Survey of Texas Advanced Practice Nurses

Matthew Eastin, Ph.D. & Michael Mackert, Ph.D.

Survey Method

The survey was conducted online from November 17 to December 3, 2008 among a population of advanced practice nurses (APNs) in Texas. The sample was comprised ofthe Coalition for Nurses in Advanced Practice (CNAP) affiliated organizations and their members. Approximately 3,831 members were successfully sent an e-mail solicitation to complete the survey with two reminder messages sent three days and two weeks after the initial invitation. Of those, 1,839 members (48%) opened the solicitation letter. A total of 961 respondents completed the survey during the allotted time period for a response rate of 52%.

The questionnaire consisted of 41 items. Respondents were asked to verify their organization membership and employment status and provide their APN title. Only respondents currently employed as an APN completed the entire survey.

The survey items covered information regarding the specialty, type, and location of respondents’ primary practice sites; job responsibilities and privileges; patient payment methods; the opportunities and barriers APNs face; current provision of services to rural or underserved populations and willingness to work in practices serving these populations; perceptions of current developments such as new technology and direct-to-consumer advertising; and demographics.

These items were designed to answer five primary research questions. The remainder of this report is organized around these five research questions:

  • RQ1: What are the demographics of APNs working in Texas? (p.2)
  • RQ2: How and where do APNs practice? (p.3-5)
  • RQ3: What are APNs’ job tasks and responsibilities? (p.6)
  • RQ4: What are APNs’ perceived career limitations? (p.7-8)
  • RQ5: What other issues are impacting APNs’ practice? (p.9-10)

RQ1: What are the demographics of APNs working in Texas?

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# / %
Age / 18-29 / 16 / 3%
30-44 / 189 / 31%
45-59 / 335 / 56%
60-74 / 60 / 10%
75+ / 2 / >1%
Total / 602
Gender / Male / 156 / 17%
Female / 763 / 83%
Total / 919
Race/
Ethnicity / Asian/
Pacific Islander / 38 / 4%
Black/
African American / 35 / 4%
Hispanic/
Latino / 54 / 6%
Native American/
Alaskan Native / 4 / >1%
White / 768 / 83%
Multiracial / 8 / 1%
Other / 15 / 2%
Total / 922
# / %
Nursing Education / Diploma / 60 / 6%
Associate degree / 105 / 11%
Baccalaureate degree / 317 / 33%
RN First Assist Program / 9 / 1%
Master’s degree / 757 / 79%
Advanced certificate / 257 / 27%
Doctoral degree / 71 / 7%
Credentials for APN practice / Master’s degree / 743 / 77%
Post master’s certificate / 191 / 20%
APN certificate (non-post master’s) / 213 / 22%
Doctoral degree / 33 / 3%
Sub-specialty certificate / 105 / 11%

*Percentages that do not add up to 100% are due to multiple response categories.

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Respondents have spent an average of 12 years (SD = 7.99) practicing in nursing before becoming an APN and been working as an APN for almost 11 years (SD = 8.84) on average.

RQ2: How and where do APNs practice?

Eighty-five percent of respondents are working as an APN, with an additional 6% working as both APN and RN. The majority (54%) work providing patient care at a single site, with smaller percentages providing patient care at two (21%) or three sites (11%).

APN patient care is the primary full-time position for the largest portion, and the second most common activity is administration which typically takes up 1-9 hours. Most respondents spend 80-100% of their time in primary patient care at Site 1 (54%) and Site 2 (48%). Mean score are based on a categorization of hours where 0 hours represents 1, and 40+ hours represents 6.

How many hours you work per week in nursing for each of the following activities: / 0 hours / 1-9 hours / 10-19 hours / 20-29 hours / 30-39 hours / 40+ hours / Responses / Mean
APN patient care / 1% / 7% / 7% / 12% / 22% / 51% / (849) / 5.01
RN patient care / 71% / 16% / 5% / 4% / 1% / 3% / (184) / 1.57
Research / 52% / 36% / 8% / 2% / 1% / 1% / (226) / 1.65
Teaching undergraduate nursing / 60% / 18% / 9% / 4% / 4% / 5% / (221) / 1.89
Teaching graduate nursing / 46% / 27% / 11% / 7% / 6% / 3% / (256) / 2.09
Administration / 32% / 42% / 12% / 9% / 3% / 2% / (301) / 2.17
Other (specify) / 73% / 16% / 6% / 1% / 3% / 1% / (135) / 1.51

A wide range of specialties and practice types are represented. The most common specialties were family practice (18%) and anesthesia (16%). The most common practice types were physician group practice (18%), hospital inpatient (13%), and hospital ambulatory (10%), while 10% worked at a practice owned by an APN or where an APN was the only provider.

