Health care delivery systems are “held together, glued together, enabled to function … by the nurses.”
—Adapted from Lewis Thomas, physician, essayist, researcher
Today in the United States, the health of far too many individuals, families, entire neighborhoods, and communities is compromised by social determinants of health (SDOH), such as food insecurity and poverty, as well as by limited access to health care services. The size, distribution, diversity, and educational preparation of the nursing workforce needed to assist in addressing these health challenges are therefore critically important. Even as the potential for nurses to help improve both SDOH and health outcomes has become clear, however, it has become increasingly apparent that a robust nursing workforce ready to meet these
challenges does not yet exist. In fact, some of the data discussed in this chapter highlight the potential for current gaps in the capacity of the nursing workforce to widen over the present decade.
As described in the committee’s framework for this study (see Figure 1-1 in Chapter 1), strengthening the nursing workforce is one of the key areas that will enhance nursing’s role in addressing SDOH and improving health and health care equity. This chapter focuses on building the nursing workforce needed to respond to SDOH that affect the health care needs of individuals, communities, and society, including the pressing need to reduce health and health care inequities. The chapter begins by placing the nursing workforce in context and summarizing its current state and strengths. Next, it describes key challenges nurses will face over the current decade. Comparison of these challenges against the current state of the nursing workforce illuminates numerous gaps in the workforce that will need to be filled to meet the goal of addressing SDOH and improving health equity. After summarizing research needed to help nurses meet these challenges, the chapter ends with conclusions.
The nursing workforce is composed of actively employed registered nurses (RNs), licensed practical or licensed vocational nurses (LPN/LVNs), and advanced practice registered nurses (APRNs). As described in greater detail at the end of the chapter, the data and methods used to describe the nursing workforce come primarily from the 2008 and 2018 National Sample Survey of Registered Nurses (NSSRN), the U.S. Census Bureau’s yearly American Community Survey (ACS) for 2000–2018, and other sources.
THE NURSING WORKFORCE IN CONTEXT
The number of nurses in the United States has grown steadily over the past 100 years. The nursing workforce is the largest among all the health care professions and is nearly four times the size of the physician workforce. RNs practice in a wide variety of care delivery settings, and they provide care to people living in both urban and rural areas and to vulnerable populations, including women, people of color (POC), American Indians/Alaska Natives (AI/ANs), low-income individuals, individuals with disabilities, and people who are enrolled in both Medicare and Medicaid (dual eligible).
The shift in nursing education from hospital-based diploma programs to degrees from colleges and universities has prepared RNs for more highly skilled roles that have expanded their reach and impact, benefiting both nurses and their employers. The emergence and growth of nurse practitioners (NPs) in the mid-1960s, together with other advanced practice nursing roles (certified nurse midwives, nurse anesthetists, and clinical nurse specialists), represent a significant advancement. Nurses also benefit individuals, communities, and society through their efforts as scientists conducting clinical and health services research; as executives and entrepreneurs leading health care organizations; as members of
hospital and health system boards; as public health officers and educators; and as members of federal, state, and local governments.
For decades, nurse employment has grown concurrently with increased U.S. spending on acute care, seemingly impervious to either government or market-oriented efforts aimed at constraining the overutilization of costly health care services. With unemployment rates rarely exceeding 1.5 percent, job availability has seldom been a problem for nurses (BLS, 2020; Zhang et al., 2018). Even during economic downturns, RN employment typically has increased, sometimes dramatically. Hospitals added nearly 250,000 nursing full-time equivalents (FTEs) during the Great Recession, for example, including in economically depressed areas of the country (Buerhaus and Auerbach, 2011). Even so, vacancies exist in some areas, including Indian Health Service areas, with uneven distribution across several states, ranging from 10 to 31 percent (GAO, 2018).
RNs and APRNs are among the most highly paid health professionals, making the nursing profession an economic engine for families and communities. In 2018, national RN earnings averaged $76,000, and with an estimated 3.35 million RNs working on an FTE basis in the United States, total RN earnings amounted to roughly $255 billion (not counting nonwage benefits). As a result, the value of the clinical care they deliver typically appears on the cost side rather than the revenue side of earnings statements for provider organizations. When thinking about how nurses can promote health equity, however, one should not lose sight of their contributions to the economic as well as the social and environmental fabric of the places where they live and work.
The COVID-19 pandemic has illuminated the critical importance of nurses, but it also has disrupted long-standing employment patterns and threatened nurses’ financial, psychological, and physical resilience. Nurses heroically risked exposure to the coronavirus each day to care for patients and their families, sometimes without adequate personal protective equipment. But the pandemic also exposed nurses’ vulnerability to their clinical employers’ dependence on reimbursable services, especially elective procedures, to remain in business. With revenue from private health insurers in steep decline, many hospitals and clinics seeking quick reductions in costs have cut back on nursing through furloughs and layoffs (Gooch, 2020). This counterproductive response to the pandemic could cause long-lasting damage to the nursing profession and the health care system. This and other destabilizing effects on the nursing workforce associated with COVID-19 merit close attention.
CURRENT STATE AND STRENGTHS OF THE NURSING WORKFORCE
Although this chapter’s main focus is on identifying the challenges and gaps in the nursing workforce that will develop over this decade and describing ways to overcome them, the success of such actions will depend on leveraging the capacity and the many strengths of the current nursing workforce. These strengths represent opportunities to achieve and sustain a workforce of sufficient size, distribution,
diversity, and expertise to help achieve equity in health and health care and reverse the trajectory of poor health status seen in communities across the nation.
Over the past 20 years, the number of people becoming RNs has increased rapidly, reaching 3.35 million FTEs in 2018 (see Table 3-1). Although the RN workforce continues to be composed largely of White women, the proportion of White RNs decreased from 79.1 percent in 2000 to 69 percent in 2018. The workforce has steadily become more diverse as the proportion of RNs who are Black/African American now approximates that of the nation’s population (12 percent), while the proportion of RNs who are Asian (9.1 percent) exceeds that of the population (6 percent). On the other hand, despite doubling since 2001, the proportion of Hispanic RNs in the nursing workforce (7.4 percent) is well below that of the population (18.3 percent). The proportion of men who are RNs had grown to 12.7 percent by 2018.
RNs are increasingly educated at both the undergraduate and graduate levels. It is important to note that the 2011 The Future of Nursing report recommends increasing the percentage of nurses with a baccalaureate degree to 80 percent by 2020 (IOM, 2011). The number of employed RNs prepared with at least a bachelor’s degree has surpassed the number prepared with an associate’s degree. This growth has been driven, in part, by RNs completing RN-to-bachelor of science in nursing (BSN) education programs, which provide additional education needed by RNs with an associate’s degree to earn a BSN. The increase in educational attainment has been particularly strong among POC RNs. Table 3-2 shows that nationally, a higher percentage of Black/African American, Hispanic, and particularly Asian RNs relative to White RNs have a BSN.1 Proportionately, more Black/African American and Asian RNs than White and Hispanic RNs have a master’s degree, or a doctor of nursing practice (DNP) or a PhD in nursing. Box 3-1 provides information on the nursing workforce educated in countries outside of the United States.
