Congress created the National Health Service Corps (NHSC) in 1970 with the intent to strengthen the healthcare safety net for medically underserved and economically distressed areas of the United States.1,2 The NHSC's approach has been to enjoin clinicians to provide care in areas where services are particularly scarce, whether in rural or urban settings. Since 2000, most NHSC clinicians have participated in its loan repayment program, which offers practicing clinicians up to $50,000 to repay student loans in exchange for 2 years of service, with the option for contract renewals.3 As of 2014, more than 45,000 NHSC clinicians have served in thousands of practice sites within designated healthcare professional shortage areas nationwide.1
The NHSC supports primary medical, dental, and mental healthcare practitioners. Physician assistants (PAs) and nurse practitioners (NPs) have served with physicians and certified nurse midwives (CNMs) as the NHSC's primary medical care providers. Periodically, calls are made to increase PA and NP numbers in order to extend the NHSC's reach into the smallest of communities and at a lower cost to the program than that required for physicians' higher loan repayment amounts.4,5 Over the years, PA and NP numbers in the NHSC have risen and fallen with the growth and contraction of the NHSC's total workforce, responding to changes in the program's funding. With support from the American Recovery and Reinvestment Act of 2009, the NHSC's overall workforce doubled to more than 7,700 clinicians by early 2011; the PA workforce tripled to 1,071 clinicians, and NP numbers nearly quadrupled to 1,233 clinicians.6 As of August 2014, the NHSC's overall workforce stood at 7,883 full-time equivalent (FTE) clinicians, with 1,003 FTE PAs, 1,191 FTE primary care NPs, and 1,636 FTE primary care physicians.7 The president's fiscal year 2015 budget calls for the NHSC's workforce to again expand to help meet the growing care needs of the poor who have gained health insurance through the Affordable Care Act.8
Various aspects of PA and NP involvement in the NHSC have been documented over the decades, including the locations and types of practices where they work, issues in their site selection process, how they regard their NHSC experience and their retention. As was common among clinicians of all types within the NHSC before 2000, most PAs and NPs served in states where they had not previously lived or trained, which can affect their integration into their communities and willingness to remain there after their service terms.9-12 The success of PAs and NPs in the NHSC depends in part on how well their practices and communities understand and accommodate their disciplines' unique roles and practice needs.13,14 And because the NHSC targets newly graduated PAs and NPs, role success and job satisfaction depend on their working where they have the right balance between adequate interprofessional support and backup on the one hand, and clinical autonomy on the other.13-15 Perhaps for these and other reasons, when NHSC clinicians were last broadly assessed in the late 1990s, fewer PAs and NPs than physicians were satisfied with their and their families' experiences in the NHSC.9
This study was undertaken at a time when PAs and NPs are playing larger roles in the overall US primary care workforce, within community health centers, and in an expanding NHSC.16-18 Because of their special roles, reassessment of PAs' and NPs' experiences in the NHSC with contemporary data is important information for policy makers. Understanding the experiences of NHSC clinicians, with their successes and challenges, can assist the NHSC's overall program planning, guide the selection of best-suited applicants, improve the quality of clinician-site matches, and help sites know how best to support practitioners. Understanding differences in the experiences and needs of each discipline can inform NHSC managers how to tailor their approaches for each group. PAs and NPs contemplating NHSC loan repayment can learn how others have progressed and know how best to structure their own NHSC participation.
This study describes and compares PAs and NPs who served in the NHSC in 2010.9 The two disciplines were characterized by their demographics, backgrounds, motivations for participating in the NHSC, sites where they served, and how they fared within these sites and communities. PAs and NPs were assessed side-by-side because they are often used in similar staffing roles within community health centers and other primary care practices and because health workforce planners generally have treated the two disciplines as interchangeable in the roles they fulfill.16
This study draws data from a broader 2011 survey commissioned by the Bureau of Clinician Recruitment and Service (BCRS), titled “Evaluating Retention in BCRS Programs.”19 In 2010, the BCRS provided information from its BCRS management information system solution (BMISS) file on all clinicians actively serving in the NHSC as of September 1, 2010. For purposes of survey efficiency in the 2011 parent study, a stratified random sampling approach was used to select subjects, with rural and urban practice location strata used within each of 16 discipline specialty group strata, and an additional separate frontier county location stratum containing all disciplines. Within this scheme and as a part of the sampling for the original 2011 study, 287 of the 868 total PAs in the loan repayment program as of September 2010 were sampled, along with 257 of the program's 910 NPs (excluding psychiatric NPs). CNMs also were sampled for the 2011 study but not included in this study because of their small numbers. Sample sizes were set based on a power analysis that showed that 133 respondents for each discipline would permit identification of a 15% difference between disciplines in important outcomes at a power of 0.80. The study's survey sample sizes, survey procedures, and instrumentation were reviewed and approved by the US Office of Management and Budget. The University of North Carolina's Public Health-Nursing institutional review board found this study exempt from required institutional review board approval, as it was principally program evaluation.
