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Sunday January 15, 2017

Nurse Practitioners can transform primary care NOW

By Greer Glazer, PhD, RN, CNP, FAAN and Karen Bankston, PhD, RN, MSN, FACHE


A commitment to primary care has long been established as a way to begin to close the healthcare disparities in the United States; specifically to move from an illness model of care delivery to a framework that supports wellness. However, despite the legislative changes, such as the Affordable Care Act (ACA, 2010) and social movements across the nation promoting health and wellness, we continue to see gaps in quality and disparities in health outcomes that impact the individual and their families. Unfortunately we also continue to see challenges directly related to access. Despite the improvements to the system, there remains a lack of access of providers in certain regions of the country and to certain demographic populations. While there are an estimated 20 million more Americans gaining health insurance coverage under the ACA, it created a challenge to an already fragile primary care system, especially for vulnerable populations in already medically underserved communities (U.S. Department of Health and Human Services, 2016).

In its 2010 National Healthcare Disparities Report, the Agency for Healthcare Research and Quality (AHRQ) concluded that there was a need to increase the progress of achieving better quality of care and more equitable care for all.

Specifically, the report outlined the following:

  • Healthcare quality and access are suboptimal, especially for minority and low-income groups.
  • Quality is improving, access and disparities are not.
  • Urgent attention is warranted to ensure improvements in quality and progress in reducing disparities with respect to certain services, geographic areas, and populations
  • Disparities in preventive services and access to care
  • Progress is uneven with respect to eight national priority areas:
    • Two are improving in quality: 1) palliative and end-of-life care and 2) patient and family engagement
    • Three are lagging: 3) population health, 4) safety and 5) access
    • Three require more data to assess: 6) care coordination, 7) overuse and 8) health system infrastructure
    • All eight showed disparities related to race, ethnicity and socioeconomic status.

This report, among others, provides support that there is a need for graduates of healthcare professions to choose to serve people in underserved communities that have a shortage of primary care providers. Nurse Practitioners are one such provider that is prepared to meet those growing needs.

Nurse Practitioners Infographic

Nurse Practitioners (NP) are primary care providers with graduate (masters and doctoral) academic and clinical preparation to provide care to individuals and populations that includes health promotion, disease prevention, diagnosis of disease and management of chronic conditions. Drs. Loretta Ford and Henry Silver (interestingly enough a nurse and physician) developed the first NP program at the University of Colorado in 1965. The Massachusetts General Nurse Practitioner Program, also directed by a nurse and physician team began in 1968. Since that time, NP programs have increased to meet the demand for access to quality healthcare and currently there are approximately 350 NP programs in the U.S. For over 50 years, research has consistently shown that NPs provide high quality, cost effective primary, acute and long-term care.

Here are the facts:

National rural health snapshot

Statistics used with permission from “Eye on Health” by the Rural Wisconsin Health Cooperative, from an article entitled “Rural Health Can Lead the Way,” by former NRHA President, Tim Size: Executive Director of the Rural Wisconsin Health Cooperative

In the 2015 Assessing Progress on the IOM Report, The Future of Nursing, there is continued emphasis regarding the importance of ensuring that the nursing workforce be fully involved in the transformation that will ultimately shift the care delivery system. In fact, the promotion of the use of Advanced Practice Registered Nurses (APRNs) or Nurse Practitioners to the full extent of their education and training, along with collaborative practice models is foundational to the report. Despite the consistent and convincing evidence that leads to the logical conclusion to expand the use of NPs to improve access to high quality, cost effective primary care, one major impediment addressed in the IOM report, is the restriction of full practice for NPs in many states. Currently, only 19 states and the District of Columbia allow for full independent practice. The remaining states have reduced (19) or restricted (12) practice.

Nurse Practitioner State Practice Environment

In addition to the Institute of Medicine, other prestigious groups such as the Federal Trade Commission, VA System, Robert Wood Johnson Foundation, National Governors Association and American Association of Retired Persons have advocated for reduced barriers for NPs. In spite of this support the American Medical Association and American Academy of Family Physicians continue to oppose full independent practice for NPs citing concerns about safety and quality (which is unsupported by data).

The enrollment and graduation rates in NP programs has continued to increase with approximately 14,000 new NPs graduating in 2014 compared to 6,556 graduates in 2005-2006 (AANP, 2016). Conversely, 50% of medical students chose primary care in the 1990s, whereas only 20-25% choose primary care now (West and Dupras, 2012). This change in graduating medical students choosing primary care is believed to be attributed to a perceived unfavorable lifestyle with being a primary care physician (Haver et. al, 2008). However, today there are more than 205,000 NPs practicing in the U.S., 87% of whom are prepared in primary care.

To contribute to the needs outlined in the 2010 AHRQ report, NPs have increased access to care by treating those with Medicaid, Medicare and without any source of payment. Specifically, 85% of NPs treat people with Medicare, 84% treat people with Medicaid, and approximately 60% of Family Nurse Practitioners and Advanced Practice Nurses treat people without a source of payment (AANP, 2016).

NPs are more likely than other primary care disciplines to practice in underserved rural and urban communities. Both settings have similar healthcare disparities and barriers to healthcare. Periyakoil (2010) provides a national picture of urban and rural health that illustrates the need for a better distribution of primary care providers who can address barriers and reduce health disparities.

We believe that we must return to the roots of the NP movement which was started and supported by physicians and get beyond “long-simmering disputes over ‘turf’” (NIHCM, 2014) to allow NPs (and others like Physician Assistants) to practice to the full extent of their education and training all over the United States. No one disputes that there are not enough primary care physicians, an increased demand for primary care services and a projection for both situations to worsen. NPs are a viable, evidenced based solution to this current and impending crisis. Let’s all forget our professional self-interests and focus on the real goal: Every American deserves high quality, cost-effective healthcare by their provider of choice. Acceptance of the critical role of Nurse Practitioners in primary care’s time has come.

Nurse Practitioner State Practice Environment

Full Practice
State practice and licensure law provides for all nurse practitioners to evaluate patients, diagnose, order and interpret diagnostic tests, initiate and manage treatments—including prescribing medications—under the exclusive licensure authority of the state board of nursing.
This is the model recommended by the Institute of Medicine and National Council of State Boards of Nursing.

Reduced Practice
State practice and licensure law reduces the ability of nurse practitioners to engage in at least one element of NP practice. State law requires a regulated collaborative agreement with an outside health discipline in order for the NP to provide patient care or limits the setting or scope of one or more elements of NP practice.

Restricted Practice
State practice and licensure law restricts the ability of a nurse practitioner to engage in at least one element of NP practice. State requires supervision, delegation, or team-management by an outside health discipline in order for the NP to provide patient care.

Source: State Nurse Practice Acts and Administrative Rules – © American Association of Nurse Practitioners

Greer Glazer is on the Board of Directors of The Sullivan Alliance. She is the Dean and Schmidlapp Professor of Nursing and Associate Vice President of Health Affairs for the College of Nursing at the University of Cincinnati.

Karen Bankston is Associate Dean of Clinical Practice, Partnership and Community Engagement for the College of Nursing at the University of Cincinnati.

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