Abstract: The nurse practitioner (NP) role is marking its 50th anniversary in 2015. This article explores the history and future of the role by talking with NP thought leaders.
By C yn thia S aver, M S , RN
n her TEDx talk, “Rising from the Mud,” Debra Barksdale, PhD, FNP-BC, ANP-BC, CNE, FAANP, FAAN, describes the African Sankofa bird.1As the bird flies forward, holding an egg in its m outh, it looks back. “San” means “reach,” “ko” means “to go,” and “fa” means to “look, seek, and take”. The image com municates the idea to “Reach back and get it” o r “Go back and get w hat you have forgotten.”
bird teaches us to take what you need from the past and give back to the next generation.” As the NP profession marks its 50th anniversary, it seems a good tim e to reach back to the past and rem em ber lessons learned as the role has evolved. “Some people forget the fights that had to occur so NPs could be recognized as legitim ate, necessary, an d viable healthcare providers,” Dr. Barksdale says. “If we don’t under stand our history, we’re likely to repeat some of the failures.”
“It symbolizes the gems of knowledge in the past,” says Dr. Barksdale, professor and director o f the doctor of nurs-
■
ing practice program at Chapel Hill School o f N ursing, University o f N orth Carolina. Dr. Barksdale, a nurse prac titioner (NP) since 1988 and form er president o f the Na tional Organization of Nurse Practitioner Faculties, says “the
A tu rb u le n t s ta rt
“It was a turbulent, uncertain time, a very opportunistic time to bring about change,” says Loretta Ford, EdD, PNP, FAAN, o f 1965, the year she and H enry Silver, MD, a pediatrician, started the first NP program at the University o f Colorado.
K e yw o rd s: history, n u rse p ra c titio n e r
www.tnpj.com
The Nurse Practitioner
•
May 2015
15
50 years o f NP excellence
Dr. Ford is currently dean and professor emerita for the School of Nursing at the University of Rochester. “There were social, political, and organizational forces.” The Vietnam War was raging, civil rights issues filled the airwaves, and President Lyndon Johnson had declared war on poverty. Many physicians were choosing specialty prac tice, leaving a dearth of general practitioners, and nursing was beginning to move away from a focus on tasks. The American Nurses Association’s First Position on Education for Nursing was published at the end of 1965.’ The position paper, which defined technical (2 years) and professional (4 years) preparation divided the nursing community. “There was a great deal of rhetoric about what nursing should be in the future,” Dr. Ford says. N u r s e s ' p e r c e p tio n s o f N P s
"M y experience was one of the most traumatic that I have had in my life," Dr. Ford says about the reaction from nurses when she and Dr. Silver started the NP role. She experienced bullying, including "a lot of backstabbing, a lot of shunning, and a lot of silence" from nurse educators who were her colleagues. "I had not been so unpopular in my life." Ultimately, the group worked with a community activist who discussed change theory. "We all began to look at things a little differently," she says. "I began to understand how threatened people were.They could see their work changing." Educators also worried that physicians would gain control of nursing programs. Dr. Ford says it was important to reassure people that NPs were not physician assistants, another new role in its early stages of development. "The hard part was our colleagues who weren't supportive," says JanTowers, PhD, NP-C, CRNP, FAANP, FAAN, a founder of and consultant for the American Association of Nurse Practitioners (AANP) who has been an NP since the 1970s. Nurses had just been recognized as not being handmaidens to physicians and, "here we were doing physician things." After this rocky start, nurses have come to embrace NPs. "RNs and LPNs now look at us as collaborators, consultants, and nursing experts who help them decipher some of the difficulties in the healthcare arena and how challenging it can be to take care of increasingly ill patients, particularly in the outpatient setting," says Margaret Fitzgerald, DNP, FNP-BC, NP-C, FAANP, CSR FAAN, DCC, president of Fitzgerald Health Education Associates, Inc., and an FNP at Greater Lawrence (MA) Family Health Center. She notes that the regard goes both ways, "I greatly respect my RN colleagues where I practice. I do not know how I could possibly do my job without them." Charity McClure, MSN, FNP-C, who works locum tenens in federally qualified health centers in Connecti cut, adds, "I have a good relationship with the nurses I work with. I use them as a resource and I want them to see me as a resource. All nurses, not just NPs, should work at the top of their license."
16 The Nurse Practitioner • Vol. 40, No. 5
Perhaps most significantly, Medicare and Medicaid pro grams started providing healthcare coverage to low-income women, children, older adults, and individuals with disabilities, which increased the demand for primary care services.3Many have credited the increased demand for care coupled with a physician shortage as the catalysts for creat ing the NP role, but Dr. Ford disagrees. “We started this for the health needs of people, not because of a shortage of physicians,” Dr. Ford says. “I’m not the least bit interested in filling the physician role.” Dr. Silver and Dr. Ford partnered to develop the NP role. “My strength was public health nursing and his was child care and development,” Dr. Ford says. “We brought different strengths to the partnership.” Dr. Ford, who by then had a decade of public health experience behind her, worked with Dr. Silver to study what services public health nurses were providing, what families needed, and what a nurse could do. “We developed a model and decided to test it and then in tegrate it into nursing programs,” she says. The pair took a proactive approach to communicating their actions. “We decided on transparency in describing what we were doing,” Dr. Ford says. She and Dr. Silver met with the state boards of nursing and medicine to let them know what services the NPs were providing. In addition to publications, Dr. Ford and Dr. Silver responded to many requests to speak at conferences, even launching one of their own. “We tried to be open with what we were doing. Every one wanted to learn about the program,” Dr. Ford says. Unfortunately, these initial efforts were met with resis tance, which puzzled Dr. Ford (see Nurses’perceptions of NPs). “I didn’t see this as a great change,” she says. “I just thought it was nurses doing what they were already doing clandestinely in the field. We were pushing the boundaries of knowledge, evaluating, and reporting.” The resistance, primarily from nurse educators, “was a big surprise to me,” Dr. Ford says. Fortunately, her students’ reactions bolstered her confidence. “There was an enthusiasm for nursing and confidence once they got over the hump of taking on more responsibilities,” she says. “I was sure it was the right thing to do to help the patients we serve.” The students, experi enced public health nurses with BSNs, joined Dr. Ford in the endeavor. ■
F orgin g a h e a d
Perhaps not surprisingly, NPs found a home caring for underserved patients. Many NPs worked in rural areas , which, in a pre-Internet era, meant they had to rely solely on their expertise. “The only GP (general practitioner) might by 60 miles away and the road to get there was closed in the winter,” says Michael Carter, DNSc, DNP, FAAN, FNP/GNPBC, University Distinguished Professor in the department www.tnpj.com
50 years o f NP excellence
of advanced practice and doctoral studies at the University of Tennessee College o f Nursing. Dr. Carter, an NP since 1973, is also a family NP for the Christian Health Center in Heber Springs, Arkansas. Because of the focus on the underserved, Dr. Carter says the initial push back from physicians was m uted. T hat changed as NPs ventured into caring for patients in higher socioeconomic classes and started to receive reimbursement. “In the early 1970s, there were no states that enabled NP practice,” he recalls. Because state nurse practice acts said nurses could not diagnose or prescribe, the early NPs were technically in violation of the acts. “I would get calls from the Board of Pharmacy or Board of Medicine asking if we were practicing medicine,” says Dr. Carter, who worked at a prim ary care clinic in Marche, Arkansas. “We literally had to push and push to practice as we had been educated.” It is easy to forget those early battles. “Sometimes they (NPs today) don’t realize what mavericks we were back then,” says Jan Towers, PhD, NP-C, CRNP, FAANP, FAAN, a found er o f and consultant for the American Association of Nurse Practitioners (AANP) who has been an NP since the 1970s. Dr. Towers recalls her days as a com m unity health nurse when she would see a child crying and pulling at his or her ear. “You knew the child had otitis media but you couldn’t look in the ear and you couldn’t get anyone to see the child because the family was on Medicaid,” she says, adding that she remembers thinking, “We should be able to care for these people. We started sticking our necks out, pushing to get those doors open.” (See Patients’ perceptions o f NPs.) The m otivation to care for underserved patients re m ains strong today. “O ne o f the things I saw pretty quick ly in the hospital setting was the dearth o f access to care that many people experience,” says Charity McClure, MSN, FNP-C, w ho, after 4 years as a nurse, becam e an NP in 2012. “I saw a num ber of patients who had poor outcom es from their chronic diseases because they didn’t have access to prim ary care. I realized I w anted to w ork at the other end o f the spectrum to prevent patients from getting to that point.” A g ro w in g fo rc e
