Nurse Practitioners for Children—Past and Future

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Patricia A. McAtee, MS., and Henry K. Silver, M.D.

From the Department of Pediatrics, University of Colorado School of Medicine, Denver

ABSTRACT. During the past decade there has been a

sig-nificant expansion in the role of the nurse in providing pa-tient care. Studies have shown that nurse practitioners can,

by themselves, care for approximately three fourths of all

those who come to ambulatory settings, and that nurse

practitioners are well accepted, highly competent in assess-ing health status, and provide improved as well as increased health care.

It is recommended that there be more meaningful and

extensive incorporation of the teaching of nurse practition-er concepts, training, and goals into undergraduate curricu-Ia of schools of nursing; that nursing students should have

an opportunity to apply nurse practitioner concepts and

practices in a supervised orientation and practical experi-ence (a nursing “internship”); that less well-trained health

workers (licensed practical nurses, nurse’s aides, etc.)

should be trained as “assistant nurse practitioners” to meet

many basic health assessment and management needs; and

that the scope of nursing needs to be expanded further so

that its practitioners can give even more comprehensive, direct, and responsible health care to the public. Pediatrics,



health care system results in improved as well as increased health care.

(4) Nurse practitioners make significant contri-butions in the care of patients in many areas in-cluding pediatrics, school health, adult health, geriatrics, and obstetrics.

(5) The role of the nurse in providing care to patients includes assessment and management skills previously considered within the exclusive province of the physician.

(6) The special skills that are part of the ex-panded robe of the nurse are presently best taught in separate, structured nursing programs which allow and encourage the evolution of the extend-ed role.

(7) Accreditation of nurse practitioner pro-grams and certification of qualified graduates of these programs will bead to an improved role-identity for the nurse and greater acceptance of the expanded role by other health professionals and the public.

Pediatric Nurse Practitioners

During the past decade there has been a

signifi-cant expansion in the role of the nurse in provid-ing direct patient care. To a considerable degree, this expansion has evolved from the development and implementation of a variety of nurse practi-tioner programs. The first of these, Colorado’s pe-diatric nurse practitioner program, was started a decade ago.13 In the ten years since then, it has been widely recognized that:

(1) Nurses are a key group to meet the need for additional well-trained health professionals capa-bbe of providing direct primary patient care, and that the key nurses are nurse practitioners.

(2) Nurses can make a major contribution in providing direct primary health care to patients of all ages.

(3) The addition of nurse practitioners to the

At present, the largest group of nurse practi-tioners consists of pediatric nurse practitioners who, in addition to providing comprehensive well-child care, identify, appraise, and manage many acute and chronic conditions of the sick child. Pediatric nurse practitioners obtain com-plete histories; perform extensive physical exam-inations; carry out necessary immunization and other preventive services; evaluate hearing, speech, and vision; and determine developmental

(Received March 26; revision accepted for publication May

16, 1974.)


Pedi-atrics, University of Colorado School of Medicine, 4200


status. They also perform laboratory tests; counsel parents; assist in managing emergencies; care for newborn infants; and provide health maintenance

through personal contacts and telephone calls.

Since 1965, when the first pediatric nurse prac-titioner graduated from our program, approxi-mately 50 other pediatric nurse practitioner programs have been established in the United States. These programs have graduated more than

1,100 nurses.4

Surveys and evaluation studies of the Colorado

pediatric nurse practitioner program have shown that:

(1) Pediatric nurse practitioners can, by them-selves, care for approximately three fourths of all children coming to ambulatory health care set-tings.5

(2) Pediatric nurse praactitioners can provide almost total care to all well children and can eval-uate and manage the problems of a majority of all sick and injured children seen in office settings.5


Pediatric nurse practitioners are very well accepted by parents; 94% of parents expressed satisfaction with the combined care provided jointly by a pediatrician and a pediatric nurse

practitioner in a private office, and more than one half of the parents indicated that joint care was better than that which they had received from the same pediatrician alone.

