Workforce Assessment of Nurse Anesthetists to Mitigate Intent to Leave and Improve Labor Participation

Abstract

OBJECTIVE

The purpose of this study was to analyze the nurse anesthesia workforce in rural settings to identify strategies to improve retention of employees and encourage increased labor participation.

BACKGROUND

Nurse anesthetists are the primary anesthesia provider for many rural areas and are critical in providing patients' access to care. Anesthesia shortages have a disproportionate impact on at-risk populations and contribute heavily to rural hospital closures.

METHODS

This was an exploratory study using a cross-sectional design with paper-based surveys delivered via postal mail.

RESULTS

Although salary was the top response supporting retention, other effective nonmonetary approaches that included guaranteed time off, feeling valued, and fellow employee morale were identified.

CONCLUSION

The findings of this study imply that work-life balance with flexibility in scheduling are effective tools to reduce intent to leave and recruitment of nurse anesthetists. Recruitment efforts need to focus more on female providers because they have the greatest potential to enhance labor participation. Nurse executives can use this information to collaborate with the recruitment and retention of these advanced practice providers.

Anesthesia workforce shortages across the United States are impacting patient access to surgical services and disproportionately impacting rural settings.¹ Nurse anesthetists are the primary anesthesia providers for many rural areas and are critical in providing patients' access to obstetrical, surgical, pain management, and trauma stabilization services.¹ The state of Mississippi is 79.3% rural and has the highest number of Black residents (37.8%) more than any other state.² Mississippi is ranked 51st for having the highest proportion of residents living below the poverty line (19.1%).² Thus, an anesthesia workforce shortage in Mississippi will have a disproportionate impact on vulnerable populations.

The Nurse Anesthesia Workforce

Workforce-related topics have impacted the nurse anesthesia profession. The aging workforce complicates the threat of a workforce shortage as 49.2% of all nurse anesthetists nationally are older than 50 years.³ Studies report that nurse anesthetists' job satisfaction is related to workload, working conditions, job characteristics, financial compensation, and benefits.^4,5 Job dissatisfaction has been consistently identified as a predominant factor for nurse anesthetists' intent to leave their current employer.^4,5

Intent to Leave

Intent to leave is defined as the desire or consideration of an employee to leave their current employer for other organizations.^5-7 The terms anticipated turnover and turnover intention are also used in the literature for this concept.^6,7 Developing interventions targeting intent to leave allows for management to attempt to prevent staff turnover, increased costs, and staffing shortages.⁷ It has been previously reported that the predominant reasons a nurse anesthetist intends to leave their job are improved working conditions, retirement, and increased financial compensation.⁷ Among nurse anesthetists, men are more likely to quit their jobs for better working conditions (72%) and to leave for better pay (64%) than women.⁷ This has contributed to female nurse anesthetists being paid less than male anesthetists.⁷

Healthcare workforce studies inform workforce development and training programs, promote care in underserved areas, and guide regulatory policy related to scope of practice and reimbursement for services.⁸ The purpose of this workforce study was to analyze the nurse anesthesia workforce in the state of Mississippi, a primarily rural state, to identify strategies to improve retention of employees and encourage increased labor participation of individual nurse anesthetists. The aims to achieve this purpose are the following:

• 1)Describe the current labor participation of nurse anesthetists.
• 2)Describe anticipated labor participation in 2 years after this study.
• 3)On the basis of other studies, explore the impact of psychosocial, job satisfaction, available employee benefits, and demographic information on future labor participation.

Materials and Methods

Study Design, Participants, Setting, and Recruitment

This was an exploratory study using a cross-sectional design with paper-based surveys delivered via postal mail. Study participants were nurse anesthetists whose primary employment was within the state of Mississippi and able to read/write in the English language. Because the team used the American Association of Nurse Anesthetists' (AANA) Survey Research Services for study participant recruitment, nonmembers whose mailing addresses were unavailable were excluded.⁹ The University of Alabama at Birmingham Institutional Review Board reviewed and approved this study.

