Pediatric Nurse Practitioner Workforce Shortage Threatens Child Health Equity: Key Contributors and Recommendations

Abstract

The pediatric nurse practitioner (PNP) workforce shortage has begun to limit access to providers participating in Medicaid and/or the Children’s Health Insurance Program, threatening child health equity in the United States (U.S.). The following are key contributors: an emphasis on adult-focused nurse practitioner (NP) programs and subsequent reduction in undergraduate pediatric content, common practice of student advisement to choose family NP programs, decreased PNP student enrollment leading to non-urban pediatric program closures, an acute shortage of PNP preceptors, and invisibility of the PNP workforce in national workforce data and strategic planning. We outline feasible action steps that nurses, NPs, educators, physicians, and policymakers can take to support PNP workforce growth to advance child health equity in the U.S.

The United States (U.S.) is facing an emerging crisis in child healthcare equity, as a critical shortage of pediatric nurse practitioners (PNPs) begins to limit access to essential services (Gigli et al., 2019). Key contributors to the issues are the evolving challenges in pediatric healthcare. Recent national data reveal a troubling picture: 40% of children suffer from one or more chronic conditions, and rates of child suicide increased 45% since the onset of the COVID-19 pandemic, particularly among children aged 5–11 years (Child and Adolescent Health Initiative (CAHMI), 2020; Children’s Hospital Association, 2021). PNPs are key primary and specialty care providers in the Medicaid/Children’s Health Insurance (CHIP) program, serving 43 million children, representing 56% of the nation’s child population. Remarkably, this includes two out of three children from backgrounds characterized by racial, ethnic, socioeconomic, or geographical disadvantage (Brooks T. and Gardner A., 2020). Yet, a nationwide study of 403,013 physicians showed that 24.2% of family physicians and 15.3% of pediatricians are now refusing new Medicaid/CHIP patients in favor of children with private insurance (Medicaid and CHIP Payment and Access Commission, 2021).

This trend has grave implications for child health equity, with projections indicating a severe PNP shortage that will further constrain care access for vulnerable children (Gigli et al., 2019). A historical perspective reminds us that the original NP role was created in the 1960s specifically to ensure equitable healthcare access for underserved children (Silver et al., 1968). Addressing this looming crisis will necessitate concerted efforts to grow and support the PNP workforce, reinforcing their vital role in the infrastructure of child health equity in the U.S. Key factors contributing to the PNP shortage include a decline in undergraduate pediatric nursing content, a prevalent trend in faculty advisement to favor the family nurse practitioner (FNP) specialty, non-urban PNP program closures, a shortage of PNP preceptors, and inadequate workforce data affecting funding (Chesney M.L., 2021; Gigli et al., 2019; U.S. Dept. of Health and Human Services HRSA, 2022a). We sought to describe these factors in detail and propose targeted solutions for each:

Factors Leading to PNP Shortage

1. Emphasis on Adult-focused NP Programs Led to a Reduction in Undergraduate Pediatric Content

In the 1960s and 70s, governmental investments enhanced the PNP workforce, resulting in better child health equity (Pulcini et al., 2019). The success spurred increased funding for adult-focused Nurse Practitioner (NP) training programs, scholarships, and loan repayment programs, targeting care for the aging baby boomer population. However, by the early 2000’s, funding excluded PNP programs and students entirely (Chesney M.L., 2021). The shift in funding came with a change in essential curricular content for undergraduate nursing set by the American Association of Colleges of Nursing (AACN) in 2008 to a generalist preparation, leading to a decline in pediatric content (American Association of Colleges of Nursing, 2008; Chesney M.L., 2021). These funding and curricula shifts are blamed for sidelining PNP program and workforce growth, as many PNPs chose their careers based on undergraduate pediatric clinical experiences (Chesney M.L., 2021).

