The Nursing Workforce (2024)

Size and Sociodemographic Characteristics

The total number of APRNs increased considerably in the 10-year period between the last two NSSRNs (2008 to 2018), reaching nearly 375,000 in 2018 (see Table 3-4), although APRN shortages remain in Indian Health Service areas—with vacancy rates ranging between 12 and 47 percent for NPs (GAO, 2018). By a wide margin, NPs outnumber any other APRN role, and their numbers grew more rapidly relative to other APRN roles, nearly doubling over this period. The number of APRNs working in the role of a CNS also increased. Although the total number of RNs prepared as a CRNA-only decreased, the number of CRNAs who were also prepared in another APRN role increased substantially. With regard to CNMs, difficulties associated with question wording in the 2008 and 2018 NSSRNs, combined with small numbers of CNMs sampled in each survey, make estimating the numbers of CNMs problematic. Instead, using data from the American Midwifery Certification Board (AMCB), the number of AMCB-certified nurse midwives in the United States increased from an estimated 11,262 in 2014 to 12,276 in 2018 (AMCB, 2019).

The racial/ethnic composition of NPs has become more diverse (see Figure 3-2), though it lags behind the gains of the basic RN workforce. The proportion of Hispanic NPs increased the most between 2008 and 2018, from 3.8 percent of all NPs to 9.2 percent (an increase of 12,900). The number of Black/African American NPs also increased over this period, from just under 8,000 to nearly 13,000, while the numbers of Asian and other POC NPs increased more slowly.

Similar to the basic RN workforce, NPs and CNSs have remained overwhelmingly women (in 2018, 90.3 percent and 96.7 percent, respectively). The number of male NPs increased slowly between 2008 and 2018, accounting for about 10 percent of NPs in the latter year. In contrast, the proportion of male CRNAs exceeded 40 percent in 2008 but had decreased to 32.7 percent by 2018. CNMs are predominantly female (99 percent) and White (87 percent), with only 6 percent Black or African American (AMCB, 2019).

Employment Settings and Clinical Specialties

Table 3-5 shows that NPs provide access to care for millions of Americans in a wide variety of settings. In 2018, more than 100,000 NPs (52 percent of all NPs) worked in different types of clinics or ambulatory settings (including nurse-managed health centers; private medical practices; school health services; outpatient mental health/substance abuse facilities; and public clinics, including rural health centers, FQHCs, and Indian Health Service facilities). Another 14,000 (7.3 percent of all NPs) worked in various other settings, such as home health agencies, occupational health/employee health services, and universities or colleges. Roughly 68,000 (35 percent of all NPs) worked in hospitals, ranging from critical access hospitals to inpatient units, hospital ambulatory clinics, and emergency departments. Nearly 11,000 (5.6 percent of all NPs) worked in other inpatient settings, including nursing homes, rehabilitation and long-term care facilities, and correctional facilities. With regard to annual earnings, NPs’ median earnings varied considerably by setting, ranging from a low of $90,000 for those employed in school health settings to $120,000 for those working in emergency departments in non–critical access hospitals.

In 2018, a little more than half of NPs (54.7 percent or nearly 106,000) were certified as a family NP. The next largest group were NPs certified in the care of adults (33,620) and in pediatrics (21,622). The numbers of NPs certified in gerontology and psychiatric and mental health care grew the least between 2008 and 2018—9.7 percent and 5.3 percent, respectively, and in 2018 numbered only 15,921 and 10,174, respectively.

Within the different settings in which they work, NPs provide a vast array of clinical specialty care. Of the nearly two dozen clinical specialties shown in Table 3-6, NPs were most likely to provide primary and ambulatory care (39.2 percent), followed by general medical surgical care (9.1 percent), psychiatric or mental health care (6.4 percent), critical care (5.9 percent), and gynecology and women’s health care (4.3 percent). The remaining 35 percent of NPs provided care in 17 other specialties, ranging from oncology (3.9 percent) to infections/communicable diseases (0.8 percent).

