Joanne M. Pohl, Ph.D., A.N.P.-B.C., FAAN, Charlene. M. Hanson, Ed.D., F.N.P.-B.C., FAAN,
Jamesetta A. Newland, Ph.D., R.N., F.N.P.-B.C., FAANP
INTRODUCTION
Primary Care and Nurse Practitioners
Primary care is the foundation of most national healthcare systems; yet, the vision for primary care in the United States and who should provide it is less than clear. Nurse practitioners (NPs) have been providing primary care for over 45 years, and there is strong evidence that this care is cost effective, of high quality, and of great service in increasing access to care for vulnerable populations.1,2Nevertheless, despite the evidence, barriers to NP practice, along with “supervision” processes that increase the costs of primary care, continue. For the first time, in a recent policy monograph, the American College of Physicians (ACP) acknowledged that NPs and physicians had common goals related to high-quality, individual patient outcomes and enhanced population health.3 The ACP acknowledged the shared concerns of medicine and nursing with respect to the decline in the primary care workforce and the need for appropriate reimbursement for services—especially those related to coordination of
care. The ACP also called for testing of new models, specifically related to multidisciplinary teams and the patient-centered medical home (PCMH) and addressed the question of who might lead and participate in primary care teams of the future. Amidst the significant obstacles to NP practice supported by physician organizations to date, this monograph provides hope for new dialogue regarding who will provide primary care and how these providers will be prepared. This paper is intended to support this dialogue by providing an overview of the history of NP education and practice, a description of the current workforce and how its members are prepared, and a presentation of visions for the future from the viewpoint of nurse practitioners.
When the first NP program started in the mid-1960s, it was a pediatric NP program response to a physician workforce shortage. Other specialties (family and adult NP) developed quickly. The original conception of this advanced practice role was that NPs would care for patients with routine, common, and stable problems with a focus on health promotion and disease prevention.4 Although that focus continues, the reality was—and continues to be—that NPs in primary care are frequently asked to care for some of the most complex and challenging patients (eg, homeless, uninsured, chronically ill, and mentally ill). Nonetheless, NPs have managed these patients well, either collaboratively or at some level of independence. Over the past 40 years or more, hundreds of studies have documented the contributions NPs have made to primary care and the quality of that practice. In addition, over four decades, the scope of NP practice has been more clearly articulated, with professional regulatory mechanisms that support both education and practice.5 About 150,000 NPs are now practicing in the United States, with a majority of those in primary care and 20 percent in rural or frontier settings.6
History of Advanced Practice Nursing
NPs constitute one of four advanced practice nursing (APN) roles. The other three are certified registered nurse anesthetists (CRNA), clinical nurse specialists (CNS), and certified nurse midwives (CNM). CRNAs and CNMs have a long history dating back a century, while the NP and CNS roles were both initiated in the 1960s. The sociopolitical context for these newer roles was an era of questioning the status quo, including a political climate that supported changes in civil rights and women’s rights.