(4) Pediatric nurse practitioners and pediatri-cians exhibit a high degree of agreement in assess-ing the health status of children; significant differ-ences in assessment occurred in only 1% of cases.7


The salaries of the graduates of this

pro-gram ranged from $7,680 to $15,500 per year.8


Nurse Practitioners

The school nurse practitioner is another cate-gory of nurse practitioner who is also able to assume basic responsibility for identifying and managing many of the health problems of school children.9 School nurse practitioners perform routine health assessments; provide extensive well-child care; evaluate and assist in managing children who are ill or injured; and assess and coordinate the evaluation of perceptual and other learning disorders, psychoeducational problems, and be-havior disturbances.

111 comparing school nurse practition-ers and “regular” school nurses have shown that:

(1) School nurse practitioners spend twice as much time as “regular” school nurses providing direct patient care.

(2) School nurse practitioners devote a large proportion of their time with patients to thorough and extensive assessments and in-depth appraisals of health problems, while “regular” school nurses

are occupied primarily with brief patient encoun-ters.


School nurse practitioners triple the num-ber of daily contacts with parents of students to discuss emotional, physical, learning, or other problems that students have.

(4) School nurse practitioners exclude (dismiss from school) only one-half as many pupils from school as do “regular” school nurses. Nurse practi-tioners can recognize and manage more health problems in the school setting.

(5) School nurse practitioners manage a signifi-cantly greater proportion of the health problems of school children and are less likely to refer pu-pils inappropriately to physicians or others for consultation or care.

(6) School nurse practitioners counsel parents with more specific recommendations about their children’s health problems. These more sharply focused recommendations are better understood by parents, and children sent home from school are more likely to receive needed medical atten-tion.

In many instances school nurse practitioners provide ongoing health care and services not pres-ently available from any other source. Effective utilization of competent school nurse practition-ers ensures greater continuity of care and ushers more children into the overall health care system. Increased availability of school nurse practition-ers will result in the school becoming the place where an increased proportion of health care of children could be provided.



level of clinical preparation and competence had been attained.


Undergraduate Education

The next decade should see more meaningful

and extensive incorporation of the teaching of nurse practitioner concepts, training, and goals into the undergraduate teaching programs of schools of nursing. This will require extensive modification of nursing school curricula to prepare nurses for expanded nursing roles in providing health care to children. In baccalaureate

nursing programs exposure to the knowledge and

concepts needed for practice as a nurse practi-tioner should become part of the basic curricu-him and should be taught by nursing faculty who have themselves graduated from standard nurse practitioner programs. Instruction in history taking, interpersonal communication, physical assessment, and diagnosis should occur very early in the course of study. Students should also be pre-pared to manage a spectrum of social, economic, cultural, and behavioral situations and have an understanding of their influence on health and disease and on optimum patient care management. Throughout the undergraduate years considerable attention should be devoted to the development of skills in problem-solving and an understanding of the new and expanded role and increased responsibilities that the nurse practitioner can have in patient care.

To practice as highly competent, well-qualified

nurse practitioners it is suggested that the

bacca-laureate nursing course of study should include: two years of basic nursing, the basic sciences, and the humanities and at least two years of advanced nursing school preparation, including a period of approximately one year of supervised orientation and practical experience (a nursing “internship”).

Nursing students need to be exposed to a wide

va-riety of nurse practitioner practice settings so that they can make intelligent choices of the type of practice that would suit them best. During the 4 or 4#{189}years of study, students should acquire knowledge about the evaluation, maintenance, and supervision of health, and the diagnosis, pre-vention, and treatment of disease, as well as a wide variety of nursing skills pertaining to the di-rect care, comforting, and nurturing of patients.

During the first half of the last year in nursing school, nursing students should have rotations in various traditional settings including outpatient departments, hospital wards, public health facili-ties, patients’ homes, physicians’ offices, and

op-erating rooms. In these settings they would re-ceive practical experience in providing direct care to patients of all ages with a variety of prob-lems.

