Nurse Practitioners in Primary Care
Millions of Americans choose a nurse practitioner (NP) as their primary care provider. NPs are advanced practice registered nurses (APRNs) who are prepared at the master’s or doctoral level to provide primary, acute, chronic and specialty care to patients of all ages and backgrounds. As clinicians who blend clinical expertise in diagnosing and treating health conditions with an emphasis on disease prevention and health management, NPs bring a comprehensive perspective and personal touch to health care. Utilizing NPs to the fullest extent of their education and clinical training — especially in primary care — is critical to meeting the nation’s health care needs and combating chronic disease and rising health care costs.
Primary Care and NP Scope of Practice
NPs diagnose, treat and manage acute and chronic diseases, while emphasizing health promotion and disease prevention. NPs practice in every primary care setting, including but not limited to clinics, health care systems, health maintenance organizations, private physician offices, NP-owned practices, nursing homes, schools, colleges, public health departments, nurse managed clinics and homeless shelters.
NP practice includes, but is not limited to, assessing patients; ordering, performing, supervising and interpreting diagnostic and laboratory tests; making diagnoses; initiating and managing treatment, including prescribing medication and non-pharmacologic treatments; coordinating care; counseling; and educating patients, their families and their communities. NPs practice autonomously and, like other clinicians, coordinate with health care professionals to manage patients’ health needs. In all 50 states and the District of Columbia, NPs hold prescriptive authority, and they complete more than 1 billion patient visits annually.
NP Preparation and Growth of the NP Role
More than 88% of the 355,000 licensed NPs in the U.S. are educated and prepared in primary care, and more than 70% of those NPs who are clinically practicing deliver primary care, according to information from the American Association of Nurse Practitioners® (AANP) National NP Database (2021) and the 2020 AANP National NP Sample Survey.
NPs graduate from nationally accredited advanced degree programs that include didactic courses and clinical rotations. These programs are held accountable by the Commission on Collegiate Nursing Education (CCNE) and the Accreditation Commission for Education in Nursing (ACEN) to ensure core content and national education standards are maintained. Both CCNE and ACEN are recognized and accountable to the U.S. Department of Education for maintaining accreditation standards.
NPs are board certified and pass a standardized national certification exam. These exams are rigorous, psychometrically sound, legally defensible and competency-based. They test for knowledge and expertise in patient care. NP certification exams are accredited by the Accreditation Board of Specialty Nursing Certification (ABSNC) and the National Commission of Certifying Agencies (NCCA).
The NP role is consistent with the APRN Consensus Model, practicing in the population foci of family, pediatrics, women’s health, adult-geriatrics, neonatal and psychiatric mental health. The scope of practice is not setting specific, but rather, is based on the needs of the patient (APRN Consensus Model, 2008). Table 1 highlights the percentage of new NP graduates by examination for each primary care certification population.
Table 1 — Distribution of New NP Graduations* by Certification Exam, 2019-2020
| Percentage of All NP Graduations |
|
| Family | 65.3% |
| Adult Gerontology Primary Care | 8.4% |
| Psych Mental Health ** | 8.4% |
| Pediatric Primary Care | 3.3% |
| Women's Health | 1.7% |
| Non-Primary Care Certifications (e.g., Adult Acute Care, Neonatal and Pediatric Acute Care | 12.9% |
*Includes master’s, post-master’s, post-master’s DNP NP and BSN-DNP NP program graduate data.
**Psychiatric-mental health NPs are educated, licensed and certified as primary care providers with a population focus of psychiatric-mental health. As the number of patients seeking mental health care in primary care settings continues to grow, there is an increasing need to manage these conditions in primary care settings (Moise et al., 2021; Poghosyan et al., 2019).
