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.

[prelift]

I honestly do not understand the intro story either. It is basically a quick shot at physicians, labeling them as socially inept, and prompting forced equality between NPs and the resident in the story. Explicitly stating that he is being supervised by an NP in his final year of residency and that residents across america are fighting to rotate with the God-figure NP Evelyn. Lmao give me a break with the emotion pumping OP, it doesn't add to the article at all and is obviously placed in there to give you and your colleagues a false sense of superiority. Plus if there are no PCP physicians, then why would he be rotating with a PCP in his last year???? For a professional blogger this is an example of an awful ability to tie a story into the agenda . I guess if it raises the reader's ego a few inches though its good content right?

[Dodongo, APRN, NP]

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)

This person didn't specifically state USMLE step 1. Probably talking about steps 2 and 3.

I agree with a lot of what you said. The majority of NP schools are too easy to matriculate into and waaaay too easy to sail on through to graduation. There are a handful, probably, that do a good job, but most students do not attend these schools. Search this forum and you'll see endless posts of people with terrible gpas and no rn experience asking which school is easiest to get into and requires the least amount of time spent studying to get the degree. It's embarrassing. And scary.

I'm attending what I think is a pretty good school, however, I am still supplementing my education. I have time to read extra so I am. Currently reading through Robbins and just started Cecil's Essentials of medicine. I think if you are going to go to NP school you have to know that this is a must. But, again, the point has been made of people looking for the path of least (...no...) resistance to being a provider.

[prelift]

You'll prob do great if you have the motivation and ethic to read those two books. Robbins is a good read, have not read entire thing but used the pictures and charts in it and went back to the text as needed for step 1, and used its review question book for path. Our teachers used a lot of robbins charts/texts and got their reference info from it also back in the lecture years. Cecil mostly used as a reference text along with up to date. There is so much good info out there that people don't use and instead use their nursing run offs of medical texts. Always found the nursing books more wordy and less meaty than the medical books......

[Dodongo, APRN, NP]

You'll prob do great if you have the motivation and ethic to read those two books. Robbins is a good read, have not read entire thing but used the pictures and charts in it and went back to the text as needed for step 1, and used its review question book for path. Our teachers used a lot of robbins charts/texts and got their reference info from it also back in the lecture years. Cecil mostly used as a reference text along with up to date. There is so much good info out there that people don't use and instead use their nursing run offs of medical texts. Always found the nursing books more wordy and less meaty than the medical books......

This is exactly it. These nursing texts condense and abridge everything into snippets that schools are trying to get you to learn by rote memorization, rather than going to the medical texts to have you actually understand the material. I'm just not buying the nursing books and instead purchasing the medical text equivalents for classes (like robbins for pathophysiology, albeit I bought the baby and intermediate versions) and reading those. So far the only class that I've purchased the actual text in is pharm as my instructor is a pharmd that teaches out of the same book in the pharmacy program. I read most of Saladin's anatomy and physiology and took an extra gross anatomy class through the medical school. I wasn't allowed to do their gross dissections but I was able to audit the lectures and used the same text (Netter's atlas).

[SmilingBluEyes]

I am dismayed by the trend allowing people with zero nursing experience the express-method of entry to advanced practice. Got a bachelor's degree in whatever? Good, get an MSN/NP and be a nurse practitioner. It makes me question their qualifications and whether I want to have one for my provider. It really does. I don't care how you slice it. Several hundred hours of clinical experience hands-on with patients does not equal YEARS of experience assessing and caring for people as a nurse. And it never will. SOLID Assessment skills are honed with experience and time. People argue that it is a different "skill set". Maybe but it's still "NURSE" practice, folks.

[mrl3fnp]

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.

Thanks for the clarification. But you questioned whether NP schools have appropriate pre-admission requirements. Did you not? Likewise you questioned whether RNs with certain experience levels are adequately prepared to study as an NP. Did you not? Call it what you want, but if what you saying is true then that is called a bad NP school and that is called a dumb NP student.

You speak as if your "crazy morbid curiosity" (your words not mine) has now given you special enlightenment about NP programs.

1) Have you ever been in an NP program???

2) Do you know how intensive and difficult it is???

3) Have you ever taken the AANP/ANCC???

4) Can you back up your claim that NP schools will accept an RN with only 1 year of experience??? (I have never seen any NP school with lower than a 2 year RN requirement).

