What can we do as PMH-APRNs to close the existing disparities in Mental Health? Do you consider there is a stigma associated with specializing in PMH? The student must answer the grad

APNA 2022 PSYCHIATRIC-MENTAL HEALTH NURSING

WORKFORCE REPORT

www.APNA.org

The First Study Specifically Targeting the

Psychiatric-Mental Health Nursing Workforce

2Acknowledgements | APNA 2022 PMH NURSING WORKFORCE REPORT

ACKNOWLEDGMENTS

The American Psychiatric Nurses Association Board of Directors would like to thank the APNA Workforce Task Force for developing the APNA Psychiatric-Mental Health

Nursing Workforce Survey, analyzing data, and preparing this report.

APNA Workforce Task Force: Angela M. Gerolamo, PhD, CRNP, PMHNP-BC (Chair); Kathleen R. Delaney, PhD, PMHNP-BC, FAAN; Bethany Phoenix, PhD, RN, FAAN; Amy Rushton, DNP, PMHCNS-BC; Janette Stallings, MA, MSN, APRN, PMHNP, BC; Patricia

Black, PhD, RN, FAAN (APNA Staff)

The task force would like to thank Dawn Vanderhoef for her leadership and assistance with survey development, the APNA Board of Directors Student Scholars (Whitney D.

Bagby, Brook Alicia Condrey, Geo Guerrero, Tashae Gomez Jones, Bethany Mandy, Sarah O’Neil and Alexandra Taylor) for assistance with data analysis, and Hugh

Vondracek for statistical analysis support. Finally, the authors would like to express gratitude to the PMH-RNs and PMH-APRNs who participated in the surveys.

3tAble of contents | APNA 2022 PMH NURSING WORKFORCE REPORT

Key Findings of the 2022 APNA Psychiatric-Mental Health Nursing Workforce Survey ……………………4

Survey Methodology ………………………………………………………………………………………………………………………………..6

Psychiatric-Mental Health Registered Nurse (PMH-RN) Survey Findings …………………………………………7 Executive Summary ……………………………………………………………………………………………………………….7 Demographics ………………………………………………………………………………………………………………………..8 Human Capital ………………………………………………………………………………………………………………………..12 Employment ……………………………………………………………………………………………………………………………13 Earnings …………………………………………………………………………………………………………………………………..16 Discussion ………………………………………………………………………………………………………………………………17

Psychiatric-Mental Health Advanced Practice Registered Nurse (PMH-APRN) Survey Findings ……20 Executive Summary ……………………………………………………………………………………………………………….20 Demographics ………………………………………………………………………………………………………………………..21 Human Capital ………………………………………………………………………………………………………………………..23 Employment ……………………………………………………………………………………………………………………………26 Earnings …………………………………………………………………………………………………………………………………..31 Discussion ………………………………………………………………………………………………………………………………32

Report Summary ………………………………………………………………………………………………………………………………………35

References ………………………………………………………………………………………………………………………………………………..37

TABLE OF CONTENTS

4key findings | APNA 2022 PMH NURSING WORKFORCE REPORT

KEY FINDINGS

Key Findings of the 2022 APNA Psychiatric-Mental Health Nursing Workforce Survey

PSYCHIATRIC-MENTAL HEALTH REGISTERED NURSES (PMH-RNs):

• Among all age groups of PMH-RNs, the 20-29 age range comprises the smallest percentage of nurses.

• The PMH-RN workforce has a different racial/ethnic and gender composition than the general RN population, with double the number of Black or African American nurses and a greater proportion of multiracial nurses and males in the PMH-RN population.

• About half of the sample reported a Bachelor of Science in Nursing (BSN) as their highest degree, and 82% of respondents ages 20-29 indicated their initial degree is a BSN

• The hospital is the primary employment setting for a majority (62%) of PMH-RNs.

• The majority of respondents (61-71%) reported that they assess physical health status, assess mental health status, and educate patients and families for most patients. About 40% of PMH-RNs reported that they are providing counseling and developing therapeutic relationships to most patients, which has historically been a key component of the PMH-RN role.

