Too Many Nurse Practitioners?

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. Nurses General Nursing Article

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.

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.

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.

But isn't a large part of this problem the programs that admit these students? You're always going to have unqualified applicants applying, whether it be MD/DO, CRNA, NP, PA, etc. The school should implement minimum requirements to ensure their matriculants are of a certain quality. FNP programs, unanimously, do not do this. Medical schools certainly do with gpa and mcat scores and PA programs have higher standards. CRNA schools have a minimum work requirement. Many/Most NNP and ACNP programs have minimum work requirements (my program has a minimum 2 years of ICU prior to application). But FNP programs have none. In fact, minimum gpa requirements are overlooked at many FNP programs. Like I said, you'll always have that 2.9 gpa or lower, and terrible mcat scores student applying to medical school. But they won't be accepted. However, for NP, it's simply an application away.

I don't believe that information is published (exception being Advanced Pro Nursing Institute, I mean golly how did an advanced pro fail?). Only the ones that they did approve. I would make sure my school was on that list. Nursing Programs

Here's the general instructions: http://www.rn.ca.gov/pdfs/education/unapproved.pdf

Hopefully other states will either follow and do what Ca did, or just use their list like they do for Caribbean schools (can't believe I just suggested following Ca, but in nursing its the thing to do).

MDs are better trained than NPs. Some NPs barely have much clinical experience to pull from. Maybe a NP/MD program could be put into place to fix this. It should be able to be done in a shorter period of time than that of a primary care physician.

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.

If all these NP schools that you speak of are so bad and the NPs graduating from them are so dumb then why do they continually get accreditation and why do the NPs keep passing the ANCC/AANP? Maybe your advocation should be refocused.......

If all these NP schools that you speak of are so bad and the NPs graduating from them are so dumb then why do they continually get accreditation and why do the NPs keep passing the ANCC/AANP? Maybe your advocation should be refocused.......

Perhaps you should re-read my post. Nowhere did I say the schools were bad or the NPs graduating from them are dumb. Just because someone can pass a test doesn't mean they're prepared to be a primary care provider. Experience makes a good primary care provider. An "advanced practice degree" should mean just that...the degree holder should have more than the equivalent of a year-and-a-half of on-hands patient care.

But hey, thanks for putting words in my mouth.

Um nursing school is long enough and to get a bachelor then go to medical school is ok but not to go from bachelor nurse to a np? you make no sense.

If all these NP schools that you speak of are so bad and the NPs graduating from them are so dumb then why do they continually get accreditation and why do the NPs keep passing the ANCC/AANP? Maybe your advocation should be refocused.......

So the retort would be that accreditation standards are low and certifying exams are tailored towards the information presented in these programs, or, conversely, the information presented in these programs is tailored to the certifying exam. This certainly isn't a metric by which to tout excellence of NP educational standards.

Well said, Addie! Some of the older generations are stuck on having new nurses go the same route they did (when nursing was less dynamic and there were far less choices for advancement). Although they will never admit that their desire for nurses to work bedside for X amount of years is actually punitive, because they didn't have the option of going from BSN to NP at the time. I will say it, bedside nursing and primary care are different and trying to equate experience in one area as prepatation for the other is not realistic.

If working bedside actually prepared you for primary care, then those with 10 years of bedside nursing experience would just breeze through NP programs and managing HTN, HLP, DM2, prescribing, diagnosing, interpreting diagnostics would be second nature, right? Not so! No NP program gives "credit" for years of bedside experience and even those with 10+ years have to take every class in the NP program... Just food for thought...

Here is my take on this situation:

1. Nursing school has been oversold for the last ten years to boost enrollment and make more money. Notice the sheer numbers of people flocking to nursing schools as a second career and the increase in nursing schools themselves.

2. Staff nursing hasn't changed at all, but the demographics and expectations of nursing students have. For example, I have met very few BSN students who have a career goal of staff nursing. Everybody wants to be an NP, CRNA etc. I have no problem with this, just an observation.

3. Many existing staff nurses are tired of working their butts off doing shift work and want a better job.

4. Nursing schools responded to increased demand for graduate education by increasing the flexibility in programs through online offerings and GRE waivers etc. After all, students will go to the school that requires the least amount of work to get the credential. Why wouldn't they?

Summary, staff nursing can be brutal, nobody wants to do it long term. The only surefire way to escape staff nursing is to become an NP or CRNA. Most people who don't want to be staff nurses enroll in these programs. The programs pump out a bunch of grads. The grads will eventually saturate the market. NPs will eventually have the same difficulty current RNs are experience landing jobs. NP wages will stagnate, as their job can be done by PAs, MDs, and DOs. Nursing schools will respond by increasing admission standards. There will be a subsequent increase in disenfranchised staff nurses who only became a nurse to be an NP, Midwife, or CRNA, who can't get into these mega-competitive programs. BSN enrollment will drop due to uncertainty in getting NP degrees and jobs. There will be a new shortage of RNs, which will increase RN wages and pull some NPs back into pool nurse jobs for better wages. The RN market will remain short, while the NP market will remain saturated.