Site 1 is equally likely to be designated as providing care for a medically underserved population (43% Yes, 45% No), while a second practice site (when applicable) is less likely to serve the underserved (35% Yes).

Over half of the patients at the primary site paid with some form of government-subsidized program—the most common being Medicaid (24%) and Medicare (19%). About one quarter (26%) of the respondents’ patients had some form of private insurance plan.

Approximately what percentage of the patients that you see at practice site 1 uses each of the following payment methods or insurance plans? / Mean % / SD
Government-subsidized program / 56%
Medicaid / 24% / 25.77
Medicare / 19% / 23.7
Other government-subsidized program (e.g., Texas State employee, Texas Teacher Retirement, Tricare, Indigent County Health, Comprehensive Care Program, other public health programs, etc.) / 8% / 19.76
CHIP / 5% / 12.02
Private health insurance or managed care plan / 26% / 27.05
Self-pay / 10% / 19.14
Other / 9% / 27.17
Medical savings account / >1% / 2.05

The largest proportion of primary practice sites (focusing on Site 1) are in inner cities (31%) or other urban areas (23%), with only 9% in rural areas.

Although few practice in rural areas, three-quarters of the respondents indicated they would be extremely (28%), very (22%), or somewhat (25%) willing to work in a rural or underserved location if having a delegating physician to diagnose and prescribe was no longer a requirement. Those not willing to work in a rural area cited lifestyle considerations (33%) and family/spouse considerations (32%) as the two largest obstacles.

RQ3: What are APNs’ job tasks and responsibilities?

The majority (63%) of respondents had some form of hospital privileges. The most common privileges were ordering diagnostic tests (53%), writing progress notes (50%), and seeing inpatients (44%). Overall, almost all respondents were able to order lab tests (90%) and perform patient histories (88%), with most being able to make specialist referrals, order other diagnostic tests, and write prescriptions. Fewer than half (40%) provide on-call services.

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What hospital privileges do you currently have at practice Site 1? / %
Order diagnostic tests / 53%
Write progress notes / 50%
See inpatients / 44%
Perform procedures / 41%
Write orders (without physician co-signature) / 40%
Admit and discharge patients with sponsoring physician / 22%
Write orders only as verbal orders or with physician co-signature / 18%
Attend deliveries / 8%
Admit and discharge patients as provider of record / 6%
First Assist at surgery / 3%
None / 37%
Base / (929)
At practice Site 1, what job tasks and responsibilities do you have? / %
Order laboratory tests / 90%
Perform history and physical examinations / 88%
Make referrals to specialists / 81%
Order diagnostics such as x-ray, sonogram, MRI, etc. / 80%
Write prescriptions / 73%
Individually counsel and/or educate on areas such as primary prevention, nutrition, exercise, etc. / 73%
Perform procedures / 69%
Administer medications/vaccinations / 63%
Precept APN students / 57%
Provide on-call services / 40%
Order medical supplies/durable medical equipment (DME) / 38%
Precept other health care professional students / 35%
Precept medical students and/or residents / 24%
Administer anesthesia / 23%
Mental health counseling / 19%
Group counsel for health related concerns / 16%
None of the above / 1%
Base / (930)

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RQ4: What are APNs’ perceived career limitations?

Respondents were most likely to have last searched for a job more than two years ago (42%) or within the last 12 months (35%). Only 27% had a difficult time finding a satisfactory APN position, the most commonly cited reason being inadequate compensation or benefits (28%). Some felt there were limited practice opportunities in their desired specialty (18%), desired type of practice (16%), or desired geographic location (15%).

Similarly, only one quarter (25%) of those working in a non-APN position claimed their situation was because of difficulties finding a satisfactory APN position. Most (67%) gave “other” reasons for not being currently employed as an APN including going to school, teaching, or family reasons.

In general, respondents feel there are some (but not many) job openings in their specialty across the different types of practice sites. The exceptions are APN-owned practices (for which many feel there are also no job openings) and home health/hospice (which was evenly split between no job openings and some job openings).