A single questionnaire was designed for clinicians of all 16 disciplines serving in the NHSC loan repayment program in 2010. Items were drawn from questionnaires that two of the authors (Pathman and Konrad) have refined and reported in previous studies of clinicians both with and without service commitments who worked in rural, urban, underserved, and nonunderserved areas.10,20-23 The questionnaire incorporated validated items querying clinicians' satisfaction with various dimensions of their work, drawn from the Physician Worklife Study.24 Other items queried clinicians' demographics (age, sex, race, ethnicity, marital status), backgrounds (for example, the state and nature [rural, suburban, or urban] of the communities where clinicians were raised, and selected aspects of their training), characterization of clinicians' participation in the NHSC (for example, their reasons for joining the NHSC; if they were currently serving a renewal contract), and characteristics of clinicians' work in their first NHSC site (for example, number of patients seen per day; on-call responsibilities). Most items from the 2011 survey questionnaire used in the current PA and NP report were multiple choice, including some with 5-point Likert-formatted response options to report levels of satisfaction and agreement with positive statements about practices and communities. The questionnaire was reviewed and modestly amended by BCRS staff, principally to verify that it addressed issues of importance to the NHSC.
From August 2011 through January 2012, the sampled clinicians of all disciplines were e-mailed a survey invitation with a link to the online questionnaire. For the 4% of the overall (all disciplines) 2010 sample whose messages were returned due to inaccurate e-mail addresses, project staff searched for new e-mail addresses; when no new e-mail addresses were found, hard-copy questionnaires were mailed to clinicians' street addresses as reported in the BMISS file. Subjects reached by e-mail could also request hard-copy questionnaires. Up to six e-mail invitations were sent.
The invitation e-mail message and mailed cover letter stated that the study was being conducted by researchers of the University of North Carolina at Chapel Hill and Quality Resources Systems, Inc., for the purpose of helping the NHSC better understand the experiences of its participating clinicians and to maximize retention. Anonymity of responses was promised.
Analysis consists of response numbers, proportions, and means for the PA and NP groups. Group comparisons were made with chi-square and t-tests. For ease of presentation, all Likert-scaled items were dichotomized into “agree” and “strongly agree” versus “neutral,” “disagree,” and “strongly disagree.” All descriptive and comparative analyses conducted and displayed here were reweighted to account for group sampling probabilities and response rates. A P value of statistical significance was set at 0.05, and group differences below 0.10 are noted as “tending” to differ. All analyses were carried out with SPSS 18.0 statistical software (PASW Statistics, Hong Kong).
A total of 148 of the 287 (51.6%) surveyed PAs and 137 of the 257 (53.3%) surveyed NPs responded with near-complete data. The overall response rate was 52.4%, with a combined 285 respondents. Response rates varied across the six stratification groups (PA/NP x urban/rural/frontier) from 46% among frontier NPs to 60% among urban NPs.
Item non-response rates were less than 3.5% for all Likert-scaled items, and for items addressing clinicians' backgrounds and characteristics of their service sites and work. Non-response was higher for some clinician demographics (sex, 6%; race, 7%; age, 17%), salary (7%), and whether clinicians planned to renew their NHSC contracts (14%). Missing values were not imputed.
In analyses weighted to reflect each profession as a whole in the NHSC, PAs were younger than NPs (mean age, 31 versus 35 years, respectively, P<0.001) (Table 1). Twice as many PAs than NPs were under age 30 years (41.0% versus 20.2%, respectively). Although both disciplines were predominantly female, there were comparatively more male PAs than NPs (32% versus 9% male, P<0.001). Both groups were predominantly non-Hispanic white in race/ethnicity (76.4% versus 81.2%) and married (86% versus 80.1%). Fewer than one in six clinicians or spouses of both discipline groups were from rural backgrounds. About half of both groups reported that during their training they had moderate-to-extensive exposure to community and migrant health centers, rural healthcare, and inner city healthcare for the poor.