The sample size was determined by including the entire population of nurse anesthetists who were employed within Mississippi as of August 2023 (n = 608). The response rates for electronic delivery of surveys via the AANA have been as low as 3% recently.⁹ Electronic surveys have consistently been shown to have lower response rates than other modalities (postal, telephone, or in-person interviews).¹⁰ Studies have shown that paper-based postal surveys have a median increase of up to 20% in response rates compared with electronic delivery.¹¹ Researchers in this study chose to use postal delivery of the survey to maximize the response rate and reduce nonresponse bias.

Survey Development

Development of the Conceptual Model

The conceptual model (Figure 1) used to generate the survey used in this study was adapted from a theoretical framework titled Minnick and Roberts Outcomes Model.^12,13 This framework focuses on administratively mediated variables and has been used in many health services research-based studies since 1997.^13-15 Administratively mediated variables are mutable factors controllable by organizational leadership under the assumption that decision making influences all model outcomes.^13-15

Figure 1.

Conceptual model used to develop survey items. This conceptual model was adapted from the Minnick and Roberts Outcomes Model. The concepts above are administratively mediated variables controllable by organizational leadership under the assumption that decision making influences all model outcomes. Labor inputs mediate the impact of employment terms and organizational facets on employee behavior. These concepts were used to generate the questions in the survey used in this study.

For this study, the concepts used from the Minnick and Roberts Outcomes Model included employment terms, organizational facets, labor input, employee behavior, and employee attitudes. The concepts excluded from this study are related to patient-related characteristics, experiences, and outcomes, which were deemed to not apply to the targeted sample (nurse anesthetists). The final survey contained 20 questions plus a demographic section asking for anesthesia specialty, academic degrees held, gender, race/ethnicity, age, gross annual household income, and year of initial nurse anesthetist's certification.

Employment terms are time-related workload requirements of nurse anesthetists and include the number of regular hours worked, hours of overtime required, hours on call, and shift scheduling.^12-14 Organizational facets include characteristics of the work environment, promotion of worker autonomy, and staffing models (medical direction, medical supervision, and independent providers).^12-14 Labor input can have diverse definitions but, in this study, is defined as years of experience, anesthesia specialty (eg, cardiovascular, pediatric, etc), and level of education of nurse anesthetists. An underlying assumption of labor input is that it mediates the concepts of employee terms and organizational factors on employee behavior (Figure 1 for visual depiction).^12-14 Employee attitudes reflect internal disposition of nurse anesthetists related to their perceptions of their employment and may include items such as interpersonal relationships, feeling valued, and pace of work (production pressure).^12-14

Development of Survey

Questions were developed and refined using the recommendations from Dillman et al¹⁶ and Rea and Parker.¹⁷ Content and face validity were established using a review of the literature, an expert card sort, and a survey trial among 10 nurse anesthetists. Initially, a focused literature review identifying previous surveys studying the concepts of interest was identified so that researchers could reuse previously established question items.^8,18-20 The expert card sort involved anesthesia experts matching each question item to the study aim it is supposed to address. Researchers used the conceptual model to select relevant question items for the final survey (SDC #1, http://links.lww.com/JONA/B245).

Procedures

The surveys were sent via US Postal Service to home addresses of nurse anesthetists (N = 608) between August 2023 and November 2023. The individual mailings were composed of a cover letter explaining the purpose of the survey, a paper copy of the survey, and a self-addressed stamped return envelope. The data were directly entered into SPSS Statistics, version 29 (IBM Corp, Armonk, New York).

Data Analysis

The final data set was cleaned and processed before data analysis. Missing data were assessed for each study variable. Outliers were defined as anything more than 3 SDs from the mean. All Likert scales ranged from 1 (lowest) to 10 (highest). Data analysis included descriptive statistics, analyses of variance, Pearson r, or appropriate nonparametric equivalent.

Results

The returned surveys (N = 151) were screened for eligibility and missing data. Surveys were excluded if the nurse anesthetist identified as retired (n = 4), if they were returned and marked as undeliverable (n = 3), or if the nurse anesthetist identified the state of primary employment as outside Mississippi (n = 2). The final data set (N = 142) contained 2.1% missing data.

