Too Many Nurse Practitioners?

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    What do future employment prospects hold for NPs ? There are mixed views on whether we will experience a surplus or a shortage of NPs by 2025.

    Too Many Nurse Practitioners?

    The year is 2043 and Maria waits patiently in the receiving pod for her primary care provider. The cool blue light is on, indicating scanners are continuously monitoring her vital functions. Her measurements display on the virtual wall to her right. Maria notes that her blood pressure is reading a bit high at 150/85.

    Maria needs to see an orthopedic surgeon for her worsening hip problem but national healthcare resource utilization guidelines issued back in 2030 as part of the Healthcare Reform Act prohibits patients from self-referring to specialists; only Nurse Practitioners (NPs) can authorize consults to medical specialists. In 2043, there are no primary care physicians; NPs provide all of the nation’s primary care and medical schools only graduate specialists, such as surgeons and neurologists.

    Evelyn, Maria’s NP, enters the pod with a shy appearing young man deferentially trailing behind, “Maria, this is Dr. David. He’s in the final year of his medical residency. I’m supervising his clinical rotation. Would you be OK with him joining us?”

    “Sure”, said Maria. She’s used to medical residents in the office. Evelyn is a well-renowned clinician and medical residents line up to have her as a preceptor.

    “Maria, don’t worry. I’m sending you for a multiplex InstaTran full body scan. It’ll be wirelessly transmitted so I can view it right away and we can go from there. David, can you please make sure the scan is ordered, notify my colleague, Dr. Narang, and let’s schedule her for a re-check on her blood pressure?”

    What is the employment future of primary care NPs? Will they be in demand, supplying the bulk of primary care services, as the vignette suggests?

    Nursing schools, graduating increasing numbers of NPs every year, with thousands more in the pipeline, seem to think so. Is this an indicator of future need or are schools riding the “Now” train? Can the job market sustain the rapid growth?

    Forecasting the supply and demand of healthcare practitioners is difficult. One thing we do know is that NPs in primary care have a projected growth rate higher than that of other registered nurses with graduate-level degrees such as certified registered nurse anesthetists and certified nurse midwives .

    It’s generally believed that there is a shortage of NPs and that the shortage will continue. But a recent report by the U.S. Department of Human and Health Services (DHHS) Health Resources and Services Administration (HRSA) says otherwise. HRSA predicts an oversupply of NPs.

    By the year 2025 there will be an estimated 110,540 full time equivalent (FTE) primary care NPs. This is close to twice the number of FTE primary care NPs in 2013 and almost double the projected 2025 demand.

    Even though there are geographic disparities in the distribution of primary care NPs, every state, plus the District of Columbia, is predicted to have an oversupply. No state is predicted to have a shortage of NPs by 2025.

    Florida alone is estimated to have 7,640 FTE primary care NPs by 2025- but the projected demand is for 3,120. Similarly, Tennessee is estimated to have 3,100 NPs- with a projected demand of only1,400.

    How did HRSA arrive at the numbers? HRSA used a Health Workforce Simulation Model (HWSM) to calculate state level and national projections.

    Future supply and demand was estimated by taking into consideration:

    • Population growth
    • Aging baby boomers
    • Expanded health coverage
    • Changes in health care reimbursement
    • Geographic location
    • Workforce participation
    • Retirement


    HRSA also looked at the projected supply and demand for primary care physicians and Physician Assistants (PAs). While the supply of NPs and PAs is predicted to outpace the demand, the supply of primary care physicians will grow more slowly than the demand, with an overall national shortage that masks regional and state-level variations.

    With a focus on wellness and disease prevention, it stands to reason that NPs are in a key position to ease the burden of the physician shortages and provide access to effective primary health care. Nurses are being recognized as key members of healthcare.

    Perhaps the projected oversupply will turn into a much-needed opportunity for NPs to assume more primary care roles. It would be good for NPs and good for the health of our nation.



    Resources
    NP Fact Sheet. (2016). American Association of Nurse Practitioners. Accessed April 2017 from
    AANP - NP Fact Sheet

    Bodenheimer, T., & Bauer, L. (2016). Rethinking the Primary Care Workforce—An Expanded Role for Nurses. New England Journal of Medicine, 375(11), 1015-1017.

