The use of nurse practitioners (NPs) as hospitalists has grown over the last two decades. In 2006, 20% of hospital medicine groups employed NPs; in 2019, 83.3% of hospital groups caring for adults employed NPs (Darves, 2007; Society of Hospital Medicine, 2020). Demand for NPs in critical care alone is expected to increase 16% between 2012 and 2025 (U.S. Department of Health and Human Services [USDHHS], 2016). Nurse practitioner hospitalists provide full coverage and work in hospital intensive care units; medical, surgical, and observation units; and a wide range of specialty units, such as neurology, oncology, burn, orthopedics, and palliative care (Kaplan & Klein, 2019). Based on current educational preparation, certification, and scope of practice, the acute care NP (ACNP) is considered by professional standards the best prepared to care for the needs of acutely and critically ill patients (Adult-Gerontology NP Competencies Workgroup [AGNPCW], 2016; Bell, 2017).

Results of the 2016 American Association of Nurse Practitioners (AANP) National NP Sample Survey (NNPSS) indicated nearly 10% of all NPs were certified as an ACNP of which 28% were employed in a hospital inpatient setting (Kleinpell et al., 2018). Despite the growing need for acute care prepared NPs, the 2019 AANP NNPSS indicated only 9.7% of NPs identified as being certified in acute care (AANP, 2020).

The majority of NPs in the United States are certified in primary care (family, adult, adult-gerontology, gerontology, pediatrics, and women's health) (AANP, 2020). Among the top five main work sites for NPs, hospital outpatient and hospital inpatient were number one and two followed by private group practice, private physician practice, and urgent care (AANP, 2020).

Despite the pressing need for more primary care providers, many NPs who work as hospitalists with acutely and critically ill populations are not certified in acute care. There is no current national certification that specifically confirms or validates preparation as an NP hospitalist. Little is known regarding employment characteristics specific to the NP hospitalist role, particularly in regard to the type of education, certification, qualification for the hospitalist role, and previous experience.

Boards of nursing have taken varying positions on whether NP hospitalists certified for a primary care role, such as the family NP (FNP), are practicing within their scope (Arizona State Board of Nursing, 2009; Burns, 2017; Ohio Board of Nursing, 2016). Our study contributes to the literature with self-reported data from NP hospitalists regarding their certification, preparation for employment as a hospitalist, services provided, and job satisfaction. This allows for a careful examination of whether the positions of nursing education programs, professional associations, and boards of nursing regarding qualifications for NP hospitalist practice align with the experience of the NP workforce.

This article reports on phase 2 of a national study, Hiring, Credentialing, and Privileging of Nurse Practitioners as Hospitalists: A National Workforce and Employment Analysis, designed to describe characteristics of the NP hospitalist workforce. The aims of phase 2 were to (1) identify the NP hospitalist workforce's characteristics, including education, licensure and certification, qualifications for the hospitalist role, and services provided; and (2) describe the NP hospitalist workforce's perception of the work environment, including relationships with physicians, utilization of education and of scope of practice, and job satisfaction.

Methods

Study design

The design of phase 2 of this study was a quantitative descriptive survey that consisted of five workforce questions deployed in the 2019 AANP NNPSS.

Sample

The sample for the study is a subset of respondents to the AANP 2019 NNPSS. The survey used a randomly selected stratified (by state) sample of all licensed NPs in the United States who had a valid email address from a state board of nursing or a business relationship (such as having purchased continuing education) with AANP and an associated email address and NP status. There were 880 respondents who answered the question: "Which setting best describes your main NP work site?" by selecting "hospital inpatient unit, VA facility, Military/DOD, psychiatric/mental health facility, Indian Health Service, Other." Those working in the acute care setting with patients younger than 18 years were excluded from this sample by selective survey skip logic, leaving a total sample of 366 NP hospitalists who practice with adult patients.

