biostatistic

Journal of Midwifery & Women’s Health www.jmwh.org Original Research

The Midwifery Workforce: ACNM 2012 and AMCB 2013 Core Data Judith Fullerton, CNM (ret), PhD, Theresa Ann Sipe, CNM, PhD, Marie Hastings-Tolsma, CNM, PhD, Barbara L. McFarlin, CNM, PhD, Kerri Schuiling, CNM, PhD, Carrie D. Bright, IOM, CAE, Lori B. Havens, Cara J. Krulewitch, CNM, PhD

Introduction: Core data are crucial for detailing an accurate profile of the midwifery workforce in the United States. The American College of Nurse-Midwives (ACNM) and the American Midwifery Certification Board, Inc. (AMCB), at the request and with support from the US Health Resources and Services Administration (HRSA), are engaged in a collaborative effort to develop a data collection strategy (the Midwifery Master- File) that will reflect demographic and practice characteristics of certified nurse-midwives (CNMs) and certified midwives (CMs) in the United States.

Methods: Two independent datasets, one collected by ACNM in 2012 and one by AMCB in 2013, were examined to determine key workforce information. ACNM data were collected from the online Core Data Survey sent to ACNM members. AMCB data were extracted from information submitted online by applicants seeking initial certification in 2013 and applicants seeking to recertify following 5 years of initial certification.

Results: The ACNM 2012 survey was partially or fully completed by 36% (n = 2185) of ACNM members (N = 6072). AMCB respondents included 100% of new certificants (N = 539) and those applying for recertification in 2013 (n = 1323) of the total 11,682 certificants in the AMCB database. These two datasets demonstrate that midwives remain largely white, female, and older in age, with most engaged in clinical midwifery while employed primarily by hospitals and medical centers. Differences were reported between the ACNM membership and AMCB certification datasets in the numbers of midwives holding other certifications, working full-time, attending births, and providing newborn care.

Discussion: The new collaboration among HRSA, ACNM, and AMCB, represented as the Midwifery MasterFile, provides the opportunity to clearly profile CNMs/CMs, distinct from advanced practice registered nurses, in government reports about the health care workforce. This infor- mation is central to identifying and marketing the role and contribution of CNMs/CMs in the provision of primary and reproductive health care services. J Midwifery Womens Health 2015;60:751–761 c© 2015 by the American College of Nurse-Midwives.

Keywords: survey research, midwifery workforce, health policy

INTRODUCTION

The American College of Nurse-Midwives (ACNM), the pro- fessional association of certified nurse-midwives (CNMs) and certified midwives (CMs), has conducted a series of core data surveys of its membership over the last 3 decades.1–6 The sur- veys have addressed selected demographic characteristics and descriptive profiles of CNMs and CMs who actively engaged in or retired from employment, and students enrolled in mid- wifery education programs accredited by the Accreditation Commission for Midwifery Education (ACME). The descrip- tive information obtained from these surveys has been used by ACNM to generate a public profile about the midwifery workforce (defined for the purpose of this article as American Midwifery Certification Board, Inc. (AMCB)–certified CNMs and CMs as well as ACNM members currently or previously certified).

The AMCB is the national certifying body for CNMs and CMs. After initial certification, CNMs and CMs are enrolled in the Certification Maintenance Program that has operated on a 5-year cycle since 2011. Recertification by AMCB is mandatory for all CNMs/CMs who choose to maintain active

Address correspondence to Judith Fullerton, CNM (ret), PhD, 7717 Canyon Point Lane, San Diego, CA 92126. E-mail: [email protected]

certification. The descriptive information obtained from the applications is used by AMCB to maintain a database of cur- rently or previously certified CNMs/CMs that can be searched by individuals or agencies who require this information for employment verification or research.

The US Health Resources and Services Administration (HRSA), National Center for Health Workforce Analysis (NCHWA), as well as other government and nongovern- ment organizations, have also been conducting surveys in recent years, to generate profiles of the workforce of registered nurses, advanced practice registered nurses, and midwives.7–12 A limitation of some of these surveys is that they often do not address midwives prepared though non- nursing pathways, thereby excluding CMs in the analysis.7–9 In late 2012, HRSA and NCHWA contacted ACNM and AMCB, announcing the availability of funding to allow selected “nursing specialty” organizations to engage in a data-sharing process, so that members of those organizations could be separately identified within the larger workforce studies. This offered the opportunity to include both CNMs and CMs in the HRSA data about the midwifery workforce.

Accordingly, ACNM and AMCB entered into a collab- orative data-sharing agreement in 2013 in the interest of constructing a minimum dataset that includes specific demo- graphic, education, and practice variables for all CNMs and

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✦ The American College of Nurse-Midwives (ACNM) Core Data Surveys have provided valuable midwifery workforce data over the past 3 decades.

✦ The American Midwifery Certification Board (AMCB) is now collaborating with ACNM for the collection of core mid- wifery data, which should improve both the quantity and the quality of data, as recertification by AMCB is mandatory for all CNMs/CMs who choose to maintain active CNM/CM certification status.

✦ Expansion of data collected by AMCB will promote a more robust Midwifery MasterFile that, when integrated into fed- eral workforce studies, will allow inclusion of both CNMs and CMs in government reports that offer comparisons with advanced practice registered nurses, physicians, and allied health professionals.

CMs. The agreement led to the modification of the AMCB initial examination and recertification applications to include questions that matched the ACNM membership Core Data Survey and additional questions that reflect similar informa- tion gathered in the HRSA workforce surveys.7,12

The purpose of this article is to present findings from the 2012 ACNM Core Data Survey (the most recent year of that survey), and 2013 AMCB new and recertification applica- tions, to preserve ACNM’s history of reporting of trends in the midwifery workforce. The article will also describe the current status and future intentions of the ACNM and AMCB transi- tion to the Midwifery MasterFile as the principal repository of data concerning the CNM/CM workforce.

BACKGROUND

The 2 datasets that are used in this analysis are separate and distinct properties of the 2 organizations, ACNM and AMCB. The 2012 Core Data Survey was developed by ACNM for an annual survey of members. The 2013 AMCB application forms were developed for the purpose of identification and tracking of individuals requesting to sit for the national certi- fication examination for the first time, or for renewal of certi- fication status.

