Recently released data from the American Association of Colleges of Nursing (AACN) and the National Council of State Boards of Nursing (NCSBN) highlight several important trends in academic nursing education that have wider implications for the healthcare system and the NP and RN workforce.1 First, the NP workforce continues to expand at a fast rate. According to the AACN's annual Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing report, the number of individuals graduating from NP programs grew again in the 2016-2017 academic year, making 2017 the ninth consecutive year of strong growth in the number of individuals graduating from NP programs.2 Second, although the RN workforce is growing quickly as well, it perhaps is not expanding quickly enough to keep up with growing demand. The number of RN graduates in 2016-2017 exceeded the number of new RNs the Bureau of Labor Statistics (BLS) projects is needed each year for the next decade to replace RNs leaving the field and to meet increasing demand.1
However, as discussed below, the supply of new RN graduates will not likely be sufficient to meet the future workforce demands projected by the BLS because not all RN candidates enter the field following graduation.
Strong growth in NP workforce continues
The number of NPs graduating from academic programs has grown every year for the past nine years, and 2016-2017 continued that trend, with nearly 28,000 new NP graduates. This value is more than triple the number of NPs who graduated in 2007-2008 (8,248). During this nine-year period (2008 to 2017), the number of new graduates increased by a low of 11.5% in 2010-2011 and by a high of 20.5% in 2014-2015, with a mean annual increase of 14.6%. These data are taken from the AACN's yearly Enrollment and Graduations report, which presents the results of the Association's survey of baccalaureate and graduate nursing programs in the United States and surrounding territories. This survey collects data on student enrollment and graduations as well as demographics, academic characteristics, and salaries of faculty and deans. With high response rates (89.2% for the 2016 Survey), the survey and subsequent reports represent an authoritative source of information concerning baccalaureate and graduate nursing programs.
This strong growth in NP graduates is reflected in the more than doubling of the NP workforce in the United States over the past 10 years. The American Association of Nurse Practitioners (AANP) recently released data showing that there are more than 248,000 NPs currently licensed to practice in the United States, as compared with 120,000 in 2007.3 The AANP notes that approximately 86% of new NP graduates have been trained in primary care, and nearly two-thirds have graduated from family NP programs. A recent study of trends in NP presence in primary care practices that looked at both rural and nonrural primary care practices between 2008 and 2016 found that in 2016 NPs constituted 25.2% of providers in rural practices and 23% in nonrural practices, compared with 17.6% and 15.9%, respectively, in 2008.
RN program enrollment growing, but not fast enough
The healthcare system continues to face shortages of RNs and is projected to do so for at least the next decade.4 A number of factors contribute to this shortage, including an aging population with an increased need for healthcare services, an aging workforce with approximately one million RNs older than 50 years and thus nearing retirement age within the next 15 years, and a shortage of nursing school faculty and clinical sites forcing schools to turn away applicants.4,5 The number of RN graduates has steadily increased over the past 15 years, rising from approximately 68,700 in 2001 to an average of 157,000 over the past several years. The current pace of new RN graduates exceeds the number of new RNs the BLS estimates is needed annually to replace RNs leaving the field and to meet increasing demand (135,000).1
NCLEX-RN passing rates
Despite increasing graduation rates, a considerable proportion of RN graduates do not immediately enter RN practice because they do not pass the National Council Licensure Examination (NCLEX-RN), which is a prerequisite to becoming licensed. Over the past 4 years, on average 17.7% of RNs who took the NCLEX-RN did not pass the exam on their first attempt,1 and up to one quarter who retake the exam do not pass.6 Delayed entry into the RN workforce due to failing the NCLEX-RN significantly reduces the number of RNs who enter practice.
RNs pursuing advanced practice careers
The growing number of RNs who leave RN practice to pursue careers as NPs suggests that the number of new RNs entering the workforce is actually below the projected annual need (including RNs to provide healthcare services as well as RN faculty and researchers). As such, RN shortages are expected to become more widespread in the future.4
Trends in RN education
Another notable trend among RN graduates is that for the first time a majority of new nurses passing the NCLEX-RN to become an RN had a bachelor's degree in nursing (BSN) rather than a 2-year associate's degree in nursing (ADN). In 2017, 68,380 BSN candidates passed the exam, as compared with 66,980 ADN candidates who passed.1 This trend reflects the movement toward the BSN becoming the entry-level degree for new RNs, which has been steadily building since 2001, when only 21,331 BSN candidates passed the NCLEX-RN exam on their first attempt. In 2010, the Institute of Medicine released its report, The Future of Nursing, containing eight recommendations that were designed to serve as a framework for changes in the nursing profession and the healthcare delivery system.7 One of the recommendations was to increase the proportion of nurses with a baccalaureate degree to 80% by 2020. At the time the report was released, 50% of the 3.1 million RNs in the US had a BSN or higher degree in nursing and only 39% of new grads who passed the NCLEX-RN exam came from BSN programs.8 Although the shift toward BSN candidates becoming the majority of RNs passing the NCLEX-RN represents a positive step toward reaching the 80% goal, the split between BSN and ADN is nearly 50/50 and thus further work will be needed as acknowledged by the American Nurses Association.8
As the healthcare system continues to evolve with an emphasis on disease management and prevention and redirecting care from institutional to community and home-based settings, opportunities and roles for NPs and RNs have grown substantially. The ongoing expansion of the NP workforce, particularly in primary care, is a benefit to patients as it helps facilitate timely access and high-quality care in a time of growing healthcare needs. At the same time, schools of nursing continue to struggle to enroll and graduate a sufficient number of students to meet the ongoing demand for RNs.
2. American Association of Colleges of Nursing. 2017-18 enrollment and graduations in baccalaureate and graduate programs in nursing. Washington, DC: AACN; 2018.
7. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2011.