OBJECTIVE: There is little nationally representative information describing the current manner in which nurse practitioners (NPs) and physician assistants (PAs) work in pediatric practices and their professional activities. To understand better the current NP and PA workforce in pediatric primary and subspecialty care, we conducted a national survey of pediatricians.
METHODS: A survey study of a random national sample of 498 pediatric generalists and 1696 subspecialists in the United States was performed by using a structured questionnaire administered by mail. The survey focused on practice settings, employment, and scope of work of NPs and PAs.
RESULTS: Response rates were 72% for generalists and 77% for subspecialists. More than one-half (55%) of generalists reported that they do not currently work with NPs or PAs, compared with only one-third of subspecialists who do not. Many generalists and subspecialists intend to increase the number of NPs and PAs in their practices in the next 5 years. More generalist and subspecialty practices work with NPs than with PAs. There was great variability between generalists and subspecialists and among different subspecialties in the proportions that worked with NPs and PAs. The scope of work of NPs and PAs also varied between generalists and subspecialists.
CONCLUSIONS: Planned increases in the number of NPs hired and expansion of their scope of work might put subspecialists and general pediatricians in competition with regard to recruitment and hiring of a limited pool of new pediatric NPs. Similar issues might arise with PAs.
WHAT'S KNOWN ON THIS SUBJECT:
Nurse practitioners (NPs) and physician assistants (PAs) play important roles in the care of children. Previous research has examined the roles and scope of work of this workforce from the perspective of NPs and PAs.
WHAT THIS STUDY ADDS:
This study's results provide a better understanding of the current roles of and future market trends for NPs and PAs, in both general and subspecialty settings, from the physician perspective.
There has been significant recent interest in the structure and organization of care delivery for children, involving pediatricians, nurse practitioners (NPs), and physician assistants (PAs). As part of the process of envisioning the future of pediatrics in the year 2020, the American Academy of Pediatrics has hypothesized that there will be increased reliance on teams of providers providing primary care to our nation's children.1 However, there is little nationally representative information on the current manner in which NPs and PAs work in pediatric practices and on descriptions of their professional activities.
As members of the health care team, NPs and PAs play important roles in the care of children. Approximately 13 000 pediatric NPs (PNPs) and 2000 PAs are engaged in the care of children in the United States.2,3 Recent studies examined the perceptions of PNPs, neonatal NPs, family NPs, and PAs regarding their clinical roles, practice settings, scope of work, and career plans and goals.3,–,5 Most PNPs reported that they are engaged in primary rather than subspecialty care, few PAs are engaged in pediatric practice, and only a small proportion of family NPs' time is spent in the care of children.
A recent Institute of Medicine report on the future of nursing declared that nurses should practice to the full extent of their education and training and that they should be full partners with physicians and other health care workers in redesigning health care in the United States.6 The report also noted that “effective workforce planning and policymaking require better data collection and information infrastructure.”6 Unfortunately, most efforts at defining advanced practice nursing and the NP workforce have focused on the care of adults or have included children only in the overall health care workforce needs of the entire population.7,–,9 Because children constitute a decreasing proportion of the US population, such studies are not truly applicable to pediatric care.10 The pediatric health care delivery system in this country often functions with a different set of parameters, workforce constraints, and financing and delivery systems.11 To understand better the current NP and PA workforce in pediatric primary and subspecialty care, we conducted a national study of general and subspecialty pediatricians, to assess employment and work patterns for NPs and PAs.
The American Board of Pediatrics maintains a database of all pediatrics-certified physicians. To characterize the employment of NPs and PAs within general pediatric practices, we surveyed a random national sample of 498 pediatric generalists in the United States. We also surveyed a stratified random national sample of 1696 subspecialists from 5 varied subspecialties. The subspecialist sample included 350 pediatric cardiologists, 323 pediatric critical care physicians, 300 pediatric gastroenterologists, 350 pediatric hematologists-oncologists, and 373 neonatologists.
In collaboration with the American Board of Pediatrics Research Advisory Committee, we developed a 15-item, fixed-choice, structured questionnaire to be administered by mail. The survey was designed to be completed in ≤10 minutes. The survey focused on practice setting, employment, and scope of work of NPs and PAs.
The first mailing of questionnaires was sent via priority mail to the 498 general pediatricians and 1696 subspecialty pediatricians in March 2010. The survey packet contained a personalized cover letter signed by Dr Freed, the survey instrument, a business reply mail envelope, and a $5 bill as an incentive to complete the questionnaire. Two additional mailings were sent to nonrespondents in May and June 2010.
First, frequency distributions were calculated for all survey items. Then, bivariate analyses of responses were conducted according to practice type and subspecialty, and χ2 statistics were used to determine the level of association between the outcome variables and the predictor variables. The study was approved by the University of Michigan Medical School institutional review board.