Questionnaire

We deployed five workforce questions in the AANP survey. The first question determined whether the respondent worked with patients age 18 years or older in the inpatient setting as a hospitalist. The second question asked how the NP obtained qualifications to work as a hospitalist. The third, fourth, and fifth questions were adapted from the 2012 National Sample Survey of Nurse Practitioners (USDHHS, 2014). These each asked about the NPs' professional relationships with physician work colleagues, whether they could practice to the full extent of their education and legal scope of practice, and what services they provided to their patients.

In addition to the data obtained through the five workforce questions, AANP's collaborative data agreement provided demographic indicator data, such as the state where the NP worked, age, gender, race/ethnicity, highest level of education, and number of years of experience. The American Association of Nurse Practitioners also provided variables related to whether the NP had an employment contract, collaborative agreement with a physician, and the level of satisfaction with their job.

Procedures

American Association of Nurse Practitioners conducted the survey between September 13, 2019 and November 22, 2019. Contact was made via email with weekly reminders sent to nonrespondents for up to 9 weeks. The survey was administered using Qualtrics as the platform. Participants who matched the criteria for inclusion were directed to the five questions. Anyone who did not respond affirmatively that they provided care to patients aged 18 years and older in the inpatient setting as a hospitalist was asked to stop the hospitalist-specific survey questions and returned to the main survey. Washington State University and the University of Iowa evaluated the proposed study and determined the study procedures were exempt from institutional review board review under 45 CFR 46.101 (b) (2).

Analysis

We used SPSS version 24 to perform descriptive statistics and evaluate correlations between the relationship with a physician and the state's scope of practice using full, reduced, and restricted based on definitions provided by AANP (2019). We also correlated the extent to which NPs reported using their education and scope of practice and job satisfaction.

Results

Table 1 describes the characteristics of the sample, which was primarily female, White, master's degree educated, and working with a collaborative/supervisory agreement. Just over half (n = 191, 52%) were certified as FNPs although 20 also had certification as an acute care NP or adult-gerontology acute care NP. Overall, the majority (n = 275, 74.7%) were certified in primary care, which includes family, adult, adult gerontology primary care, pediatric primary care, gerontology, and women's health certification.

Table 1. Characteristics of the samplea

Qualifications

Participants indicated the ways they obtained their qualification to work as a hospitalist with six responses offered. They could choose all responses that applied: postgraduate residency/fellowship, initial NP education, board certification, on-the-job training, "boot camp" hospitalist course, or other. The most common response was on-the-job training (n = 274), followed by initial NP education (n = 171), board certification (n = 139), "boot camp" (n = 27), other (n = 23), and postgraduate residency/fellowship (n = 18). Two respondents selected five responses; four selected four responses; 62 selected three responses, 124 selected two responses, and 159 selected only one response of which 106, or 29.9%, chose on-the-job training. Among those that selected three responses, board certification, initial education, and on-the-job training were the most commonly (n = 43) reported. Board certification and initial education were most common (n = 52) for those who selected two responses.

Relationship with physicians

We asked about the type of relationship the NP had with the physician(s) with whom they worked, selecting all that applied. The most common response (n = 252, 68.9%) was the NP collaborated with a physician on site. The next most common response (n = 139, 38%) was that the NP was considered an equal colleague to the physician(s). Almost one third of NPs (n = 112, 30.6%) indicated a physician sees and signs off on the patients for whom the NP cares. Nearly one quarter of NPs (n = 81, 22.1%) were accountable to a physician who served as a medical director, and almost one fifth of NPs (n = 70, 19.1%) were supervised by a physician and had to accept his/her clinical decisions about patient care. More than half of NPs (n = 207, 57%) selected more than one response (Figure 1).

Figure 1. Nurse practitioner (NP)-physician relationships.

