He a l t h w o r k f o r c e planning for

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The New Generation Of Nurse

Practitioners: Is More Enough?

A boom in nurse practitioner education has added significantly to the

workforce of clinicians. Where can nurse practitioners’ expertise best be used?

b y D o r een C . H ar p er a n d Je a n Jo h n s o n

H

e a l t h wo r k f o r c e planning for

the twenty-first century has entered a new era with recent changes in the supply of and demand for clinicians. The em-phasis on producing primary care clinicians has shifted from an assumption of undersup-ply in the early 1990s toward a possible sur-plus in today’s market. Policymakers and health care executives continue to be con-cerned with finding the appropriate mix and distribution of clinicians to maximize quality and minimize cost.

Nurse practitioners (NPs) have been part of the health professional workforce for more than three decades and have contributed sub-stantially to providing primary and preventive care throughout the nation. Although NPs are prepared to provide up to 80 percent of the tasks performed by generalist physicians in primary care settings, they often are under-used in these settings.1Since NPs form a

sig-nificant portion of the primary care work-force, it is important to examine changes in the production of NPs, such as educational preparation, that influence NP supply and overall health workforce policy. This paper explores three key policy questions related to the NP workforce: (1) How is the supply of NPs changing? (2) How does the NP work-force “fit” within the context of advanced practice and professional nursing? (3) What

is the appropriate mix of primary care clini-cians required for the future health work-force?

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OLICY

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ORCES

I

NFLUENCING

NP

P

REPARATION

Health policy recommendations and market trends converged to augment the role and preparation of NPs in the 1990s. In 1993 Presi-dent Bill Clinton’s health care reform initia-tive provided policy support for NPs as pri-mary care providers. During this period the Pew Health Professions Commission recom-mended expanding the use of NPs and called for a doubling of the NP workforce by 2005.2

The Institute of Medicine explicitly recog-nized NPs as an integral part of the primary care team.3 In addition, several national

re-ports and literature reviews recognized NPs as affordable, accessible, high-quality care providers.4The recent passage of direct

Medi-care reimbursement for NPs reflected public policymakers’ continuing support for NPs as primary care providers.5 These policy

state-ments coincided with and likely contributed to a growth spurt in the NP workforce during the 1990s as graduate NP programs expanded within schools of nursing.

The financial support of the federal govern-ment also has been instrugovern-mental in developing

Doreen Harper is director of community partnerships and faculty practice at George Mason University, in Fairfax, Virginia, and director of the nurse practitioner program at the George Washington University School of Medicine and Health Sciences in Washington, D.C. Jean Johnson is associate dean for the health sciences programs at the George Washington University School of Medicine and Health Sciences and project director of the Partnerships for Training Initiative of the Robert Wood Johnson Foundation.

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the role of the NP. NP educational programs have received consistent appropriations since 1976 from the U.S. Department of Health and Human Services (HHS) Division of Nursing Programs through Title VIII under Section 822 of the Public Health Service Act.6

Appro-priations have ranged from $3 million in 1976 to $16 million in 1996, with these awards sup-porting seventeen and sixty-five grants, re-spectively, and more than 1,500 programs (al-though growth in the number of programs led to a decrease in the percentage of total pro-grams supported by the federal government).7

From 1965 to 1977 NP programs offered tra-ditional primary care clinical tracks (adult, family, women’s health, and pediatrics) for relatively small clusters of students in a variety of institutional settings. Initially, NPs were educated through continuing education pro-grams located in schools of medicine, hospi-tals, and other private organizations, such as Planned Parenthood. From 1978 to 1990 these educational programs were incorporated into graduate schools of nursing. By 1990 the ma-jority of NPs received educational preparation in master’s-level nursing programs. Graduate programs for NPs grew slowly but steadily during this time with federal support through Title VIII funding. At the same time, NP prac-tice became firmly established in the regula-tory environment, with nearly every state rec-ognizing NP practice in respective nurse practice acts.8In addition, the acquisition of

reimbursement from third-party payers and prescriptive authority strengthened the prac-tice potential.9

The progressive growth between 1978 and 1990 established a substantial infrastructure for supporting NP education. Therefore, in the early 1990s, when policymakers called for increased numbers of primary care providers, graduate NP programs were positioned and eager to meet this demand.10These programs

continued to expand as increases occurred in the number of institutions initiating NP pro-grams, the number and types of NP clinical tracks being offered, and the number of stu-dents and faculty in these programs. The NP educational enterprise became a significant

part of the graduate nursing education pro-gram, and a new emphasis was placed on post-master’s NP programs designed for post- master’s-prepared clinical nurse specialists and nurse managers. As the health care system shifted hospital nursing resources toward commu-nity-based care, these master’s-level nurses sought additional NP preparation.