In the second half of the last year, students should be given the opportunity of developing their practice skills in a single specialty area (e.g., pediatrics, geriatrics, industrial health, school health, mental health, obstetrics) where they could further integrate their roles as nurse practi-tioners. On completion of this period of training, nurses would be prepared to practice as qualified nurse practitioners. For those students who wished specialized training in one of the tradi-tional nursing disciplines (nursing administration, general duty nursing, or other type of nursing practice), this half of the fourth year in nursing school could be used to perfect their skills in these areas.

In time, the inclusion of nurse practitioner con-cepts and practices into the undergraduate nurs-ing curriculum would obviate the need for sepa-rate postgraduate nurse practitioner programs since the material presently taught in these pro-grams would be covered in the regular under-graduate course of study.

Assistant Nurse Practitioners

To meet the needs of many medically deprived

rural areas and urban neighborhoods which find it

impossible to acquire the services of fully trained nurse practitioners, consideration should be given to the preparation of less well-trained health workers (e.g., licensed practical nurse, nurse’s aide) who do not have all the necessary prerequi-sites to be admitted to structured nurse practi-tioner programs, but who could be given suffi-cient training to meet many of the existing health needs of the community. These health workers who might be cabled “assistant nurse practition-ens,” could provide many of the basic assessment and management skills needed in emergency sit-uations. They could care for a variety of minor health problems, offer certain preventive ser-vices, and provide triage for those problems which require attention from more highly trained health personnel. Those chosen for assistant nurse practitioner training might be selected from med-icalby deprived areas in the expectation that this would increase the likelihood that they would re-turn there to practice.


Although utilization of nurse practitioners has


nurse, to her employer, and to the public,12’3 costs have been a deterrent in developing and main-taming nurse practitioner programs. At present,

many of these programs are funded as pilot or demonstration projects by the Federal Govern-ment or private institutions. A national govern-mental program is needed for the ongoing support of established projects that already prepare nurse practitioners, for the development of new nurse practitioner programs, and to stimulate and assist

nursing schools to introduce nurse practitioner

concepts into the regular undergraduate course of study.


At present, the roles of various categories of health professionals in providing primary health care are still being defined. Many members of the nursing profession, m particular, are dissatisfied with the traditional role of the nurse; they believe that nursing as a profession must change and be-come more responsible to the people’s need for health care by adapting to changing conditions.’ The scope of nursing during the next decade

needs to be expanded further so that its

practi-tioners can give even more comprehensive, di-rect, and responsible health care to the public. In addition to the important functions and activities having to do with traditional nursing skills, nurses should be prepared to provide a wider spectrum of health services including many previously re-served to physicians. Nurses should be involved in a variety of ambulatory and hospital settings in the planning, implementation, supervision, evabu-ation, and maintenance of health, and the diag-nosis, prevention, and treatment of disease. Based on their assessments of clinical situations in their extended roles, nurses are able to make more value judgments and independent decisions, and they should, within limits, be expected to assume greater responsibility and accountability for their decisions and performance.

Acceptance of the extended role of nursing will occur when it is shown that the nurse is prepared for an expanded scope of practice. In time, new nursing activities will become authorized nursing acts, particularly if they have been commonly performed by qualified nurses using the tech-niques and skills that were taught and acquired under established curricula in duly approved un-dergraduate and graduate nursing programs.

Depending on the circumstances of their prac-tice and the social and health needs of the public,

nursing should be a profession whose practitioners

practice independently, interdependently,

de-pendently, collaboratively, or as partners with physicians and other health professionals deliver-ing patient care.


To increase and improve the utilization of nurse practitioners and the concepts they repre-sent, and to improve care for many different types of patients from a variety of socioeconomic back-grounds, we recommend that:

(1) Nurse practitioner skills and concepts in the future should be taught as part of the basic un-dergraduate nursing school curriculum.

(2) As part of the regular course of study, bac-calaureate schools of nursing should provide a year of supervised clinical orientation and practi-cal experience for nurses planning to function as nurse practitioners.