M argaret Fitzgerald, DNP, FNP-BC, NP-C, FAANP, CSP, FAAN, DCC, president o f Fitzgerald Health Education As sociates, Inc., and a family NP at Greater Lawrence (MA) Family Health Center, has witnessed a trem endous increase in the NP profession since she started in 1986. “There were approxim ately 25,000 in the entire country. This is a very big country to spread 25,000 of any profession around,” she says. “We were mostly, as we are now, taking care of people who are disenfranchised, who are poorer, who are not on the healthcare radar screen in general, so we could practice www.tnpj.com
Patients' perceptions of NPs Patients m ig h t n o t have kn o w n w h a t an NP w as, b u t fro m th e sta rt, th e y liked w h a t th e y did. "P a tie n ts th o u g h t it w as th e g re a te st th in g since sliced bread," says Dr. Ford o f p a tie n ts ' in itia l re action. "I used feedback fro m p a tie n ts to he lp p ro m o te th e role." "S ta rtin g o u t in th e 1970s, p a tie n ts d id n 't kn o w a b o u t NPs," Dr. Carter says. "B u t eve ryo n e had heard o f a nurse." "P atients w e re so g ra te fu l th a t so m e o n e cared and listened," he adds. " It w as th e nurse part, n o t th e NP part, th a t th e y tie d into." He encourages NPs to get p a tie n ts to speak o u t a b o u t th e ir experiences w ith NPs. "O ften pa tie n ts say th e y go to a doctor, b u t th e y re a lly see an NP and th e y like th a t. We need to have th e m say that." "W h e n I firs t becam e an NP o ve r 30 years ago, it w as like, 'You're a w h a t? "' Dr. Fitzgerald says. "T h e re w as ve ry little p u b lic re co g n itio n as to w h o w e are and w h a t w e do. N o w I have fo u n d , e sp e cially o ve r th e last 10 years, th a t fa r m o re o ften w h e n I in tro d u c e m y s e lf to a m e m b e r o f th e general pu b lic, I g e t th e fo llo w in g reactions: 'O h, m y w ife sees an NP, m y co usin is in school to becom e an NP, I see an NP.' I d o n 't have to educate th e m on w h a t the role is.That's re a lly e xcitin g to see." Jam esetta N e w la n d , PhD, APRN, FNP-BC, e d ito r-in c h ie f o f The Nurse Practitioner, adds th a t pa tie n ts tru s t NPs. "T h e y re a lly do like seeing a nurse p ra c titio n e r," she says. A lth o u g h so m e patients still call her a "d o c to r" because th e y believe th e y have s im ila r skills, Dr. N ew land says, "I try to stress th a t d o cto rs and w e are co m p le m e n tary. W e w o rk to g e th e r."
as invisible entities. Part of that was good; there wasn’t as much scrutiny of the practice, but as the profession matured, we needed more scrutiny to show what our outcomes were.” This scrutiny, in the form of research studies, dem on strated the value and effectiveness o f NPs. M any o f the studies were published in physician journals, such as the landm ark 2000 study by M undinger and colleagues, which appeared in The Journal o f the American Medical Associa tion.4 By the 2000s, “We started having some really good studies saying NPs are as good as or better than physicians,” Dr. Carter says. W ith the evidence and num bers, NPs surged to the forefront. “Now that we are pushing 200,000, we can no longer be ignored,” Dr. Fitzgerald says. “We are finally making our mark, and part o f it is due to our strength in num bers.” She notes that some believe the m arket may be reaching saturation but disagrees with the premise. “I feel the higher num bers have brought us to our rightful place in contem porary healthcare where we are that disruption innovation, we are changing the status quo, and we are making a nam e for ourselves.” As it has grown, the NP role has expanded from p ri m ary care into many specialty areas, including acute care. A ccording to AANP, however, 89% o f NPs are prepared The Nurse Practitioner • May 2015
17
50 years of NP excellence
in primary care, and more than 75% of actively practicing NPs provide primary care.5Several key issues have thread ed their way through the history of the NP role, including full practice authority, payment, education, and licensure. ■ Full practice authority
The past few years have shown a rise in the number of states removing restrictions on NP practice by eliminating the need for physician collaboration or supervision. Susanne Phillips, MSN, FNP-BC, a clinical professor at the Univer sity of California in Irvine who has been an NP since 1996, credits the recent surge to passage of the Affordable Care Act. “It’s really ramped up in terms of states moving towards full practice authority,” she says, adding, “The amount of legislation that will be passed in the next 5 to 7 years is going to be impressive.” As of 2014, 20 states allow full practice authority.5 Phillips credits NPs in all states with working to enact change. “There is a tremendous amount of work that goes on in every state that aren’t the big ticket items,” she says. Even minor changes such as insurance empanelment and reimbursement help advance the NP role. Phillips has seen NPs become much more involved in legislative initiatives over the past 20 years. “More NPs attend lobbyist days, visit their legislative representatives, and support organiza tions advocating for NPs,” she says. “We are truly autonom ous healthcare providers,” Dr. Fitzgerald says of the NP role, but adds there is still work to be done. “More than two-thirds of all NPs con tinue to practice in states where we need to have a physician collaborator or supervisor to do a role that we have been educated to do autonomously.” Autonomy does not mean independence, according to Dr. Fitzgerald. “There isn’t a single one of us, whether we’re NPs, PAs, or MDs, who practice independently. We are in terdependent on one another, we rely on one another for second opinions and clinical consults.”
Payment
A watershed moment in reimbursement came with passage of The Balanced Budget Act of 1997, which granted NPs provider status and the ability to bill Medicare directly for services.7“It was a turning point and made us able to move forward,” Dr. Towers says. Dr. Carter also credits patients with pushing their insurers to reimburse NPs. However, Dr. Towers adds that Medicare reimbursement also prompted physicians to challenge NPs more. “They became more hardball,” she says, noting that in the early years of the role, many physicians supported NPs. “People were willing to help us and didn’t see us as a turf issue.” NPs still struggle with payment issues. “Even now, there are regulatory rules that do not include NPs,” says Jamesetta Newland, PhD, APRN, FNP-BC, editor-in-chief of The Nurse Practitioner. Dr. Newland, who launched her NP career in 1986, adds that even when insurers reimburse NPs, they may do so at a lower rate than physicians. NPs have not negotiated rates as well as their physician colleagues, according to Dr. Newland. “NPs should seek expert guidance when negotiating rates with an insurer with a goal of 100% reimbursement,” she says. Education
NP education has evolved from a certificate to master’s level to, most recently, doctoral preparation. Dr. Carter says the 1980s saw NP programs move to the master’s level. Part of the stimulus was enrollment in master’s programs was flagging at the time. “We saw a rapid proliferation of mas ter’s programs, sometimes without adequate faculty,” he says. “Almost every school created an NP program .” Ultimately, it became clear that the 30 credits typically associated with a master’s program weren’t enough to pre pare the NP for their evolving role. “Programs kept getting longer and longer,” Dr. Carter says. “Some of us started saying we have to move to the doctorate— not the PhD, but a clinical doctorate.”