    U.S. Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis. 2016. State-Level Projections of Supply and Demand for Primary Care Practitioners: 2013-2025. Rockville, Maryland.
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  3. by   pro-student
    We would be better off considering primary care as a type of healthcare services that can be provided by several different professional: the physician, NP, and PA. The model, however, assumes they are not at all similar and cannot be used interchangeably. For example, by 2025 they project a shortage of primary care MDs in 2/3 of states but an excess of primary care NPs in every state. A fundamental flaw with the HWSM model is that it assumes a sequestration of healthcare providers despite market forces opposing it. So basically they are suggesting there will be both a shortage and excess of primary care providers at the very same time and in the very same states.

    I know this can be a controversial statement but primary care is the area in which providers are the most interchangeable. There is an excellent record of quality care provided by non-physicians. There are a limited number of skills and procedures in which one type of provider can perform and another cannot. And there is an expectation that significant problems are managed by either consulting or referring to a specialist whether you are an MD, NP, or PA. If we think of primary care in terms of the type of healthcare service rather than the type of provider delivering care, there is a great deal of flexibility in the system for one type of provider to fill in gaps in the availability of another even without making any significant reforms to healthcare policy either legislatively or by healthcare administrators.

    Physicians, by and large, are choosing not to practice primary care on a dramatic level. With a primary care shortage already in place and a dwindling supply of physicians providing these services, the void has to be filled one way or another. In some countries, physicians are required to practice in primary care for a period of time before they even have the option of moving into specialties. This is incredibly unlike to happen in the United States and it is unnecessary. I think this data suggest that the only practical solution to the primary care shortage is to facilitate NPs and PAs filling these roles. I don't think we will ever get to the point that all primary care is delivered by non-physicians but I also don't think it would be problem if we did. Assuming we can keep standards high for NP education and give them a period to practice with some supervision for a period of time post-grad, I think NPs are ideally suited to the role of primary care provider. We are certainly capable of providing the range of primary care services but also have the advantage of a background based on building relationships with patients/families, supporting health and wellness rather that just looking for illness, and considering the multitude of factors affecting an individual like SES, psychosocial issues, nutrition, and ability for self-care.

    The vignette reminded me of countries such as the UK where a majority of pregnant women are cared for by midwives rather than physicians. Outcomes are excellent, satisfaction is high among patients, midwives, and physicians who are only sought when there is a condition that requires a higher level of care. Even in this country, many midwives do train physicians in normal childbirth of which they are the true experts. I can be an ideal situation in which each professional recognizes their niche and strengths and works cooperatively with others when a patient's needs overlap their expertise with that of another.
  4. by   dirtyhippiegirl
    Quote from pro-student
    Assuming we can keep standards high for NP education and give them a period to practice with some supervision for a period of time post-grad, I think NPs are ideally suited to the role of primary care provider.
    lol. Those are huge assumptions given the current state of NP schooling and employment.
  5. by   smartassmommy
    Your story might not be far off base. The way health care reform is working out, national healthcare could become the only fix.
  6. by   smf0903
    Quote from dirtyhippiegirl
    lol. Those are huge assumptions given the current state of NP schooling and employment.
    People can flame away if they want, but the idea of a grad with one year (or less!) of experience going back to school for NP is crazy. Crazy with a capital c. I see it time and time again in our facility. Out of morbid curiosity I looked into some of the NP programs to see what kind of clinical contact hours and such were required. 500-600 hours. That's it. That's the equivalent of 6 months of patient contact for me (I'm part time-24 hours a week). I don't know if other schools require more in their NP curriculum, but I think the equivalent of 1 1/2 years of experience (given a year as an RN and then NP clinical hours) is NOT "advanced practice" in my opinion.