NHSC loan repayment program participation
Far greater proportions of PAs than NPs reported debt levels at graduation of more than $100,000 (55.5% versus 23.9%) and far fewer reported debt levels under $65,000 (10.2% versus 50.0%) (P<0.001) (Table 2). As might be expected for a clinician group with greater debt, PAs tended to commit for NHSC loan repayment sooner after graduation than NPs (P=0.053), tended more often to be serving renewed (for example, second or third) contracts with the NHSC when surveyed (17.4% versus 6.9%, P=0.07), and if they were serving their first contract were more likely planning to renew their contracts (60.8% versus 39.8%, P=0.002). Perhaps relatedly, PAs tended more often than NPs to rate “needing assistance to repay educational debt” higher than “wanting to provide care to the underserved” among reasons they joined the NHSC loan repayment program (37.7% versus 27.1%, P=0.057).
The vast majority of PAs and NPs had been working in their service site practices when they applied for the NHSC loan repayment program (86.1% and 93.1%, respectively). Most were aware that their practices might qualify for loan repayment when they chose to work there (73.7% and 60.6%, P=0.03).
Most of these NHSC PAs and NPs were serving in states where they had either grown up or graduated from professional school (74.5% and 81.9%, P=0.12). Among PAs and NPs who were married, about half the spouses had lived in the clinician's service state (46.7% and 52.9%, P=0.37) (Table 3).
Among subjective measures of clinicians' and their families' fit with their service communities, ratings were generally high (Table 3). Two-thirds or more of both groups agreed with positive statements about feeling that they belong to their communities, that their spouses and their children were happy, and that their children had satisfactory educational opportunities; only one in five were concerned about safety in their communities. The substantial majority of both discipline groups reported that their children were happy in the community, with rates higher among PAs (90.9% versus 75.3%, P=0.02).
Only the lack of local professional opportunities for spouses was a problem for significant numbers of respondents. About half of PAs and NPs indicated that there were enough opportunities available for their spouses.
NHSC service sites and work
The PAs and NPs in the NHSC served in comparable settings and reported similar content of work (Table 4). About 40% of both groups worked in rural areas, as so-designated in the NHSC files. About half of both groups worked in community and migrant health centers, with decreasing numbers working in rural health clinics, other primary care practices, and prisons. Both groups reported an average clinical workload of about 20 patients per day, almost half of each group had on-call responsibilities, and more than half of each group taught students at their NHSC sites. Salaries within their NHSC sites were also comparable between the two; median annual starting salaries ranged between $70,000 and $79,900 (2010 dollars).
Work, practices, and colleagues
As a group, PAs and NPs were satisfied on most measures of their practices (Figures 1 and 2). When rating satisfaction directly (Figure 1), the two groups reported greatest satisfaction with the support they received from other clinicians and the practice's goals and mission. Collectively they reported least satisfaction with their salaries and their relationships with their practice administrators. When satisfaction was addressed through positive statements about various aspects of practices, work, and relationships (Figure 2), the greatest proportions of the PA and NP groups agreed that they were doing important work, were able to provide a full range of services for which they were trained, had strong personal connections to patients, and were pleased overall with their work. On the other hand, fewer PAs and NPs agreed that work rarely encroached upon their personal time and that their practice administrator was effective.
Comparing the two groups, PAs provided statistically and significantly higher satisfaction ratings than NPs on three of the six items: salaries, cross-coverage availability, and support from other clinicians. Similarly, in comparing proportions that agreed with positive statements about service sites and communities, statistically greater proportions of PAs than NPs agreed that they had good clinical backup from senior and supervising clinicians, and that they could provide a full range of services. PAs also tended more often to report overall satisfaction with their practices than NPs.
When the NHSC was inaugurated in 1970, the PA and NP movements were in their infancy.25,26 That PAs and NPs (along with CNMs) were included suggests their roles within primary care systems and their growth in numbers were anticipated. Indeed, between 1990 and 2012, the number of physicians in the United States increased by 50%, but the combined PA and NP workforce grew 500%.27 Where and how PAs and NPs are dispersed geographically remains important, given persistent pockets of physician scarcity within many communities. With the Affordable Care Act reshaping access to care for many economically disadvantaged people, by most accounts PAs and NPs are playing increasing roles in access to primary care services. 28 Their combined numbers are anticipated to grow again by half by 2025.29-31
The roles of PAs and NPs in the NHSC have been underreported and largely overlooked. This report provides a keyhole view comparison of these two groups, as well as information on how they interpret their roles and lives while serving in the NHSC's loan repayment program. We find in the aggregate, both groups are predominantly female, married, and from urban and suburban backgrounds, but differ in that PAs are 4 years younger on average. The younger age of PAs within the NHSC mirrors the younger age of the PA workforce generally relative to NPs in the United States, and the younger age at which PAs generally complete their training.29,32 The typical educational path for PAs is to complete an undergraduate degree and then soon thereafter complete the 2 years of PA training. In contrast, many NPs work as registered nurses for some period before commencing NP training. The fact that NP students often work before and while completing their training may account for their lower educational debt reported in this study.
