This report presents results from the third biannual survey on the work status of advanced practitioners (APs) in nephrology, conducted by the National Kidney Foundation Council of Advanced Practitioners (NKF/CAP).
In 2012, the NKF/CAP report highlighted an apparent doubling of minority participation in the annual survey. Data also revealed higher numbers of relatively new APs (25% of the workforce) with less than five years of experience. Consequently, a CKD Basics program at the NKF, and a CKD track at the Renal Physician Association’s (RPA) annual meeting were initiated to provide training opportunities for new practitioners.
The 2014 survey describes the demographics of the AP workforce [nurse practitioners (NP), physician assistants (PA) and clinical nurse specialists (CNS)] in the United States, their work affiliations and scope of work, and their salaries, benefits, and work satisfaction. Moreover, data from 2012 are provided.1 The study’s main significance is in describing the work status of the AP workforce across the United States and highlighting areas amenable to improvement.
A survey questionnaire was distributed via an online listserv to 346 nephrology APs. In turn, listserv members distributed the survey to other nephrology AP colleagues (including non-NKF/CAP members). The survey consisted of a 72-item questionnaire in web-based Survey Monkey format and took about 20 minutes to complete. The questions encompassed three focus areas: job, benefits, and work satisfaction. Data was collected from December 2013 to June 2014. Reminders on the survey were sent on a monthly basis, and then on a weekly basis in June. The 2012 survey had used a similar questionnaire and sampling methodology. Descriptive statistics were conducted. Frequencies, percentages, means, and medians are presented. Average salaries in aggregate were calculated using an algorithm based on a pre-designated salary range rubric.
A total of 248 completed surveys were returned in 2014.
APs responding to the 2014 survey are almost evenly distributed in the following age groups: 30-39 (26.6%), 40-49 (26.6%), and 50-59 (30.2%) years. The majority are female (91%), Caucasian (87%), and hold a Master’s degree (82%). Sixty-seven percent of the respondents are NP's; 45% have been at their current job for < 5 years, and 85% have ≤ 15 years of experience.
Realizing that the survey is a snapshot in time, it appears that the AP community is trending towards younger practitioners. As to whether this is goord or bad for the profession remains to be seen. However, it does mean that coverage of nephrology practices will be done by less experienced practitioners in the near future (see Figure 1).
We present characteristics of the 2012 survey respondents (n=287) as their data are depicted in the results section. The 2012 survey participants had an age distribution of 30-39 (24.7%), 40-49 (27.9%), and 50-59 (30.7%) years, 86% being Caucasian, 82% white, and 80% holding a Master’s degree. Fifty-six percent of the respondents were NPs; 41% had been at their current job for < 5 years, and 82% had ≤ 15 years of experience.
Given this specific target population of nephrology APs, sample overlap is expected between the two years; percent overlap cannot be traced, as surveys were anonymous. However, it is worth to note that the nationwide distribution of APs by state varied between the 2012 and 2014 surveys.
Work affiliations and Scope of work
APs are found in all areas of nephrology practice (see Figure 2). Hemodialysis patient care and patient visits at the office are the most common areas of practice, followed by hospital duties and peritoneal dialysis sessions. In 2014, a higher number of APs report involvement with private industry work, compared to the reports in 2012. Conversely, fewer APs (29%) report engagement in education in 2014, compared to the 2012 reports (58%). In 2014, about 17% of APs reported being involved in transplant patient care. We note that the 2012 survey did not address transplant practice.
Most APs are involved in various office duties with regards to patient care (see Figure 3); almost 70% of APs reported conducting chronic kidney disease (CKD) clinics in 2014. Of the APs who have hospital-related responsibilities (45%), the most commonly occurring functions are patient rounds, consultation services, history-taking/physical assessments, and patient discharge (see Figure 4). This is a similar pattern to that in the 2012 survey.
APs functioning at hemodialysis centers are mostly involved in weekly rounds, primary care issues, history-taking/physical assessment, Monday to Friday calls, and intravenous drug management, including arthropod-stimulating agents (ESA) and Vitamin D (see Figure 5); a pattern similar to that seen in 2012 data. About 30% of APs round on 50-99 patients on hemodialysis per week, while another 29% report rounding on 100-150 patients per week. Forty one percent of APs report having peritoneal dialysis patient care responsibilities, and 32% of APs provide care to kidney transplant patients. The majority of survey respondents are not involved in interventional or pediatric nephrology.
For APs involved in research, the most common tasks include data collection and patient monitoring in clinical trials. Research is often a cost center for nephrology practices. However, many practices are not participating in the depth and breadth of research studies they had in 2012 (see Figure 6). The largest percentage of APs will function as the sub-investigators, allowing them to fully utilize their training and licenses. However less than 1 in 5 practices will use their AP for research.