Analysis of data from the American Association of Colleges of Nursing (AACN) shows that between 2010 and 2017, the number of RNs who obtained a doctoral degree increased rapidly, with those obtaining a DNP far outnumbering those obtaining a PhD (see Figure 3-1). Among White RNs, the number of DNP graduates increased from 982 in 2010 to 4,138 in 2017 (an increase exceeding 3,000 percent), while the number of PhD graduates increased from 363 to 462
1 It is possible that nurses educated in other countries are more likely to have earned a bachelor’s degree, which could partially account for the higher percentage of bachelor’s-level education reported by Black/African American and Asian RNs relative to White RNs. When the committee investigated this possibility, it found no supporting evidence with regard to Black/African American nurses but a significant impact for Asian RNs. Additionally, when we examined RNs under age 40, the pattern of results persisted, as a higher proportion of Black/African American (67.3 percent), Asian (76.7 percent), and other (68 percent) RNs compared with White (65 percent) RNs had earned a bachelor’s degree in nursing, Hispanics (58 percent) being the exception.
|Total FTE RNs||1,985,944||2,142,353||2,542,703||3,352,461|
|Gender||Men||157,285 (7.9%)||211,891 (9.9%)||244,363 (9.6%)||424,342 (12.7%)|
|Women||1,828,709 (92.1%)||1,930,462 (90.1%)||2,298,340 (90.4%)||2,928,119 (87.3%)|
|Race||White||1,571,136 (79.1%)||1,673,073 (78.1%)||1,906,756 (75.0%)||2,313,002 (69.0%)|
|Black/African American||175,669 (8.8%)||191,102 (8.9%)||269,271 (10.6%)||401,755 (12.0%)|
|Asian||128,064 (6.4%)||161,598 (7.5%)||211,751 (8.3%)||305,740 (9.1%)|
|Other||37,266 (1.9%)||28,027 (1.3%)||37,370 (1.5%)||84,454 (2.5%)|
|Hispanic||73,859 (3.7%)||88,553 (4.1%)||117,556 (4.6%)||247,511 (7.4%)|
|Education||Associate’s Degree||703,959 (37.7%)||839,506 (37.4%)||997,671 (38.1%)||910,629 (29.3%)|
|Bachelor’s Degree||610,735 (32.7%)||778,513 (34.7%)||957,422 (36.6%)||1,411,525 (45.4%)|
|Master’s Degree/PhD||202,018 (10.8%)||296,245 (13.2%)||361,559 (13.8%)||644,764 (20.7%)|
|Employment||Hospital||1,307,476 (63%)||1,352,356 (63.1%)||1,606,924 (63.2%)||2,071,034 (61.8%)|
|Nonhospital||778,461 (37%)||789,997 (36.9%)||935,779 (36.8%)||1,281,424 (38.2%)|
|Age||<35||895,759 (23.0%)||486,098 (22.7%)||584,982 (23.0%)||980,779 (29.3%)|
|35–49||2,017,925 (51.8%)||968,308 (45.2%)||1,017,328 (40.0%)||1,202,345 (35.9%)|
|50+||980,651 (25.2%)||687,947 (32.1%)||940,394 (37.0%)||1,169,337 (34.9%)|
SOURCE: Calculations of data from the American Community Survey (IPUMS USA, 2020).
|Nursing Education||White||Black/African American||Asian||Hispanic||Other||All|
|Diploma||118,131 (5.9%)||6,584 (2.9%)||4,794 (2.8%)||13,366 (4.3%)||3,056 (3.6%)||5.3%|
|Associate’s Degree||687,671 (34.6%)||67,163 (29.6%)||26,491 (15.6%)||112,409 (36.2%)||24,429 (29.1%)||33.1%|
|Bachelor’s Degree||968,411 (48.8%)||119,605 (52.07%)||117,425 (69.0%)||155,324 (49.8%)||49,783 (59.2%)||50.8%|
|Master’s Degree||196,362 (9.9%)||28,582 (12.6%)||19,465 (11.4%)||27,701 (8.9%)||6,612 (7.9%)||10.0%|
|Doctor of Nursing Practice (DNP) or PhD||14,897 (0.8%)||4,841 (2.1%)||1,908 (1.1%)||2,388 (0.8%)||179 (0.2%)||0.9%|
SOURCE: Calculations of data from the 2018 National Sample Survey of Registered Nurses.
(27 percent). The proportionate growth among POC RNs was even greater. For example, the number of Black/African American RNs who obtained a DNP increased from 139 in 2010 to 826 in 2017 (a nearly 5,000 percent increase), while the number earning a PhD increased from 52 to 107 (105 percent) over this same period. Unfortunately, because RNs who have earned DNPs could not be identified in the 2018 NSSRN public use files, it is impossible to identify the sociodemographic, economic, or employment characteristics of this growing segment of the doctoral-level nursing workforce. It will be important for future NSSRNs to ensure the ability to identify RNs who have obtained a DNP so that the sociodemographic, economic, and practice characteristics of this rapidly growing segment of the nursing workforce can be identified and analyzed, particularly in relation to whether and how DNPs are addressing SDOH.
The average age of the RN workforce has decreased to just under 44 years as the large number of RNs belonging to the baby boom generation (estimated at 1.2 million) have retired and younger RNs have entered the workforce. RNs working in hospitals are younger (42.3) than those working in nonhospital settings (47.0) (see Table 3-1), which suggests that the large numbers of RNs retiring over this decade will likely be among those working in non–acute care settings.
While many policy makers, consumers, and the media often associate RNs with working in hospitals (in fact, hospitals employ almost two-thirds of the RN workforce), what should not be overlooked is that RNs come into contact with individuals in a large number and wide array of settings. Table 3-3 shows more than 30 settings in which some RNs provide direct primary care, while others
supplement the primary care workforce, provide care to rural populations, help improve maternal health outcomes, deliver acute and emergency care, provide health education and preventive care, coordinate patient care, and facilitate continuity of care for patients and families across settings and providers. The table also shows that the average annual earnings of RNs are lowest in settings (e.g., critical access hospitals, nursing homes, inpatient and outpatient mental health facilities, public clinics, public health, school health, and home health) where RNs often interact with people facing multiple social risk factors.
|Employment Setting||All RNs||Percentage of All RNs||Average Annual Earnings||RNs Older Than Age 50||Percentage of RNs Older Than Age 50|
|Hospital (not mental health)|
|Critical access hospital||309,822||11.2||$77,122||120,353||38.8|
|Inpatient unit—not critical access hospital||755,639||27.2||72,668||210,958||27.9|
|Emergency department—not critical||161,603||5.8||76,577||32,708||20.2|
|Hospital-sponsored ambulatory care||253,347||9.1||77,826||128,015||50.5|
|Hospital ancillary unit||54,181||2.0||82,063||23,514||43.4|
|Hospital nursing home unit||13,288||0.5||72,442||7,564||56.9|
|Other hospital setting||20,133||0.7||88,454||8,054||40.0|
|Other hospital setting (consultative)||49,717||1.8||85,924||34,436||69.3|
|Other Inpatient Setting|
|Nursing home unit not in hospital||60,615||2.2||69,479||30,557||50.4|
|Rehabilitation facility/long-term care||110,554||4.0||74,832||50,160||45.4|
|Inpatient mental health||55,089||2.0||68,044||24,091||43.7|
|Employment Setting||All RNs||Percentage of All RNs||Average Annual Earnings||RNs Older Than Age 50||Percentage of RNs Older Than Age 50|
|Other inpatient setting||11,938||0.4||70,729||4,414||37.0|
|Nursing-managed health center||9,183||0.3||91,244||2,594||28.2|
|Private medical practice (clinic, physician)||138,291||5.0||72,787||58,379||42.2|
|Public clinic (rural health center, federally qualified health center [FQHC], Indian Health Service, tribal clinic, etc.)||33,484||1.2||69,983||14,210||42.4|
|School health service (K–12 or college)||65,015||2.3||57,506||36,718||56.5|
|Outpatient mental health/substance abuse facility||14,995||0.5||68,288||7,124||47.5|
|Ambulatory surgery center (freestanding)||8,807||0.3||63,668||3,062||34.8|
|Other clinical setting||67,182||2.4||71,599||28,773||42.8|
|Other Types of Settings|
|Home health agency/service||175,212||6.3||71,277||96,400||55.0|
|Occupational health or employee health||11,360||0.4||77,556||8,346||73.5|
|Public health or community health||41,176||1.5||71,712||16,952||41.2|
|Government agency other than public/community health or correctional facility||41,229||1.5||81,423||23,777||57.7|
|Outpatient dialysis center||27,704||1.0||81,032||11,231||40.5|
|University or college academic department||34,698||1.2||70,857||19,178||55.3|
|Case management/disease management and insurance company||78,637||2.8||81,324||38,202||48.6|
|Call center/telenursing center||15,935||0.6||79,754||9,613||60.3|
|Other type of setting||12,197||0.4||89,431||7,298||59.8|
|Other type of setting (consultative)||38,130||1.4||92,522||21,366||56.0|
SOURCE: Calculations based on the 2018 National Sample Survey of Registered Nurses.
