III. Current NP Practice

Professional Activities

Among those who reported working as an NP, about 80 percent worked 20 patient care hours a week or more as an NP. About 9 percent worked fewer than ten patient care hours a week as an NP (over half of these also worked some patient care hours as an RN), while one-third worked forty patient care hours or more as an NP (13 percent of these full-time NPs also worked some RN patient care hours).

[D]

Of those NPs who also worked as RNs, 51 percent who reported their RN hours reported fewer than 10 per week. Twenty percent of the NP/RNs who reported their RN hours reported 20 or more RN hours per week, and only 9 percent reported 30 or more RN hours. It should be noted, however, that fully one-third of respondents who reported working as both an NP and an RN did not report any RN hours. The meaning of this isn’t clear; perhaps some respondents reported themselves as both an RN and an NP under the rationale that they had been trained as an RN, although the option given was worded as “Working in positions as both NP and RN”. It is also possible the RN hours of those who worked in both positions were very variable, and therefore some respondents did not feel comfortable reporting a number.

Fifty-seven percent of active patient care NPs reported that they did not engage in any administrative, teaching, or research tasks, although 7 percent reported spending some time in all three. Twenty-four percent of NPs spent some time in administration, although the vast majority of these (61 percent) spent fewer than 10 hours a week on such activities. Only 3 percent reported 40 hours or more a week on administrative activities. Thirty-one percent of NPs spent some time teaching.  The majority of teaching NPs (58 percent) spent less than 10 hours a week on teaching activities. Only 14 percent of NPs spent time on research activities, and of those that did, only 2 percent spent 40 hours a week or more on such activities. Seventy-four percent of NPs who did research spent less than 10 hours a week doing so.

[D]

Specialty Certification

The most common specialty reported by NPs was family health (33 percent), followed by adult health (31 percent). Almost 14 percent reported a specialty in pediatrics. Other areas included women’s health, obstetrics/gynecology, gerontology, neonatology, and acute care. Very small numbers of NPs reported certifications in community health, perinatology, oncology, or school health (Figure 10).

[D]

Specialty by race

The highest percentage of most racial/ethnic groups specialized in either adult health or family health, because these were the most popular certifications. Looking at the racial distribution within specialties, some racial/ethnic differences become clear. The specialty with the highest concentration of non-Hispanic whites was psychiatry, at 92 percent, while the specialty with the lowest concentration of non-Hispanic whites was neonatology, at 81 percent. African-Americans were found in the highest numbers in gerontology (11 percent), while no African-American NPs were found in acute care. Acute care, on the other hand, had a large percentage of Puerto Rican NPs (14 percent), while psychiatry had none. Other Hispanics/Latinos were concentrated most heavily in gerontology and obstetrics/gynecology (both 2.4 percent), while no NPs of other Hispanic ancestry were found in women’s health or acute care (Figure 11).

[D]

Specialty distribution by age

Specialty distribution changed somewhat between the most recent cohorts of NP graduates and earlier cohorts, with family health and psychiatry becoming more popular among the recent cohorts, and obstetrics/gynecology, pediatrics, and women’s health becoming less popular. None of the NPs graduating after 1990 reported certification in oncology, perinatology, or school health. None of those graduating before 1997 reported certifications in community health, and none graduating before 1991 reported certifications in acute care (Figures 12a and 12b).

[D]

[D]

It is especially important with the NP profession, however, to look at graduation year and age separately. Although the youngest NPs are by definition recent graduates, many of the older NPs may be recent graduates as well. Therefore, cohort trends will not necessarily reflect age trends.

In fact, adult health, which had become slightly more popular among the most recent cohorts, was less popular among the youngest NPs. Pediatrics, which had been declining steadily in popularity by graduation cohort, was actually a more popular certification among the younger NPs than the older ones. The reverse was true for psychiatry. Although it had been more popular in recent cohorts of NPs, it had been so primarily among older NPs. Women’s health, declining in popularity by cohort, was somewhat more popular among younger than among middle-aged NPs (Figures 13a and 13b).

