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• W4248506009 abstract "We always overestimate the change that will occur in the next two years and underestimate the change that will occur in the next ten. Don’t let yourself be lulled into inaction. —Bill Gates The annual National Council of State Boards of Nursing (NCSBN) Environmental Scan provides regulators and other nursing leaders with a current, comprehensive portrait of nursing in the United States, including emerging issues and challenges. It describes the current state of nursing and where we are headed, and it asks questions about our readiness to enter the modernized era of health care. As you are reading it, ask yourself: Are we ready to take nursing to the next level? Are educators ready to evaluate their curricula and incorporate new content? Are regulators ready to accept present and future challenges of mobility, workforce, confidentiality issues, new treatment methods, advancements in scope of practice, and, potentially, fresh approaches to opioid addiction? Are state legislators willing to take the necessary steps to pass legislation to modernize regulation and to be an important part of this transformation? Modernization of health care cannot adequately be achieved without the participation of nursing, and a new era of nursing depends on a contemporary and revitalized regulatory system. The environmental scan is present and future based and reflects substantial professional, social, and political changes needed for regulators and other nursing leaders to keep pace with potential health care system transformations. Nursing is at the heart of health care. Sufficient numbers of nurses at all levels and the ability to forecast and plan for shortages is integral to safe and quality patient care. For this reason, NCSBN has acted to ensure that researchers have the data required to monitor future workforce needs. In 2017, NCSBN collaborated with the National Forum of State Nursing Workforce Centers to conduct a national workforce study to assess and describe the current RN and LPN workforce (in press). The findings data will be published in the July 2018 issue of the Journal of Nursing Regulation. Individual boards of nursing (BONs) are also collecting workforce data with licensure renewals, which are being deposited into NCSBN’s National Nursing Workforce Repository. When all boards can provide these data, nursing will have a profound and accurate database, including population data, with which to analyze the workforce and make predictions. It is expected that 2018 will be a historic and landmark year for nursing regulation and the nursing workforce. The enhanced Nurse Licensure Compact (eNLC), nursing regulation’s newest licensure model, was officially implemented on January 19, 2018. Currently adopted by 29 states, the eNLC enables nurses to receive a multistate license in their state of residence with the privilege to practice in all other states that joined the compact. The eNLC increases public protection as it: (a) mandates specific nursing licensure requirements for participating states; (b) provides improved access to care through greater workforce mobility, allowing nurses to migrate to locations with the greatest need and job availability; (c) enhances telehealth nursing, which can expand the workforce into shortage areas; and, (d) perhaps most importantly, mobilizes nursing care quickly, efficiently, and safely during a disaster. For military spouses who are nurses and who may have to frequently move and change jobs, the eNLC offers an opportunity for many to move without being relicensed. In addition, nurses with compact/multistate licenses have the flexibility to care for patients across state borders without the time and expense of obtaining additional licenses. In 2018 and beyond, workforce mobility will be vital for patients’ access to care and nurses’ access to jobs as studies predict both shortages and surpluses in the nursing workforce. Currently, the number of employed registered nurses (RNs) per population in each state varies widely, from fewer than 700 RNs per 100,000 population in Nevada to over 1,500 RNs per 100,000 in the District of Columbia (United States Department of Labor, Bureau of Labor Statistics, 2017aUnited States Department of Labor, Bureau of Labor Statistics Occupational employment statistics, May 2016.https://www.bls.gov/oes/current/oes291141.htmDate: 2017Google Scholar; United States Census Bureau, 2017United States Census Bureau National population totals tables: 2010-2016.https://www.census.gov/data/tables/2016/demo/popest/nation-total.htmlDate: 2017Google Scholar). Other states with approximately 700 RNs per 100,000 people are California, Georgia, Oklahoma, and Utah. Conversely, South Dakota (1,402 per 100,000), Massachusetts (1,250 per 100,000), and Delaware (1,189 per 100,000) have the highest ratios of employed RNs per population along with the District of Columbia. Appendix B provides a detailed portrayal of