in Georgia working in academic settings (7.9% compared to 3% nationally) (Budden et al., 2013). Considerably fewer work in public and community health settings (4.7% in Georgia compared to 9% nationally) (Budden et al., 2013). Table 17. Primary employment setting of APRNs in Georgia Hospital Ambulatory Care Public Health Occupational Health Insurance Claims/Benefits Nursing Home/ Extended Care/ Assisted Living Home Health Academic Correctional Facility School Health Service
All APRNs† % (n) 39.2% (1,943) 25.8% (1,279)
NP % (n) 31.1% (1,202) 28.0% (1,082)
CNM % (n) 46.7% (148) 18.3% (58)
CRNA % (n) 75.4% (619) 18.3% (150)
2.8% (137) 0.8% (29)
3.4% (130) 1.0% (38)
1.9% (6) 0
0.2% (2) 0.1% (1)
0.3% (13)
0.3% (11)
0.3% (1)
0.1% (1)
2.0% (98)
2.4% (92)
0.3% (1)
0.6% (5)
1.5% (72) 4.3% (212) 0.9% (47)
1.6% (61) 4.7% (183) 1.2% (45)
2.2% (7) 7.9% (25) 0.3% (1)
0.6% (5) 0.9% (7) 0.1% (1)
1.0% (49)
1.2% (47)
0.3% (1)
0.1% (1)
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Other Community Health Policy/Planning/ Regulatory/ Licensing Agency † Excluding CNS
16.3% (809) 5.0% (250)
19.0% (734) 6.3% (243)
18.9% (60) 2.8% (9)
3.4% (28) 0.1% (1)
0.1% (3)
0.1% (3)
0
0
Primary employment specialties vary considerably among the APRN types (see Table 18). Georgia NPs specialize in adult/family health and acute/critical care, and they seem to do so more than NPs in the rest of the country (13.4% and 33.4% compared to 10% and 16% respectively) (Budden et al., 2013). However, this could also be due to the fact that the national survey included primary care as a separate specialty. Georgia NPs also tend to specialize more in pediatrics than nationally (14.5% compared to 10%) (Budden et al., 2013). In Georgia, there are fewer NPs in psychiatric/mental health/substance abuse (3% compared to 7% nationally) and none in women’s health (compared to 7% nationally) (Budden et al., 2013). More Georgia CNMs specialize primarily in maternal-child health (63.8% compared to 56% nationally), and fewer specialize in medical-surgical (5% in Georgia compared to 13% nationally) (Budden et al., 2013). Zero Georgia CNMs selected “women’s health” as a specialty area although nationally 23% of CNMs selected this (Budden et al., 2013). Table 18. Primary employment specialty of APRNs in Georgia Acute/Critical Care Adult/Family Health Anesthesia Community Geriatric/ Gerontology Home Health Maternal-Child Health Medical Surgical Occupational Health Oncology Palliative Care Pediatrics/ Neonatal Public Health Psychiatric/ Mental Health/ Substance Abuse Rehabilitation School Health Trauma Women’s Health Other † Excluding CNS
All APRNs† % (n) 11.6% (519) 26.6% (1,193) 15.9% (715) 1.2% (53) 2.9% (131) 0.5% (24) 3.4% (153) 2.6% (116) 0.8% (35) 2.9% (131) 1.4% (61) 11.5% (517) 1.1% (50) 2.6% (115)
NP % (n) 13.4% (478) 33.4% (1,187) 0.7% (24) 1.5% (53) 3.6% (127) 0.5% (19) 1.6% (56) 2.6% (94) 0.9% (33) 3.5% (125) 1.7% (59) 14.5% (515) 1.4% (49) 3.0% (105)
CNM % (n) 8.1% (13) 7.5% (12) 0 0 0 1.3% (2) 63.8% (102) 5.0% (8) 0.6% (1) 1.9% (3) 0.6% (1) 0.6% (1) 0 3 1.9%
CRNA % (n) 3.7% (30) 0.5% (4) 86.8% (697) 0 0.5% (4) 0.4% (3) 0.5% (4) 1.7% (14) 0.1% (1) 0.5% (4) 0.1% (1) 0.4% (3) 0.1% (1) 1.0% (8)
0.8% (34) 0.8% (34) 0.6% (28) 0 12.9% (579)
0.9%(32) 0.9% (31) 0.7% (25) 0 15.3% (546)
0 0.6% (1) 0 0 8.1% (13)
0.2% (2) 0.2% (2) 0.4% (3) 0 2.7% (22)
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The primary position description of all Georgia APRNs is “advanced practice nurse” (see Table 19). More Georgia NPs are employed as staff nurses (5.3% compared to 2% nationally) (Budden et al., 2013). More Georgia CNMs have the job title of “advanced practice nurse” and fewer are staff nurses (71% and 16.1% compared to 68% and 22% nationally), and more CNMs identify themselves as faculty (6.6% compared to 3%) (Budden et al., 2013). Table 19. Primary position description of APRNs in Georgia Staff Nurse Nurse Manager Nurse Researcher Nurse Faculty Nurse Executive Nursing Consultant Advanced Practice Nurse Other: health-related Other: not healthrelated † Excluding CNS
All APRNs† % (n) 6.7% (331) 1.7% (84) 0.7% (37) 2.9% (143) 1.0% (49) 0 85.6% (4,231)
NP % (n) 5.3% (206) 1.8% (70) 0.9% (36) 3.1% (118) 1.0% (38) 0 86.6% (3,349)
CNM % (n) 16.1% (51) 1.9% (6) 0.3% (1) 6.6% (21) 2.2% (7) 0 71.0% (225)
CRNA % (n) 9.5% (78) 1.1% (9) 0 0.9% (7) 0.6% (5) 0 86.3% (707)
1.3% (66) 0% (2)
1.2% (48) 0% (1)
1.6% (5) 0.3% (1)
1.6% (13) 0
GEOGRAPHY Respondents were asked to provide the zip code of their primary employer. These zip codes were matched to counties in order to gain a better understanding of the geographical distribution of practicing APRNs. There are 159 counties in Georgia. Twenty-two counties (13.8%) have no practicing NPs (see Map 2) and they are all rural counties. Eighty-nine (55.9%) have five or less. There are even more counties with no practicing CNMs (see Map 3) or CRNAs (see Map 4).
