Evolving roles and workforce trends among nurse practitioners in Aotearoa New Zealand (2014–2022)

Nurse practitioners (NPs; mātanga tapuhi) are registered nurses who have completed an accredited clinical Master’s programme, have demonstrated expert nursing and have clinical and scientific knowledge coupled with complex decision-making skills within an area of practice.¹ The role is grounded in nursing values, knowledge and experience, and is distinguished in part by its capacity for autonomous clinical care. NPs are authorised to assess, diagnose, prescribe and manage patient and family (whānau) care independently and collaboratively with other members of the healthcare team.^2,3 In addition to their clinical responsibilities, NPs are positioned as change agents, advancing clinical practice and knowledge through research, health policy, education and workforce development.⁴

The NP role was established in Aotearoa New Zealand in the early 2000s as part of a strategic response to persistent health system challenges.⁵ The purpose was to improve access to high-quality healthcare, with a particular focus on rural Māori and other underserved populations. The role is now seen as a partial solution to workforce shortages in primary care and as a means of strengthening continuity of care across the sector. NPs are expected to deliver culturally responsive, whānau-centred care while responding to the increasing complexity of population health needs.

Initial growth of the NP workforce was slow. Structural and regulatory barriers limited awareness, and the absence of formal training pathways constrained early implementation. However, legislative and policy changes have progressively expanded the NP scope of practice. The introduction of the Nurse Practitioner Training Programme has played a pivotal role in increasing the number of NPs by providing structured clinical and academic pathways to registration.^6,7

NPs practice across a wide range of settings, including primary care, aged residential care, rural health services and high-acuity environments such as emergency departments and neonatal intensive care units. They work collaboratively with interdisciplinary teams, whānau and communities to provide timely, person-centred and culturally responsive care. Their practice reflects a strong commitment to social justice and health equity, with a focus on reducing access barriers and supporting integrated models of care.⁴

Despite more than two decades of NP practice, there is little longitudinal evidence on workforce characteristics, the evolution of practice or the barriers and enablers shaping sustainability. Existing administrative datasets, such as those collected by the Nursing Council of New Zealand, provide demographic information but offer little insight into how NPs practice, the conditions that support or hinder their work and the wider impact on patients and whānau. Evaluation of outcomes also remains scarce.

To offer greater insight into NP practice, a series of national surveys was conducted between 2014 and 2022. This paper reports findings on NP workforce characteristics, clinical practice and systemic enablers and barriers across five survey rounds, providing the first longitudinal overview of the role in Aotearoa New Zealand.

Methods

Eligible respondents were registered NPs who were practicing in Aotearoa New Zealand. Recruitment for the survey was conducted via social media, email distribution and word of mouth. Key organisations, including Nurse Practitioners New Zealand (NPNZ), the College of Nurses Aotearoa (CoN), the New Zealand Nurses Organisation (NZNO) and directors of nurses, supported the dissemination of the survey, seeking to maximise the reach and participation.

Data were collected electronically via SurveyMonkey and surveys were conducted biennially  between 2014 to 2022. The timing for each survey varied but all were open for at least 8 weeks, during which fortnightly reminders were placed on social media platforms and emailed to key organisations, including NPNZ. Due to the snowball method of data collection, the number of eligible participants who the survey reached was unable to be determined.

The development of the survey content was led by the primary investigator (DW) in collaboration with the executive committee of NPNZ. Each survey collected quantitative and qualitative data through multiple-choice questions, Likert scale items and open-ended text responses. The content of the questions included basic demographics, area of practice, barriers to practice, and professional development. Prior to each survey being circulated, feedback was sought from executive members of NPNZ to ensure the questions were comprehensive and reflective of the profession’s priorities. NPs completed the survey with the awareness that completion of the survey gave consent.

The five standalone survey datasets were cleaned, with questions and response options compared for consistency across survey rounds. Duplicate responses were removed and all five surveys were amalgamated for clear comparison and analysis. Following this, retrospective ethical approval to use the cleaned data was been approved by Te Herenga Waka—Victoria University of Wellington, Human Ethics Committee, reference 2024/HE000107.