It is very likely and expected that some of the respondents to the 2012 Core Data Survey of ACNM members and some of those who completed applications to AMCB in 2013 are the same individuals. This would include those who applied to AMCB in 2013 to renew their certification status, and, as a member of the ACNM, also responded to the Core Data Sur- vey in 2012. It would also include the small minority who re- sponded to the ACNM 2012 Core Data Survey as a student nurse-midwife/student midwife (SNM/SM) but did not ap- ply to AMCB for initial certification until 2013. Nevertheless, both respondent cohorts can be considered samples represen- tative of their respective ACNM or AMCB populations in the descriptive analyses conducted for this report.

An almost 3-decade history of reports profiles ACNM membership. The 2012 data in this article are compared with data from the prior 3 years (2009-2011)6 to identify trends. The 2013 AMCB data are reviewed simply to highlight com- parisons or differences in selected indicators, but true trends cannot be inferred.

ACNM and AMCB have collaborated in the development of the Midwifery MasterFile to take full advantage of AMCB data that profile all currently certified CNMs/CMs. AMCB

data represent a more robust source of information about the midwifery workforce, and, when integrated into federal work- force studies, would allow inclusion of both CNMs and CMs in government reports that offer comparisons with advanced practice registered nurses, physicians, and allied health pro- fessionals. The newly merged and amended data, now known as the Midwifery MasterFile, was initiated in 2014 and then further amended. These additional amendments will be in- corporated into the Midwifery MasterFile in 2015. The Mid- wifery MasterFile will be prospectively managed by AMCB. However, given the 5-year certification cycle, the data file will not be complete for all certificants until the end of 2019.

METHODS

Two independent data files were used for this report. Mem- bership surveys have been conducted and reported by ACNM for almost 3 decades.1–6 These surveys were distributed ini- tially via a paper-and-pencil process, which was then aug- mented by an online survey process, and distributed on a calendar-year basis, beginning in 2006. Surveys have been dis- tributed only in the online version since 2010. Invitations to participate in the survey were sent to all ACNM members who provided ACNM with an e-mail address (most members).

AMCB data are collected at initial certification during the new applicant process and again at the time of application for recertification. Candidates newly eligible for national certifi- cation must register with AMCB and fill out an application to sit for the National Certification Examination. This initial application form collects demographic and background data. Initial certification can occur throughout the year.

All recertification cycles end on December 31 of the 5th year after certification, by which time the recertification application must be submitted, if the individual wishes to re- tain active CNM/CM certified status. The recertification ap- plication updates and expands information collected at initial registration.

Ethics

Data for this analysis were gathered in full compliance with the federal guidelines for ethical approval of survey research. The Core Data Survey data were gathered in accord with the ACNM Data Protection Policy.13 Data are maintained on a secure server by an external software vendor (Verint Systems, Melville, NY). Prior to exporting data, all potential

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personal identifiers are removed. All downloaded data are stored by ACNM on a secure internal server according to ACNM policy.

AMCB applicants must check a box before filling out the survey form that indicates they understand the AMCB gen- eral data-use policies and procedures, which state that data may be used for analysis purposes in an aggregated manner. There is a general option to opt out of data analyses when ap- plicants complete the online form and specific opt-out options for all demographic data. Data are maintained on a password- protected secure server. Only AMCB employees with au- thorization from the chief executive officer may access data files. All AMCB certificant data were de-identified prior to analysis.

Survey Instruments

The ACNM membership survey (the Core Data Survey) has been reviewed and revised annually, through 2012, when the effort to create the Midwifery MasterFile was initiated. The Core Data Survey instrument used in 2012 consisted of 27 questions categorized by the following information: demo- graphics, certification, education, and employment. Respon- dents who selected the option “other” for some questions were asked to provide further information in a space provided. Re- spondents did not need to respond to all questions. ACNM membership survey data for 2012 were collected via a propri- etary software package (Verint Systems).

AMCB used various database resources for data collec- tion. AMCB data were collected via a proprietary data man- agement system designed by Cobalt (Alexandria, VA). In 2013, initial registration and the CNM examination applica- tion combined to generate 19 items of information includ- ing the categories of demographics, nursing and/or midwifery education (including practice settings), and additional ad- vanced practice registered nurse certifications (if applicable). Respondents are able to provide further descriptive informa- tion when “other” is selected as the response option for certain questions.

The CM examination application and initial registration profile generated 13 items of information. Categories included demographics, midwifery education, and additional advanced practice registered nurse certifications (if applicable).

The recertification application asked 6 questions that ex- panded and/or updated the information available within the candidate’s CNM/CM personal file. These questions were organized into 3 categories: additional advanced practice reg- istered nurse certification, education, and employment (in- cluding practice areas). In parallel to the initial application, respondents are able to provide further descriptive informa- tion when “other” is selected as the response option for certain questions.

ACNM and AMCB designees conducted a side-by-side review of the organizational data collection instruments to identify variables that were comparably worded in each of the 2 survey years, in the interest of selecting data elements that could be compared one to the other, and also to previous ACNM Core Data Survey reports, in this analysis. Other vari- ables that appeared in one, but not both, of the instruments were identified for independent analysis and reporting.

Data Analysis

ACNM data were downloaded, cleaned, re-coded as nec- essary, and imported into SPSS version 16.0 for analysis. AMCB data were downloaded into SPSS version 22.0 for analysis. Descriptive analytical approaches were used in both datasets.

RESULTS

Response Rate

The 2012 Core Data Survey was e-mailed to 6071 ACNM members who provided ACNM with an e-mail address; 2185 responded to the request to take the survey, resulting in a 36% response rate, which was within the response rate range reported for the 2009 to 2011 Core Data Survey.6 Not all respondents answered all of the questions, includ- ing 11 who failed to indicate their respondent type (ie, SNM/SM or CNM/CM) and thus were excluded from the analysis, resulting in a sample of 204 SNMs/SMs and 1970 CNMs/CMs.

The AMCB data include the population of 539 CNMs/CMs newly certified in calendar year 2013 and 1323 participants who were recertified in calendar year 2013. These numbers represent 4.6% and 11.3%, respectively, of the total CNM/CM certified body, which, as of Septem- ber 2013 totaled 11,682.14 No applicants chose to decline (opt-out) the use of their data for research purposes in 2013.