• Less than two-thirds of respondents reported feeling either safe or very safe in their work settings. Patient acuity (59%), level of administrative support (56%), staffing ratio (55%), and level of staff training (54%) were cited by a majority of respondents as factors that influenced their feelings of workplace safety.

• Pre-tax annual income from primary employment was in the $50,000- 99,000 range for 65% of respondents.

5key findings | APNA 2022 PMH NURSING WORKFORCE REPORT

PSYCHIATRIC-MENTAL HEALTH ADVANCED PRACTICE REGISTERED NURSES (PMH-APRNs):

• The average age of PMH-APRNs is 54 years, with more than half of the respondents in their 50s or 60s.

• 27% of respondents plan on retiring in the next six years, with a greater percent of intended retirements among Clinical Nurse Specialists.

• Although the majority of PMH-APRNs identify as white (84%), the proportion of respondents that identified as Black or African American in the PMH-APRN sample is slightly larger (10%) than the broader NP population, but lower (3%) in terms of PMH-APRNs who identify as Latinx.

• More than two-thirds of respondents reported a Master of Science (MSN) as their highest degree, and their initial PMH-APRN preparation.

• Most respondents (70%) practice in outpatient settings that include mental health clinics, community-based programs, federally qualified healthcare centers (FQHCs), and community health centers.

• Approximately 42% of respondents completed Medication for Addiction Treatment (MAT) training and 72% of these subsequently applied for a U.S. Drug Enforcement Administration (DEA) X-waiver to prescribe Buprenorphine for opioid use disorders.

• A majority of respondents treat patients who hold commercial insurance or Medicaid/Medicare, with close to half stating most of their clients were covered by federal insurance.

• Pre-tax annual income from primary employment was in the $100,000- 150,000 range for 47% of respondents.

6methodology | APNA 2022 PMH NURSING WORKFORCE REPORT

METHODOLOGY

Workforce Survey Methodology

The American Psychiatric Nurses Association (APNA) convened a Workforce Task Force comprised of six members to develop a comprehensive survey of the Psychiatric-Mental Health (PMH) Nursing workforce. The goal of the survey is to understand the demographic, education, employment characteristics, and earnings of PMH nurses working throughout the United States. The primary data source for this report was from a voluntary survey offered to contacts in APNA’s database, registered nurses, and advanced practice nurses with current certification by the American Nurses Credentialing Center (ANCC).

The Workforce Task Force began survey development on September 7, 2018. Separate surveys were developed for Psychiatric-Mental Health Registered Nurses (PMH-RNs) and Psychiatric-Mental Health Advanced Practice Registered Nurses (PMH-APRNs) to reflect the unique scope of each role. To inform survey development, the Task Force examined the following sources: American Psychological Association 2015 survey; APNA minimum data set (MDS); Health Resources and Services Administration National Sample Survey of Nurse Practitioners; National Workforce Survey of RNs; Nursing Minimum Data Set; Minimum Data Set for the Behavioral Health Workforce developed by the University of Michigan; and the American Psychiatric Association Draft Workforce Survey. This approach ensured a systematic and comprehensive examination of the types of data that other behavioral health disciplines collect. Both surveys were reviewed by a researcher with content and methodological expertise in workforce research. Each survey was pilot tested with 100 individuals. Survey items were revised to improve readability and clarity. Each survey included a glossary of terms to ensure consistent interpretation among participants.

The PMH-RN survey included 51 questions and the PMH-APRN survey included 52 questions. Surveys were administered from October 21, 2020 to February 24, 2021. The PMH-RN survey was completed by 4,088 PMH-RNs and the PMH-APRN survey was completed by 5,158 PMH- APRNs. The combined response rate for the surveys is 12.1%. Statistical Package for the Social Sciences (SPSS) was used for data management and analysis. Frequencies, percentages, and cross tabulations were used to summarize the data. A consultant was engaged to assist with statistical analysis.

