A primary care shortage is causing problems and resource gaps across the nation’s health care landscape, particularly in rural and underserved communities. Limited access to primary care resources and a shortage of licensed health practitioners can exacerbate the challenges populations in these communities face.
In 2020, the Health Resources and Services Administration (HRSA) — part of the Department of Health and Human Services (HHS) — estimated more than 82 million Americans lived in an officially designated health professional shortage area (HSPA).
Ensuring rural and underserved patients have efficient and cost-effective access to primary care is of great importance to the nation’s population health. And family nurse practitioners (FNPs) have a potentially crucial part to play in delivering high-quality primary care and health education to those who need it most.
The FNP role is broad, but also dovetails nicely with the emerging care needs of rural and underserved communities. As advanced practice registered nurses (APRNs), FNPs are educated to provide primary care, make diagnoses and prescribe medications. Also, state law may grant them full practice authority, which is the ability to practice without direct physician oversight.
Together, the clinical competencies of an FNP and the extension of full practice authority are powerful tools in providing rural and underserved communities with the primary care resources they need. Let’s take a closer look at the FNP role, how FNPs can help battle care access challenges and what education you’ll need to become an FNP.
What Is an FNP?
A family nurse practitioner is a specialized nurse practitioner (NP) who is certified to deliver care to patients of all ages across their lifespans. On a regular day, an FNP may see and treat an infant, expectant parents, a teenager and a retired couple. As such, they have a wide range of clinical job responsibilities, which may range from conducting routine health assessments and prescribing cholesterol medication to a middle-aged patient to talking with patients about disease prevention.
Family practice is a popular career field. Of NPs prepared in primary care, nearly 66% were certified FNPs in 2019, according to the American Association of Nurse Practitioners (AANP).
Given their extensive education and preparation, FNPs are employed across diverse work settings, including hospitals, nurse education and health systems. A large number of FNPs are employed in physician’s offices or work in independent practice. This is important to meeting the care needs of rural and underserved populations because some states allow FNPs to perform their clinical duties without direct supervision or instruction from a physician. This oversight requirement — which we’ll discuss more later — can complicate care delivery and access for rural and underserved patient populations.
What Is an FNP’s Scope of Practice?
To understand why the FNP role is such an effective resource in combating care gaps, let’s examine their scope of practice. As NPs, these health care professionals are educated and experienced in many core nursing disciplines. Typically, an FNP either holds a Master of Science in Nursing (MSN), which is the standard for licensure as an APRN, or they’ve earned a Doctor of Nursing Practice (DNP).
This level of preparation ensures that certified FNPs are qualified and skilled to:
- Perform health assessments
- Order and interpret diagnostic and laboratory tests
- Make diagnoses and create, implement and manage treatment plans
- Manage patient data in electronic health records
- Coordinate care with other stakeholders and medical professionals
- Treat and help patients manage acute and chronic conditions
- Provide counseling and health education to patients and their families
That last competency is especially important. FNPs, and NPs in general, are differentiated by their approach to holistic care. Not only do they treat conditions, but they also talk to patients and their families about disease prevention, healthy lifestyle choices and other topics relevant to a patient’s well-being. NPs might also act as health care researchers, interdisciplinary consultants and patient advocates.
Prescriptive authority is another differentiator for FNPs and NPs. According to the AANP, nurse practitioners hold prescriptive authority in 2020, including controlled substances, in all 50 states plus the District of Columbia. Nearly 96% of NPs prescribe medications. Those in full-time practice write 20 prescriptions a day, on average.
As we’ll see, these characteristics and abilities of the FNP role are crucial in meeting the care needs of rural and underserved populations.
Primary Care Shortage Impacts Rural Communities
Trends across the health care landscape are making it harder for rural and underserved patient populations to find the efficient, cost-effective care they require. The most influential factors include:
- An aging population: By 2030, 1 in 5 Americans will be of retirement age, according to the U.S. Census Bureau. By 2034, there will be 77 million people aged 65 years and older compared to 76.5 million under the age of 18. The number of Americans aged 65 and over will reach more than 80 million by 2040. An aging population naturally comes with greater care needs, which can stress understaffed providers and the entire U.S. health system at large.