Demographic Characteristics

American College of Nurse-Midwives

The demographic characteristics of respondents to the 2012 ACNM Core Data Survey are presented in Table 1. The CNM/CM and SNM/SM respondents included 72 retired CNMs and 23 CMs, 2 of whom were also nurse-midwifery students. The majority of the respondents in both groups are white females with a mean age of 35.0 years for SNMs/SMs and 51.4 years for CNMs/CMs. Six percent of respondents or less reported race/ethnicity as black/African American or His- panic/Latino. The majority of CNMs/CMs reported a mas- ters’ degree as their highest degree and 10.3% have earned a doctorate.

CNMs/CMs reported certification for an average of nearly 16 years (standard deviation [SD], 10.8) in 2012 and 20% held other certifications: 13.1% were certified as women’s health nurse practitioners and less than 5% certified as adult health nurse practitioners or family nurse practitioners (Table 2).

American Midwifery Certification Board

Applications for initial certification by AMCB were received from students enrolled in 37 of the 38 programs accredited by ACME in the same year that these applications were received. The total number of applications (N = 539) represents an increase of 87 applicants from the number of new applicants in 2012. Three CM applications were received from the 2 programs that offered that pathway to the credential in 2013.

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Table 1. Demographic Characteristics of ACNM Member SNMs/SMs and CNMs/CMs and AMCB New Applicant and Recertified CNMs/CMs, 2012–2013

ACNM ACNM AMCB New Applicant AMCB Recertified

Characteristic SNM/SMa  CNM/CM  CNM/CM  CNM/CM  Number of respondents 204 1970 539 1323

Age, y

Mean (SD) 35.0 (8.9) 51.4 (11.6) 35.6 (7.4) 45.5 (15.2)

Range of values 23-65 24-86 24-60 24-83

Missing/unknownb 3 (1.5) 35 (1.8) 2 (0.4) 6 (0.5)

Sex, n (%)

Female 202 (99.0) 1925 (97.7) 521 (96.7) 348 (26.3)

Male 1 (0.5) 19 (1.0) 0 (0.0) 4 (0.3)

Missing/unknownc 1 (0.5) 26 (1.3) 18 (3.3) 971 (73.4)

Race/ethnicity, n (%)d

American Indian/Alaska Native 2 (1.0) 5 (0.3) 5 (0.9) 6 (0.4)

Asian/Pacific Islander 0 (0.0) 9 (0.5) 11 (2.0) 13 (1.0)

Black/African American 7 (3.4) 58 (2.9) 37 (6.9) 38 (2.9)

Caucasian/Euro-American/White 184 (90.2) 1804 (91.6) 420 (77.9) 724 (54.7)

Hispanic/Latino 5 (2.5) 61 (3.1) 21 (4.0) 18 (1.4)

Native Hawaiian/Pacific Islander 0 (0.0) 3 (0.2) 0 (0.0) 0 (0.0)

Mixed (more than one race/ethnicity) N/A N/A 4 (0.7) 1 (0.1)

Other 5 (2.5) 43 (2.2) 4 (0.7) 4 (0.3)

Missing/unknownc 6 (2.9) 48 (2.4) 37 (6.9) 519 (39.2)

Highest academic degree, n (%)e

Associate 14 (6.9) 35 (1.8) 27 (5.0)

Bachelor’s 145 (71.1) 87 (4.4) 284 (52.7)

Master’s 41 (20.1) 1606 (81.5) 134 (24.9)

Doctorate 3 (1.5) 202 (10.3) 8 (1.5)

Missing/unknown 1 (0.5) 40 (2.0) 86 (16.0)

Doctoral Degree Categories, n (%)

PhD (Nursing) 0 (0.0) 80 (4.1)

PhD (Other discipline) 0 (0.0) 27 (1.4)

Education 0 (0.0) 4 (0.2)

Health-related 0 (0.0) 17 (0.9)

Other type of PhDf 0 (0.0) 6 (034)

Nursing science (DNS or DNSc) 0 (0.0) 8 (0.4)

Nursing practice (DNP/ND) 3 (1.5) 55 (2.8)

Public Health (PhD or DrPh) 0 (0.0) 18 (0.9)

Doctorate (Other type)g 0 (0.0) 14 (0.7)

aSNMs/SMs are not considered part of the midwifery workforce as defined in this paper. bIncludes invalid as well as nonresponse. cIncludes missing as well as ‘choose not to respond.’ dMultiple responses possible for 2012 ACNM data. eFor 2013 new applicant data, highest degree reflects the highest degree earned at the time the application is submitted to AMCB. AMCB verifies that applicants have been awarded the minimum of a master’s degree before authorization is granted to take the certification examination in nurse-midwifery/midwifery. fOther PhD types includes categories of anthropology, sociology, or psychology. gDoctorate (other type) includes categories of education and medical anthropology (EdD), law (JD), or unspecified.

New CNM certificants in 2013 varied widely in the number of years of nursing experience (0-35 years). The average number was 6.16 years (SD, 6.52).

Table 1 also presents the demographic characteristics of new and recertification applicants. Although recertified

CNMs/CMs were, on average, aged 45 years, female, and white, the mean age of those who were newly certified was 35.6 years. There were no male applicants newly certified in 2013, and only 4 (0.3%) applied for recertification. The majority of AMCB 2013 new applicants reported a bachelor’s

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Table 2. Certification, Employment Status, and Primary Employer of ACNM Member CNM/CM and AMCB New Applicant and Recertified CNMs/CMs, 2012-2013

ACNM AMCB Recertified

Characteristic CNM/CM  CNM/CM  Number of respondents n = 1970 n = 1323 Years certified as CNM/CM

Mean (SD) 15.9 (10.8) 19.3 (8.0)

Min-Max 0-51 8.0-41.8

Missing/unknown, n (%)a 8 (0.4) 0 (0.00)

Other certification, n (%)

Adult health nurse practitioner 20 (1.0) 6 (0.5)

Family nurse practitioner 93 (4.7) 48 (3.6)

Women’s health nurse practitioner 258 (13.1) 68 (5.1)

Other 41 (2.1) 65 (4.9)

Employment status, n (%)

Full-time 1298 (65.9)b 515 (38.9)

Full-time and employed in a second job (either part-time or full-time) 94 (4.8) 14 (1.1)

Part-time 379 (19.2)c 202 (15.3)

Employed, but not as a midwife N/A 112 (8.5)

Unemployed during past year for reason other than retired 105 (5.3) 55 (4.2)

Retired 90 (4.6) 30 (2.3)

Other N/A 26 (2.0)

Missing/unknown 4 (0.2) 369 (27.9)

Primary employer, n (%)

Hospital/medical center 543 (27.6) 363 (27.4)

Physician-owned practice 414 (21.0) 197 (14.9)

Educational institution 238 (12.1) 115 (8.7)

Midwifery-owned practice 157 (8.0) 91 (6.9)

Community health center 148 (7.5) 81 (6.1)

Nonprofit health agency 83 (4.2) 71 (5.4)

Military 25 (1.3) 17 (1.3)

Federal government 35 (1.8) 19 (1.4)

Other 119 (6.0) 0 (0.0)

Missing/unknown 208 (10.6) 369 (27.9)

aIncludes invalid as well as nonresponse. bDefined as 35 or more hours. cDefined as 34 or fewer hours.

degree as their highest degree, and 24.9% reported a master’s degree as their highest degree at the time of application. Eight (1.5%) of the AMCB 2013 new applicants reported holding a doctorate, but the type of doctoral degree was unspecified.

