The use of non-physician advanced practitioners, especially in primary care, has been touted as a solution to filling looming physician shortages, which are only expected to get worse as the decade marches on.
While that sounds great in practice, medical group and hospital executives considering or already planning to tap NPs to fill physician gaps should understand that in reality there are barriers in the way, notably diversity, expanding education programs and regulations that prevent these clinicians from practicing at the top of their license.
What's needed now? Education and diversity. Those are longer-term fixes, of course, and hospitals can take some steps in the meantime.
Nurse practitioner educational programs: More needed
Already, populations of nurse practitioners tend to be higher in counties where more primary care physicians operate -- showing that already underserved counties with a fewer doctors also had fewer nurse practitioners, potentially exacerbating a gap in care access, according to a study in Health Affairs.
Nurse practitioner education also seemed to fall along those same lines. California has 23 nurse practitioner education programs and 11 of them are in counties where the density of both physicians and NPs is higher. Only eight of them were in counties where those populations were lower, the study said. Going further, NPs living in counties with high NP and physician density reported that their initial RN education was bachelor's degree and their initial NP education was an entry level master's degree. That compares to NPs in counties with low NP/physician populations whose initial RN education was an associate's degree.
"Nurse practitioner education programs designed for nurses with associate degrees could help address primary care shortages," the study said.
Results of the research, which was based on data from 1,270 nurse practitioners in California, found that employed NPs who lived in counties with high nurse practitioner or physician density reported that they less often were "always allowed to practice to the full legal scope of practice" or to always use their nurse practitioner skills fully, compared to those in other counties.
Also, NPs in the counties with high NP or physician density more often reported that scope-of-practice restrictions were an important barrier to providing high-quality care. However the differences between the high density counties and others were not significant, indicating that these problems are ubiquitous. In twenty-two states and the District of Columbia, NPs can care for patients without physician collaboration or supervision. Other research has indicated patient support for NPs taking a greater role in care, as well as patient satisfaction with the care they give.
"A large and growing body of research demonstrates comparable performance between nurse practitioners and physicians on primary care clinical outcomes, even when nurse practitioners practice without physician supervision, and that access improves when nurse practitioners do not face physician supervision requirement," the study said.
Aging and diversity are problems and opportunities
As with the aging physician population, more than 40 percent of NPs in California are 55 and older. Growing the number of new graduates is essential to making sure the industry doesn't end up with a shortage here too.
"Only eight of California's twenty-three nurse practitioner education programs are located in counties with lower-than-average nurse practitioner and physician density. Surveys have revealed that more than half of recently graduated RNs work within forty miles of where they attended high school. Some nurse practitioner education programs offer expanded distance education opportunities for rural students but face difficulty securing enough clinical training sites and faculty," researchers said. "These challenges need to be addressed to expand education access in rural regions."
Additionally, diversity can be an issue among NPs. In California, African Americans represent 12.4 percent of the state's population but only 4.4 percent of employed nurse practitioners. Hispanics or Latinos make up nearly 18 percent of California's residents but only constitute 8.2 percent of employed nurse practitioners.
According to Health Affairs, nonwhite nurse practitioners are more likely to live in counties that have lower than-average nurse practitioners and physician populations. The upside: Increasing diversity in the overall NP population could boost the number of NPs in underserved areas.
What hospitals can do now
Ramping up educational programs and improving wide-ranging diversity problems are, naturally, going to take a while. Given the hot job market, hospitals can fine-tune operational aspects of the business, such as coordinating work schedules and to help retain the clinicians they already have on staff.
This is also a good time to rethink some of the basics, such as hiring, mentorship and staff development programs and the overall work environment.
Another tactic some hospitals are taking is to establish pipelines that expand the hiring pool, whether by partnering with local colleges, offering training for nursing students or establishing internal groups to fill vacancies as needed.
Other health systems, meanwhile, are deploying telehealth tools to productivity by connecting clinicians with patients more easily as well as other clinicians to share information about imaging and test results, for instance, and other speciality expertise.