Care for People of Color and People with Limited English Proficiency

Analysis of the 2018 NSSRN shows that a majority (70.6 percent) of NPs who reported managing a panel of patients as a primary provider said at least 25 percent of their patient panel consisted of “racial/ethnic minority groups”; one in five indicated that this was the case for 75 percent or more of their panel. Slightly more than one-quarter of NPs (25.9 percent) also reported that 25 percent or more of their patient panel had limited proficiency in English. Additionally, the vast majority of NPs indicated that to a “great or somewhat extent” (versus “very little” or “not at all”), they participated in team-based care (85.8 percent), and felt confident in their ability to practice effectively in interprofessional teams (96.1 percent) and to use health information technology effectively in their practice to manage their patient population (81.1 percent). Most NPs had observed their organization emphasizing team-based care (84 percent) and evidence-based care (97 percent); only 60 percent reported observing their organization emphasizing discharge planning to a great extent or somewhat. Refer to Chapter 7 for more detailed information on interprofessional education and training.

Growth in the Size of the Nurse Practitioner Workforce

The NP workforce is growing rapidly. Using data from the 2001–2016 American Community Survey (ACS), Auerbach and colleagues (2018) project that the number of FTE NPs will more than double from 157,025 in 2016 to 396,546 in 2030 (increasing 6.8 percent annually). As discussed later, the contributions of the growing NP workforce will be useful to overcome projections of primary care and specialty physician shortages over the decade.

The Aging Population

The aging of the U.S. population means that over this decade, increasing numbers of people will age into their 70s, 80s, 90s, and beyond. In 2030, 73.1 million people or 21 percent of the U.S. population, including all baby boomers, will be older than 65 (Vespa et al., 2020). The prevalence of multiple comorbid chronic conditions (e.g., diabetes, heart disease, obesity, cancer, disabilities, mental illness, Alzheimer’s disease, dementia) is high among older people and greatly increases the complexity of their care (Figueroa et al., 2019). Increases can also be expected in the number of frail older adults—those who need assistance with multiple activities of daily living, are weak and losing body mass, have multiple chronic or complex illnesses, and have an increased risk of dying within the next 2–3 years (Collard et al., 2012; Fried et al., 2001). The old-age dependency ratio (the number of people aged 65 and over per 100 people aged 20–64) in the United States will increase from 21 in 2010 to more than 35 by the end of the decade (Vespa et al., 2020). The nation’s aging population will pose extraordinary challenges for society at large and for health care delivery organizations, nurses, social workers, and families.

There are wide disparities in the economic and physical welfare of older adults by gender, racial/ethnic group, and geographic location. Older women are more likely than men to live alone and are twice as likely to be poor. At age 50, Black men and women still have lower life expectancies relative to their White counterparts. Among adults aged 65 and older, POC individuals are much more likely than Whites to rely solely on Social Security for their family income. In addition to the increased risk of age-associated mental health problems and cognitive degenerative diseases, older adults living in rural areas are more likely than their counterparts living in urban areas to be poor; to experience social isolation; and to have significantly less access to fewer health and social resources, including mental health services (Administration on Aging, 2013). It is essential for policy makers and others to pay attention to these gender and racial/ethnic gaps and geographic trends, which could undermine progress in advancing the well-being of older Americans in the present decade.

As the nation’s health care and social support systems come to terms with caring for increasing numbers of older people, increases will be seen not only in the demand for nurses but also in the intensity and types of nursing care required to care for these older adults, extending across inpatient, community-based, and home settings. The gap in the ability of nurses to respond to these needs is already deep and worrisome; according to the 2018 NSSRN, relatively few RNs work in a long-term care facility (60,000) or provide home care (91,000). Similarly, relatively few NPs work in nursing homes (in 2018, 2,700 or 1.4 percent of all employed NPs) or provide home health care services (4,100 NPs or 2.1 percent).

Increases in Mental and Behavioral Health Conditions

Prior to the COVID-19 pandemic, sharp increases in suicide, substance abuse, the opioid crisis, gun violence, and severe depression among younger people were placing growing demands on the mental and behavioral health care workforce, including nurses. Yet, the rising demand for mental and behavioral health services, let alone treatment for the 44 million American adults who are estimated to have a diagnosable mental health condition, is occurring in the face of a shortage of behavioral health professionals that the HRSA (2016) projects could worsen to a shortfall of as many as 250,000 workers by 2025.

