Too Many Nurse Practitioners?

[Nurse Beth]

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.

[Jules A, MSN]

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 nominate RegularNurse as CEO for the CCNE. Something has got to change.

This is the most refreshing thing I have read in years. Unfortunately I'm one of the grumpy old NPs who won't live long enough to see the pendulum swing this far back but the beautiful picture you created in my mind is worth a thousand thanks.

[KatieMI, BSN, MSN, RN]

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. .

PA programs admit students with good academical achievents (BS degree and around 1000 on GRE, which is good but to no means stellar) and minimal (CNA, EMT) to NONE AT ALL medical experience.

Nope. Zero. A dude never saw a patient in entire life and now he is getting a somewhat softened medschool course crammed down into his head in 2 years. Communications, teaching, lifetime management consideration, etc., etc. be d***ed, no time for that, memorize those 3 different criteria sets for acute knee injury evaluation - nobody cares if they contradict each other. I'd heard more time than I can count that patients prefer NPs because they talk to them. Well, that's not much surprising, isn't it?

BTW, among FNP schools I shopped for my own admission (only high-rankers with none of them having first-attempt Board passing below 98% over at least 3 years before), no one has mean course composite GPA below 3.5. With FNP, it is a matter of finding the right place, not "overall" quality.

[KatieMI, BSN, MSN, RN]

In the light of everything being said about terrible quality of NP education, can someone explain why over the last 10 years there was no evidence of any kind of the said NPs delivering care with worse outcomes than PAs, MDs or DOs in the areas where they all provide comparable level of services such as routine primary care/chronic management? If the system would be churning out so much of poorly qualified NPs in such great numbers, the statistics of quality indicators for diabetes/HTN/etc. must at least start to look skewed. It doesn't happen.

[Dodongo, APRN, NP]

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...

Here's the thing - medical schools don't teach their students everything either. Medical students put in hundreds upon hundreds of hours studying on their own time. I remember seeing a stat somewhere that most medical students skip the majority of their lectures. They read the text book. They review. They buckle down and learn it themselves. Learning something comes from studying it and going over it multiple times. You can blame a program for not covering something all you want, but the material is available. I am in the middle of reading "Cecil Essentials of Medicine". Not because it is required in my program, because it isn't, but because I need to know that information.

If you are enlightened to the fact that your program has shortcomings compared to other provider pathways, then do something to make up for it. Your program only requires clinical 2 times a week, go 5 times a week. I'm sure your preceptor will be more than happy to know they're assisting you in becoming a competent provider - especially if your preceptor is an MD.

Don't complain about only being required to do the bare minimum while still just doing the bare minimum. Do extra. You have the capacity. If NP students just took it upon themselves a bit more to put in extra work, well, problem solved. But they will do the least amount of work possible and then lament the poor quality of their training.

[KatieMI, BSN, MSN, RN]

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.

Agree. It is changing right now, though, as the new grads job crisis of 2012 - + is still continuing, although it becomes more local. People noticed that nursing diploma doesn't guarantee any job at all, or the type job they want. So, they either drop the idea or go to nursing school with plan to bypass bedside nursing and go directly to advanced degree. That way, the risk of not finding job after graduation is still there but at least it wouldn't be one of running till you are dead in a LTC.

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

Agree; see above why it is so.

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

Oh, yeah. Running all day like a chicken with its head just cut off vs. sitting peacefully in doctors' room, sipping coffee and putting orders online for at least twice more money. Easy to choose, isn't it?

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?

Because there are students, and plenty of them, who know very well what they are going to play with. My program full time cohort is known affectionately as "suicidals". The program admitted approximately 30 or 40% of qualified applicants. It is FNP Master's.

P.S. GRE is a test of overall education level and, that is to say, mastery of reading and writing in particular style of English. It has nothing at all in common with any quality or skill actually required from a health care provider, and therefore it represents completely purposeless spending of time, money and brain power except of getting a prooof of passing it. MCAT would be way more appropriate.

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.

Or MSN/Ed, MSN/MBA, MSN/Leadership, CNL, PhD and then some more, all these without patho, pharm, biochem and other horror courses. BTW, there are tons of avenues to be removed from daily grind of bedside without a new degree. QA, QI, ID control, "wellness coordinators", case managers, IT "guides", tele triage, insurance, doc review, etc.