5) 2 years of direct patient care as an RN = about 3700 hours prior to NP school + any part-time or full-time hours while going to NP school + NP clinical hours an RN could easily acquire more that 6000 direct patient care hours before being licensed as an NP.

6) In contrast, many PA schools that I have seen do not even have a direct patient care hours requirement and if they do it's jobs like CNA, MA, Scribe, etc.....which really isn't the equivalent to direct patient care as an ICU or ER RN. If PAs have a 12 month clinical rotation requirement during PA school = 40hr x 52=2080 direct patient care hours prior to being licensed as a PA. Yet, no one ever mentions that is "crazy with a capital C" (your words not mine).

That is why NP schools have a lower clinical rotation hours requirement during NP school.......because as an RN you have an adequate amount of direct patient care hours already acquired.

See.......that's the difference between me and many folks out there that have an opinion without any idea of what they are talking about.

[Jules A, MSN]

Thanks for the clarification. But you questioned whether NP schools have appropriate pre-admission requirements. Did you not? Likewise you questioned whether RNs with certain experience levels are adequately prepared to study as an NP. Did you not? Call it what you want, but if what you saying is true then that is called a bad NP school and that is called a dumb NP student.

You speak as if your "crazy morbid curiosity" (your words not mine) has now given you special enlightenment about NP programs.

1) Have you ever been in an NP program???

2) Do you know how intensive and difficult it is???

3) Have you ever taken the AANP/ANCC???

4) Can you back up your claim that NP schools will accept an RN with only 1 year of experience??? (I have never seen any NP school with lower than a 2 year RN requirement).

5) 2 years of direct patient care as an RN = about 3700 hours prior to NP school + any part-time or full-time hours while going to NP school + NP clinical hours an RN could easily acquire more that 6000 direct patient care hours before being licensed as an NP.

6) In contrast, many PA schools that I have seen do not even have a direct patient care hours requirement and if they do it's jobs like CNA, MA, Scribe, etc.....which really isn't the equivalent to direct patient care as an ICU or ER RN. If PAs have a 12 month clinical rotation requirement during PA school = 40hr x 52=2080 direct patient care hours prior to being licensed as a PA. Yet, no one ever mentions that is "crazy with a capital C" (your words not mine).

That is why NP schools have a lower clinical rotation hours requirement during NP school.......because as an RN you have an adequate amount of direct patient care hours already acquired.

See.......that's the difference between me and many folks out there that have an opinion without any idea of what they are talking about.

Unfortunately there are plenty of direct entry NP programs that require no RN experience and in fact I have had a professor of a well known top 10 university tell me their focus was on retention so they didn't lose the students if they actually went to work as a RN.

1) Have you ever been in an NP program???

I have, two in fact, both well known brick and mortar with excellent reputations.

2) Do you know how intensive and difficult it is???

Sure do, yawn, and trust me I'm not all that and a bag of chips, the work was not difficult.

3) Have you ever taken the AANP/ANCC???

I have in fact, ANCC, twice passed both within 50 minutes.

4) Can you back up your claim that NP schools will accept an RN with only 1 year of experience??? (I have never seen any NP school with lower than a 2 year RN requirement). CRNP programs are still smart enough to require actual experience and some but not all ACNP programs still do also.

Did you miss this dust up?

https://allnurses.com/nurse-practitioners-np/brave-or-just-1100340.html

I truly wish you were correct and that a majority of programs did have admission requirements but that just isn't the case and yes, I agree 100% the reason we are able to get away with 500 clinical hours vs 2,000 for PAs is because the intent was to have solid years of RN experience. Its a sad state of affairs, imvho.

[Dodongo, APRN, NP]

4) Can you back up your claim that NP schools will accept an RN with only 1 year of experience??? (I have never seen any NP school with lower than a 2 year RN requirement).

5) 2 years of direct patient care as an RN = about 3700 hours prior to NP school + any part-time or full-time hours while going to NP school + NP clinical hours an RN could easily acquire more that 6000 direct patient care hours before being licensed as an NP.

That is why NP schools have a lower clinical rotation hours requirement during NP school.......because as an RN you have an adequate amount of direct patient care hours already acquired.

Seriously. No FNP programs require RN work experience. None. The only advanced practice nursing specialities that (for the most part) require RN work experience are CRNA (1 year ICU), NNP (1-2 years NICU) and ACNP (1 year ICU).

Yes, NP school was designed to build on a person's experience as a nurse. However, working as a nurse does not substitute for clinical training as a NP. Carrying out orders is completely different than diagnosing and developing treatment plans.