Despite current and projected shortages of mental and behavioral health workers, the regulatory policies of many states limit the capacity of existing NPs who provide psychiatric and mental health care. For example, a study by Alexander and Schnell (2019) assessing independent practice authority for NPs between 1990 and 2014 showed that broadening prescriptive authority was associated with improvements in self-reported mental health and decreases in mental health–related mortality, including suicides. These improvements were concentrated in areas underserved by psychiatrists and among populations traditionally underserved by mental health providers. According to the authors, “results demonstrate that extending prescriptive authority to NPs can help mitigate physician shortages and extend care to disadvantaged populations” (Alexander and Schnell, 2019, p. ii).

Similarly, Barnett and colleagues (2019) examined the issuing to NPs and physician assistants of federal waivers for prescribing buprenorphine following passage of the 2017 Comprehensive Addiction and Recovery Act. The waiver expansions were intended to increase patients’ access to opioid use treatment, which is particularly important in rural areas underserved by physicians. The study found that between 2016 and 2019, the number of waivered clinicians per 100,000 population in rural areas increased by 111 percent, with NPs and physician assistants accounting for more than half of this increase. Furthermore, rural counties in states that granted full scope-of-practice authority to NPs saw significantly faster growth in NPs’ buprenorphine treatment capacity compared with states with restrictive scope-of-practice regulations. “By March 2019 this pattern of growth had led to rural counties in states with full scope of practice having twice as many waivered NPs per 100,000 population, compared to those in states with restricted scope of practice (5.2 versus 2.5)” (Barnett et al., 2019, pp. 2051–2052).

The COVID-19 pandemic has added new stresses for many people, particularly those living in or near places with large outbreaks of the virus, increasing the need for mental and behavioral health treatment. As nurses continue to care for people with COVID-19, many will experience added stress; feelings of inadequacy, guilt, compassion fatigue, and physical exhaustion; and uncertainty over their employment. Some of these nurses may leave the profession, many will need help, and too many will suffer alone (Lai et al., 2020).

Increasing demand for mental and behavioral health care in the face of the decreasing capacity of mental and behavioral health care professionals implies that the nursing workforce will be relied upon to help address gaps in this care (Henderson, 2020). In addition to the capacity-reducing effect of regulations, however, the nursing workforce is unlikely to fill these gaps over the current decade because such a small percentage of RNs (3.5 percent or 78,300) provide care in psychiatric, mental health, or substance abuse settings. Similarly, small numbers of NPs work in inpatient (2,500 NPs in 2018) and outpatient (5,500) mental health/substance abuse settings.

Increases in Lack of Access to Primary Health Care

On the eve of the Patient Protection and Affordable Care Act’s (ACA’s) 2014 health insurance expansions, nearly 60 million people had inadequate access to primary care in the United States (Graves et al., 2016), and HRSA reported 5,900 health professional shortage areas (HPSAs). While the ACA eventually expanded insurance coverage to an estimated 20 million individuals, not all of those who gained coverage had adequate access to health care. Unfortunately, the size of the population with inadequate access to health care is rising: in March 2020, HRSA reported that the number of HPSAs nationwide had increased to 7,059, affecting 80.6 million people.

The persistent lack of access to primary health care has led to recommendations to increase the number of nurses practicing in primary care and community-based settings (Bodenheimer and Bauer, 2016). A 2016 report of the Josiah Macy Jr. Foundation, Registered Nurses: Partners in Transforming Primary Care (Bodenheimer and Mason, 2016), emphasizes the need to overcome the limited ways in which many primary care practices currently use RNs (e.g., telephoning prescriptions to pharmacies, performing administrative duties). Instead, the report urges primary care practices to expand the role of RNs in providing primary care services and allow them to practice to the full extent of their education and training (e.g., by managing stable patient panels with controlled diabetes, hypertension, and other conditions). As discussed in Chapter 7, nursing education programs have historically emphasized preparing students for inpatient acute care and medical and surgical nursing. Consequently, too few nurses today are adequately prepared to practice in non–acute care settings. To address the growing need for primary care providers, educators will have to increase coursework and student clinical experiences in primary care settings, which in turn could lead to more graduates choosing careers in primary care and ambulatory and community-based settings.