Participant Demographics

Demographic information collected in the survey included age, gender, predominate staffing approach, and academic degrees held. The average age was 48.2 (SD, 11.2) years, which ranged from 26 to 75 years. See Table 1 for demographics for age, gender, and years of practice according to predominate staffing approach (medical direction, medical supervision, and independent practice). The sample was 51% (n = 72) female. There was a statistically significant difference (F_2,139 = 9.58, P < 0.001) with nurse anesthetists in independent practice having 9.1 more years of experience compared with those in anesthesia care teams. The most common academic degrees included the BSN degree (n = 132, 93%) and MSN degree (n = 79, 55.6%) (Table 2). The years of initial certification of the nurse anesthetists ranged from 1971 to 2022.

Table 1.

Demographics of Nurse Anesthetists by Predominate Staffing Approach

	Medical Directiona	Medical Supervisionb	Independentc	Total
N	64	36	42	142
Age, mean (SD), y	49.59 (11.59)	50.55 (9.91)	53.5 (12.7)	48.2 (11.2)
Gender, n (%)
Female	34 (53)	17 (47)	21 (50)	72 (51)
Male	30 (47)	19 (53)	21 (50)	70 (49)
Years of experience, mean (SD)	13.9 (7.0)	16.1 (12.4)	23 (13.0)	17.2 (11.2)

This table shows age, gender, and years of anesthesia experience by predominate staffing approach.

^aOne physician overseeing fou4 nurse anesthetists.

^bOne physician overseeing more than 4 nurse anesthetists.

^cIndependent nurse anesthetist.

Table 2.

The Academic Degrees Held by the Nurse Anesthetists

	na	Percentage
Certificate (in anesthesia)	3	2.1%
Associate Degree in Nursing	28	19.7%
Bachelor in Anesthesia (nonnursing)	4	2.8%
BSN	132	93.0%
MSN	79	55.6%
Master of Nurse Anesthesia	11	7.7%
Doctor of Nursing Practice	33	23.2%
Doctor of Nursing Anesthesia Practice	7	4.9%
PhD	1	0.7%
Otherb	9	6.3%

This table displays the number of each type of academic degree of the nurse anesthetist survey respondents. Some persons may have held more than 1 degree.

^aThe total number of nurse anesthetists to calculate percentage is 142 (ie, the denominator).

^bThese included other types of bachelor and master degrees.

Most participants worked full-time (n = 128, 90.1%), with few nurse anesthetists reporting employment outside nursing (n = 3, 2.1%). The largest employer was hospitals (n = 90, 63.4%), followed by anesthesia practices (n = 27, 19%) and office-based settings (n = 23, 16.2%). In addition, 63 (44.4%) employers were in federal/state underserved areas.

Benefits and Job Attributes

Gender Differences

There was a moderate effect size association (Cramer's V = 0.28, P < 0.045) with female participants reporting more desire for schedule flexibility in potential jobs (χ² = 23.3, df = 10, P = 0.01) compared with male participants. Female participants were also more likely to have part-time employment (χ² = 7.62, df = 1, P = 0.006), which may limit eligibility for some employee benefits. Male participants worked 6.3 hours more per week than female participants (t₁₃₉ = 2.07, P = 0.04; mean [SD], 44.7 [19.1] vs 38.4 [17.1], respectively). There were female participants who commented in the survey that they would work more hours per week if benefits such as paid maternity leave or partial financial reimbursement of in vitro fertilization were offered. There were no statistically significant differences in the other desired benefits between genders that were identified.

Age Differences

The major differences in study participants based on age include schedule flexibility, salary, all hours worked in a week, and availability of overtime. Older nurse anesthetists (older than 50 years) were less likely to desire flexibility in their schedules (ρ = −0.20, P < 0.001). They rated the importance of salary lower than younger nurse anesthetists (ρ = −0.33, P = 0.03). Nurse anesthetists' age was indirectly associated with the number of hours worked in a week (r = −0.35, P < 0.001) and desired availability of overtime (ρ = −0.18, P = 0.034). Overall, older nurse anesthetists are less willing to work extra regularly scheduled and overtime hours.

