The COVID-19 pandemic has highlighted emergency care in unanticipated ways, reshaping emergency care delivery and highlighting the emergency department (ED) workforce. Ultimately, these changes have significant implications for emergency nurse practitioner (ENP) education and practice. This editorial highlights historical trends in ED practice, the role and scope of nurse practitioner (NP) practice in emergency care, and recent evidence of the emergency medicine (EM) workforce surplus to support reenvisioning the future ENP profession (American College of Emergency Physicians [ACEP], 2021; Bennett et al., 2020; Reiter & Allen, 2020).
EMERGENCY DEPARTMENT WORKFORCE GAPS
During the 1990s, ED census volumes rapidly increased following passage of the Emergency Medical Treatment and Labor Act (EMTALA) as the ED became a safety net and a convenient setting for unscheduled care (Kellerman, Hsai, Yeh, & Morganti, 2013). This dramatic increase created a strain on emergency care delivery, and was described in an Institute of Medicine (IOM) report that concluded emergency care was at a breaking point (IOM, 2007). These conclusions increased the demand for specialty prepared emergency physicians (EPs) to improve patient safety and quality of care (IOM, 2007). Solutions to improve emergency care delivery included increasing residency programs to meet the goal of staffing all EDs nationwide with EM residency-trained and board-certified physicians. However, ED workforce studies launched during this same time warned that even with increasing the number of EM residency programs and graduates, shortages of EPs would persist until 2019 or 2038 in best case scenarios (Camargo et al., 2008) or, at worst case, persist for decades, especially in rural communities (Ginde, Sullivan, & Camargo, 2009). These shortages led to a rapid increase in utilization of NPs and physician assistants (PAs) to reduce ED workforce gaps and improve access to emergency care.
USE OF NURSE PRACTITIONERS IN EMERGENCY CARE
Specialty educational programs for NPs in emergency care grew to fill critical ED workforce needs that accelerated in the 1990s (Hoyt et al., 2018). In an analysis of National Hospital Ambulatory Medical Care Survey (NHAMCS) data, Ginde and Camargo (2010) found that from 1993 to 2005, the number of ED patients seen by NPs increased from 1.7% to 3.8%. In a similar analysis of ED utilization of advanced practice providers (APPs), Menchine, Wiechmann, and Rudkin (2009) found that between 1997 and 2006, the number of EDs utilizing APPs increased from 12.7% to 77%. Menchine et al. (2009) also noted that although APPs saw a greater percentage of lower acuity patients (18.2%) than EPs (10.3%), they also saw 11% of high acuity patients and 8% of patients requiring hospital admission. Although they concluded there was a need for a national policy on APP scope of practice and supervision at that time, APP scope of practice, supervision, and medical–legal implications remain continued concerns among EPs (ACEP, 2021; Clark, Amanti, & Sheng, 2020; Wiler & Ginde, 2015). Additional concerns are NP educational preparation, readiness to practice, and competency deficits (ACEP, 2021; Berlin, 2018; Phillips, Klauer, & Kessler, 2018).
CURRENT ED TRENDS
Of immediate concern among EPs is the EM workforce surplus combined with reductions in ED census levels across all acuities and ages and reduced ED revenues resulting from the COVID-19 pandemic (ACEP, 2021; Bennett et al., 2020; Clay et al., 2021; Pines et al., 2021; Reiter & Allen, 2020). These factors and the increased utilization of APPs are believed to be responsible for increased competition and limited employment opportunities for new EM residency graduates. In the past 2 years, several national ED workforce studies were conducted to examine existing and projected workforce needs. Their conclusions have significant implications for the ENP profession.
