OBJECTIVE: The goal was to characterize the pediatric role and scope of practice of family nurse practitioners (FNPs).
METHODS: A mail survey of a random national sample of 1000 FNPs, stratified according to states that license nurse practitioners to practice independently, was performed. Frequencies were calculated and bivariate analyses were performed to determine the level of association between practice characteristics and practice state, practice location (urban versus rural), and type of care provided (primary versus specialty).
RESULTS: The overall response rate was 75.9%. Sixty-six percent of respondents (n = 416) reported that they currently provided care to children, and 18% (n = 110) reported that they had never provided care to children. Fifty-four percent of FNPs who provided care to children (n = 222) reported that children represented ≤25% of their current patient populations. Few FNPs (9% [n = 39]) reported that children represented >75% of their total patient populations.
CONCLUSIONS: Among FNPs who provide care to children, pediatric patients represent only a small fraction of their patient populations. FNPs are unlikely to have a significant impact on the availability of either primary or subspecialty care for children in the near future.
WHAT'S KNOWN ON THIS SUBJECT:
Health care workforce planning efforts are increasingly incorporating the roles of nurse practitioners and physician assistants.
WHAT THIS STUDY ADDS:
This study characterizes the pediatric roles and scope of practice of family nurse practitioners. Family nurse practitioners may play an important but underrecognized role in the care of children.
Family nurse practitioners (FNPs) constitute one of the specialty areas of nurse practitioners (NPs) and are trained to provide care across the life span. Recently, there has been marked expansion in the number of FNPs being trained throughout the nation.1 There are ∼66 000 FNPs in the United States, constituting ∼50% of all NPs in the country.2
Health care workforce planning efforts are increasingly incorporating the roles of NPs and physician assistants.3,–,5 However, the medical workforce is organized differently for adults and children, for both primary and subspecialty care.6 Recent trends highlight the implications for future workforce planning across the age spectrum. The proportion of pediatric visits (ages of 0–14 years) provided by family physicians has decreased from 33% to 22% over the past 25 years, and the trend has accelerated in the past 10 years.7
It is not known what proportion of FNPs currently provide care to children and to what extent they are engaged in the pediatric medical workforce. Because there are many more FNPs than pediatric NPs,2 they may play an important but underrecognized role in the care of children.
We obtained data on a random sample of FNPs through Medical Marketing Service (Wood Dale, IL). The Medical Marketing Service list contains information on >43 000 FNPs in the United States and is updated on a monthly basis. The final sample contained 400 FNPs in the 22 states that license NPs to practice independently and 600 FNPs in states that require physician involvement.
We designed a 16-item structured questionnaire that focused on practice settings and scope of pediatric practice.
Three mailings were sent. The first was sent via priority mail in January 2010. The initial survey packet contained a personalized cover letter signed by the principal investigator (Dr Freed) and 2 faculty members (Drs Loveland-Cherry and Martyn) in the University of Michigan School of Nursing, the instrument, a business reply envelope, and $5 as an incentive. Two additional mailings were sent to nonrespondents, in February and March 2010.
Frequency distributions were calculated. Subsequently, bivariate analyses were performed to determine the levels of association between practice characteristics and practice state, location, and type of care provided. The study was approved by the University of Michigan institutional review board.
Of the 1000 survey packets mailed, 687 FNPs returned the survey and 95 surveys were undeliverable, which yielded a 75.9% response rate. Fifty-five FNPs were ineligible because they had retired, and 6 FNPs refused, which left 626 surveys for analysis. Because not every FNP responded to every question, the total numbers of responses differed slightly among the questions.
Respondent Demographic Features
Ninety-one percent of FNP respondents (n = 567) were female, and 42% (n = 260) worked in states that allow independent practice. Sixty-six percent of respondents (n = 416) currently provided care to children (Table 1). Of this group, the majority (71% [n = 290]) worked in urban areas, whereas 13% (n = 55) worked in areas with a population center of <10 000. Most FNPs who provided care to children (71% [n = 290]) reported that they were certified by the American Nurses Credentialing Center, whereas 32% (n = 133) were certified by the American Academy of Nurse Practitioners. Seventy-four percent of FNPs who provided care to children (n = 307) reported that they were employed full-time.
Two-thirds of respondents (66% [n = 416]) reported that they currently provided care to children, whereas 18% (n = 110) reported that they had never provided care to children (Table 1). Of the 100 respondents who had provided care to children previously, 30% (n = 30) reported that they intended to provide care to children again, and 44% (n = 44) were not sure (Table 2).
FNPs Currently Providing Care to Children (N = 416)
Pediatric patients were not a large proportion of FNPs' patients. More than one-half of FNPs who provided care to children (54% [n = 222]) reported that children represented ≤25% of their current patient populations. Few FNPs (9% [n = 39]) reported that children represented >75% of their total patient populations (Table 3). The pediatric populations for FNPs tended to include older children and adolescents. Of the total time that FNPs cared for children, an average of 39% was spent with patients from birth through 8 years of age, whereas 61% was spent with patients from 9 to 18 years of age.