Employment and Anticipated Timeframe for Retirement

Most nurse anesthetists planned on staying with their current employer in either the same position (n = 96, 67.6%) or a different position (n = 5, 3.5%). Examples of different positions include other hospitals or surgery centers owned by the same employer. Another 26 nurse anesthetists (18.3%) planned on leaving their current employer within the next 2 years. There were 15 (10.5%) who planned on retiring from the anesthesia profession within the next 2 years. Some stated they are leaving the profession early because of occupational burnout (n = 2, 1.4%).

What Would It Take for Nurse Anesthetists to Work More Hours?

The top 5 factors that nurse anesthetists stated that would encourage them to work more hours each week include salary increase (n = 67, 54%), no call requirement (n = 40, 32.3%), set schedule with guaranteed time off (n = 39, 31.4%), increased overtime pay (n = 34, 27.4%), and feeling valued (n = 34, 27.4%) (Table 3). Improved morale of coworkers is another factor that was mentioned frequently (n = 27, 21.8%). Some of these factors cannot be realistically changed by administration (eg, decreased patient acuity or shorter commute).

Table 3.

Employee Attitude Differences Between Current and Future Jobs

	Current Employera	Prospective Employerb
	Mean (SD)	Mean (SD)	P
Benefits	6.2 (3.2)	7.1 (3.4)	<0.001c
Salary	7.3 (2.4)	9.0 (7.8)	<0 .001c
Overtime pay	5.4 (3.5)	6.6 (3.7)	<0.001c
Work schedule flexibility	6.8 (2.9)	8.8 (2.6)	<0.001c
Environmental safety (eg, crime)	7.9 (2.6)	6.5 (3.7)	<0.001c
Physical environment (eg, noise)	8.0 (2.3)	5.9 (2.8)	<0.001c
Relationships with physicians	8.2 (1.9)	7.5 (2.6)	0.004
Relationships with other providers	8.2 (2.2)	7.6 (2.7)	0.006c
Input into policies and procedures	5.9 (3.1)	5.7 (3.0)	0.864
Commuting time	7.8 (2.7)	7.2 (2.8)	0.077
Pace of work	7.5 (2.5)	7.5 (2.6)	0.875
Retirement plan	5.5 (3.4)	6.6 (3.7)	<0.001c

This table shows the rankings nurse anesthetist gave for each aspect related to their current and future job. Likert scales for the questions are ranked from 1 (lowest) to 10 (highest). The Wilcoxon signed rank test was used.

^aThese are values reflecting nurse anesthetists' satisfaction with their current employer.

^bThese values reflect nurse anesthetists' desire for aspects in their next employer.

^cStatistically significant.

Employee Attitudes Toward Future Jobs

The top reason nurse anesthetists choose a prospective employer is salary (mean [SD], 9.0 [7.8]), followed by work schedule flexibility (mean [SD], 8.8 [2.6]) and relationships with other providers (mean [SD], 7.6 [2.7]). Interestingly, the relationship with physicians was not reported to be important. See Table 3 for a full list of employee attitudes related to the different aspects used to evaluate future employers. Nurse anesthetists' attitudes toward the physical environment (eg, noise) and input into policies and procedures were ranked the lowest (mean [SD], 5.9 [2.8] vs 5.7 [3.0], respectively) in terms of things the respondent would find desirable in their next employer.

Discussion

Role of Gender

Gender is a commonly reported source of discrimination in anesthesia practice.²¹ Women in anesthesia earn less income per year when controlling for hours worked, age, and geographical location.²¹ Women have unique work-life demands related to their roles as primary caregivers (including motherhood and pregnancy).²² The lack of focus on family planning in anesthesia training and clinical practices has been cited as a leading factor in limiting the participation of women in the workforce.²³ Increasing the labor participation of women indicates a need to address these inherent biases and discrimination. Actively promoting equity in pay and supporting unique work-life balance issues through flexible scheduling options and benefits should be addressed.