[D]

[D]

Recent graduation increasingly cohorts were more likely to do specialty care, and less likely to do primary care. In the most recent cohort, the percentage practicing specialty care was larger than the percentage practicing primary care. A similar pattern occurs by age – within most age groups, the numbers practicing primary and specialty care were about equal. Among the oldest age group, however, primary care was much more common than specialty care. Eighty percent of the NPs who were age 65 and older practiced primary care.

[D]

Practice Settings

Seventy percent of NPs reported working at only one practice site. Another 23 percent reported working at two practice sites, and 8 percent reported working at three or more. About half of NPs reported that they provided primary care at their first practice site, while the other half reported providing specialty care.

The most common principal practice settings for NPs are M.D. group practices (22 percent), hospital ambulatory care (15 percent), other settings (13 percent), hospital inpatient care (11 percent), M.D. solo practice (9 percent), community health centers (7 percent), nursing homes/extended care facilities (5 percent), NP group practices (5 percent), hospital emergency rooms (2.4 percent), NP solo practices (2 percent), occupational health (2 percent), elementary or high school health services (1.9 percent), hospital psychiatric facilities (1.8 percent), and state or local health departments (1.5 percent).  Small numbers of NPs also work in home health agencies, schools of nursing, ambulatory surgical centers, HMO/MCOs, and temporary agencies (Figure 15).

[D]

A similar distribution was found for the second practice site of NPs, with 17 percent of those who reported a second practice site working for a group medical practice, 10 percent working in a hospital inpatient setting, and 9 percent working in a hospital ambulatory care setting. Over 8 percent reported that their second practice site was a community health center. More than 5 percent of NPs list that they were in solo practice as a second practice setting.

NPs were most likely to report working for a first practice site with a physician specialty in family practice (13 percent), obstetrics/gynecology (12 percent), general internal medicine (11 percent), and general pediatrics (11 percent). The most popular second practice sites, however, were somewhat different. Of NPs reporting a second practice site, 15 percent reported that the physician at their second site specialized in obstetrics/gynecology, 10 percent reported psychiatry, and 10 percent reported family practice. More than 7 percent of NPs who worked at a second site reported that the physician specialized in geriatrics.

The majority of those with a specialty in adult health (46 percent) worked in either general internal medicine or one of its subspecialties (including 9 percent who worked with geriatricians). Those with a specialty in family health tended to work with family practitioners (31 percent). Fifty-five percent of those with a specialty in gerontology worked with geriatricians (and another 17 percent worked with either general internists or general family practitioners). Eighty-five percent of those with a specialty in pediatrics worked with a pediatrician (either generalist or specialist), while 28 percent of those with a neonatology specialty worked with pediatricians. Seventy-four percent of those specializing in obstetrics or gynecology worked for an obstetrician/gynecologist, as did 86 percent of those with a specialty in women’s health. Ninety-four percent of those with a psychiatry specialty worked with psychiatrists.

Practice setting by age

Perhaps the greatest change in practice by graduation cohort was the diversity of practice settings. Those NPs who graduated between 1970 and 1974 reported only four descriptions of their principal practice site: MD group practice, hospital ambulatory care, community health center, and “other”. Recent cohorts, on the other hand, were found in 19 practice settings.

Recent cohorts were also more likely to work in NP group practice, MD solo practices, hospital inpatient settings, home health agencies, nursing homes, and ambulatory surgical centers. They were less likely to be in hospital ambulatory care, in elementary or high school health services, in nursing education programs, community health centers, HMOs/MCOs, state and local health departments, or occupational health.  Overall, the trends seem to have been relatively static since at least the 1985-1989 cohort. 

[D]

Trends by age were less distinct, possibly indicating that the deciding factor in practice patterns was the climate of the profession at the year of one’s graduation. There was a clear trend, however, towards more employment in physician group practices among younger NPs. The likelihood of having one’s own practice appeared to be higher among older NPs. This would be logical, as older NPs might have the greater experience and established patient panel necessary to start a solo practice, but the numbers of NPs who have their own practice was so low as to make a detailed breakdown by age group unreliable.