Key even ts in NP h is to ry 4 7 1 1 ' 13 Dr. Loretta Ford and Dr. Henry Silver establish the first NP pro gra m at the U n ive rsity o f Colorado.
National Association of Pediatric Nurse Practitioners established.
Idaho is the first state to endorse NPs' scope of practice to include diagnosis and treatment.
18 The Nurse Practitioner • Vol. 40, No. 5
First issue of
The Nurse Practitioner journal is published.
American Nurses Association develops the Council of Primary Care Nurse Practitioners.
The American Academy of Nurse Practitioners is established.
The National Organization of Nurse Practitioner Faculties holds its first organizational meeting in Albuquerque, New Mexico.
"Nurse Practitioners, Physician Assistants and Certified Nurse Midwives: A Policy Analysis" released.
www.tnpj.com
50 years o f NP excellence
Dr. Barksdale adds that the DNP m ovem ent was par tially prom pted by the realization that NPs needed more
Dr. Barksdale says educators face challenges in teaching NP students. “We try to teach too much specific information
education in finance, healthcare systems, and larger health care issues, topics that she says used to be included in some master’s programs. “Somewhere along the way, we lost some of th at content that we now realize is essential.”
that no one can keep up with because it changes so quickly. It’s difficult to prepare students for a world we can’t imagine so our default is to prepare them the way we have always prepared them.”
Dr. Barksdale says there are pros and cons to the DNP.
But technology and p atien t d em ands are forcing a change. “We’re at a point that robots are diagnosing, so we are going to need m ore education in hum ans relating to hum ans,” Dr. Barksdale says. “NPs m ight not just be p ri mary care providers, they may be life coaches.”
O ne rationale for requiring a DNP is to have parity with other professionals, b u t she says, “I d on’t think having a degree gives you parity. It’s how you conduct yourself and how you are able to show your worth and influence change.” She is also not convinced that the DNP will lead to better com pensation. Despite these concerns, Dr. Barksdale says, “I believe if done properly, there is incredible potential for DNP-prepared NPs.” She calls for m ore consistency in DNP program s and adds that the bottom line will be the impact that DN P-prepared NPs have on the healthcare system. “If you aren’t making an impact, it doesn’t make sense.” In the future, Dr. Fitzgerald envisions the DNP being the requirem ent for entry into practice for NPs. “We should anticipate that our profession will go more and more to doc toral level study as the entry into practice.” Dr. Newland agrees that the profession is moving to the DNP as entry to practice and adds that DNP programs need to be standardized. “The DNP program needs to be substantive and con crete and prepare students for practice as NPs,” says Mc Clure. M cClure’s concern is that doctorate program s will n o t offer enough clinical experiences for students. She noted that some of today’s future NPs are enrolling in directentry programs, so they have limited to no experience work ing as a nurse. McClure completed a residency to help ease the transi tion from school to practice, but Dr. Barksdale cautions that legislatively requiring such program s for all NPs “disadvan tages us.” These programs may allow those outside the pro fession to gain control over the role, which will reduce the num ber of NPs that can be prepared.
Mundinger publishes "Advanced practice nursing — Good medicine for physicians" in The New England Journal o f Medicine.
Mundinger and colleagues publish their primary care outcomes study in JAMA.
r
-1994
-1992
AANP works with associations to develop an international role of NPs.
www.tnpj.com
2000
L 1997 Balanced Budget Act grants NP provider status and authorizes them to bill Medicare directly.
T hat m eans educators “will have to w ork h arder to help students learn how to acquire, interpret, and apply inform ation instead of just pouring inform ation from our heads into theirs,” Dr. Barksdale says. Educators will also need to becom e savvier in evidence-based ed u catio n . “W hether students like som ething is different than w heth er it helps them to learn,” she notes, saying that some re search shows e-books are associated with more distraction and lower retention, for example. Finally, the role of simulation in replacing clinical hours in NP education needs to be studied. “Clinical sites are becoming more difficult to obtain,” Dr. Barksdale says. “But I hope we d o n ’t get to the po in t th at we have too many clinical hours substituted with simulation. That would give more am m unition for medicine to say NPs aren’t prepared to care for real patients.” ■ Licensure
In 2002, the National Council o f State Boards of Nursing delegate assembly approved the APRN Licensure Compact.8 The compact is designed to create consistency in legislation related to NP practice and allow for mobility from state to state. “It makes no sense for me to need to practice with physician collaboration in Massachusetts, yet I could walk out the door to New Hampshire and practice autonomously,” Dr. Fitzgerald says.
Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education is published.
The American Academy and the American College of Nurse Practitioners form the American Association of Nurse Practitioners.
2008
2013
2006
2010
NPs have obtained some level of prescriptive privileges in all states and the District of Columbia.
The Institute of Medicine releases The Future of Nursing: Leading Change, Advancing Health.
-2015
NPs celebrate 50 years of practice.
The Nurse Practitioner • May 2015
19
50 years of NP excellence
Resistance to m ultistate licensure remains. Phillips speculates that part of the resistance is the potential loss of revenue from license fees, which could hinder the abil ity of boards of nursing to investigate possible practice infractions. Practical considerations stand in the way as well. “If a nurse is licensed in one state and commits an action that requires discipline in another state, who bears responsibility for that?” she says. Challenges for the future
NPs will continue to face challenges as they enter the next half-century of the role. “The challenge is to not let the momentum slow down,” Dr. Fitzgerald says. “We are on a roll. We need to be poised to move forward to continue the battle for autonomy.” She adds that, “It will be a tough, long fight to update the practice act so that state to state we are autonomous healthcare providers.” Dr. Carter also sees full practice authority as an ongoing challenge. “NPs still can’t fully exercise their abilities (in some states) and that’s criminal,” he says. Conflicts can arise if NPs are more experienced than their collaborating physi cians. Dr. Carter also adds that patients don’t expect practice to vary by state, so why should NPs? An aging population has resulted in more people with chronic health problems. “We’re all seeing patients who are sicker, more complex, who require a very high level of skill in order to properly take care of. We’re all doing this at a time when we’re expected to be faster, more comprehensive, and be able to address myriad health problems in a very short
Growth opportunities The NP role is one of the fastest growing roles in the United States as new opportunities open up. According to an article in Kiplinger, the 10-year projected growth for NPs is 22%.9 NPs will see growing opportunities, particularly in the area of convenient care clinics, according to Dr. Carter. He says that NPs are ideally suited for these clinics "because we know that an illness can only be understood in the context of the patient living with it." For instance, a patient with symptoms of a cold may also have diabetes that needs to be considered when deciding on treatment. Another growth opportunity is long-term care facilities. "It's a travesty that NPs can't be medical directors of nursing homes," Dr. Carter says. "A few studies have found that patients do better with an NP in charge." NPs are even making house calls, as patients demand great access and are willing to pay for it. Heidi Johnson, a pediatric nurse practitioner, charges $80 per visit and does not accept insurance.™ One family who used Johnson's services says her fee is comparable to their regular pediatrician (and they would need to go into the office) and to a local urgent care center. "If we can deliver prescrip tions, why not deliver an NP to you?" Dr. Carter says.
