NP Insights
N urse practition ers: Enhancing h ea lth c a re fo r 50 years
By Tom Bartol, APRN
This year, we celebrate the 50th anniversary of the nurse practitioner (NP) profession. It is a time to remember our history, to remember how far we have come, and to look forward to the future. It is not a story of a single person or a single event that brought the NP profession to where it is today but rather the continued passion and commitment of our colleagues, persisting despite what seemed at times like failure, often working against the odds, but always striving for something beyond themselves. Each of us must continue to be part of this movement, not sit back and let our profession “happen,” but always looking for and creating opportunities for growth. ■ An opportunity for change
The 1960s were a tim e of social and political change. Physicians were focusing on narrow, consultant care (“specialty practices”), while the federal government initiated the Medicare and Medicaid programs. The result was increased healthcare coverage for older adults, people with disabilities, and those with lower incomes while the number of primary care clinicians to care for them decreased. Loretta Ford, EdD, PNP, FAAN, a public health nurse in rural Boulder County, Colorado saw an opportunity for doing things better—something that could enhance healthcare and bring healthcare to more people. Collabo rating with pediatrician, Henry Silver, 14
The Nurse Practitioner • Vol. 40, No. 6
MD, she started the first NP program in 1965 at the University of Colorado Schools of Medicine and Nursing.’ The NP role was not created as a turf battle with nurses wanting to be physicians. It was created to fill a need. It did not begin as a coalition, organization, or by government direc tive but through a visionary nurse leader who saw that the nurse’s role in health promotion, disease prevention, and caring for patients fit the needs of the time well.
Over the past 50 years, our colleagues and NP predecessors have worked passionately and persistently to establish a profession that is credible, competent, known, and reimbursed for the services and the care that we provide. This was not a single-step process but one that took place over years, sometimes with setbacks, but always moving forward, regrouping, and making incremental progress. ■ Legislative recognition of our profession
■ We have only just begun
As we commemorate 50 years since the birth of the NP profession, we must realize we are not at an end point or that our profession has fully evolved. The NP profession did not suddenly happen in 1965 when Dr. Ford and Dr. Silver established that first NP program in Colorado. It was the beginning, a first step of a process. Our practice, image, role, and reimbursement have changed dramatically since 1965 and will continue to grow and change. Dr. Ford gave us the vision, and over the years, many individuals and organizations have worked hard to achieve the privilege and status our profession holds today. We must never take what has been achieved for granted. There are still needs, opportunities, and improve ments in our profession and in healthcare we can achieve. We must continue Loretta Ford’s vision of growth. It is not enough to be just good clinicians. There is an opportu nity for each of us to do something more.
In 1974, the first federal legislation was introduced before any national NP organizations existed. There were about 65 NP programs nationwide and about 10,000 practicing NPs at that time.2 It was a bill to amend the Social Security Act to provide for inclusion of services of NPs under Medicare and Medicaid. Over the next 23 years, there were at least 10 pieces of federal legislation that gradually established the role and the reimbursement of the NP. They culminated with President Clinton signing the Balanced Budget Act of 1997, which granted provider status to NPs and authorized NPs to bill directly for providing Medicare services in any setting.3 Despite the bill’s passage, many NPs still have restricted practices depending on their individual state’s statute. When I lived in Missouri in the 1990s, I worked at a dependent practice requiring a collaborative practice agreement with a physician. I was told that NPs were not compe tent and safe to practice without physi cian supervision. I moved to Maine www.tnpj.com
NP Insights in 1998 and, thanks to legislation in Maine 3 years earlier designating NP practice as independent, I was suddenly considered competent and safe to perform all the functions of an NP independently! My competency or safety of practice did not change at all—it was only based on the state law where I lived. We continue to face challenges to practice along with opportunities for continued growth of our profession so we can more effectively enhance healthcare. ■
asked them what they knew about the bill, what they wanted to know (assessment), planned strategies to educate and inform legislators (planning), made follow-up contacts and had meetings with legislators (implementation), and then evaluated what had been successful and where further action was needed (evalua tion). This “practice” of nursing, building relationships, and using the nursing process was in contrast to the expensive paid lobbying efforts taking place against the legislation.
