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.

[RiskManager]

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.

I cannot point to any studies, since I have not done the research, but my anecdotal experience of working in healthcare for many years, and going all over the country to do risk consulting leads me to think that PAs often tend to gravitate to inpatient and NPs often gravitate to ambulatory care. I wonder if there are studies on this.

[RegularNurse]

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.

Well said and "liked"

One of the overarching issues in nursing is the simple fact that nurses don't want to be bedside nurses anymore, and there is nothing wrong with that. This is the root cause of the impending surplus of APRN providers.

Why is there so much demand (right now) for APRNs? They are cheap compared to doctors. Bottom line. They are only cheap due to reimbursement restrictions outside of primary care- and also in primary care in some states.

If public and private payers reimbursed for NP care the same as doctors, then the payroll convenience of having them is nullified. Although, the abbreviated training would still keep supply up, and control wages.

Yes, there is still tremendous APRN opportunity for those who want it. The problem going forward will be that everyone wants it because nursing schools cherry pick students because the field was oversold. It is unreasonable for anyone to expect the best of the best students to settle for staff nursing.

Nursing is in a weird place right now in the US. As a field, there was a huge push for all this education etc. Now that everyone actually got it, institutions are saying, "now what." I think nursing will have to re-evaluate the scope of undergraduate education. It's not good that so many nurses report nursing school to be some sort of helpless drudgery that does little to prepare them for actual practice. And its not good that graduate level nursing education does little to prepare people to hit the ground running- especially in the absence of residency programs.

I think a lot of it comes down to nursing's weakness in expertise. There is no shortcut in becoming an expert at anything. Nursing has tried to dance around this reality in both education, practice, and high level administration. Unfortunately, these issues are beginning to manifest themselves in small ways with labor surpluses.

Nursing has been marketed as a field of convenience and exposed for the pitfalls of that very approach. There is nothing "convenient" about becoming truly competent in the workforce. Until nursing changes this culture, the glass ceiling, clinical and otherwise, will remain.

[RegularNurse]

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.

I think a lot of what you wrote is right on the money.

However, I think nursing schools raised admission standards due to increased demand for nursing education. Schools must thin the herd of applicants to stay within their enrollment capabilities. I'm not sure its a bad thing that smart people are becoming nurses. After all, the smarter the people becoming nurses, the smarter the NPs will be.

I think good non-clinical opportunities for nurses with graduate degrees are overstated. Administrative staff are being cut nationwide (loosening the grip of administrative control measures in healthcare is one of the key selling points of all healthcare reform policies).

The healthcare crisis in America is not due to staffing, but the result of sick people (mostly from lifestyle decisions) using significant costly healthcare resources. In short, healthcare ineffectiveness is not a provider problem, but a system and public health problem. Most NPs I've met are regular people. They just want to go to work and go home, they do not want to solve the nations healthcare disparities.

I tend to agree that care will shift more peripherally, but I'm not sure many NPs want to work in telehealth or make home visits. In my experience, people put forth the effort in grad school etc. to get a nice comfortable 9-5 with solid compensation. Many of those roles are a departure from that.

Thanks for your post, you brought up some nice angles on healthcare that I hadn't considered.

[KatieMI, BSN, MSN, RN]

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.

Sorry, nope. The expansion of online advanced nursing programs started approximately 10 years ago, a few years before the Great Recession. During this time, masses of new grads were pumped out to practice; if they were so bad for real, every insurance company would had the data about falling outcomes already, and physicians would parade them on every corner. 10 years in this business is quite enough for accomulating a good body of evidence, if there is something to accomulate in the first place.

You can deceive yourself all you like, but you cannot deceive numbers. There is NO EVIDENCE that, as a composite body, NPs provide inferior care as long as they stay within their scope of practice. It is not about that stupid thing I spent an hour last shift to explain that turning off TF for 2 hours every 4 hours will starve and dehydrate the patient unless we change its rate. But I saw MDs who were even worse.

[KatieMI, BSN, MSN, RN]

Doing home visits/LTCs is considered "cushy" job for AGNPs. They pay approximately like anything else +/- some% or quite a lump if you do it for insurance, you deal with issues which are usually preexisting, well-known and not going to be "compensated" or "cured" doesn't matter what, there is always a way to call beforehead and so avoid those crazy families, many issues (falls, constipations, uncontrolled DM, etc) can be moved to blame home care/LTC nursing staff (with full knowledge that nothing, period, will be ever done about it) and, if any trouble, you can ask to call 911 and let others deal with the mess. Only one thing is driving like crazy between places but you are very flexible and can run your own errands in between.

