EDITORIALS
cation and sex education in the schools in 1975. There is much to be done for our youth, and mother's knee is not the answer.
ROBERT P. MASLAND, JR., MD Address reprint requests to Dr. Robert P. Masland, Jr., Chief, Division of Adolescent Medicine, The Children's Hospital Medical Center, 300 Longwood Avenue, Boston, MA 02115.
REFERENCES 1. Shaw GB: Man and Superman, 1905. 2. Lancet M, Modan B, Kavenaki S, et al: Sexual knowledge, attitudes, and practice of Israeli adolescents. Am J Public Health 68:1083-1089, 1978. 3. Sorensen RC: Adolescent Sexuality in Contemporary America. New York: World Publishing Co., 1973. 4. Guttmacher AT: 11 Million Teenagers. New York: Planned Parenthood Federation of America, Inc., 1976.
The Nurse Practitioner Movement-Where Does It Go from Here? Thirteen years ago Loretta Ford and Henry Silver started a unique nurse training project at the University of Colorado.' The purpose of the project was to determine whether nurses could be trained to expand the scope of their practice in order to provide better and more widely available health care for children. Thus, the role of the nurse practitioner was born. As the role became institutionalized its focus changed in the process; today, its main thrust is to provide primary health care. The family nurse practitioner, as a generalist, delivers such primary health care services to members of both sexes and all ages. Also, there are specialist roles, such as the gerontological nurse practitioner, the pediatric nurse practitioner, and others. It is estimated that there are currently about 12,000 nurse practitioners in this country.2 They function in a large variety of settings, continually widening their scope of practice and developing new foci of thrust. The implementation of this role has given rise to inquiry about its reception. An interesting study contrasting the attitudes of nurses and physicians to the nurse practitioner role in 1976 is reported in this issue of the Journal.3 The institutionalization of social change frequently occurs not only in association with an enlarged focus, but also with an altered purpose. So it has been with the nurse practitioner. Loretta Ford states that, "The nurse practitioner project originally was conceptualized as an experiment to test one aspect of the clinical specialist role for graduate and post master's preparation in community health nursing."' Today, I believe that the nurse practitioner exemplifies a new role, requiring new skills, new understandings and, particularly, new behaviors. It is especially the latter which makes me reject its designation as an "expanded" role and why I consider it to be a new one. This new role is complementary to that of the physician; the nurse practitioner and the physician form the dyad of principal health and illness care providers in primary care. At this point in time there are enough research findings to convince me that: * the nurse practitioner has demonstrated that she fulfills a role intensely needed by society; * perhaps 75-80 per cent of all primary care requests made in any given primary care setting can be met by the 1074
appropriately trained nurse practitioner; * the nurse practitioner has proven herself to be an efficient coordinator of an individual's or a family's health care needs as well as an effective consumer advocate; * patients and clients, once they have had contact with the nurse practitioner, have confidence in her and rate her as equal to or preferable to other health care providers for the services she can provide; * health and illness care provided by the nurse practitioner is cost equitable, at times even cost desirable; * nurse practitioners, because they extend the services heretofore unavailable to consumers, make a precious contribution to the health and illness care of people. In fact, a recent study showed 57 per cent of nurse practitioner employers reported the extension of services to more people as the most significant contribution of nurse practitioners to practice;* another 40 per cent considered improvement in the quality of care provided to be their most significant effect.4 It is remarkable how quickly the nursing role implemented by the nurse practitioner has become appreciated by the public. The nursing profession, on the other hand, has had a more tortuous time.5 Not only did it initially refuse to accept this role, but it also failed to recognize the paramount message carried by the nurse practitioner movement for nursing, namely the return of nurses to the side of the patient! Explicitly, this means nurses will quit nursing the desk, the telephone, and the report sheets, and resume nursing's core thrust-meeting the nursing needs of the public. Today, the corner has been turned. There are many indications that the nursing profession is committed to the nurse practitioner role and, even more significantly, to the inclusion of the new behaviors of that role into the preparation of all nurses.6 Nursing students are now being socialized to be risk takers, to develop autonomy based on competence, to act as patient advocates, and to assume responsibility for self-growth and continued learning. It seems to me that society gains twice as a result of the development of the nurse practitioner-first, because of the *Personal communication to the author.
