BACKGROUND: There are ∼13 000 pediatric nurse practitioners (PNPs) in the United States. PNPs have been suggested as professionals who could provide care to the growing cadre of children with chronic illnesses and expand the pool of subspecialty care providers. Little is known about current roles of PNPs in primary or subspecialty care.
OBJECTIVE: To gain a better understanding of the roles, focus of practice, professional setting, and professional responsibilities of PNPs.
METHODS: We conducted a mail survey of a random national sample of 1200 PNPs stratified according to states that license NPs to practice independently. χ2 statistics were used to assess responses from PNPs in states that allow independent practice versus those that do not and on PNPs in primary versus specialty care.
RESULTS: The overall response rate was 82.4%. Ninety-six percent (n = 636) of the PNPs were female. More than half of all the respondents (59% [n = 391]) worked in primary care, and almost two-thirds (64% [n = 394]) did not provide care in inpatient settings. Only 11% of the PNPs in states that allow independent practice, practiced independently.
CONCLUSIONS: The majority of PNPs currently work in primary care, and most do not have any inpatient roles. It does not seem that independent PNP practices are responsible for a significant portion of pediatric visits. For those who posit that PNPs will help alleviate the currently perceived shortage of pediatric subspecialists, our findings indicate that it likely will not occur without a significant change in the PNP workforce distribution.
WHAT'S KNOWN ON THIS SUBJECT:
There are ∼13 000 pediatric nurse practitioners (PNPs) in the United States. PNPs have been suggested as professionals who could provide care to the growing cadre of children with chronic illnesses and expand the pool of subspecialty care providers.
WHAT THIS STUDY ADDS:
Little is known about the current roles of PNPs in primary or subspecialty care. Results of this study help us gain a better understanding of the roles, focus of practice, professional setting, and professional responsibilities of PNPs.
Pediatric nurse practitioners (PNPs) are important members of the health care workforce that provides care to children. They represent a segment of advanced-practice nurses, a designation that requires advanced education in a specific discipline after completion of registered nurse (RN) training as well as successful completion of a national certification examination. There are ∼13 000 PNPs in practice today.1
Recent attention has focused on the role of PNPs in providing care for children, vis à vis projections of shortages of pediatric subspecialty physicians. PNPs, whose training and certification are distinct from those of neonatal nurse practitioners (NNPs), have been suggested as professionals who can provide care to the growing cadre of children with chronic illnesses.2,–,4 Researchers have also posited that PNPs are well suited to manage the transition of these patients to adult care providers.5 However, recent reports have suggested that the number of PNPs has remained static for the past several years and is not poised to increase.1 Approximately 600 PNPs complete training each year, a number that is relatively unchanged from a decade ago.
Some states allow NPs to practice independently without the direct supervision of a physician, and some allow independent prescription of certain medications.6,7 Although there has been significant focus on NPs in independent-practice arrangements,8,–,10 the actual proportion of PNPs engaged in this practice environment is unknown.
To gain a better understanding of the roles, generalist versus subspecialty focus of practice, professional setting, and responsibilities of PNPs, we undertook a national assessment of these health care providers.
We conducted a mail survey of a random national sample of PNPs. The sample was obtained through Medical Marketing Service, Inc. Their list contains information on >12 000 PNPs (excluding NNPs) and is updated on a monthly basis.
We stratified the sample according to the 22 states and federal district which license NPs to practice independently without physician involvement. The final sample contained 550 PNPs in states that allow independent practice and 650 PNPs in states that do not.
We developed a structured questionnaire to be administered by mail. The survey contained 15 fixed-choice items and 1 open-ended item and focused on practice setting, scope, and career plans.
The first mailing was sent via US Postal Service Priority Mail to the 1200 NPs in the sample in September 2009. The packet contained a personalized cover letter signed by the principal investigator (Dr Freed) and nursing faculty coinvestigators (Drs Loveland-Cherry and Martyn), the survey instrument, a business reply envelope, and $5 as an incentive. Two additional mailings were sent to nonrespondents in October and November 2009.
Frequency distributions were calculated for all survey items. Bivariate analyses using χ2 statistics were conducted on responses from PNPs in states that allowed independent practice versus states that do not and on PNPs who work in primary versus specialty care. The study was approved by the University of Michigan Medical Institutional Review Board.