20 The Nurse Practitioner • Vol. 40, No. 5
period of time,” Dr. Fitzgerald says, adding that the situation poses the question, “How can we do this job faithfully under the current pressures of contemporary healthcare?” Dr. Newland agrees that patients have become more complex and says NPs are functioning as providers and case managers. “In the past, a lot of these patients would have immediately been shifted to a physician, but now NPs are managing them,” she says. NPs are coordinating specialty visits with patients returning to them for primary care. “Even NPs in specialties are managing more complex patients.” The concept of a health home is likely to be another battleground, Dr. Newland says. Physicians are becoming the leaders of these homes, but she says, “An NP who has the education, training, and experience—particularly the admin istrative experience—should be able to lead a medical home not only with poor and marginalized patient populations but also with the well-educated and well-insured.” Despite NPs’ skills, she says, “That’s going to be a battle. Wherever there’s money to be made, establishment wants to push us aside.” Phillips says, “The biggest challenge remains the op position from organized medicine.” The Robert Woods Johnson Foundation and the Future of Nursing Campaign are leading efforts to garner support from consumer groups for full practice authority for NPs. “The push by organized medicine to prevent passage of legislation granting full practice authority is not evidence based, it’s about protect ing turn and financial efforts, not about protecting patients,” Phillips says, citing 40 years of research about the effective ness of the NP role. “There is no longer the debate as to whether NPs can do the job. The research is there.” Perhaps the most important challenge is, as Dr. Newland says, “keeping the nurse part in NP, which distinguishes us from physicians.” “We take a holistic approach,” Dr. Newland says. “When we see patients, we really listen to what is going on in their lives and incorporate that information into a plan of care.” “The NP role has been very much more medicalized compared to the early models,” Dr. Ford says, noting that healthcare delivery, reimbursement, and outcomes are all predicated on a medical model. “If you’re not careful, you’ll lose the nurse,” she cautions. She is heartened by the Affordable Care Act’s focus on prevention and sees treatment as a conduit to prevention. “When patients are tending to treatments, it’s time to introduce ideas of prevention, promotion, and protection,” Dr. Ford says. “You have to bring in the nursing focus.” Dr. Ford adds that primary care, as it is currently prac ticed, “is a dying system. It’s not fulfilling the needs of peo ple and it’s oriented to symptoms,” she says. “It’s ridiculous that you have to have a symptom to get into primary care.” Instead, there should be a focus on primary health services. www.tnpj.com
50 years o f N P excellence
In t h e i r o w n v o ic e : N P s l o o k d o w n t h e r o a d
Here are how some of the NPs interviewed responded when asked about their hope for the role 5 to 10 years down the road: "I would like to see more NPs as leaders in innovative delivery systems and involved in community health organizations and more sustainable nurse-managed centers." — Dr. Jamesetta Newland "All NPs have full authority in all states and we continue to work with all healthcare professionals. One profession (such as medicine) doesn't have supervisory rights over another." — Susanne Phillips "The role of all healthcare providers is going to change in the relatively near future because there is so much technology that allows individuals to assess health information without having a healthcare provider present. Our role is going to be bringing that human touch; to help people process that information." — Dr. Debra Barksdale
omy in different states and the struggle for NPs to function to the full level of their skills. That battle is still being fought. I see the challenge for other NPs and me is to get involved in the fight, especially as healthcare needs increase with the aging population. I hope we can position ourselves well, be vocal, and expand our ability to practice as autonomously and collaboratively as possible.” (See In their own voice: NPs look down the mad.) At the same time, these NPs haven’t forgotten their roots. When asked what she would say to Dr. Ford, McClure says, “1 would probably thank her for her contributions to the field and tell her that I feel that what I do is really a privilege. I feel for the first time in my life I am doing the job I was meant to do. I really love it.” “We all have to roll up our sleeves,” Dr. Towers says. “The more we support each other and keep our eye on the goal, the better chance we have for success.” Dr. Towers can still see the apple tree in her back yard, where NPs gathered to form local, state, and national organizations. “It’s still there, ready for more planning.” © REFERENCES
"We've got to get rid of agreements that tie us in any way to anyone else. We need full scope of practice in every state." — Dr. Michael Carter "I would see NPs functioning at their full scope with no laws to limit that, no tethers. We would become the primary care provider in the United States." — Dr. Jan Towers "They'll be counselors and advisors and involved in inventing things. We are always tinkering to get things better for patients, but then we give our ideas away. It's unfathomable as to how many opportunities there will be." — Dr. Loretta Ford
1. Barksdale D. Rising from the mud. TEDxUNC. 2014. https://www.youtube. com/watch?v=3HjIDEStfyI. 2. Donley R, Flaherty MJ. Revisiting the American Nurses Association’s First Position on Education for Nursing: a comparative analysis of the first and second position statements on the education of nurses. Online J Issues Nitrs. 2008; 13(2). http://www.nursingworld.org/MainMenuCategories/ ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/vol 132008/ No2May08/ArticlePreviousTopic/EntryIntoPracticeUpdate.aspx. 3. O’Brien JM. How nurse practitioners obtained provider status: lessons for pharmacists. Am I Health Syst Pharm. 2003;60(22):2301-2307. 4. Mundinger MO, Kane RL, Lenz ER, et al. Primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trial. JAMA. 2000;283(l):59-68. 5. American Association of Nurse Practitioners. Nurse practitioners in primary care, http://www.aanp.org/images/documents/publications/ primarycare.pdf. 6. Phillips SJ. 27th annual legislative update. The Nurse Practitioner. 2014;40(1): 16-42. 7. Balanced Budget Act of 1997. P.L. 105-33. www.gpo.gov/fdsys/pkg/PLAW105publ33/html/PLAW-105publ33.htm.
With challenges come growth opportunities (see Growth opportunities). For instance, Dr. Ford says there is going to be a “tremendous shift” in healthcare, with responsibility in the hands of the patient. “The patient will be the first one to receive the information (not the provider),” she says. “He will first go to his computer, then other people who have the conditions, then reach out to a provider.” Dr. Ford believes NPs are ideally positioned to be the “first responders” when those patients decide to reach out. T h e n e x t g e n e r a t io n
Fortunately, the new generation of NPs is ready to take on the task of meeting the future needs of patients and advancing the NP role. “I think a lot about how much further there is to go,” McClure says. “I have seen the different levels of auton www.tnpj.com
8. Nurse Licensure Compact Administrators. APRN (advanced practice nurse) licensure compact. https://www.ncsbn.org/APRN_Compact_hx_timeline_ April_2012_%282%29.pdf. 9. 10 best jobs of the future. Kiplinger. 2014. http://rn.kiplinger.com/slideshow/ business/T012-S001-now-hiring-10-of-today-s-hottest-jobs/index. html?page=2. 10. Lankford K. Pay cash for your health care. Kiplinger’s Personal Finance. 2015. http://rn.kiplinger.com/article/insurance/T027-C000-S002-pay-cashfor-your-health-care.html. 11. American Association of Nurse Practitioners. Historical timeline, http:// www.aanp.org/all-about-nps/historical-timeline. 12. National Council ol State Boards of Nursing. Consensus model for APRN regulation: Licensure, accreditation, certification 8c education. July 7, 2008. 13. National Organization of Nurse Practitioner Faculties. History and goals. http://www.nonpf.org/?page= 1. Cynthia Saver is President, CLS Development, Inc., Columbia, Md. The author has disclosed that she has no financial relationships related to this article. DO I-10.1097/01 .NPR.0000463786.21636.47
The Nurse Practitioner • May 2015
21
Copyright of Nurse Practitioner is the property of Springhouse Corporation and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
By C yn thia S aver, M S , RN
n her TEDx talk, “Rising from the Mud,” Debra Barksdale, PhD, FNP-BC, ANP-BC, CNE, FAANP, FAAN, describes the African Sankofa bird.1As the bird flies forward, holding an egg in its m outh, it looks back. “San” means “reach,” “ko” means “to go,” and “fa” means to “look, seek, and take”. The image com municates the idea to “Reach back and get it” o r “Go back and get w hat you have forgotten.”
bird teaches us to take what you need from the past and give back to the next generation.” As the NP profession marks its 50th anniversary, it seems a good tim e to reach back to the past and rem em ber lessons learned as the role has evolved. “Some people forget the fights that had to occur so NPs could be recognized as legitim ate, necessary, an d viable healthcare providers,” Dr. Barksdale says. “If we don’t under stand our history, we’re likely to repeat some of the failures.”
