Nurse Practitioners in Primary Care

With 89 percent of the nurse practitioner (NP) population prepared in primary care and more than 75 percent of actively practicing NPs providing primary care, NPs are a vital part of the U.S. primary care workforce. Evidence supports the high quality and cost effectiveness of NP care and the continued interest of the discipline to contribute to solving the primary care dilemma.


Ninety percent of the 192,000 NPs credentialed to practice in the U.S. are actively practicing. Fulfilling the potential of the Affordable Care Act (ACA) requires transformation of primary care delivery within the U.S. NPs are a vital element of the primary care workforce, with a major role in making high-quality, patient-centered health care available to the broadest possible range of consumers. In fact, NPs make up the most rapidly growing component of the primary care workforce. As licensed, independent providers, with a blend of medical and nursing preparation, NPs are uniquely qualified to provide the patient-centered care that is central to meeting the existing and future primary care needs of our nation.

NP Scope of Practice and Preparation

The NP scope of practice includes blending nursing and medical services for individuals, families and groups. NPs diagnose and manage acute and chronic conditions and emphasize health promotion and disease prevention. Their services include, but are not limited to: ordering, conducting and interpreting diagnostic and laboratory tests; prescribing pharmacologic agents and non-pharmacologic therapies; and teaching and counseling. They practice autonomously and in collaboration with other health care professionals to manage patients’ health needs. NPs are prepared through academic graduate (master’s or doctoral) programs, which include didactic and clinical courses designed to provide graduates with specialized knowledge and clinical primary care competencies. Members of the profession are responsible for advancing the NP role, specifying the professional standards and competencies, as well as ensuring that these are met.

NP Commitment to Primary Care

Almost all NPs (89 percent) are prepared in a primary care focus, e.g., adult, family, gerontological, pediatric or women’s health. The family NP (FNP) focus is the most prevalent category (see below). Regardless of their population focus, primary care NPs are prepared to fulfill the definition of primary care across settings, including the provision of care at first contact for undifferentiated conditions, ongoing management of acute and chronic conditions, health promotion and care coordination.

Specialty Percent
Acute Care 5.3
Adult 17.9
Family 49.2
Gerontological 3.0
Neonatal 2.3
Oncology 0.8
Pediatric 9.4
Psychiatric/Mental Health 2.9
Women’s Health 9.1

NP Growth

Over the past few years, the enrollment and graduation rates of NP programs have consistently increased, with a growing trend towards a greater percentage of NPs being prepared in family health and a steady percentage providing primary care. Enrollment and graduation rates for programs over the past five academic years are summarized below.

Years Enrollments Graduations
2005-2006 22,115 6,556
2006-2007 25,473 7,197
2007-2008 28,744 7,550
2008-2009 31,445 8,451
2009-2010 35,371 9,203

NP Quality and Cost Effectiveness

Four decades of evaluation and research on NP practice consistently support the high quality and cost effectiveness of NP care. In early 2010, having reviewed the literature regarding NPs, Bauer concluded that there is extensive and consistent evidence that NPs provide care of equal or better quality at a lower cost than comparable services provided by others. In the 2010 Institute of Medicine (IOM) report, “The Future of Nursing: Leading Change, Advancing Health,” Safriet described the “proven track record” of advanced practice registered nurses (APRNs), such as NPs, to provide care across populations and settings.

NPs in Rural Health

Compared to other primary care disciplines, NPs are most likely to practice in rural communities. Indeed, 18 percent of NPs practice in communities of fewer than 25,000 residents. In states with both a favorable regulatory environment and a large percentage of rural residents, NPs are significantly more likely to practice in rural settings. The five states with the greatest reported percentage of NPs in rural areas are Vermont (56 percent), South Dakota (50 percent), Wyoming (43 percent), Montana (40 percent) and Maine (39 percent). By contrast, Texas has both great expanses of rural communities and restrictive supervisory requirements; only 13 percent of Texas NPs practice in communities of fewer than 25,000 residents.

NPs and Select Populations

The vast majority of FNPs (93 percent) and Adult Specialty NPs (ANPs) (97 percent) treat patients between the ages of 66 and 85 yea. The majority of FNPs (79 precent) and ANPs (84 percent) treat patients older than 85. More than 88 percent of both FNPs and ANPs accept Medicare patients, and more than 80 percent of both groups accept Medicaid patients. Almost 60 percent of FNPs and ANPs accept charitable or uncompensated patients. Both FNPs and Pediatric NPs (PNPs) are likely to treat young children. Eighty-nine percent of PNPs report treating children covered by Medicaid as their primary coverage. Most (74%) PNPs report that they are currently accepting new patients with Medicaid.



Summary

For more than 45 years, NPs have provided patient-centered health care to a broad range of populations. The American Association of Nurse Practitioners’ (AANP) vision for the future calls for high-quality health care for all by the patient’s provider of choice. There is a critical need for all primary care providers to practice to the full extent of their scope of practice. As our nation faces the future challenges of an aging population, rising health care costs and the growing burden of chronic disease, NPs bring strength to the health care workforce and maximize our available potential to address these challenges.


References

American Association of Nurse Practitioners (AANP) (2013). Scope of practice for nurse practitioners. Retrieved April 2013.

AANP (2013). Standards of practice for nurse practitioners. Retrieved April 2013.

AANP (2013). Nurse practitioner cost effectiveness. Retrieved April 2013.

AANP (2013). Documentation of quality NP care. Retrieved April 2013.

Bauer, J.C. (2010). Nurse practitioners as an underutilized resource for health reform: Evidence-based demonstrations of cost-effectiveness. JAANP, 22 (4), 228-231.

Goolsby, M. (2011). 2009-2010 AANP national nurse practitioner sample survey: An overview. JAANP, 23 (5), 266- 268.

Institute of Medicine (2010). The future of nursing: Leading change, advancing health. Washington, DC: National Academies of Science.

National Task Force of Quality Nurse Practitioner Education (2008). Criteria for the evaluation of nurse practitioners programs. Washington, DC: Author.

NONPF (2013). Population-focused nurse practitioners competencies. Retrievied April 2013.

Nurse Practitioners in Primary Care