Table 3-3 also shows the percentages of RNs in each employment setting who are over the age of 50, many of whom are expected to retire by the end of the decade. Indeed, the number of employment settings in which more than 40 percent of RNs are over age 50 is striking: critical access hospitals (40 percent); outpatient dialysis centers (40.5 percent); public health/community health (41.2 percent); private physician offices (42 percent); public clinics, such as rural health centers, federally qualified health centers (FQHCs), and Indian Health Service facilities (42.4 percent); inpatient mental health facilities (43.7 percent); outpatient mental health/substance units (47.5 percent); case management/disease management (48.6 percent); nursing home units not in hospitals (50 percent); hospital-sponsored ambulatory clinics (50.5 percent); home health agencies (55 percent); school health (56.5 percent); hospital nursing home units (57 percent); call centers (60.3 percent); occupational health (73.5 percent); and other settings (>50 percent). As RNs in these settings retire, they will be replaced by more recently educated nurses who, as discussed below, may not be as prepared for taking care of medically complex patients and addressing SDOH.
Fewer RNs are working in rural areas today than in the past (17 percent in 2005 versus 14.4 percent in 2018). The percentage working in rural hospitals also decreased over these same years (from 16.4 percent to 13.4 percent), as did the percentage of rural RNs working in nonhospital settings (18 percent to 16 percent). Furthermore, the decline in rural practicing RNs occurred more rapidly among younger RNs (under age 40) (from 18.1 percent to 13.7 percent) than among RNs over age 40 (from 16.4 percent to 14.9 percent). If this decrease continues, it will threaten access to care among the nation’s rural population. Given the large number of RNs working in critical access hospitals (more than 300,000) and the concern that more rural hospitals will close in the years ahead (Frakt, 2019), the number of RNs and physicians practicing in rural areas could decline further during this decade, complicating policies aimed at increasing access to care for the populations in these areas.
Looking to the future, the size of the FTE RN workforce is projected to grow substantially, from 3.35 million in 2018 to 4.54 million in 2030, enough to replace all the baby boom RNs who will retire over the decade. However, this projected growth will not occur uniformly across the nation because the replacement of the large numbers of retiring RNs by younger nurses will vary by state and by region. Thus, health care delivery organizations in some regions of the country will confront more rapid retirements and slower replacements among their RN workforce relative to other regions, which could in turn result in staffing disruptions. Still, the estimated growth in the RN supply is encouraging and means that large, long-lasting national shortages of RNs are unlikely to be seen during the decade. At the same time, as with all projections, these estimates are based on assumptions that may not hold over the projection period and are subject to unforeseen developments, such as the economic and noneconomic effects of the COVID-19 pandemic.
Licensed Practical/Vocational Nurses
LPN/LVNs (for brevity, referred to here as LPNs) support RNs and APRNs in providing patient care. In 2018, an estimated 701,650 LPNs provided health care to mostly racially and ethnically diverse populations both in the community and in health care organizations. These nurses also add meaningfully to the pipeline for RN and APRN roles and, importantly, allow RNs to concentrate on caring for medically complex patients (NCSBN, 2020). As the U.S. population ages, LPNs are likely to become an important resource for home care, long-term care, and care for individuals with disabilities and otherwise vulnerable groups. As in the case of RNs, the majority of LPNs are White (71.4 percent), but there are proportionately more Black/African American LPNs (18.5 percent) than is the case among RNs (12 percent). Also, as with RNs, the proportion of Hispanic (7.4 percent) and male (7.7 percent) LPNs in 2017 was far below their proportion in the population. Smiley and colleagues (2018) report that newer cohorts of LPNs are younger and more likely to be racially and ethnically diverse (Smiley et al., 2018, p. S46).
As of 2018, more than one-third (38 percent) of LPNs worked in nursing and residential care facilities, considerably more than in hospitals (15 percent), physician offices (13 percent), and home health care facilities (12 percent). Almost one in four LPNs lived in rural areas (166,000). Because nearly one-third of LPNs are over age 55, their impending retirement over the next decade raises concern about a potential shortage of these nurses (Smiley et al., 2018, p. S59). A 2017 Health Resources and Services Administration (HRSA) analysis suggests that, because the demand for LPNs is growing at a slightly faster rate than the supply, a shortfall of roughly 150,000 FTE LPNs is possible by 2030 (HRSA, 2017, p. 13). Such a shortage could mean that home care, long-term care, and care for individuals with disabilities and otherwise vulnerable groups will increasingly have to be provided by the RN workforce.
Box 3-2 provides information on the impacts of COVID-19 on the nursing workforce in nursing homes.
Advanced Practice Registered Nurses
APRNs are nurses who hold a master’s degree, post-master’s certificate, or practice-focused DNP degree in one of four roles: NP, certified registered nurse anesthetist (CRNA), clinical nurse specialist (CNS), or certified nurse midwife (CNM). As shown in Table 3-4, counting the number of APRNs is complicated because many APRNs are prepared in more than one role (e.g., they could be an NP and also a CNM or a CNS), and because a considerable number are employed in a position that is not what they were prepared for (e.g., an NP might be working as an RN rather than as an NP, or a CNM working as an NP). For consistency, this section focuses on APRNs who are employed in nursing and are working in the role for which they were prepared. Also, because of the larger numbers of APRNs practicing in the NP role relative to other advanced practice roles, this section focuses largely on NPs.
Size and Sociodemographic Characteristics
The total number of APRNs increased considerably in the 10-year period between the last two NSSRNs (2008 to 2018), reaching nearly 375,000 in 2018 (see Table 3-4), although APRN shortages remain in Indian Health Service areas—with vacancy rates ranging between 12 and 47 percent for NPs (GAO, 2018). By a wide margin, NPs outnumber any other APRN role, and their numbers grew more rapidly relative to other APRN roles, nearly doubling over this period. The number of APRNs working in the role of a CNS also increased. Although the total number of RNs prepared as a CRNA-only decreased, the number of CRNAs who were also prepared in another APRN role increased substantially. With regard to CNMs, difficulties associated with question wording in the 2008 and
|All APRN-Prepared Registered Nurses (RNs) Employed in Nursing|
|Prepared in a single APRN role||205,074||347,861|
|Prepared in more than one APRN role||18,015||2,968|
|Share of all APRNs prepared in more than one role||8%||7%|
|Nurse Practitioner (NP)–Prepared RNs Employed in Nursing|
|Prepared in the role of an NP only||125,264||258,241|
|Prepared as an NP and also in another APRN role||17,527||24,395|
|Share of all NP-prepared APRNs also prepared in another APRN role||12%||9%|
|Clinical Nurse Specialist (CNS)–Prepared RNs Employed in Nursing|
|Prepared in the role of a CNS only||34,987||55,111|
|Prepared as a CNS and also in another APRN role||14,806||15,626|
|Share of all CNS-prepared APRNs also prepared in another APRN role||30%||22%|
|Certified Registered Nurse Anesthetist (CRNA)–Prepared RNs Employed in Nursing|
|Prepared as a CRNA only||31,156||29,869|
|Prepared as a CRNA and also in another APRN role||871||7,542|
|Share of all CRNA-prepared APRNs also prepared in another APRN role||3%||20%|
SOURCE: Calculations based on the 2008 and 2018 National Sample Survey of Registered Nurses.
2018 NSSRNs, combined with small numbers of CNMs sampled in each survey, make estimating the numbers of CNMs problematic. Instead, using data from the American Midwifery Certification Board (AMCB), the number of AMCB-certified nurse midwives in the United States increased from an estimated 11,262 in 2014 to 12,276 in 2018 (AMCB, 2019).