Carrying greater debt may explain why this study's PAs were more likely than NPs to be serving a second NHSC contract when surveyed and also more likely to be anticipating another NHSC contract in the future. Two or even 4 years participation in the NHSC will not be enough to repay the educational debt of the 55.5% of this study's PAs who owed more than $100,000. Higher educational debt may explain why more PAs than NPs rated the NHSC's financial benefits higher than the opportunity the NHSC provides to work with the underserved as reasons they joined the NHSC.
Working in familiar locations is one measure of a clinician's match or fit to the community where he or she works.33 Unlike the 1990s, when many NHSC clinicians served in its scholarship program, three out of four of this study's PAs and NPs in the NHSC loan repayment program were serving in the same states where they had grown up and/or trained.9 Half of those who were married served in states where their spouses had grown up. Fewer clinicians participating in the NHSC in the 1980s and 1990s served in states familiar to them.9 Reassuringly, both PAs and NPs serving in 2010 generally indicated that their communities met their families' needs, although spouses of about half the survey respondents reported that they could not find adequate employment opportunities locally. To our knowledge, the NHSC has not assisted spouses with their employment needs, which would address one reason why some families relocate after NHSC contracts are fulfilled.19
Three-quarters of this study's representative sample of NHSC PAs and NPs worked in community health centers and rural health centers, which are the NHSC's principal service sites for clinicians generally. Measures of work within these and other types of sites—daily patient encounter numbers, on-call participation, and involvement in teaching—also were comparable for the two disciplines.
The PA and NP cohorts were similar in the aspects of their practice they found most and least satisfying. Like other NHSC disciplines in 2010 and previously, these PAs and NPs felt rewarded through the important work they did and the patients they served, and were satisfied overall with their work.10,19 Both groups were also least satisfied with work's encroachment on their personal lives, with their practice administrators, and with their incomes.10 Comparing the two groups, satisfaction was more common among PAs than NPs on 13 of the 14 aspects of work, with differences statistically significant for six measures. The last comprehensive evaluation of the NHSC similarly found that more PAs than NPs serving in 1998 reported being satisfied overall with their jobs.9 A systematic review of 29 studies on PA job satisfaction finds almost without exception that PAs are satisfied with their employment.34 Although this study did not have the statistical power (enough cases) to identify possible reasons why the groups differ in their satisfaction, the greater proportion of men, younger age, greater debt, and in some cases different priorities for joining the NHSC may be significant factors deserving more exploration.
Although this study's data are drawn from a survey with a greater than 50% response rate—considered good for clinician surveys—nearly half did not respond, which leaves open the possibility of nonresponse bias. Second, this study was powered to compare the PA and NP groups but did not provide enough subjects to support further analyses to explore possible reasons for between-group differences in outcomes. Lastly, NHSC clinicians serving in 2010 were generally recruited during the NHSC's unprecedented growth from 2009 through 2011 under the American Recovery and Reinvestment Act (known as the stimulus), when the NHSC's clinician and site eligibility and selection processes were significantly modified to handle rapid growth.35 The people, sites, and experiences of clinicians now serving in NHSC may be different because they generally entered service after 2011, when the NHSC's operations returned to prestimulus approaches.
Including PAs and NPs in the NHSC 40 years ago, in retrospect, was a bold policy enacted at a time of limited information about their overall deployment and their place within the primary healthcare system. This study finds that PAs recently serving in the NHSC, compared with NPs, were younger, more often male, carried greater debt, and placed greater value on the financial benefits of NHSC participation. The groups were similar in the types of practices and their roles where they worked, and both demonstrated generally good fit with their communities. The two groups were also similar in the aspects of their work and practice that they found satisfying and the aspects they found less satisfying, but PAs reported generally higher satisfaction levels for reasons not yet assessed. To improve the NHSC experience for PAs and NPs, the NHSC could look for ways to help practices shape work so that it interferes less with personal lives, strengthen relationships with their site administrators, and guarantee that pay and benefits are comparable with PAs and NPs not in the NHSC. The NHSC might adapt its assistance for the two groups to account for PAs being younger and more often male, and NPs being older and perhaps more experienced as clinicians. Reasons for the somewhat lower satisfaction of the NHSC's NPs should be identified and addressed. Additional topics to be learned about PAs and NPs within the NHSC include their retention and ways it can be maximized, and ways the NHSC can best support each group as they serve.
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Keywords:© 2014 American Academy of Physician Assistants.
physician assistant; nurse practitioner; National Health Service Corps; loan repayment; educational debt; underserved