COMMENTARY

Growth of the Nurse Practitioner Workforce

Laurie Scudder, DNP, NP

Disclosures

April 12, 2012

Will the NP Workforce Grow in the Future? New Forecasts and Implications for Healthcare Delivery

Auerbach DI
Med Care. 2012; Feb 17. [Epub ahead of print]

Study Summary

The nurse practitioner workforce. The shortage of primary care physicians is a well-recognized problem that is likely to worsen. An increase in demand for primary care providers is anticipated in response to a projected flood of patients into the healthcare system as the Patient Protection and Affordable Care Act is fully implemented. Policymakers have increasingly turned their attention to nurse practitioners (NPs) as a critical means to fill the gap. However, estimates of future growth in the NP workforce are complicated by factors such as the average age of NPs, differing projections for full-time equivalents (FTEs), fluctuating school enrollments, and difficulties in estimating how many NPs will remain in clinical practice. These internal dynamics have contributed to widely varying forecasts for growth in the NP workforce. The purpose of this study was to apply a novel method that has been used to project registered nurse (RN) and physician workforces.

Study methodology. The National Sample Survey of Registered Nurses (NSSRN)[1] of 2008 was the primary data source for this study. The NSSRN is a random survey of more than 30,000 RNs and has been conducted every 4 years since 1977. The NSSRN began to include data about NPs in 1992. Additional information about the numbers and age distribution of NPs was obtained from the American Academy of Nurse Practitioners. Data on number of students enrolled in and graduated from NP educational programs were obtained from the American Association of Colleges of Nursing. Finally, population forecasts for both age and sex were obtained from the US Census Bureau. An age-cohort regression analysis was conducted using varying assumptions about future population growth and numbers of NPs in the workforce after considering life-cycle effects such as childbearing and retirement.

Results. The NP workforce, which grew rapidly from 1992 to 2004, continued to expand, although more slowly, from 2004 to 2008. Furthermore, the growth in proportion of NPs in the RN population has slowed recently. Nurse practitioners are also getting older, as evidenced by a near doubling of the proportion of full-time NPs over the age of 50 years from 1992 to 2008.

An examination of number of NPs by grouping the workforce according to decade of birth found that each successive cohort produced more NPs than the previous cohort. For example, NPs born in the 1970s far surpassed NPs born in the 1950s in terms of both overall number and average number of hours worked. The NPs who entered the workforce recently are slightly younger than earlier cohorts and spent less time working as RNs before beginning their NP education.

In the current study, Auerbach estimates that the NP workforce can be predicted to continue to grow steadily, with an additional 6000-7000 NPs entering the profession annually. This will represent a 94% increase in the number of NPs between 2008 and 2025. When the analysis is limited to NPs who consider their position title to be "NP" rather than administrator, educator, or some other role, the workforce is projected to grow from 86,000 FTEs in 2008 to 198,000 FTEs in 2025, an increase of 130%. From 1992 to 2008, the percentage of NPs who considered their position title to be "NP" increased from 47% to 67%.

Viewpoint

This study offers the most comprehensive analysis of the NP workforce to date, taking into account both the aging of the RN and NP populations and the wide-ranging roles of NPs, many of which do not involve direct patient care. Still, the study is subject to some limitations. Of greatest importance, the NSSRN had a fairly small number of NP respondents because NPs have been specifically identified in the survey only since 1992, long after the role was established and well recognized. With that understanding, the continuing growth in the NP role seems to bode well for the future of primary care.

It is interesting to speculate on the reasons for the large increase in proportion of NPs who consider their job title to be "NP." With the growing recognition and support for the NP role, more NPs are able to find clinical positions that appropriately use their education and skills, and NPs are not forced to work outside of their field, in stark contrast to the milieu that characterized the early decades of the NP role.

The influence that the growth of the NP workforce will have on physician/NP ratios is of critical importance. Currently, that ratio is 5:1 but it is anticipated to fall to 3:1 by 2025. When limited to clinicians practicing in primary care (where approximately half of all NPs are assumed to practice) the ratio declines from its current 4:1 to only 2.3:1. The first recommendation made by the Institute of Medicine in its Future of Nursing report[2] was the removal of scope-of-practice barriers for all advanced practice nurses to allow these professionals to practice to the full extent of their education and training. Auerbach's data make NPs' continuing struggle to remove these artificial barriers to practice even more imperative.

Abstract

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