the distribution of RNs and licensed practical nurses/vocational nurses (LPNs/VNs) across the country. The ratio of employed LPNs/VNs is between 65 and 70 per 100,000 people in Alaska, Oregon, and Utah and over 400 per 100,000 in Arkansas and Louisiana (United States Department of Labor, Bureau of Labor Statistics, 2017aUnited States Department of Labor, Bureau of Labor Statistics Occupational employment statistics, May 2016.https://www.bls.gov/oes/current/oes291141.htmDate: 2017Google Scholar; United States Census Bureau, 2017United States Census Bureau National population totals tables: 2010-2016.https://www.census.gov/data/tables/2016/demo/popest/nation-total.htmlDate: 2017Google Scholar). States with shortages include Maine and most of the western states except for California, which has slightly more VNs per 100,000 population than its neighboring states. (Figure 1 provides a broad comparison of the numbers of RNs and LPNs across the country.) A number of studies published in 2017 indicated that the nursing workforce needs will continue to fluctuate according to state and region of the country. In 2017, the Health Resources and Services Administration (HRSA) released national projections for the U.S. nursing workforce through 2030 (HRSA, 2017a). Projections made from the Health Workforce Microsimulation Model used nurse data from the American Community Survey along with information reflecting the economy and labor markets. The model estimated the growth in RN supply (39%) will outpace the growth in RN demand (28%) by 2030 resulting in an excess of almost 300,000 RNs nationally. For LPNs, the growth in supply is estimated to be 26% while the growth in demand is expected to be 44%. This imbalance could result in national-level shortage of 151,000 LPNs by 2030; however, the report indicates a shortage of this magnitude is unlikely because LPNs can be educated relatively quickly. According to the HRSA report (2017) inequitable distributions of nurses exist across states. Seven states are projected to have a RN shortage, and 33 states are projected to have a LPN shortage by 2030. The greatest shortages of RNs are predicted in California, Texas, New Jersey, and South Carolina. Texas and Pennsylvania are expected to have the greatest LPN shortages. Florida, Ohio, Virginia, and New York could expect a surplus of RNs. A LPN surplus is projected for Ohio and California. HRSA’s proposed solution is optimal migration (i.e., nurses moving to states where the in-state supply is less than demand). Thus, nurses would move to or work in areas of greater need. The distribution of the nursing workforce is likely to improve as more states join the eNLC. Buerhaus et al., 2017Buerhaus P.I. Skinner L.E. Auerbach D.I. Staiger D.O. Four challenges facing the nursing workforce in the United States.Journal of Nursing Regulation. 2017, July; 8: 40-46Abstract Full Text Full Text PDF Scopus (73) Google Scholar identified four factors affecting the supply and demand of U.S. nurses in the future: (a) aging baby boomers, (b) the number of nurses retiring, (c) health care reform, and (d) the physician shortage. They also forecast regional shortages, rather than a national shortage. The aging baby boomers may exceed both the clinical capacity of the nursing workforce and the number of new graduates with geriatric expertise. The rate at which RNs retire from the workforce could reduce the number of nurses available, particularly in the New England and Pacific Regions (where the number of RNs per capita is lowest), as well as decrease the overall experience level of the workforce. Changes to the Patient Protection and Affordable Care Act (ACA, 2010), such as provisions to increase efficiency and a shift toward value-based purchasing, could result in greater recognition of the cost efficiency of nurses and the expanded roles of RNs in Medicare accountable care organizations. Finally, the physician shortage (Streeter et al., 2017Streeter R.A. Zangaro G.A. Chattopadhyay A. Perspectives: Using Results from HRSA’s Health Workforce Simulation Model to Examine the Geography of Primary Care.Health Services Research. 2017; 52: 481-507Crossref PubMed Scopus (27) Google Scholar) is likely to increase demand for nurses providing primary care, particularly to rural and vulnerable populations. As of November 23, 2017, the U.S. workforce consisted of 4,015,250 RNs and 922,196 LPNs/VNs *Data regarding all Oklahoma and Hawaii nurses and LPNs/VNs in Louisiana were unavailable and are not included. (National Council of State Boards of Nursing (NCSBN), 2017eNational Council of State Boards of Nursing (NCSBN) The National Nursing Database: A profile of nursing licensure in the US.https://www.ncsbn.org/national-nursing-database.htmDate: 2017Google Scholar). Of these, 2,857,180 RNs and 702,400 LPNs/VNs were employed in the United States as of May 2016, the most recent statistics available (United States Department of Labor, Bureau of Labor Statistics, 2017aUnited States Department