White Paper: Critical Shortage of Pediatric Nurse Practitioners Predicted
2019; Elsevier BV; Volume: 33; Issue: 3 Linguagem: Inglês
10.1016/j.pedhc.2019.02.008
ISSN1532-656X
AutoresKristin Hittle Gigli, Michelle A. Beauchesne, Mary Dirks, Jessica L. Peck,
Tópico(s)Emergency and Acute Care Studies
ResumoPediatric health care providers play an essential role in the attainment of optimal child health. Ensuring that children have access to qualified pediatric health care providers is as important in improving outcomes as other variables contributing to child health outcomes (Children's Hospital Association n.dChildren's Hospital Association. (n.d.). About children's hospitals. Lenexa, KS: Author. Retrieved from https://www.childrenshospitals.org/About-Us/About-Childrens-HospitalsGoogle Scholar, Institute for Healthcare Improvement 2019Institute for Healthcare ImprovementThe IHI triple aim. Author, Boston, MA2019http://www.ihi.org/Engage/Initiatives/TripleAimGoogle Scholar). Pediatric nurse practitioners (PNPs) are uniquely qualified advanced practice registered nurses (APRNs) with specialized education and focused clinical practice dedicated to the care of all children (American Nurses Association 2015American Nurses AssociationScope and standard of practice: Pediatric nursing.2nd ed. American Nurses Association, Silver Spring, MD2015Google Scholar). The delivery of high-quality care across the health care continuum allows PNPs working in primary, acute, and specialty care settings to influence child health. PNPs offer clinical expertise and care focusing on children's development, health promotion, disease prevention, and anticipatory guidance, which contribute to child health and family well-being. The purpose of this white paper is to highlight the roles of PNPs in the care of children, synthesize what is known about the PNP workforce, and elucidate the value of PNPs as members of interdisciplinary care teams. This paper can support PNPs in advocating for their clinical practice and professional development, help health care administrators understand the role of specialized PNPs, promote the wise council of APRN faculty when students are enrolling in graduate nursing education programs, and encourage researchers and policy makers to undertake studies on the state of the pediatric workforce. This scoping review of the current literature identifies gaps in knowledge and makes recommendations for future research on the state of the PNP workforce and roles in care delivery. There are more than 270,000 nurse practitioners (NPs) currently licensed in the United States, with approximately 5% of those certified to practice in pediatrics (American Association of Nurse Practitioners 2019American Association of Nurse PractitionersNP fact sheet. Author, Austin, TX2019https://www.aanp.org/all-about-nps/np-fact-sheetGoogle Scholar). Of the almost 18,000 PNPs currently holding active certification from the Pediatric Nursing Certification Board (PNCB), 85% are certified to practice in a primary care setting, and only 10% are certified to practice in an acute care setting. An additional 5% hold dual certification in both primary and acute care (Pediatric Nursing Certification Board 2018Pediatric Nursing Certification Board2017 Exam statistics. Author, Rockville, MD2018https://www.pncb.org/sites/default/files/resources/PNCB_Exam_Statistics.pdfGoogle Scholar). Almost an additional 3,000 PNPs are certified in primary care through the American Nurses Credentialing Center (Pediatric Nursing Certification Board 2019aPediatric Nursing Certification BoardCPNP-PC vs. PPCNP-BC. Author, Rockville, MD2019https://www.pncb.org/compare-pnp-certificationsGoogle Scholar). Nearly half of all newly certified PNPs surveyed reported working in outpatient general pediatrics, and 26% of PNPs reported working in outpatient specialty care clinics. Although only 8% of PNPs are certified in providing acute care, 22% report practicing in inpatient settings (Freed et al., 2014Freed G.L. Dunham K.M. Martyn K. Martin J. Moran L.M. Spera L. Pediatric nurse practitioners: Influences on career choice.Journal of Pediatric Health Care. 2014; 28: 114-120Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar). These numbers reflect the complexity of role designation and