    I personally am an advocate of a minimum amount of experience before an RN can apply for an NP program. A year as an RN people are just starting to get comfortable in their skills, etc. A primary care provider 3 years after sitting for nclex-RN? Nope.
  7. by   blondy2061h
    Considering some of the nurses I've seen nursing programs graduate lately, I'm scared for the future of nursing in general- not just NP's! The impact will be all the more obvious with NP's, though, as the push is for them to fill more and more roles. This is in no way a dig at new grad nurses. I've worked with a variety of intelligent, professional, and enthusiastic new grad nurses. But the gaps the questions I get asked by them sometimes are astounding and make me wonder what is going on at the schools. There seem to be some major gaps in the curriculum now.
  8. by   Ruas61
    It is almost too easy to get into nursing and now it is getting too easy to get an advanced practice degree.
  9. by   Borntobenurse?
    Over double what the HRSA is projecting? Aren't they the same ones in 2002-2006 who said we needed a ton more nurses and were used to justify hugely increased nursing schools till the floor fell out? I graduated in 2008 and I remember what that was like. If we are graduating that many NPs we are gonna see a lot more of them on the floor.

    Also I find the fantasy at the top not internally consisent at all. If Physcians are only specialists why is a medical student doing a round in primary care with an NP? And why is this NP ordering doctors around if none of them work in primary? I think this is someones personal fantasy not a projection at all. BP cuffs will still be around in 30 years anyway: they are cheap, and they work, and have worked for over 100 years.

    I am glad this kind of article exists questioning whether we are repeating the same mistakes (yes we are). But the baseline assuption that there is a shortage of primary care anything is a lie. There is a maldistribution of primary care cause most people don"t want to live in BFE around nothing getting poorly paid with few patient visits.

    My moral? Pick your NP school very carefully girls and boys, cause it will soon matter a lot. California BON has already started not accepting online only NP programs. Seeing what they have approved is a at least one way to see if your getting scammed at a degree mill. This is where NPing is going in the US, its not fantasy its happening. We allowed online schools to proliferate like bunnies and the backlash is starting.

    Or you can just go CRNA, little more of a bottleneck, and they arent saturated yet.
  10. by   Borntobenurse?
    Quote from pro-student
    We would be better off considering primary care as a type of healthcare services that can be provided by several different professional: the physician, NP, and PA. The model, however, assumes they are not at all similar and cannot be used interchangeably. For example, by 2025 they project a shortage of primary care MDs in 2/3 of states but an excess of primary care NPs in every state. A fundamental flaw with the HWSM model is that it assumes a sequestration of healthcare providers despite market forces opposing it. So basically they are suggesting there will be both a shortage and excess of primary care providers at the very same time and in the very same states.

    I know this can be a controversial statement but primary care is the area in which providers are the most interchangeable. There is an excellent record of quality care provided by non-physicians. There are a limited number of skills and procedures in which one type of provider can perform and another cannot. And there is an expectation that significant problems are managed by either consulting or referring to a specialist whether you are an MD, NP, or PA. If we think of primary care in terms of the type of healthcare service rather than the type of provider delivering care, there is a great deal of flexibility in the system for one type of provider to fill in gaps in the availability of another even without making any significant reforms to healthcare policy either legislatively or by healthcare administrators.

    Physicians, by and large, are choosing not to practice primary care on a dramatic level. With a primary care shortage already in place and a dwindling supply of physicians providing these services, the void has to be filled one way or another. In some countries, physicians are required to practice in primary care for a period of time before they even have the option of moving into specialties. This is incredibly unlike to happen in the United States and it is unnecessary. I think this data suggest that the only practical solution to the primary care shortage is to facilitate NPs and PAs filling these roles. I don't think we will ever get to the point that all primary care is delivered by non-physicians but I also don't think it would be problem if we did. Assuming we can keep standards high for NP education and give them a period to practice with some supervision for a period of time post-grad, I think NPs are ideally suited to the role of primary care provider. We are certainly capable of providing the range of primary care services but also have the advantage of a background based on building relationships with patients/families, supporting health and wellness rather that just looking for illness, and considering the multitude of factors affecting an individual like SES, psychosocial issues, nutrition, and ability for self-care.

    The vignette reminded me of countries such as the UK where a majority of pregnant women are cared for by midwives rather than physicians. Outcomes are excellent, satisfaction is high among patients, midwives, and physicians who are only sought when there is a condition that requires a higher level of care. Even in this country, many midwives do train physicians in normal childbirth of which they are the true experts. I can be an ideal situation in which each professional recognizes their niche and strengths and works cooperatively with others when a patient's needs overlap their expertise with that of another.
    There are large incorrect assumptions in this quote. The first and most laughable being the high quality of NP education 'currently." There is a reason the California BON started cracking down, no one else was doing it, and standards were getting beyond low for too many online only NP programs. Also, the Physician shortage, I know that no one is paying much attention here, but DO schools have almost tripled their enrollment in the last 10 years, with something like 30 new schools opened dedicated to producing primary care physcians.