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.

There is the problem. MDs and DOs, having spent fortunes on their education, more often than not do not want, or just cannot afford to sit in office in the middle of nowhere in the center of Great Plains and prescribe Norco by tankloads for local farmers' pains and hurts and then be paid for that 58% of what Medicare would. Over 50% of primary care MDs/DOs go to some sort of fellowship or clinical program and then become sport medicine physicians, open med spa salons, procedural offices, boutique practices, etc. PAs are, and will be, physically depending on MDs and DOs, so where there are none of the latter ones, ther will be no of the former ones as well.

The currect health care crisis in the USA caused, in very significant part, by total failure of prevention and chronic management programs. These programs are compensated in pennies at the best, they are tedious to do and require lots and lots of speaking with stubborn, reluctant, denying, capricious, uneducated and distrustful people. Neither MDs/DOs, nor PAs even know how to speak with these folks.

Look at this:

Aging

Functional reversal of symptoms of Alzheimer achieved by life changing measures. Now, try to imagine an MD spending time for which he won't be "compensated" painstakingly explaining all that to Auntie Anne whose MMSE dropped 3 points in half a year, who almost burned her house because she forgot to turn off heat in her stove and who is having 3 eggs with plenty of bacon every day of her life for breakfast and sits there gued to TV for half a day. Only one who was running with drug cart among such Aunties Annies for a few years in LTC knows how to do that - and how to get results.

Nursing schools will respond by increasing admission standards.

NURSING (Diploma/LPN/ADN/BSN) schools already inflated their admission standards through the sky. It is their big mistake, because they thus admit extremely smart people who will not tolerate unhuman treatment, lateral violence, NETY politics, restriction of their rights and such as things being given and escape from bedside ASAP.

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.

It is named "occupation cycle" or "job bubble" and happens in pretty much every profession known. The same story happened in IT and data science around 2000, in advanced science/industry in 2006 - 2010, in real estate in 2008 - 2012, and now happens in some parts of service industry. It is caused by objective changes on the market, and there is nothing short of building of totalitarian society like former Soviet Union to prevent it from repeating.

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.

NP schools are already considered to be "soft way to medicine". There are more people than you think who can calculate that, because of shorter education and early entrance into job market, summary lifetime earnings of a CRNA can easily exceed ones of FP MD.

The level of nursing boards may (and, IMHO, should) be raised, but there will be subjects which will continue to pertain to nursing because physicians so far plain refuse to deal with them, such as teaching.

I think that within the next 30 years or so, as the USA is slowly and jerkingly moving to where all other developed coutries already are, which is single payer medical system, NPs will constitute at least 70% of primary care providers. FP MDs/DOs will become exclusion from the rule and manage either boutique type of practices or serve as "consultants" for NP support or more complicated cases. There will be wide structure of outpatient treatments for chronically ill people, with postdischarge follow up including home calls, run by midlevels with MDs doing consultant roles. Home health and outpatient sector will proliferate, while inpatient minimally shrink.

[RiskManager]

Of note, in the Seattle area, there are many more NPs than there are PAs practicing. I suspect a major reason for that is that the state has one PA program and seven NP programs. The large primary care clinics and integrated health systems in the state are snapping up as many NP and PA providers as they can, and I don't see that slowing down any time soon.

[Wuzzie]

In the light of everything being said about terrible quality of NP education, can someone explain why over the last 10 years there was no evidence of any kind of the said NPs delivering care with worse outcomes than PAs, MDs or DOs in the areas where they all provide comparable level of services such as routine primary care/chronic management? If the system would be churning out so much of poorly qualified NPs in such great numbers, the statistics of quality indicators for diabetes/HTN/etc. must at least start to look skewed. It doesn't happen.

Because ten years ago and up until the recent past most NP schools required experience to be admitted. I'm not sure those numbers will hold given the current status of NP education. I mean, come on, 600-800 hours of clinical to be considered an advanced practitioner without ever having touched a patient prior? PA students get 2000 and have medical oversight once in practice. We should be ashamed.

[Dranger]

Here's the thing - medical schools don't teach their students everything either. Medical students put in hundreds upon hundreds of hours studying on their own time. I remember seeing a stat somewhere that most medical students skip the majority of their lectures. They read the text book. They review. They buckle down and learn it themselves. Learning something comes from studying it and going over it multiple times. You can blame a program for not covering something all you want, but the material is available. I am in the middle of reading "Cecil Essentials of Medicine". Not because it is required in my program, because it isn't, but because I need to know that information.