Response Rates for Generalists
Of the 498 survey packets mailed, 310 surveys were returned and 65 were undeliverable. This yielded an overall response rate of 72%. Sixty-one of those who returned the survey were ineligible because they were retired or no longer working clinically in the field of general pediatrics, and 2 pediatricians refused to complete the survey. This left a total of 247 surveys for analysis, with a 66% response rate among eligible respondents. The number of ineligible pediatricians is likely higher than in previous studies we conducted with this roster source because this sample was not truncated according to age. There were no significant differences between respondents and nonrespondents.
Response Rates for Subspecialists
Of the 1696 survey packets mailed, 1193 surveys were returned and 138 were undeliverable. This yielded an overall response rate of 77%. One hundred twelve of those who returned the survey were ineligible because they had retired or were no longer working in the field of pediatrics, and 13 subspecialists refused to complete the survey. This left a total of 1067 surveys for analysis, with a 74% response rate among eligible respondents. The response rates ranged from 84% for pediatric cardiologists to 64% for pediatric hematologists-oncologists.
Respondent Demographic Features
Among generalists, 76% of respondents (n = 188) were US medical school graduates and 54% (n = 134) were female. Eighty-seven percent of respondents (n = 216) were <60 years of age.
Among subspecialists, 73% of respondents (n = 788) were US medical school graduates and 39% (n = 420) were female. Eighty-seven percent of respondents (n = 926) were <60 years of age.
Working With NPs and PAs
More than one-half of respondents (55% [n = 135]) reported that they do not currently work with NPs or PAs (Table 1). When those 135 respondents were queried regarding the reasons why they do not currently work with NPs or PAs, one-half (49% [n = 65]) indicated that they did not make the decision for their practices. More than one-fourth of respondents reported that they prefer to hire or to work with physicians (28% [n = 37]) and that patients want to see a physician (27% [n = 36]).
Approximately one-third of respondents (n = 335) reported that they do not currently work with NPs or PAs. Larger proportions of cardiologists (43% [n = 95]), critical care physicians (45% [n = 104]), and gastroenterologists (34% [n = 65]), compared with other subspecialists, reported that they do not currently work with NPs or PAs. Approximately one-half of respondents who do not currently work with NPs or PAs (53% [n = 178]) reported that they are not responsible for making the decisions regarding employment for their practices. Thirty-one percent of gastroenterologists (n = 20) and 22% of cardiologists (n = 21) indicated that they do not supervise NPs or PAs because they think that patients want to see a physician (Table 1).
Respondents Who Currently Work With NPs or PAs
The rest of the reported results apply only to the 45% of generalist respondents (n = 112) and the 69% of subspecialist respondents (n = 749) who reported that they currently work with NPs or PAs. Among those general pediatricians, 89% (n = 100) reported that there were NPs in their practices and 37% (n = 41) reported that there were PAs in their practices. For subspecialists overall, 96% (n = 719) reported that there were NPs in their practices, whereas 32% (n = 238) reported that their practices included PAs. There was very little variation among the subspecialties.
Trends in Working With NPs and PAs
More than one-half (53% [n = 59]) of general pediatricians who work with NPs or PAs indicated that their practices have included NPs and/or PAs for ≥10 years, whereas only 10% (n = 11) have done so for <2 years. For subspecialists, approximately one-half of respondents who work with NPs or PAs (51% [n = 379]) indicated that their practices have included NPs or PAs for ≥10 years. Larger proportions of hematologists-oncologists (64% [n = 104]) and neonatologists (76% [n = 152]), compared with other subspecialists, reported that they have included NPs or PAs for ≥10 years (Table 2).
Hiring Trends and Scope of Work for NPs and PAs
Approximately one-third of generalist respondents reported that the number of NPs in their practices (34% [n = 38]) and the NP scope of work (33% [n = 37]) have not changed in the past 5 years. However, 38% of respondents (n = 42) reported that their practices increased the number of NPs and 16% of respondents (n = 18) reported that the scope of work of NPs expanded during that time period. In contrast, nearly two-thirds of subspecialists who work with NPs or PAs (64% [n = 477]) reported that their practices increased the number of NPs in the past 5 years and 41% (n = 305) indicated that their practices expanded the scope of work of NPs (Table 3).
Thirty-nine percent of pediatricians whose practices currently include NPs or PAs (n = 44) reported that their practices plan to maintain the current number of NPs over the next 5 years, and 22% (n = 25) reported that no change is planned in relation to the current scope of work of NPs. Fifteen percent (n = 17) reported that they plan to increase the number of NPs at their practices (Table 4).