the inconsistencies in employment practices related to certification and licensure. The Pediatric Nursing Certification Board 2018Pediatric Nursing Certification Board2017 Exam statistics. Author, Rockville, MD2018https://www.pncb.org/sites/default/files/resources/PNCB_Exam_Statistics.pdfGoogle Scholar defines the role of the Certified PNP–Primary Care (CPNP-PC) as a provider of care to children from birth through young adult ages with specialized, extensive knowledge and experience in pediatric health care, including well-child care and prevention, health promotion, and management of acute and chronic pediatric conditions. This care is holistic in nature and seeks to support optimal health outcomes within family, community, and environmental contexts. The current CPNP-PC and Pediatric Primary Care NP–Board Certified (PPCNP-BC) role has progressed to accommodate the rapidly changing and increasingly complex needs of both the pediatric community and health care system (Aruda, Griffin, Schartz and Geist, 2016Aruda M.M. Griffin V.J. Schartz K. Geist M. Evolving role of pediatric nurse practitioners.Journal of the American Association of Nurse Practitioners. 2016; 28: 68-74Crossref PubMed Scopus (9) Google Scholar). A CPNP-PC/PPCNP-BC may work in settings including, but not limited to, office-based practices, school-based health centers, hospital newborn nurseries, and telehealth practices (American Nurses Association 2015American Nurses AssociationScope and standard of practice: Pediatric nursing.2nd ed. American Nurses Association, Silver Spring, MD2015Google Scholar). A certified Acute Care PNP (CPNP-AC) has specialized education that supports care for patients with acute and critical illnesses who experience episodic illness or exacerbation of chronic illness or who require end-of-life care (Bolick et al., 2013Bolick B.N. Bevacqua J. Kline-Tilford A. Reuter-Rice K. Haut C. McComiskey C.A. Verger J.T. Recommendations for matching pediatric nurse practitioner education and certification to acute care populations.Journal of Pediatric Health Care. 2013; 27: 71-77Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar). CPNP-ACs have specialized clinical skills and competencies to assess, diagnose, manage, and evaluate pediatric patients (American Nurses Association 2015American Nurses AssociationScope and standard of practice: Pediatric nursing.2nd ed. American Nurses Association, Silver Spring, MD2015Google Scholar), including responsibilities to “stabilize the patient's condition, prevent complications, restore maximum health, and/or provide palliative care” (National Organization of Nurse Practitioner Faculties 2013National Organization of Nurse Practitioner FacultiesPopulation-focused nurse practitioner competencies. Author, Washington, DC2013https://cdn.ymaws.com/www.nonpf.org/resource/resmgr/Competencies/CompilationPopFocusComps2013.pdfGoogle Scholar, p. 39). They work in diverse settings including, but not limited to, hospitals, emergency departments, intensive care units, urgent care centers, and home care with technology-dependent patients. CPNP-ACs work as members of interprofessional teams in which the responsibility of caring for acutely and critically ill patients is distributed among multiple providers: CPNP-ACs, physicians, nurses, and others (Chesluk et al., 2012Chesluk B.J. Bernabeo E. Hess B. Lynn L.A. Reddy S. Holmboe E.S. A new tool to give hospitalists feedback to improve interprofessional teamwork and advance patient care.Health Affairs. 2012; 31: 2485-2492Crossref Scopus (26) Google Scholar, Reuter-Rice, Madden, Gutknecht and Foerster, 2016Reuter-Rice K. Madden M. Gutknecht S. Foerster A. Acute care pediatric nurse practitioner: The 2014 practice analysis.Journal of Pediatric Health Care. 2016; 30: 241-251Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar). As interprofessional team members, CPNP-AC providers are responsible for independent and collaborative decisions when providing patient care and engaging families in the process of care delivery (Stocker et al., 2016Stocker M. Pilgrim S.B. Burmester M. Allen M.L. Gijselaers W.H. Interprofessional team management in pediatric critical care: Some challenges and possible solutions.Journal of Multidisciplinary Healthcare. 