AJPH November 1978, Vol. 68, No. 11
primary care services provided ahd, second, because all of nursing is turning its impact toward meeting the nursing needs of society. The employment of nurse practitioners, however, since it usually depends upon non-nurse employers, does encounter problems. Current barriers to such employment, as perceived by nurse practitioners and their employers, are reported by Judith Sullivan and her colleagues in this issue of the Journal.7 Now to the question of the future. How will the nurse practitioner movement fare? What barriers and facilitators will affect the success of this role? Conceptually, I see this role as complementary to that of the physician. As he is occupied with illness care, the nurse practitioner deals with the patients' health maintenance, health education, self-care education, attainment of higher levels of health, and the achievement of a dignified, peaceful death. Manifestly, there is an overlap of functions between the physician and the nurse practitioner in the area of physical assessment and in the management of simple and common illnesses. Thus, one would assume that the contribution of nurse practitioners in this area of overlap would alleviate the need for any large increase in the number of primary care physicians. Although a recent report from the Institute of Medicine does not bear out such expectations,8 one must continue to hope that the medical profession will resume its inherent commitment to provide secondary and tertiary care in accordance with societal needs. Otherwise, a future where secondary and tertiary care would be available only at a premium, or not at all, may be in store for us. Unfortunately, organized medicine reacts without appreciation to nursing's contribution to primary health care. In fact, there are instances when a stance of conflict is assumed. One cannot help but feel that this emerges out of a threat physicians seem to experience as they observe the competent delivery of services by nurse practitioners. The resultant invoking of constraining legal prerogatives, which appear increasingly all over the land, is a matter of record. A number of State Medical Societies, as for instance in Texas in 1977, openly opposed revisions of nurse practice acts which would update nursing practice.* In Tennessee, the Medical Society did not support the Nurse Association's endeavor to legalize the practice of physician-supervised prescription writing by nurse practitioners of protocol listed drugs.* In New Jersey, the Medical Board of Examiners charged two Nurse Practitioners with practicing medicine, despite the insistence on the part of the State Board of Nurs-
AJPH November 1978, Vol. 68, No. 11
ing that these Nurse Practitioners are indeed practical nursing.9 Many other similar instances are on record which deplorably exemplify the fact that medicine not only does not support nursing in its endeavors to render care of quality where needed, but actually opposes it. Do these barrier to nurse practitioner practice represent the best interest of the society? Surely not. Surely, there is ample work to keep both nurse practitioners and physicians busy. Also, it appears that society has come of age in its understanding of the significance of health and illness care; it demands the best not only in terms of quality and in terms of the widest range of services, but it also insists that such services be delivered by providers who are free, accountable, and unencumbered by constraints which counteract consumer interests. My hope for the future is that the barriers to the functioning of nurse practitioners will be removed so that they, collaboratively with their physician colleagues, will be enabled to deliver the primary health care services needed by society. Whether or not this hope will be realized remains to be seen. The decision now rests with the people.
INGEBORG G. MAUKSCH, PHD, FAAN Address reprint requests to Ingeborg G. Mauksch, PhD, FAAN, Professor and Family Nurse Clinician, Vanderbilt University, School of Nursing, Nashville, TN 37240.
REFERENCES 1. Ford LC: (Editorial) Reaffirmation of the nurse practitioner movement. The American Nurse, June 15, 1978, p. 4. 2. American Nurses' Association, Department of Statistics, 1978. 3. Burkett GL: A comparative study of physicians' and nurses' conceptions of the role of the nurse practitioner. Am J Public Health 68:1090-1096, 1978. 4. Sullivan JA, Dachelet CZ, Sultz HA, and Henry M: The rural nurse practitioner: A challenge and a response. Am J Public Health 68:972-976, 1978. 5. Rogers M: Nursing is coming of age through the nurse practitioner movement-A con position. Am J Nursing, Vol. 75, No. 10, October 1975. 6. National League for Nursing: Proceedings of the Council of Academic and Higher Degrees, 1974. 7. Sullivan JA, Dachelet CZ, Sultz HA, et al: Overcoming barriers to the employment and utilization of the nurse practitioner. Am J Public Health 68:1097-1103, 1978. 8. Institute of Medicine, National Academy of Sciences, Washington, DC: Report of a Study, A Manpower Policy for Primary Care, May, 1978. 9. News: Nurse practitioners fight to restrict their practice. American Journal of Nursing, Vol. 78, No. 8, p. 1285.