Of the 1200 survey packets mailed, 905 PNPs returned the survey and 102 survey packets were undeliverable. The overall response rate was 82.4%. A total of 237 PNPs were ineligible because they were no longer working in pediatrics and 5 refused to participate; 662 surveys remained for analysis.
Ninety-six percent (n = 636) of the PNPs were female. The majority (93% [n = 603]) of them worked in areas of at least 50 000 residents.
More than half of the respondents (59% [n = 391]) worked in primary care, and almost two-thirds (64% [n = 394]) did not work in inpatient settings. Three-quarters (78% [n = 514]) provided mostly outpatient and 12% (n = 78) mostly inpatient care. Thirty-nine percent (n = 254) spent most of their time in a private practice (Table 1).
Independent- Versus Non–Independent-Practice States
PNPs in independent-practice states were more likely to work in an independent-NP practice (11 vs 3%; P < .0001) (Table 2). However, only a small proportion of the overall PNPs in these states actually did so.
Primary Versus Specialty Care
PNPs in primary care were more likely than the PNPs in specialty care to report that they typically provided outpatient care (93 vs 56%; P < .0001) (Table 3).
Scope of Practice
The majority of PNPs in primary and specialty care reported that they often or sometimes perform most general practice roles such as development of treatment plans and patient assessment and diagnosis. (Table 4) A greater number of PNPs working in primary care than specialty care reported that they often or sometimes provided immunizations (86 vs 35%) and well-child examinations (89 vs 30%).
Career Plans and Demographics
A total of 69% (n = 440) of the PNPs reported that they were employed full-time, and 43% (n = 285) worked 40–60 hours/week. Approximately one-fifth of PNPs reported that they had been in practice for <5 years (20%) or >20 years (19%).
The majority (67% [n = 437]) of PNPs were certified by the Pediatric Nursing Certification Board, whereas 20% (n = 196) were certified by the American Nurses Credentialing Center. More than two-thirds of the PNPs (71% [n = 466]) reported that they planned to continue practicing at their current hours for the next 5 years, whereas 14% (n = 89) planned to decrease and 7% (n = 44) planned to increase their hours.
Among the most important findings in our study are that the majority of the PNPs worked in primary care settings, and most had no inpatient roles. In addition, the greatest proportion of PNPs was employed in private practices.
However, for those who posit that PNPs will be positioned to alleviate the currently perceived shortage of pediatric subspecialists, our findings indicate that likely will not occur without a significant change in the PNP workforce distribution. A substantial increase in the number of PNPs working with pediatric subspecialists will require many PNPs to change from their current primary care practice settings or a marked increase in the number of NPs pursuing pediatric training.
Previous studies that assessed the primary care/subspecialist ratio of PNPs were only conducted in limited geographic areas or specific samples of graduates from specific institutions. For example, a 2007 study in the St Louis, Missouri, metropolitan area revealed that 70% of PNPs engaged in subspecialty care.11 It is likely that regional market variation exists. Sources of this variation could be factors that ranged from local norms to PNP workforce availability to reimbursement patterns.
Competition to employ the limited pool of PNPs is likely to increase and may begin to pit private practices against academic centers and generalists against subspecialists, potentially resulting in a cost increase of PNP labor. Two previous studies12,13 found that salaries for PNPs in specialty practice and inpatient settings were higher than in primary care. New models of care delivery in either or both settings may be influenced by financial as well workforce as variables.
The finding that only 11% of the PNPs in states that allowed independent practice were actually practicing in such arrangements is important. Efforts to create legislation that allowed independent practice have their roots in providing increased access to primary care, especially in areas where there are perceived physician shortages. However, results of a previous study showed that those states that allow NP independent practice are frequently not the ones with the highest concentration of PNPs.1 In this and other issues related to the PNP workforce, it is important to keep in perspective that <10% of all NPs are PNPs and that larger market forces likely influence state and federal policies regarding the medical workforce.
There has been considerable interest expressed regarding the role and impact of PNPs engaging in independent practice. This has also been a flashpoint of controversy between medical and nursing professional organizations.14,15 It is interesting to note that until this study there were no data reflecting the magnitude of the phenomenon of independent practice among PNPs. Our finding that barely 1 in 10 PNPs in those states that allow such an arrangement actually engaged in independent practice indicates that the actual market impact is quite small. In addition, the likelihood of expansion, given the lack of growth in the overall pipeline of PNPs, is minimal.