Fortunately, more than 160,000 NPs certified in either family health, adult health, or pediatrics provide primary care. And a large and growing body of evidence shows that primary care NPs are more likely than their physician counterparts to practice in rural areas—areas characterized by more uninsured individuals and chronic physician shortages—and to provide care to vulnerable populations that are impacted by SDOH (Barnes et al., 2018; Buerhaus, 2018; Buerhaus et al., 2015; DesRoches et al., 2017; Xue et al., 2019). Yet, despite the growing shortage of physicians practicing primary care and growing calls from public- and private-sector organizations to expand the roles and uses of NPs, many states, hospitals, and health systems continue to restrict NPs’ scope of practice. These restrictions limit access to the high-quality primary care needed by millions of Americans.

Persistently High Maternal Mortality Rates

In addition to filling gaps in the delivery of mental and behavioral and primary care, momentum is growing to address the increasing rates of maternal morbidity and mortality that are disproportionately affecting Black/African American and AI/AN women (Leonard et al., 2019; Petersen et al., 2019). As discussed in Chapter 4, these inequities can be reduced by using RNs and expanding the number of CNMs and nurses prepared to provide women’s health care to help improve the health status of and health care provided to pregnant women. Although perinatal RNs currently serving this population are concentrated in acute care hospitals, they could become a community resource in antenatal and postpartum maternity care. This use of RNs could be particularly effective if informed by established, evidence-based public health home visiting models.

Crucial gaps in the APRN workforce need to be filled to improve maternal health. At a time when CNMs are needed more than ever, their numbers are growing slowly. There were 3.745 million U.S. births in 2019 (Hamilton et al., 2020). Acute care hospitals are the site of 98 percent of U.S. births (MacDorman and Declercq, 2019), and only about 2,900 hospitals provide maternity care (AHA, 2018). If the supply of CNMs, NPs, and CNSs who specialize in perinatal care/women’s health is not expanded (let alone maintained), millions of women will continue to be excluded from critical APRN services at a time when maternal care is increasingly complex, and improving the quality, safety, and equity of maternal care is paramount. Additionally, evidence of disparate care provided by White clinicians to Blacks, AI/ANs, and other POC (Altman et al., 2019; Davis, 2019; Johnson et al., 2019; McLemore et al., 2018; Serbin and Donnelly, 2016; Vedam et al., 2019; Williams et al., 2020) highlights the crucial need to strengthen efforts to increase the racial and ethnic diversity of the nursing workforce providing care for pregnant women. Finally, a recent study by McMichael (2020) examined all births in the United States between 1998 and 2015 (n = 69 million) and found “consistent evidence that allowing APRNs and PAs [physician assistants] to practice with more autonomy reduces the use of medically intensive procedures” (p. 880), specifically caesarean section rates, which place both mothers and infants at risk. This study adds new evidence of how restrictive scope-of-practice regulations (discussed further below) negatively affect maternal and child well-being.

Worsening Physician Shortages

A 2020 report prepared for the American Association of Medical Colleges estimates that by 2033, current physician shortages could increase, ranging between 21,400 and 55,200 for primary care physicians, and between 33,700 and 86,700 for non–primary care specialty physicians (AAMC, 2020). These projections, made prior to the COVID-19 pandemic, took into account decreasing hours worked by physicians, accelerating retirements, and increasing demands for medical care among aging baby boomers. Separately, HRSA projected a shortage of 24,000 primary care physicians by 2025, due mainly to population aging and overall population growth exceeding the growth in physician supply (HRSA, 2016). Current and projected shortages of primary care and specialty care physicians over the next 10 years mean that both RNs and APRNs will increasingly be called upon to fill gaps in individuals’ access to care.

Ensuring a Diverse Workforce

Over the next decade (and beyond), the U.S. population is expected to become more racially and ethnically diverse. Based on data reported by the U.S. Census Bureau, while the number of White individuals will increase by roughly 4 percent, the numbers of all other races will grow much more rapidly: Blacks/African Americans and AI/ANs both by 10 percent, Hispanics by 20 percent, and Asians by 22 percent (Vespa et al., 2020). The fastest growth will be seen among people of two or more races. Box 3-3 provides information on the health disparities that the AI/AN population face and the critical need for nurses to provide culturally competent care. Of note, data on the AI/AN population are limited. More accurate and timely collection of data on AI/AN populations living in and outside tribal lands in the United States is needed to help in determining the allocation of essential resources and services to improve health equity for these populations.