“It symbolizes the gems of knowledge in the past,” says Dr. Barksdale, professor and director o f the doctor of nurs-
■
ing practice program at Chapel Hill School o f N ursing, University o f N orth Carolina. Dr. Barksdale, a nurse prac titioner (NP) since 1988 and form er president o f the Na tional Organization of Nurse Practitioner Faculties, says “the
A tu rb u le n t s ta rt
“It was a turbulent, uncertain time, a very opportunistic time to bring about change,” says Loretta Ford, EdD, PNP, FAAN, o f 1965, the year she and H enry Silver, MD, a pediatrician, started the first NP program at the University o f Colorado.
K e yw o rd s: history, n u rse p ra c titio n e r
www.tnpj.com
The Nurse Practitioner
•
May 2015
15
50 years o f NP excellence
Dr. Ford is currently dean and professor emerita for the School of Nursing at the University of Rochester. “There were social, political, and organizational forces.” The Vietnam War was raging, civil rights issues filled the airwaves, and President Lyndon Johnson had declared war on poverty. Many physicians were choosing specialty prac tice, leaving a dearth of general practitioners, and nursing was beginning to move away from a focus on tasks. The American Nurses Association’s First Position on Education for Nursing was published at the end of 1965.’ The position paper, which defined technical (2 years) and professional (4 years) preparation divided the nursing community. “There was a great deal of rhetoric about what nursing should be in the future,” Dr. Ford says. N u r s e s ' p e r c e p tio n s o f N P s
"M y experience was one of the most traumatic that I have had in my life," Dr. Ford says about the reaction from nurses when she and Dr. Silver started the NP role. She experienced bullying, including "a lot of backstabbing, a lot of shunning, and a lot of silence" from nurse educators who were her colleagues. "I had not been so unpopular in my life." Ultimately, the group worked with a community activist who discussed change theory. "We all began to look at things a little differently," she says. "I began to understand how threatened people were.They could see their work changing." Educators also worried that physicians would gain control of nursing programs. Dr. Ford says it was important to reassure people that NPs were not physician assistants, another new role in its early stages of development. "The hard part was our colleagues who weren't supportive," says JanTowers, PhD, NP-C, CRNP, FAANP, FAAN, a founder of and consultant for the American Association of Nurse Practitioners (AANP) who has been an NP since the 1970s. Nurses had just been recognized as not being handmaidens to physicians and, "here we were doing physician things." After this rocky start, nurses have come to embrace NPs. "RNs and LPNs now look at us as collaborators, consultants, and nursing experts who help them decipher some of the difficulties in the healthcare arena and how challenging it can be to take care of increasingly ill patients, particularly in the outpatient setting," says Margaret Fitzgerald, DNP, FNP-BC, NP-C, FAANP, CSR FAAN, DCC, president of Fitzgerald Health Education Associates, Inc., and an FNP at Greater Lawrence (MA) Family Health Center. She notes that the regard goes both ways, "I greatly respect my RN colleagues where I practice. I do not know how I could possibly do my job without them." Charity McClure, MSN, FNP-C, who works locum tenens in federally qualified health centers in Connecti cut, adds, "I have a good relationship with the nurses I work with. I use them as a resource and I want them to see me as a resource. All nurses, not just NPs, should work at the top of their license."
16 The Nurse Practitioner • Vol. 40, No. 5
Perhaps most significantly, Medicare and Medicaid pro grams started providing healthcare coverage to low-income women, children, older adults, and individuals with disabilities, which increased the demand for primary care services.3Many have credited the increased demand for care coupled with a physician shortage as the catalysts for creat ing the NP role, but Dr. Ford disagrees. “We started this for the health needs of people, not because of a shortage of physicians,” Dr. Ford says. “I’m not the least bit interested in filling the physician role.” Dr. Silver and Dr. Ford partnered to develop the NP role. “My strength was public health nursing and his was child care and development,” Dr. Ford says. “We brought different strengths to the partnership.” Dr. Ford, who by then had a decade of public health experience behind her, worked with Dr. Silver to study what services public health nurses were providing, what families needed, and what a nurse could do. “We developed a model and decided to test it and then in tegrate it into nursing programs,” she says. The pair took a proactive approach to communicating their actions. “We decided on transparency in describing what we were doing,” Dr. Ford says. She and Dr. Silver met with the state boards of nursing and medicine to let them know what services the NPs were providing. In addition to publications, Dr. Ford and Dr. Silver responded to many requests to speak at conferences, even launching one of their own. “We tried to be open with what we were doing. Every one wanted to learn about the program,” Dr. Ford says. Unfortunately, these initial efforts were met with resis tance, which puzzled Dr. Ford (see Nurses’perceptions of NPs). “I didn’t see this as a great change,” she says. “I just thought it was nurses doing what they were already doing clandestinely in the field. We were pushing the boundaries of knowledge, evaluating, and reporting.” The resistance, primarily from nurse educators, “was a big surprise to me,” Dr. Ford says. Fortunately, her students’ reactions bolstered her confidence. “There was an enthusiasm for nursing and confidence once they got over the hump of taking on more responsibilities,” she says. “I was sure it was the right thing to do to help the patients we serve.” The students, experi enced public health nurses with BSNs, joined Dr. Ford in the endeavor. ■
F orgin g a h e a d
Perhaps not surprisingly, NPs found a home caring for underserved patients. Many NPs worked in rural areas , which, in a pre-Internet era, meant they had to rely solely on their expertise. “The only GP (general practitioner) might by 60 miles away and the road to get there was closed in the winter,” says Michael Carter, DNSc, DNP, FAAN, FNP/GNPBC, University Distinguished Professor in the department www.tnpj.com
50 years o f NP excellence
of advanced practice and doctoral studies at the University of Tennessee College o f Nursing. Dr. Carter, an NP since 1973, is also a family NP for the Christian Health Center in Heber Springs, Arkansas. Because of the focus on the underserved, Dr. Carter says the initial push back from physicians was m uted. T hat changed as NPs ventured into caring for patients in higher socioeconomic classes and started to receive reimbursement. “In the early 1970s, there were no states that enabled NP practice,” he recalls. Because state nurse practice acts said nurses could not diagnose or prescribe, the early NPs were technically in violation of the acts. “I would get calls from the Board of Pharmacy or Board of Medicine asking if we were practicing medicine,” says Dr. Carter, who worked at a prim ary care clinic in Marche, Arkansas. “We literally had to push and push to practice as we had been educated.” It is easy to forget those early battles. “Sometimes they (NPs today) don’t realize what mavericks we were back then,” says Jan Towers, PhD, NP-C, CRNP, FAANP, FAAN, a found er o f and consultant for the American Association of Nurse Practitioners (AANP) who has been an NP since the 1970s. Dr. Towers recalls her days as a com m unity health nurse when she would see a child crying and pulling at his or her ear. “You knew the child had otitis media but you couldn’t look in the ear and you couldn’t get anyone to see the child because the family was on Medicaid,” she says, adding that she remembers thinking, “We should be able to care for these people. We started sticking our necks out, pushing to get those doors open.” (See Patients’ perceptions o f NPs.) The m otivation to care for underserved patients re m ains strong today. “O ne o f the things I saw pretty quick ly in the hospital setting was the dearth o f access to care that many people experience,” says Charity McClure, MSN, FNP-C, w ho, after 4 years as a nurse, becam e an NP in 2012. “I saw a num ber of patients who had poor outcom es from their chronic diseases because they didn’t have access to prim ary care. I realized I w anted to w ork at the other end o f the spectrum to prevent patients from getting to that point.” A g ro w in g fo rc e