This expansion in graduate nursing pro-grams has generated controversy regarding the number, distribution, and types of NPs needed in the future health workforce. The prevailing wisdom is that there is no need to increase the supply of NPs, but other litera-ture highlights the cost savings associated with an increased supply of all types of NPs.11

The use of NPs in large group practices also has been cited as an alternative to expanding the primary care physician workforce.12

D

ESCRIBING

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HE

NP

E

DUCATIONAL

E

NTERPRISE

To assess the preparation and supply of nurse practitioners, the National Organization of Nurse Practitioner Faculties (NONPF) con-ducted three surveys of NP programs span-ning the period from 1990 to 1995.13Surveys

were sent to institutions in the spring of 1991, 1993, and 1995. Each survey asked for informa-tion for the current year as well as previous years. The findings of these three surveys have allowed NONPF and NP educators to begin to assess changes in the NP workforce during a critical time of change. The results are in-tended to contribute to the discussion on workforce policy recognizing the need to in-tegrate workforce information about nurses, physician assistants, and physicians to de-velop a rational, overall workforce policy at the national, state, and local levels.

NP programs were identified using multi-ple strategies, including the 1992 and 1994

NONPF National NP Education Program Directory

for the year of the survey, self-referral, referral by other program directors, and advertising in NONPF and other NP organizational news-letters. Surveys were distributed to NP pro-gram directors and/or coordinators. Multiple

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attempts were made to include all NP pro-grams in each survey. Data collection ex-tended from April through October for each of the surveys, with repeated mailings and tele-phone follow-up to nonresponders.

Although other sources of data on graduate nursing programs have provided summaries of NP program changes, the NONPF surveys collect information and track trends about NP preparation at all levels, including master’s, post-master’s, and certificate or post-basic registered nurse (RN)

pro-grams.14 Master’s and

post-master’s programs are offered as graduate course work and award graduate degrees or credit in schools of nursing, whereas post-basic RN pro-grams most often award con-tinuing education credits. Pre-requisites for the graduate NP programs include RN licen-sure, a bachelor’s degree in nursing for master’s prepara-tion or an RN license, and a master’s degree in nursing for post-master’s preparation. NP

educational programs are defined as the edu-cational structure in which one or more NP clinical tracks are offered. NP clinical tracks, in turn, offer curriculum and supervised clini-cal experiences that match standards in spe-cific practice areas such as family (FNP), adult (ANP), geriatrics (GNP), pediatrics (PNP), women’s health (WHNP), neonatal (NNP), and acute care (ACNP).15

The first survey (1988–1990) was sent in 1991 to 101 institutions representing 210 clini-cal tracks; 147 tracks responded for a response rate of 70 percent. The second survey (1991–1992) was sent in 1993 to 119 institu-tions representing 253 tracks; 173 tracks re-sponded for a response rate of 68.5 percent. The third survey (1993–1995) was sent in 1995 to 391 programs at 202 institutions repre-senting 527 tracks; 423 tracks responded for a response rate of 80 percent. The unit of analy-sis is the clinical track (family, adult, women’s health, and pediatrics). Respondents for each

of these three surveys constituted the sample for the known universe of NP programs.

The results of these surveys show a strik-ing increase in the number of institutions that offer NP programs and in the number of clini-cal tracks offered. The number of academic institutions with NP tracks increased from 101 in 1990 to 119 in 1992 to 202 in 1995. The number of clinical tracks more than doubled between 1992 and 1995, increasing from 210 in 1990 to 253 in 1992 to 527 in 1995. The prepa-ration of NPs occurs predomi-nantly in master’s and post-master’s programs, and there were huge increases between 1992 and 1995 in the number of programs at each of these lev-els. In 1992 there were nine-teen certificate programs, eighty-eight master’s pro-grams, and thirty-seven post-master’s programs. By 1995 these numbers had increased to twenty-nine certificate pro-grams, 383 master’s propro-grams, and 252 post-master’s pro-grams.