2016; 9: 47-58Crossref PubMed Scopus (26) Google Scholar). PNPs working in specialty care may often work between the inpatient and outpatient care settings. PNP roles in specialty care are often developed to manage a specific population of patients. As providers in pediatric subspecialties, including but not limited to cardiology, surgery, endocrinology, neurology, nephrology, urology, trauma, pain/sedation, palliative care, and genetics, these PNPs assume a variety of clinical roles. Postgraduate, structured orientations—sometimes referred to as residency or fellowship programs—can augment the role PNPs play in care delivery in specific specialties and should be competency based (Bolick et al., 2013Bolick B.N. Bevacqua J. Kline-Tilford A. Reuter-Rice K. Haut C. McComiskey C.A. Verger J.T. Recommendations for matching pediatric nurse practitioner education and certification to acute care populations.Journal of Pediatric Health Care. 2013; 27: 71-77Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, Martsolf, Nguyen, Freund and Poghosyan, 2017Martsolf G.R. Nguyen P. Freund D. Poghosyan L. What we know about postgraduate nurse practitioner residency and fellowship programs.Journal for Nurse Practitioners. 2017; 13: 482-487Abstract Full Text Full Text PDF Scopus (35) Google Scholar, Sorce, Simone and Madden, 2010Sorce L. Simone S. Madden M. Educational preparation and postgraduate training curriculum for pediatric critical care nurse practitioners.Pediatric Critical Care Medicine. 2010; 11: 205-212Crossref PubMed Scopus (30) Google Scholar). Roles in care can include pre- and postoperative care, management of chronic conditions, high-risk clinics, and hospital consultations (American Nurses Association 2015American Nurses AssociationScope and standard of practice: Pediatric nursing.2nd ed. American Nurses Association, Silver Spring, MD2015Google Scholar). Given the spectrum of roles assumed by PNPs working in specialty care and the overlap in the scope of practice between primary and acute care PNPs, the education, certification, and licensure of PNPs in specialty care should match their practice (APRN Consensus Work Group & National Council of State Boards of Nursing APRN Advisory Committee 2008APRN Consensus Work Group & National Council of State Boards of Nursing APRN Advisory CommitteeConsensus model for APRN regulation: Licensure, accreditation, certification & education.2008https://www.ncsbn.org/Consensus_Model_for_APRN_Regulation_July_2008.pdfGoogle Scholar).PNP roles in specialty care are often developed to manage a specific population of patients. PNP roles in specialty care are often developed to manage a specific population of patients. Focused competencies for CPNP-PC and CPNP-AC practice differentiate the clinical practice of these providers but retain additional core competencies common to all NPs (National Organization of Nurse Practitioner Faculties 2013National Organization of Nurse Practitioner FacultiesPopulation-focused nurse practitioner competencies. Author, Washington, DC2013https://cdn.ymaws.com/www.nonpf.org/resource/resmgr/Competencies/CompilationPopFocusComps2013.pdfGoogle Scholar, National Organization of Nurse Practitioner Faculties 2017National Organization of Nurse Practitioner FacultiesNurse practitioner core competencies content. Author, Washington, DC2014https://cdn.ymaws.com/www.nonpf.org/resource/resmgr/competencies/2017_NPCoreComps_with_Curric.pdfGoogle Scholar). Master's and doctoral degrees and postgraduate certificate education programs support potential certification as a PNP (Pediatric Nursing Certification Board 2019bPediatric Nursing Certification BoardPNCB exams. Author, Rockville, MD2019http://www.pncb.org/ptistore/control/about/about_examsGoogle Scholar). The Doctor of Nursing Practice (i.e., DNP) degree is the appropriate credential and a terminal level of education for APRNs, which in some cases is the entry level for nurses as experts in clinical practice (National Association of Pediatric Nurse Practitioners 2017National Association of Pediatric Nurse PractitionersNAPNAP position statement on the doctor of nursing practice (DNP).Journal of Pediatric Health Care. 2017; 31: A17-A19Abstract Full Text Full Text PDF Google Scholar). At the completion of a graduate-level PNP educational program, the