A s to ry o f p a s s io n a n d p e rs is te n c e
Opportunities come through a perceived need and through the vision and action of individuals. This year, NPs in Maine celebrate the 20th anniversary of legislation, granting us independent practice. The change did not suddenly happen 20 years ago; it began around 1990 when a group of NPs saw a need and had a vision for independent NP practice. There was no state NP organization, no lobbyist for NPs—just a group of passionate, motivated, and energetic nurses. Individuals worked together and formed a coalition of advanced practice registered nurses (APRNs), bringing together certified nurse midwives, certi fied registered nurse anesthetists, and clinical nurse specialists along with NPs. They began by unifying, building relationships among the APRNs and developing strategies for achieving independent practice. An independent practice bill was written by these nurses, and they found a sponsor in the legislature.4These were nurses— not politicians—willing to venture into the political venue to advance the role of NPs in Maine. Opposition was strong, especially from the medical community. Nurses rallied together and contacted their legislators to support the bill. Instead of trying to “sell” the bill to legislators, these nurses used the nursing process. Meeting with their legislators, they www.tnpj.com
■
F a ilu re le a d s to s u c c e s s
After negotiations and compromise, the legislation passed in the final hours of the legislative session. Unfortunately, the brief moments of elation were dampened when the governor promptly vetoed the legislation. The persistence and perseverance that grew our profes sion on a national level continued in Maine, and a new bill was intro duced the following session with a motivated coalition of APRNs behind it. The decision was made to hire a lobbyist, though there was no formal organization, no budget, no funds, just a group of dedicated individuals. These APRNs, many like you and me, pulled out checkbooks and supported the cause—a cause that would benefit many NPs beyond them. This legislation passed again in 1995 as a stronger, independent practice bill.5The experience of the first attempt resulted in a better bill the second time. What initially seemed like defeat in the veto of the first bill actually helped to create better legislation. In the meantime, there had been a change in administration, and the new governor signed and sup ported the bill. The vision, passion, persistence, and relationships of these APRNs created a path to enhancing and bringing healthcare to more residents of Maine.
The story of the NP profession and the story of independent NP practice in Maine are some of the many stories of opportunity, persistence, passion, and patience. All that NPs have accomplished over the years did not take place because NPs stood back and waited for it to happen. We as NPs cannot sit back either. Each of us must play a role. Your role may not be going to Washington, DC to testify before congress or writing legislation. But there is still a role each of us must play. We believe in what we do, we want what is best for our patients, and we must take steps to keep our profession thriving in an ever-changing health care environment. ■
In v e s t in y o u r p ro fe s s io n
Joining your state and national NP organizations is crucial. Joining officially makes you a member represented by these organizations, and these organizations have power and influence in numbers. Joining gives us all a stronger voice and is a simple way you (as a member) can make a difference. Members of these organizations have given all of us the privilege of doing what we do. The price of membership is investing in your profession, contributing a small part for all of what has gone before and for all that is to come. Second, we must cultivate relationships and build connections. Building relationships is a key to transforming healthcare. We build them with our patients, with our colleagues, and we must build them with our policy makers as well. We may not see ourselves as politically active, but we all have resources that we can share about healthcare with our legislators, and they are usually eager to have these resources. Find out the names and contact information for your state and federal representative and senator. Put them in your electronic address The Nurse Practitioner • June 2015
15
NP Insights book or contact list. When a call goes out to contact your legislators, it will be as convenient as sending an e-mail from your contact list. It is even better to make contact with these people when there is not an issue or legislation affecting NPs. A simple letter or e-mail to them sharing that you are an NP in their district (always tell briefly what NPs are, as it is another opportunity to educate) and letting them know you are interested in healthcare. NPs should offer to be healthcare resources on issues that pertain to them. You are not selling or pushing any issue, merely building relation ships and making connections. Most people contact legislators asking for something. Your simple offer can often be very useful and a pleasant
change from people asking them for something. When you do need support for legislation, you have already established a relationship.