The racial/ethnic composition of NPs has become more diverse (see Figure 3-2), though it lags behind the gains of the basic RN workforce. The proportion of Hispanic NPs increased the most between 2008 and 2018, from 3.8 percent of all NPs to 9.2 percent (an increase of 12,900). The number of Black/African American NPs also increased over this period, from just under 8,000 to nearly 13,000, while the numbers of Asian and other POC NPs increased more slowly.
Similar to the basic RN workforce, NPs and CNSs have remained overwhelmingly women (in 2018, 90.3 percent and 96.7 percent, respectively). The number of male NPs increased slowly between 2008 and 2018, accounting for about 10 percent of NPs in the latter year. In contrast, the proportion of male CRNAs exceeded 40 percent in 2008 but had decreased to 32.7 percent by 2018. CNMs are predominantly female (99 percent) and White (87 percent), with only 6 percent Black or African American (AMCB, 2019).
Employment Settings and Clinical Specialties
Table 3-5 shows that NPs provide access to care for millions of Americans in a wide variety of settings. In 2018, more than 100,000 NPs (52 percent of all NPs) worked in different types of clinics or ambulatory settings (including nurse-managed health centers; private medical practices; school health services;
|Employment Setting||Number||Percentage||Median Full-Time Equivalent (FTE) Annual Earnings|
|Clinic or Ambulatory Care Settings|
|Nurse-managed health center||1,736||0.9||$99,000|
|Private medical practice (e.g., clinic, physician office)||63,155||32.6||100,000|
|Public clinic (e.g., rural health center, federally qualified health center [FQHC], Indian Health Service [IHS])||16,309||8.4||97,000|
|School health service (K–12 or college)||4,060||2.1||90,000|
|Outpatient mental health/substance abuse facility||5,528||2.9||110,000|
|Other clinic/outpatient/ambulatory care setting||9,742||5.0||106,000|
|Home health agency/service||4,118||2.1||$105,000|
|Occupational health/employee health service||1,459||0.8||106,000|
|Public health/community health agency||995||0.5||100,000|
|Government agency, other than public/community health or correctional facility||3,558||1.8||110,000|
|University or college academic department||2,021||1.0||91,000|
|Case mgmt./disease mgmt. in insurance company||970||0.5||114,000|
|Other setting (outpatient dialysis center, call center)||1,064||0.5||100,000|
|Critical access hospital (CAH)||7,971||4.1||$112,000|
|Inpatient unit, non-CAH||28,855||14.9||110,000|
|Hospital-sponsored ambulatory care||21,464||11.1||109,000|
|Emergency department, non-CAH||6,077||3.1||120,000|
|Other hospital-based setting||3,758||1.9||105,000|
|Other Inpatient Settings|
|Nursing home, nonhospital||2,687||1.4||$105,000|
|Rehabilitation facility/long-term care||3,705||1.9||105,000|
|Inpatient mental health/substance abuse||2,502||1.3||111,000|
|Other inpatient setting||288||0.1||103,000|
SOURCE: Calculations from data in the 2018 National Sample Survey of Registered Nurses.
outpatient mental health/substance abuse facilities; and public clinics, including rural health centers, FQHCs, and Indian Health Service facilities). Another 14,000 (7.3 percent of all NPs) worked in various other settings, such as home health agencies, occupational health/employee health services, and universities or colleges. Roughly 68,000 (35 percent of all NPs) worked in hospitals, ranging from critical access hospitals to inpatient units, hospital ambulatory clinics, and emergency departments. Nearly 11,000 (5.6 percent of all NPs) worked in other inpatient settings, including nursing homes, rehabilitation and long-term care facilities, and correctional facilities. With regard to annual earnings, NPs’ median earnings varied considerably by setting, ranging from a low of $90,000 for those employed in school health settings to $120,000 for those working in emergency departments in non–critical access hospitals.
In 2018, a little more than half of NPs (54.7 percent or nearly 106,000) were certified as a family NP. The next largest group were NPs certified in the care of adults (33,620) and in pediatrics (21,622). The numbers of NPs certified in gerontology and psychiatric and mental health care grew the least between 2008 and 2018—9.7 percent and 5.3 percent, respectively, and in 2018 numbered only 15,921 and 10,174, respectively.
Within the different settings in which they work, NPs provide a vast array of clinical specialty care. Of the nearly two dozen clinical specialties shown in Table 3-6, NPs were most likely to provide primary and ambulatory care (39.2 percent), followed by general medical surgical care (9.1 percent), psychiatric or mental health care (6.4 percent), critical care (5.9 percent), and gynecology and women’s health care (4.3 percent). The remaining 35 percent of NPs provided care in 17 other specialties, ranging from oncology (3.9 percent) to infections/communicable diseases (0.8 percent).
Care for People of Color and People with Limited English Proficiency
Analysis of the 2018 NSSRN shows that a majority (70.6 percent) of NPs who reported managing a panel of patients as a primary provider said at least 25 percent of their patient panel consisted of “racial/ethnic minority groups”; one in five indicated that this was the case for 75 percent or more of their panel. Slightly more than one-quarter of NPs (25.9 percent) also reported that 25 percent or more of their patient panel had limited proficiency in English. Additionally, the vast majority of NPs indicated that to a “great or somewhat extent” (versus “very little” or “not at all”), they participated in team-based care (85.8 percent), and felt confident in their ability to practice effectively in interprofessional teams (96.1 percent) and to use health information technology effectively in their practice to manage their patient population (81.1 percent). Most NPs had observed their organization emphasizing team-based care (84 percent) and evidence-based care (97 percent); only 60 percent reported observing their organization emphasizing discharge planning to a great extent or
|Ambulatory Care (including primary care outpatient setting, except surgical)||28,787||14.9|
|General Medical Surgical||17,564||9.1|
|Psychiatric or Mental Health (substance abuse and counseling)||12,460||6.4|
|Cardiac or Cardiovascular Care||5,224||2.7|
|Other Specialty (neonatology)||2,048||1.1|
|Labor and Delivery||1,019||0.5|
|Other Specialty (including school health service, gerontology, and radiology)||12,482||6.4|
SOURCE: Calculations based on data from the 2018 National Sample Survey of Registered Nurses.
somewhat. Refer to Chapter 7 for more detailed information on interprofessional education and training.
Growth in the Size of the Nurse Practitioner Workforce
The NP workforce is growing rapidly. Using data from the 2001–2016 American Community Survey (ACS), Auerbach and colleagues (2018) project that the number of FTE NPs will more than double from 157,025 in 2016 to 396,546 in 2030 (increasing 6.8 percent annually). As discussed later, the contributions of
the growing NP workforce will be useful to overcome projections of primary care and specialty physician shortages over the decade.
CHALLENGES FOR THE NURSING WORKFORCE THROUGH THE CURRENT DECADE
Looking out over this decade, the nursing workforce is growing and providing many different types of care in a variety of settings, giving them opportunities to understand and interact with people who face substantial social risk factors. The strengths of the nursing workforce are many, yet they will be tested by formidable challenges that are already beginning to affect nurses and the health care systems and organizations in which they work. These challenges will arise from changes occurring throughout the broader society that are increasing the number of people who need health care; from within the nursing and larger health care workforce; and from health-related public policies and other factors that affect the size, distribution, diversity, and educational preparation of nurses. These challenges include the need to
- increase the number of nurses available to meet the nation’s growing health care needs;
- rightsize the clinical specialty distribution of nurses;
- increase the distribution of nurses to where they are needed most;
- ensure a nursing workforce that is diverse and prepared with the knowledge and skills to address SDOH;
- overcome current and future barriers affecting workforce capacity; and
- anticipate long-term impacts of the COVID-19 pandemic on the nursing workforce.
These challenges will unfold simultaneously over the decade, and will expose shortcomings throughout the nursing workforce, widening current gaps that should be filled if nurses are to fully leverage their expertise in helping to address SDOH for individuals, communities, and society.