To better understand the relationship between NPs and physicians, we performed Pearson correlation coefficient analysis of this variable with the scope of practice of the state in which the NP worked. Nurse practitioners in reduced practice states were significantly more likely to collaborate with a physician on site (p = .054) than NPs in restricted or full practice states. Nurse practitioners in restricted practice states were significantly less likely (p = .023) to report being considered an equal to the physician. They were also more likely to be supervised by and accept the clinical decision of a physician (p = .001) as well as have a physician see and sign-off on patients (p = .044). Conversely, NPs in full practice states were significantly less likely to be supervised by and have to accept the clinical decision of a physician or have a physician see and sign-off on patients (p = .001).

Utilization of education and scope of practice

Using a Likert scale for responses, participants indicated whether they strongly agreed, agreed, disagreed, or strongly disagreed with statements regarding their ability to practice to the full extent of the state's legal scope of practice and whether their education was fully used. Over three quarters (n = 303, 83.9%) of the NPs strongly agreed or agreed their education was fully used and that they could practice to the full extent of the state's legal scope of practice (n = 299, 82.8%).

Services provided

The last question investigated the percentage of patients for which the NPs reported providing certain services. Respondents commonly provided physical examinations and histories; ordered, performed, and interpreted laboratory tests and other diagnostic studies; and prescribed drugs for almost all of their patients. Of note, respondents were less likely to regularly diagnose, treat, and manage chronic illness or provide preventive services on a majority of their patients (Figure 2) One third (32.2%) of respondents did not perform any procedures; 27.8% performed procedure on few patients (1-25%); and 16.4% performed procedures on some patients (26-50%). Just under one quarter (23.6%) of respondents performed procedures on most or almost all patients.

Figure 2. Services provided by nurse practitioner hospitalists.

Job satisfaction

Overall job satisfaction among the respondents was high; 30.3% (n = 111) were very satisfied and 51.6% (n = 189) satisfied, a combined total of 81.9% (n = 300). With 13.9% (n = 51) neutral, only 4.1% (n = 15) were dissatisfied or very dissatisfied. We examined the correlation between job satisfaction and the report of using one's education fully and being able to practice to the full extent of the state's legal scope. Using Pearson correlation coefficient, job satisfaction was significantly correlated with full utilization of one's education and practicing to the fullest extent of the state's scope of practice with an r(360) = .719, p = .00 (two-tailed).

Limitations

The overall response rate of the AANP survey was low. It is possible some survey participants who work as hospitalists were excluded from our sample if they had a different certification than the ones we used as a filter. For example, we did not include certification as a pediatric acute care NP; however, some pediatric certified hospitalists may care for young adult patients between the ages of 18 and 21 years. With slightly more than half of the participants and hospitalist subsample members of AANP, study results may not be generalizable to hospitalists affiliated with other organizations.

Discussion

There is a need to better understand institutional and privileging variables which affect NP practice as a hospitalist (Pittman et al., 2020). This is the first study that comprehensively describes characteristics of a NP hospitalist workforce, which is primarily female, White, master's educated, and works with a collaborative or supervisory agreement. This national sample reveals that just over half of NP hospitalist respondents were certified as FNPs although the ACNP is considered by professional standards to be clinically prepared to care for acutely and critically ill patients (AGNPCW, 2016; Bell, 2017). In previous surveys conducted by AANP, NPs certified for acute care, adult-gerontology acute care, and pediatric acute care represented only 9.7% of NPs, whereas FNPs represented 65.4% of NPs that may account for the dominance of FNPs working as hospitalists (AANP, 2020). There are 125 acute care NP programs in the country, according to AANP's NP program database, which are predominantly located in the eastern United States. Some states have none or few programs leaving geographic areas without programs available to nurses interested in becoming an acute care NP.

Preparation for the role

There is often a difference between the scope and standards for NP practice and that of the NPs health care organizations choose to employ as hospitalists. Physicians also have a variety of backgrounds that prepare them for the hospitalist role (Pantilat, 2006). Nurse practitioner hospitalists provide care to patients in a variety of units, including emergency department, cardiology service, intensive care units, observation units, and as full coverage hospitalists (Klein et al., 2020).

