1. Lyttle, Bethany


Confluence of events hastens the demand for NPs.


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With the persisting physician shortage (see and health care legislation that will increase the number of insured Americans by more than 32 million, the need for NPs is expected to increase dramatically. Changes to health care, including more school-based health centers, nurse-managed clinics, and programs like the Nurse-Family Partnership, will further increase demand. And, as a result of increased exposure, thousands of patients who had either limited or no understanding of the profession may now turn to NPs for primary care. Indeed, as of this writing, 28 states have planned to expand NPs' authority. And $15 million has been allocated from the Prevention and Public Health Fund created by the Affordable Care Act to establish 10 NP-led clinics that provide comprehensive primary health services.

Figure. Amanda Cockr... - Click to enlarge in new windowFigure. Amanda Cockrell, NP, (left) examines a patient at Rush Lifetime Medical Associates in Chicago. With a looming shortage of primary care physicians, 28 states are considering expanding the authority of NPs. Photo by John Smierciak / Associated Press.

Already, many universities that offer accelerated programs for nurses with college degrees in other fields have seen a marked surge in interest and enrollment. Judy Honig, EdD, DNP, director of the Doctor of Nursing Practice (DNP) program at the Columbia University School of Nursing, said that the school's bachelor of science-master of science class reached record numbers this past year and that all of these students intend to pursue an NP specialty. She anticipates the uptrend to continue. "As predicted, the numbers of primary care providers will not be sufficient to meet the needs of our country," she said. "As access widens-and as more people seek prevention and wellness care in addition to episodic and urgent care-manpower becomes a serious issue. NPs provide safe, high-quality primary care. And DNP graduates are filling a growing societal need for expert clinicians who are prepared for the complexity of care, the growth of information and biomedical technology, an aging and increasingly diverse population, and worsening disparities in care."


This view is not shared by the American Medical Association (AMA), which has long opposed expanding the scope of NPs' practice. Even in the face of the physician shortage, which by the AMA's own estimates will reach 160,000 by 2025, the organization's position hasn't wavered. Along with several physicians' groups that have organized at the state level, the AMA argues that offsetting the shortfall by increasing the number of NPs and expanding their roles presents a risk to patient safety (read more on pushback from physicians on National Public Radio's Web site:


"All of the evidence points to NP care being as safe and effective as care provided by MDs," said former AJN editorial director Karen Roush, MS, RN, FNP-BC, of New York City. "Although there are core philosophical differences between the two professions, and the models of care in their truest sense are different, in primary care the day-to-day practice roles overlap in many ways."


In part it's this overlap that accounts for the intensity of the debate. NPs can practice with significant autonomy and prescriptive authority in many states and can perform minor surgery and provide disease management and diagnostic and preventative care in most. What's more, they do so at a lower cost. The urgent need for their services may not level the playing field, but it certainly gets the bulldozer started. As advanced practice nursing grows more visible and satisfies populations beyond the underserved and uninsured, patients are more likely to equate care by an NP with care by a physician. "For patients, this can be a breakthrough because it represents increased access," said Janice Ely, an NP with a specialty in women's health. "But for many of the general practitioners whose numbers are dwindling, this is perceived as a threat that comes down to control and economics."


These tensions are expected to escalate as NPs assert the need to eliminate state requirements for physician supervision or collaboration. Arguing that such regulations restrict care and that nursing should be an autonomous profession that's monitored and regulated from within, nurses say that these external controls feed a public misconception that NPs are hierarchically inferior to-rather than philosophically different from- physicians. Ely noted that in the last 30 years there has been a dramatic upswing in both public opinion and knowledge of NPs but agreed with Roush, who said, "We need to be more vocal about our role and our effectiveness, be more involved in policymaking, and be willing to speak up more often."


Taking a stand is nothing new for NPs. And neither are the responses of the AMA and physicians' groups that question the quality and breadth of advanced practice nursing education and criticize the lack of uniform credentialing for NPs across states and between specialties. It's a goal of the American Association of Colleges of Nursing (AACN) to "move the current level of preparation necessary for advanced nursing practice from the master's degree to the doctorate level [the DNP] by the year 2015." (See for more.) Regardless of whether the AACN can achieve that goal, admissions policies and standards have come under fire, and accelerated programs have been targeted as quick-fix solutions that will compromise patient care by turning out practitioners who aren't adequately prepared. Nurses acknowledge the risk but note that large pools of applicants and unprecedented interest also make it incumbent on schools to practice highly selective admissions and uphold rigorous programs of study.


"I think what we'll see in the profession is what we've seen here all along," said Ely. "Law follows practice. For decades NPs have been adapting and expanding their roles." As NPs are called upon to provide primary care to millions of Americans over the next few years, a new patient base will discover their expertise. And as a result of health care changes, there will be a renewed reliance on their lower salaries, lower Medicare reimbursement, and specialized experience with aging populations.


But will this new dependence help the profession or hurt it? NPs will likely be expected to take on greater patient loads, an ironic twist that could dismantle an important element of NP care-the ability to spend high-quality time with patients. Coupled with greater education requirements, questions arise regarding salary. Ultimately, NPs may find themselves redefining the profession at the same time they're subjected to more scrutiny than ever before. Given that the profession hasn't even been able to set the baccalaureate as the minimum education level required for entry into RN practice, this certainly won't be easy.-Bethany Lyttle