beyond. With passion, persistence, and patience, we must all act in the spirit of our founder, Dr. Loretta Ford, taking action to enhance healthcare and bring healthcare to more people. ©
■
REFERENCES
C o n d u its fo r c h a n g e
Let us celebrate as our profession reaches its 50th birthday, but we must not sit back. We must celebrate our NP colleagues who have helped make our profession what it is. Healthcare has a lot of opportunity for growth, and NPs must continue, as Dr. Loretta Ford did, looking beyond the status quo as healthcare changes. We must be a part of that transformation, seeing opportunities and then being part of the change. NPs are the solution to many of the healthcare problems we face today, so we must be the conduits for change in the exam room and
1. Ford L. Nurse, nurse practitioners: the evolution of primary care. Image J Nurs Sch. 1986; 18:177-8. 2. American Association of Nurse Practitioners. Historical Timeline, http://www.aanp.org/allabout-nps/historical-timeline. 3. U.S. Government Publishing Office. Balanced Budget Act of 1997. http://www.gpo.gov/fdsys/ pkg/BILLS-105hr2015enr/pdf/BILLS105hr2015enr.pdf. 4. Law and Legislative Digital Library. 116th Maine Legislature. An Act to Increase Access to Primary Care by Redefining the Practice of Advanced Nursing (Legislative Document Number 1185). http://lldc.mainelegislature.org/Open/LegRec/116/ House/LegRec_1993-04-06_HP_pH0389-0431.pdf. 5. Law and Legislative Digital Library. 117th Maine Legislature. An Act to Provide Greater Access to Health Care (Legislative Document Number 948). http://lldc.mainelegislature.org/Open/ LDs/117/117-LD-0948.pdf. D O I-10.1097/01 .NPR.0000465128.80771 .ec
Product News ■ ________________
■
FD A a p p ro v e s fe c a l in c o n tin e n c e d e v ic e fo r w o m e n
Pelvalon Inc. (Sunnyvale, Calif.) has received FDA approval for its Eclipse System for the treatment of fecal incontinence (FI) in adult women. The device is intended to treat FI in women 18 to 75 years old who have had four or more FI episodes in a 2-week period. The device includes an inflatable balloon that is placed in the vagina. Upon inflation, the balloon exerts pressure through the vaginal wall onto the rectal area, which reduces the number of FI episodes. The device is initially fitted and inflated by a clinician;
after proper fitting, the patient can inflate and deflate the device at home as needed. The Eclipse System should be periodically removed for cleaning. Adverse events associated with the device include: pelvic cramping and discomfort, pelvic pain, vaginal abrasion, vaginal redness, vaginal discharge, and urinary incontinence. All adverse events were mild or moderate, and none required any significant intervention. N e w b lo o d -d r a w te c h n o lo g y re d u c e s n e e d le e x p o s u re s
Velano Vascular (Philadelphia, Pa. and San Francisco, Calif.) has received FDA marketing clearance for a new technology that reduces the need for venipunctures during blood draws in the hospital. The technology
is designed to reduce unnecessary pain and anxiety for patients receiving medications and hydration via I.V. delivery while aiming to provide a safer work environment for healthcare providers performing blood draws. According to Valano Vascular, the disposable, single-use technology allows newly-placed peripheral I.V. catheters to be momentarily repur posed to draw blood from patients, reducing the need for additional needle sticks. The company’s research has found that one of every three hospital patients is stuck two or more times daily for blood draws, with a significant subset of these patients receiving as many as three blood draws or more. CD D O I-10.1097/01. NPR.0000465126.73148.4b
Product descriptions and claims are based on materials furnished by the manufacturer. No endorsement by The Nurse Practitioner's intended.
1 6 The Nurse Practitioner • Vol. 40, No. 6
www.tnpj.com
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.