of Labor, Bureau of Labor Statistics Occupational employment statistics, May 2016.https://www.bls.gov/oes/current/oes291141.htmDate: 2017Google Scholar). Although employment data are not as recent as licensing data, they show that the number of employed RNs in the United States has steadily increased since 2012 (Figure 2a), whereas the number of employed LPN/VNs, despite a slight rise from 2014 to 2016, has decreased substantially since 2012 (Figure 2b). The predominant employers of RNs and LPNs/VNs will be hospitals and long-term care facilities, respectively. According to the most recent data from the U.S. Department of Labor, Bureau of Labor Statistics, RNs held an estimated 3 million jobs in the United States in 2016. Of those, 61% were in hospitals. Hospitals were followed by ambulatory health services (18%), nursing and residential facilities (7%), government facilities (5%), and educational services (3%). The same data showed that LPNs/VNs held approximately 724,500 jobs in 2016. The largest employers of these nurses were nursing and residential care facilities (38%), hospitals (16%), physician offices (13%), home health care services (12%), and government facilities (7%) (United States Department of Labor, Bureau of Labor Statistics, 2017aUnited States Department of Labor, Bureau of Labor Statistics Occupational employment statistics, May 2016.https://www.bls.gov/oes/current/oes291141.htmDate: 2017Google Scholar). It is anticipated that a greater proportion of nursing employment will be seen in ambulatory and home care settings as health care shifts to those settings (Bauer and Bodenheimer, 2017Bauer L. Bodenheimer T. Expanded roles of registered nurses in primary care delivery of the future.Nursing Outlook. 2017; 65: 624-632Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar). In fact, Bauer and Bodenheimer, 2017Bauer L. Bodenheimer T. Expanded roles of registered nurses in primary care delivery of the future.Nursing Outlook. 2017; 65: 624-632Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar predict a dramatic shift in the RN role in primary care as the demand for primary care providers and services increases alongside payment models that allow for add-on payments for RN-delivered services in primary care settings. As primary care practices use team models to greater extent, the scope of RNs in primary care will include managing chronic disease, leading complex care management teams, and coordinating care between the primary care practice and communities (Bauer and Bodenheimer, 2017Bauer L. Bodenheimer T. Expanded roles of registered nurses in primary care delivery of the future.Nursing Outlook. 2017; 65: 624-632Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar). As new health care models move care into the community setting and as the need for providers in rural and health shortage areas increases, some RN and LPN responsibilities may be provided by nonnursing personnel such as community health workers (CHWs). As of May 2016, 51,900 CHWs were working in the United States, with the highest levels of employment in individual and family services, local government, outpatient care centers, general medical and surgical hospitals, and physician offices (United States Department of Labor, Bureau of Labor Statistics, 2017cUnited States Department of Labor, Bureau of Labor Statistics Occupational outlook handbook, community health workers.https://www.bls.gov/oes/current/oes211094.htm#indDate: 2017Google Scholar). Figure 3 depicts employment of CHWs by state. States with the highest employment of CHWs include California, New York, Texas, Massachusetts, and Illinois (United States Department of Labor, Bureau of Labor Statistics, 2017cUnited States Department of Labor, Bureau of Labor Statistics Occupational outlook handbook, community health workers.https://www.bls.gov/oes/current/oes211094.htm#indDate: 2017Google Scholar). CHWs differ from home health aides, who may assist with activities of daily living, and from certified nurse assistants (CNAs), who may assist in carrying out a nursing plan of care. Community health workers are often part of the patient’s community and usually share the language, ethnicity, and life experiences of their patients. This commonality helps them be uniquely valued by both the patient and the health care team (Rural Health Information Hub, 2017Rural Health Information Hub Community health workers in rural settings.https://www.ruralhealthinfo.org/topics/community-health-workersDate: 2017Google Scholar). In 2017, CHWs gained federal recognition for their ability to help address social determinants of health (Malcarney et al., 2017Malcarney M.B. Pittman P. Quigley L. Horton K. Seiler N. The changing roles of community health workers.Health Services Research. 2017; 52: 360-382Crossref PubMed Scopus (72) Google Scholar). CHWs are more likely to have “linguistic and cultural concordance” with their patients, which contributes to their effectiveness in reaching underserved communities and addressing health disparities (Malcarney et al., 2017Malcarney M.B. Pittman P. Quigley L. Horton K. Seiler N. The changing roles of community health workers.Health Services Research. 