Hospital care is complex and requires educational preparation; however, the majority of respondents indicated they had on-the-job training. On-the-job training was not defined in this survey and could vary widely from bedside teaching to a structured training program with outcome standards and evaluation. There is no known evaluation of the level and depth of on-the-job training as compared with formalized programs. Additionally, there are structured programs outside of academic pathways in which some respondents participated such as the one offered by Society of Hospital Medicine, which is a Boot Camp for NPs and physician assistants that serves as a foundation to care for people with conditions commonly encountered in the hospital setting (American Association of Physician Assistants, 2020).

It is important to further determine what best prepares an NP for work as a hospitalist to assure quality and effectiveness. Evaluation of qualifications should include consideration of the patient population for which the NP will be caring, the education, certification, and previous nursing experience of the NP, and alignment of these qualifications with the competencies identified by national organizations required for the role (Haut & Madden, 2015).

Empowered role

The NP hospitalist role is highly empowered. Although nearly all study participants reported having a collaborative/supervisory agreement, few reported being supervised by a physician whose clinical decision must be accepted. Additionally, over one third of the participants reported being considered an equal colleague to the physicians with whom they worked. The finding that NPs in full practice authority states are more likely to report being an equal colleague is expected given the nature of practice in reduced and restricted practice states in which collaboration and supervision, respectively, is required. Moreover, most of the NPs fully used their education and practiced to the full extent of the state's legal scope of practice consistent with the recommendations from the Institute of Medicine's (now the National Academies of Science) The Future of Nursing report (Institute of Medicine, 2011).

Services

The services most commonly performed by the NP hospitalist align with those identified by a 2016 Practice Analysis Survey of adult-gerontology acute care NPs conducted by the American Association of Critical Care Nurses Certification Corporation (Becker et al, 2020). In our sample, NPs performed physical examinations and histories; ordered, performed, and interpreted laboratory tests and other diagnostic studies; and prescribed drugs for almost all of their patients.

Satisfaction

Over three quarters of the respondents were satisfied or very satisfied with their job which correlated with practicing to the full extent of their education and licensure. This finding is supported by a systematic review in which several studies identified the intrinsic job factor of autonomy as the most significantly associated with job satisfaction (Han et al., 2018). It is likely that the collaborative nature of the NPs' relationships with physicians contributed to job satisfaction. A favorable practice environment, including the relationship with physicians and administration, also significantly predict NP job satisfaction (Poghosyan et al., 2017).

Conclusions

Nurse practitioners are increasingly and successfully employed as hospitalists. This study found that FNPs, educated for primary care, represent approximately half of this NP hospitalist workforce. The prevalence of on-the-job training as the most common preparation for the hospitalist role suggests a need to evaluate the effectiveness and outcomes of NPs not initially educated as acute care NPs who work as hospitalists. It would also be important to investigate whether FNP hospitalists work in the same units as acute care certified NP hospitalists and fulfill the same role.

Further evaluation of what constitutes on-the-job training is also warranted. The mismatch between the primary care educational preparation of an NP and the knowledge, skills, and competencies required for the NP hospitalist must be reconciled. An example of an institution's approach to bridge this gap is a program with multiple pathways developed by the University of Maryland Medical Center. This includes a standardized general and specific competency-based training program; postgraduate fellowship program in adult critical care; and a mentorship program (Simone et al., 2016).

The work of the NP hospitalist is clearly contextual and defined by factors such as patient population, skills required, opportunities for collaboration with other hospitalists, and the individual's competencies and expertise. Although the acute care NP has foundational educational preparation to care for acutely ill and complex patients, employers may still favor previous RN employment experience as an essential factor when hiring NPs as hospitalists if all other qualifications are similar. Nurse practitioner education is not meeting the growing demand for acute care certified NPs as hospitalists that leads to reliance on NPs educated for primary care being hired. It is imperative that those who educate NPs assess the best way to balance the evolving workforce needs of both primary care and hospitalized patients without compromising the competencies needed for each area of practice.

References