NPs are one of the most rapidly growing provider groups within the primary care workforce. Recent estimates from the Bureau of Labor Statistics indicate the job outlook for NPs is expected to grow by 28% between 2018 and 2028, compared to overall job growth of just 5% for all occupations (Chi, 2020). Additionally, an increasing number of Medicare beneficiaries are seeing NPs for their primary care needs (Medicare Payment Advisory Commission, 2022). Within rural and underserved communities, NPs are providing a larger share of primary care to patients. NPs make up more than 25% of rural providers, and it is estimated that nearly 1 in 3 primary care providers nationwide will be an NP by the middle of the decade (Barnes et al., 2018).
The number of NP graduates is also rising to meet evolving health care needs within the U.S. In fact, data from the American Association of Colleges of Nursing indicates NP program graduations leading to certification in an area of primary care have increased consistently in recent years (see Table 2).
Table 2 — Growth in Primary Care NP Graduations* and Percentage Increase by Year, 2015-16 to 2019-20
| Year | Primary Care NP Graduations | % Change From Previous Year |
| 2015-2016 | 22,734 | 14.2% |
| 2016-2017 | 25,721 | 13.1% |
| 2017-2018 | 28,063 | 9.1% |
| 2018-2019 | 30,161 | 7.5% |
| 2019-2020 | 32,129 | 6.5% |
*Includes master’s, post-master’s, post-master’s DNP NP and BSN-DNP program graduate data.
Summary
For more than 50 years, NPs have provided patient-centered health care to a broad range of populations — with positive patient outcomes and cost savings observed. A brief review of studies examining NP outcomes is available in the Quality of Care Bibliography and NP Cost-Effectiveness position papers. Currently, our nation is facing new and emerging health challenges. As noted by the National Academies of Sciences, Engineering, and Medicine (2021), there is a critical need for all primary care providers to function at the fullest extent of their scope of practice. By establishing a strong health care system with a robust primary care workforce, the U.S. can better address its aging population, rising health care costs and the growing burden of chronic disease. NPs are key to building this solid foundation and bring added strength to the health care workforce. Maximizing this available potential is pivotal to addressing the current and emerging challenges.
References
American Association of Colleges of Nursing (2015-2021). Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing. Washington, D.C.
American Association of Nurse Practitioners. (2021). National Nurse Practitioner Database.
American Association of Nurse Practitioners. (2020). AANP National Nurse Practitioner Sample Survey. https://www.aanp.org/practice/practice-related-research/research-reports
Barnes, H., Richards, M. R., McHugh, M. D., & Martsolf, G. (2018). Rural and nonrural primary care physician practices increasingly rely on nurse practitioners. Health Affairs, 37(6), 908–914. https://doi.org/10.1377/hlthaff.2017.1158
Chi, J. (2020, March). Careers for nurses: Opportunities and options. U.S. Bureau of Labor Statistics. https://www.bls.gov/careeroutlook/2020/article/careers-for-nurses-opportunities-and-options.htm
Medicare Payment Advisory Commission. 2022. Report to the Congress: Medicare Payment Policy. Washington, DC: MedPAC
Moise, N., Wainberg, M., & Shah, R. N. (2021). Primary care and mental health: Where do we go from here? World Journal of Psychiatry, 11(7), 271–276. https://doi.org/10.5498/wjp.v11.i7.271
National Academies of Sciences, Engineering, and Medicine. (2021). The future of nursing 2020–2030: Charting a path to achieve health equity. Washington, DC: The National Academies Press.
National Council of State Boards of Nursing. (2008). APRN Consensus Model: The consensus model for APRN regulation, licensure, accreditation, certification and education. https://www.ncsbn.org/aprn-consensus.htm
Poghosyan, L., Norful, A. A., Ghaffari, A., George, M., Chhabra, S., & Olfson, M. (2019). Mental health delivery in primary care: The perspectives of primary care providers. Archives of Psychiatric Nursing, 33(5), 63–67. https://doi.org/10.1016/j.apnu.2019.08.001
©American Association of Nurse Practitioners
Revised May 2022