NP education will become more rigorous due to job uncertainty, and start mirroring med school curriculum. Perhaps NPs will be forced to take the medical boards once the market becomes truly saturated to demonstrate expertise beyond that of the nursing boards. NPs will have gold standard education, but still be limited in practice autonomy to primary care. The ANA will begin lobbying to get NPs specialist residencies with doctors. Graduate nursing school will then basically be what the DO was 20 years ago. NP school will be viewed as a pathway to medicine and will no longer even be considered nursing.

1 Votes
Here is my take on this situation:

1. Nursing school has been oversold for the last ten years to boost enrollment and make more money. Notice the sheer numbers of people flocking to nursing schools as a second career and the increase in nursing schools themselves.

2. Staff nursing hasn't changed at all, but the demographics and expectations of nursing students have. For example, I have met very few BSN students who have a career goal of staff nursing. Everybody wants to be an NP, CRNA etc. I have no problem with this, just an observation.

3. Many existing staff nurses are tired of working their butts off doing shift work and want a better job.

4. Nursing schools responded to increased demand for graduate education by increasing the flexibility in programs through online offerings and GRE waivers etc. After all, students will go to the school that requires the least amount of work to get the credential. Why wouldn't they?

Summary, staff nursing can be brutal, nobody wants to do it long term. The only surefire way to escape staff nursing is to become an NP or CRNA. Most people who don't want to be staff nurses enroll in these programs. The programs pump out a bunch of grads. The grads will eventually saturate the market. NPs will eventually have the same difficulty current RNs are experience landing jobs. NP wages will stagnate, as their job can be done by PAs, MDs, and DOs. Nursing schools will respond by increasing admission standards. There will be a subsequent increase in disenfranchised staff nurses who only became a nurse to be an NP, Midwife, or CRNA, who can't get into these mega-competitive programs. BSN enrollment will drop due to uncertainty in getting NP degrees and jobs. There will be a new shortage of RNs, which will increase RN wages and pull some NPs back into pool nurse jobs for better wages. The RN market will remain short, while the NP market will remain saturated.

NP education will become more rigorous due to job uncertainty, and start mirroring med school curriculum. Perhaps NPs will be forced to take the medical boards once the market becomes truly saturated to demonstrate expertise beyond that of the nursing boards. NPs will have gold standard education, but still be limited in practice autonomy to primary care. The ANA will begin lobbying to get NPs specialist residencies with doctors. Graduate nursing school will then basically be what the DO was 20 years ago. NP school will be viewed as a pathway to medicine and will no longer even be considered nursing.

I would like this more than once if I could. With maybe the exception of the last paragraph I think you are dead on (I don't know if crazy nursing can ever fully adopt the medical model, and quite frankly the science background required for USMLE would be daunting for most nurses although it would be good for the profession). The market will correct this situation, it already is.

I get it why current students think its just 'frumpy old nurses who are mad they had to put in time on the floor,' but its just not true. That time needs to be done, you can't just replace experience with some classes. The study's done to show equivalence are very limited, and they are based off of mostly older NP's who weren't being graduated in the online age. There is no doubt in my mind outcomes will decrease, and there are enough physicians out there who won't check it. I had a pain doc tell me, literally, 'all you need is a license.' Thats it, didn't care about my background or w/e, he just wanted another cheap midlevel. Thats no good, at all.

People can do what they want, and run immediately to their online NP program immediately after graduating from their one year 'other bachelors to BSN program.' Will I go to them, or recommend any of my family to? Heck no. Give me a dang intern or PA with no experience over that (I don't want to go to either of them as well). But you know apparently I am a grumpy old nurse who just wants to punish everyone, it isn't possible that I actually care about the patients I see and think people should be able to do a good job before flying on their own.

I take it back, their right. I do want them to go on the floor as punishment. Two years of floor experience will at least weed out some of those who shouldn't be here and just saw nursing as the path of least resistance to becoming a midlevel.

As someone finishing an ACNP program, I can tell you that NP school in general woefully prepares you for full fledged practice based on the simple fact we have no residency. Are you telling me 600-700 clinicals hours can make up for the 20,000 gained through med school rotations and residency? I have had to constantly teach myself things that simply aren't covered in my program, because it's literally not possible given the curriculum and clinical hours. I am an experienced CCU RN by the way, not that that really matters to being a NP.

With the advent of online schooling, NP programs just aren't competitive. If I had a dime for every substandard RN that went to NP school I would be rich by now. Crappy RNs don't suddenly make great providers but hey the barriers to entry are essentially 0...

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