Don't even get me started on the "intensity" and difficulty" of NP programs...

I love how Jules A just threw down!

[KatieMI, BSN, MSN, RN]

Seriously. No FNP programs require RN work experience. None. The only advanced practice nursing specialities that (for the most part) require RN work experience are CRNA (1 year ICU), NNP (1-2 years NICU) and ACNP (1 year ICU).

Yes, NP school was designed to build on a person's experience as a nurse. However, working as a nurse does not substitute for clinical training as a NP. Carrying out orders is completely different than diagnosing and developing treatment plans.

Don't even get me started on the "intensity" and difficulty" of NP programs...

I love how Jules A just threw down!

The FNP program I am in requires bedside experience all right. The problem is that they want any kind of experience - from NICU to LTC. I wonder what students who never in their lives dealt with a kid of any age are actually doing on peds rotation.

Don't let me even start on difficulty and intensity as well... I do not even care to buy some books, much less to read them. I love my Harrison, though.

As I see things standing right now, the problem with advanced practice nursing is not that much with bedside experience as with particular way of thinking, which, IMH(umble)O, at least in part stems directly from mindless following orders, policies and shmolicies of all kinds for years before finally getting into advanced practice. When this way of thinking is combined with chronic deficiency of knowledge, it makes very dangerous mix.

P.S. just to let some people here know, foreign medical grads are eligible for taking all parts of NCLEX without any US education at all as long as they have documents confirming their degree.

[MurseJJ]

Yes, NP school was designed to build on a person's experience as a nurse. However, working as a nurse does not substitute for clinical training as a NP. Carrying out orders is completely different than diagnosing and developing treatment plans.

While I agree that experience as a bedside RN is not the same as or a substitute for clinical training for an NP, is there not value in RN experience beyond mere "carrying out orders" (I know I don't just carry out orders in my job)?

[ThePrincessBride, MSN, RN, NP]

Some acute care NP programs don't even require experience and some FNP programs require one year of acute care experience. Problem is that experience isn't quantified or standardized. I know many NICU nurses who are going for FNP who have never touched an adult patient in their careers. That is terrifying to me.

Seriously. No FNP programs require RN work experience. None. The only advanced practice nursing specialities that (for the most part) require RN work experience are CRNA (1 year ICU), NNP (1-2 years NICU) and ACNP (1 year ICU).

Yes, NP school was designed to build on a person's experience as a nurse. However, working as a nurse does not substitute for clinical training as a NP. Carrying out orders is completely different than diagnosing and developing treatment plans.

Don't even get me started on the "intensity" and difficulty" of NP programs...

I love how Jules A just threw down!

[KatieMI, BSN, MSN, RN]

While I agree that experience as a bedside RN is not the same as or a substitute for clinical training for an NP, is there not value in RN experience beyond mere "carrying out orders" (I know I don't just carry out orders in my job)?

In my personal experience, "bedside nursing" can be valuable for future NPs only if it implies what it should - assessments, certain degree of autonomy, critical thinking and coordination of care. The problem is, in so many places nurses are so busy with computer charting and "customer service" related tasks and so limited in their decisions due to policies/schmolicies regulating their every breath, that they virtually have no time to practice what they should do as bedside nurses. If nurses are prohibited from doing blood sugar checks without Holy Written Order, are disciplined for following every schmolicy to the letter whether it is clinically appropriate or not and have to respond on every silly request within 30 seconds of call light going on, they just do not have time to do full head-to-toe on every of 6 or 7 patients they care for on med/surg floor, although they are theoreticaly responsible for doing so.

One can do bedside for 10 years before desiding to go to NP school, but what the nurse actually did for those 10 years makes a lot of difference. If those 10 years were spent mastering a fine art of placing patients on bedpans, writing notes about Mrs. M. wanting her bagel toasted and call light easily accessible as per policy, holding hands, chatting about life, fluffing pillows and micromanaging every new hire - and not reading a single good textbook, much less learning new skills and changing areas every 3 to 5 years, - this seasoned nurse will not succeed despite of all her experience. She will become one of those pitiful, forever lost creatures who never forget to order CBC/diff q24h for 5 days and metodically sign all restrain papers as per policy, but otherwise have no idea what is going on with any of their patients.

Oh, the feeling of finding one of them doubling b-blocker dose for patient with HR of 120, no Foley and Levophed already flowing in and titrating up pretty quickly