Nurse Practitioner Workforce More Than Doubled, Study Finds

The nurse practitioner (NP) workforce more than doubled as the healthcare industry promoted the delivery of more primary care, according to new research from the University of Montana and Dartmouth College.

The number of full-time equivalent (FTE) NPs in the US increased from approximately 91,000 in 2010 to 190,000 in 2017, according to the analysis of Census Bureau data published in Health Affairs on Monday. At the same time, the number of registered nurses (RNs) who were not advanced practitioners increased by just 22 percent from roughly 2.5 million to 3.0 million, spelling trouble for hospitals and other acute care providers.

“Most RNs work in inpatient hospital settings, whereas the majority of NPs practice in primary care—typically in ambulatory care practices, where they collaborate with physicians, PAs, and other professionals. Thus, when RNs become NPs, this can lead to a net shift of labor out of the acute hospital setting,” wrote David Auerbach of Montana State University and coauthors.

Rapid growth in entry into NP programs spurred the recent increase in the NP workforce, the analysis found. NP graduates more than tripled from 2006 to 2007 to 2016 to 2017, with younger RNs entering NP programs at a record rate by the end of the period.

These NPs primarily stayed in the outpatient setting, with outpatient care centers and physician offices increasing the number of practicing NPs at their organizations by 142 and 125 percent, respectively. Meanwhile, the hospital-based NP workforce increased by 116 percent.

The overall growth in the NP workforce has been particularly rapid in outpatient clinics as health policy and care delivery shifted out of the acute care setting, Auerbach et al. explained.

NPs have filled critical gaps in the primary care setting, especially in rural settings. While the NP workforce rapidly grew, the physician workforce increased by only 9 percent from 2010 to 2017, the analysis showed.

A significant physician shortage is looming over the entire industry, but the slow growth in the physician workforce has hit rural areas particularly hard. A 2018 report from UnitedHealth Group found that rural residents were about five times more likely to live in a county with less than one primary care physician per 2,000 individuals compared to urban and suburban residents.

A recent relaxation of scope of practice laws in many states have enabled NPs and other advanced practice providers to alleviate problems stemming from physician shortages. Team-based care delivery promoted by population health management and value-based care models has also spurred more practices to hire NPs and the like to succeed under new arrangements.

Research shows the advanced practice providers have been effective in helping healthcare organizations maintain adequate patient access to care and appointment availability. The growth in the NP workforce has also been associated with reduced physician burnout.

While the growing NP workforce will continue to help fill gaps in value-based care delivery – demand is likely to keep growing, according to Auerbach et al. – hospitals may face staffing issues as a result.

“[N]ew RN graduates seem to be increasingly leaving hospital positions after only one or two years (during which time they acquire clinical experience) to begin a master’s degree or a doctor of nursing practice program,” the authors wrote. “While some of these RNs continue to work part time, others need to be replaced. Our analysis that showed the growth of the NP workforce outpacing that of the RN workforce is aligned with these observations.”

The analysis found that the reduction in the supply of RNs resulting from the relatively quicker growth in the NP workforce suggests that there were up to 80,000 fewer RNs than would have otherwise been the case.

The authors reassured hospitals that the increase in NPs is unlikely to result in such a large reduction in RNs that hospitals will face a “deep and prolonged” shortages of RNs, but hospital chief nursing executives will need to consider alternative staffing options.

“[E]ven in an era of strong RN workforce growth fueled by Millennials in particular, hospitals must innovate and test creative solutions to contend with tight or fluctuating RN staffing—as they have during past disruptions in their RN labor supply. Meanwhile, researchers should monitor and assess any signs of oversupply and differences in NPs’ effectiveness and quality of care by level and type of educational preparation,” they concluded.