CNMs/CMs recertified in 2013 were certified for an aver- age (SD) of 19.3 (8.0) years. Less than 15% of the recertifica- tion respondents held other certifications, the majority were either a women’s health nurse practitioner (5.1%) or a family nurse practitioner (3.6%) (Table 2).

Most midwives (92%) who recertified also held an ac- tive midwifery license. There was little difference in the mean (SD) age of those who had a midwifery license (44.5 [15.6] years) compared to those who did not (47.6 [14.3] years).

Employment and Practice Characteristics

American College of Nurse-Midwives

Nearly 71% of CNM/CM respondents to the 2012 ACNM Core Data Survey reported employment as full-time or full- time and in a second job, whereas 19.2% were employed part- time, 4.6% were retired, and 5.3% were unemployed (Table 2). More than a quarter of these CNMs/CMs were employed by hospitals or medical centers (27.6%), followed by physician- owned practices (21.0%), educational institutions (12.1%), and midwifery-owned practices (8.0%).

The majority of CNM/CM respondents to the 2012 ACNM survey reported primary responsibilities in full-time employment (Table 3) in antepartum (80.5%), intrapartum (73.5%), postpartum (76.9%), and reproductive care (69.8%).

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Table 3. Responsibilities in Full-Time Employment of ACNM Member CNM/CM and AMCB New Applicant and Recertified CNMs/CMs, 2012-2013

Characteristic ACNM CNM/CM  AMCB Recertified CNM/CM  Responsibilitiesa in full-time employment, n (%)b,c

Number of respondents n = 1392 n = 529 Antepartum 1121 (80.5) 477 (90.2)

Intrapartum 1023 (73.5) 432 (81.7)

Postpartum 1070 (76.9) 468 (88.5)

Newborn 233 (16.7) 276 (52.2)

Women’s health: reproductive care 972 (69.8) 392 (74.1)

Women’s health: primary care 618 (44.4) 99 (18.7)

Midwifery education 366 (26.3) 215 (40.6)

Education not midwifery 322 (23.1) 154 (29.1)

Administration, midwifery related 262 (18.8) 102 (19.3)

Administration, not midwifery related 98 (7.0) 30 (5.7)

Research, midwifery related 72 (5.2) 29 (5.5)

Research, not midwifery related 35 (2.5) 18 (3.4)

Other 104 (7.5) 0 (0.0)

a2012 CNMs/CMs responded as their primary responsibilities; 2013 CNMs/CMs responded as any responsibility. bMultiple responses possible. cWorks full-time or full-time and in a second job.

Table 4. Responsibilities in Part-Time Employment of ACNM member CNM/CM and AMCB New Applicant and Recertified CNMs/CMs, 2012-2013

Characteristic ACNM CNM/CM  AMCB Recertified CNM/CM  Responsibilitiesa in part-time employment, n (%)b,c

Number of respondents n = 473 n = 216 Antepartum 298 (63.0) 166 (76.9)

Intrapartum 234 (49.5) 121 (56.0)

Postpartum 275 (58.1) 155 (71.8)

Newborn 53 (11.2) 88 (40.7)

Women’s health: reproductive care 274 (57.9) 144 (66.7)

Women’s health: primary care 152 (32.1) 29 (13.4)

Midwifery education 95 (20.0) 66 (30.6)

Education not midwifery 93 (19.7) 43 (19.9)

Administration, midwifery related 45 (9.5) 13 (6.0)

Administration, not midwifery related 16 (3.4) 6 (2.8)

Research, midwifery related 11 (2.3) 8 (3.7)

Research, not midwifery related 6 (1.3) 3 (1.4)

Other 60 (12.7) 0 (0.0)

a2012 CNMs/CMs responded as their primary responsibilities. 2013 CNMs/CMs responded as any responsibility. bMultiple responses possible. cWorks part time or full time and in a second job.

Almost half (44.4%) reported primary care of women as a pri- mary responsibility, but only 16.7% reported newborn care as a primary responsibility. In part-time employment (Table 4), the primary responsibilities followed a similar pattern but to a lesser degree.

For CNMs/CMs working full-time outside the clinical arena in 2012, 36% reported primary responsibilities in some type of education. The majority were working in midwifery- related education (26.3%), followed by education of non- midwifery students (23.1%).

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American Midwifery Certification Board

Most of those who were recertified in 2013 (40.0%) reported working full-time or full-time and in a second job, and more than a quarter (27.4%) were employed in a hospi- tal/medical center. For recertified CNMs/CMs reporting full-time employment in 2013, most were also engaged in providing antepartum (90.2%), intrapartum (81.7%), or post- partum (88.5%) care. Almost three-quarters also provided re- productive care (74.1%), but fewer than one in 5 (18.7%) were engaged in primary care. More than half (52.2%) provided newborn care as a responsibility in 2013. Two in 5 reported involvement in midwifery education in 2013 (40.6%), and one in 3 were involved in other education (29.1%).

American College of Nurse-Midwives and American Midwifery Certification Board

In both datasets, a small number of midwives reported that they conducted midwifery-related research, with less than 10% reporting full- or part-time employment in this area. Al- though close to 20% of midwife respondents were engaged in midwifery-related administration in both the ACNM 2012 and AMCB 2013 datasets, fewer than 10% reported that they were involved when employed part-time. Seven percent or less reported that they were engaged in other administration on a full- or part-time basis.

