The number of nurse practitioners (NPs) in the United States has doubled in less than 7 years, a new study finds, which is raising questions among health care professionals about the implications.
The report, “Implications of the Rapid Growth of the Nurse Practitioner Workforce in the U.S., published February in Health Affairs, reviews a period between 2010-17 and finds the number of NPs grew from 91,000 to 190,000 and the number of the registered nurses (RNs) decreased by 80,000 nationwide.
“In the future, hospitals must innovate and test creative ideas to replace RNs who have left their positions to become NPs,” states the report. The report notes that NPs are working in hospitals, physician offices, and outpatient care centers, and their earnings have grown 5.5 percent (adjusted for inflation). The report urges educators to track growth in earnings for signs that NPs could be flooding the market.
NP education programs increased from 356 to 467, the report notes, and have graduated new NPs at a rate similar to that of traditional medical schools. A number of schools offer virtual programs.
Factors Driving Growth
One development driving growth appears to be more acceptance by states to expand scope-of-practice laws.
Increasingly, states have allowed NPs to practice independently of physicians and prescribe medications. According to the American Association of Nurse Practitioners (AANP), 22 states allow what is known as “full practice authority” by which NPs can function under licensure of the state board of nursing and can diagnose, treat and prescribe medication without the supervision of a physician. Sixteen states allow reduced practice, whereas 12 states restrict NPs to work independently altogether.
Different work conditions are also attracting more people to the NP profession, especially RNs in hospital settings, says Brittany Hay, NP and assistant professor at the University of South Florida College of Nursing.
“Most people who are becoming NPs have a desire to do more and to provide more comprehensive care and to make a difference in the lives of patients in a different way,” Hay said. “Instead of seeing them in the hospital [as nurses], where [patients] are already experiencing health problems that haven’t been controlled or risk factors that haven’t been well-managed, a lot of nurses are driven to become [NPs]. It’s too late when they are in the ICU (intenstive care unit).”
Too Many NPs?
The shift of nurses to primary care from acute care in hospital settings is an unsettling trend, say two physicians, Marilyn Singleton, M.D., president of the Association of American Physicians and Surgeons and Rebekah Bernard, M.D., board member of Physicians for Patient Protection.
“The lure of an outpatient setting and higher pay and setting one’s own hours would lead some nurses, particularly new grads, to abandon hospital nursing,” Singleton said.
“There is already a shortage of nurses in this country, and as more nurses become NPs, the number of bedside nurses will decrease,” Bernard said. “Nursing organizations hat aggressively promote NP degrees have done little to increase the number of bedside nurses.”
Bernard says a 2010 report by the Institute of Medicine’s Future of Nursing failed to recognize the need for associate level RN’s but instead pushed for nurses with more advanced degrees.
Singleton and Bernard also say a glut of NPs could impact health care delivery.
“The market will attempt to absorb NP graduates by using them to replace physicians,” said Rebekah Bernard, MD, board member of Physicians for Patient Protection.
“Hospitals are buying up physician practices and replacing the doctors with nurses looking to reduce costs,” Singleton said. “I’m sure there is always room for health care workers. The question [is whether] the new crop of workers has the knowledge and skills to perform the tasks they claim to be independently qualified for. Even older nurse practitioners decry the level of training and proliferation of online [NP] schools. When these programs started, hands-on nursing experience was required. Now, one can obtain an NP entirely on didactic learning.”
The Physician Shortage
One reason a number of states have granted NPs full practice authority is in response to the shortage of physicians, especially in rural areas.
“We have a lot of federally qualified health centers that are more rural and supervisory physicians aren’t available, in some cases,” Hays said.
A more adequate remedy would be to increase Medicare funding for more physician residencies, Singleton says. Additionally, states could encourage tracks that allow medical school graduates could provide more care, Singleton states.
“[These tracks] allow medical school graduates who did not obtaining a residency to be assistant physicians until they are able to ‘match’ in a residency program,” Singleton said. “This allows supervised young doctors to work in underserved areas.”
Arkansas, Kansas, Missouri, and Utah have enacted such a track, and Arizona, Georgia, New Hampshire, Oklahoma, and Washington are considering legislation to do so. Additionally, The Resident Physician Shortage Reduction Act of 2019 (H.R. 1763), introduced by Reps. Terri Sewell, (D-Ala.), and John Katko, (R-N.Y.), would add up to 15,000 Medicare-funded residency positions over five years. This bill mirrors SB 348, introduced in January.
NPs vs. Physicians
Over the years, the term “provider” has entered the standard medical care lexicon to describe any professional providing patient care, Singleton says.
“The term tends to equalize, in the patient’s mind, the talents of the individual professionals with amazingly different range of training and skills,” Singleton said. “There will come a time, when [patients] will not be told the difference, even though certain states and a pending federal bill require titles of health professionals to be prominently displayed.”
The issue is not NPs over physicians or vice versa, Hays says. “It’s about collaboration that can bring the most holistic care to patients,” Hays said. “Every discipline is finding where they fit. We have an aging population with multi-morbidity who require a lot of ongoing care.”