The United States was in the midst of a controversial war. Within nursing, a move toward bachelor’s and higher degree preparation was occurring. At the same time, there was a shortage of primary care physicians, especially pediatricians. During these years intensive care units were expanded, creating nursing positions that required a high level of skill and clinical decision-making. The CNS role had its roots in this expanded acute care function, whereas the NP’s roots were in community-based primary care. Autonomy and independence based on licensure and certification were sought for each role. Almost 20 years ago, the National Council of State Boards of Nursing issued a statement on advanced practice nursing in which they asked that “each individual who practices nursing at an advanced level” should do so “with substantial autonomy and independence resulting in a high level of accountability.” 7
It is also notable that the NP role emerged during a time of increasing emphasis on specialization in medicine.8 Throughout the history of healthcare, nursing has expanded into overlapping roles with medicine, especially in the area of community health and midwifery. Pioneers in these areas were Margaret Sanger (Planned Parenthood), Mary
Breckenridge (midwifery) and Lillian Wald (community health), who had expanded and overlapping roles a century ago. These women provided the vision, expertise, and backbone that set the stage for a maturing profession within which the NP advanced practice role was formalized.9
Certified Nurse Anesthetists
The first organized program in nurse anesthesia education was offered in 1909. More than 37,000 certified nurse anesthetists (CRNA) are now practicing, and 109 nurse anesthesia programs exist. CRNAs have been certified nationally by the American Association of Nurse Anesthetists (AANA) since 1945. A minimum of 7 calendar years of education and experience are required to prepare for practice as a CRNA. Between 1,300 and 1,700 student nurse anesthetists graduate each year. CRNAs must be recertified every 2 years, and CRNAs are the sole anesthesia providers in more than two thirds of all rural hospitals in the United States.10
Clinical Nurse Specialists
The CNS role preceded the NP role, and some say it set the stage for the NP practice role, which has a greater overlap of scope with medicine.11
Although the NP and CNS roles have at times been blurred, each group of practitioners has distinguishing aspects. The CNS performs more as a consultant-facilitator whereas the NP emphasizes direct patient care management. Also, the CNS generally practices in the secondary or tertiary care setting.12 Unlike the NP role, which emerged out of primary care, the role of the CNS is based in acute and chronic illness, most often for hospitalized patients. Overall, about 1,000 individuals graduate from CNS programs each year (compared to 7,000 NP graduates).13 An estimated 69,017 CNSs are now working in the field, and approximately 14,643 are qualified as both NPs and CNSs. There are 449 CNS programs across the country.13
Certified Nurse Midwives
CNMs have been practicing in the United States since the 1920s. The role developed out of concerns about the lack of access to care and the poor quality of that care when it did exist in the form of midwifery (not nurse- related) and medical practice at the turn of the nineteenth to the twentieth century.14 Today, CNMs are registered nurses who have graduated from nurse-midwifery education programs accredited by the Accreditation Commission for Midwifery Education (ACME). Currently there are 10,000 certified CNMs and certified midwives who are not nurses (CMs) nationally; 6,000 of those are members of the ACNM and only 100 of those 6,000 are CMs.
A CNM/CM provides a full range of primary healthcare services to women throughout the lifespan, including gynecologic care, family planning services, preconception care, prenatal care, postpartum care, childbirth, and care of the newborn. Nurse-midwives are recognized in all 50 states with licensure under the jurisdiction of one or more of the Boards of Nursing, Medicine, or Midwifery. Thirty-eight accredited programs exist in the United States, with 300 graduates in 2008. As of Fall 2010, preparation as a CNM or CM will require a minimum of a master’s degree.
Nurse Practitioners
The first NP program was started in 1965 at the University of Colorado under the direction of nurse leader Dr. Loretta Ford and her physician colleague Dr. Henry Silver.4,9 The Colorado program emphasized pediatric care and was based on a model that focused on health promotion, growth, and development for children and the prevention of disease and disability.15,16 Since the mid-1960s, the primary care NP focus has expanded markedly to include family NPs. Family NPs now comprise the largest group of NPs, with others in the profession categorized as adult NPs, women’s health NPs, and gerontological NPs. As a result of a consensus process, APN stakeholders recently decided to merge the adult and gerontological NP into one focus.17 Approximately 650 primary care NP programs now exist in the United States, enrolling approximately 32,000 students and with more than 7,500 graduates in the past year.13 There are a total of approximately 150,000 NPs nationally, a majority of whom work in primary care.18
Summary
Most of the early APN programs were certificate programs in which a registered nurse could qualify for admission. Over the years, the basic preparation for all APNs has moved to a master’s degree. A majority of all graduates from NP programs have a master’s degree from an accredited program. Recently, 92 schools have started doctoral programs in nursing practice (DNP). There were 361 DNP graduates in 2008 and over 3,000 enrollees. An increase in doctoral preparation is expected over the next decade.
In summary, of the four APRN roles, NPs represent the largest number of graduates each year (approximately 7,000), with a majority of those graduates (almost 6,000) having a primary care focus. About 1,700 CRNAs, 1,000 CNSs, and 300 midwives graduate each year. Clearly, the largest numbers of nursing primary care providers prepared each year are NPs.13 The remainder of this paper will focus on the NP.