Traczynski and Udalova (2018) estimate a shortage of 15,000 to 52,000 primary care doctors in the United States by 2025. In comparison about NPs, Cashin, Theophilos, and Green (2016) estimate that by 2025, there will be a deficit of 2,701 physicians and 109, 490 nurses in Australian healthcare, implying that this is not only an issue in the United States, but globally as well. This increasing shortage in primary care providers has created new, abundant opportunities to implement nurse practitioners as independent providers. This utilization of NPs has stemmed debate over the degree of independence that should be allowed, and a great deal of discussion concerning how these roles influence healthcare.
Traczynski and Udalova (2018) state that advanced practice nurses are registered nurses who serve as healthcare providers in a variety of settings, primarily family practice, women’s health, pediatrics and gerontology. The title of advanced practice nurse can include nurse practitioners, certified nurse midwifes, certified registered nurse anesthetists, and clinical nurse specialists (Traczynski & Udalova, 2018). Traczynski and Udalova (2018) state that nurse practitioners make up the majority of advanced practice nurses in the United States, providing care in various settings, including clinics, health centers, urgent care centers, hospitals, private practices, and walk-in clinics.
Despite the proven benefits of expanding the autonomous practice of nurse practitioners, these efforts have been met with a great deal of resistance. Cashin et al. (2016) discuss both the benefits and the barriers to the implementation of NPs in primary care on an international scale, stating that the increasing burden of disease coupled with an increasing shortage of physicians creates a substantial argument for the use of NPs as primary care providers in both the United States and Australia. Barriers to development of the role of nurse practitioners in primary care include state limitations on scope of practice, inconsistencies in scope of practice between states, lack of uniformity in licensure, differing credentialing requirements, reimbursement issues, resistance from physicians, as well as intrinsic nursing factors.
A particularly high demand for primary care providers has been identified in rural areas (Cashin et al., 2016). Traczynski and Udalova (2018) discuss the benefits of nurse practitioners practicing independently in medically underserved areas. These regions are known as Health Professional Shortage Areas (HPSAs), and are classified as an area with a population to primary care physician ratio greater than 2,000 to 1, according to the Department of Health and Human Services, as cited by Traczynski and Udalova (2018).
One issue that has been found to impede expansion of the nurse practitioner role lies within the specific culture of the healthcare field. As discussed by Pritchard (2017), the medical field has long been viewed as a hierarchy, rather than a collaborative interdisciplinary team, with physicians holding more power than any other discipline. Since the implementation of NPs, Pritchard (2017) states that many medical providers have felt that their authority is threatened, predicting negative outcomes related to nurse prescribing that have not proven true. Changing the culture of healthcare from a hierarchy to a collaborative system has resulted in improved overall outcomes for patients.
Whitehead, Dittman, and McNulty (2017) describe change in healthcare as “inevitable and ongoing” (p. 18). Whitehead et al. (2017) discuss Kotter’s (1996) eight steps toward successful organizational change, which can also be directly applied to policy change. The first step in Kotter’s (1996) theory is to establish a sense of urgency by discussing opportunities for improvement and possible outcomes prior to making a change. This allows leaders to anticipate barriers and undesired outcomes and formulate means of overcoming obstacles. This correlates with the advocacy and research conducted on the benefits of NPs as providers to both the financial well-being and overall health of a community. In order to enact change, stakeholders must first understand the reason behind the change. As discussed by Cashin et al. (2016), open communication, the use of expert consultants and evidence are necessary to promoting policy change related to nurse practitioners. Nickitas et al. (2020) state that it is the responsibility of nurses and, in this case, advanced practice nurses to continue to educate colleagues and meet with representatives on state and local levels in order to enact policy change.
As previously stated, physician resistance is a major barrier to the autonomous practice of nurse practitioners in the primary care setting (Cashin et al., 2016). Cashin et al. (2016) speculate that this resistance may result from a perceived threat to the medical profession and market share. As discussed by Pritchard (2017), collaboration between nursing and medical professionals is vital to enacting change within a healthcare setting in order to improve patient and population outcomes.
Another barrier to the successful implementation of nurse practitioners as providers is described by Cashin et al. (2016) as “intrinsic nursing factors.” These include the “subtext of subordination to the medical field within nursing’s psyche”, as well as jealousy among nurses in response to the expanding role of advanced practice nurses. This jealousy stems from the previously mentioned culture of hierarchy within the healthcare field. By eliminating this concept of hierarchy and emphasizing the need for collaborative action, advanced practice nurses would have a great deal more support, aiding in creating these policy changes.
According to Traczynski and Udalova, “health care costs and the supply of primary care providers are critical issues in current and future U.S. health policy”. The use of NPs as independent primary care providers has a major impact on the overall financial well-being of the affected community, as well as local, state, and federal governments. Improving access to care by increasing the number of available primary care providers leads to reduced medical cost by avoiding the use of emergency services related to chronic disease exacerbations. The same study found that full NP independence could reduce costs by more than 0.6 to 1.3%. Implications for Advanced Practice Nurses Regardless of the capacity, advanced practice nurses have a large role to play in the healthcare system.
Repeated studies have shown that the benefits of nurse practitioners in primary care roles include better access to care, decreased costs, decreased hospital admissions and wasted resources, as well as improved overall population health. Many states within the United States still mandate restricted practice authority for advanced practice nurses. In order to enact change, there must be a collaborative effort from the healthcare community. Relationships between healthcare professionals from all disciplines must be improved upon in order to eliminate the hierarchal culture that has been in place for so long. This change must take place in order to create a new collaborative dynamic that will improve quality of care and patient outcomes, and it is the responsibility of advanced practice nurses to initiate this change.