Scope of Practice
Our study provides information regarding the similarities and differences in the scope of practice performed by PNPs working in primary care and subspecialty practices.
PNPs in subspecialty care are more likely than those in primary care to work at least a portion of their time in an inpatient setting. However, more than half of the PNPs in subspecialty care mostly worked with outpatients. This finding suggests that there is significant variation among, and possibly within, specific subspecialties in how PNPs are used.
Unique Nature of the PNP Workforce
Frequently, workforce studies aggregate providers in the primary care specialties of pediatrics, internal medicine, and family medicine. Such aggregation has been shown to misrepresent the unique nature of the organization and financing of care for children.16 The unique nature of PNPs is no exception. Compared with reports that from 85% to 95% of NPs overall participate in primary care,3,17 that only 59% of the PNPs in our survey did so is important for projections of future pediatric workforce capacity.
PNPs have, and will continue to have, an important role in pediatric primary and subspecialty care. A more comprehensive appreciation of the nature and scope of PNP care provision is essential to understanding their role in the changing landscape of the organization of care for children. It is important to note that it does not seem that independent PNP practices are responsible for a significant portion of pediatric visits. To meet both the needs of the private and academic settings, attention should likely be focused on mechanisms to increase the numbers of NPs entering pediatric care, which will help to ensure that there will be a sufficient pediatric workforce to address demand in the primary and subspecialty domains.
- Accepted July 30, 2010.
- Address correspondence to Gary L. Freed, MD, MPH, University of Michigan, Child Health Evaluation and Research (CHEAR) Unit, 300 North Ingalls Building, Room 6E08, Ann Arbor, MI 48109-0456. E-mail:
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
- PNP =
- pediatric nurse practitioner •
- RN =
- registered nurse •
- NNP =
- neonatal nurse practitioner
- Freed GL,
- Dunham KM,
- Loveland-Cherry CJ,
- Martyn KK
- Hooker RS,
- Berlin LE
- Pearson LJ
- 7.↵National Council of State Boards of Nursing, Inc. Member board profiles. Available at: www.ncsbn.org/2009_Member_Board_Profiles(1).pdf. Accessed April 5, 2010
- Anderson J
- 15.↵National Association of Pediatric Nurse Practitioners. NAPNAP is stunned by AAP's statements about NPs in Pediatric News, May1, 2009. Available at: www.napnap.org/newsarticle/09-05-01/NAPNAP_is_stunned_by_AAP%E2%80%99s_statements_about_NPs_in_Pediatric_News.aspx. Accessed April 5, 2010
Why Does Pediatrics Seem to Favor One Topic or Subspecialty More Than Others?: Do you ever think that our journal seems to favor articles on one topic or subspecialty more than others? As it turns out, our data suggests otherwise although some topics do seem more prevalent than others. All articles submitted to Pediatrics for publication are assigned one of 48 topic codes that correspond to the various sections of the American Academy of Pediatrics (AAP). Of the 3855 manuscripts submitted to Pediatrics between July 2009 and June 2010, 483 were published. The top 5 topic areas published during this time were categorized as (1) administration and practice management, which includes general pediatric topics (14.4% of published manuscripts), (2) perinatal medicine (11.1%), (3) gastroenterology, hepatology, and nutrition (9.5%), (4) infectious diseases (6.8%), and (5) developmental and behavioral pediatrics (4.3%). Most notably, in the past academic year articles were published from each of the 48 sections of the AAP. In addition, many articles overlap more than one category or section, so if your specific interest is not reflected above as a top 5 category, (eg, such as emergency pediatrics or hospitalist medicine), odds are these interests are certainly contained in the journal in higher percentages than we can reflect since we assign only one category per article when we could easily assign several to almost every article we publish. So while some sections may seem more prevalent than others, our journal continues to be applicable to all members of the AAP regardless of their specialty or the section they belong to. Hopefully, this helps dispel any myths that we favor only one or two specialties or topics in Pediatrics.
Noted by LRF, MD and WVR, MD
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