    Sure physicians don't want to go into primary care (in no small part due to fear of compitition against cheaper NPs), but the way they are being pumped out in increasing numbers and the fact that the specialty residencies aren't expanding, means that there will be huge amounts of primary care physicians in the future. You think its hard to get a job now in primary NP? Just wait till they have lots of DOs competing.

    This is a dream scenarios for hospitals, they can now snatch up cheap physicians who have no choice because they are oversaturating too, and then fill in the rest with the 'cream of the crop' NPs from the 'best' schools with residencys most likely required. The market will regulate us, just like it did in 2008/09. And it won't be nice. You want a projection? There it is, B2Bnurse's 2025 prediction.
    Last edit by Borntobenurse? on May 8 : Reason: Grammer phone post
  11. by   dirtyhippiegirl
    I wonder if there will eventually be statistics to back up my anecdotal experience that more and more NPs are avoiding primary care for the same reasons physicians do. There's just too much pressure to see as many patients as possible without equal monetary compensation to make up for the stress of being overworked in many of these jobs. We hire experienced FNPs for the clinic I work in and I am always kinda surprised at how many we get who have gone through five or six or seven primary care-style jobs in, like, a decade. (Although this could just be symptomatic of the type of NP applicants we get, who knows?)

    The "but NPs care about the WHOLE person" schtick is such trite bs. You have a patient slotted every 20 minutes for the next eight hours, just like your physician counterpart. Being a NP doesn't make the time or caseload complaints magically vanish.
  12. by   lrobinson5
    Quote from Borntobenurse?
    My moral? Pick your NP school very carefully girls and boys, cause it will soon matter a lot. California BON has already started not accepting online only NP programs. Seeing what they have approved is a at least one way to see if your getting scammed at a degree mill. This is where NPing is going in the US, its not fantasy its happening. We allowed online schools to proliferate like bunnies and the backlash is starting.
    I was trying to look up more information on California putting the brakes on online only NP schools. I can only find a list of approved programs and the policy on APRN education. Is there a published article that talks about specific instances they declined a school? I am not planning on attending an online school, but I am curious about the future of NP education. Thanks!
  13. by   AceOfHearts<3
    Quote from smf0903
    People can flame away if they want, but the idea of a grad with one year (or less!) of experience going back to school for NP is crazy. Crazy with a capital c. I see it time and time again in our facility. Out of morbid curiosity I looked into some of the NP programs to see what kind of clinical contact hours and such were required. 500-600 hours. That's it. That's the equivalent of 6 months of patient contact for me (I'm part time-24 hours a week). I don't know if other schools require more in their NP curriculum, but I think the equivalent of 1 1/2 years of experience (given a year as an RN and then NP clinical hours) is NOT "advanced practice" in my opinion.

    I personally am an advocate of a minimum amount of experience before an RN can apply for an NP program. A year as an RN people are just starting to get comfortable in their skills, etc. A primary care provider 3 years after sitting for nclex-RN? Nope.
    I agree and so do many others. There is a thread, I think in the student section maybe or the speciality section, where somebody asked about opinions for a DE NP program. The poster iasn't very happy with the replies she/he has gotten.

    I'm a newer nurse with just under 2 years of experience and I'm also a second career nurse. Going into nursing I felt like I would eventually go to school for my DNP, but I'm certainly not in any rush. I was on a very busy tele unit with very acute patients my first 1.5 years. I'm now in an ICU and I want to learn as much as I can. I don't envision myself going back to school for probably at least another 5 years.
  14. by   SaltySarcasticSally
    Quote from dirtyhippiegirl
    lol. Those are huge assumptions given the current state of NP schooling and employment.
    I have to agree. unfortunately. The standards for many of the NP programs in my area are shockingly low, to the point I won't see an NP unless recommended by a friend. We had an NP student in an office I used to float at that had not even worked the floor a year, why that's not scary to more people is beyond me. I certainly hope they will not be the future of primary care until there is mandated minimal experience and more stringent requirements.

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