The largest growth in actual numbers of tracks occurred in the family and adult NP primary care tracks (Exhibit 1). However, the greatest increase occurred in specialty tracks. Specialty tracks represented 18.2 percent of all NP tracks in 1992 and 23.2 percent in 1995. Within the specialty tracks, the acute care, other, and psychiatric NP tracks increased at the highest rates.

We found moderate increases in the num-bers of NP program applicants, enrollees, and graduates between 1990 and 1992, followed by slight decreases in 1993 and substantial in-creases after 1993 (Exhibit 2). The decrease in 1993 might be spurious because of the rapid increase in new programs and the variability in item response rates among new program directors who were not familiar with the NONPF survey. Approximately 50 percent of enrollees in master’s and post-master’s tracks in 1995 were part-time students. The total number of graduates increased from 1,537 in

“NPs increasingly

serve as the clinical

decision-making

experts within

nursing because of

their diagnostic,

management, and

prescriptive skills

and training.”

160

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1992 to 3,105 in 1995; however, the increase in graduations lagged behind the increase in en-rollees because of the large number of part-time students. In 1995, 80.9 percent of enrollees (6,414) sought master’s-level preparation, while 13.3 percent (1,057) were in post-mas-ter’s programs and 5.7 percent (455) were in post-basic RN certificate tracks.

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MPLICATIONS n CHANGE IN SUPPLY. In the early 1990s, when the policy community gave a green light to educational institutions to increase nurse practitioner production, some institutions saw an opportunity to prepare a cadre of NPs who could provide services to specific con-stituents, particularly underserved popula-tions. Others saw an opportunity to alleviate budgetary pressures by expanding tuition revenue and gaining access to federal support (albeit limited) for NP programs. Our findings show a dramatic increase in the number of NP students and graduates throughout this pe-riod as well as an increase in the number of programs and tracks offered.

At the same time that support for primary

care and NP practice increased, a decline in hospital bed days resulted in less need for hospital-based nurses. In response to poten-tial job loss and a perceived positive climate for primary care, many nurses who were al-ready prepared at the master’s level as clinical nurse specialists opted to pursue retraining as NPs in post-master’s programs. Our survey findings reflect this changed health care envi-ronment, showing notable program growth in master’s and post-master’s programs. There also were indications that NP practice was expanding into new clinical areas as evi-denced by new types of tracks, particularly in acute care and psychiatry. The increase in acute care NP students likely reflects the in-creased demand from hospitals and other acute care settings as the resident pool re-cedes and the retraining of nurses already in acute care settings.16

The implications of the increase in the number of NPs are not yet known. Some have expressed concern about a potential oversupply of NPs.17Others believe that the demand for

NP services will continue to grow because managed care organizations find NPs to be EXHIBIT 1

Growth In Primary Care And Specialty Tracks For Nurse Practitioners, 1992 And 1995

1992 1995

Primary care tracks Family practice

Women’s health and OB/GYN Adult health 71 31 30 141 58 73 School health Pediatrics Gerontology 3 37 35 6 69 58 Total 207 405 Specialty tracks Neonatal care Acute care 27 1 33 26 Occupational therapy Psychiatric care Other 3 3 12 6 21 36 Total 46 122

SOURCE: National Organization of Nurse Practitioner Faculties, 1992 and 1995.

NOTES: OB/GYN is obstetrics and gynecology. “Other” includes acute care subspecialties such as pediatric critical care, neurosurgical cardiology, and tertiary care.

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cost-effective providers.18The original calls to

double the NP workforce have abated with recommendations that the rapid expansion of programs stabilize.19

n THE NURSING PROFESSION. Discus-sions of the NP workforce have centered on the numbers needed in primary care to bal-ance the supply and demand of physicians and physician assistants. Although these are important discussions, they tend to overlook the roles and potential roles that NPs play as part of the nursing profession. NPs increas-ingly serve as the clinical decision-making ex-perts within nursing because of their diagnos-tic, management, and prescriptive skills and training. This definition of NPs’ role goes be-yond the settings in which they work or the populations they serve and focuses on their clinical expertise.

