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Julie A. Fairman, PhD, RN, FAAN
​Overview 

Today, many Americans use Nurse Practitioners (NPs) for much of their health care needs and NPs are now fully accepted by both health care consumers and most other care providers as a critical component of a modern health care system. For more than fifty years, NPs have provided a vast amount of services in both acute, chronic and community settings, making their presence in the health care system essential. Furthermore, expectations are that NPs will become even more crucial to health care delivery as more Americans gain access to broader services through health care reform efforts. This essay discusses several of the major factors involved in the establishment of the nurse practitioner role identifying past and current critical issues revolving around this significant health care provider.


What is a Nurse Practitioner? 

NPs (also referred to as Advanced Practice Registered Nurses or APRNs) are one of the four roles that encompass advanced practice nursing: nurse mid-wife, nurse anesthetist, nurse practitioner, and clinical nurse specialist. All four roles require graduate degrees in order to qualify as a practitioner. In most states, NPs must be registered nurses, graduates from accredited graduate programs, and hold certification that reflects the specialized nature of the graduate program (e.g. primary care certification if graduating from a primary care nurse practitioner program).  In addition, as NPs become more commonplace in health care settings, the licensure, accreditation, and certification requirements continue to evolve in response to changing needs. In the United States, each state sets its own requirements for practice, and NPs must meet the particular state’s criteria in which they work. Because different practice requirements are confusing and in some cases can lead to inefficiencies in care, recent efforts on the part of nurse practitioner groups have been directed towards creating standards that are national in scope. For example, a new regulatory document finalized in 2008 and released by the National Organization of Nurse Practitioner Faculties, called the Consensus Model, set new national standards for core competencies, roles, and six population-based foci (individual/family health across the life span: adult-gerontology, pediatrics, neonatal, women’s health/gender, and psychiatric/mental health). Currently, states are in the process of revising practice acts, and schools of nursing are examining their APRN or NP programs to reflect the new model, which is expected to be nationally implemented by 2015 for new practitioners.[1]​​

The Evolution of the Nurse Practitioner Movement

A major factor that supported the development and evolution of the Nurse Practitioner role in the 1960s was lack of access to health services. The American public’s struggles to gain access to primary care and preventive services are certainly nothing new, and this need crosses socioeconomic lines. Although health reform efforts promise to bring over 30 million previously uninsured people into the health system, those currently without health care access are not the only ones who sometimes have difficulty finding quality services. For instance, insured Americans find they cannot get urgent care or primary care health services when needed. Nurse practitioners are situated to provide greater access to high quality, reasonable cost care if allowed by state regulations to practice to the fullest extent of their knowledge and skills.  

NPs are part of the constant change, however subtle, in how the public decides who has the authority to provide health care. Physicians traditionally were considered the normative providers of medical services by patients and the state. Indeed, it is the physicians’ perspective that guides much of what is understood about patients, health policies, and institutions. However, as access to physicians has dwindled, it has been midwives, nurse practitioners, and physician assistants that have emerged as primary care providers within the mainstream health care system. For example, independent nurses and lay providers were and are the norm in many rural clinics, but, until recently, not in urban academic institutions or in places with many physicians. One of the only consistencies across types of practices is the satisfaction of patients with nurse practitioner services which has always been and remains quite high.

Over the years, the role of the nurse has expanded in response to advances in scientific knowledge and changes in health care needs. As a consequence of the broadening of the role of the nurse within health care, the need for additional formal education and training became more commonplace. Such was the case with the development of the advanced practice nurses.[2] urmc 2pp.jpg

Many contextual factors supported the development and growth of the nurse practitioner clinical role. For instance, by the 1960s, American medicine had become highly specialized with growing numbers of medical students moving into more economically and socially lucrative specialty practices. The general practitioner, long a staple for primary care in suburban and rural communities, was slowly disappearing from the health care landscape. At the same time, the demographics of the American public were changing and marked by an aging population as well as a growing number of chronically ill adults and children. Medical education, situated primarily in academic acute care hospitals, failed to reconceptualize​ medical education and residency offerings in a way that could offset the specialization trend. Even the development of family practice specialties and medical schools that focused on community-based medicine could not counterbalance a trend that was supported by higher payment and status for specialists. At the same time, nurses were looking for ways to apply the skills and knowledge they already possessed through experience or their own education programs. Nursing’s growth occurred organically in clinics, as well as visiting nurse associations and private offices, where daily interactions with physician colleagues facilitated a vast amount of new and advanced knowledge and skills.  Over time, it became clear that many in the nursing profession were particularly eager to formalize further and expand their clinical practice responsibilities. In pockets across the country, in poor rural and urban areas, individual nurses and physicians began to work together in response to the shortage of primary care physicians, growing numbers of people with health insurance, and population changes to improve patient care. Soon, formal education and training programs followed at the University of Colorado, spearheaded by nurse Loretta Ford and pediatrician Henry Silver; at the University of Kansas, with Barbara Resnick and Charles Lewis and at the University of Rochester, with nurses Joan Lynaugh and Harriet Kitzman and physicians Barbara Bates and Evan Charney—the latter funded by the Division of Nursing of the U.S. Public Health Service.

As reports of these experiments were published, the number of programs for nurse practitioners grew rapidly, supported in part by federal funding through the Nurse Training Acts in the next two decades, and through the largesse of private foundations which supported new types of service models and training programs. Nursing education responded to both the opportunity for funding and to the numbers of nurses demanding access to nurse practitioner programs. The number of programs increased, and so did specialization. Early on, pediatrics and gerontology programs were the most common programs, but by the 1990s, NPs specialized in oncology, neonatology, and cardiology. Certification programs that focused on training the practitioner to work in a specific field followed specialization, and were sometimes tied to state licensure requirements.

By the early 1980s, nurse practitioner education moved into graduate programs and by 1981, most states required graduate degrees for nurse practitioner practice.  In response to the scientific knowledge explosion, programs kept adding new courses, expanding their length and their credit loads. By the turn of the 21st century, most nurse practitioner programs credit hours far exceeded those in other graduate programs. At the same time there was a growing movement towards practice doctorates in other professions and this led educators to think about new types of nurse practitioner programs. By 2005, the Doctorate of Nursing Practice (DNP) became the newest level of practitioner training, giving credit for the breadth of content in the nurse practitioner programs.

Conclusion

Today, NPs have proven their effectiveness in delivering high quality, lower cost heath care services. Health care consumers, recognizing the value of a good service flock to NPs for numerous health care needs. While it remains unclear at this time how health care reform effort will change health care delivery, it is abundantly clear that nurse practitioners will be a vital component of future American health care services. 

References 

[1] APRN Consensus Work Group & the National Council of State Boards of Nursing APRN Advisory Committee (May, 2008). Consensus Model for APRN Regulation:

Licensure, Accreditation, Certification & Educationhttps://www.ncsbn.org/APRNJoint_Dia_report_May_08.pdf  accessed June 30, 2010.

 

[2] Julie Fairman, Making Room in the Clinic: Nurse Practitioners and the Evolution of Modern Health Care, New Brunswick, NJ: Rutgers University Press, 2008.

 

  



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