- A primary care shortage: A shortfall of licensed health practitioners is compounding the stress put on health care providers. According to the American Nurse Association (ANA), more than 500,000 registered nurses are anticipated to retire by 2022. Meanwhile, the U.S. Bureau of Labor Statistics projects the need for 1.1 million new RNs to replace retirees, expand the workforce and avoid a nursing shortage. That leads to a gap of about half a million Additionally, the American Association of Medical Colleges (AAMC) estimated in 2019 the U.S. would experience a shortage of 122,000 primary care physicians by 2032.
Rural and underserved communities are poised to bear the brunt of these challenges if the health care industry cannot find solutions. More than 82 million Americans live in a health professional shortage area; another 14 million live in a location designated as a medically underserved area (MUA).
Of geographic areas designated as HPSAs, 1,098 occur in rural or partially rural areas, and 236 occur in nonrural areas. Of designated MUAs, 2,193 occur in rural or partially rural areas, whereas 1,211 occur in nonrural areas.
Additionally, the HRSA tracks medically underserved populations (MUPs), of which there were 4 million in 2020. Common groups of MUPs include:
- Individuals with limited income
- Individuals without health insurance
- Individuals who qualify for Medicaid and other forms of government assistance
- Native Americans
- The elderly
- Individuals with limited mobility due to disabilities
HRSA data shows the majority of such populations typically live in rural or partially rural areas, especially those with limited income.
FNPs in Rural and Underserved Communities
The FNP role has been a critical asset in addressing the challenges of making quality, cost-effective primary care available to rural and underserved populations. They’ve risen to the call, as evidenced by a 2018 study published in the journal Health Affairs. In 2008, NPs made up 17.6% of primary care providers in rural areas. By 2018, NPs had risen to constitute more than a quarter (25.2%) of all such providers.
Meaningful Work, High Job Satisfaction
FNPs and other NPs employed in rural areas may be among the only primary care providers available for miles. They may also travel around rural populations or deliver telehealth services to meet those needs. This makes them a focal point for care demand, meaning rural NPs never lack work.
A 2018 study published in the journal Medical Care Research and Review found:
- NPs in urban areas had a mean weekly patient load of 66.1
- NPs in large rural areas had a mean weekly patient load of 70.1
- NPs in small rural areas had a mean weekly patient load of 76.7
- NPs in isolated rural areas had a mean weekly patient load of 71.3
On average, NPs in rural areas were more likely than their counterparts in urban areas to have hospital admitting privileges, work in more than one practice location and work more hours per week.
Despite the workload, rural NPs were by and large more satisfied with their jobs and the community services they provide than NPs in urban locations:
- 9% of NPs in urban areas were satisfied with their current position
- 2% of NPs in large rural areas were satisfied
- 9% of NPs in small rural areas were satisfied
- 2% of NPs in isolated rural areas were satisfied
In terms of patient load, just 86.9% of urban NPs were satisfied, compared with 87.9% of NPs in large rural areas, 90.4% of NPs in small rural areas and 92.7% of NPs in isolated rural areas.
Rural NPs were also more likely to agree that their education and skills were being fully utilized in their positions, while 87.5% of urban NPs said the same, versus NPs in large (90.3%), small (89%) and isolated (92.3%) rural areas.
Movement to Extend Practice Authority
Providing full practice authority to NPs and FNPs is a major component to ensuring rural and underserved populations get the care they need. The extension of practice authority has become a flashpoint in the health care community, as a growing movement calls for states to give nurses more latitude in meeting care needs by removing or reducing physician oversight rules.
State nursing boards decide to what extent nurses licensed in the state can practice. Some allow FNPs to perform duties across their scope of practice without physician supervision, but others require more burdensome arrangements and have more red tape. The autonomy granted through full practice authority has the potential to empower FNPs to meet the primary care needs of those in medically underserved areas or populations more effectively, along with those in locations experiencing a health professional shortage.