If we look at NPs as clinical nursing ex-perts, the supply issue takes on a different perspective. Based on the HHS Division of Nursing’s National Sample Survey of Regis-tered Nurses data for 1996, an estimated 2.5 million nurses are currently licensed, of whom about 71,000 are prepared as NPs.20NPs

there-fore represent approximately 2.8 percent of the total nursing workforce. They represent

44 percent of all advanced practice nurses, who represent about 6.3 percent of the total RN population.21By these estimates, NPs are a

very small percentage of all nurses. From a professional perspective, nursing practice would be enhanced if a greater portion of nurses were NPs. Allowing NP production to grow until NPs represent a substantial por-tion of the total nursing workforce would en-hance the clinical decision-making capacity of nurses in all settings.

n FUTURE WORKFORCE NEEDS. The spiraling changes in the NP supply are paral-leled in the supply of physician assistants.22

When combined with the existing physician supply, these increases in the numbers of NPs and physician assistants are likely to contrib-ute to a clinician surplus.23Absent a national

health policy, interactive factors such as mar-ket forces, provider preference, and federal and state support will continue to determine the size, composition, and distribution of the clinician workforce. Specific policy-making bodies, foundations, and organizations have recommended a reduction and/or stabiliza-tion within specific disciplines to balance supply and demand.24

When we discuss the appropriate mix of

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providers, we assume some division of labor among persons with complementary skills. However, we know very little about what team composition will provide the most effec-tive care at the least cost. The increased older population and its attendant chronic disease burden will expand the need for clinical serv-ices across settings, and the optimal use of NPs could help to improve this population’s access to health care and preventive services. Likewise, managed care organizations that seek to deliver cost-effective care to their en-rollees could expand their use of NPs and physician assistants in interdisciplinary teams based on scope of practice.

Models of interdisciplinary team practice should be factored into the development and planning of the health workforce. Innovative models of interdisciplinary team practice, particularly for delivering services to the chronically ill and other populations in man-aged care, would provide opportunities for matching the mix of clinicians with popula-tions’ needs. Steps for the creation of a coher-ent workforce model might include (1) estab-lishing a dialogue among these disciplines and policymakers by forming a consortium of rep-resentatives from educational and profes-sional organizations; (2) establishing national and state policy for health workforce needs; and (3) conducting research to determine how interdisciplinary teams can best be used in population-based care and chronic care to improve cost-effectiveness and clinical out-comes.

N

u r s e p r a c t i t i o n e r workforce production has expanded rapidly. The data on NP education in this pa-per can be used to inform policymakers and others interested in primary care workforce issues. The phenomenal growth of the NP educational enterprise in graduate nursing programs represents a transition that should be monitored to assess whether the current level of NP production will result in a surplus, a deficit, or an appropriate number of NPs in the twenty-first century. Purposeful work-force planning for the health professions

should consider all disciplines, including phy-sicians, physician assistants, NPs, and nurses. Such planning calls for national and statewide policy to guide the production and distribu-tion of all clinicians.

Support for this work was provided by the W.K. Kellogg Foundation. The authors thank Janet Allan, Jan Bull, Patricia Burns, Catherine Gilliss, Charlene Hanson, Tim Henderson, and Mary Wakefield for their review and comments and Ann Lindblom for her assistance.

NOTES

1. L. Nichols, “Estimating the Cost of Underutiliz-ing Advanced Practice Nurses,” NursUnderutiliz-ing Economics 10, no. 5 (1992): 343–351.

2. Pew Health Professions Commission, Critical

Challenges: Revitalizing the Health Professions for the Twenty-first Century (San Francisco: UCSF Center

for the Health Professions, 1995); Pew Health Professions Commission, Nurse Practitioners:

Dou-bling the Number of Graduates by the Year 2000 (San

Francisco: UCSF Center for the Health Profes-sions, 1994).

3. Institute of Medicine, Primary Care: America’s

Health in a New Era (Washington: National

Acad-emy Press, 1996).

4. Pew Commission, Critical Challenges; Pew Com-mission, Nurse Practitioners; Council of Graduate Medical Education and National Advisory Council on Nurse Education and Practice, Report

on PrimaryCare Workforce Projections (Washington:

U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions, December 1995); and Alliance for Health Reform, The Twenty-first

Century Nurse (Washington: Alliance for Health

Reform, 1996).