Practice setting by specialty

The practice settings of NPs varied by specialty. Those with certifications in adult health were most likely to work in a medical group practice (18 percent), or in hospital inpatient (15 percent) or ambulatory services (16 percent). Those in family health were most likely to serve in medical group practices (24 percent) or medical solo practices (11 percent), although a large number were found in community health centers (almost 9 percent). Those with certifications in gerontology were most commonly found in nursing homes and extended care facilities (34 percent), followed by hospital ambulatory care. The vast majority of neonatal NPs (84 percent) worked in hospital inpatient settings, while the remainder 16 percent) worked in medical group practices. Those certified in obstetrics/gynecology were most often found (37 percent) in medical group practices, and community health centers (12 percent), and almost 10 percent were found in NP group practices.

The most common setting for pediatric NPs (32 percent) was in medical group practices, while most psychiatric NPs were in psychiatric hospitals or community health centers. Those specializing in women’s health were equally likely to be found in medical group practice or in hospital ambulatory practice (27 percent). The majority of acute care NPs (57 percent) were found in hospital inpatient settings (Table 1).

Table 1.  Broad Practice Settings for NPs, by Certification, NYS, 2000

Scope of practice and reimbursement/provider status

Sixty-eight percent of NPs reported that they were Drug Enforcement Agency (DEA) certified to prescribe controlled substances, 25 percent had their own Medicaid provider number, and 32 percent had their own Medicare provider number. Twenty-four percent were listed as a participating practitioner with a health insurance plan, and only 10 percent were listed as a “primary care practitioner” with a managed care plan (Figure 17).

These numbers depended in part upon whether the NP reported providing primary or specialty care at the primary practice site. Although there were few differences by DEA certification and having a Medicaid or Medicare provider number, primary care NPs were more likely than specialty care NPs to be listed as a participating practitioner with a health insurance plan (31 percent versus 19 percent), and to be listed as a primary care provider with a managed care plan (18 percent versus 4 percent).

[D]

Although 47 percent of NPs had no hospital privileges, 15 percent could see inpatients and write both notes and orders, while over 7 percent had admitting privileges. Ninety-three percent of NPs performed histories and physical examinations, 94 percent ordered laboratory tests, 90 percent made direct referrals to specialists, and 32 percent provided on-call services. Fewer than 5 percent reported that they assisted physicians in the operating room.

Scope of practice by specialty

Although a majority of NPs were DEA certified to prescribe controlled substances, this varied substantially by specialty, as shown in Figure 18. NPs in acute care were most likely to have this privilege (86 percent), followed by those in gerontology (78 percent) and in adult health and psychiatry (both 76 percent). Least likely to have such privileges were those in neonatology (19 percent) and women’s health (41 percent).

[D]

Most likely to have a Medicaid provider number were NPs in obstetrics/gynecology (44 percent), followed by family health (30 percent). No acute care NPs had their own Medicaid number, and only 9.5 percent of those in neonatology did. A slightly different pattern emerged in regard to Medicare provider numbers. Not unexpectedly, the NPs most likely to have such a number were those in gerontology (50 percent). More surprising is that psychiatric NPs were second most likely to have a Medicare number, at 46 percent. No neonatology NPs had such a number, and only 5.6 percent of pediatric NPs did (Figure 19).

[D]

NPs in obstetrics/gynecology were most likely to be listed with a health insurance plan (47 percent), followed by those in psychiatry (43 percent). Least likely were those in acute care (none), and those in neonatology (4.8 percent). Those in women’s health care were most likely to be listed as a PCP with a managed care plan (18 percent), followed by those in pediatrics (17 percent). Those in neonatology (0 percent) and psychiatry (1.9 percent) were least likely (Figure 20).

[D]

Scope of practice also depended in part upon the type of care provided, as shown in Figure 21.  There was little difference in terms of visiting or admitting privileges, performing exams, ordering lab tests, or providing on call services (although primary care NPs were slightly more likely to do all of these), but primary care NPs were more likely to make direct referrals to specialists (98 percent versus 88 percent).