student qualifies to take the PNP national certification examination that corresponds with his or her educational program, primary and/or acute care (Pediatric Nursing Certification Board 2019bPediatric Nursing Certification BoardPNCB exams. Author, Rockville, MD2019http://www.pncb.org/ptistore/control/about/about_examsGoogle Scholar). Upon successful certification, the student becomes a CPNP-PC, PPCNP-BC, or CPNP-AC and can obtain state licensure and authority to practice (APRN Consensus Work Group & National Council of State Boards of Nursing APRN Advisory Committee 2008APRN Consensus Work Group & National Council of State Boards of Nursing APRN Advisory CommitteeConsensus model for APRN regulation: Licensure, accreditation, certification & education.2008https://www.ncsbn.org/Consensus_Model_for_APRN_Regulation_July_2008.pdfGoogle Scholar). National efforts are underway in states to ensure uniform regulation of the APRN role in accordance with The Consensus Model for APRN Regulation, Licensure, Accreditation, Certification and Education (National Council of State Boards of Nursing 2017aNational Council of State Boards of NursingNCSBN's APRN campaign for consensus: State progress toward uniformity. Author, Chicago, IL2017https://www.ncsbn.org/5397.htmGoogle Scholar). Currently, all states acknowledge the NP role, and a vast majority require NP certification to attain licensure (National Council of State Boards of Nursing 2017aNational Council of State Boards of NursingNCSBN's APRN campaign for consensus: State progress toward uniformity. Author, Chicago, IL2017https://www.ncsbn.org/5397.htmGoogle Scholar). APRNs should align their education, certification, licensure, and patient population with care roles and clinical responsibilities (APRN Consensus Work Group & National Council of State Boards of Nursing APRN Advisory Committee 2008APRN Consensus Work Group & National Council of State Boards of Nursing APRN Advisory CommitteeConsensus model for APRN regulation: Licensure, accreditation, certification & education.2008https://www.ncsbn.org/Consensus_Model_for_APRN_Regulation_July_2008.pdfGoogle Scholar). Specializations in practice areas (e.g., oncology, neurology, cardiology, palliative care) result from a demand for health care delivery. Certifications in these areas are complementary but do not increase the scope of practice, nor are they required for licensure or practice beyond the PNP role and pediatric focus (Kleinpell and Hudspeth, 2013Kleinpell R.M. Hudspeth R.S. Advanced practice nurisng scope of practice for hospital, acute care/critical care, and ambulatory care settings: A primer for clinicians, executives and precpetors.Advanced Critical Care. 2013; 24: 23-39Crossref PubMed Scopus (8) Google Scholar). Employment as a PNP often requires credentialing and the attainment of privileges to provide care that are unique and vary in different hospitals or health care systems (Gigli, Dietrich, Buerhaus and Minnick, 2018bGigli K.H. Dietrich M.S. Buerhaus P.I. Minnick A. Regulation of pediatric intensive care unit nurse practitioner practice: A national survey.Journal of the American Association of Nurse Practitioners. 2018; 30: 17-26Crossref PubMed Scopus (9) Google Scholar, The Joint Commission n.dThe Joint Commission. (n.d.) Ambulatory care program: The who, what, when and wheres of credentialing and privileging. Oakbrook Terrace, IL: Author. Retrieved from https://www.jointcommission.org/assets/1/18/AHC_who_what_credentialing_booklet.pdfGoogle Scholar). An orientation program associated with employee onboarding contributes to successful transitions into clinical practice and is encouraged as part of the professional development and mentorship of the PNP (Haut and Madden, 2015Haut C. Madden M. Hiring appropriate providers for different populations: Acute care nurse practitioners.Critical Care Nurse. 