Compensation, benefits and work satisfaction
The top three states with highest paid APs in 2014 are California, Connecticut, and Kansas (see Figure 7). The calculated average salary for a nephrology AP in the 2014 survey was $95,410 (PAs=$92,600 and NPs=$96,770); and $91,240 (PAs=$91,340 and NPs=$91,170) in 2012. In 2014, higher salaries were reported than in 2012, at most levels of AP experience (see Figure 8). More than half of the APs received a raise in 2013, and 45% received a bonus. Moreover, 26% received profit sharing.
In 2014, only 53% of nephrology APs function with written contracts, where 1/3 of contracts have been requested from the employer. Almost all contracts include a non-compete clause. In terms of mainstream benefits, the majority of APs receive malpractice insurance (96%), 401K/403B retirement savings plans (93%), some form of health insurance benefit (88%) from their employer, and have continuing medical education (CME) allowances (87%). More than 50% of APs have paid time off (PTO) almost evenly distributed between 16-20, 21-25, and 26-30 days per year. Additionally, > 50% of APs are supplied with an office computer, lab coat, business cards, professional organizations memberships, mileage stipend, state dues, and drug enforcement administration (DEA) and recertification exam fees.
In terms of job satisfaction, a good work relationship with a physician colleague is the most frequently reported contributing factor (see Figure 9); this occurrence is similar to reports in previous years. Feeling valued at work, the ability to look forward to work and obtaining physician back-up when needed are also considered as significant factors in AP work life quality.
This 2014 survey reveals that APs are involved in multiple nephrology practice areas, the majority being involved in hemodialysis care and office-based patient care. In the various care settings, APs exhibit a diverse set of functions. While most APs providing office-based patient care seem to be conducting CKD clinics, APs caring for in-hospital patients are mainly involved in rounds, consultations, physical assessments, and patient discharges. In hemodialysis centers, commonly occurring functions include weekly rounds, primary care delivery, physical assessment, weekday calls, and intravenous drug management.
AP salaries reported in 2014 seem to be higher than those reported in 2012, and they closely mirror years of experience. Benefit packages contain mainstream coverages such as malpractice insurance, health care, and retirement plans. It is noteworthy, however, that 13% of APs do not obtain CME allowances; it will be helpful to identify employers who do not provide this continuing education opportunity. On the other hand, almost 40% of APs (in 2014) reported having access to Up-to-Date as an educational resource tool. There is a higher number of written contracts containing non-compete clauses in 2014 than that reported in 2012, perhaps subtly denoting the realization that the AP can be the face of the practice in the dialysis units and clinics. The increasing appreciation of the AP role is also reflected in the added benefits (journals, access to Up to Date, name on stationary, and name-plates) that were previously offered only to physicians in the practice. In 2014, more APs report involvement in private industry; APs may be seeking new venues to employ their skills, thus broadening the scope of their practice. Moreover, attention should be paid to the number of APs involved in education.
Since 2010, kidney disease education (KDE) classes have been authorized by Medicare. With fewer APs teaching these classes and fewer classes being offered, it is increasingly more difficult to sustain the KDE benefit that was acquired with great effort. Considering all the above, components related to work life exhibit an importance ranking similar to that in 2012.
Limitations of survey
A limitation in these surveys is that the representativeness of the samples are not guaranteed due to the use of snowball sampling which, in turn, limits generalizability. However, the latter sampling method was a helpful approach in locating nephrology advanced practitioners.
Conducting this biannual survey provides indirect benefits to the participants in that it increases engagement of the workforce, raises awareness on work conditions, helps capture changes on workforce status over the years, and provides data to leaders in the field for strategic planning on the future of the workforce. Finally, given the growing number of elderly patients starting on dialysis,2 the apparent dissatisfaction of nephrology fellows with their career choice,3 and anticipated upcoming shortage in nephrologists, there is an increasing need for APs in nephrology practice.2, 3 Future studies are encouraged to investigate AP to patient ratios in various settings, patient satisfaction, and address how APs influence patient outcomes (such as hospital readmission rates and other endpoints).
1. NKF-CAP salary and benefits surveys. http://www.kidney.org/professionals/CAP/sub_resources.cfm. Accessed Aug 4, 2014
2. Himmelfarb J, Berns A, Szczech L, Wesson D. Cost, quality, and value: The changing political economy of dialysis care. 2007. J Am Soc Nephrol; 18(7): 2021-2027
3. Shah HH, Jhaveri KD, Sparks MA, Mattana J. Career choice selection and satisfaction among US adult nephrology fellows. 2012. Clin J Am Soc Nephrol; 7(9):1513-1520.