Attendance at Births

American College of Nurse-Midwives

In 2012, 65% of CNMs/CMs who participated in the ACNM Core Data Survey reported attendance at births, with the ma- jority (57.0%) attending births in hospitals (Table 5). Less than 6% of CNM/CM respondents reported that they attended births in each of the alternative birth sites; most attended births in only one setting. CNMs/CMs who attend births were approximately 5 years younger than those who did not (mean [SD], 49.3 [11.1] years vs mean [SD], 54.6 [10.1] years, respectively).

American Midwifery Certification Board

A total of 553 (58%) of the 953 recertification applicants who responded to the question stated that they attended births. For respondents recertified in 2013, there was little difference in the mean age of those who reported attending births (mean [SD], 44.8 [15.0] years) and those who did not (mean [SD], 46.1 [15.4] years).

Salary

CNM/CM respondents to the 2012 ACNM Core Data Sur- vey reported salaries ranging from less than $50,000 to more than $160,000 per year for midwifery-related employment (Table 6). The median reported salary was $92,000 per year. AMCB did not collect salary information in 2013.

Table 5. Numbers of ACNM Member CNMs/CMs Attending Births, Location, and Number of Sites Where Births are Attended, 2012

Characteristic ACNM CNM/CM  Number of respondents 1970

Attend births, n (%)

Yes 1281 (65.0)

No 471 (23.9)

Missing 218 (11.1)

Birth sites,a n (%)

Hospital 1123 (57.0)

Hospital birth center 108 (5.5)

Freestanding birth center 109 (5.5)

Home 95 (4.8)

Number of sites attending birthsb

0 682 (34.6)

1 1148 (58.3)

2 133 (6.8)

3 7 (0.4)

aMultiple response possible. bThe ‘0’ response option reflects those not attending births.

Table 6. Reported Salary Ranges of All Midwifery Related Income for ACNM Member CNMs/CMs Employed Full-Time, 2012 (ACNM Core Data Survey Only)

Salary Range ACNM CNM/CM  Number of respondentsa 1392

� $50,000 49 (3.5)

$50,000 - $69,999 68 (4.9)

$70,000 - $79,999 148 (10.6)

$80,000 - $89,999 224 (16.1)

$90,000 - $99,999 269 (19.3)

$100,000 - $109,999 173 (12.4)

$110,000 - $119,999 101 (7.3)

$120,000 - $139,999 117 (8.4)

$140,000 - $159,999 38 (2.7)

$160,000 and higher 36 (2.6)

No midwifery incomeb 38 (2.7)

Missing 131 (9.4)

Median ($)c $92,000

Mode ($)c $90,000

aFor those employed full time or full time and in a second job. bNo midwifery income category not included in median and mode calculations. cn = 1223.

DISCUSSION

The 2 datasets were collected independently in different years by each organization. It is expected that some of the same mid- wives have responded to both the 2012 ACNM Core Data sur- vey and the 2013 AMCB recertification application. ACNM 2012 Core Data Survey results were compared descriptively with results of the prior 3 years of ACNM Core Data Surveys.6

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Selected indicators were also compared descriptively with AMCB 2013 data.

There seems to be little variation in demographic char- acteristics between 2009 and 2012. Average age has remained stable at approximately 51 years for CNMs/CMs and 35 years for SNMs/SMs. The proportion of male students and certified graduates remains very small over the years (�1.5%) as does the proportion for various racial and ethnic characteristics for CNMs/CMs. The proportion of African Americans appears to have decreased from 4.8% in 2009 to 3.4% in 2011 and to 2.9% in both the ACNM 2012 and AMCB 2013 datasets. How- ever, there was a higher proportion of African American stu- dents in ACNM 2012 compared to previous years as well as a higher proportion of new certificants in AMCB 2013 (3.4% and 6.9%, respectively), which it is hoped is an indication of an upward trend in diversity. Similarly the proportion of His- panics/Latinos appears to be slightly larger among the ACNM CNM/CM respondents in 2012 (3.1%) and AMCB new cer- tificants in 2013 (4.0%) compared to the ACNM CNM/CM respondents in 2011 (2.6%).6 However, the numbers are quite small, and more years of data will be needed to determine if this is an artifact or trend. In addition, the 2013 AMCB data represent only approximately 11.3% of the CNMs/CMs in the AMCB database, so this race/ethnicity information, and other values cited in the discussion that follows, may not be gener- alizable to the AMCB population. It is expected that in future years the Midwifery MasterFile will generate more robust data about race and ethnicity. This is true because most graduates of ACME-accredited midwifery education programs also ap- ply to take the AMCB initial certification examination, and thus, over time, provide a near-population estimate of the race and ethnicity of CNMs/CMs entering the profession.

The low number of African American and His- panic/Latino midwives is of concern as the midwifery workforce should ideally reflect the cultural and social values and needs of the community.15 Similarly, continued small numbers of men in midwifery should be addressed to promote diversity and openness in both education and practice.16

The proportion of doctoral degrees held by ACNM CNM/CM respondents appears to have gained a full percent- age point from 9.3% in 2011 to 10.3% in 2012. The propor- tion of CNMs/CMs with degrees in nursing practice (Doctor of Nursing Practice [DNP] or Nursing Doctorate [ND]) ap- pears to be steadily increasing from 1.0% in 2009 to 2.8% in 2012.

The number of AMCB new CNM and CM applicants has been increasing each year since 2007, with an overall increase of 3.4% since 2000.17 The number of education programs has declined over that same period, with essentially no change in the 3-year period from 2010 to 2012. However, the number of spaces available for students in existing ACME-accredited programs has increased from 782 in 2008 to 923 in 2012.18 It could be inferred from these data that accredited midwifery programs are better resourced to fill potential spaces with prospective students.

The number of years certified appears to be similar to previous time-points,6 at nearly 16 (ACNM, 2012) and 19 (AMCB, 2013) years. The proportion of ACNM CNM/CM re- spondents employed full-time appears to be declining slightly

from nearly 72.6% in 2009 to 70.7% in 2012. There are dif- ferences between the ACNM 2012 Core Data Survey and the AMCB 2013 recertification data in reported responsibilities in full- and part-time employment, most notably in newborn care. However, this may be an artifact of the difference in question wording, with ACNM 2012 respondents asked about primary responsibilities and AMCB 2013 respondents asked about all responsibilities.

The proportion of ACNM CNM/CM respondents em- ployed by hospitals/medical centers appears to have declined nearly 2.0%, from 29.5% in 2009 to 27.6% in 2012. Midwifery- owned practices as employers appear to have increased in proportion from 6.7% in 2009 to 8.0% in 2012, whereas CNMs/CMs employed in the military have declined from 2.2% in 2009 to 1.3% in 2012. Recertified CNMs/CMs in 2013 (AMCB) reported similar proportions of employer types.