N urse practition ers: Enhancing h ea lth c a re fo r 50 years
By Tom Bartol, APRN
This year, we celebrate the 50th anniversary of the nurse practitioner (NP) profession. It is a time to remember our history, to remember how far we have come, and to look forward to the future. It is not a story of a single person or a single event that brought the NP profession to where it is today but rather the continued passion and commitment of our colleagues, persisting despite what seemed at times like failure, often working against the odds, but always striving for something beyond themselves. Each of us must continue to be part of this movement, not sit back and let our profession “happen,” but always looking for and creating opportunities for growth. ■ An opportunity for change
The 1960s were a tim e of social and political change. Physicians were focusing on narrow, consultant care (“specialty practices”), while the federal government initiated the Medicare and Medicaid programs. The result was increased healthcare coverage for older adults, people with disabilities, and those with lower incomes while the number of primary care clinicians to care for them decreased. Loretta Ford, EdD, PNP, FAAN, a public health nurse in rural Boulder County, Colorado saw an opportunity for doing things better—something that could enhance healthcare and bring healthcare to more people. Collabo rating with pediatrician, Henry Silver, 14
The Nurse Practitioner • Vol. 40, No. 6
MD, she started the first NP program in 1965 at the University of Colorado Schools of Medicine and Nursing.’ The NP role was not created as a turf battle with nurses wanting to be physicians. It was created to fill a need. It did not begin as a coalition, organization, or by government direc tive but through a visionary nurse leader who saw that the nurse’s role in health promotion, disease prevention, and caring for patients fit the needs of the time well.
Over the past 50 years, our colleagues and NP predecessors have worked passionately and persistently to establish a profession that is credible, competent, known, and reimbursed for the services and the care that we provide. This was not a single-step process but one that took place over years, sometimes with setbacks, but always moving forward, regrouping, and making incremental progress. ■ Legislative recognition of our profession
■ We have only just begun
As we commemorate 50 years since the birth of the NP profession, we must realize we are not at an end point or that our profession has fully evolved. The NP profession did not suddenly happen in 1965 when Dr. Ford and Dr. Silver established that first NP program in Colorado. It was the beginning, a first step of a process. Our practice, image, role, and reimbursement have changed dramatically since 1965 and will continue to grow and change. Dr. Ford gave us the vision, and over the years, many individuals and organizations have worked hard to achieve the privilege and status our profession holds today. We must never take what has been achieved for granted. There are still needs, opportunities, and improve ments in our profession and in healthcare we can achieve. We must continue Loretta Ford’s vision of growth. It is not enough to be just good clinicians. There is an opportu nity for each of us to do something more.
In 1974, the first federal legislation was introduced before any national NP organizations existed. There were about 65 NP programs nationwide and about 10,000 practicing NPs at that time.2 It was a bill to amend the Social Security Act to provide for inclusion of services of NPs under Medicare and Medicaid. Over the next 23 years, there were at least 10 pieces of federal legislation that gradually established the role and the reimbursement of the NP. They culminated with President Clinton signing the Balanced Budget Act of 1997, which granted provider status to NPs and authorized NPs to bill directly for providing Medicare services in any setting.3 Despite the bill’s passage, many NPs still have restricted practices depending on their individual state’s statute. When I lived in Missouri in the 1990s, I worked at a dependent practice requiring a collaborative practice agreement with a physician. I was told that NPs were not compe tent and safe to practice without physi cian supervision. I moved to Maine www.tnpj.com
NP Insights in 1998 and, thanks to legislation in Maine 3 years earlier designating NP practice as independent, I was suddenly considered competent and safe to perform all the functions of an NP independently! My competency or safety of practice did not change at all—it was only based on the state law where I lived. We continue to face challenges to practice along with opportunities for continued growth of our profession so we can more effectively enhance healthcare. ■
asked them what they knew about the bill, what they wanted to know (assessment), planned strategies to educate and inform legislators (planning), made follow-up contacts and had meetings with legislators (implementation), and then evaluated what had been successful and where further action was needed (evalua tion). This “practice” of nursing, building relationships, and using the nursing process was in contrast to the expensive paid lobbying efforts taking place against the legislation.