The findings should be considered in light of the study limitations. First, the sample is comprised of PMH-RNs and PMH-APRNs who are contacts in the APNA database and/or certified by ANCC who may not be representative of the full Psychiatric-Mental Health Nursing workforce. Second, the response rate is low suggesting potential nonresponse bias. Finally, the survey was administered during the COVID-19 pandemic when social distancing and other restrictions were in place which could have influenced the findings. Despite these limitations, this is the first research study that specifically targets the PMH nursing workforce.

7Pmh-Rn suRvey findings | APNA 2022 PMH NURSING WORKFORCE REPORT

PMH-RN SURVEY FINDINGS

Psychiatric-Mental Health Registered Nurse Survey Findings

EXECUTIVE SUMMARY

Data on the characteristics and supply of Psychiatric-Mental Health (PMH) Registered Nurses (RNs) and Advanced Practice Registered Nurses (APRNs) are essential to expanding access to behavioral health care and informing workforce projections. The first section of this report contains data on the demographics of the current PMH-RN workforce and their educational preparation, employment characteristics, and earnings.

The PMH-RN workforce is aging similarly to the nurse population as a whole. The average age of PMH-RNs is 51 years, with more than half of the respondents in their 50s or 60s. Only 4% of PMH-RNs are in the 20-29 age range. The top two reasons respondents reported as barriers to becoming a PMH-RN are (1) individuals felt they needed medical-surgical experience and, (2) a faculty member told them they needed medical-surgical experience prior to becoming a PMH-RN.

Although the majority (77%) of PMH-RNs are White, the proportion of respondents that identified as Black or African American (13%) in the PMH-RN sample is double that of the national RN sample. Further, a greater proportion of PMH-RNs identified as Multiracial (4%) compared with the national RN sample. Finally, males comprise a greater proportion (12%) of the PMH-RN population compared with their male counterparts in the general nursing population.

About half of the sample reported a Bachelor of Science in Nursing (BSN) as their highest degree, and 82% of respondents ages 20-29 indicated their initial degree is a BSN. Rates of certification vary by race and age with the highest proportion of certified nurses identifying as older and White. Nurses who are certified in a specialized area of nursing are recognized as having advanced knowledge, skills, and expertise. PMH-RNs noted that the top reason for not obtaining certification is because it is not valued by their employer.

Compared with a national sample of RNs, more PMH-RNs (89%) reported a hospital as their primary employment setting. Further, the majority of respondents (between 61 and 71%) reported that they assess physical health status, assess mental health status, and educate

overview

demographics

education

employment characteristics

8Pmh-Rn suRvey findings | APNA 2022 PMH NURSING WORKFORCE REPORT

patients and families for most patients. However, approximately 60% reported that they are not providing counseling and developing a therapeutic relationship with most patients, which has historically been a key component of the PMH-RN role.

Pre-tax annual income from primary employment was in the $50,000-99,000 range for about two-thirds of respondents. Income from primary employment tended to increase with age up to 70 years and then decreased. Nurse administrators most frequently reported earning greater than $100,000, followed by nurse managers and those working in correctional facilities. PMH-RN respondents who reported earning less than $75,000 disproportionately identified as American Indian and Alaskan Native and PMH-RNs employed in rural counties. PMH-RN respondents who reported earning less than $50,000 more often reported working in school- based clinics and in home psychiatric care.

FULL DATA FROM THE APNA PMH-RN SURVEY

APNA survey findings are compared with data from the 2020 National Workforce Survey which reflects a nationally representative sample. This survey is produced by the National Council of State Boards of Nursing (NCSBN) in partnership with the National Forum of State Nursing Workforce Centers.

DEMOGRAPHICS

The average age of the 3,494 PMH-RN survey participants is 51 years (SD=12.5; median=52), ranging from 22 to 101 years old. The average age of PMH-RN survey respondents is consistent with the average age of RNs reported nationally, which is 52 years old (NCSBN, 2020). More than half of the respondents (53%) are in their 50s or 60s. In a national sample of RNs, 8% of nurses are between the ages of 20-29 (NCSBN, 2020) while only 4% of PMH-RNs in our sample are in that age range. (Figure 1 presents the age distribution of participants by selected decades.) Age is calculated by participant responses to date of birth. The large proportion of PMH-RNs in their 50s and 60s represents a significant context for many other observations in this report.