2017; 52: 360-382Crossref PubMed Scopus (72) Google Scholar; Chapman and Blash, 2017Chapman S.A. Blash L.K. New roles for medical assistants in innovative primary care practices.Health Services Research. 2017; 52: 383-406Crossref PubMed Scopus (60) Google Scholar). Job responsibilities for CHWs often include home visits, follow-up after acute care discharge, monitoring chronic diseases, and educating patients in the management of their conditions. They also act as specialists who educate the community on best practices for specific conditions, provide outreach and convene disparate stakeholders to coordinate a targeted outreach effort. Typical competencies for CHWs include patient advocacy, documentation, understanding legal and ethical boundaries, healthy living interventions, and collaboration with other team members such as nurse case managers and social workers (Larson, 2016Larson L. Bringing it home with community health workers.in: Hospitals & Health Networks. 2016, Junehttps://www.hhnmag.com/articles/7235-how-community-health-workers-can-improve-patient-outcomeskGoogle Scholar). Evolving care models and innovative trials of new models place the CHW in several health team configurations. They may be involved in health screening outreach, care team navigation, and community advocacy. CHWs may also be part of the “pathways” model that targets patients most at risk and directs the care team to focus on specific strategies likely to improve outcomes. Disease-specific models incorporating the CHW include asthma, diabetes, HIV/AIDS, hypertension, and maternal/child health. CHWs can assist with goal setting, culturally competent patient education, transportation, and structured visits and support (Minnesota Department of Health, 2016Minnesota Department of Health Community health workers: A review of the literature.http://www.health.state.mn.us/divs/orhpc/workforce/emerging/toolkit/chwlit2016c.pdfDate: 2016Google Scholar). The addition of CHWs is occurring across various health settings. For example, a study on CHWs found a “shift in CHW employment settings from community-based organizations to hospitals and health systems that hire them directly” (Malcarney et al., 2017Malcarney M.B. Pittman P. Quigley L. Horton K. Seiler N. The changing roles of community health workers.Health Services Research. 2017; 52: 360-382Crossref PubMed Scopus (72) Google Scholar). Few studies have suggested role independence. The preponderance of recent studies suggests CHW roles are well suited to round out team-based care solutions and bridge the patient’s life experiences to the planning and strategies of the larger health team (Guerra Luz, 2017Guerra Luz A. Community health workers emerging as bridge between at risk communities and healthcare.Milwaukee Sentinel Journal. 2017, August 4; https://www.jsonline.com/story/money/2017/08/04/community-health-workers-offer-bridge-health-low-income-areas/529253001/Google Scholar). Further study is needed to determine if CHWs enhance team-based outcomes and interventions. States are increasingly using emergency medicine technicians (EMTs) and paramedics to provide cost-effective, nonemergency and preventive health services to communities (Miller, 2017Miller D. States using emergency medical techs to expand health care services.http://knowledgecenter.csg.org/kc/content/states-using-emergency-medical-techs-expand-health-care-servicesDate: 2017Google Scholar). The community paramedicine (CP) model of care allows EMTs and paramedics to practice beyond their traditional emergency-response roles. CP programs are designed to integrate with existing health care resources (Innovative California community paramedicine project shows early success, 2017Innovative California community paramedicine project shows early success Journal of Emergency Medical Service.http://www.jems.com/articles/news/2017/05/innovative-california-community-paramedicine-project-shows-early-success.htmlDate: 2017, May 26Google Scholar) and use specially trained community paramedics who have typically completed 200 extra hours of study (Sequeira, 2017Sequeira M. Community Paramedicine: Bridging the gaps in healthcare delivery.https://www.vituity.com/blog/community-paramedicine-bridging-the-gaps-in-healthcare-deliveryDate: 2017Google Scholar). CP programs currently operate in 33 states and the District of Columbia (Coffman et al., 2017Coffman J.M. Wides C. Niedzwiecki M. Geyn I. Evaluation of California’s community paramedicine pilot program.https://healthforce.ucsf.edu/publications/evaluation-california-s-community-paramedicine-pilot-programDate: 2017Google Scholar) and are being piloted in several states including California, Colorado, Maine, Minnesota, North Carolina, and Texas (Sequeira, 2017Sequeira M. Community Paramedicine: Bridging the gaps in healthcare delivery.https://www.vituity.com/blog/community-paramedicine-bridging-the-gaps-in-healthcare-deliveryDate: 2017Google Scholar). The expanding roles of EMTs and paramedics may help reduce the amount of emergency department (ED) visits (Fotsch, 2015Fotsch R. Policy perspectives.Journal of Nursing Regulation. 