Nearly one-half of FNP respondents who cared for children (46% [n = 189]) reported that they worked in private practices, and 17% (n = 72) worked in community clinics (Table 4). Only 11% of FNPs who provided care to children (n = 48) worked in independent NP practices (Table 5). Among FNPs in states that allow independent practice, 17% were engaged in independent practice.
The majority of FNPs who provided care to children (70% [n = 290]) reported that they worked in primary care, whereas 20% of respondents (n = 83) worked in specialty care and 10% (n = 43) worked in emergency departments or urgent care. Ninety-one percent (n = 375) reported that they typically provided mostly outpatient care, with the rest providing only inpatient care (4% [n = 16]) or a mixture of inpatient and outpatient care (5% [n = 22]).
Scope of Practice
The majority of FNPs who provided care for children reported that they often or sometimes provided patient education (96% [n = 382]), performed assessment and diagnosis (95% [n = 376]), developed and managed treatment plans (94% [n = 373]), and wrote prescriptions (93% [n = 367]). Twenty-two percent (n = 87) of FNP respondents reported that they often managed the care of children with complex chronic illnesses. One-third of FNPs reported that they rarely or never performed immunizations (30% [n = 118]) or well-child examinations (30% [n = 119]) (Table 6).
No clinically meaningful associations regarding practice in a state that allowed independent practice, practice settings, or practice locations were seen in bivariate analyses.
Among the most important findings from our study is the finding that approximately one-third of FNPs provided no care to pediatric patients. Furthermore, among FNPs who did provide care to children, adults constituted the majority of patients for 84%. This suggests that FNPs work predominately in practices that see mostly adult patients and they likely are not employed to a great degree in pediatric practices.
This finding has important implications for understanding the overall NP workforce that provides care to children. There have been recent increases in the total numbers of NP training programs and increases in the total numbers of new NPs entering the medical workforce. However, a recent study demonstrated that the increases did not occur in any of the NP training programs focused on children, such as pediatric NP or neonatal NP training programs.1 Because FNPs are trained in the care of children, it would be possible for these clinicians to make up a significant part of the pediatric health care workforce; our results suggest otherwise.
Previous studies found that family physicians are providing less care to pediatric patients than in previous years.7 Our findings suggest that the nature of care provided by FNPs may be similar. The small proportion of FNPs for whom children represent a majority of their practices either may be employed in pediatric practices or may be the preferred providers of NP services to children within larger family physician practices.
Although some authors have posited that NPs will play increasingly important roles in the care of pediatric patients, current trends do not seem to support that idea.1,3,–,5,8 There has been no recent increase in the number of pediatric NPs being trained, and the practice patterns of FNPs in this study suggest that the increase in their numbers likely will have little impact on pediatric care. FNPs may be drawn increasingly to the care of adult patients because the employment opportunities surrounding the primary care shortage for adults will be much greater and the positions more lucrative, compared with pediatric care.6,9 Therefore, it is highly unlikely that NPs will help to alleviate the difficulties in access to pediatric subspecialty services, as some have hoped.5,10
Of note is the small proportion of FNPs engaged in independent practice. One rationale for legislation to permit independent practice was to increase the availability of primary care services in rural areas. Given the care delivery patterns found in this study, however, it is unlikely that this represents a significant influence on pediatric service availability.
Our respondents indicated that a small but important fraction of FNPs (9%) practiced in retail clinics. Retail clinics are often “in-store” clinics that provide a limited number of acute primary care services to patients.11 FNPs seem ideally suited for this role, because they are able to provide care to a wide range of patients across the age spectrum. In contrast, we found in another study that only 1% of pediatric NPs work in such settings.12
A potential limitation in the pediatric scope of practice provided by FNPs is seen in our finding that only 22% of FNPs reported that they often provided care to children with complex chronic conditions and >40% of FNPs rarely did so. It is possible that the practices that employ FNPs are less likely to have FNPs provide care to such children or that, among the limited number of pediatric patients in the practices, few have chronic conditions.
Although there has been a marked increase in the number of FNPs, many do not provide care to children. Among the FNPs who do provide care to children, pediatric patients represent only a small fraction of their patient populations. This suggests that FNPs work mostly in practices that provide care across the age spectrum and they are unlikely to influence the availability of either primary or subspecialty care for children in the near future.
This study was funded by a grant from the American Board of Pediatrics Foundation. The sponsor had no involvement in the collection of data or the preparation or submission of the manuscript.
- Accepted August 18, 2010.
- Address correspondence to Gary L. Freed, MD, MPH, University of Michigan, Child Health Evaluation and Research 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.
- FNP =
- family nurse practitioner •
- NP =
- nurse practitioner
- 2.↵American Academy of Nurse Practitioners. Nurse practitioner facts. Available at: www.aanp.org/NR/rdonlyres/54B71B02-D4DB-4A53-9FA6-23DDA0EDD6FC/0/NPFacts2010.pdf. Accessed July 19, 2010
- Hooker RS,
- Berlin LE
- Freed GL,
- Dunham KM,
- Gebremariam A,
- Wheeler JR
- Freed GL,
- Fant K
- Reynolds EW,
- Bricker JT
- Freed GL,
- Dunham KM,
- Lamarand KE,
- Loveland-Cherry CJ,
- Martyn KK
- Copyright © 2010 by the American Academy of Pediatrics