earnings

Age

20-29

25%

0% 30-39 40-49 50-59 60-69 70-79 80-89 100+

Age of the workforce Figure 1

Age by Decade

% o

f R es

po nd

en ts

9Pmh-Rn suRvey findings | APNA 2022 PMH NURSING WORKFORCE REPORT

Of 3,491 PMH-RNs, 87% reported their gender as female, 12% reported male gender, and 0.4% reported either non-binary or transgender. Similarly, 87% were assigned female on their original birth certificate while 12% were assigned male. The percentage of respondents reporting male gender is slightly higher than the 9% of RNs reporting male gender in a nationally representative sample (NCSBN, 2020). Of the PMH-RNs that responded, 8% identify as sexual minorities such as gay, lesbian, and bisexual.

Of 3,462 PMH-RNs responding, more than three-quarters (77%) identified as White (See Table 1). About one quarter of respondents identified as racial or ethnic minorities, and 4% identify as multiracial. Similarly, in a national sample, almost 81% of RNs identified as White. However, the second most frequently identified race among the national sample was Asian (7%) (NCSBN, 2020), compared with 6% of respondents in the PMH-RN sample identifying as Asian. In the PMH-RN sample, the second most frequently identified race was Black or African American (13%) compared with only 6% of RNs in the national sample (NCSBN, 2020).

The United States Census Data show that 18% of the population identifies as Hispanic and any race. The Census Data measures ethnicity and race separately through two items while our survey asked respondents to identify their race with Latinx as one of the options. Only 4% of respondents identified as Latinx suggesting a significant underrepresentation of this ethnic subgroup compared with the general population. (See Figure 2 for racial distribution among the sample of PMH-RNs.) Almost 4% of PMH-RNs identified as multiracial compared with 2% of RNs in a national sample reporting two or more races (NCSBN, 2020) and about 3% of the population reporting two or more races in the 2019 United States Census Data.

Of 3,386 responding PMH-RNs, almost one quarter speak at least one language in addition to English; 3% speak two or more languages in addition to English. The most common language spoken in addition to English is Spanish which was reported by 11% of RNs.

gender, sex, and sexual orientation

Race/ethnicity

Table 1: Race/ethnicity

White 77.2%

Black or African American 13.2%

Asian 6.4%

Latinx 4.5%

American Indian or Alaska Native 1.8%

Native Hawaiian or Pacific Islander 0.7%

Prefer not to answer 0.5%

RN Racial Distribution

White Black or African American

Asian Latin-x

American Indian or Alaska Native Native Hawai ian or Pacific Islander

Prefer not to answer

Pmh-Rn Racial distribution Figure 2

10Pmh-Rn suRvey findings | APNA 2022 PMH NURSING WORKFORCE REPORT

PMH-RNs that identify as White are likely to be older, on average, than any other racial group. This is consistent with general demographic trends in the US population. (See Table 2)

Figure 3 shows the race/ethnicity distribution across age groups. Race/ethnicity categories are not mutually exclusive.

Race/ethnicity by Age

Table 2

ethnicity n Age m (sd) min max

White 77.2% 52.17 (12.59) 22 101

Black or African American 13.2% 50.72 (11.68) 25 79

Asian 6.4% 45.75 (11.38) 24 81

Latinx 4.5% 46.31 (11.89) 25 75

American Indian or Alaska Native 1.8% 47.31 (10.85) 25 65

Native Hawaiian or Pacific Islander 0.7% 44.63 (10.31) 27 63

*scale approximate

100%

75%

50%

25%

0%

Race/ethnicity by Age* Figure 3

OVERALL (n=3494)

White (n=2671)

Black or African

American (n=456)

Asian (n=222)

Latinx (n=155)

American Indian or Alaskan Native (n=64)

Native Hawaiian or Pacific Islander (n=24)

Prefer not to answer (n=15)

20-29 30-39 40-49 50-59 60-69 70-79 80-89 100+

11Pmh-Rn suRvey findings | APNA 2022 PMH NURSING WORKFORCE REPORT

Race/ethnicity does not significantly vary by gender among responding PMH-RNs. (Table 3 shows the number of respondents that comprise each racial category by reported gender.)