On the other hand, increases in the racial diversity of the APRN workforce have not kept pace with those in the basic RN workforce. Today, most APRNs are White and female (with the exception of CRNAs, who are 30 percent male); the proportion of men who are APRNs (with the exception of CRNAs) is lower than the proportion of men in the basic RN workforce. While higher proportions of POC individuals (with the exception of Hispanics) are obtaining a master’s or PhD degree, and especially a DNP degree, APRNs have a long way to go to match RNs in achieving a more diverse workforce. At the same time, it is important to keep in mind that although three-quarters of NPs are White, a strong majority provide care to people who are poor, lack insurance, are female, and are POC with complex health and social needs, and are more likely to practice in rural areas. Despite these attributes, however, the APRN workforce will need to rapidly become more diverse over the decade or it will fall further behind in reflecting the racial make-up of many of the people it serves. Chapters 7 and 9 on leadership and education, respectively, provide further information on the need for diversity in nursing.

As recommended in the 2016 report Assessing Progress on the Institute of Medicine Report The Future of Nursing, recruitment and retention of a diverse nursing workforce is a priority (NASEM, 2016). As the nation’s population becomes more diverse, it will be important to sustain efforts to diversify the racial, ethnic, and gender composition of the nursing workforce—particularly with respect to increasing the number of Hispanics and their educational attainment. Educators can target efforts to ensure more diverse graduates and better-prepared nurses to match population and community needs by understanding the racial and ethnic characteristics of their communities, expected future trends in racial and ethnic diversity, and opportunities to capitalize on nurses’ ability to provide culturally and racially concordant care.

Overcoming Deficits in the Knowledge and Skills Needed to Address Social Determinants of Health

Nurses often treat people with multiple comorbid conditions who live in environments that exacerbate social risk factors that negatively affect their health. Yet, as described earlier, many RNs and NPs perceive gaps in their preparation in areas that would help them do their jobs better—mental and behavioral health, SDOH, population health, working in underserved communities, and care for people with complex medical/social needs. Nurses working in schools, public and community health agencies, emergency rooms and urgent care settings, and long-term care settings were most likely to identify these gaps. Furthermore, both RNs and NPs who had graduated since 2010 were more likely to indicate that they would benefit from training in these areas. If RNs and NPs in both the current and future workforce are to be relied on to address social risk factors and respond effectively to the needs of complex individuals, it is critical for them to receive education and training in these areas.

Scope-of-Practice Restrictions That Reduce the Productive Capacity of Registered Nurses and Nurse Practitioners

Frogner and colleagues (2020) write:

Ongoing payment reforms are pressing health systems to reorganize the delivery of care to achieve greater value, improve access, integrate patient care across settings, provide population health, and address social determinants of health. Many organizations are experimenting with new ways to unleash the potential of their workforce by using telehealth, various forms of digital technology and developing team- and community-based delivery models. Such approaches require flexibility to reconfigure provider roles yet states and health care organizations often place restrictions on health professionals’ scope of practice (SoP) that limit their flexibility. These restrictions are inefficient, increase costs, and decrease access to care. (p. 591)

While considerable progress has been made over the past two decades in lifting state-level regulations restricting NPs’ scope of practice, however, 27 states still do not allow full practice authority for NPs (AANP, 2020). As of January 2021, 23 states and the District of Columbia allow full practice authority for NPs (see Figure 3-3), allowing them to prescribe medication, diagnose patients, and provide treatment without the presence of a physician. Conversely, 16 states restrict NPs’ ability to prescribe medication, requiring a physician’s authorization, while 11 states require physician oversight for all NP practice (AANP, 2020). Some states have stipulations on the kinds of medications NPs can prescribe. In Arkansas, Georgia, Louisiana, Missouri, Oklahoma, South Carolina, Texas, and West Virginia, for example, NPs are prohibited from prescribing any Schedule II medications (AMA, 2017). CNMs are likewise restricted by scope-of-practice laws: they can practice independently in 27 states and the District of Columbia; a collaborative agreement with a physician is required in 19 states; and the 4 remaining states allow them to practice independently, but without the ability to prescribe medications (Georgetown University, 2019).