ACNM data indicate that the proportion of ACNM CNM/CM respondents who are attending birth in any type of birth setting, in- or out-of-hospital, is slightly lower in 2012 (65%) than in 2009 (68%), but it is too soon to speculate if this is a true decrease. The proportion of 2013 AMCB-recertified CNMs/CMs who reported attending births (sites unknown) is quite low at 58% (n = 553 of 953 respondents); however, this information was not available for an additional 370 of the 2013 recertification applicants. Nevertheless, the difference is remarkable, when compared to the 81.7% of those who re- ported having intrapartum responsibilities (n = 432 of 529 respondents). It is possible that some CNMs work in intra- partum settings but are not engaged in labor management and birth, such as those working in obstetrical triage areas. Further clarification on future surveys would be important to provide meaningful analysis to determine if this is an ar- tifact from the 2013 cohort or is suggestive of an emerging trend.

The number of births that occurred in out-of-hospital settings in the United States increased from 0.87% in 2004 to 1.36% in 2012,19 which is the highest number of out-of- hospital births since 1975. In 2012, two-thirds (66%) of out- of-hospital births occurred at home, and nearly one-third (29%) occurred in freestanding birth centers.19 In contrast, although 8.7% of ACNM CNM/CM respondents reported at- tending births in any out-of-hospital setting, similar propor- tions reported attending births in the home (4.8%) or in a freestanding birth center (5.5%). However, there appears to be an upward trend in proportions of CNM/CM respondents who reported attending births in freestanding birth centers, from 3.9% in 2009 to 5.5% in 2012.6

Further examination of out-of-hospital births in the United States indicates that the percentage that occurred at home increased from 0.56% in 2004 to 0.89% in 2012. In ad- dition, the percentage of out-of-hospital births that occurred in birthing centers increased from 0.23% in 2004 to 0.39% in 2012. At the same time, the number of freestanding birth cen- ters in the United States has also increased, from 170 in 2004 to 248 in January 2013.19

ACNM 2012 Core Data Survey findings indicate that the median annual salary for CNMs/CMs appears to have in- creased by $5000 over the period from 2009 to 2012. In gen- eral, in 2012, the number of ACNM respondents who reported annual salaries below $99,000 declined slightly, whereas the

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number of respondents who reported annual salaries higher than $110,000 increased. The mode of $90,000 has remained the same since 2010.

ACNM conducts a focused compensation and benefits survey every 3 to 4 years. The most recent survey was dis- tributed in 2014 to 7418 ACNM members who provided their e-mail addresses. About one-third of the members (n = 2087) responded to some or all of the survey questions (K. Schuiling, PhD, former Senior Staff Researcher, ACNM, written commu- nication, December 2014). Twenty-three percent of the 1735 respondents to the focused compensation salary and benefits survey indicated their salary was in the $100,000 to $119,000 category, which is higher than the 18.7% (2 categories com- bined; Table 6) who reported salaries in this range in the 2012 ACNM Core Data Survey data.

Moreover, the 2012 ACNM Core Data Survey data in- clude midwives who identify themselves as working either full-time or full-time with another part-time job in midwifery. The 2014 salary survey question asked the respondent to re- port all midwifery-related income, and the analysis made no distinction as to whether the amount included income from a second midwifery-related position, which would have served to enhance the total salary reported in each range.

At the same time, the largest proportion of 2012 ACNM Core Data Survey respondents reported an annual salary in the $90,000 to $100,000 range, which is consistent with the average nurse practitioner full-time salary of $93,032 reported in a recent nurse practitioner salary survey conducted in the same year.20 Given that CNMs/CMs may have work responsi- bilities, such as time spent on-call for births, that exceed a typ- ical 35- to 40-hour work week, it may be misleading to make direct salary comparisons between the 2 professions. Never- theless, both 2012 ACNM Core Data Survey data and find- ings from the 2014 ACNM compensation and benefits survey seem to indicate a rising salary trend that is in line with an increase in average salary noted for nurse practitioners20 and physician assistants21 over the last several years.

Ongoing efforts to accurately profile the midwifery work- force have a particular importance in ACNM’s efforts to bring attention to the profession in both consumer and policy are- nas. CNMs/CMs are becoming increasingly more visible in government-sponsored workforce studies, but role identity is not yet clearly distinct, creating difficulty in making precise projections about future workforce supply. Different HRSA publications that address the growth of the primary care work- force report data on nurse practitioners, using resources that do not clearly define nurse-midwives within the nurse practi- tioner cohort.7,12 On the other hand, CNMs (but not CMs) are specifically identified as non–primary care subspecialist ad- vanced practice nurses in an HRSA-authored companion doc- ument that presents similar information about the primary care workforce.22 Still other reports authored by both private and public organizations profiling nurse-midwives use data derived from studies of the nursing workforce, thus also omit- ting the CM population.8,23,24 Several states have conducted their own workforce studies to augment information available from various government resources (notably the HRSA Cen- ter for Workforce Analysis).10,11 Studies conducted at the state level provide the opportunity to precisely define the members of the midwifery workforce in those jurisdictions, and thus

obtain more precise information about the contribution of CNMs, CMs, certified professional midwives, and other state- licensed midwives.25,26

This workforce information is particularly timely and im- portant in the context of the federal Patient Protection and Af- fordable Care Act (ACA), enacted in 2010. The ACA contains specific provisions that support education for both nurse- midwives and nurse practitioners, it provides support for fac- ulty development, and it promotes the expansion of a health care workforce that is less physician-centered.27 These health care providers will be needed to meet the demand for both pri- mary and preventive health care services for the anticipated 30 million individuals newly eligible for services under the ACA.28 Substantive progress has been made in several states that support expanded practice authority for advanced prac- tice registered nurses29,30 and encourage development of new models for health service delivery31–33 in alignment with this current and anticipated workforce need.

There are some limitations inherent in each database. Pre- vious reports1–6 and the 2012 ACNM data in this article on the midwifery workforce have been drawn from surveys of midwives who hold membership in ACNM. The major lim- itation of this strategy is that an undetermined proportion of AMCB-certified CNMs/CMs are not represented in the mem- bership data previously available for analysis. Furthermore, the response rate from members has generally approximated only about one-third of those contacted. The major strength of this core data survey approach is that the ACNM member- ship does include both the younger and older workforce tiers, such as students, life members, and those who have retired their CNM/CM credential.