If you are enlightened to the fact that your program has shortcomings compared to other provider pathways, then do something to make up for it. Your program only requires clinical 2 times a week, go 5 times a week. I'm sure your preceptor will be more than happy to know they're assisting you in becoming a competent provider - especially if your preceptor is an MD.

Don't complain about only being required to do the bare minimum while still just doing the bare minimum. Do extra. You have the capacity. If NP students just took it upon themselves a bit more to put in extra work, well, problem solved. But they will do the least amount of work possible and then lament the poor quality of their training.

You assume a lot in your post. I have succeeded DESPITE the two programs I have been in.

The onus is on me now and not the program? I just said that I have spent substantial time outside of school teaching myself concepts that my school does not cover or delve into. Medical students do the same thing as me and I see them every day. There knowledge of medicine is greater because the programs set them up for success. Make no mistake, I do pretty well but I also know when I don't know something. I have sat in on medical school lectures for "fun" and they are much more substantial than the drivel and copy/pasteing of YT videos that many NP schools have as lectures.

I am still waiting for a rebuttal to the thousands of hours gained in residency. That is really where doctors are forged, not medical school.

5 days a week? I am glad to hear you don't have to work because I do. If the clinicals were supervised with my school and they had a more hands on approach then maybe I would consider not working. My school finds preceptors but mine dropped last minute so I had to find my own and do all of the leg work. Med or PA students don't deal with that BS.

[Dranger]

Of note, in the Seattle area, there are many more NPs than there are PAs practicing. I suspect a major reason for that is that the state has one PA program and seven NP programs. The large primary care clinics and integrated health systems in the state are snapping up as many NP and PA providers as they can, and I don't see that slowing down any time soon.

I live in Seattle and work for a LARGE hopsital here downtown. I honestly think it's 50/50 and there are probably more PAs in inpatient.

[Dranger]

I also enjoy the altruistic meme and vision that NPs are the ones filling a "need" in rural and primary care.

Let's be honest, most NPs don't want to work in the middle of nowhere USA. They want the competitive positions with salary and locale just like physicians.

The "need" thing is just a facade to make nurses look more caring.

[Dodongo, APRN, NP]

You assume a lot in your post. I have succeeded DESPITE the two programs I have been in.

The onus is on me now and not the program? I just said that I have spent substantial time outside of school teaching myself concepts that my school does not cover or delve into. Medical students do the same thing as me and I see them every day. There knowledge of medicine is greater because the programs set them up for success. Make no mistake, I do pretty well but I also know when I don't know something. I have sat in on medical school lectures for "fun" and they are much more substantial than the drivel and copy/pasteing of YT videos that many NP schools have as lectures.

I am still waiting for a rebuttal to the thousands of hours gained in residency. That is really where doctors are forged, not medical school.

5 days a week? I am glad to hear you don't have to work because I do. If the clinicals were supervised with my school and they had a more hands on approach then maybe I would consider not working. My school finds preceptors but mine dropped last minute so I had to find my own and do all of the leg work. Med or PA students don't deal with that BS.

There are NP residencies. Apply to one and you'll get thousands more hours of training.

MD and PA students do not work in their programs. There is no option. Those students take out loans and immerse themselves. You could have done the same thing, but, you chose not to do that. So how then can you complain that the school only requires 600 hours?

You can't choose to go to NP school because you need to work but then complain that you didn't have more required clinical hours.

Am I defending NP programs. Absolutely NOT. A lot of NP programs are terrible. However, you did choose to attend NP school. So it's good that you are teaching yourself more. You have to. Until NP programs are held to a higher standard, you have no other choice than to go above and beyond and supplement your education. I agree that 600 hours is abysmal. So it's on you to get more hours. Nothing is stopping you from doing extra except yourself.

[Dodongo, APRN, NP]

I also enjoy the altruistic meme and vision that NPs are the ones filling a "need" in rural and primary care.

Let's be honest, most NPs don't want to work in the middle of nowhere USA. They want the competitive positions with salary and locale just like physicians.

The "need" thing is just facade to make nurses look more caring.

Totally. It's a political ploy.