The single master dataset is supported by a comprehensive data dictionary describing variable definitions and coding. The dataset is securely stored at the CoN under research team oversight. De-identified data may be requested from the corresponding author, with access considered in accordance with the approved ethics protocols.

For the purposes of this study, respondents’ workplaces were categorised using standard definitions of healthcare settings in Aotearoa New Zealand. Primary healthcare was defined as the first point of contact with the health system and included health promotion, prevention, early diagnosis and treatment of common conditions and chronic disease management. Secondary healthcare was defined as specialist services usually provided following referral from primary care, typically delivered in hospitals or specialist clinics. Tertiary healthcare was defined as highly specialised services delivered in major centres, involving advanced technology and multidisciplinary teams.^8,9

A descriptive summary of quantitative responses, using counts and percentages, is provided for each survey round, and split into three sections. The first section reports the demographics of respondents, including the number of years since NP registration and geographic area of practice. The second section provides details of clinical practice, including the frequency of prescribing, laboratory testing and radiology investigations. The third section gives a description of the work environment, details whether respondents report working at the full extent of their education and training (top of scope), what activities are participated in to promote the NP role and the prevalence of succession planning. In 2020 and 2022, respondents were asked to report the one thing they would change about being a NP; themes were identified within the qualitative data and presented as counts and percentages of total responses.

The wording of some questions changed slightly between the survey rounds. However, the intent was the same. Some response categories from the original surveys were collapsed to aid clarity and consistency in reporting. For example, responses of yes, partially and not really were amalgamated and reported as partially. This approach was applied consistently across all survey rounds.

Results

Response rate

A total of 1,036 responses were collected between 2014 and 2022. After removal of 32 duplicates, 1,004 responses remained for analysis. Response rates ranged from 52% to 74% of registered NPs (Table 1). Most respondents were practicing clinically (>94% each year). Of the 40 who were not in clinical NP roles, the most common reasons were working as a clinical nurse specialist or in leadership/management roles, followed by a change in practice area, leave, retirement or research.

View Table 1–5, Figure 1.

Demographics

Across surveys, the proportion of respondents reporting <2 years since NP registration was similar in 2014 and 2022 (24% vs 22%), while those reporting ≥10 years rose from 0% to 15%, indicating a maturing NP workforce (Table 2). Respondents were located in all regions of Aotearoa New Zealand, with the Northern Region consistently having the largest proportion. Over time, the numbers of NPs increased in all regions.

Across surveys, most respondents reported employment with district health boards (47/85 [56%] in 2014 to 132/307 [45%] in 2022). Private practice ranged from 14/85 (16%) to 79/307 (26%), primary health organisations (PHOs) from 9/85 (11%) to 59/307 (19%), non-governmental organisations from 10/85 (12%) to 30/307 (10%) and self-employed from 8/85 (9%) to 34/307 (11%). Categories labelled “independent practice” were inconsistently defined and excluded from analysis. The proportion of respondents employed in universities ranged from 3/85 (4%) in 2014 to a peak of 22/257 (9%) in 2020, before decreasing to 16/307 (5%) in 2022.

Clinical practice

Between 2014 and 2022, daily or weekly prescribing became almost universal among respondents (98% in 2022). The proportion of daily or weekly laboratory investigations increased marginally, along with ordering of radiology investigations. Fewer respondents reported rarely or never prescribing or ordering investigations over time (Table 3).

Signing standing orders was reported by 110/257 (43%) in 2020 and 140/307 (46%) in 2022. Responsibility for signing official documentation also expanded: for example, signing death and cremation certificates rose from 45/200 (22%) in 2018 to 124/307 (40%) in 2022; Accident Compensation Corporation documentation went from 114/200 (57%) in 2018 to 210/307 (68%) in 2022; work and income documentation increased from 93/200 (46%) in 2018 to 172/307 (56%) in 2022; and enduring power of attorney applications rose from 40/257 (16%) in 2020 to 62/307 (20%) in 2022.

Change or extension in area of NP practice

As shown in Table 4, most respondents reported not changing or extending their area of practice. However, by 2022, nearly half (43%) reported either having changed/extended (31%) or planned to do so (12%).