Increasing the Number of Nurses Available to Meet the Nation’s Growing Health Care Needs
In addition to growth in the overall size of the U.S. population, other factors and health workforce imbalances will increase the demand for nurses, particularly in areas where the RN and APRN workforce are already undersized. Salient sociodemographic factors include the aging population, increases in mental and behavioral health conditions, increases in lack of access to primary health care, persistently high maternal mortality rates, and worsening physician shortages.
The Aging Population
The aging of the U.S. population means that over this decade, increasing numbers of people will age into their 70s, 80s, 90s, and beyond. In 2030, 73.1 million people or 21 percent of the U.S. population, including all baby boomers, will be older than 65 (Vespa et al., 2020). The prevalence of multiple comorbid chronic conditions (e.g., diabetes, heart disease, obesity, cancer, disabilities, mental illness, Alzheimer’s disease, dementia) is high among older people and greatly increases the complexity of their care (Figueroa et al., 2019). Increases can also be expected in the number of frail older adults—those who need assistance with multiple activities of daily living, are weak and losing body mass, have multiple chronic or complex illnesses, and have an increased risk of dying within the next 2–3 years (Collard et al., 2012; Fried et al., 2001). The old-age dependency ratio (the number of people aged 65 and over per 100 people aged 20–64) in the United States will increase from 21 in 2010 to more than 35 by the end of the decade (Vespa et al., 2020). The nation’s aging population will pose extraordinary challenges for society at large and for health care delivery organizations, nurses, social workers, and families.
There are wide disparities in the economic and physical welfare of older adults by gender, racial/ethnic group, and geographic location. Older women are more likely than men to live alone and are twice as likely to be poor. At age 50, Black men and women still have lower life expectancies relative to their White counterparts. Among adults aged 65 and older, POC individuals are much more likely than Whites to rely solely on Social Security for their family income. In addition to the increased risk of age-associated mental health problems and cognitive degenerative diseases, older adults living in rural areas are more likely than their counterparts living in urban areas to be poor; to experience social isolation; and to have significantly less access to fewer health and social resources, including mental health services (Administration on Aging, 2013). It is essential for policy makers and others to pay attention to these gender and racial/ethnic gaps and geographic trends, which could undermine progress in advancing the well-being of older Americans in the present decade.
As the nation’s health care and social support systems come to terms with caring for increasing numbers of older people, increases will be seen not only in the demand for nurses but also in the intensity and types of nursing care required to care for these older adults, extending across inpatient, community-based, and home settings. The gap in the ability of nurses to respond to these needs is already deep and worrisome; according to the 2018 NSSRN, relatively few RNs work in a long-term care facility (60,000) or provide home care (91,000). Similarly, relatively few NPs work in nursing homes (in 2018, 2,700 or 1.4 percent of all employed NPs) or provide home health care services (4,100 NPs or 2.1 percent).
Increases in Mental and Behavioral Health Conditions
Prior to the COVID-19 pandemic, sharp increases in suicide, substance abuse, the opioid crisis, gun violence, and severe depression among younger people were placing growing demands on the mental and behavioral health care workforce, including nurses. Yet, the rising demand for mental and behavioral health services, let alone treatment for the 44 million American adults who are estimated to have a diagnosable mental health condition, is occurring in the face of a shortage of behavioral health professionals that the HRSA (2016) projects could worsen to a shortfall of as many as 250,000 workers by 2025.
Despite current and projected shortages of mental and behavioral health workers, the regulatory policies of many states limit the capacity of existing NPs who provide psychiatric and mental health care. For example, a study by Alexander and Schnell (2019) assessing independent practice authority for NPs between 1990 and 2014 showed that broadening prescriptive authority was associated with improvements in self-reported mental health and decreases in mental health–related mortality, including suicides. These improvements were concentrated in areas underserved by psychiatrists and among populations traditionally underserved by mental health providers. According to the authors, “results demonstrate that extending prescriptive authority to NPs can help mitigate physician shortages and extend care to disadvantaged populations” (Alexander and Schnell, 2019, p. ii).
Similarly, Barnett and colleagues (2019) examined the issuing to NPs and physician assistants of federal waivers for prescribing buprenorphine following passage of the 2017 Comprehensive Addiction and Recovery Act. The waiver expansions were intended to increase patients’ access to opioid use treatment, which is particularly important in rural areas underserved by physicians. The study found that between 2016 and 2019, the number of waivered clinicians per 100,000 population in rural areas increased by 111 percent, with NPs and physician assistants accounting for more than half of this increase. Furthermore, rural counties in states that granted full scope-of-practice authority to NPs saw significantly faster growth in NPs’ buprenorphine treatment capacity compared with states with restrictive scope-of-practice regulations. “By March 2019 this pattern of growth had led to rural counties in states with full scope of practice having twice as many waivered NPs per 100,000 population, compared to those in states with restricted scope of practice (5.2 versus 2.5)” (Barnett et al., 2019, pp. 2051–2052).
The COVID-19 pandemic has added new stresses for many people, particularly those living in or near places with large outbreaks of the virus, increasing the need for mental and behavioral health treatment. As nurses continue to care for people with COVID-19, many will experience added stress; feelings of inadequacy, guilt, compassion fatigue, and physical exhaustion; and uncertainty over their employment. Some of these nurses may leave the profession, many will need help, and too many will suffer alone (Lai et al., 2020).
Increasing demand for mental and behavioral health care in the face of the decreasing capacity of mental and behavioral health care professionals implies that the nursing workforce will be relied upon to help address gaps in this care (Henderson, 2020). In addition to the capacity-reducing effect of regulations, however, the nursing workforce is unlikely to fill these gaps over the current decade because such a small percentage of RNs (3.5 percent or 78,300) provide care in psychiatric, mental health, or substance abuse settings. Similarly, small numbers of NPs work in inpatient (2,500 NPs in 2018) and outpatient (5,500) mental health/substance abuse settings.
Increases in Lack of Access to Primary Health Care
On the eve of the Patient Protection and Affordable Care Act’s (ACA’s) 2014 health insurance expansions, nearly 60 million people had inadequate access to primary care in the United States (Graves et al., 2016), and HRSA reported 5,900 health professional shortage areas (HPSAs). While the ACA eventually expanded insurance coverage to an estimated 20 million individuals, not all of those who gained coverage had adequate access to health care. Unfortunately, the size of the population with inadequate access to health care is rising: in March 2020, HRSA reported that the number of HPSAs nationwide had increased to 7,059, affecting 80.6 million people.
The persistent lack of access to primary health care has led to recommendations to increase the number of nurses practicing in primary care and community-based settings (Bodenheimer and Bauer, 2016). A 2016 report of the Josiah Macy Jr. Foundation, Registered Nurses: Partners in Transforming Primary Care (Bodenheimer and Mason, 2016), emphasizes the need to overcome the limited ways in which many primary care practices currently use RNs (e.g., telephoning prescriptions to pharmacies, performing administrative duties). Instead, the report urges primary care practices to expand the role of RNs in providing primary care services and allow them to practice to the full extent of their education and training (e.g., by managing stable patient panels with controlled diabetes, hypertension, and other conditions). As discussed in Chapter 7, nursing education programs have historically emphasized preparing students for inpatient acute care and medical and surgical nursing. Consequently, too few nurses today are adequately prepared to practice in non–acute care settings. To address the growing need for primary care providers, educators will have to increase coursework and student clinical experiences in primary care settings, which in turn could lead to more graduates choosing careers in primary care and ambulatory and community-based settings.
Fortunately, more than 160,000 NPs certified in either family health, adult health, or pediatrics provide primary care. And a large and growing body of evidence shows that primary care NPs are more likely than their physician counterparts to practice in rural areas—areas characterized by more uninsured
individuals and chronic physician shortages—and to provide care to vulnerable populations that are impacted by SDOH (Barnes et al., 2018; Buerhaus, 2018; Buerhaus et al., 2015; DesRoches et al., 2017; Xue et al., 2019). Yet, despite the growing shortage of physicians practicing primary care and growing calls from public- and private-sector organizations to expand the roles and uses of NPs, many states, hospitals, and health systems continue to restrict NPs’ scope of practice. These restrictions limit access to the high-quality primary care needed by millions of Americans.