For example, in an analysis of governmental data, EM residency program growth, and graduate outcomes, Reiter and Allen (2020) concluded that by 2022, the number of board-certified EPs will exceed demand and continue to grow by 2.2% annually through 2030. The authors attribute the surplus to several factors including the exponential growth of APP programs and graduates outpacing the rate of medical school graduates, a 39.4% increase over the past 10 years in the number of board-certified EPs entering the workforce, and a 46% increase in the past 5 years in the number of EM residency programs within the United States. Other factors affecting ED visit rates and demand for EPs include reduced ED volumes since the pandemic, increased costs and disincentives by insurers for patient ED visits, use of telemedicine, and the growth of urgent care and retail clinics (Pines et al., 2021; Reiter & Allen, 2020).
Clay et al. (2021) analyzed the National Emergency Department Inventory (NEDI)-USA database and state medical association physician registry data, comparing their findings with a prior workforce study by Sullivan, Ginde, Espinosa, and Camargo (2009), noting a similar maldistribution in the ED workforce. In the most current study (Clay et al., 2021), significant ED workforce gaps continue to persist in rural states including Texas, Alabama, North Dakota, and throughout the Southeast and Midwest. However, the authors also found substantial EP supply excesses and a shrinking job market throughout the Northeast and West, and in California, Colorado, Massachusetts, and Hawaii (Clay et al., 2021). Workforce excesses in these areas suggest that NPs may also encounter challenges in finding ED employment in surplus regions of the country and may need to consider practicing in rural, underserved communities where the need is greatest.
THE ENP WORKFORCE
According to ACEP's Emergency Medicine Benchmark Data, 91% of EDs in the United States with annual census volumes over 14,000 utilized APPs in 2019 (J. Augustine, personal communication, March 21, 2021). In addition, the number of NP programs is projected to increase by 109% in 2030, adding to emergency provider supply excesses (Reiter & Allen, 2020). Between 2010 and 2017, the number of NPs in the United States more than doubled from approximately 91,000 to 190,000 throughout all regions of the United States (Auerbach, Buerhaus, & Staiger, 2020). And although the NP workforce is increasing, the RN workforce is decreasing as more RNs leave bedside nursing to become NPs (Auerbach et al., 2020). This rapid increase in the NP workforce may impact NPs pursuing careers as emergency providers as competition for jobs grows, especially for NPs who are not emergency educated and certified and for those who lack emergency nursing bedside experience.
Currently, of the 290,000 certified NPs in the United States, approximately 17,110 (5.9%) report practicing in the ED (American Association of Nurse Practitioners [AANP], 2018,2020). Since ENP board certification by examination was launched by the American Academy of Nurse Practitioners Certification Board (AAPNCB) in 2017, 1,291 family nurse practitioners (FNPs) (7.54%) have obtained ENP-C specialty certification (D. Tyler, personal communication, April, 2021). In addition to these ENPs, 124 NPs across populations earned ENP-BC certification through portfolio offered by the American Nurses Credentialing Center (ANCC) in 2013 but discontinued in 2017 (M. Horihan, personal communication, September 13, 2017). Among those certificants, 68% were FNPs (M. Horihan, personal communication, September 13, 2017).
FNPs with ENP certification are increasingly being hired into emergency care teams, a result primarily steered by the continued demand for emergency care services, ED economics, and substantial evidence to support the integration of the FNP/ENP into the interdisciplinary team. Current ENP academic curricula are based on practice analysis data and utilization trends. Refinement of the ENP curriculum has continued since the publication of the AAPNCB ENP practice analysis and certification examination content blueprint and updated competencies (Ramirez et al., 2018; Tyler et al., 2018; Wilbeck et al., 2018). A new practice analysis to be conducted by AAPNCB in 2021 will further inform any needed changes to existing ENP academic and fellowship curricula along with changing ED workforce demands.
Since the inception of the specialty, ENPs have filled new role demands expanding where and how emergency care is delivered including urgent care, emergency tele medicine, critical care transport, and mobile integrated health care services. In addition, because of EP workforce maldistribution, and as more states pass full practice authority legislation, NPs are increasingly providing care in rural and frontier settings where they may manage patients with higher acuity emergency conditions and those requiring brief inpatient hospitalizations. These changes in role and scope, along with ED workforce changes, suggest it may be time to reenvision how to best prepare ENPs for new roles to meet changing health system needs.