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Map 2. Counties in Georgia where NPs are practicing
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Map 3. Counties in Georgia where CNMs are practicing
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Map 4. Counties in Georgia where CRNAs are practicing
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Discussion The demographic results of this analysis indicate some promising aspects of the APRN workforce in Georgia. It seems to be somewhat younger than the national average, which means fewer are close to retirement. More research is needed to understand why Georgia’s APRNs are younger in order to determine if this is a sustainable trend or a temporary anomaly. It is also encouraging that there are more black APRNs in the Georgia workforce than nationally, although there is still a long way to go to increase the diversity of the workforce and bring it closer to reflecting the demographics of the citizens. More research is needed to understand why Georgia has a higher percentage of black APRNs to determine strategies to keep increasing that number as well as to increase the number of Asian and Hispanic nurses. Although Georgia is similar to national findings in terms of male APRNs, more work is needed to attract males to the profession and to APRN specialties besides CRNA. There is some indication that APRNs in Georgia practice in more ambulatory settings than nationally. This may reflect the that healthcare systems have recognized the value of APRNs in these settings and/or that APRNs are positioning themselves to practice in areas where their preparation and skills can be best utilized. The relatively low number of NPs in nursing homes/extended care/assisted living facilities as well as the relatively low number of NPs specializing in psychiatric/mental health/substance abuse suggest opportunities for growth. There are somewhat fewer NPs in Georgia who specialize in gerontology than nationally (3.6% compared to 5%) (Budden et al., 2013). The fact that no NP or CNM selected women’s health as a specialty could be explained by the perception that caring for women often means caring for children as well, so respondents may have selected maternal-child health or adult/family health instead. However, APRNs nationally did select women’s health as their specialty when also given the other options. Given the shortage of nursing faculty, it is heartening to see more CNMs who identify themselves as nursing faculty, although somewhat fewer Georgia NPs do so (3.1% compared to 4% nationally) (Budden et al., 2013). This suggests a mixed future for nursing faculty. It is clear that Georgia APRNs are not evenly distributed throughout the state. This is a barrier to providing access to quality care to the citizens of Georgia. More research is needed to understand the reasons why APRNs are not better distributed, though one possibility lies in the somewhat restrictive scope of practice of APRNs in this state. In Georgia, APRNs must have a collaborative agreement with a physician and physicians cannot enter into collaborative agreements with more than four APRNs if they delegate prescriptive authority. They also must see the APRN’s patients on a quarterly basis. If the physician practices in a contiguous state, then the APRN must practice within 50 miles of that physician’s primary practice location. All of this limits APRN practice in a state that is already short of primary care physicians (Stephens, 2015).
SUMMARY The supply of Registered Nurses (RNs) and Advanced Practice Registered Nurses (APRNs) is key for planning healthcare initiatives and provision of quality care. This report presents data on the supply and distribution of RNs and APRNs in Georgia by looking at things like demographic
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variables (gender, age, race/ethnicity, & migration), as well as work variables (number of positions held, employment setting, employment specialty, employment description, & hours worked). Geographic distribution is also discussed. This report was written to provide an initial picture of the state of the registered nursing workforce in Georgia.
References APRN Consensus Work Group and National Council of State Boards of Nursing APRN Advisory Committee. (2008). Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education. Retrieved from http://www.nursingworld.org/consensusmodel Budden, J. S., Zhong, E. H., Moulton, P., & Cimiotti, J. P. (2013). The National Council of State Boards of Nursing and The Forum of State Nursing Workforce Centers 2013 National Workforce Survey of Registered Nurses. Journal of Nursing Regulation, 4(2). Migration Policy Institute. (2016). State Immigration Data Profiles: Georgia. Retrieved from http://www.migrationpolicy.org/data/state-profiles/state/demographics/GA National Center for Health Workforce Analysis. (2013). The U.S. Nursing Workforce: Trends in Supply and Education. Retrieved from Rockville, MD: http://bhpr.hrsa.gov/healthworkforce/reports/nursingworkforce/nursingworkforcefullrepo rt.pdf National Center for Health Workforce Analysis. (2014). Highlights From the 2012 National Sample Survey of Nurse Practitioners. Retrieved from Rockville, MD: http://bhpr.hrsa.gov/healthworkforce/supplydemand/nursing/nursepractitionersurvey/ Stephens, B. (2015). Perspectives on Advanced Priactice Registered Nursing in Georgia. Retrieved from http://www.georgiawatch.org/wpcontent/uploads/2015/01/APRN01072015WEB.pdf U.S. Census Bureau. (2015). State and County QuickFacts. Retrieved from http://www.census.gov/quickfacts/table/PST045215/13
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