By Lindy Keane Carter
Abby Rishovd, DNP, a 2013 graduate of MUSC’s DNP program, examines a patient at a pediatric practice in Hartsville, South Carolina.
Demand for primary care is growing in America, but physicians will be filling fewer of tomorrow’s boots on the ground. Only 2% of fourth-year medical students plan to work in general internal medicine after graduation, according to a survey published in the Journal of the American Medical Association in 2008.1 The U.S. Department of Health and Human Services predicts a shortage of 20,400 primary care physicians by 2020.2 Fortunately, the supply of primary care nurse practitioners (NPs) and primary care physician assistants (PAs) is projected to increase by 30% and 58%, respectively, by 2020.2 The question is: Will their numbers be sufficient to meet the demand?
This need is mostly due to the aging of our population and population growth, but also because of the more than 32 million Americans who have gained access to services through the Patient Protection and Affordable Care Act of 2010. The financial incentive to hire non-physician advanced practice providers is also growing stronger as health care moves away from the fee-for-service model. Nationwide, NPs earn about $93,000 a year, while PAs earn about $102,000, according to 2012 federal data. That compares with an average annual salary of about $160,000 for physicians.3
The need for primary care providers is particularly acute in South Carolina. Nearly a third (31%) of South Carolinians do not have a primary care provider.4 Almost every county in the state is designated as partially or completely medically underserved. South Carolina ranks among the worst in the nation on many health indicators, including diabetes, obesity, hypertension, cardiovascular disease, infectious disease, occupational fatalities, infant mortality, and being uninsured. The Urban Institute estimates that South Carolina will have more than 479,000 more insured residents due to reform and that the primary care workload will increase by 30%.5
Nurses represent the largest segment of the U. S. health care workforce, but 55% of them are age 50 or older and workforce analysts have been examining for years how to sustain the pipeline. In 2008, the Institute of Medicine and the Robert Wood Johnson Foundation launched a two-year initiative to assess nursing education and transform the profession. The landmark report that followed called for, among other actions, doubling the number of nurses with doctorates.6 The College of Nursing (CON) at MUSC was assessing the field as well and found that 90% of advanced practice registered nurses (APRNs) were taking primary care positions across the state and country to care for the growing population of people in rural and other underserved areas. “It became apparent that DNP-prepared APRNs were critical to not only meet the primary care needs, but also to provide cost-effective evidence-based care,” says Gigi Smith, PhD, APRN, CPNP-PC, Director of MSN/DNP Programs at MUSC’s CON. Clearly, innovative ways to prepare and educate more nurses to practice in advanced roles were needed. One innovation developed by the CON was to take education to students, especially those living in rural areas and likely to stay in their communities, Dr. Smith reports. “It has been demonstrated that when enrolled nursing students are able to pursue their degrees while working in their state, they often find jobs in their community after graduation.”
In 2008, the CON created the online Doctor of Nursing Practice (DNP) program. Its curriculum advances skills and knowledge with the purpose of preparing graduates to function as entry-level primary care nurse practitioners and nursing leaders. Since 2009, the program has graduated 239 students.
The program begins each August with a class of approximately 80 enrollees who are already registered nurses. Full-time students with a Bachelor of Science in Nursing can complete the program in three years (three semesters per year); part-time students can complete it in five years. All instruction is online with a few exceptions. Students come to the MUSC campus for orientation prior to starting the program. At the end of four designated semesters, students return for two to three days to participate in capstone learning experiences and competency evaluation. DNP students also come to campus to present proposals for their evidence-based practice or policy change projects, then return to defend the results of their projects once completed. Otherwise, students live and work in their respective communities in South Carolina, North Carolina, Georgia, and other states, where most of them remain after graduation.
As an advanced practice nurse, Dr. Abby Rishovd promotes evidence-based medicine in the community as well as the clinic.
Abby Rishovd, DNP, obtained her doctorate in the program while working part-time at MUSC. “The online DNP program at MUSC was a transformational experience for me,” Dr. Rishovd says. “It was a great academic program that provided just enough face-to-face time with mentors and faculty.” Upon graduating in December 2013, she chose a position that fulfilled her personal and professional goal of practicing in a rural community. She sees about 100 patients a week at a pediatric practice in Hartsville, SC, population 7,761, though her patients come from all over Darlington County and adjacent counties in this northeast corner of the state. Her presence has enabled the practice to meet the area’s growing demand for care. Though the pediatrician who hired her is generally in the clinic, the South Carolina Nurse Practice Act requires only that the supervising physician be within 45 miles of the practitioner.
Of the 239 DNP graduates, 109 are working in South Carolina, and the majority practice in underserved rural areas. Specifically, they provide primary care in South Carolina and other states in 182 health professional shortage areas, 176 medically underserved areas, and 73 rural areas.
Training for nurse practitioners focuses not only on treating illness, but also on promoting health overall. NPs know their population and seek to find or create interventions that improve outcomes for that population. One of the DNP students, for example, implemented a diagnostic technique in a rural clinic in a medically underserved area to screen for peripheral arterial disease. This technique saves money and time by helping staff to accurately identify patients who should be referred to a specialist. Another student implemented evidence-based screening for depression, ensuring that patients who needed further assessment of mental health issues were appropriately identified. Other DNP students have enabled cost savings for clinical practices and inpatient hospitals by implementing a variety of evidence-based guidelines. For example, one student improved management of postpartum urinary retention, leading to better outcomes for patients and overall cost-savings.
The changing demands of our nation's complex healthcare system require the highest level of education and expertise to ensure quality patient outcomes and reduce care delivery disparities. Advanced practice nurses are full partners with physicians and other health care professionals in rising to this challenge. MUSC's CON will continue to develop innovative online educational methodologies to produce graduates who will not only provide hands-on care, but also lead change in our delivery and educational systems.
1 Hauer KE, Durning SJ, et al. Factors associated with medical students’ career choices regarding internal medicine. JAMA. 2008;300(10):1154-1164.
2 Projecting the supply and demand for primary care practitioners through 2020, U.S. Department of Health and Human Services, November 2013. Available at http://bhpr.hrsa.gov/healthworkforce/supplydemand/usworkforce/primarycare/index.html.
3 Conquering the doctor shortage, The Cincinnati Enquirer February 8, 2014.
4 Bureau of Clinician Recruitment and Service, Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services, HRSA Data Warehouse: Designated Health Professional Shortage Areas Statistics, as of July 29, 2013.
5 Urban Institute. Available at http://www.urban.org/health_policy/private_insurance/index.cfm
6 The future of nursing: Leading change, advancing health. The Institute of Medicine. Reports/2010.