[RegularNurse]

Sorry, nope. The expansion of online advanced nursing programs started approximately 10 years ago, a few years before the Great Recession. During this time, masses of new grads were pumped out to practice; if they were so bad for real, every insurance company would had the data about falling outcomes already, and physicians would parade them on every corner. 10 years in this business is quite enough for accomulating a good body of evidence, if there is something to accomulate in the first place.

You can deceive yourself all you like, but you cannot deceive numbers. There is NO EVIDENCE that, as a composite body, NPs provide inferior care as long as they stay within their scope of practice. It is not about that stupid thing I spent an hour last shift to explain that turning off TF for 2 hours every 4 hours will starve and dehydrate the patient unless we change its rate. But I saw MDs who were even worse.

I think you raise a good point here. As APRNs expand their scope of practice and attain full autonomy in primary care nationwide, do similar outcomes between physicians and APRNs mean doctors are overqualified for the job?

I think everyone can agree that there is no real comparison in body of knowledge between MD and NP. Is all that training really necessary to be a PCP?

What are your thoughts?

[Wuzzie]

Sorry, nope. The expansion of online advanced nursing programs started approximately 10 years ago, a few years before the Great Recession. During this time, masses of new grads were pumped out to practice; if they were so bad for real, every insurance company would had the data about falling outcomes already, and physicians would parade them on every corner. 10 years in this business is quite enough for accomulating a good body of evidence, if there is something to accomulate in the first place.

You can deceive yourself all you like, but you cannot deceive numbers. There is NO EVIDENCE that, as a composite body, NPs provide inferior care as long as they stay within their scope of practice. It is not about that stupid thing I spent an hour last shift to explain that turning off TF for 2 hours every 4 hours will starve and dehydrate the patient unless we change its rate. But I saw MDs who were even worse.

I never said they do. Not ever. Please don't put words into my mouth. But I stand by my premise that 750 clinical hours is not enough.

[KatieMI, BSN, MSN, RN]

I think you raise a good point here. As APRNs expand their scope of practice and attain full autonomy in primary care nationwide, do similar outcomes between physicians and APRNs mean doctors are overqualified for the job?

I think everyone can agree that there is no real comparison in body of knowledge between MD and NP. Is all that training really necessary to be a PCP?

What are your thoughts?

My thoughts are that, the last time I checked, the Big Harrison's and any other medical book I know of was absolutely free for anyone in this country to purchase and study. There are tons of completely free readings, the newest articles, Grand Rounds streamlined live online. That's about theoretical knowledge. The practical one can be relatively safely accomulated within max 4 to 6 years of practice by a person with mental capacities slightly above average.

As a person who passed both NCLEX and USMLE (both with flying colors and first attempt) I can attest that any average Joe can pass them just as well if given enough time. The difference is not as much about volume as about thinking within strict protocol vs. "better/yet better/best". USMLE has no questions about "best intervention", it has plenty about "next", second next" and so forth. There was an experiment when NPs were given questions from USMLE III; they failed it totally because they were just not trained to think that way.

It is questionable if primary care is such a "mundane" area that it doesn't require advanced knowledge - after all, we all know about those one-per-million cases. My point is that nothing and nobody preclude NPs from attaining the same knowledge base as physicians if knowledge is what we are talking about. It will take some time and persistence, but it is completely OK to do, in school or after. If someone doesn't want to do it, it belongs to this very person's biography, not to mine.

[KatieMI, BSN, MSN, RN]

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.

Not exactly so.

NPs are, even in states where they are not given full autonomy yet, are less connected with physicians than PAs. PAs are, in essence, physician extenders. They do what docs do and nothing else. NPs, on top of all that, know how to basically speak with the patients. Not all physicians would value the fact that the NP will not only write a script for Viagra but also teach the guy a few things which he actually got to know before popping that miracle blue pill and spent precious 15 min to do so. So, many primary care NPs, and specialty trained as well, prefer to work relatively alone. It is an easy thing to do in rural, underserved areas, much easier than in a large academic center.

[Borntobenurse?]

Sorry, nope. The expansion of online advanced nursing programs started approximately 10 years ago, a few years before the Great Recession. During this time, masses of new grads were pumped out to practice; if they were so bad for real, every insurance company would had the data about falling outcomes already, and physicians would parade them on every corner. 10 years in this business is quite enough for accomulating a good body of evidence, if there is something to accomulate in the first place.

You can deceive yourself all you like, but you cannot deceive numbers. There is NO EVIDENCE that, as a composite body, NPs provide inferior care as long as they stay within their scope of practice. It is not about that stupid thing I spent an hour last shift to explain that turning off TF for 2 hours every 4 hours will starve and dehydrate the patient unless we change its rate. But I saw MDs who were even worse.

The spaghetti monster is real. Prove he doesn't exist. What, its difficult to prove a negative? Seems like that should be in a bio-statistics class or something.