[D]

Although over half of NPs 52 percent reported that none of their patients were from their own panel of patients, and 57 percent billed under a physician’s name, 24 percent reported that 80 percent to 100 percent of their patients were from their own panel.

The NPs most likely to have hospital visiting privileges and be able to write notes and orders, as shown in Figure 22, were those in obstetrics/gynecology (26 percent) and in women’s health (18 percent). Those least likely to have such privileges were in neonatology (0 percent) and in pediatrics (8.1 percent). A different pattern emerges for admitting privileges, however. NPs in gerontology and adult health were most likely to have these privileges (9.3 percent and 9.2 percent respectively). Those in neonatology and pediatrics were once again least likely to have such privileges (at 0 percent and 2.4 percent respectively), along with those in acute care (also 0 percent).

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Those in neonatology and acute care (both 100 percent) and in family health (99 percent) were most likely to perform histories and physical examinations, while those in psychiatry (51 percent), women’s health (96 percent) and adult health (97 percent) were least likely. Those in obstetrics and gynecology, neonatology, and acute care (all 100 percent) were most likely to order laboratory tests, while those in psychiatry (89 percent), gerontology (94 percent), and pediatrics (95 percent) were least likely (Figure 23).

[D]

Those most likely to make direct referrals as part of their NP practice were those in neonatology (100 percent), followed by those in family health (95 percent). Least likely to do so were those in psychiatry (81 percent) and acute care (86 percent). NPs in neonatology and psychiatry were the most likely to provide on call services (76 percent and 54 percent respectively), while many fewer acute care (14 percent) or women’s health (23 percent) NPs did so (Figure 24).

[D]

Almost half (47 percent) collaborated with their designated collaborating physician daily, and almost one-third (31 percent) did so weekly, although 10 percent did so monthly and 12 percent only did so every 3 months (the minimum frequency of collaboration required by law), as shown in Figure 25. [D]

Those most likely to collaborate with their designated collaborating physician on a daily basis, as shown in Figure 26, were those NPs in neonatology (100 percent), and adult health (53 percent). Those least likely to do so were those in psychiatry (17 percent) and obstetrics/gynecology (33 percent). At the other end of the spectrum, a substantial number of NPs only collaborated to the minimum extent required by law – every three months. NPs who were most likely to report this pattern were those in women’s health (14 percent) and those in family health and gerontology (both 12 percent). Those least likely to follow this pattern of collaboration were those in neonatology and acute care (both 0 percent).

[D]

Income

NPs earned a median salary of $60,000 ^[2] in 2000.  Given variations in hours worked, however, an hourly salary is a more accurate measure of the actual earning power of NPs.  In 2000, NPs earned a median of $33.65 per hour (annual salary divided by hours worked per week).  Seventy-five percent of NPs earned more than $45,000 or $27.88 per hour, while 25 percent earned more than $70,000 per year or $40.86 per hour).  Sixty-four percent reported that they were paid on an annual salary basis, while 31 percent were paid hourly.

These figures mask dramatic variation by geography, however.  NPs in New York City earn substantially more than NPs living in upstate New York.  Median salary in downstate New York was $70,000, or $38.46 per hour.  Median salary in upstate New York was $50,000, or $28.14 per hour. 

Income also varies by setting.  The highest rates per hour were commanded by those working in nursing education programs ($76.77), ambulatory surgical centers ($54.29), HMO/MCOs ($46.24), and NP solo practice ($45.15).  The lowest rates per hour were earned by those working in State or local health departments ($27.92), or in elementary or high school health services ($29.22), followed by those in M.D. group practice ($30.22) or NP group practice ($31.25). 

Income by Age/Graduation Cohort

The highest median hourly salaries were among those who graduated from their NP program between 1975 and 1979 ($39.47) ^[3] , while the lowest hourly salaries were earned by the 1970 to 1974 cohort ($29.23). Median hourly salary for the most recent graduates (1995-1999) was $33.66.  Overall, there was not a clear linear pattern in terms of graduation cohort, with years in practice seeming to have little effect upon salary.  Again, however, these figures varied by geography as shown in Figure 27.