5. M. Koehler, “Direct Medicare Reimbursement for All NPs and CNSs,” Nurse Practitioner World

News (September/October 1997): 21–22.

6. National Advisory Council on Nurse Education and Practice, Federal Support for the Preparation of the

Nurse Practitioner Workforce through Title VIII,

Re-port to the Secretary of Health and Human Serv-ices (Washington: DHHS, HRSA, BHPr, Divi-sion of Nursing, 1997).

7. Ibid.

8. B. Safriet, “Health Care and Regulatory Sense: The Role of Advanced Practice Nursing,” Yale

Journal on Regulation 9, no. 2 (1992): 149–220.

9. L. Pearson, “Annual Update to How Each State Stands on Legislative Issues Affecting Advanced Nursing Practice,” Nurse Practitioner 23, no. 1 (1998): 14–29.

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10. Pew Commission, Critical Challenges; Pew Com-mission, Nurse Practitioners; and COGME/Na-tional Advisory Council, Report on Primary Care

Workforce Projections.

11. R. Cooper, “Perspectives on the Physician Workforce to the Year 2020,” Journal of the

Ameri-can Medical Association 274, no. 19 (1996):

1534–1543; and Nichols, “Estimating the Cost of Underutilizing Advanced Practice Nurses.” 12. E. Ginzberg, “Physician Personnel: What Next?”

Pharos (Summer 1996): 44–45; and D.A.

Grandinetti, “Will Patients Choose NPs over Doctors?” Medical Economics 74, no. 14 (1997): 134–151.

13. D. Harper and J. Johnson, Workforce Policy Project

Technical Report: Nurse Practitioner Educational Pro-grams, 1988–1995 (Washington: National

Organi-zation of Nurse Practitioner Faculties, 1996). 14. National League for Nursing, Nursing Datasource

1994: Volume II—Graduate Education in Nursing: Ad-vanced Practice Nursing, Pub. no. 19-2643 (New

York: NLN, 1994); American Association of Col-leges of Nursing, 1994–1995 Special Report on

Mas-ter’s and Post-MasMas-ter’s Nurse Practitioner Programs, Faculty Clinical Practice, Faculty Age Profiles, Under-graduate Curriculum Expansion in Baccalaureate and Graduate Programs in Nursing (Washington:

AACN, 1995); and L.E. Berlin, G.D. Bednash, and D.L. Scott, “1995–1996 Enrollment and Gradu-ations in Baccalaureate and Graduate Programs in Nursing” (Washington: AACN, 1996). 15. Harper and Johnson, Workforce Policy Project

Tech-nical Report.

16. Ibid.; and R. Riportella-Muller, D. Libby, and D. Kindig, “The Substitution of Physician Assis-tants and Nurse Practitioners for Physician Resi-dents in Teaching Hospitals,” Health Affairs (Sum-mer 1995): 181–191.

17. National Advisory Council, Federal Support for the

Preparation of the Nurse Practitioner Workforce.

18. P. Buerhaus and D. Staiger, “Future of the Nurs-ing Labor Market AccordNurs-ing to Health Execu-tives in High Managed-Care Areas in the United States,” Image 29, no. 4 (1997): 313–318.

19. Harper and Johnson, Workforce Policy Project

Tech-nical Report.

20. E. Moses, The Registered Nurse Population: Findings

from the National Sample Survey of Registered Nurses

(Washington: DHHS, HRSA, BHPr, Division of Nursing, March 1996).

21. National Advisory Council, Federal Support for the

Preparation of the Nurse Practitioner Workforce.

22. J. Cawley, “A Coming Health Professions Glut,”

Perspective on PAEducation (Spring/Summer 1996):

1–2.

23. S. Schroeder, “How Can We Tell Whether There Are Too Many or Too Few Physicians? The Case for Benchmarking,” Journal of the American Medical

Association 276, no. 22 (1996): 1841–1843.

24. Harper and Johnson, Workforce Policy Project

Tech-nical Report; National Advisory Council, Federal Support for the Preparation of the Nurse Practitioner Workforce; and R.M. Politzer et al., “Matching

Physician Supply and Requirements: Testing Policy Recommendations,” Inquiry (Summer 1996): 181–194.

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