Of 3,476 PMH-RNs, 6% are veterans, 0.5% are on active duty, and 2% are in the reserves or National Guard. PMH-RNs in their 70s have the highest (9%) proportion of veterans, and those in their 20s have the lowest proportion of veterans (2%).

Race/ethnicity by gender

Active duty service

table 3

gender overall Race

n %

American Indian or Alaska Native

Asian Black or African American

Native Hawaiian or Pacific Islander

White Latinx

Female 3,009 87.2% 55 177 392 21 2,334 126

Male 426 12.4% 8 41 56 3 304 27

Non-Binary 13 0.3% 0 0 1 0 12 0

Transgender 2 0.1% 0 0 0 0 2 0

total 3,449 100% 63 222 451 24 2,668 155

12Pmh-Rn suRvey findings | APNA 2022 PMH NURSING WORKFORCE REPORT

HUMAN CAPITAL

Forty-five percent of respondents qualified for their initial RN license by obtaining an Associate Degree in Nursing, while 42% earned a Bachelor of Science in Nursing (BSN) as their first nursing degree. Eighty-two percent of PMH-RNs in their 20s and 57% of PMH-RNs in their 30s first qualified for their initial RN license by earning a BSN. This trend holds across gender. Similarly, 42% of RNs in a national sample qualified for their first RN license by earning a BSN degree, a trend that has increased over the past several years (NCSBN, 2020). Respondents who identified as Asian (66%) and Native Hawaiian and Pacific Islanders (50%) were the only racial groups where a majority obtained a BSN degree to qualify for their first RN license.

3,948 PMH-RNs reported that on average, 8% of their didactic coursework for their initial RN education was completed online (SD=18.1). Two-thirds of PMH-RN respondents reported that none of their coursework was online.

Half of responding PMH-RNs reported their highest degree as a Bachelor of Science in Nursing (BSN) which is consistent with the NCSBN (2020) survey that showing that 48% of RNs reported their highest degree as a Bachelor of Science in Nursing. There are no differences in highest degree earned by race or certification. Black or African American PMH- RNs have the highest proportion (38%) of MSN training. The proportion of PMH-RNs who hold a BSN tends to decrease with age, with PMH-RNs more likely to have either an Associate’s or Master’s degree with each successive decade.

Of 3,987 PMH-RN respondents, 15% reported that they completed a new graduate residency or fellowship program. These PMH-RNs reported that their new graduate residency or fellowship program lasted an average of 8.4 months (SD=5.8) ranging from 0 to 36 months. More than half of PMH-RN respondents to this question reported their residency or fellowship program was less than one year. About three quarters of PMH-RN respondents who completed a new graduate residency or fellowship program reported that they were either satisfied or very satisfied with the program. There were no differences in program satisfaction by age, gender, or Magnet hospital status.

One quarter of PMH-RN respondents reported current enrollment in a formal education program. More than half of all Black or African American PMH-RN respondents reported current enrollment in a formal education program while White PMH-RN respondents were the least likely to be enrolled in an education program. Slightly more men (30%) were enrolled

education

Percentage of coursework online for initial Rn education

highest degree earned

new graduate Residency or fellowship Program

current enrollment in nursing Program

13Pmh-Rn suRvey findings | APNA 2022 PMH NURSING WORKFORCE REPORT

than women (25%), and PMH-RNs in their 20s (48%) and 30s (42%) were the age groups most likely to report enrollment in a formal education program.

Respondents were licensed in all 50 states, as well as Washington, DC, with 76% of respondents licensed in one state, and 20% licensed in 2 to 4 states. Almost half of responding PMH-RNs reported holding an American Nurses Credentialing Center (ANCC) certification as a PMH-RN. Rates of certification by race include 47% of all White PMH-RNs being certified, 45% of Asian PMH-RNs, 43% of Latinx PMH-RNs, 42% of Black or African American PMH-RNs, 42% of Native Hawaiian or Pacific Islander PMH-RNs, and 28% of American Indian or Alaska Native PMH-RNs being certified. Although there is no substantive difference between the proportion of certification among men and women, the proportion of PMH-RNs holding an ANCC certification increases with age. In addition, rates of ANCC certification vary by primary role in employment setting, ranging from 64% of utilization review nurses to 43% of nurse educators. The two most common reasons reported for not being certified by ANCC are cost and that certification is not valued by current employer.