2015; 35: e1-e8Crossref PubMed Scopus (16) Google Scholar). After initial privileges are bestowed, a process of ongoing professional practice evaluation and focused professional practice evaluation with continued national certification are designed to document evidence of maintenance of a level of clinical competence, quality, and proficiency (Wise, 2013Wise R.A. OPPE and FPPE: Tools to help make prilveging decisions. The Joint Commission, Oakbrook Terrace, IL2013https://www.jointcommission.org/jc_physician_blog/oppe_fppe_tools_privileging_decisions/Google Scholar). Full practice authority (FPA) encompasses state regulations and laws allowing APRNs to practice to the full scope of their education and training independent of supervision and under the exclusive authority of state boards of nursing. The rationale for this autonomy includes increased health care access through the Patient Protection and Affordable Care Act, the current U.S. shortage of primary and acute care providers, a credible body of research showing that NPs attain outcomes equivalent to those of physician practice, and the unique position of APRNs to positively effect changes in the health care system (Dillon and Gary, 2017Dillon D. Gary F. Full practice authority for nurse practitioners.Nursing Administration Quarterly. 2017; 41: 86-93Crossref PubMed Scopus (8) Google Scholar). The APRN Consensus Model established statutory and regulatory criteria for FPA that includes (a) recognition of all four APRN roles, (b) designation of APRN title, (c) requirement for dual registered nurse/APRN licensure, (d) requirement for a graduate or postgraduate degree from an accredited program, (e) procurement and maintenance of national certification in one or more APRN roles from an accredited certification body, and (f) authority for independent practicing and prescribing (Chesney and Duderstadt, 2017Chesney M.L. Duderstadt K.G. States’ progress toward nurse practitioner full practice authority: Contemporary challenges and strategies.Journal of Pediatric Health Care. 2017; 31: 724-728Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar). The Consensus Model recommended FPA for all NPs in all states by 2015, but barriers, including opposition from organized medicine and variations in state legislative body statutes and processes, continue to waylay progress recommended at the national level from being uniformly applied at the state level (Brom, Salsberry and Graham, 2018Brom H.M. Salsberry P.J. Graham M.C. Leveraging health care reform to accelerate nurse practitioner full practice authority.Journal of the American Association of Nurse Practitioners. 2018; 30: 120-130Crossref PubMed Scopus (12) Google Scholar). Currently, 22 states plus the District of Columbia and U.S. Territory of Guam are designated as FPA. Sixteen states are designated as reduced practice, meaning that state practice and licensure laws reduce the ability of APRNs in at least one area of practice and require a regulated collaborative practice agreement with another health care provider or limit the setting or other practice element. Twelve states are designated as restricted practice, meaning that state practice and licensure laws reduce the ability of APRNs in at least one area of practice and that career-long supervision or management by another health care provider is required (American Association of Nurse Practitioners 2018cAmerican Association of Nurse PractitionersState practice environment. Author, Austin, TX2018https://www.aanp.org/legislation-regulation/state-legislation/state-practice-environmentGoogle Scholar). In 2017, the U.S. Department of Veterans Affairs granted FPA throughout its network of federal medical centers to three of the four designations of APRNs (NPs, Clinical Nurse Specialists, and Certified Nurse Midwives), allowing them to independently practice to the full scope of their education, training, and certification without unnecessary oversight (Sofer, 2017Sofer D. VA grants most APRNs full practice authority.American Journal of Nursing. 2017; 117: 14Crossref Scopus (4) Google Scholar). The American Academy of Nursing (AAN) issued a statement in 2017 supporting FPA, recognizing APRNs as a ready workforce to improve access to care, lower health care costs, and help achieve health equity for marginalized populations. In doing so, the AAN joined the NCSBN, the Robert Wood Johnson Foundation, the American Hospital Association, the Federal Trade Commission, and the American Association of Retired People, among others, in supporting greater use of the APRN workforce and subsequent access to quality, accessible, affordable care through FPA (Bosse et al., 2017Bosse J. Simmonds K. Hanson C. Pulcini J. Dunphy L. Vanhook P. Poghosyan L. Position statement: Full practice authority for advanced practice registered nurses is necessary to transform primary care.Nursing Outlook. 