2015; 6: 57-58Abstract Full Text Full Text PDF Scopus (3) Google Scholar), avoid unnecessary ambulance transports, reduce hospitalizations and readmissions (O’meara et al., 2017O’meara P.F. Furness S. Gleeson R. Educating paramedics for the future: a holistic approach.Journal of Health and Human Services Administration. 2017; 40Google Scholar), and create greater access to quality care for rural populations (Allison et al., 2017Allison G. Macphee C. Noulett H. Violence prevention exercises: Enhancing safety through simulation training.Canadian Nurse. 2017; 113: 36-38Google Scholar). A recent independent study evaluated 13 CP programs being piloted in California (Innovative California community paramedicine project shows early success, 2017Innovative California community paramedicine project shows early success Journal of Emergency Medical Service.http://www.jems.com/articles/news/2017/05/innovative-california-community-paramedicine-project-shows-early-success.htmlDate: 2017, May 26Google Scholar). The San Diego program saved $45,607 per month in health care costs, reduced the number of 911 calls (by frequent 911 callers) by 52%, and connected patients to more appropriate medical and social services (Coffman et al., 2017Coffman J.M. Wides C. Niedzwiecki M. Geyn I. Evaluation of California’s community paramedicine pilot program.https://healthforce.ucsf.edu/publications/evaluation-california-s-community-paramedicine-pilot-programDate: 2017Google Scholar). Cost savings and improved clinical outcomes have also been reported in Colorado, Nevada, New York, and Texas (Bennett et al., 2017Bennett K.J. Yuen M.W. Merrell M.A. Community paramedicine applied in a rural community. [Epub ahead of print March 23, 2017].The Journal of Rural Health. 2017; https://doi.org/10.1111/jrh.12233Crossref Scopus (32) Google Scholar). As with any emerging role, CP programs face implementation challenges. In many cases, payers may not reimburse CP programs for non–transport related emergency medical services (EMS) (Bennett et al., 2017Bennett K.J. Yuen M.W. Merrell M.A. Community paramedicine applied in a rural community. [Epub ahead of print March 23, 2017].The Journal of Rural Health. 2017; https://doi.org/10.1111/jrh.12233Crossref Scopus (32) Google Scholar) and training programs lack a consistent set of standards (Glenn et al., 2017Glenn M. Zoph O. Weidenaar K. Barraza L. Greco W. Jenkins K. Fisher J. State regulation of community paramedicine programs: A national analysis.Prehospital Emergency Care. 2017; : 1-8Google Scholar). Although pilot studies have been promising, such evaluations often do not include a comparison group to solidify the evidence (Bennett et al., 2017Bennett K.J. Yuen M.W. Merrell M.A. Community paramedicine applied in a rural community. [Epub ahead of print March 23, 2017].The Journal of Rural Health. 2017; https://doi.org/10.1111/jrh.12233Crossref Scopus (32) Google Scholar). CP programs face legislative challenges as well. Only seven states have laws specific to CP scope of practice (Glenn et al., 2017Glenn M. Zoph O. Weidenaar K. Barraza L. Greco W. Jenkins K. Fisher J. State regulation of community paramedicine programs: A national analysis.Prehospital Emergency Care. 2017; : 1-8Google Scholar), and existing legislation often prevents EMTs from engaging in activities beyond emergency response (National Association of Emergency Technicians, 2017). As community paramedics find their role in the interdisciplinary team, CP programs must be mindful of scope-of-practice conflicts that may occur with other health professions (Fotsch, 2015Fotsch R. Policy perspectives.Journal of Nursing Regulation. 2015; 6: 57-58Abstract Full Text Full Text PDF Scopus (3) Google Scholar; National Conference of State Legislatures, 2017aNational Conference of State Legislatures Beyond 911: State and community strategies for expanding the role of first responders.http://www.ncsl.org/research/health/expanding-the-primary-care-role-of-first-responder.aspxDate: 2017Google Scholar). On the other end of the spectrum, legislation in some states is contributing to the blurring of scope of practice lines concerning health care professions such as EMS workers and paramedics. In 2017, for example, Illinois became one of a small but growing number of states that allows EMS personnel to administer Schedule II through Schedule V controlled substances without the order of a prescriber (Ill. Legis. HB3910. Reg. Sess. 2016–2017, 2017bIll. Legis. HB3910. Reg. Sess. 2016–2017 http://www.ilga.gov/legislation/publicacts/100/100-0280.htmDate: 2017Google Scholar). Currently, the EMS community is working on a 2-year project called EMS Agenda 2050­–with a mission to write a new EMS Agenda for the Future. The project’s Technical Expert Panel has provided numerous opportunities for stakeholders as well as the public to engage in agenda development (EMS Agenda 2050, 2017EMS Agenda 2050 About the project.http://emsagenda2050.org/about-the-project/Date: 2017Google Scholar). The landmark EMS Agenda for the Future (1996) envisioned EMS as community-based entities with expanded roles contributing directly to population health outcomes (Bennett et al., 2017Bennett K.J. Yuen M.W. Merrell M.A. Community paramedicine applied in a rural community. [Epub ahead of print March 23, 2017].The Journal of Rural Health. 