ENP AS SPECIALTY VERSUS POPULATION
The growing debate over whether the ENP continues to meet the Consensus Model for Regulation's definition of a specialty (APRN Consensus Work Group & NCSBN APRN Advisory Committee, 2008) or instead meets the definition of a population, as role and scope have evolved, is at a tipping point. Contributing factors include the ED workforce and population demographic changes, employment opportunities, regulatory barriers from individual state boards of nursing, and reimbursement challenges from commercial insurers.
According to the Consensus Model (APRN Consensus Work Group & NCSBN APRN Advisory Committee, 2008), advanced practice registered nurse (APRN) licensure and regulation occur at the level of the role and population. Graduate NP program accreditation oversight also occurs at the role/population level. However, educational preparation, competency delineation, and practice oversight at the specialty level are not regulated by boards of nursing but rather by specialty professional organizations (APRN Consensus Work Group & NCSBN APRN Advisory Committee, 2008, p. 6). APRNs cannot be licensed solely at the specialty level because licensure and certification are regulated by role and population (APRN Consensus Work Group & NCSBN APRN Advisory Committee, 2008, p. 6). Because specialty certification and practice oversight are not regulated at the state board of nursing level, some state boards of nursing have refused to acknowledge emergency certification as evidence of specialized competency for FNPs. Refusal to recognize ENP certification is threatening access to emergency care. Obtaining additional education in a population-specific acute care NP program (adult vs. pediatrics) is insufficient because pediatric patients make up nearly a quarter of all ED visits nationwide and older adults represent the fastest ED demographic (Dall et al., 2013; Goto, Hasegawa, Faridi, Sullivan, & Camargo, 2017; Hooker, Mallow, & Oglesby, 2019). Furthermore, acute care programs lack content specific to emergency care management and legislation (e.g., EMTALA).
Because ENPs are not licensed or regulated at the specialty level, many health care organizations, including insurers, will not credential ENPs to practice according to the specialty's scope and standards. Although emergency-specific educational preparation is essential for safe practice as an ENP, the reality is that ED employers often do not know the difference in the educational scope of practice among NP populations. For NPs practicing in emergency care settings without advanced practice emergency education, the lack of specialty competencies required for safe emergency patient care is a challenge. This contributes to continued concerns by EPs that compared with PAs, NPs are less prepared, use more resources, and require more supervision in ED settings (Aledhaim, Walker, Vesselinov, Hirshon, & Pimentel, 2019; Clark et al., 2020; Phillips et al., 2018; Wiler & Ginde, 2015).
CHALLENGES AND OPPORTUNITIES IN TRANSITIONING FROM ENP AS A SPECIALTY TO A POPULATION
The most appropriate manner in which to transition the ENP from a specialty focus to a population focus will require a paradigm shift among NPs now practicing in emergency care—those who are certified and those who are not. Transitioning from specialty to a population will require that all ENPs become board certified in the ENP population for licensure and regulation by state boards. How to grandfather those currently specialty-certified ENPs will also need to be considered. NPs working in emergency settings who decline emergency certification may be at a disadvantage as organizations, state boards, and insurers begin to require ENP certification for employment.
Transitioning to a population presents the opportunity for the profession to lead transformational change by reenvisioning ENP curricula that provide the necessary breadth and depth of knowledge and skills specific to changing ENP roles (Greenwood-Ericksen & Kocher, 2019). This will require synthesizing current and future U.S. population-level census and demographic projections, examining emerging, cost-effective emergency care delivery models that meet quality benchmark outcomes, and reviewing ED census trends with consideration of ENP practice analysis findings. Stakeholder involvement will be critical for role delineation and in revising ENP scope and standards of practice based on the evidence collected.