M argaret Fitzgerald, DNP, FNP-BC, NP-C, FAANP, CSP, FAAN, DCC, president o f Fitzgerald Health Education As sociates, Inc., and a family NP at Greater Lawrence (MA) Family Health Center, has witnessed a trem endous increase in the NP profession since she started in 1986. “There were approxim ately 25,000 in the entire country. This is a very big country to spread 25,000 of any profession around,” she says. “We were mostly, as we are now, taking care of people who are disenfranchised, who are poorer, who are not on the healthcare radar screen in general, so we could practice www.tnpj.com
Patients' perceptions of NPs Patients m ig h t n o t have kn o w n w h a t an NP w as, b u t fro m th e sta rt, th e y liked w h a t th e y did. "P a tie n ts th o u g h t it w as th e g re a te st th in g since sliced bread," says Dr. Ford o f p a tie n ts ' in itia l re action. "I used feedback fro m p a tie n ts to he lp p ro m o te th e role." "S ta rtin g o u t in th e 1970s, p a tie n ts d id n 't kn o w a b o u t NPs," Dr. Carter says. "B u t eve ryo n e had heard o f a nurse." "P atients w e re so g ra te fu l th a t so m e o n e cared and listened," he adds. " It w as th e nurse part, n o t th e NP part, th a t th e y tie d into." He encourages NPs to get p a tie n ts to speak o u t a b o u t th e ir experiences w ith NPs. "O ften pa tie n ts say th e y go to a doctor, b u t th e y re a lly see an NP and th e y like th a t. We need to have th e m say that." "W h e n I firs t becam e an NP o ve r 30 years ago, it w as like, 'You're a w h a t? "' Dr. Fitzgerald says. "T h e re w as ve ry little p u b lic re co g n itio n as to w h o w e are and w h a t w e do. N o w I have fo u n d , e sp e cially o ve r th e last 10 years, th a t fa r m o re o ften w h e n I in tro d u c e m y s e lf to a m e m b e r o f th e general pu b lic, I g e t th e fo llo w in g reactions: 'O h, m y w ife sees an NP, m y co usin is in school to becom e an NP, I see an NP.' I d o n 't have to educate th e m on w h a t the role is.That's re a lly e xcitin g to see." Jam esetta N e w la n d , PhD, APRN, FNP-BC, e d ito r-in c h ie f o f The Nurse Practitioner, adds th a t pa tie n ts tru s t NPs. "T h e y re a lly do like seeing a nurse p ra c titio n e r," she says. A lth o u g h so m e patients still call her a "d o c to r" because th e y believe th e y have s im ila r skills, Dr. N ew land says, "I try to stress th a t d o cto rs and w e are co m p le m e n tary. W e w o rk to g e th e r."
as invisible entities. Part of that was good; there wasn’t as much scrutiny of the practice, but as the profession matured, we needed more scrutiny to show what our outcomes were.” This scrutiny, in the form of research studies, dem on strated the value and effectiveness o f NPs. M any o f the studies were published in physician journals, such as the landm ark 2000 study by M undinger and colleagues, which appeared in The Journal o f the American Medical Associa tion.4 By the 2000s, “We started having some really good studies saying NPs are as good as or better than physicians,” Dr. Carter says. W ith the evidence and num bers, NPs surged to the forefront. “Now that we are pushing 200,000, we can no longer be ignored,” Dr. Fitzgerald says. “We are finally making our mark, and part o f it is due to our strength in num bers.” She notes that some believe the m arket may be reaching saturation but disagrees with the premise. “I feel the higher num bers have brought us to our rightful place in contem porary healthcare where we are that disruption innovation, we are changing the status quo, and we are making a nam e for ourselves.” As it has grown, the NP role has expanded from p ri m ary care into many specialty areas, including acute care. A ccording to AANP, however, 89% o f NPs are prepared The Nurse Practitioner • May 2015
17
50 years of NP excellence
in primary care, and more than 75% of actively practicing NPs provide primary care.5Several key issues have thread ed their way through the history of the NP role, including full practice authority, payment, education, and licensure. ■ Full practice authority
The past few years have shown a rise in the number of states removing restrictions on NP practice by eliminating the need for physician collaboration or supervision. Susanne Phillips, MSN, FNP-BC, a clinical professor at the Univer sity of California in Irvine who has been an NP since 1996, credits the recent surge to passage of the Affordable Care Act. “It’s really ramped up in terms of states moving towards full practice authority,” she says, adding, “The amount of legislation that will be passed in the next 5 to 7 years is going to be impressive.” As of 2014, 20 states allow full practice authority.5 Phillips credits NPs in all states with working to enact change. “There is a tremendous amount of work that goes on in every state that aren’t the big ticket items,” she says. Even minor changes such as insurance empanelment and reimbursement help advance the NP role. Phillips has seen NPs become much more involved in legislative initiatives over the past 20 years. “More NPs attend lobbyist days, visit their legislative representatives, and support organiza tions advocating for NPs,” she says. “We are truly autonom ous healthcare providers,” Dr. Fitzgerald says of the NP role, but adds there is still work to be done. “More than two-thirds of all NPs con tinue to practice in states where we need to have a physician collaborator or supervisor to do a role that we have been educated to do autonomously.” Autonomy does not mean independence, according to Dr. Fitzgerald. “There isn’t a single one of us, whether we’re NPs, PAs, or MDs, who practice independently. We are in terdependent on one another, we rely on one another for second opinions and clinical consults.”
Payment
A watershed moment in reimbursement came with passage of The Balanced Budget Act of 1997, which granted NPs provider status and the ability to bill Medicare directly for services.7“It was a turning point and made us able to move forward,” Dr. Towers says. Dr. Carter also credits patients with pushing their insurers to reimburse NPs. However, Dr. Towers adds that Medicare reimbursement also prompted physicians to challenge NPs more. “They became more hardball,” she says, noting that in the early years of the role, many physicians supported NPs. “People were willing to help us and didn’t see us as a turf issue.” NPs still struggle with payment issues. “Even now, there are regulatory rules that do not include NPs,” says Jamesetta Newland, PhD, APRN, FNP-BC, editor-in-chief of The Nurse Practitioner. Dr. Newland, who launched her NP career in 1986, adds that even when insurers reimburse NPs, they may do so at a lower rate than physicians. NPs have not negotiated rates as well as their physician colleagues, according to Dr. Newland. “NPs should seek expert guidance when negotiating rates with an insurer with a goal of 100% reimbursement,” she says. Education
NP education has evolved from a certificate to master’s level to, most recently, doctoral preparation. Dr. Carter says the 1980s saw NP programs move to the master’s level. Part of the stimulus was enrollment in master’s programs was flagging at the time. “We saw a rapid proliferation of mas ter’s programs, sometimes without adequate faculty,” he says. “Almost every school created an NP program .” Ultimately, it became clear that the 30 credits typically associated with a master’s program weren’t enough to pre pare the NP for their evolving role. “Programs kept getting longer and longer,” Dr. Carter says. “Some of us started saying we have to move to the doctorate— not the PhD, but a clinical doctorate.”