Persistently High Maternal Mortality Rates
In addition to filling gaps in the delivery of mental and behavioral and primary care, momentum is growing to address the increasing rates of maternal morbidity and mortality that are disproportionately affecting Black/African American and AI/AN women (Leonard et al., 2019; Petersen et al., 2019). As discussed in Chapter 4, these inequities can be reduced by using RNs and expanding the number of CNMs and nurses prepared to provide women’s health care to help improve the health status of and health care provided to pregnant women. Although perinatal RNs currently serving this population are concentrated in acute care hospitals, they could become a community resource in antenatal and postpartum maternity care. This use of RNs could be particularly effective if informed by established, evidence-based public health home visiting models.
Crucial gaps in the APRN workforce need to be filled to improve maternal health. At a time when CNMs are needed more than ever, their numbers are growing slowly. There were 3.745 million U.S. births in 2019 (Hamilton et al., 2020). Acute care hospitals are the site of 98 percent of U.S. births (MacDorman and Declercq, 2019), and only about 2,900 hospitals provide maternity care (AHA, 2018). If the supply of CNMs, NPs, and CNSs who specialize in perinatal care/women’s health is not expanded (let alone maintained), millions of women will continue to be excluded from critical APRN services at a time when maternal care is increasingly complex, and improving the quality, safety, and equity of maternal care is paramount. Additionally, evidence of disparate care provided by White clinicians to Blacks, AI/ANs, and other POC (Altman et al., 2019; Davis, 2019; Johnson et al., 2019; McLemore et al., 2018; Serbin and Donnelly, 2016; Vedam et al., 2019; Williams et al., 2020) highlights the crucial need to strengthen efforts to increase the racial and ethnic diversity of the nursing workforce providing care for pregnant women. Finally, a recent study by McMichael (2020) examined all births in the United States between 1998 and 2015 (n = 69 million) and found “consistent evidence that allowing APRNs and PAs [physician assistants] to practice with more autonomy reduces the use of medically intensive procedures” (p. 880), specifically caesarean section rates, which place both mothers and infants at risk. This study adds new
evidence of how restrictive scope-of-practice regulations (discussed further below) negatively affect maternal and child well-being.
Worsening Physician Shortages
A 2020 report prepared for the American Association of Medical Colleges estimates that by 2033, current physician shortages could increase, ranging between 21,400 and 55,200 for primary care physicians, and between 33,700 and 86,700 for non–primary care specialty physicians (AAMC, 2020). These projections, made prior to the COVID-19 pandemic, took into account decreasing hours worked by physicians, accelerating retirements, and increasing demands for medical care among aging baby boomers. Separately, HRSA projected a shortage of 24,000 primary care physicians by 2025, due mainly to population aging and overall population growth exceeding the growth in physician supply (HRSA, 2016). Current and projected shortages of primary care and specialty care physicians over the next 10 years mean that both RNs and APRNs will increasingly be called upon to fill gaps in individuals’ access to care.
Rightsizing the Clinical Specialty Distribution of Nurses
As described above, the health and social ramifications associated with the nation’s aging population, growth in mental and behavioral health conditions, inadequate access to primary care, and unacceptably high maternal mortality rates will increasingly fall on the nursing workforce. Not only are there too few nurses and APRNs working in the settings where these populations receive care, but also the number of nurses specializing in these clinical areas needs to increase.
Despite the availability of many fellowship programs and the high career satisfaction reported by clinicians in geriatrics, the number of physicians entering the specialty has consistently been far below the need. Currently, there are 6,671 board-certified geriatricians in the United States—1 for every 7,242 older Americans (Fried and Rowe, 2020). According to the 2018 NSSRN, fewer than 1 percent of RNs (0.4 percent) cited gerontology as the type of specialty care they provide in their primary employment position, and only 8.2 percent of NPs (just under 16,000) were certified in gerontology. With regard to mental and behavioral health, despite current and projected shortages of psychiatrists, only 4 percent of RNs (91,750) spent most of their time providing patient care, including substance abuse treatment and counseling, in psychiatric or mental health care settings, and just 5.3 percent of NPs (10,173) were certified in psychiatric or mental health care. It is not enough merely to increase the number of RNs and APRNs during the decade ahead; rather, there is an urgent need to increase the numbers of nurses in gerontology, mental and behavioral health care, primary care, and maternal health.
Increasing the Distribution of Nurses to Where They Are Needed Most
A third major challenge facing the nursing workforce over this decade is to address the large portions of the U.S. population that are unable to access affordable health care because of geography, insurance status, and other circumstances. In 2018, HRSA reported that 66 percent of HPSAs for primary care and 62 percent of those for mental health care were located in rural or partially rural areas. Because of a lack of education or transportation and competing needs, such as housing and food, individuals and families living in rural areas too often are unable to manage their health and chronic conditions. NPs and the expertise they possess have in many cases markedly expanded access to care in rural and other underserved locations, making them an important resource to help meet individual and community health care needs. As noted earlier, however, too often reimbursement policies and limitations on NPs’ scope of practice impede their effective deployment to help address these challenges. Indeed, as discussed below, state-level restrictions on the practice authority of NPs are associated with decreased access to primary care.
Beyond current and growing physician shortages discussed above, particularly in the areas of primary care, mental health, and gerontology, the physician workforce has historically been unevenly distributed. Unfortunately, this trend is expected to worsen during this decade, with the number of physicians per 10,000 population in rural areas projected to decrease by 23 percent between 2017 and 2030 (from 12.2 to 9.4 physicians per 10,000 population) (Skinner et al., 2019). Over the same years, by contrast, the number of physicians per capita practicing in metropolitan areas will remain roughly constant at 31 per 10,000 population. The major reason for the forecast decline in rural physicians is the large number expected to retire over the decade and the need to be replaced by smaller cohorts of younger physicians. As a result, current large disparities in physician supply between rural and nonrural areas will grow over the decade, with resultant gaps in unmet needs for care falling increasingly on the nursing workforce.
As noted earlier, however, fewer RNs are working in rural areas and in rural hospitals today than in the past, a decrease occurring most rapidly among younger RNs. If this trend continues, it will threaten access to care among the nation’s rural populations at a time when nurses will be counted on to fill gaps in their care. Moreover, given the large number of RNs working in critical access/rural hospitals (more than 300,000) and the number of such hospitals that could close in the years ahead, the number of nurses practicing in rural areas could decline even more during the decade, further complicating policies aimed at increasing access to care for rural populations.
With respect to the NP workforce, studies show that NPs providing primary care are more likely to practice in rural areas than are physicians, and states that do not versus those that do restrict NPs’ scope of practice have a much larger supply of NPs per capita (Barnes et al., 2018; Graves et al., 2016; Xue et al.,
2019). For nurses to respond successfully to rural access problems associated with growing physician shortages and falling numbers of rural physicians projected over the next 10 years, restrictive scope-of-practice provisions will need to be removed and the trend of fewer RNs working in rural areas to be reversed.
Ensuring a Nursing Workforce That Is Diverse and Prepared with the Knowledge and Skills to Address Social Determinants of Health
A fourth challenge facing the nursing workforce over the current decade is to ensure that nurses reflect the people and communities with whom they interact. In addition, nurses need to be prepared to address SDOH that negatively affect health and well-being.