Forty-three percent of subspecialists who currently work with NPs or PAs (n = 320) reported that their practices plan to increase the number of NPs in the next 5 years, and one-fourth (n = 184) indicated that their practices will expand the scope of work. Twenty-nine percent of respondents (n = 215) reported that the number of NPs in their practices likely will remain the same (Table 4).
Almost one-half of pediatricians (45% [n = 50]) whose practices include either NPs or PAs reported that there were no PAs in their practices over the previous 5 years (Table 5). Sixteen percent of respondents (n = 18) reported that the number of PAs in their practices have not changed in the past 5 years (Table 5).
Among subspecialists who indicated that they work with NPs or PAs, nearly one-half (46% [n = 342]) reported that there were no PAs in their practices over the previous 5 years. Seventeen percent (n = 128) reported that they increased the number of PAs in the previous 5 years (Table 5). Only 5% of generalists and 12% of subspecialists (n = 87) who currently work with NPs or PAs reported that their practices plan to increase the number of PAs in that time frame (Table 6).
Practice Roles of NPs and PAs
General pediatricians whose practices include NPs (n = 100) reported that the majority of NPs often perform assessment and diagnosis (95% [n = 94]), perform patient education (93% [n = 92]), develop and manage treatment plans (87% [n = 86]), perform well-child examinations (83% [n = 81]), coordinate care (81% [n = 79]), and interpret laboratory or test results (79% [n = 78]). Thirty-four percent of respondents (n = 33) indicated that NPs rarely or never manage the care of children with complex chronic illnesses. Among general pediatricians whose practices include PAs (n = 41), most reported that PAs often perform assessment and diagnosis (94% [n = 33]), perform patient education (94% [n = 33]), develop and manage treatment plans (89% [n = 31]), coordinate care (88% [n = 31]), and interpret laboratory or test results (86% [n = 30]).
Most general pediatricians whose practices include PAs reported that the PAs rarely or never perform inpatient rounding (85% [n = 28]), perform consultations (77% [n = 27]), complete discharges (76% [n = 26]), or write progress notes (70% [n = 23]). Approximately one-fourth of respondents indicated that PAs rarely or never manage the care of children with complex chronic illnesses (26% [n = 9]) or perform well-child examinations (23% [n = 8]).
Subspecialists working in academic hospitals were more likely than their peers in private practice to report that their practices increased the number of NPs (68% vs 39%; P < .0001) and their scope of work (47% vs 25%; P < .0001) in the previous 5 years. Similar trends were not seen for the employment of PAs. Subspecialists working in academic hospitals and outpatient clinics also were more likely than their peers to report that their practices plan to expand the scope of work of NPs in the next 5 years.
Impact of NPs and PAs on Outcomes
Forty-nine percent of generalist pediatricians (n = 53) reported that their practices assess the impact of NPs or PAs on patient satisfaction, and 38% (n = 41) indicated that their practices assess their impact on the cost of care. Thirty percent (n = 33) reported that they assess treatment variations between physicians and NPs or PAs.
Nearly two-thirds (61% [n = 431]) of subspecialists who work with NPs and PAs reported that their practices do not assess the impact of NPs and PAs on outcomes. More than one-fourth of subspecialists who work with NPs or PAs indicated that their practices assess the impact of NPs and PAs on patient satisfaction (30% [n = 211]) and cost of care (27% [n = 195]).
Among the most important findings of this study are the variations among and within general and subspecialty pediatric practices with regard to their inclusion of NPs and PAs. Currently, more than one-half of primary care pediatricians in the United States do not work with NPs or PAs. In contrast, NPs and PAs commonly work in the practices of the 5 subspecialties included in this study, averaging 69% overall. There was significant heterogeneity among these subspecialties, however, with a range from 84% in neonatology to 55% in critical care. NPs were much more common than PAs in the practices of all subspecialties examined. This is consistent with previous research that found a nationwide paucity of PAs working in nonsurgical pediatric care.3
Also of significant interest are the recent trends in NP and PA employment. Less than 25% of general pediatric practices that employ these providers have worked with them for <5 years. This suggests that the decision to begin working with NPs and PAs was not a recent decision for the majority of practices in which these providers are employed currently and there is long-term experience with this model of care.
The majority of the subspecialists had, over the past 5 years, both increased the number of NPs in their practices and expanded the scope of work the NPs performed. This increase in numbers is likely a response to greater patient care demands for specific subspecialties. The expansion in the scope of work is consistent with a recent Institute of Medicine report and others calling for a greater role for NPs in the care of patients.6,12 This broad-based expansion in the pediatric subspecialty setting might be seen as contrasting with the efforts of some in pediatric primary care to limit some aspects of NP care provision.13
The continued real and/or perceived shortage of subspecialty pediatric care providers14,15 also is manifest in our finding that >40% of our subspecialty respondents overall plan to increase the number of NPs in their practices in the next 5 years and 25% plan to expand further the scope of their work. Of interest is the finding that the subspecialties that were most likely to report plans for increased hiring of NPs were those that are ICU-based, that is, critical care and neonatology. Some authors have postulated that additional restrictions in duty hours for residents will have a significant impact on the ability to provide patient care without expanding both the number and scope of care providers of a variety of types.16 These trends are expected to result in even greater demands on the pediatric NP and PA workforce.