Key even ts in NP h is to ry 4 7 1 1 ' 13 Dr. Loretta Ford and Dr. Henry Silver establish the first NP pro gra m at the U n ive rsity o f Colorado.
National Association of Pediatric Nurse Practitioners established.
Idaho is the first state to endorse NPs' scope of practice to include diagnosis and treatment.
18 The Nurse Practitioner • Vol. 40, No. 5
First issue of
The Nurse Practitioner journal is published.
American Nurses Association develops the Council of Primary Care Nurse Practitioners.
The American Academy of Nurse Practitioners is established.
The National Organization of Nurse Practitioner Faculties holds its first organizational meeting in Albuquerque, New Mexico.
"Nurse Practitioners, Physician Assistants and Certified Nurse Midwives: A Policy Analysis" released.
www.tnpj.com
50 years o f NP excellence
Dr. Barksdale adds that the DNP m ovem ent was par tially prom pted by the realization that NPs needed more
Dr. Barksdale says educators face challenges in teaching NP students. “We try to teach too much specific information
education in finance, healthcare systems, and larger health care issues, topics that she says used to be included in some master’s programs. “Somewhere along the way, we lost some of th at content that we now realize is essential.”
that no one can keep up with because it changes so quickly. It’s difficult to prepare students for a world we can’t imagine so our default is to prepare them the way we have always prepared them.”
Dr. Barksdale says there are pros and cons to the DNP.
But technology and p atien t d em ands are forcing a change. “We’re at a point that robots are diagnosing, so we are going to need m ore education in hum ans relating to hum ans,” Dr. Barksdale says. “NPs m ight not just be p ri mary care providers, they may be life coaches.”
O ne rationale for requiring a DNP is to have parity with other professionals, b u t she says, “I d on’t think having a degree gives you parity. It’s how you conduct yourself and how you are able to show your worth and influence change.” She is also not convinced that the DNP will lead to better com pensation. Despite these concerns, Dr. Barksdale says, “I believe if done properly, there is incredible potential for DNP-prepared NPs.” She calls for m ore consistency in DNP program s and adds that the bottom line will be the impact that DN P-prepared NPs have on the healthcare system. “If you aren’t making an impact, it doesn’t make sense.” In the future, Dr. Fitzgerald envisions the DNP being the requirem ent for entry into practice for NPs. “We should anticipate that our profession will go more and more to doc toral level study as the entry into practice.” Dr. Newland agrees that the profession is moving to the DNP as entry to practice and adds that DNP programs need to be standardized. “The DNP program needs to be substantive and con crete and prepare students for practice as NPs,” says Mc Clure. M cClure’s concern is that doctorate program s will n o t offer enough clinical experiences for students. She noted that some of today’s future NPs are enrolling in directentry programs, so they have limited to no experience work ing as a nurse. McClure completed a residency to help ease the transi tion from school to practice, but Dr. Barksdale cautions that legislatively requiring such program s for all NPs “disadvan tages us.” These programs may allow those outside the pro fession to gain control over the role, which will reduce the num ber of NPs that can be prepared.
Mundinger publishes "Advanced practice nursing — Good medicine for physicians" in The New England Journal o f Medicine.
Mundinger and colleagues publish their primary care outcomes study in JAMA.
r
-1994
-1992
AANP works with associations to develop an international role of NPs.
www.tnpj.com
2000
L 1997 Balanced Budget Act grants NP provider status and authorizes them to bill Medicare directly.
T hat m eans educators “will have to w ork h arder to help students learn how to acquire, interpret, and apply inform ation instead of just pouring inform ation from our heads into theirs,” Dr. Barksdale says. Educators will also need to becom e savvier in evidence-based ed u catio n . “W hether students like som ething is different than w heth er it helps them to learn,” she notes, saying that some re search shows e-books are associated with more distraction and lower retention, for example. Finally, the role of simulation in replacing clinical hours in NP education needs to be studied. “Clinical sites are becoming more difficult to obtain,” Dr. Barksdale says. “But I hope we d o n ’t get to the po in t th at we have too many clinical hours substituted with simulation. That would give more am m unition for medicine to say NPs aren’t prepared to care for real patients.” ■ Licensure
In 2002, the National Council o f State Boards of Nursing delegate assembly approved the APRN Licensure Compact.8 The compact is designed to create consistency in legislation related to NP practice and allow for mobility from state to state. “It makes no sense for me to need to practice with physician collaboration in Massachusetts, yet I could walk out the door to New Hampshire and practice autonomously,” Dr. Fitzgerald says.
Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education is published.
The American Academy and the American College of Nurse Practitioners form the American Association of Nurse Practitioners.
2008
2013
2006
2010
NPs have obtained some level of prescriptive privileges in all states and the District of Columbia.
The Institute of Medicine releases The Future of Nursing: Leading Change, Advancing Health.
-2015
NPs celebrate 50 years of practice.
The Nurse Practitioner • May 2015
19
50 years of NP excellence
Resistance to m ultistate licensure remains. Phillips speculates that part of the resistance is the potential loss of revenue from license fees, which could hinder the abil ity of boards of nursing to investigate possible practice infractions. Practical considerations stand in the way as well. “If a nurse is licensed in one state and commits an action that requires discipline in another state, who bears responsibility for that?” she says. Challenges for the future
NPs will continue to face challenges as they enter the next half-century of the role. “The challenge is to not let the momentum slow down,” Dr. Fitzgerald says. “We are on a roll. We need to be poised to move forward to continue the battle for autonomy.” She adds that, “It will be a tough, long fight to update the practice act so that state to state we are autonomous healthcare providers.” Dr. Carter also sees full practice authority as an ongoing challenge. “NPs still can’t fully exercise their abilities (in some states) and that’s criminal,” he says. Conflicts can arise if NPs are more experienced than their collaborating physi cians. Dr. Carter also adds that patients don’t expect practice to vary by state, so why should NPs? An aging population has resulted in more people with chronic health problems. “We’re all seeing patients who are sicker, more complex, who require a very high level of skill in order to properly take care of. We’re all doing this at a time when we’re expected to be faster, more comprehensive, and be able to address myriad health problems in a very short
Growth opportunities The NP role is one of the fastest growing roles in the United States as new opportunities open up. According to an article in Kiplinger, the 10-year projected growth for NPs is 22%.9 NPs will see growing opportunities, particularly in the area of convenient care clinics, according to Dr. Carter. He says that NPs are ideally suited for these clinics "because we know that an illness can only be understood in the context of the patient living with it." For instance, a patient with symptoms of a cold may also have diabetes that needs to be considered when deciding on treatment. Another growth opportunity is long-term care facilities. "It's a travesty that NPs can't be medical directors of nursing homes," Dr. Carter says. "A few studies have found that patients do better with an NP in charge." NPs are even making house calls, as patients demand great access and are willing to pay for it. Heidi Johnson, a pediatric nurse practitioner, charges $80 per visit and does not accept insurance.™ One family who used Johnson's services says her fee is comparable to their regular pediatrician (and they would need to go into the office) and to a local urgent care center. "If we can deliver prescrip tions, why not deliver an NP to you?" Dr. Carter says.