Recent ED census changes have shown increasing visit rates among older adults with complex health care needs, women with obstetric and gynecological problems, infants and young children, and patients with mental health problems (Dall et al., 2013; Hooker et al., 2019). Existing FNP curricula that currently are the required foundation for specialty education focus heavily on preventive care, community health, ongoing management of chronic disease, and comprehensive care. This focus is different from the unique competencies required by ENPs to provide unscheduled care for patients of all ages and acuities in collaboration with an interprofessional team. As ED delivery models have moved beyond the walls of hospital and freestanding EDs, ENPs must be prepared to provide emergency care within patient homes, via telehealth, following acute resuscitation and stabilization, and care for psychiatric patients awaiting transfer when delays occur. ENPs must also be prepared to practice where they are most needed, including critical access settings and rural communities. And ENP leaders must work to advance policy at the state and federal levels to support loan repayment benefits for ENPs who commit to practicing in rural areas and in those regions of the country where ED workforce gaps persist (Clay et al., 2021; Greenwood-Erickson & Kocher, 2019).
THE ENP AS A DOCTORATE OF NURSING PRACTICE
One final opportunity in the transition of the ENP role as a population is to align ENP competencies and curricula with the newly published Doctorate of Nursing Practice (DNP) Essentials (American Association of Colleges of Nursing [AACN], 2021). This will advance the profession while also meeting the National Organization of Nurse Practitioner Faculties' (NONPF) goal of transitioning all NP programs to the DNP by 2025. With the recent release of newly developed DNP Essentials/Competencies by the AACN (2021), and NONPF's proposed BSN–DNP curriculum with competency mapping templates (NONPF, 2020), tools now exist to build an ENP curriculum that meets workforce needs and updated competencies. The additional clinical hours required for the DNP will provide more time to strengthen ENP/DNP clinical competencies within the four spheres of care including additional content in systems-based practice, quality and safety, and leadership and professionalism providing a stronger foundation for ENPs to contribute to the science and practice of emergency care. Until these changes are implemented nationally, it is critically important that practicing ENPs obtain specialty certification. ENP certification informs the public and our emergency care colleagues that we possess unique knowledge and skills that promote high-quality and safe emergency care.
SURVIVAL IN THE ERA OF WORKFORCE SURPLUS
Despite concerns of the workforce surplus expressed by ACEP, the American Academy of Emergency Medicine (AAEM), EM researchers, and residency associations, NPs and PAs are anticipated to continue to care for 20% of all ED visits (ACEP, 2021). Given the current rapid increase in NPs entering the U.S. workforce (Auerbach et al., 2020), consideration of an ENP workforce surplus needs to be carefully monitored. Physician leaders have proposed that future APP utilization include participation/oversight of EM APP curricular content and limiting APP patient care to lower acuity patients or management of higher acuity patients with strict protocol-driven guidelines. Such opinions may impact how ENPs are prepared for the future and further supports the need for NPs to obtain emergency-specific education and board certification. As the EM workforce continues to evolve postpandemic, and with a workforce surplus, now is the appropriate time for the ENP role to be clarified and more widely recognized within the larger health care delivery model.
Dian Dowling Evans, PhD, FNP-BC, ENP-C, FAANP, FAAN
Professor and Director
Family/Emergency Nurse Practitioner Program
Nell Hodgson Woodruff School of Nursing
K. Sue Hoyt, PhD, RN, FNP-BC, ENP-C, FAEN, FAANP, FAAN
Professor, ENP/NP Programs,
University of San Diego
Hahn School of Nursing and Health Science
Beyster Institute for Nursing Research
San Diego, California
Wesley D. Davis, DNP, ENP-C, FNP-C, AGACNP-BC, CEN, FAANP
Dual Family Nurse Practitioner/Emergency Nurse Practitioner Track Coordinator
Emergency Nurse Practitioner Specialty Coordinator
University of South Alabama
American Academy of Emergency Nurse Practitioners
Jennifer Wilbeck, DNP, RN, FNP-BC, ACNP-BC, ENP-C, FAANP, FAAN
Professor and Director
Vanderbilt University School of Nursing
American Academy of Emergency Nurse Practitioners
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