Contrasting NPs and PAs
There were significant differences in the proportions of general pediatric practices that employ either PAs or NPs, with many more practices working with NPs. Furthermore, approximately one-third of practices that employ NPs increased the number of NPs in their practices over the past 5 years. This is in contrast to only 11% of practices that increased the number of PAs they employed during the same time period.
Similarly, a much smaller proportion of our subspecialty pediatric respondents indicated that they increased the number of PAs and/or expanded their scope of work in the past 5 years. Furthermore, only 12% indicated that they plan to increase the number of PAs in their practices in the upcoming 5 years. This is likely a result of the historic pattern of few PAs choosing a career in either primary care or subspecialty pediatrics,3 as well as a smaller overall supply of PAs within the workforce, relative to the supply of NPs. Unless there are specific efforts to recruit more PAs for the care of pediatric patients, these patterns are likely to continue.
Assessing the Impact of NPs on Practice
Although there seems to be great interest in the impact of NPs and PAs on a wide range of potential outcome measures, the majority of subspecialists working with these providers do not assess outcomes related to patient satisfaction, cost, or treatment variations. Among respondents who reported conducting assessments, assessments were performed most commonly to examine effects on patient satisfaction (30%) and the cost of care (27%). Only 13% overall reported assessing treatment variations between the care provided by NPs and/or PAs and that provided by the physician subspecialists. In contrast, a larger proportion of primary care pediatricians reported making such assessments. Previous research in this area mostly found a high level of patient satisfaction with NPs and PAs and little or no difference in the cost of care or clinical outcomes, compared with physician care.7,17,–,19
Roles of NPs
Some authors have postulated a potentially increased role for NPs in the primary care of children with complex chronic illnesses, especially with respect to the expanding concept of the medical home.1 However, our data indicate that this is not a common role for NPs now in practice. Only 26% of our respondents indicated that NPs in general pediatrics often manage the care of children with complex chronic illnesses. This is in contrast to the 72% who stated that NPs often manage the care of children with acute care needs. However, 81% reported that NPs often engage in the coordination of care for the patients in their practices. Delineation of the meaning of these terms (coordination versus management) for practitioners currently engaged in primary care pediatrics will be necessary for better understanding of the current roles of NPs and potential changes in future roles in their practices.
Future NP Hiring Plans of Generalists and Subspecialists
Our findings indicate that ∼1 in 7 pediatric primary care practices intend to increase their numbers of NPs within the next 5 years. Recently published studies demonstrated a limited flow of new PNPs into the health care workforce.2 Therefore, it is likely that PNPs will become increasingly scarce resources for practices planning such hiring. Competition for the limited number of PNPs and pediatric PAs likely will increase, because more might be recruited to assist in academic centers to fill the voids left through increasing restrictions on resident duty hours.16 The impact of this scarcity on workforce planning for primary care provision for children will need to be addressed.
Furthermore, currently only ∼40% of PNPs work in subspecialty settings, with most of the rest in primary care.4 The relatively robust plans of subspecialists to hire additional NPs over the next 5 years might signal greater competition between generalists and subspecialists and among subspecialties for this limited pool of providers. This will become manifest very quickly (if it is not already occurring) because the aforementioned supply of new PNPs entering the workforce has not increased in a manner similar to the growth seen for NPs trained in the care of adults.2,20
Planned increases in the numbers of NPs hired and expansion in their scope of work might put subspecialists and general pediatricians in competition with respect to the recruitment and hiring of a limited pool of new PNPs. Similar issues might arise with PAs. To meet demands, examination of strategies to increase the pool of NP and PA trainees interested in developing a career in the care of children should be prioritized.
The American Board of Pediatrics Research Advisory Committee included Linda Althouse, William Balistreri, Alan Cohen, Lewis First, Marshall Land, George Lister, Gail McGuinness, Julia McMillan, Paul Miles, Joseph St Geme, and James Stockman.
- Accepted June 10, 2011.
- Address correspondence to Gary L. Freed, MD, MPH, University of Michigan, Child Health Evaluation and Research Unit, 300 N 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.
- NP —
- nurse practitioner
- PA —
- physician assistant
- PNP —
- pediatric nurse practitioner
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- Copyright © 2011 by the American Academy of Pediatrics