Ensuring a Diverse Workforce
Over the next decade (and beyond), the U.S. population is expected to become more racially and ethnically diverse. Based on data reported by the U.S. Census Bureau, while the number of White individuals will increase by roughly 4 percent, the numbers of all other races will grow much more rapidly: Blacks/African Americans and AI/ANs both by 10 percent, Hispanics by 20 percent, and Asians by 22 percent (Vespa et al., 2020). The fastest growth will be seen among people of two or more races. Box 3-3 provides information on the health disparities that the AI/AN population face and the critical need for nurses to provide culturally competent care. Of note, data on the AI/AN population are limited. More accurate and timely collection of data on AI/AN populations living in and outside tribal lands in the United States is needed to help in determining the allocation of essential resources and services to improve health equity for these populations.
On the other hand, increases in the racial diversity of the APRN workforce have not kept pace with those in the basic RN workforce. Today, most APRNs are White and female (with the exception of CRNAs, who are 30 percent male); the proportion of men who are APRNs (with the exception of CRNAs) is lower than the proportion of men in the basic RN workforce. While higher proportions of POC individuals (with the exception of Hispanics) are obtaining a master’s or PhD degree, and especially a DNP degree, APRNs have a long way to go to match RNs in achieving a more diverse workforce. At the same time, it is important to keep in mind that although three-quarters of NPs are White, a strong majority provide care to people who are poor, lack insurance, are female, and are POC with complex health and social needs, and are more likely to practice in rural areas. Despite these attributes, however, the APRN workforce will need to rapidly become more diverse over the decade or it will fall further behind in reflecting the racial make-up of many of the people it serves. Chapters 7 and 9 on leadership and education, respectively, provide further information on the need for diversity in nursing.
As recommended in the 2016 report Assessing Progress on the Institute of Medicine Report The Future of Nursing, recruitment and retention of a diverse nursing workforce is a priority (NASEM, 2016). As the nation’s population becomes more diverse, it will be important to sustain efforts to diversify the racial, ethnic, and gender composition of the nursing workforce—particularly with respect to increasing the number of Hispanics and their educational attainment. Educators can target efforts to ensure more diverse graduates and better-prepared nurses to match population and community needs by understanding the racial and ethnic characteristics of their communities, expected future trends in racial
and ethnic diversity, and opportunities to capitalize on nurses’ ability to provide culturally and racially concordant care.
Overcoming Deficits in the Knowledge and Skills Needed to Address Social Determinants of Health
Nurses often treat people with multiple comorbid conditions who live in environments that exacerbate social risk factors that negatively affect their health. Yet, as described earlier, many RNs and NPs perceive gaps in their preparation in areas that would help them do their jobs better—mental and behavioral health, SDOH, population health, working in underserved communities, and care for people with complex medical/social needs. Nurses working in schools, public and community health agencies, emergency rooms and urgent care settings, and long-term care settings were most likely to identify these gaps. Furthermore, both RNs and NPs who had graduated since 2010 were more likely to indicate that they would benefit from training in these areas. If RNs and NPs in both the current and future workforce are to be relied on to address social risk factors and respond effectively to the needs of complex individuals, it is critical for them to receive education and training in these areas.
Overcoming Current and Future Barriers Affecting Workforce Capacity
A fifth major challenge facing the nursing workforce over the current decade involves overcoming regulatory restrictions placed on nurses’ scope of practice and avoiding disruptions in care associated with the retirement of large numbers of baby boom RNs. Such restrictions limit access to care generally and to the high-quality care offered by APRNs. Those supporting these restrictions maintain that nonphysician providers are less likely to provide high-quality care because they are required to receive less training and clinical experience. However, evidence does not show that scope-of-practice restrictions improve quality of care (Perloff et al., 2019; Yang et al., 2020). Rather, these regulations restrict competition and can contribute to higher health care costs (Adams and Markowitz, 2018; Perloff et al., 2019).
Scope-of-Practice Restrictions That Reduce the Productive Capacity of Registered Nurses and Nurse Practitioners
Ongoing payment reforms are pressing health systems to reorganize the delivery of care to achieve greater value, improve access, integrate patient care across settings, provide population health, and address social determinants of health. Many organizations are experimenting with new ways to unleash the potential of
their workforce by using telehealth, various forms of digital technology and developing team- and community-based delivery models. Such approaches require flexibility to reconfigure provider roles yet states and health care organizations often place restrictions on health professionals’ scope of practice (SoP) that limit their flexibility. These restrictions are inefficient, increase costs, and decrease access to care. (p. 591)
While considerable progress has been made over the past two decades in lifting state-level regulations restricting NPs’ scope of practice, however, 27 states still do not allow full practice authority for NPs (AANP, 2020). As of January 2021, 23 states and the District of Columbia allow full practice authority for NPs (see Figure 3-3), allowing them to prescribe medication, diagnose patients, and provide treatment without the presence of a physician. Conversely, 16 states restrict NPs’ ability to prescribe medication, requiring a physician’s authorization, while 11 states require physician oversight for all NP practice (AANP, 2020). Some states have stipulations on the kinds of medications NPs can prescribe. In Arkansas, Georgia, Louisiana, Missouri, Oklahoma, South Carolina, Texas, and West Virginia, for example, NPs are prohibited from prescribing any Schedule II medications (AMA, 2017). CNMs are likewise restricted by scope-of-practice laws: they can practice independently in 27 states and the District of Columbia; a collaborative agreement with a physician is required in 19 states; and the 4 remaining states allow them to practice independently, but without the ability to prescribe medications (Georgetown University, 2019).
Not permitting NPs and CNMs to practice to the full extent of their license and education decreases the types and amounts of health care services that can be provided for people who need care. As noted earlier, this artificially imposed reduction in NP and CNM capacity has significant implications for addressing the disparities in access to health care between rural and urban areas. According to the above-cited study by Graves and colleagues (2016), state-level scope-of-practice restrictions on NPs were associated with up to 40 percent fewer primary care NPs per capita in restrictive versus full-practice states, and people living in states allowing for the full practice authority of NPs had significantly greater access to primary care (63 percent) relative to those living in states that reduced (47 percent) or restricted (34 percent) NPs’ scope of practice.
The harmful consequences of restricting NPs’ scope of practice become starker in light of the findings of a 2018 UnitedHealth report on primary care and NP scope-of-practice laws. According to that report, if all states were to allow NPs to practice to the full extent of their graduate education, advanced clinical training, and national certification, the number of U.S. residents living in a county with a primary care shortage would decline from 44 million to fewer than 13 million (a 70 percent reduction). Furthermore, the number of rural residents living in a county with a primary care shortage would decline from 23 million to 8 million (a 65 percent reduction).
A 2020 study (Xu et al., 2021) examined the geographic locations of dual eligibles and primary care providers and found that one-third (n = 271) of the 791 counties with the highest density of dual eligibles in the United States were designated as HPSAs. These counties were more likely to be rural, located in the Southeast region of the country, and encumbered by high poverty rates and a heavy burden of chronic conditions. The investigators found that in nearly half (n = 128) of the 271 counties with both a high-density dual eligible population and a primary care physician shortage, the density of primary care NPs (PCNPs) was the highest, meaning that the distribution of PCNPs was within the highest quartile of the overall supply of PCNPs in the country. The study found that Southeastern states “impose the most restrictive scope of practice regulations that limit the capacity of NPs. Such restrictions may also increase NPs’ reluctance to locate in these states. Thus, a first step to expand access to care is to lessen the state-imposed restrictions on scope of practice for the NPs” (Xu et al., 2021).
The damaging effects of scope-of-practice restrictions on access to care were recently acknowledged during the COVID-19 pandemic when several states (Florida, Kentucky, Louisiana, New Jersey, New York, Tennessee, West Virginia, and Wisconsin) and the Centers for Medicare & Medicaid Services eased supervision and other restrictions placed on NPs to increase the capacity of the health care workforce. It is uncertain whether these restrictions will be reinstated after the pandemic subsides (Yuanhong et al., 2020). Clearly, however, if government leaders concluded that removing restrictions on NPs was beneficial in expanding the public’s access to care during the pandemic, it would be counterproductive to
reimpose those restrictions once the pandemic eases, thereby decreasing access to care.