A s to ry o f p a s s io n a n d p e rs is te n c e
Opportunities come through a perceived need and through the vision and action of individuals. This year, NPs in Maine celebrate the 20th anniversary of legislation, granting us independent practice. The change did not suddenly happen 20 years ago; it began around 1990 when a group of NPs saw a need and had a vision for independent NP practice. There was no state NP organization, no lobbyist for NPs—just a group of passionate, motivated, and energetic nurses. Individuals worked together and formed a coalition of advanced practice registered nurses (APRNs), bringing together certified nurse midwives, certi fied registered nurse anesthetists, and clinical nurse specialists along with NPs. They began by unifying, building relationships among the APRNs and developing strategies for achieving independent practice. An independent practice bill was written by these nurses, and they found a sponsor in the legislature.4These were nurses— not politicians—willing to venture into the political venue to advance the role of NPs in Maine. Opposition was strong, especially from the medical community. Nurses rallied together and contacted their legislators to support the bill. Instead of trying to “sell” the bill to legislators, these nurses used the nursing process. Meeting with their legislators, they www.tnpj.com
■
F a ilu re le a d s to s u c c e s s
After negotiations and compromise, the legislation passed in the final hours of the legislative session. Unfortunately, the brief moments of elation were dampened when the governor promptly vetoed the legislation. The persistence and perseverance that grew our profes sion on a national level continued in Maine, and a new bill was intro duced the following session with a motivated coalition of APRNs behind it. The decision was made to hire a lobbyist, though there was no formal organization, no budget, no funds, just a group of dedicated individuals. These APRNs, many like you and me, pulled out checkbooks and supported the cause—a cause that would benefit many NPs beyond them. This legislation passed again in 1995 as a stronger, independent practice bill.5The experience of the first attempt resulted in a better bill the second time. What initially seemed like defeat in the veto of the first bill actually helped to create better legislation. In the meantime, there had been a change in administration, and the new governor signed and sup ported the bill. The vision, passion, persistence, and relationships of these APRNs created a path to enhancing and bringing healthcare to more residents of Maine.
The story of the NP profession and the story of independent NP practice in Maine are some of the many stories of opportunity, persistence, passion, and patience. All that NPs have accomplished over the years did not take place because NPs stood back and waited for it to happen. We as NPs cannot sit back either. Each of us must play a role. Your role may not be going to Washington, DC to testify before congress or writing legislation. But there is still a role each of us must play. We believe in what we do, we want what is best for our patients, and we must take steps to keep our profession thriving in an ever-changing health care environment. ■
In v e s t in y o u r p ro fe s s io n
Joining your state and national NP organizations is crucial. Joining officially makes you a member represented by these organizations, and these organizations have power and influence in numbers. Joining gives us all a stronger voice and is a simple way you (as a member) can make a difference. Members of these organizations have given all of us the privilege of doing what we do. The price of membership is investing in your profession, contributing a small part for all of what has gone before and for all that is to come. Second, we must cultivate relationships and build connections. Building relationships is a key to transforming healthcare. We build them with our patients, with our colleagues, and we must build them with our policy makers as well. We may not see ourselves as politically active, but we all have resources that we can share about healthcare with our legislators, and they are usually eager to have these resources. Find out the names and contact information for your state and federal representative and senator. Put them in your electronic address The Nurse Practitioner • June 2015
15
NP Insights book or contact list. When a call goes out to contact your legislators, it will be as convenient as sending an e-mail from your contact list. It is even better to make contact with these people when there is not an issue or legislation affecting NPs. A simple letter or e-mail to them sharing that you are an NP in their district (always tell briefly what NPs are, as it is another opportunity to educate) and letting them know you are interested in healthcare. NPs should offer to be healthcare resources on issues that pertain to them. You are not selling or pushing any issue, merely building relation ships and making connections. Most people contact legislators asking for something. Your simple offer can often be very useful and a pleasant
change from people asking them for something. When you do need support for legislation, you have already established a relationship.