Nurse practitioners should be prepared to practice in a variety of clinical settings and with patients of all ages and conditions.

(4) In areas where fully trained nurse practi-tioners or nurses capable of becoming nurse prac-titioners are not available, consideration should be given to the utilization of less well-trained health workers (“assistant nurse practitioners”) to meet many existing health needs.

(5) Funds should be made available to provide ongoing financial assistance to support established nurse practitioner programs and the develop-ment of new programs, and to stimulate and assist

nursing schools to incorporate nurse practitioner

training as part of the regular undergraduate nursing course of study.

(6) The scope of nursing should be expanded further so that its practitioners can give even more comprehensive, direct, and responsible health care to the public.


1. Silver, H. K.. Ford, L. C., and Stearly, S. C.: A program to increase health care for children: The pediatric nurse practitioner program . Pediatrics, 39:756, 1967.

2. Silver, 11. K., and Ford, L. C.: The pediatric nurse prac-titioner at Colorado. Ani. J. Nurs., 67:1443, 1967. 3. Silver, H. K., Ford, L. D., and Day, L. R.: The pediatric

nurse practitioner program: Expanding the role of

the nurse to provide increased health care for chil-dren. J.A.M.A., 204;298, 1968.

4. Duiker, WI. J.: Personal communication. Office of

Al-lied Health Manpower, American Academy of

Pedi-atrics, July 5, 1973.

5. Silver, H. K.: Use of new types of allied health

pro-fessionals in providing care for children. Am. J. 1)is.

Child., 116:486, 1968.

6. Day, L. R., Egli, R., and Silver, 11. K.: Acceptance of

pediatric nurse practitioners: Parents’ opinion of


nurse practitioner in a private practice. Am. J. Dis. Child., 119:204, 1970.

7. Duncan, B., Smith, A. N., and Silver, H. K.: Compan-son of the physical assessment of children by pediat-ric nurse practitioners and pediatricians. Am. J. Pub-lic Health, 61:1170, 1971.

8. Alexander, M.: Personal communication.

9. Silver, H. K.: The school nurse practitioner program: A

new and expanded role for the school nurse.

J.A.M.A., 216:1332, 1971.

10. McAtee, P. A.: Nurse practitioners in our public

schools?: An assessment of their expanded role as

compared with school nurses. Clin. Pediatr., 13:360,


11. Hilmar, N. A., and McAtee, P. A.: The school nurse

practitioner and her practice: A study of traditional and expanded health care responsibilities for nurses

in elementary schools. J. School Health, 43:431,


12. Schiff, D., Fraser, C. H., and Walters, H. L.: The pedi-atric nurse practitioner in the office of pediatricians in private practice. Pediatrics, 44:62, 1969.

13. Charney, E., and Kitzman, H.: The child-health nurse

(pediatric nurse practitioner) in private practice. N.

Engl. J. Med., 284:1353, 1971.

14. Dilworth, A. S.: Joint preparation for clinical nurse spe-cialists. Nurs. Outlook, 18:22, 1970.




Governor John Winthrop, Jr. (1606-1676), the first Governor of Connecticut, was famous throughout New England for his medical ability. He was often consulted by better for medical ad-vice about the management of sick children. The type of medicine he practiced can be gained from his better below written in 1652 to the father of a sick child. The letter also shows that orthography -as we know it-had not yet been decided upon.

I received your letter about 2 daies since wherin you

de-sire directions concerning your child, wch indeed is very

uncertaine to doe in the absence of the pty, it being diffi-cult to find out the true cause & seat of the originall of such disease by the most diligent & curious observation, when the patient is dayly present: for though by your description I iudge it to be a palsy, yet the cause of that diseas is often very differing for in Some it is through too much drinesse in some too much moisture in some the cause is in the Nerves

of the third coniugation of the braine sometymes in other

nerves, in others it hath its onginall in ye marrow of the

back bone: This seems to be that kind wch we call

Hemi-plegia where one halfe of the spinall marrow is affected or (wch is often in others, and makes me doubt it may be so in this child, by reason of the suddainnesse wherewth she was stroken) it may come fro a light apoplexye (a stronger