2017; https://doi.org/10.1111/jrh.12233Crossref Scopus (32) Google Scholar). Due to the changing landscape of U.S. health care systems, this 20-year-old vision will continue to adapt. Evidence suggests both CHWs and community paramedics fill valuable and much-needed roles in the interdisciplinary health care team by providing care planning, patient education, and health care cost reduction in a culturally competent manner, particularly in underserved areas (National Conference of State Legislatures, 2017aNational Conference of State Legislatures Beyond 911: State and community strategies for expanding the role of first responders.http://www.ncsl.org/research/health/expanding-the-primary-care-role-of-first-responder.aspxDate: 2017Google Scholar). Questions regarding oversight and role remain. It is important for nursing regulators to play an active part in role development and, possibly, regulation of these providers. The articulation of roles between these providers may need refining, along with decisions regarding certification, delegation, and oversight of multidisciplinary teams. This year marks the 10-year anniversary of the Consensus Model for APRN Regulation, Licensure, Accreditation, Certification and Education (The Consensus Model), and despite substantial advances, not all states have completely embraced it. Regulators have consistently advocated for the Consensus Model elements and, in 2018, an enhanced legislative effort will help states adopt it. This strong advocacy is based on profound evidence that advanced practice registered nurses (APRNs) are a key part to solving the nation’s access-to-care crisis. HRSA’s health workforce simulation model (based on 2013 data) examined the geography of primary care in 2025 and made the following national-level projections: the United States will experience a shortage of primary care physicians by 2025 (−9% of 2025 demand) and a surplus of primary care certified nurse practitioners (CNPs) in 2025 (62% of 2025 demand) (Streeter et al., 2017Streeter R.A. Zangaro G.A. Chattopadhyay A. Perspectives: Using Results from HRSA’s Health Workforce Simulation Model to Examine the Geography of Primary Care.Health Services Research. 2017; 52: 481-507Crossref PubMed Scopus (27) Google Scholar). The authors noted that, in the 37 states with provider shortages in 2013, 27 states restricted CNP practice. They also estimated that if CNP scope of practice remains unchanged, CNPs will have restricted scopes of practice in over half the states that are projected to have a shortage of at least one type of primary care provider in 2025 (Streeter et al., 2017Streeter R.A. Zangaro G.A. Chattopadhyay A. Perspectives: Using Results from HRSA’s Health Workforce Simulation Model to Examine the Geography of Primary Care.Health Services Research. 2017; 52: 481-507Crossref PubMed Scopus (27) Google Scholar). The removal of restrictions on APRNs has far-reaching implications for many of the nation’s health care challenges. The U.S. rate of maternal deaths, for example, has increased over the past 15 years, resulting in the highest rate in the developed world, whereas other countries have a consistent downward trend (Martin and Montaigne, 2017Martin N. Montaigne R. U.S. has the worst rate of maternal deaths in the developed world.http://www.npr.org/2017/05/12/528098789/u-s-has-the-worst-rate-of-maternal-deaths-in-the-developed-worldDate: 2017Google Scholar). Across the U.S., 46% of counties do not have an obstetrician-gynecologist and 56% are without a certified nurse midwife (CNM) (Improving access to maternity care act: Hearing of the House Committee on Energy and Commerce Subcommittee on Health, House of Representatives, 114th Cong. 5, 2015Improving access to maternity care act: Hearing of the House Committee on Energy and Commerce Subcommittee on Health, House of Representatives, 114th Cong. 5 (2015).Google Scholar). Frequently, restrictions in prescribing authority, required collaborations, medical staff credentialing, and third-party reimbursement inhibit CNM practice in rural areas (Patterson et al., 2017Patterson E. Hastings-Tolsma M. Dunemn K. Callahan T.J. Tanner T. Nurse-Midwives on the front lines: Serving the rural and medically underserved.Journal of Nursing and Patient Care. 2017; 2: 2Google Scholar" @default.
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