This analysis of 2013 AMCB data is the first presentation of data from that application process. There are missing data in this first report, which is a limitation of the 2013 data, be- cause initial or recertification applicants were not required to complete the data fields for several of these categories of inter- est in that year, and additional data fields were not yet added to the survey. As of May 31, 2014, all initial and recertifica- tion applicants are required to complete all fields (with opt- out provisions for demographic data). This will increase the amount of data available over each of the next 5 years until 2019, when all certificants have gone through the recertifica- tion process.

These constraints were given careful consideration as the 2 organizations worked to craft the structure of the Midwifery MasterFile. A primary interest of ACNM was the ability to generate a more complete picture of the midwifery workforce, for policy and advocacy purposes. The benefit of using AMCB data is the anticipated generation of a 100% population of CNMs/CMs holding current certification for midwifery prac- tice, although it will take 5 years for the entire population of certificants to receive and answer the additional questions. Af- ter 5 years, the AMCB data should stabilize and, when cou- pled with ACNM special survey data, should result in a more comprehensive picture of the midwifery workforce that will be helpful to researchers and others interested in this topic. The next publication about the CNM/CM workforce will be written when this 5-year AMCB cohort has been aggregated.

It is important to understand the limitations inherent in the use of each of the ACNM and AMCB databases, and

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the new Midwifery MasterFile, when making historical trend comparisons. Special attention will need to be paid to the in- dividuals who have chosen not to recertify. As of fall 2014, there were 505 individuals holding AMCB CNM/CM retired status. AMCB will not be updating the demographic or prac- tice profiles of these individuals. ACNM membership is open to those ever-certified; therefore, ACNM does not query its members about their AMCB active or retired certification sta- tus. Thus there is no way to know how many individuals who hold CNM-retired or CM-retired status with AMCB continue their membership in ACNM. A new data element for AMCB- retired certification status would need to be added to the ACNM membership database in order to identify those who would be subjects of an independent ACNM Core Data Sur- vey. As growing numbers of midwives approach retirement age, and health care demands increase, it will be important to understand changes in work patterns and involvement in health-related volunteer activities of these current members of the midwifery workforce.

AMCB does not collect information from students en- rolled in ACME-accredited midwifery education programs. Therefore, students would also need to be subjects of a spe- cial survey conducted by ACNM, if information related to their entry into the workforce cannot be obtained from other sources. ACME and the Directors of Midwifery Education are among the organizations that could be approached for col- laboration or partnership in gathering information about the general student profile (both those who hold ACNM student membership and those who are not members).

A third group of interest are AMCB previously certified CNMs/CMs (CNM-retired, CM-retired status) who are not members of ACNM, and are therefore not tracked by either ACNM or AMCB. ACNM would need to make special out- reach to these CNMs/CMs to invite their participation in a complementary survey that would augment the information obtained through the ACNM membership survey process. These graduates of ACME-accredited midwifery education programs are almost certainly making important contribu- tions through employment or volunteer services but are not members of the midwifery workforce as defined for this anal- ysis. Therefore, this added value cannot be documented using ACNM or AMCB databases.

CONCLUSION

There are several challenges to the generation of a robust pro- file of the demographic identity of the midwifery workforce and of services provided by midwives. Careful detailing of de- mographic and workforce data via the mechanism of the Mid- wifery MasterFile will serve a vital role in the development of a professional dashboard that summarizes and integrates this key information. Such information is central to marketing midwifery and formulating a roadmap for further research.34

AUTHORS

Judith Fullerton, CNM (ret), PhD, FACNM, is an indepen- dent consultant in international women’s health, research, and evaluation.

Theresa Ann Sipe, CNM, PhD, is adjunct associate profes- sor in the Department of Behavioral Sciences and Health

Education at the Rollins School of Public Health, Emory University.

Marie Hastings-Tolsma, CNM, PhD, FACNM, is professor at Baylor University Louise Herrington School of Nurs- ing in Dallas, Texas and Visiting Professor at the Univer- sity of Johannesburg Department of Nursing Science, South Africa.

Barbara L. McFarlin, CNM, PhD, RDMS, FACNM, FAAN, is Associate Professor and Department Head of Women, Chil- dren, & Family Health Science at the University of Illinois at Chicago College of Nursing.

Kerri Schuiling, CNM, PhD, FACNM, FAAN, is Provost and Vice President for Academic Affairs, Northern Michigan Uni- versity, and former Sr. Staff Researcher for ACNM.

Carrie D. Bright, IOM, CAE, is the Chief Executive Officer of the AMCB.

Lori B. Havens is the Data Coordinator of the AMCB.

Cara J. Krulewitch, CNM, PhD, FACNM, is the President of the Board of Directors for AMCB.

CONFLICT OF INTEREST

JF and TS have no conflicts of interest to declare. KS was an employee of the ACNM at the time this manuscript was writ- ten. CB and LH are employees of AMCB. CK, M H-T, and BM are AMCB Board or committee members.

ACKNOWLEDGMENTS

The authors acknowledge Tiffany J. Callahan, MPH, Uni- versity of Colorado, for conducting the analysis of data for AMCB. We also acknowledge the University of Colorado Cen- ter for Nursing Research for the contribution of physical and computer resources in support of the analysis.

We thank Lorrie Kaplan, BA, CAE, ACNM Chief Execu- tive Officer, and Elaine Germano, CNM, DrPH, FACNM, for their efforts toward development of the Midwifery MasterFile.

REFERENCES

1.Walsh L, DeJoseph J. Findings of the 1991 annual American College of Nurse-Midwives membership survey. J Nurse Midwifery. 1993;38:35- 41.

2.Walsh LV, Boggess JH. Findings of the American College of Nurse- Midwives annual membership surveys, 1993 and 1994. J Nurse Mid- wifery. 1996;41:230-235.

3.Kovner CT, Burkhardt P. Findings from the American College of Nurse-Midwives annual membership survey, 1995–1999. J Midwifery Womens Health. 2001;46:24-29.

4.Schuiling DK, Sipe TA, Fullerton J. Findings from the analysis of the American College of Nurse-Midwives’ membership surveys: 2000- 2003. J Midwifery Womens Health. 2005;50:8-15.

