Reid Ponte: Can you tell me about what brought you into the nursing profession?
Muench: I was born and raised in a small village near Bremen, Germany. During a high school summer program in the mid 1990s, I worked in a local hospital. During that experience, I became aware of the power differential between nurses and physicians. Nurses had little autonomy in their practice, and the hierarchical structure between nurses and physicians struck me as ineffective for patient care. I began thinking about whether patient care would be improved if nurses were recognized as equal players. It was evident to me that this would mean closing the educational gap between nurses and physicians. The dominant form of nursing education in Europe at the time was a diploma, offered through an apprenticeship model. I decided that I would not only become a bachelor of science in nursing (BSN) trained nurse myself but that I would continue my academic education to be able to answer questions such as whether higher education of nurses and better nurse-physician teamwork improve patient care. I did not know at the time that this was called nursing health services research.
Upon graduating from high school, I applied to Cambridge University in the United Kingdom (UK) to train as a nurse. The UK was one of few European countries that had moved nursing training from an apprenticeship model to a university-based model. I initially obtained a diploma, followed by a BSN degree. My BSN program thesis advisors knew how passionate I was about advancing the role of nurses, and she advised me to go to the U.S. for my graduate education. She also provided my 1st research opportunities, which I loved. I was admitted to the Women's Health advanced practice registered nurse (APRN) program at Yale and then continued in the Health Policy and Systems PhD program. My dissertation consisted of 3 empirical nursing workforce studies, and this is when I began examining the pay gap among female and male nurses as well as prescribing patterns of APRNs, which are both still research interests of mine. For my postdoctoral training, I was mentored by Peter Buerhaus, PhD, RN, FAAN, who was at Vanderbilt University at the time. Needless to say, I learned a great deal from Peter. He introduced me to the fun world of Medicare data, and he taught me Grant Management 101.
Reid Ponte: I have been aware of some of the data about the differences in earnings between male and female nurses across the nation and across specialty areas, but I do not know how significant it is. Can you provide a summary of the disparities?
Muench: We evaluated earnings of registered nurses (RNs) over 2 decades using nationally representative data from the American Community Survey (ACS) and the National Sample Survey of Nurses (NSSRN) and found that the unadjusted pay gap is approximately 10%. When we accounted for specialty areas, roles, years of experience, and other factors, the gap was still 5% and existed across all specialty areas and settings.1 This is about $5300/year per female nurse of unearned wages. These findings are generally unexplained.2
Reid Ponte: What is the main message to JONA readers you'd like to send given this information?
Muench: Review the hiring practices across your health system. There appears to be more discretion in salary determinations in ambulatory practice settings for instance, but hospital nurses in most settings are also affected.1 It is important to raise the awareness of gender inequalities in the pay of nurses. Nursing is a predominantly female profession, and pay differentials affect close to 3 million women. Over time, this can lead to gender disparities in living standards, including retirement. Health systems should consider open wage policies and using such policies to their advantage to attract staff.
Reid Ponte: I realize that you are currently working on several other workforce studies. Could you tell me about another study that you are leading at University of San Francisco (UCSF) School of Nursing?
Muench: For several years, I have been using Medicare data to study the prescribing patterns of APRNs.3,4 When the prescribing of opioids increasingly became a concern, especially in the primary care setting, I began thinking about the roles of APRNs in family practice and internal medicine in potentially mitigating the epidemic. APRNs write roughly one-third of all opioid prescriptions nationally, yet few studies have examined NP opioid prescribing practices. In 1 analysis, we discovered that APRNs prescribe fewer opioids than physicians but found that, when they do prescribe opioids, they prescribe higher dosages.5 So, it's really important that we conduct more research in this area to understand what drives these differences. For example, it is possible that APRNs take care of chronic pain patients more frequently than physicians?
Reid Ponte: What is your current funding source for this important work, and are there any other studies that you would like to mention?
Muench: We currently have a grant from the National Council of State Boards of Nursing that allows us to answer many of the opioid prescribing questions and also help us identify the role of scope of practice. I also lead a study that is examining the emerging role of APRNs and physician assistants (PAs) in the treatment of opioid use disorder, funded through the Clinical and Translational Science Institute (CTSI) at UCSF (grant number UL1 TR001872). We have too few providers who can prescribe medications for opioid use disorder. In 2016, the Comprehensive Addiction and Recovery Act (CARA)6 granted APRNs and PAs waivers. We are evaluating how this policy change affected uptake of buprenorphine prescribing by APRNs and PAs for Medicare beneficiaries.
Reid Ponte: I look forward to reading about the results of these and other studies. The role of APRNs is so critical to the health of the nation. What one thing would you like JONA readers to know?
Muench: In the midst of the coronavirus disease 2019 (COVID-19) pandemic, the important contributions of APRNs, as well as of all other members of the healthcare workforce, cannot be stressed enough. The health of our nation depends on allowing healthcare providers to execute the services they are qualified to provide. States should give APRNs independent practice authority and consider role expansions for other providers, including PAs, pharmacists, licensed practical nurses, and paramedics.
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