Not permitting NPs and CNMs to practice to the full extent of their license and education decreases the types and amounts of health care services that can be provided for people who need care. As noted earlier, this artificially imposed reduction in NP and CNM capacity has significant implications for addressing the disparities in access to health care between rural and urban areas. According to the above-cited study by Graves and colleagues (2016), state-level scope-of-practice restrictions on NPs were associated with up to 40 percent fewer primary care NPs per capita in restrictive versus full-practice states, and people living in states allowing for the full practice authority of NPs had significantly greater access to primary care (63 percent) relative to those living in states that reduced (47 percent) or restricted (34 percent) NPs’ scope of practice.

The harmful consequences of restricting NPs’ scope of practice become starker in light of the findings of a 2018 UnitedHealth report on primary care and NP scope-of-practice laws. According to that report, if all states were to allow NPs to practice to the full extent of their graduate education, advanced clinical training, and national certification, the number of U.S. residents living in a county with a primary care shortage would decline from 44 million to fewer than 13 million (a 70 percent reduction). Furthermore, the number of rural residents living in a county with a primary care shortage would decline from 23 million to 8 million (a 65 percent reduction).

A 2020 study (Xu et al., 2021) examined the geographic locations of dual eligibles and primary care providers and found that one-third (n = 271) of the 791 counties with the highest density of dual eligibles in the United States were designated as HPSAs. These counties were more likely to be rural, located in the Southeast region of the country, and encumbered by high poverty rates and a heavy burden of chronic conditions. The investigators found that in nearly half (n = 128) of the 271 counties with both a high-density dual eligible population and a primary care physician shortage, the density of primary care NPs (PCNPs) was the highest, meaning that the distribution of PCNPs was within the highest quartile of the overall supply of PCNPs in the country. The study found that Southeastern states “impose the most restrictive scope of practice regulations that limit the capacity of NPs. Such restrictions may also increase NPs’ reluctance to locate in these states. Thus, a first step to expand access to care is to lessen the state-imposed restrictions on scope of practice for the NPs” (Xu et al., 2021).

The damaging effects of scope-of-practice restrictions on access to care were recently acknowledged during the COVID-19 pandemic when several states (Florida, Kentucky, Louisiana, New Jersey, New York, Tennessee, West Virginia, and Wisconsin) and the Centers for Medicare & Medicaid Services eased supervision and other restrictions placed on NPs to increase the capacity of the health care workforce. It is uncertain whether these restrictions will be reinstated after the pandemic subsides (Yuanhong et al., 2020). Clearly, however, if government leaders concluded that removing restrictions on NPs was beneficial in expanding the public’s access to care during the pandemic, it would be counterproductive to reimpose those restrictions once the pandemic eases, thereby decreasing access to care.

Until all APRNs are permitted to practice to the full extent of their education and training, significant and preventable gaps in access to care will continue. Millions of people who need health care will be unable to obtain needed care as readily as others who happen to live in states where NPs’ scope of practice is not restricted. For many people, delays in obtaining care lead to worsening of symptoms and disease progression, and to greater costs when care is ultimately provided. Allowing APRNs to practice to the full extent of their education and training as recommended in the 2011 The Future of Nursing report would help remediate inequities in access to health care and enable more people to enjoy the benefits of care provided by NPs and other APRNs.

Disruptions in Care Delivery Associated with the Retirement of Baby Boom Registered Nurses

An estimated 600,000 baby boom RNs have not yet retired and are expected to leave the workforce by 2030. The exit from the workforce by so many experienced RNs (about 70,000 per year) means that health care delivery organizations that depend on RNs will face a significant loss of nursing knowledge, clinical expertise, leadership, and institutional history. The number of experience-years lost from the nursing workforce is estimated to exceed 2 million each year in the current decade (Buerhaus et al., 2017). As shown earlier in Table 3-3, in 2018 more than one-third and in many cases more than half of RNs working in noninpatient settings, including many settings where nurses are vital in ensuring access to care for minority and other vulnerable populations, were over age 50. The loss of nursing knowledge, clinical expertise, leadership, and institutional history associated with the retirement of baby boom RNs is likely to increase gaps in nurses’ ability to provide needed care to vulnerable populations, who often have complex clinical conditions. It is crucial for nurses who enter the workforce during this decade to be well prepared for their role in addressing SDOH and reducing health inequities.

BOX 3-4

Agenda for Nursing Health Services Research.