5.Schuiling K, Sipe T, Fullerton J. Findings from the analysis of the American College of Nurse Midwives’ membership surveys: 2006– 2008. J Midwifery Womens Health. 2010;55:299-307.

6.Schuiling K, Sipe TA, Fullerton J. Findings from the Analysis of the American College of Nurse-Midwives’ membership surveys: 2009 to 2011. J Midwifery Womens Health. 2013;58:404-415.

7.Health Resources and Services Administration. National Center for Health Workforce Analysis. Projecting the supply and demand of primary care practitioners through 2020 (2013). Available from:

760 Volume 60, No. 6, November 2015

http://bhpr.hrsa.gov/healthworkforce/supplydemand/usworkforce/ primarycare/primarycarebrief.pdf. Accessed October 10, 2014.

8.HRSA Highlights from the 2012 National Sample Survey of Nurse Practitioners. 2012. Available from: http://bhpr.hrsa.gov/ healthworkforce/supplydemand/nursing/nursepractitionersurvey/ npsurveyhighlights.pdf. Accessed November 13, 2014.

9.Pulcini J, Jelic M, Gul R, Loke AY. An international survey on advanced practice nursing education, practice and regulation. J Nurs Scholar- ship. 2010;42(1):31–39.

10.Brewin D, Kelleher C. Caring for women: A profile of the mid- wifery workforce in Massachusetts. Center for Women in Politics & Public Policy. Boston, 2011. Available from: http://www.umb. edu/cwppp/research/projects/midwifery care. Accessed September 12, 2014.

11.Hastings-Tolsma M, Tasaka Y, Burton A, et al. A profile of Col- orado Nurse Midwives: Implications for Health Care. West J Nurs Res. 2009;31(1):24–43.

12.Health Resources & Services Administration. National Center for Workforce Analysis. The U.S. Health Workforce Chartbook. 2013. Available from: http://bhpr.hrsa.gov/healthworkforce/supplydemand/ usworkforce/chartbook/index.html. Accessed September 12, 2014.

13.American College of Nurse-Midwives web site. ACNM policy on pro- tection of membership data used for research purposes: Available from: http://www.midwife.org/siteFiles/descriptive/Research Policy Protection of Membershp˙ Data 6.09.pdf. Accessed September 15, 2014.

14.American Midwifery Certification Board. AMCB report of CNM/CM by state. Available from: www.amcbmidwife.org/docs/default- document-library/amcb-report-of-cnm-cm-by-state—updated-may- 8-2014.pdf?sfvrsn=4. Accessed September 30, 2014.

15.Health Resources and Services Administration HRSA invest- ments in the nursing workforce. 2014. Available from:. www.hrsa. gov/ourstories/nursesweek/investmentsinnursing.pdf-33k-2014-06- 16. Accessed December 27, 2014.

16.Kantrowitz-Gordon I, Ellis SA, McFarlane A. Men in Midwifery: A Na- tional Survey. J Midwifery Women’s Health 2014:59(5):516-522.

17.American Midwifery Certification Board Annual Report 2012. Avail- able from: http://www.amcbmidwife.org/docs/annual-reports/2012- amcb-annual-report.pdf?sfvrsn=4. Accessed January 9, 2015.

18.American College of Nurse Midwives. Midwifery Educa- tion Trends Report. 2013. Available from http://www.midwife. org/index.asp?bid=59&cat=12&button=Search&rec=284. Accessed December 14, 2014.

19.MacDorman MF, Matthews TJ, Declercq E. Trends in out-of-hospital birth in the United States, 1990–2012. NCHS Data Brief. 2014;144:1- 8.

20.Wolfgang K. National salary report 2012. Advance for NPs & PAs 2013;4(2):13–15.

21.Physician Assistant Medical Salaries. Available from: http://www1.salary.com/Physician-Assistant-Medical-salary.html. Accessed January 9, 2015.

22.Health Resources and Services Administration. National Cen- ter for Health Workforce Analysis. (2014) Projecting the sup- ply of non-primary care specialty and subspecialty clinicians: 2010–2025. Available from: http://bhpr.hrsa.gov/healthworkforce/ supplydemand/usworkforce/clinicalspecilaties/. Accessed October 13, 2014.

23.Health Resources and Services Administration. National Center for Health Workforce Analysis. The U.S. nursing workforce: trends in supply and education. 2013. Available from: http://bhpr.hrsa.gov/ healthworkforce/reports/nursingworkforce/nursingworkforcefull report.pdf. Accessed October 13, 2014.

24.Budden J, Zhong E, Moulton P, Cimiotti J. Highlights of the na- tional workforce survey of registered nurses. J Nursing Regulation. 2013;4(2):5-14.

25.Bipartisan Policy Center. The complexities of national health care workforce planning. 2011. Available from: http://bipartisan policy.org/library/complexities-national-health-care-workforce- planning/. Accessed October 13, 2014.

26.Debisette A, Sandvold I, Easterling B, Martilli A. An integrative re- view of nursing workforce studies. Annu Rev Nurs Res. 2010;28:317- 38.

27.Fontenot S. The Affordable Care Act, the FTC and the independent practice of nurses. PE (Physician Executive). 2014. Available from: http://www.pej-acpe.org/pej-acpe/may june 2014?pg=100#pg100. Accessed December 7, 2014.

28.Schiff M. The role of nurse practitioners in meeting increasing demand for primary care. 2012. Available from http://www.nga.org/ cms/home/nga-center-for-best-practices/center-publications/page- health-publications/col2-content/main-content-list/the-role-of- nurse-practitioners.html. Accessed December 7, 2014.

29.Phillips S. 27th annual legislative update: Advancements continue for APRN practice. The Nurse Practitioner. 2015;40(1):16-42.

30.Phillips S. 26th annual legislative update: Progress of APRN authority to practice. The Nurse Practitioner. 2014;39(1):29-52.

31.Garson A. New systems of care can leverage the health care work- force: how many doctors do we really need? Acad Med. 2013;88(12): 1817-21.

32.Green L, Savin S, Lu Y. Primary care physician shortages could be elim- inated through use of teams, nonphysicians and electronic communi- cations. Health Affairs. 2013;32(1):11–17.

33.Inglehart J. Expanding the role of advanced nurse practitioners – risks and rewards. N Engl J Med. 2013;368(20):1935–1941.

34.Pauwels K, Ambler T, Clark BH, et al. Dashboards as a service: why, what, how, and what research is needed? J Service Research. 2009;12:175-189.

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