About half of PMH-RN respondents plan to retire more than 10 years from now with 13% undecided. Unsurprisingly, older PMH-RNs in more senior roles tend to anticipate retiring sooner than their younger or more junior counterparts. There were no differences in characteristics among respondents who were undecided about retirement.

EMPLOYMENT CHARACTERISTICS

The average number of years of experience among respondents is 6.6 (SD=8.7) with a median of three years of RN experience prior to becoming a PMH-RN. Twenty-nine percent of those respondents did not have any prior nursing experience, and 10% had only one year of experience prior to becoming a PMH-RN. Older nurses tend to have more nursing experience prior to becoming a PMH-RN. However, years of experience as an RN prior to becoming a PMH-RN does not vary by type of role. While more than half of respondents did not experience barriers to becoming a PMH-RN, the most common barriers reported by those who reported barriers are, ‘I felt I needed general/medical nursing experience before entering PMH nursing’, and ‘faculty advised me that I needed medical-surgical experience before going into psychiatric-mental health.’ Females and younger RN respondents were more likely to feel that they needed more nursing experience before becoming a PMH-RN.

Of 3,787 responding PMH-RNs, 52% are staff nurses, 13% are nurse educators, 9% are nurse managers, 7% are nurse administrators, and 6% are nursing supervisors. The remainder of respondents selected ‘other’ noting roles such as care/case manager, utilization review nurse, consultant, and retired. The proportion of respondents working in staff nurse roles decreases with age and with years of experience.

state licensure and certification

Plans for Retirement

experience as a Psychiatric- mental health nurse

Pmh-Rn Roles

14Pmh-Rn suRvey findings | APNA 2022 PMH NURSING WORKFORCE REPORT

Of 2,069 responding PMH-RNs, only 12 work in rural counties. PMH-RN respondents overwhelmingly work in metropolitan counties. 2,214 PMH-RNs reported living an average of 14.56 miles (SD=11.76; median=11.2; range: 0.5-91) from their primary employment.

Of 3,756 responding PMH-RNs, 62% work in a hospital setting, 14% in an ambulatory care/ outpatient setting and 7% in an education/academic setting. The percentage of PMH-RNs working in a hospital as their primary employment setting is higher than that reported by a national sample of RNs which is 55%. (NCSBN, 2020). The proportion of PMH-RNs working in hospital settings decreases with age. Other settings less frequently reported by PMH-RN respondents include: residential/long-term care, psychiatric home care, college/university counseling center, school-based clinic, correctional facility, private practice/consulting, health plan/insurance, and retired or unemployed.

Of PMH-RN respondents who reported working in a non-hospital setting, 22% reported working in a mental health clinic and 9% reported working for the Veterans Health Administration. Almost three-quarters of these respondents reported completing an orientation for their position, but only 10% completed a fellowship or residency, and only 11% work at a Magnet certified facility. The majority of respondents working in a non- hospital setting are female and White. More than two- thirds of PMH-RNs working in non-hospital settings are age 50 or older. However, primary or specialist medical care and community health center settings had more than 30% of PMH-RNs under age 40. A BSN in nursing degree is the most common maximum credential, with the exception of PMH-APRN offices, academic settings, and long-term care settings.

Of 3,394 responding PMH-RNs, 88% reported having completed an orientation for their primary RN position. Of 2,995 responding PMH-RNs, 32% reported having an orientation that lasted 10-19 days, with PMH-RNs working at ANCC Magnet certified facilities representing the greatest proportion of PMH-RNs reporting an orientation of greater than one month. Orientation length was longest in hospitals, ambulatory or outpatient settings, and correctional facilities. As the length of orie