Until all APRNs are permitted to practice to the full extent of their education and training, significant and preventable gaps in access to care will continue. Millions of people who need health care will be unable to obtain needed care as readily as others who happen to live in states where NPs’ scope of practice is not restricted. For many people, delays in obtaining care lead to worsening of symptoms and disease progression, and to greater costs when care is ultimately provided. Allowing APRNs to practice to the full extent of their education and training as recommended in the 2011 The Future of Nursing report would help remediate inequities in access to health care and enable more people to enjoy the benefits of care provided by NPs and other APRNs.
Disruptions in Care Delivery Associated with the Retirement of Baby Boom Registered Nurses
An estimated 600,000 baby boom RNs have not yet retired and are expected to leave the workforce by 2030. The exit from the workforce by so many experienced RNs (about 70,000 per year) means that health care delivery organizations that depend on RNs will face a significant loss of nursing knowledge, clinical expertise, leadership, and institutional history. The number of experience-years lost from the nursing workforce is estimated to exceed 2 million each year in the current decade (Buerhaus et al., 2017). As shown earlier in Table 3-3, in 2018 more than one-third and in many cases more than half of RNs working in noninpatient settings, including many settings where nurses are vital in ensuring access to care for minority and other vulnerable populations, were over age 50. The loss of nursing knowledge, clinical expertise, leadership, and institutional history associated with the retirement of baby boom RNs is likely to increase gaps in nurses’ ability to provide needed care to vulnerable populations, who often have complex clinical conditions. It is crucial for nurses who enter the workforce during this decade to be well prepared for their role in addressing SDOH and reducing health inequities.
Anticipating Long-Term Impacts of the COVID-19 Pandemic on the Nursing Workforce
A final challenge concerns the pandemic’s economic and noneconomic impacts on the nursing workforce over the immediate (next few years) and longer-term future. The impacts are difficult to predict because of uncertainties about the length and severity of the pandemic; its effects on health care systems and other health care professions; and whether it leads to a deep or shallow economic recession, how long the recession lasts, and the speed with which the economy recovers.
During the first half of 2020, health care systems reoriented their operations to manage a substantial influx of COVID-19-related testing, hospitalizations, and use of postacute care. Stay-at-home orders and social distancing then led to a massive reduction in hospital admissions, surgeries, tests, diagnostic procedures, and elective procedures. As revenues fell, hospitals took actions to decrease their costs, including furloughing nurses. Many physician offices and clinics similarly reduced their staffing. The magnitude of these short-run cost-cutting actions has varied by region and type of employer and may result in disparities in impacts by providers’ race, ethnicity, gender, and age. In the longer run, the pandemic may lead to fundamental shifts in the demand for and supply of nurses. On the demand side, there may be a substantial restructuring of care delivery (e.g., toward telehealth or permanent staffing reductions in hospitals) that affects the nursing workforce. On the supply side, the pandemic may either increase or decrease entry into nursing and accelerate or slow retirement from nursing among the older members of the nursing workforce.
RESEARCH NEEDS TO HELP NURSES MANAGE THESE CHALLENGES
This chapter has provided information about the state of the nursing workforce, its strengths, and the many formidable challenges nurses will face in the coming years. Throughout this report, many ideas are provided for how nurses can address SDOH. What will be useful is to conduct research on how well nurses are implementing these ideas and evaluate whether the desired results are being achieved. For example, nurses are urged to become more active in community-based settings, and nurse educators are urged to modify their curriculum to expand the diversity of the workforce and better prepare nurses for practicing effectively in such settings. Over the decade, then, it will be important to assess whether and how effectively educators and nurses have responded to the ideas put forth in this report and determine whether and how their efforts have impacted SDOH that negatively affect health.
Research is also needed in many other areas to generate information and evidence on what is working and fill gaps in knowledge. Box 3-4 provides questions that can be addressed through a robust research agenda. These questions were generated by experts in nursing health services research and represent their views on the most important and feasible research questions that need to be investigated to increase nurses’ ability to
- improve access to mental and behavioral health care and assess the effectiveness of interventions and services;
- improve access to primary health care and the effectiveness of primary care delivery systems;
- improve maternal health outcomes and the delivery of maternal health care;
- improve the care provided to the nation’s aging population, particularly frail adults; and
- control health care spending, reduce costs, and increase the value of nurses’ contributions to improving health and health care delivery.
As can be seen, these questions mirror many of the concerns about the gaps in the nursing workforce and their implications for SDOH that have been discussed throughout this chapter.
The many strengths of the nursing workforce—its large and growing numbers of increasingly educated nurses; provision of basic and advanced specialty care in numerous types of acute care and community-based settings; delivery of public health, school health, and home health services; and compassion in caring for vulnerable populations in rural and undeserved locations, as well as the public’s positive perceptions of and trust in nurses, will be tested by a variety of challenges that will develop over this decade. These challenges will widen gaps in the size, distribution, diversity, and expertise of the full spectrum of the nursing workforce, gaps that will need to be addressed to help achieve health equity and reverse the trajectory of poor health status too often found in communities across the nation.
Among these challenges is the growing population of older people, many of whom, particularly frail older adults, have multiple comorbid conditions that increase the complexity and intensity of the nursing care they require. Nurses at all levels will also be challenged to help expand the capacity of the primary care workforce, provide care to rural populations, improve maternal health outcomes, and deliver more health and preventive care in community-based settings. And nurses will be called on to provide mental and behavioral health care to treat growing numbers of Americans with mental health conditions and help stem increases in substance abuse, suicide, and gun violence. Projected shortages of physicians in both primary care and non–primary care specialties, combined with projections of decreasing numbers of physicians practicing in rural areas, will increase the demand for RNs and APRNs. Yet, scope-of-practice restrictions that persist in many states and within many health care organizations will reduce the capacity of the nursing workforce when and where it is most needed. Meanwhile, various health care reforms expected to evolve over the decade will require a well-prepared and engaged nursing workforce if they are to succeed.
All of these challenges will be faced by a nursing workforce that will be expanding unevenly across the nation and whose composition and capabilities will be changing as the most experienced nurses in the nation’s history retire,
leading to fewer RNs practicing in rural areas and many nurses being ill prepared to practice in non–acute care settings. Furthermore, the number of nurses in the specialties that are most needed to serve all Americans and achieve improved population health are woefully lacking. While each of these challenges is uniquely consequential, it is important to recognize that the nursing workforce in the United States will confront all of these challenges simultaneously. And not to be forgotten are the unknown effects of the COVID-19 pandemic on the near- and longer-term supply of and demand for nurses.
The many gaps in the capacity of the current nursing workforce will need to be overcome if the nation is to build a future workforce that can provide the health care it needs. Such a workforce would address social risk factors that negatively affect individual and overall population health and help ensure that all people can attain their highest level of well-being. Currently, there are insufficient numbers of nurses providing enough of the right types of care to the people who need health care the most, particularly in underserved locations. To overcome these deficits, substantial increases in the numbers, types, and distribution of the nursing workforce, as well as improvements in the knowledge and skills needed to address SDOH, will be needed. These improvements will occur more rapidly, more uniformly, and more successfully if programmatic, policy, and funding opportunities can be leveraged by health systems, government, educators, and payers, as well as stakeholders outside of the health care sector.
Conclusion 3-1: A substantial increase in the numbers, types, and distribution of members of the nursing workforce and improvements in their knowledge and skills in addressing social determinants of health are essential to filling gaps in care related to sociodemographic and population factors. These factors include the aging population, the increasing incidence of mental and behavioral health conditions, and the increasing lack of access to primary and maternal health care.
Conclusion 3-2: Eliminating restrictions on the scope of practice of advanced practice registered nurses and registered nurses so they can practice to the full extent of their education and training will increase the types and amount of high-quality health care services that can be provided to those with complex health and social needs and improve both access to care and health equity.
Conclusion 3-3: As the nation’s population becomes more diverse, sustaining efforts to diversify the racial, ethnic, and gender composition of the nursing workforce will be important.
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