2017; 65: 761-765Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar). FPA has been associated with more practicing NPs in a state, especially in rural areas and in primary care capacities (Barnes, Richards, McHugh and Martsolf, 2018Barnes H. Richards M.R. McHugh M.D. Martsolf G. Rural and nonrural primary care physician practices increasingly rely on nurse practitioners.Health Affairs. 2018; 37: 908-914Crossref PubMed Scopus (124) Google Scholar, Reagan and Salsberry, 2013Reagan P.B. Salsberry P.J. The effects of state-level scope-of-practice regulations on the number and growth of nurse practitioners.Nursing Outlook. 2013; 61: 392-399Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar). NPs are more likely than their physician counterparts to serve minority, disadvantaged, and vulnerable populations; thus, FPA can maximize the capacity ofthe NP workforce in underserved areas with the mosthealth disparities and urgent need for care (Xue et al., 2018Xue Y. Kanna V. Greener E. Smith J.A. Brasch J. Johnson B.A. Spetz J. Full scope-of-practice regulation is associated with higher supply of nurse practitioners in rural and primary care health professional shortage counties.Journal of Nursing Regulation. 2018; 8: 5-13Abstract Full Text Full Text PDF Scopus (38) Google Scholar). From 2008 through 2016, the percentage of NPs asrural providers increased from 17.6% to 25.2%, whereas the percentage of NPs as primary care providers increased from 15.9% to 23.0% in nonrural practices (Barnes, Richards, McHugh and Martsolf, 2018Barnes H. Richards M.R. McHugh M.D. Martsolf G. Rural and nonrural primary care physician practices increasingly rely on nurse practitioners.Health Affairs. 2018; 37: 908-914Crossref PubMed Scopus (124) Google Scholar). There is a growingconsensus that FPA is a viable pathway to provide patients quality, accessible, affordable health care amid the growing complexities of the U.S. health care system. Strategies to achieve FPA in all states include effective stakeholder communication, implementation of innovative care models with documented outcomes, dissemination of effective collaborative models, and showing the effective impact of APRN-delivered care at institutional, state, and national levels (Dillon and Gary, 2017Dillon D. Gary F. Full practice authority for nurse practitioners.Nursing Administration Quarterly. 2017; 41: 86-93Crossref PubMed Scopus (8) Google Scholar).There is a growing consensus that FPA is a viable pathway to provide patients quality, accessible, affordable health care amid the growing complexities of the U.S. health care system. There is a growing consensus that FPA is a viable pathway to provide patients quality, accessible, affordable health care amid the growing complexities of the U.S. health care system. The NP workforce is growing, and workforce forecasting shows that growth will be strong (Auerbach, 2012Auerbach D.I. Will the NP workforce grow in the future? New forecasts and implications for healthcare delivery.Medical Care. 2012; 50: 606-610Crossref PubMed Scopus (99) Google Scholar, Maier, Barnes, Aiken and Busse, 2016Maier C.B. Barnes H. Aiken L.H. Busse R. Descriptive, cross-country analysis of the nurse practitioner workforce in six countries: Size, growth, physician substitution potential.BMJ Open. 2016; 6e011901Crossref Scopus (70) Google Scholar, Poghosyan and Brooks Carthon, 2017Poghosyan L. Brooks Carthon J.M. The untapped potential of the nurse practitioner workforce in reducing health disparities.Policy, Politics, & Nursing Practice. 