beyond. With passion, persistence, and patience, we must all act in the spirit of our founder, Dr. Loretta Ford, taking action to enhance healthcare and bring healthcare to more people. ©
■
REFERENCES
C o n d u its fo r c h a n g e
Let us celebrate as our profession reaches its 50th birthday, but we must not sit back. We must celebrate our NP colleagues who have helped make our profession what it is. Healthcare has a lot of opportunity for growth, and NPs must continue, as Dr. Loretta Ford did, looking beyond the status quo as healthcare changes. We must be a part of that transformation, seeing opportunities and then being part of the change. NPs are the solution to many of the healthcare problems we face today, so we must be the conduits for change in the exam room and
1. Ford L. Nurse, nurse practitioners: the evolution of primary care. Image J Nurs Sch. 1986; 18:177-8. 2. American Association of Nurse Practitioners. Historical Timeline, http://www.aanp.org/allabout-nps/historical-timeline. 3. U.S. Government Publishing Office. Balanced Budget Act of 1997. http://www.gpo.gov/fdsys/ pkg/BILLS-105hr2015enr/pdf/BILLS105hr2015enr.pdf. 4. Law and Legislative Digital Library. 116th Maine Legislature. An Act to Increase Access to Primary Care by Redefining the Practice of Advanced Nursing (Legislative Document Number 1185). http://lldc.mainelegislature.org/Open/LegRec/116/ House/LegRec_1993-04-06_HP_pH0389-0431.pdf. 5. Law and Legislative Digital Library. 117th Maine Legislature. An Act to Provide Greater Access to Health Care (Legislative Document Number 948). http://lldc.mainelegislature.org/Open/ LDs/117/117-LD-0948.pdf. D O I-10.1097/01 .NPR.0000465128.80771 .ec
Product News ■ ________________
■
FD A a p p ro v e s fe c a l in c o n tin e n c e d e v ic e fo r w o m e n
Pelvalon Inc. (Sunnyvale, Calif.) has received FDA approval for its Eclipse System for the treatment of fecal incontinence (FI) in adult women. The device is intended to treat FI in women 18 to 75 years old who have had four or more FI episodes in a 2-week period. The device includes an inflatable balloon that is placed in the vagina. Upon inflation, the balloon exerts pressure through the vaginal wall onto the rectal area, which reduces the number of FI episodes. The device is initially fitted and inflated by a clinician;
after proper fitting, the patient can inflate and deflate the device at home as needed. The Eclipse System should be periodically removed for cleaning. Adverse events associated with the device include: pelvic cramping and discomfort, pelvic pain, vaginal abrasion, vaginal redness, vaginal discharge, and urinary incontinence. All adverse events were mild or moderate, and none required any significant intervention. N e w b lo o d -d r a w te c h n o lo g y re d u c e s n e e d le e x p o s u re s
Velano Vascular (Philadelphia, Pa. and San Francisco, Calif.) has received FDA marketing clearance for a new technology that reduces the need for venipunctures during blood draws in the hospital. The technology
is designed to reduce unnecessary pain and anxiety for patients receiving medications and hydration via I.V. delivery while aiming to provide a safer work environment for healthcare providers performing blood draws. According to Valano Vascular, the disposable, single-use technology allows newly-placed peripheral I.V. catheters to be momentarily repur posed to draw blood from patients, reducing the need for additional needle sticks. The company’s research has found that one of every three hospital patients is stuck two or more times daily for blood draws, with a significant subset of these patients receiving as many as three blood draws or more. CD D O I-10.1097/01. NPR.0000465126.73148.4b
Product descriptions and claims are based on materials furnished by the manufacturer. No endorsement by The Nurse Practitioner's intended.
1 6 The Nurse Practitioner • Vol. 40, No. 6
www.tnpj.com
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.
