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Maintaining a Stable AP Workforce

January 12, 2023

Mid-January 2023

Sandra Kurtin, PhD, ANP-C, AOCN

Sandra Kurtin, PhD, ANP-C, AOCN
Hematology/oncology nurse practitioner, assistant professor of clinical medicine, and adjunct clinical assistant professor of nursing at the University of Arizona in Tucson.



Burnout and resilience among health care professionals, including advanced practitioners (APs), remains one of the greatest challenges in health care today. Although most surveys of burnout in health care professionals have focused on physicians, surveys that include the broader interdisciplinary team provide insight into the strength and vulnerability of the entire team. The Association of Community Cancer Centers (ACCC) conducted a Mini Z burnout survey in 2019 and repeated it in 2022 (n=118). The greatest changes among APs and registered nurses indicated worsened stress, job satisfaction, burnout, control over workload, time for documentation, and general teamwork.1 In a 2017 study of physician assistants (PAs; n=250), burnout was reported by 34.8% of respondents who also cited emotional exhaustion (30.4%), high depersonalization (19.6%), and a low sense of personal accomplishment (19.6%).2

Priorities for maintaining a stable AP workforce include recruiting, onboarding, and mentoring new APs and implementing strategies to retain APs who are in clinical practice; however, finding APs with experience in hematology and oncology – or even experience as an AP – has become increasingly difficult. New hires, even those with some experience, require a comprehensive onboarding process, yet onboarding programs and processes vary widely across practices and institutions.

It can take up to a year for a new AP graduate without hematology or oncology experience to be fully productive, and expectations for time to productivity (ramp-up) must be better defined. There are currently no national benchmarks for APs in hematology and oncology, resulting in use of physician benchmarks.3 Fellowships that provide comprehensive specialty training for APs in hematology and oncology over a one-year period are being deployed by a number of large organizations to facilitate effective onboarding and retention of APs.4,5

As a result of the significant financial strain from the COVID-19 pandemic over the past three years, many organizations are re-evaluating productivity benchmarks for providers, including APs. Adding to the need for clear productivity benchmarks tailored to the AP in hematology and oncology is the recent update to the Centers for Medicare & Medicaid Services (CMS) guidelines for billing patient visits, which requires delineation and attestation of the percentage of time spent by physicians and APs to designate the billing provider in any shared visits.6 (ASH Clinical News will highlight the AP perspective on these new guidelines in an upcoming AP Voices column.) Collectively, this presents a challenge to AP leaders who are tasked with staffing a wide variety of outpatient and inpatient hematology and oncology settings.

Since 2019, the Advanced Practitioner Society of Hematology and Oncology (APSHO) has convened a leadership summit in conjunction with the annual meeting, JADPRO Live. The APSHO professional development and leadership committee plans the content for each summit based on input from committee members and the broader APSHO membership with consideration of national trends. The group includes APs employed in leadership roles with AP direct reports across a broad range of practice settings such as academic, community, hospital-based, and specialty clinics. Collectively, the 20 APs who participated in the 2022 summit manage more than 2,500 hematology/oncology APs across these settings. The 2022 summit focused on developing national benchmarks for AP productivity, implementing strategies for effective onboarding and retention of APs, and discussing how leaders can facilitate work-life balance, including for themselves.

A productivity, burnout, and work-life balance survey of APSHO members is underway and is expected to be published in 2023. Preliminary results confirm the presence of burnout and a lack of work-life balance among the 256 respondents thus far. Productivity metrics that adequately reflect the non-billable activities that APs conduct each day and that are necessary for patient triage, clinical management, and practice efficiency will be compiled to illustrate the need to better quantify the essential leadership role APs play in clinical workflows, the patient experience, and practice efficiency beyond billing individual patient visits.

APSHO has also deployed a survey to highlight national trends in AP compensation. These results are also planned to be published in early 2023. An ASH-sponsored focus group discussing optimizing collaboration between APs and physicians in hematology and oncology provided insight into some of the challenges clinicians face today. A follow-up survey of hematology and oncology APs in collaboration with APSHO and George Washington University has been deployed and will provide further insight into training and education, productivity, organizational support, and practice satisfaction for APs in hematology and oncology.7

Developing a national benchmark for productivity of hematology and oncology APs remains a primary goal for AP leaders. Training and retention of APs, including advocating for broader implementation of fellowship programs, empathetic engagement with staff, optimized workflows, and cultivation of new AP leaders were among other priorities identified during the APSHO leadership summit.

The AP leaders at the program acknowledge the challenge inherent in recruiting, training, nurturing, and maintaining an AP workforce in today’s health care environment. We look forward to the results from the surveys and continued collaboration with our interdisciplinary colleagues to stabilize the AP workforce, reduce burnout among APs, and cultivate a culture of empathy, collaboration, and innovation.

Sandra Kurtin, PhD, ANP-C, AOCN
Associate Editor


  1. Schmidtman B. Burnout in oncology: results from ACCC’s 2022 mini Z survey. November 8, 2022. Accessed December 12, 2022. https://www.accc-cancer.org/acccbuzz/blog-post-template/accc-buzz/2022/11/08/burnout-in-oncology-results-from-accc-s-2022-mini-z-survey.
  2. Raphael MJ, Fundytus A, Hopman WM, et al. Medical oncology job satisfaction: results of a global survey. Semin Oncol. 2019;46(1):73-82.
  3. Astrin J. Are current metrics adequate to demonstrate the value of oncology advanced practitioners? J Adv Pract Oncol. 2021;12(3):247-249.
  4. Hwa YL, Shelly JL, Zblewski DL, et al. Mayo Clinic hematology fellowship for advanced practice providers. J Adv Pract Oncol. 2020;11(4):395-400.
  5. Kramer JA, Valente CP. Development of a hematology-oncology advanced practice provider fellowship program. J Adv Pract Oncol. 2020;11(4):407-410.
  6. CMS.gov. Calendar year (CY) 2023 Medicare physician fee schedule proposed rule. July 7, 2022. Accessed December 12, 2022. https://www.cms.gov/newsroom/fact-sheets/calendar-year-​cy-2023-medicare-physician-fee-schedule-proposed-rule.
  7. Massenlink L, Erikson C. APP Survey in process. George Washington University; 2022.

The content of the Editor’s Corner is the opinion of the author and does not represent the official position of the American Society of Hematology unless so stated.

Have a comment about this editorial? Let us know what you think; we welcome your feedback. Email the editor your response, along with your full name and professional affiliation if you’d like us to consider publishing it, at ACNEditor@hematology.org.


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