2. Nursing Students Desiring Pediatrics Advised to Choose Family NP Programs

Mentors commonly advise students desiring to become child health services providers to select the family (FNP) track to enhance their employability (Loman & Clinton, 2010). The literature remains ambiguous on whether students were aware of the key distinctions in FNP and PNP competency standards for national certification and state licensure. Past standards for FNP education did not align with PNP competencies in areas including child-specific evidence-based practice, ethics related to child assent, developmental/psychological/social behavior assessments, and other crucial pediatric contents (National Organization of Nurse Practitioner Faculties, 2013). Despite recent revisions, these standards still broadly focus on minimum competency for NP roles across the lifespan, leaving uncertainties about FNP preparedness for complex child healthcare (American Association of Colleges of Nursing, 2021; National Organization of Nurse Practitioner Faculties, 2022). Evidence indicates most FNPs spend under 25% of their time providing child health, mostly for older adolescents (Freed et al., 2010). With FNPs comprising 70% of NPs, this adult and family focus appears successful but has sacrificed the PNP workforce for younger children. The guidance toward FNP programs has contributed to decreased PNP enrollment, causing non-urban PNP program closures (Freed et al., 2015).

3. Non-urban Pediatric Programs Close; Training Shifts to Urban Programs

Nearly 10% of PNP programs were shuttered or suspended in the past decade, mainly in non-urban areas, partly due to decreased enrollment (Freed et al., 2015). This led to a reduction in Medicaid/CHIP providers in underserved regions, threatening child health equity. While urban PNP programs grew, evidence also reveals similar contraction in pediatric medical residency programs (Vinci, 2021). About 20% of rural and suburban pediatric hospital beds closed in the same period, centralizing pediatric medical training in urban academic medical centers and children’s hospitals (Vinci, 2021). This geographic shift resulted in significant loss of child health services in underserved areas and longer wait times in urban areas, further undermining equitable access to care (Freed et al., 2015; Vinci, 2021).

4. Acute Shortage of Preceptors for PNP Students

The shift of training programs and child health services from rural to urban settings led to an increased workload for PNPs and pediatricians in cities, limiting their capacity to mentor students (Vinci, 2021). This change ironically contributed to a shortage of PNP preceptors and even caused pediatricians to prefer training pediatric residents over PNP students (Chesney M.L., 2021). As most PNPs don’t receive financial incentives to precept, and earlier funding omitted PNP programs, finding available PNP preceptors and training sites became challenging. This limited availability constrains PNP program student intake, leading to fewer practicing PNPs and Medicaid/CHIP providers – an essential component of U.S. child health equity. Adequate funding for PNP programs and preceptors could alleviate the problem.

5. HRSA Strategic Plan Inadequately Represents the PNP Workforce

Recent studies show an over-inflated NP workforce at 206% over demand, which could impact future funding (U.S. Dept. of Health and Human Services HRSA, 2022a). This analysis, unfortunately, aggregated all NP specialties together, obscuring individual specialty growth, including the PNP workforce. The supposed ‘oversupply’ could limit nationwide funding to NP training programs and scholarships, jeopardizing access to essential Medicaid/CHIP providers. Moreover, the NP workforce suffers from inadequate representation in key stakeholder groups that influence congressional funding for the U.S. health workforce. The Coronavirus Aid, Relief, and Economic Security Act (CARES Act) regulations for developing a coordinated health workforce plan excluded NPs as a statutory consultative stakeholder, casting doubt on the sufficiency and impartiality of data that informs PNP workforce funding (U.S. Dept. of Health and Human Services HRSA, 2022b). Additionally, the latest HRSA strategic plan overlooks provisions to support pediatric nursing and PNP programs (U.S. Dept. of Health and Human Services HRSA, 2022b). The potential merging of PNP data into broader NP categories may lead to an exaggerated projected NP supply, analogous to using a single dataset for all physicians to represent pediatric physicians. This over-simplification has severe consequences for accurate planning and could damage child health equity. Given that prominent pediatric societies including American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatrists recently highlighted an unprecedented pediatric workforce crisis in the U.S., the omission of PNP workforce data in the 2019–2022 strategic plan is an egregious oversight (Children’s Hospital Association, 2022; U.S. Dept. of Health and Human Services HRSA, 2022a). This error hinders proper workforce planning and necessary funding to sustain the PNP workforce.