20 The Nurse Practitioner • Vol. 40, No. 5
period of time,” Dr. Fitzgerald says, adding that the situation poses the question, “How can we do this job faithfully under the current pressures of contemporary healthcare?” Dr. Newland agrees that patients have become more complex and says NPs are functioning as providers and case managers. “In the past, a lot of these patients would have immediately been shifted to a physician, but now NPs are managing them,” she says. NPs are coordinating specialty visits with patients returning to them for primary care. “Even NPs in specialties are managing more complex patients.” The concept of a health home is likely to be another battleground, Dr. Newland says. Physicians are becoming the leaders of these homes, but she says, “An NP who has the education, training, and experience—particularly the admin istrative experience—should be able to lead a medical home not only with poor and marginalized patient populations but also with the well-educated and well-insured.” Despite NPs’ skills, she says, “That’s going to be a battle. Wherever there’s money to be made, establishment wants to push us aside.” Phillips says, “The biggest challenge remains the op position from organized medicine.” The Robert Woods Johnson Foundation and the Future of Nursing Campaign are leading efforts to garner support from consumer groups for full practice authority for NPs. “The push by organized medicine to prevent passage of legislation granting full practice authority is not evidence based, it’s about protect ing turn and financial efforts, not about protecting patients,” Phillips says, citing 40 years of research about the effective ness of the NP role. “There is no longer the debate as to whether NPs can do the job. The research is there.” Perhaps the most important challenge is, as Dr. Newland says, “keeping the nurse part in NP, which distinguishes us from physicians.” “We take a holistic approach,” Dr. Newland says. “When we see patients, we really listen to what is going on in their lives and incorporate that information into a plan of care.” “The NP role has been very much more medicalized compared to the early models,” Dr. Ford says, noting that healthcare delivery, reimbursement, and outcomes are all predicated on a medical model. “If you’re not careful, you’ll lose the nurse,” she cautions. She is heartened by the Affordable Care Act’s focus on prevention and sees treatment as a conduit to prevention. “When patients are tending to treatments, it’s time to introduce ideas of prevention, promotion, and protection,” Dr. Ford says. “You have to bring in the nursing focus.” Dr. Ford adds that primary care, as it is currently prac ticed, “is a dying system. It’s not fulfilling the needs of peo ple and it’s oriented to symptoms,” she says. “It’s ridiculous that you have to have a symptom to get into primary care.” Instead, there should be a focus on primary health services. www.tnpj.com
50 years o f N P excellence
In t h e i r o w n v o ic e : N P s l o o k d o w n t h e r o a d
Here are how some of the NPs interviewed responded when asked about their hope for the role 5 to 10 years down the road: "I would like to see more NPs as leaders in innovative delivery systems and involved in community health organizations and more sustainable nurse-managed centers." — Dr. Jamesetta Newland "All NPs have full authority in all states and we continue to work with all healthcare professionals. One profession (such as medicine) doesn't have supervisory rights over another." — Susanne Phillips "The role of all healthcare providers is going to change in the relatively near future because there is so much technology that allows individuals to assess health information without having a healthcare provider present. Our role is going to be bringing that human touch; to help people process that information." — Dr. Debra Barksdale
omy in different states and the struggle for NPs to function to the full level of their skills. That battle is still being fought. I see the challenge for other NPs and me is to get involved in the fight, especially as healthcare needs increase with the aging population. I hope we can position ourselves well, be vocal, and expand our ability to practice as autonomously and collaboratively as possible.” (See In their own voice: NPs look down the mad.) At the same time, these NPs haven’t forgotten their roots. When asked what she would say to Dr. Ford, McClure says, “1 would probably thank her for her contributions to the field and tell her that I feel that what I do is really a privilege. I feel for the first time in my life I am doing the job I was meant to do. I really love it.” “We all have to roll up our sleeves,” Dr. Towers says. “The more we support each other and keep our eye on the goal, the better chance we have for success.” Dr. Towers can still see the apple tree in her back yard, where NPs gathered to form local, state, and national organizations. “It’s still there, ready for more planning.” © REFERENCES
"We've got to get rid of agreements that tie us in any way to anyone else. We need full scope of practice in every state." — Dr. Michael Carter "I would see NPs functioning at their full scope with no laws to limit that, no tethers. We would become the primary care provider in the United States." — Dr. Jan Towers "They'll be counselors and advisors and involved in inventing things. We are always tinkering to get things better for patients, but then we give our ideas away. It's unfathomable as to how many opportunities there will be." — Dr. Loretta Ford
1. Barksdale D. Rising from the mud. TEDxUNC. 2014. https://www.youtube. com/watch?v=3HjIDEStfyI. 2. Donley R, Flaherty MJ. Revisiting the American Nurses Association’s First Position on Education for Nursing: a comparative analysis of the first and second position statements on the education of nurses. Online J Issues Nitrs. 2008; 13(2). http://www.nursingworld.org/MainMenuCategories/ ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/vol 132008/ No2May08/ArticlePreviousTopic/EntryIntoPracticeUpdate.aspx. 3. O’Brien JM. How nurse practitioners obtained provider status: lessons for pharmacists. Am I Health Syst Pharm. 2003;60(22):2301-2307. 4. Mundinger MO, Kane RL, Lenz ER, et al. Primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trial. JAMA. 2000;283(l):59-68. 5. American Association of Nurse Practitioners. Nurse practitioners in primary care, http://www.aanp.org/images/documents/publications/ primarycare.pdf. 6. Phillips SJ. 27th annual legislative update. The Nurse Practitioner. 2014;40(1): 16-42. 7. Balanced Budget Act of 1997. P.L. 105-33. www.gpo.gov/fdsys/pkg/PLAW105publ33/html/PLAW-105publ33.htm.
With challenges come growth opportunities (see Growth opportunities). For instance, Dr. Ford says there is going to be a “tremendous shift” in healthcare, with responsibility in the hands of the patient. “The patient will be the first one to receive the information (not the provider),” she says. “He will first go to his computer, then other people who have the conditions, then reach out to a provider.” Dr. Ford believes NPs are ideally positioned to be the “first responders” when those patients decide to reach out. T h e n e x t g e n e r a t io n
Fortunately, the new generation of NPs is ready to take on the task of meeting the future needs of patients and advancing the NP role. “I think a lot about how much further there is to go,” McClure says. “I have seen the different levels of auton www.tnpj.com
8. Nurse Licensure Compact Administrators. APRN (advanced practice nurse) licensure compact. https://www.ncsbn.org/APRN_Compact_hx_timeline_ April_2012_%282%29.pdf. 9. 10 best jobs of the future. Kiplinger. 2014. http://rn.kiplinger.com/slideshow/ business/T012-S001-now-hiring-10-of-today-s-hottest-jobs/index. html?page=2. 10. Lankford K. Pay cash for your health care. Kiplinger’s Personal Finance. 2015. http://rn.kiplinger.com/article/insurance/T027-C000-S002-pay-cashfor-your-health-care.html. 11. American Association of Nurse Practitioners. Historical timeline, http:// www.aanp.org/all-about-nps/historical-timeline. 12. National Council ol State Boards of Nursing. Consensus model for APRN regulation: Licensure, accreditation, certification 8c education. July 7, 2008. 13. National Organization of Nurse Practitioner Faculties. History and goals. http://www.nonpf.org/?page= 1. Cynthia Saver is President, CLS Development, Inc., Columbia, Md. The author has disclosed that she has no financial relationships related to this article. DO I-10.1097/01 .NPR.0000463786.21636.47
The Nurse Practitioner • May 2015
21
Copyright of Nurse Practitioner is the property of Springhouse Corporation and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