There were changes over time in how respondents reported practicing at the top of scope of practice. While most respondents reported working at or near their full scope, the data suggest underutilisation remains an issue. Although the proportion answering absolutely increased from 20/85 (24%) in 2014 to 157/307 (51%) in 2022, nearly half of respondents still reported less than full alignment with their scope.     

Employer support for funding to maintain Nursing Council of New Zealand competencies varied by setting. Among primary care respondents, partial support was the most frequent arrangement but fell over time (20/34 59%) in 2014 to 79/186 (42%) in 2022, while full support increased (7/34 [21%] to 67/186 [36%]). In secondary care, full support rose substantially (14/47 [30%] to 110/141 [78%]), with a corresponding reduction in partial support (30/47 [64%] to 28/141 [20%]). While the absence of any support was uncommon in secondary care, it remained an issue for a small group in primary care.

Succession planning has been reported as being consistently limited since its inclusion in the 2016 survey. In 2016, 38/115 (33%) respondents reported that succession planning was in place, increasing to 113/257 (44%) in 2020 before declining to 117/307 (38%) in 2022. Overall, from 2016, 55% of respondents indicated that no succession planning was in place.

Of the 188 respondents indicating there was no succession planning for their role in 2022, 32 respondents (17%) indicated they were planning retirement in the next 2–5 years.

When asked in 2020 and 2022 what one thing they would change about being an NP, respondents most frequently identified issues related to recognition and systemic barriers. Across both survey years, 21% (119/564) cited recognition and 18% (99/564) reported systemic barriers as the main issues they would address. A common barrier to practice was reported to be Section 29 of the Medicines Act constraining NP prescribing for unapproved medicines, with 15% (39/257) of NPs in 2020 and 20% (60/307) in 2022 identifying Section 29 as a barrier leading to duplicated consultations and delays.

Professional development (76/564 [13%]) and pay (57/564 [10%]) were also commonly mentioned. Other less-frequent themes included workload and autonomy, the education pathway, isolation and scope of practice. Twenty-eight percent (157/564) of respondents provided no response to this question.

Discussion

Over the five surveys (2014 to 2022), NPs reported strong engagement in clinical practice, with more than 90% providing direct patient care. Prescribing medications was almost universal, and most ordered laboratory and radiology investigations. Many also contributed to the workforce with clinical teaching, mentoring and service development. At the same time, issues of sustainability were reported. The proportion of NPs working fully to scope increased over time. However, almost half reported not practicing at their full scope, suggesting the role being valued but not yet realising its full potential. Our findings highlight both the strength of the NP workforce and the systemic barriers that continue to limit the role’s contribution to health and social care in Aotearoa New Zealand.

Although the surveys were conducted between 2014 and 2022, the themes remain highly relevant given current workforce shortages. Underutilisation of NPs represents a significant loss of capacity when health and social care demand is rising. NPs are educated to deliver expert, whānau-centred care and manage complex health needs, yet legislative barriers continue to constrain their practice.¹⁰ Section 29 of the Medicines Act illustrates this inefficiency.¹¹ Originally intended as a mechanism for occasional use of unapproved medicines, in practice it encompasses many treatments that form part of routine care. While doctors can prescribe under Section 29, NPs cannot. Successive ministers of health have acknowledged the need for reform, and decades of effort from lobbying NPs has resulted in the first reading in Parliament for a change to the Medicines Act.¹² However, until the legislation is changed there remains avoidable patient care delays, bottlenecks and duplication of appointments, which reduce system capacity and compromise patient safety. Supporting NPs to practice at their full scope would provide an immediate, evidence-based means of improving access, strengthening service delivery and alleviating pressure on an already stretched workforce.

Employment diversification was evident across the survey period, with increasing numbers of NPs working in PHOs, private practice and self-employed roles. This expansion suggests improved access to care, mirroring international patterns of NP deployment into underserved areas. However, without succession planning and deliberate workforce strategies, these gains are fragile. Integration across macro, meso and micro levels is required to sustain access for many communities vulnerable to poor access and healthcare equity.