Intent to Leave, Retention, and Recruitment

Employee retention should be a primary focus because it is more expensive and time-consuming to recruit new employees than to prevent staff turnover.⁷ Characteristics of the workplace (eg, facility setting, anesthesia delivery model, and hours worked) greatly contribute to job satisfaction, intent to leave, and improved recruitment efforts.⁴ With regard to the nurse anesthesia workforce, hospitals with high-acuity patients report less job satisfaction and more occupational burnout compared with ambulatory surgery centers or office-based settings.⁴ In addition, older nurse anesthetists are more likely to value less demanding job roles, which includes lower acuity patients and fewer work hours.²⁴ Independent nurse anesthetists reported a higher job satisfaction compared with those working with physician anesthesiologists.⁴ The number of hours worked during regular employment, call time, and overtime greatly influence job satisfaction and intent to leave.⁴

The previously mentioned characteristics that are mutable factors controllable by administration include the anesthesia staffing model and quantity of hours required to work. Requiring 24-hour anesthesia availability for emergency surgery contributes to occupational burnout and intent to leave.¹ Offering flexible scheduling options with guaranteed time off could improve job satisfaction and reduce employee turnover. This is also a viable option to facilitate recruitment because the amount of required call and weekly work hours is a large determinant of nurse anesthetists' decision to accept an employment offer.^1,25

Implication for Nurse Executives

There is very little published literature related to anesthesia staffing management to guide evidence-based decision making related to costs.²⁶ The leading causes of rural hospitals closing include inadequate anesthesia staffing combined with low patient volumes.²⁷ This is due to the inability to meet the need for anesthesia services that surgeons and other physicians require to generate revenue to support a hospital's budget. This highlights the presence of adequate anesthesia staffing as crucial for rural operating rooms to function daily, provide emergency services, and maintain a positive revenue stream to keep hospitals open.²⁶ It is important to address employee retention, recruitment, and improvement of labor participation to maximize revenue. Assessing the job satisfaction of nurse anesthetists routinely would be a beneficial strategy for nurse executives because it is less expensive to focus on retaining current nurse anesthetists than to recruit or incur lost revenue from surgical services. Promoting work-life balance should be stressed for current and future employees.

When recruiting nurse anesthetists, salary, schedule flexibility, and a collegial work environment are the top 3 most attractive job characteristics to promote. Although low patient acuity or shorter commute distances cannot be altered, these are attractive job characteristics for nurse anesthetists that can be used for recruitment. Women reflect 60% of all nurse anesthetists but are more likely to work fewer hours and report part-time status. Thus, female anesthetists are the greatest potential opportunity for increased labor participation. On the basis of this study, their labor participation could be enhanced by offering additional benefits including paid maternity leave, infertility treatment coverage, childcare, and so forth as well as flexible scheduling options including guaranteed time off, no call, or shorter work shifts.

Limitations

There are several limitations to this study. Nonresponse bias is a concern with survey-based research.^10,11 It is possible there are other benefits that these study participants would have preferred but were not identified because they were not specifically asked about them. Although Mississippi has the highest proportion of Black residents of any state in the United States, the study sample is almost exclusively White. Only 3% of nurse anesthetists nationally are Black. Another limitation is that this study was conducted in 1 state; thus, the findings may not be generalizable to other states and nurse anesthetist populations.

Conclusion

Anesthesia workforce shortages have a more proportionally negative impact on surgical services in rural settings. The purpose of this study was to analyze the nurse anesthesia workforce in Mississippi to identify strategies to improve retention of employees and increase labor participation. The results of this study suggest that women are a targeted population that should be focused on because they have a larger potential increase in labor participation. Recruiting women should focus on pay equity, work-life balance through flexible scheduling options, and benefits as identified in this study. This study identifies workplace characteristics (eg, facility setting, anesthesia delivery model, geographical location, total work hours/call, or patient acuity) as the greatest contributors to job satisfaction, lower intent to leave a job, and easier employee recruitment. Focusing on the improvement of nurse anesthesia job satisfaction is important to promote adequate staffing for operating rooms to function and maintain a positive revenue stream necessary to keep a hospital open.