Please indicate your assessment of employment opportunities for APNs in your APN role in the following settings within 50 miles of your primary practice locations. / No job openings / Some job openings / Many job openings / Base
Hospitals-Inpatient / 12% / 49% / 21% / (722)
Hospitals-Outpatient/ Emergency Room / 11% / 48% / 15% / (612)
Long-term care / 15% / 31% / 10% / (452)
Home Health/Hospice / 22% / 22% / 4% / (374)
Public Health/ Community, School, or Rural Health Clinics / 13% / 39% / 8% / (495)
Physician Offices / 6% / 57% / 16% / (653)
APN-owned practice / 30% / 23% / 2% / (458)
Retail clinics/Convenient care clinics / 18% / 30% / 19% / (555)

All barriers to APN practice averaged at the mid-point or above to confirm that all of them are perceived as barriers to a certain extent. Inequitable reimbursement was the highest rated barrier to practicing as an APN. Other barriers ranking near the top include limitations on ordering services for Medicaid patients, the inefficiencies of needing a delegating physician for prescriptive authority, and being denied the opportunity to be a provider on managed care plans.

Interestingly, while needing a delegating physician is thought to be inefficient, it was not considered difficult to find a physician to serve this role. Of those who had prescriptive authority, an overwhelming majority found it to be very easy (64%) or somewhat easy (24%) to find a delegating physician for their current position. Hence, it is not surprising this was rated as one of the lowest barriers.

For each statement below, please rate the extent to which you agree or disagree that it is a barrier (e.g., a barrier to efficient patient care) toyour practice as an APN. / Mean / SD
Inequitable reimbursement / 5.46 / 1.58
Medicaid not allowing APNs to order services, e.g. DME, PT, OT / 5.26 / 1.71
Inefficiencies of needing a physician to delegate and supervise prescriptive authority / 5.18 / 1.85
Managed care refusing APN as a provider / 5.15 / 1.75
Managed care refusing APN as a primary care provider / 5.14 / 1.70
Limitations on hospital privileges / 4.87 / 1.72
Law preventing APNs from verifying patients needing a disabled parking placard / 4.84 / 1.75
Affordability of liability insurance / 4.51 / 1.76
Not having admitting hospital privileges / 4.46 / 1.77
Delegated ordering of drugs and devices for CRNAs / 4.36 / 1.53
Fear of lawsuit / 4.16 / 1.69
Difficulty finding a physician to provide supervision for prescriptive authority / 3.97 / 1.84
Need for additional education / 3.51 / 1.71

* Respondents rated each barrier on a scale of 1-7 (1 = strongly disagree that it is a barrier, 7 = strongly agree), so the higher the number the more it is a barrier.

RQ5: What other issues are impacting APNs’ practice?

Items focusing on other issues impacting APN’s practice focused on two primary areas – the use of new technology and direct-to-consumer (DTC) advertising of drugs.

Most APNs are using some form of new information technology in their practice. Electronic medical records (53%) and online health resources (48%) are the most common technologies in use.

Respondents generally find the new technology helpful in improving patient care. Over half (60%) perceive the technology as extremely (29%) or very (31%) helpful with an average rating of 5.50 (SD = 1.46) on a 7-point scale. Evaluations of the training provided for using the technology are also on the positive side (M = 4.54, SD = 1.48) with the majority (72%) of ratings ranging from neutral (24%) to very good (21%).

APNs appear to think DTC advertising does not have much impact on their relationships with patients. Almost half (49%) believed it is neither helpful nor harmful. When asked about specific consequences of DTC advertising, respondents endorsed most strongly statements that illustrate patients using DTC ads to take more charge of their health. In some cases, however, this has clearly negative connotations – leading patients to be misinformed and demand unnecessary or inappropriate treatments.

How do direct-to-consumer advertisements of prescription drugs affect the relationship you have with your patients? / %
Harms the relationship /
/ 5%
/ 9%
/ 17%
Neither helps nor harms /
/ 49%
/ 14%
/ 5%
Helps the relationship /
/ 1%
Base:e / (840)
Please rate the extent to which you agree or disagree that direct-to-consumer advertisements have led your patients to... / Mean / SD
Request a specific drug brand / 5.08 / 1.36
Be misinformed about treatments or health conditions / 4.93 / 1.30
Request a change in the prescription drug they’re taking / 4.73 / 1.29
Be more involved in their health care / 4.71 / 1.19
Demand unnecessary or inappropriate treatment / 4.70 / 1.44
Ask intelligent questions about treatments and medical conditions / 4.65 / 1.19
Be more informed about health care / 4.58 / 1.23
Be more critical about my health care advice / 4.33 / 1.34
Correctly raise the possibility of a new diagnosis or treatment / 4.08 / 1.19
Be more compliant with prescribed treatments / 3.87 / 1.20

* Respondents rated each statement on a scale of 1-7 (1 = strongly disagree, 7 = strongly agree)

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