These findings sit against the backdrop of almost 25 years of NP practice in Aotearoa New Zealand.⁵ Despite this milestone, there is little longitudinal evidence on patient outcomes, cost effectiveness or equity impact. This evidence gap is striking—given the shift in healthcare delivery, where nurses and other professionals increasingly provide services once led by doctors—yet not surprising, as the care provided by NPs is often invisible in hospital and primary care datasets. This means that the NP contribution is difficult to quantify and measure. International evidence consistently shows that well-integrated NPs achieve equivalent or better outcomes at stable or reduced cost.¹³ Building an Aotearoa New Zealand evidence base that captures outcomes, equity and patient safety is essential.

Furthermore, the absence of a dedicated workforce dataset explains in part why evidence on NP contribution remains limited. While the Nursing Council collects limited workforce data,¹⁴ the Nurse Practitioner Workforce Survey (NPWORKS) has been established to continue to generate longitudinal, self-reported data, governed jointly by Māori and non-Māori leadership.¹⁵ The first round of data collection is complete, and findings are expected in 2026. This will provide the first opportunity to monitor equity and outcomes systematically. However, funding is currently restricted to a Health Research Council Activation Grant and support by the CoN. Without secure, long-term investment, this critical infrastructure risks being lost.¹⁵

Taken together, the surveys highlight that underutilisation is not a professional shortcoming but a policy limitation. Health New Zealand – Te Whatu Ora has acknowledged NPs in its workforce strategy and continues to invest in NP education.⁹ However, the absence of a nursing workforce strategy contributes to the lack of accountability for integration of the role, and for many the NP role remains unclear. International experience demonstrates that systematic NP integration improves access, safety and cost effectiveness.^13,16,17 Aotearoa New Zealand can achieve the same gains, but only if NPs are embedded as essential contributors to the health workforce rather than positioned as supplementary.

When the NP role was established in 2001, registration was tied to a defined area of practice (e.g., neonatology), with annual practicing certificates listing the specialty. Following a review (2014–2016), the Nursing Council implemented a regulatory change in April 2017, creating a single, flexible NP scope of practice.¹⁸ NPs are now registered simply as nurse practitioner, with their practice defined by education, competence, experience and employment context.² This shift aimed to reduce barriers, improve adaptability to service needs and simplify regulation while maintaining accountability through competence assessment, professional development and employer credentialling. Since the 2017 regulatory change, NPs have greater flexibility to move across areas of practice, but there is little formal reporting on how these shifts occur in practice. In this context, our survey data provide valuable insight into workforce mobility that is not otherwise captured.

These surveys relied on self-reported data, which may have introduced bias in how activities were described. More critically, there was no capture of ethnicity- or equity-related information. In Aotearoa New Zealand, where equity is a central policy goal, this omission is a substantial limitation. This is particularly important given that equity is central to improving health and social outcomes;^19,20 NPs are expected to practice in ways that actively advance equity, regardless of political winds. Recent evidence has reported Māori NPs as being fundamental in improving patient safety for Māori patients, whānau and communities, demonstrating the critical importance of increasing Māori NPs in the workforce.²¹ There is an unfortunate scarcity of Pacific NP workforce data. The findings from NPWORKS, funded through a Health Research Council Activation Grant, will collect ethnicity data, which will increase the visibility of Māori and Pacific representation and support equity-focussed workforce planning.²²

The NP role is delivering tangible benefits.^23–27 Respondents reported managing complex patients, leading service improvements, improving access and strengthening interprofessional teams. Yet outcomes-focussed research in Aotearoa New Zealand is scarce. Data on patient outcomes, cost effectiveness and equity impact remain limited. Embedding research capacity within NP roles, and supporting NP-led studies, is necessary to influence policy and optimise workforce use. Research must be core business, not an optional extra.

Conclusion

NPs are now a firmly established part of Aotearoa New Zealand’s health workforce, delivering advanced care, service innovation and workforce leadership. Yet systemic barriers continue to prevent the role from reaching its full potential. Legislative reform, sustainable workforce planning, equity-focussed deployment and investment in data and research are required to secure the NP role as a core part of a modern, high-performing health system. International evidence shows that when NPs are systematically integrated, health systems benefit through improved access, safety and sustainability. The opportunity now is for the Ministry of Health to recognise NPs as essential to workforce strategy and ensure that their contribution is embedded, equitable and enduring.