2017; 18: 84-94Crossref PubMed Scopus (28) Google Scholar, U.S. Department of Health and Human Services 2017U.S. Department of Health and Human ServicesEvaluation of the Graduate Nurse Education Demonstration Project: Report to Congress. Author, Washington, DC2017https://innovation.cms.gov/Files/reports/gne-rtc.pdfGoogle Scholar). In March 2018, the American Association of Nurse Practitioners (AANP) released the 2017 National Nurse Practitioner Sample Survey results with objectives to (a) update NP compensation data as it relates to education, experience, region, setting, and specialty; (b) identify typical NP benefit packages and employment arrangements, (c) identify associations between practice characteristics and compensation, and (d) identify trends in NP compensation. Data show that 248,000 NPs are currently licensed to practice in the United States, representing a substantial increase from the estimated 120,000 NPs reported in 2007 (American Association of Nurse Practitioners 2018aAmerican Association of Nurse Practitioners2017 National Nurse Practitioner Sample Survey: An overview. Author, Austin, TX2018https://www.aanp.org/news-feed/2017-national-nurse-practitioner-sample-survey-resultsGoogle Scholar). The supply of PNPs, however, has not appreciably grown compared with other NP subspecialties (American Association of Nurse Practitioners 2018bAmerican Association of Nurse PractitionersNumber of nurse practitioners hits new record high. Author, Austin, TX2018https://www.aanp.org/news-feed/number-of-nurse-practitioners-hits-new-record-highGoogle Scholar, Freed et al., 2010aFreed G.L. Dunham K.M. Lamarand K.E. Loveland-Cherry C. Martyn K.K. Pediatric nurse practitioners: Roles and scope of practice.Pediatrics. 2010; 126: 846-850Crossref PubMed Scopus (31) Google Scholar, Schell et al., 2015Schell G.J. Lavieri M.S. Li X. Toriello A. Martyn K.K. Freed G. Strategic modeling of the nurse practitioner workforce.Pediatrics. 2015; 135: 68-74Crossref PubMed Scopus (11) Google Scholar). This same AANP survey reported that an additional 23,000 new NPs graduated from programs in the 2015/2016 academic year, an increase of 3,000 graduates, or 15.5%, from the 2014/2015 academic year. Although an estimated 85.5% of new graduates were educated as primary care NPs, approximately two out of three new NPs entering the workforce reported graduating from family NP (FNP) programs. (American Association of Nurse Practitioners 2018aAmerican Association of Nurse Practitioners2017 National Nurse Practitioner Sample Survey: An overview. Author, Austin, TX2018https://www.aanp.org/news-feed/2017-national-nurse-practitioner-sample-survey-resultsGoogle Scholar) FNPs are certified to provide care to children, but most report their total pediatric population in practice to be less than 25%. In addition, most FNPs report that their pediatric patient population consists of mostly older children and adolescents (Freed, Dunham, Loveland-Cherry and Martyn, 2010bFreed G.L. Dunham K.M. Loveland-Cherry C. Martyn K.K. Family nurse practitioners: Roles and scope of practice in the care of pediatric patients.Pediatrics. 2010; 126: 861-864Crossref PubMed Scopus (9) Google Scholar). Physician assistants (PAs) can practice in pediatric settings, but only 2% of the more than 80,000 currently licensed report working in pediatric settings (National Commission on Certification of Physician Assistants 2016National Commission on Certification of Physician Assistants2015 statistical profile of certified physician assistants: An annual report of the National Commission on Certification of Physician Assistants. Author, Johns Creek, GA2016https://www.nccpa.net/Uploads/docs/2015StatisticalProfileofCertifiedPhysicianAssistants.pdfGoogle Scholar). As a result, the PNP workforce is increasingly assuming a larger role in the care of pediatric patients across the health spectrum (Coombs, 2015Coombs L.A. The growing nurse practitioner workforce in specialty care.Journal of Nurse Practitioners. 2015; 11: 907-909Abstract Full Text Full Text PDF Scopus (16) Google Scholar, Freed, Dunham, Moran and Spera, 2012Freed G.L. Dunham K.M. Moran L.M. Spera L. Resident work hour changes in children's hospitals: Impact on staffing patterns and workforce needs.Pediatrics. 2012; 130: 700-704Crossref PubMed Scopus (27) Google Scholar, Martyn, Martin, Gutknecht and Faleer, 2013Martyn K.K. Martin J. Gutknecht S.M. Faleer H.E. The pediatric nurse practitioner workforce: Meeting the health care needs of children.The Journal of Pediatric Health Care. 2013; 27: 400-405Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar). Workforce models describe increasing inclusion of the PNP role to meet pediatric health care demands (Basco and Rimsza, 2013Basco W.T. Rimsza M.E. Pediatr
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