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cation and sex education in the schools in 1975. There is much to be done for our youth, and mother's knee is not the answer.
ROBERT P. MASLAND, JR., MD Address reprint requests to Dr. Robert P. Masland, Jr., Chief, Division of Adolescent Medicine, The Children's Hospital Medical Center, 300 Longwood Avenue, Boston, MA 02115.
REFERENCES 1. Shaw GB: Man and Superman, 1905. 2. Lancet M, Modan B, Kavenaki S, et al: Sexual knowledge, attitudes, and practice of Israeli adolescents. Am J Public Health 68:1083-1089, 1978. 3. Sorensen RC: Adolescent Sexuality in Contemporary America. New York: World Publishing Co., 1973. 4. Guttmacher AT: 11 Million Teenagers. New York: Planned Parenthood Federation of America, Inc., 1976.
The Nurse Practitioner Movement-Where Does It Go from Here? Thirteen years ago Loretta Ford and Henry Silver started a unique nurse training project at the University of Colorado.' The purpose of the project was to determine whether nurses could be trained to expand the scope of their practice in order to provide better and more widely available health care for children. Thus, the role of the nurse practitioner was born. As the role became institutionalized its focus changed in the process; today, its main thrust is to provide primary health care. The family nurse practitioner, as a generalist, delivers such primary health care services to members of both sexes and all ages. Also, there are specialist roles, such as the gerontological nurse practitioner, the pediatric nurse practitioner, and others. It is estimated that there are currently about 12,000 nurse practitioners in this country.2 They function in a large variety of settings, continually widening their scope of practice and developing new foci of thrust. The implementation of this role has given rise to inquiry about its reception. An interesting study contrasting the attitudes of nurses and physicians to the nurse practitioner role in 1976 is reported in this issue of the Journal.3 The institutionalization of social change frequently occurs not only in association with an enlarged focus, but also with an altered purpose. So it has been with the nurse practitioner. Loretta Ford states that, "The nurse practitioner project originally was conceptualized as an experiment to test one aspect of the clinical specialist role for graduate and post master's preparation in community health nursing."' Today, I believe that the nurse practitioner exemplifies a new role, requiring new skills, new understandings and, particularly, new behaviors. It is especially the latter which makes me reject its designation as an "expanded" role and why I consider it to be a new one. This new role is complementary to that of the physician; the nurse practitioner and the physician form the dyad of principal health and illness care providers in primary care. At this point in time there are enough research findings to convince me that: * the nurse practitioner has demonstrated that she fulfills a role intensely needed by society; * perhaps 75-80 per cent of all primary care requests made in any given primary care setting can be met by the 1074
appropriately trained nurse practitioner; * the nurse practitioner has proven herself to be an efficient coordinator of an individual's or a family's health care needs as well as an effective consumer advocate; * patients and clients, once they have had contact with the nurse practitioner, have confidence in her and rate her as equal to or preferable to other health care providers for the services she can provide; * health and illness care provided by the nurse practitioner is cost equitable, at times even cost desirable; * nurse practitioners, because they extend the services heretofore unavailable to consumers, make a precious contribution to the health and illness care of people. In fact, a recent study showed 57 per cent of nurse practitioner employers reported the extension of services to more people as the most significant contribution of nurse practitioners to practice;* another 40 per cent considered improvement in the quality of care provided to be their most significant effect.4 It is remarkable how quickly the nursing role implemented by the nurse practitioner has become appreciated by the public. The nursing profession, on the other hand, has had a more tortuous time.5 Not only did it initially refuse to accept this role, but it also failed to recognize the paramount message carried by the nurse practitioner movement for nursing, namely the return of nurses to the side of the patient! Explicitly, this means nurses will quit nursing the desk, the telephone, and the report sheets, and resume nursing's core thrust-meeting the nursing needs of the public. Today, the corner has been turned. There are many indications that the nursing profession is committed to the nurse practitioner role and, even more significantly, to the inclusion of the new behaviors of that role into the preparation of all nurses.6 Nursing students are now being socialized to be risk takers, to develop autonomy based on competence, to act as patient advocates, and to assume responsibility for self-growth and continued learning. It seems to me that society gains twice as a result of the development of the nurse practitioner-first, because of the *Personal communication to the author.