Apo-plexye is comoly present death) This lighter kind of

Apo-plexy strikes suddainly & leaves comoly one side wthout sence or motion, and after continueth it wholy paraliticall: it may also come fro some thick flegme stopping the influ-ence and distribution of ye vitall spiritts in the nerves, wch may also cause that suddaine apoplecticall stupor. The cure

depends upon the knowledge of the right cause, and not

only that but the constant and due application of such

things as may conduce thereto, wch is difficult to doe at a

distance. I am not provided of things alwaies ready for such cures yt are usuall to be had ready made in other places at the Apothecaries, and am forced to prepare things myselfe

in such cases when any neighbours doe want helpe and

therfore am not able to send you many things that might be

usefull, and I suppose it would be uselesse to prescribe you

such receipt as phisitians commend in these cases wch I

know it is not probable any of them to be had wth you, if

the child were nere me I might doe mine indeaveur to

pro-vide such things as I could heave make my selfe and see to

the due administration therought, otherwise I accout it an

hopelesse to direct for the cure of so dangerous a disease wherein the best meanes often faile of helpe: some generall

things that may be helpfull in all kinds of those disease I

shall mention-there is a coidnesse comoly accopanes this

disease, whatever other cause be, therfore warmeth by apli-cation of hares or ffox ifurre (wch is also specificall to

para-litical disteprs) or in want therof Racoones or lamb or

swanes or such can be had: also artificall meanes of heat by hott clothes, hott trenchers or bnckes wraped up in cloths

aplied to the place most benumnd also oyntments of hott

chimicall oyles as of rosmary tyme Origanu also oyle of cas-tor mixed wth a greater quantity of oyle of wormes & fox grease, or for want of these wth fox grease alone: or wch is

counted very efficatious the Balsam of Guido if you have

any (it is any ordinary knowne oyntmet) though at present I

have none of it but have sent you an other oyntment

in-stead whereof wth wch or wth any of the other if they be to

be had anonyt the whole backe bone as hott as can be

in-dured & that side that is affected twice a day covering It

presently wth hott clothes, also the aplying of cupping

glasses to the heads of the muskles, they might be such

glasses as have very narrow mouths and must be aplied

wthout scarification, & wth a great & quick flame but must not continue as long as in other cases, but be often reiter-ated and a plaister of Colophony frankincense & rosin wth the pouder of Bayberries, these mixed wth as much melisett plaister all melted together & made into a plaister, and

aplied to the places after the cupping glasses, also some

bathes wherein the decoction of Betony Rosmary sage in a

quanty of sweete sacke or muskadell but better the spiritts of those herbes, & other hot herbes mixed with it: but spe-ciall care must be in the using of bath least it overcome the patient or too much relax the nerves by being too long in it or too hott aplied: I use in such cases a bath of minerall spiritts wch I find both safe & effectuall in many cases

corn-ing neere the virtue of the naturall bathes wch must be

used immediately after it is prepared, therfore I never pre-pare it but as it is used, nor cannot contrive a way to supply you wth it so farre of: I commend also to be used inwardly the decoction of Guaicu & Sassaparilla also some drops of spirit of rosmary in bere if it may be had, or in want of it

Rosemary boyled in broth & so taken often, a vomitt in

some kind of such disease is usefull but not in every kind, an Issue on the contrary arme or legge as the nature of the

dis-ease appeares if most upward in the legge if most

down-ward in the arme may be usefull: but if she be of a very

spare bode it will not be good: this is what I ca for present advise. Your loving freind, J. Winthrop’

Noted by T. E. C., Jr., M.D.


1. Viets, H. R.: A Brief History of Medicine in

Massachu-setts. Boston: Houghton-Miffhin Company, 1930, pp.




Patricia A. McAtee and Henry K. Silver

Past and Future


Nurse Practitioners for Children


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