Advanced Practice Nurses as Primary Care Providers

Nurses in advanced practice are often underutilized especially in the context of health care reform. Given the existing and chronic undersupply of physicians, nurse practitioners expand the primary care provider stock. Patient managers and primary care providers, nurses in advanced practice have unique insights into care management and delivery models and enhance existing and new health delivery models.

In 1980 the medical-education community foresaw an oversupply of doctors, says Edward Salsberg, Director of the Center for Workforce Studies at the Association of American Medical Colleges, a nonprofit group of medical schools, teaching hospitals and academic societies . A cap on medical-school enrollment was instituted to control supply, but during that time U.S. population growth outpaced physician graduation and retention rates. The American Medical Association (AMA) says that as the U.S. population rose 31 percent between 1980 and 2003 as the number of U.S. medical school graduates remained static.

A 2008 survey of 12,000 doctors conducted by the Physicians' Foundation , a grant-making organization, found that nearly half of respondents plan to reduce their patient load or stop practicing in the next three years. The organization claims this percentage correlates to 150,000 physicians nationwide.

And, the Council on Physician and Nurse Supply says the United States may lack as many as 200,000 needed physicians by 2020 . The Bureau of Labor Statistics predicts there will be 212,000 physician openings by 2014 due to growth and net replacement of retiring physicians. That number represents more than 25 percent of the current physician work force.

Although the Bureau of Labor Statistics inappropriately merges advanced practice nurses into the registered nursing category, thereby making it hard to track and effectively count APN and make comparison to MD statistics, the 2009 Pearson Report conducts an annual survey of nurse practitioners and indicates that there are 147,295 nurse practitioners in the United States. CNN estimates that there are 19,000 nurse anesthetists. The National Association of Clinical Nurse Specialists uses the National Nurse Sample survey estimate of 75,000 clinical nurse specialists. The American College of Nurse-Midwives has more than 6300 members. Additionally, each year approximately 400 nurse-midwives pass the national certification exam. Thus, there are almost 250,000 nurses in advanced practice and the rate of growth of this branch of nursing practice is growing exponentially each year. In 2004, 62% of NPs in all specialties reported seeing approximately 3 to 4 patients in an hour, and 27% reported seeing 1 to 2 patients an hour. Twenty-seven percent reported they take calls. Seventy-one percent of the NPs reported having a physician available on site between 45% and 100% of the time.

Thus, the numbers and rate of growth of the profession over the past decade clearly reflects a supply of providers who can augment and expand the primary care system. Combine the profession doubling its numbers since 2000 with the expansion of the profession to incorporate doctorates in nursing practice, and it is clear that the advanced practice nursing supply is not only growing, but, also expanding its knowledge base to better serve the public.

With educational programs structured to address primary, specialty care, and related health administrative and management services, advanced practice nurses are the providers of care in retail clinic settings, hospitals and urgent care centers and private practices. They provide care in over thirty (30) different specialties to include women's health, oncology, geriatrics and pediatrics. Experienced nurse practitioners or DNPs often teach, conduct medical research, own or administer new health ventures to include health clinics, pharmaceutical research or cutting edge genometric or life sciences business enterprises.

Clinical nurse specialists are also specifically trained in patient teaching/ disease prevention and patient management, and are typically involved in case/patient management and health systems support/quality improvement/risk management in health concerns, facilities or systems. Nurse anesthetists work in virtually any setting where there is a need for anesthesia or pain management; and nurse midwives provide obstetric and gynecological services.

The American Association of Colleges of Nursing’s policy of adoption of the Doctor of Nursing Practice (DNP) as the entry level practice degree for advanced practice nurses by 2015 has led to the movement towards DNP practice. Presently, there are over 122 DNP programs and over 100 schools considering expanding their nursing programs to accommodate the DNP. While issues still exist related to the appropriateness or incorporation of the doctorate into the regulatory network, nurse practitioner students are entering these programs.

The convergence of acceptance of nurses in advanced practice as primary care providers, and the creation of DNP programs, with the long-term physician shortage should compel the public to think about the use of advanced practice nurses as primary care providers.