As hospitals and health systems prepare for the additional 38 million newly insured patients that will soon flood waiting rooms, they're aggressively hiring mid-level providers, such as nurse practitioners, to fill in access to care disparities. But that's not the only reason advanced practice registered nurses are highly desirable.
Studies have shown that hiring nurse practitioners helps healthcare organizations improve safety and quality, patient flow, physician productivity, as well as the continuity of care and patient experience. Despite all of the benefits associated with hiring nurse practitioners, however, major obstacles stand in the way of incorporating nurse practitioners into team-based medicine.
1. There aren't enough of them
In 2010 the population of APRNs was 125,000, with at least 66% practicing primary care—a population that is growing at 2.4% compared to 1.4% growth rate of primary care physicians, according to a 2010 report published by the Robert Wood Johnson Foundation. But the pace is not keeping up with demand.
"We're seeing an estimated 200% increase in the demand for advanced practice nursing positions, which includes nurse practitioners in various specialties, as well as physician assistants," says Melissa Knybel, RN, BSN, Director of Operations at Randstad Healthcare.
"These are employers of various types, both from an outpatient clinic type of setting to the acute care setting. Our increase in demand is coming in large part from our acute care hospitals where before, traditionally it has been in the outpatient setting."
To keep up with the anticipated 712,000 new positions, BLS predicts that the nursing workforce also needs to expand by 495,500. The American Journal of Medical Quality in 2012 predicted the worse of these shortages will be in the South and West regions of the country, which happens to be where the tightest APRN scope of practice restrictions are.
2. Doctors resent them on the front lines and in the board rooms
Despite the primary care shortage, The American Academy of Family Physicians released a report in September 2012 arguing that "The interests of patients are best served when their care is provided by a physician or through an integrated practice supervised directly by a physician… We must not compromise quality for any American, and we don't have to."
"I think a lot of this turf tension is the whole prestige issue about how physicians are revered. There's a combination of things, part of it is money, and part of it is around not being the one in charge. The team approach is spreading not only the workload, but also the component of who is in charge here. But it shouldn't be like that, it should be that whoever can provide care at the time should be in charge," says Mary C. Smolenski, EdD, MS, FNP, CAE, FAANP. She is a consultant and writer on advanced practice issues and the former Director of Certification Services for the American Nurses Credentialing Center, a subsidiary of the American Nurses Association.
According to Knybel at Randstad, if an APRN decides to voluntarily leave a position, more often than not it is because he or she didn't have the support of the physician or the physician teams. She says engaging the physicians in the decision to hire more nurse practitioners are a way to avoid this conflict.
"If you don't seek out that approval, then you're going to be fighting an uphill battle the entire way," says Knybel.
"There's a whole hierarchy level that controls what a practitioner can do—but it all comes down to how you're restricted by the boards within the hospitals. They control who can work there, what they can do and how they can practice," says Smolenski.
"But most of these boards are run by physicians. Some are more progressive, but it really varies from place to place or where there are less physicians and physicians have more authority they don't want to give that up. It really depends on the physicians on these boards."
3. State licensing standards limit their mobility
State nurse practice acts still vary from state to state. In 2006, the Consensus Model for APRN Regulation brought together the accreditation programs, state boards, and nursing bodies to come to some agreement on what the APRN standards should be across states. This was meant to improve nurse practitioners' mobility across states as well as provide some consistency to their licenses because every state was, and still is, handling APRNs differently.
But according to the AANP, out of the 155,000 nurse practitioners in the United States, only 43% hold hospital privileges. "Now the issue is that the states are going to have to relook at their nurse practice acts so everyone is more consistent across state lines, which will make it easier for people who are hiring," says Smolenski.
There are certain geographic areas where more advanced nurse practitioners have multi-state licenses, but compared to the RN world, where compact licensures exist for as many as 25 states at a time, on the advanced practice side that doesn't exist, and according to Knybel this is a challenge to recruiting and placing nurse practitioners in positions that require a move across state lines.
"Our pools of nursing candidates are traditionally more mobile. So we can take people from Massachusetts and provide them with a temporary home in the state of California and give them an assignment for three months. This same process can verify them to secure licenses in other states, but for advanced practitioners that's not as easy—the regulations that oversee their practices vary so much more."
When you line up the ratio of nurse practitioners to state population and the state's scope of practice laws, a picture emerges of the impact restrictive and heavily regulated state policies have on the APRN population.
Alabama scores an 'F' from the The American Journal of Nurse Practitioner's 2011 Pearson Report for the scope of patient access to nurse practitioners, and it also has the fifth lowest ratio of nurse practitioners to state population (40 per 100,000 people). Meanwhile, New Hampshire scored an 'A+' with no restrictions on nurse practitioners' scope of practice and has the second highest ratio of nurse practitioners to patient population (114 per 100,000 people).
"Are the patients different in different states? What's the big deal?" says Smolenski.
Isn't the common goal to treat the sick and heal those who are suffering? This hierarchical culture of medicine needs to shift—it's not about who is in charge, it's about treating the overflowing waiting rooms.
Chelsea Rice is an associate editor for HealthLeaders Media.