Even so there are some studies out there but they are limited in scope, poorly designed, and are old. Bonus points if you can find one of them. But lets reason together, why would insurance want to close down the online NP pipeline? They pay less for NP's, why would they care if the care is worse, its close enough right. With insurance its always a matter of 'good enough.' Ditto hospitals. 5:1 ratio is just like 6 like 7 right? We only have a minor uptick in adverse effects and sentinel events, why have a ratio?

And lastly, I have to comment on using the MCAT to gauge preparedness for NP school. I appreciate the thought, but it tests Chemistry, Physics, BioChem, Biology, Verbal Reasoning and Sociology. Very little of that is relevant to nursing, and almost no nurse with a BSN has taken all those classes (now whether they should, debatable). Not a good yardstick.

Also thumbs up to you for working hard to become a good NP. You will not get any slack from me about that.

[Borntobenurse?]

Not exactly so.

NPs are, even in states where they are not given full autonomy yet, are less connected with physicians than PAs. PAs are, in essence, physician extenders. They do what docs do and nothing else. NPs, on top of all that, know how to basically speak with the patients. Not all physicians would value the fact that the NP will not only write a script for Viagra but also teach the guy a few things which he actually got to know before popping that miracle blue pill and spent precious 15 min to do so. So, many primary care NPs, and specialty trained as well, prefer to work relatively alone. It is an easy thing to do in rural, underserved areas, much easier than in a large academic center.

Hmm, drinking the coolaid are we? Doctors and PAs educate too. And on working alone in a rural setting fresh out of NP school, just because something is easy to do, doesn't mean it should be done (i.e. online only NP programs for one).

[prelift]

My thoughts are that, the last time I checked, the Big Harrison's and any other medical book I know of was absolutely free for anyone in this country to purchase and study. There are tons of completely free readings, the newest articles, Grand Rounds streamlined live online. That's about theoretical knowledge. The practical one can be relatively safely accomulated within max 4 to 6 years of practice by a person with mental capacities slightly above average.

As a person who passed both NCLEX and USMLE (both with flying colors and first attempt) I can attest that any average Joe can pass them just as well if given enough time. The difference is not as much about volume as about thinking within strict protocol vs. "better/yet better/best". USMLE has no questions about "best intervention", it has plenty about "next", second next" and so forth. There was an experiment when NPs were given questions from USMLE III; they failed it totally because they were just not trained to think that way.

It is questionable if primary care is such a "mundane" area that it doesn't require advanced knowledge - after all, we all know about those one-per-million cases. My point is that nothing and nobody preclude NPs from attaining the same knowledge base as physicians if knowledge is what we are talking about. It will take some time and persistence, but it is completely OK to do, in school or after. If someone doesn't want to do it, it belongs to this very person's biography, not to mine.

you have to have completed 2 years of med school to sit for USMLE, why would anybody drop out of med school to do nursing after 2 years? Very few questions are about treatment rationale, its mostly science based mechanisms on step 1. you probably have never really taken it if you think its about treatments. step 2 and 3 are about treatments.

I went back to med school, currently in 4th year, bc I was ashamed of nurse practitioners. I was one for a year and quit bc I couldnt stand the sight of how ignorant most of them were. The training is lackluster, pathetic, and they should not be able to prescribe medications. Only way I figured out how to survive was by ignoring the curriculum and reading real books like you said. And I went to a state school.

Took me 25 minutes to pass the NCLEX, an hour or so to pass the AANC exam, and the USMLE, while not super difficult, took 8 hours, and was much more thorough than the nursing tests. Step 2 was a little more difficult even but easier to score well on since people do not take it as seriously.

Give me a break with this NP garbage, you learn about 1/8th of what you learn in med school in NP school. I have met a few great NPs but they are few and far between. Sorry, nursing really needs to stay at the bedside, where it belongs at this point. Unless they rehash the curriculum, graduate nursing at the NP level is laughable.

Also, of course there will be an over supply. Its so easy anybody can do it, and they are. Basic economics my friends. And please do not get started on the equality studies. They are funded by nurses, what do you expect the results to show? They also do not control variables well in any of them.

Just look at the pharm industry.... every study done on each companies own drug that is PUBLISHED, shows that their drug is better. Ever think of how many of these equality of NP vs MD studies were performed and tossed bc they did not fit the narrative? It happens in the pharm industry when it is regulated by the FDA, dont think it does not happen in nursing either. Anybody with common sense knows nearly all MD>NP. But the lay person still thinks that the newest antipsychotics work better than the originals when no outside studies have proven this currently.

But hey believe what you want, Dunning Kruger effect at its finest is rampent in the nursing community. (and many others TBH)