In summary, national decision-makers and data infrastructure have omitted the PNP workforce in strategic plans and funding priorities. Prioritizing an adult-focused NP workforce left the U.S. unprepared to serve the child health needs of 25% of the population, including 84 million infants, children, and adolescents under age 18, with 43 million of them being minorities more vulnerable to health disparities. With a declared national emergency in the pediatric workforce, achieving U.S. child health equity appears unlikely unless the PNP workforce receives visibility, priority and funding. We propose these 5 action steps to address the outlined problems:

Action Steps to Support PNP Workforce Growth to Advance Child Health Equity

1. Prioritize child health equity content and pediatric workforce growth.

Engage and inform the American Academy of Colleges of Nursing and National Organization of Nurse Practitioner Faculties about the overall pediatric workforce shortage, highlight the implications for child health equity, and underscore the opportunity to advance equitable access to child healthcare by prioritizing a robust pediatric nursing and PNP workforce. This can be achieved by strong advocacy for requiring undergraduate pediatric clinical experiences that emphasize child health equity in all nursing undergraduate programs. Reinvigorate rural PNP programs with virtual didactic learning and community-based clinical experiences. For FNP programs, assure standards include child-focused competencies formally aligned with national PNP competencies because historically FNP standards omitted those necessary for child health equity including ethics of child assent, developmental/psychological/social behavior assessments, counseling for young child growth and development, child abuse assessments, advocacy for child protection, and parent/child transitions of care (National Organization of Nurse Practitioner Faculties, 2013). This recommendation addresses recently revised competency standards for NP roles across the lifespan, as not all FNPs are using standardized developmental screening tools which can impact child health equity (Gellasch, 2019; National Organization of Nurse Practitioner Faculties, 2022).

2. Encourage the PNP track to support child health equity.

Undergraduate nursing and graduate FNP and PNP program leaders have an ethical obligation to inform students collaboratively and clearly on the evidence base on different workforce contributions to child health equity and the knowledge, skills, and attitudes each program is designed to provide to advance child health equity. Encourage and guide undergraduate nursing students interested in child health equity to pursue the PNP track.

3. Avoid program closures by expanding clinical experiences to underserved community-based settings, exposing students to child health inequities.

Clinical experiences for pediatric nursing and PNP students should expand beyond traditional hospital settings to include rural, suburban, and urban underserved settings where children live, work, and play (McCarthy & Wyatt, 2014). Opportunities abound for students to collaborate with community-based professionals in a variety of settings, such as schools, camps, non-profit organizations, shelters, food kitchens, and youth programs, in line with recommendations to address social determinants of health (National Academies of Sciences & Medicine Committee on the Future of Nursing, 2021).

4. Develop a non-traditional network of preceptors for child health services.

Additionally, a non-traditional network of preceptors should be developed for child health services. PNPs and FNPs providing child health services who are not currently precepting should contact nursing and PNP programs and step up to expose students to child health services. If you are already precepting, invite your community-based collaborators and contacts to consider precepting pediatric nursing and PNP students, and connect them with undergraduate and PNP programs. These actions will foster and strengthen the interprofessional community-based network vital for advancing child health equity with a pediatric nursing perspective.

5. Lobby policymakers and assure PNP workforce representation in workforce plans.

Lobbying policymakers to ensure PNP workforce representation in workforce planning discussions, research studies, and strategic plans is vital to achieve child health equity in the U.S. Additionally, all NPs should ensure their national provider identification profile (NPI) includes their specialty to assure accurate data collection. Go to https://nppes.cms.hhs.gov/#/ and choose the specialty taxonomy code for your specialty. Taxonomy codes are available online (National Uniform Claim Committee, 2023).

As nurses, we are the most trusted profession in the U.S. We take pride in our profession’s code of ethics that demands we strive to reduce health disparities, proclaiming health is a universal right. Working to eliminate children’s health disparities will pave the path for achieving health equity in adulthood, ultimately resulting in a healthier and more equitable U.S. population. The recommendations provided are feasible for nurses across all levels, including NPs, NP academic program directors, Deans of schools of nursing, chief nursing officers, and nurse leaders of professional organization/political action committees. Collectively, these actions can foster growth in the PNP workforce and advance equitable access to child health services.

Conclusion

The responsibility to improve access to care for children from disparate backgrounds rests with each one of us. The decline in pediatric nursing content, shortage of PNP preceptors, steerage of NP students to pursue FNP tracks, and misleading NP workforce data are converging to exacerbate a PNP shortage, threatening child health equity. To combat this, the integration of pediatric clinical content highlighting child health equity, increasing PNP preceptors, steering students toward PNP careers, and robust NP representation in key workforce and funding discussions are essential. Unaddressed, these challenges will continue to undermine the PNP workforce and child health equity, emphasizing the need for urgent, purposeful action.