[D]

Income by race

The highest median hourly salaries were reported by Asian, Puerto Rican, and African-American NPs ($39.84, $40.60, and $40.84) ^[4]

The lowest were reported by non-Hispanic whites and non-Puerto Rican Hispanics (both $32.69). There were too few Native American NPs to discuss salary reliably.  The apparent salary advantage of being Asian, Puerto Rican, or African American was, however, due almost completely to geographical distribution as shown in Figure 27.  All of the Asian NPs, 96 percent of the African-American NPs, and 92 percent of the Puerto Rican NPs practiced in the downstate area (where salaries are substantially higher on average), compared to only 50 percent of the non-Hispanic white NPs.  Hourly salaries were very similar across ethnicity in the downstate area, with the exception of Hispanic/Latinos other than Puerto Rican, who earned substantially less than the others. 

Income by specialty

The highest median hourly salary was reported by neonatology NPs ($41.40) ^[5] , followed by acute care NPs ($40.87). The lowest was reported women’s health ($30.59), and family health ($31.42) NPs (Figure 28). 

[D]

Once again, variation existed in salary by geographical location, with neonatology, psychiatry, and acute care the highest-paid specialties in downstate New York, while psychiatry, obstetrics/gynecology, and neonatalogy ranked highest in upstate New York.  Gerontology, which ranks sixth out of nine specialties overall, ranked eighth out of nine downstate and last of nine upstate.  More geriatric NPs practice downstate where salaries are higher, therefore artificially inflating their overall median salary (Table 2).

Table 2.  Median Hourly Salaries for NPs by Certification, Downstate versus Upstate New York, 2000

Despite having a median age of 45 (compared to 39 for the civilian labor force), very few NPs reported plans to retire (1.8 percent) or reduce their NP patient care hours (3 percent) in the next 12 months. The numbers of those who planned to move their practice to another county (2.7 percent) or to move to another State (2.3 percent) were also small. Although almost 34 percent reported having been at their current position at their principal NP practice for less than 2 years (not surprisingly, since 32 percent had graduated in the 3 years before the survey), over 12 percent had been at their position for more than 10 years.

Location of practice

Although 32 percent of NPs practiced in a suburban area, almost as many (31 percent) reported that they practiced in an inner city area. Twenty-two percent practiced in a non-inner city urban area, while 15 percent practiced in a rural area or small town (Figure 29). 

[D]

Location of practice by race

The location of an NP’s principal practice site was strongly associated with race/ethnicity. Over 80 percent of African-American NPs reported that they worked in an inner-city area, compared to less than 27 percent of non-Hispanic whites. A large share of Puerto Rican NPs (57 percent) and Asian NPs (45 percent) also worked in inner city areas. Fewer non-Puerto Rican Hispanics (30 percent) and no Native Americans worked in the inner city.

Almost 81 percent of Native American NPs worked in a small town or rural settings (there were, however, too few Native American respondents for this to be reliable). Whites were also likely to work in a small town or rural environment, at 16 percent. No African-American NPs and only 6 percent of Asian NPs worked in such environments, although almost 13 percent of Puerto Ricans and 12 percent of other Hispanics did so (Figure 30).

[D]

Geographical distribution by age

More recent graduates were more likely than earlier graduates to practice in the New York City and Nassau-Suffolk Health Service Area (HSA), and also slightly more likely to practice in the Northeastern New York HSA. They were less likely than older cohorts to practice in other New York HSAs. They were somewhat more likely to practice in inner cities and in suburbs than older cohorts, but were less likely to practice in other urban areas and in rural areas.

Type of care provided also varied by geographical site of practice, as shown in Figure 31. NPs were substantially more likely to provide primary care in rural areas (67 percent) than in any other type of area. They were most likely to provide specialty care in a non-inner city urban area (64 percent).

[D]