AJPH November 1978, Vol. 68, No. 11
primary care services provided ahd, second, because all of nursing is turning its impact toward meeting the nursing needs of society. The employment of nurse practitioners, however, since it usually depends upon non-nurse employers, does encounter problems. Current barriers to such employment, as perceived by nurse practitioners and their employers, are reported by Judith Sullivan and her colleagues in this issue of the Journal.7 Now to the question of the future. How will the nurse practitioner movement fare? What barriers and facilitators will affect the success of this role? Conceptually, I see this role as complementary to that of the physician. As he is occupied with illness care, the nurse practitioner deals with the patients' health maintenance, health education, self-care education, attainment of higher levels of health, and the achievement of a dignified, peaceful death. Manifestly, there is an overlap of functions between the physician and the nurse practitioner in the area of physical assessment and in the management of simple and common illnesses. Thus, one would assume that the contribution of nurse practitioners in this area of overlap would alleviate the need for any large increase in the number of primary care physicians. Although a recent report from the Institute of Medicine does not bear out such expectations,8 one must continue to hope that the medical profession will resume its inherent commitment to provide secondary and tertiary care in accordance with societal needs. Otherwise, a future where secondary and tertiary care would be available only at a premium, or not at all, may be in store for us. Unfortunately, organized medicine reacts without appreciation to nursing's contribution to primary health care. In fact, there are instances when a stance of conflict is assumed. One cannot help but feel that this emerges out of a threat physicians seem to experience as they observe the competent delivery of services by nurse practitioners. The resultant invoking of constraining legal prerogatives, which appear increasingly all over the land, is a matter of record. A number of State Medical Societies, as for instance in Texas in 1977, openly opposed revisions of nurse practice acts which would update nursing practice.* In Tennessee, the Medical Society did not support the Nurse Association's endeavor to legalize the practice of physician-supervised prescription writing by nurse practitioners of protocol listed drugs.* In New Jersey, the Medical Board of Examiners charged two Nurse Practitioners with practicing medicine, despite the insistence on the part of the State Board of Nurs-
AJPH November 1978, Vol. 68, No. 11
ing that these Nurse Practitioners are indeed practical nursing.9 Many other similar instances are on record which deplorably exemplify the fact that medicine not only does not support nursing in its endeavors to render care of quality where needed, but actually opposes it. Do these barrier to nurse practitioner practice represent the best interest of the society? Surely not. Surely, there is ample work to keep both nurse practitioners and physicians busy. Also, it appears that society has come of age in its understanding of the significance of health and illness care; it demands the best not only in terms of quality and in terms of the widest range of services, but it also insists that such services be delivered by providers who are free, accountable, and unencumbered by constraints which counteract consumer interests. My hope for the future is that the barriers to the functioning of nurse practitioners will be removed so that they, collaboratively with their physician colleagues, will be enabled to deliver the primary health care services needed by society. Whether or not this hope will be realized remains to be seen. The decision now rests with the people.
INGEBORG G. MAUKSCH, PHD, FAAN Address reprint requests to Ingeborg G. Mauksch, PhD, FAAN, Professor and Family Nurse Clinician, Vanderbilt University, School of Nursing, Nashville, TN 37240.
REFERENCES 1. Ford LC: (Editorial) Reaffirmation of the nurse practitioner movement. The American Nurse, June 15, 1978, p. 4. 2. American Nurses' Association, Department of Statistics, 1978. 3. Burkett GL: A comparative study of physicians' and nurses' conceptions of the role of the nurse practitioner. Am J Public Health 68:1090-1096, 1978. 4. Sullivan JA, Dachelet CZ, Sultz HA, and Henry M: The rural nurse practitioner: A challenge and a response. Am J Public Health 68:972-976, 1978. 5. Rogers M: Nursing is coming of age through the nurse practitioner movement-A con position. Am J Nursing, Vol. 75, No. 10, October 1975. 6. National League for Nursing: Proceedings of the Council of Academic and Higher Degrees, 1974. 7. Sullivan JA, Dachelet CZ, Sultz HA, et al: Overcoming barriers to the employment and utilization of the nurse practitioner. Am J Public Health 68:1097-1103, 1978. 8. Institute of Medicine, National Academy of Sciences, Washington, DC: Report of a Study, A Manpower Policy for Primary Care, May, 1978. 9. News: Nurse practitioners fight to restrict their practice. American Journal of Nursing, Vol. 78, No. 8, p. 1285.
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