However, just a quarter of NPs in large and isolated rural areas worked in a state without physician oversight, and under 20% of those in small rural areas were in a similar position, as noted in a 2018 study by the Medical Care Research and Review.
The push to extend full practice authority has made progress, but it has also been held back in states where full NP practice authority could make the biggest differences.
As of 2020, states and territories have the following levels of authority:
- Full practice authority: Alaska, Arizona, Colorado, Connecticut, District of Columbia, Guam, Hawaii, Idaho, Iowa, Maine, Maryland, Minnesota, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Dakota, Northern Mariana Islands, Oregon, Rhode Island, Vermont and Washington
- Reduced practice authority (i.e., NPs are limited in at least one element of their practice by oversight regulations): Alabama, Arkansas, American Samoa, Delaware, Illinois, Indiana, Kansas, Kentucky, Louisiana, Mississippi, New Jersey, New York, Ohio, Pennsylvania, Puerto Rico, Utah, Virgin Islands, Wisconsin and West Virginia
- Restricted practice authority (i.e. NPs are required to have career-long supervision or be delegated tasks): California, Florida, Georgia, Massachusetts, Michigan, Missouri, North Carolina, Oklahoma, South Carolina, Tennessee and Virginia
According to HRSA data, the states with the highest number of HSPAs are Texas, California, Arkansas, Missouri and Florida. All reduce or restrict full practice authority of NPs in some way.
A 2018 study and analysis of literature published in the journal Healthcare argued expanding practice laws could mitigate primary care provider shortages and lead to other benefits, particularly for rural communities.
“Restrictions on (APRNs’) scope of practice were associated with up to 40% fewer primary care nurse practitioners (PCARNPs) in states with restricted APRN practice environment(s) compared to their full practice counterparts,” the authors wrote. “These practice restrictions may contribute to limitations in access to primary health care services and perpetuate rural health disparities. Relaxing restrictions on APRN scope of practice may also expand the capacity of primary care services in rural areas.”
How to Become an FNP
Are you motivated to help deliver high-quality primary care to families in rural or underserved areas? FNP may be your calling for a rewarding and fulfilling career. If you’re interested, it’s important to be aware of the steps to becoming a licensed FNP.
Broadly, the steps break down to:
- Earn a Bachelor of Science in Nursing (BSN): Becoming an FNP commonly starts with earning a Bachelor of Science in Nursing (BSN). With a BSN, students can become registered nurses (RNs), as well as apply to enter a graduate degree nursing program.
- Become a licensed registered nurse (RN): This entails passing the NCLEX-RN.
- Earn a graduate degree, whether a master’s or doctorate: Earning at least an MSN from an accredited institution is a requirement for licensure as an APRN.
- Secure national board certification: According to the AANP, nurses can be certified as an FNP through the American Academy of Nurse Practitioners National Certification Board (AANPCB) or the American Nurses Credentialing Center (ANCC) Certification Program.
- Become licensed by a state board of nursing: The final step is to become licensed by or registered with the nursing board of the state in which you intend to practice.
Complete Your FNP-Focused Degree at Bradley
When mapping out your career path to practicing as an FNP, consider earning your graduate degree at Bradley University. While an MSN is required for licensure, a DNP can provide further skills, knowledge and education to ensure you are prepared at the highest level of nursing practice.
And at Bradley, we offer both MSN and DNP online degree programs specifically constructed to prepare nurses for FNP certification:
- Students can enter the online MSN-FNP program with a BSN, nursing diploma or non-nursing bachelor’s. The program is offered 100% online and depending on the entry track can take 3.3 or 2.7 years to complete
- Students can enter the online DNP-FNP program with either a BSN or MSN. The program is also offered 100% online and the timeline to completion depends on the entry degree
The curricula for both programs is specially formulated to prepare students in the principles of FNP practice, covering subjects such as gerontology, acute and chronic conditions across the lifetime, advanced pharmacology and ethics of advanced practice.