Growth and Development of the Nurse Practitioner Role Around the Globe

History in the United States 

Advanced practice roles developed out of a need that was identified, and nurses were the ones who stepped in to fill the need. In the case of the nurse anesthetist, the job was being done by surgeons, but because they had a greater interest in the surgery than in the anesthesia, the job was not being done well (Diers, 1991). The midwife role initially was brought here from England and filled a need in rural areas and underserved areas where people could not afford a doctor to assist with delivery. With the advent of the First World War, there were not enough English midwives who either came to or stayed in the United States, so the Frontier Nursing Service under Mary Breckenridge began to train nurse midwives to fill the need (Frontier Nursing Service, 2000). The final advanced practice role to develop was the NP role, which began in the 1960s and 1970s in direct response to a shortage of primary care physicians in underserved areas, especially rural areas. Traditionally, the role is agreed to have begun with the continuing education program developed by Loretta Ford and Henry Silver in Colorado in 1965-1966 (Ford & Silver, 1967).

Interestingly, when one begins to look at the development of the advanced practice roles in other cultures and other parts of the world, one finds very similar developmental patterns, and the course of the developmental challenges and issues also are very similar. It would appear that although other cultures potentially could learn from what occurred in the United States, much like developing children, they seem to need to go through the stages themselves in order to establish the role in their culture. This article describes the development of the advanced practice role and specifically the NP role, discussing the “developmental issues” that seem to occur as the role develops across cultures.

Developmental Pattern 

Historically in the United States, a very clear developmental pattern has emerged regarding the NP role. This article will begin with an outline of the “developmental progress” of the role in the United States and will compare the role development of the NP to that of Erickson's developmental stages in children.

In Childhood and Society, Erikson, 1950, Erikson, 1980 describes the psychosocial development of children by stages and suggests that all children need to go through each stage before progressing to the next. This article proposes that the development of the NP role occurs similarly (Table).

Table. Comparison of Erikson's developmental stages with those of the nurse practitioner role

	Erikson's developmental stages	Nurse practitioner developmental stages
	1. Infancy (trust)	1. Infancy (learning the role)
	2. Toddlerhood (autonomy)	2. Establish independence (autonomy)
	3. Preschool (initiative)	3. Expanding (initiative)
	4. School age (industry)	4. Consolidation (industry)
	5. Adolescence (identity, intimacy)	5. Rebellion (identity)
	6. Early adulthood (generativity)	6. Reaching out (generativity)
	7. Later adulthood (integrity)	7. Integrity

This article will describe these stages and identify NP exemplars from around the globe.

Matching the Development 

Erikson (1950) described eight stages of psychosocial growth and development that a person needs to go through and master as he or she grows. According to Erikson, the individual must go through each stage before he or she can progress to the next stage. The development of the NP in a jurisdiction seems to have the same developmental mandate. The first stage in Erikson's development is trust versus mistrust. During this time the infant learns to trust his or her environment and learns to hope. NPs in a jurisdiction learn the role and the possibilities and learn to believe that they can do this work.

The second stage is autonomy versus shame and doubt, and during this phase children begin to assert themselves and develop autonomy; however, this development is not without some overestimation of stubbornness and will. NPs move to a new level of autonomy and begin to establish their position within a jurisdiction, but this development is not without a certain amount of dissention within the jurisdiction.

Erikson's third stage of development is initiative versus guilt. During this stage children learn to broaden their skills, cooperate with others, and imagine the possibilities of the future. The development of purpose occurs in this stage. The third stage of development for the NP is expansion—the initiative to broaden the skill set, the cooperative learning, and the imagination of the possibilities of the role in the future.

The fourth stage of the psychosocial development of the child is industry versus inferiority. In this stage the child learns more formal skills, progressing from free play to following rules, mastering particular skills, and developing self-discipline. The fourth stage of role development for the NP is consolidation of the skill set that has been developed, the formalization of the role within the medical community, and the self-regulation of the role in terms of education and policy.

The next stage of psychosocial development is identity versus role confusion. Children spends this time figuring out exactly who they are and how they fit into society. Often this stage involves rebellion against authority and the establishment. Similarly, NPs need to rebel from medicine and establish their own role in the marketplace and in society.

Erikson separates the adolescent years into two stages, but for the purposes of this article, we will consider adolescence one stage. According to Erikson, most of adulthood is identified as a period of generativity, which involves generating and supporting the next generation. For the NP, that role is reaching out to new places to support and help generate the role, as well as supporting new nurse practitioners in one's own society.

Finally, Erikson maintains that once the other stages have been achieved, the individual has established a good self-esteem and is satisfied and happy. The NP role once established would fit the same mold; however, it is hard to say if there are any jurisdictions in which that stage has yet occurred.

Learning the Role (Infancy) 

The NP role begins as a response to a specific need in the health care of the particular society. The nurses in that society must learn the role and then find a situation in which they can practice the role. The role in the United States began with an identified need for additional providers of primary care in rural and underserved areas as a result of a shortage of physicians to fill the role. In Botswana, the need was related to the human immunodeficiency virus (HIV) epidemic and lack of providers to care for patients with HIV. There was a 2-year backlog of patients waiting to be seen in HIV clinics and a lack of providers to see them. Clinics now have developed that utilize family NPs who see the patients in the HIV clinics. The backlog of patients has decreased, and more patients with HIV are being treated and are leading more normal lives. Advanced practice nurses have had a very positive impact on these clinics and have been recognized internationally (L. Chite, M. Kgositau, & O. Seitio, personal communication, International Council of Nurses/Advanced Practice Network [ICN/APN] Conference, June 2006).

Establishing Independence, Autonomy (Toddler) 

In Thailand there was a need for a reduction in health care costs that could best be achieved through the use of NPs in a community setting. Thailand had masters-prepared nurses but not NPs, so in order to address the shortage, a continuing education program was developed for masters-prepared nurses to educate them as NPs. These NPs are now functioning in community settings (W. Deoisres, personal communication, ICN/APN Conference, June 2006). Many countries are still trying to determine what the education should be. Also, certification of advanced practice nurses is either not yet developed or sporadic, and regulations are inconsistent in many locations such as Australia. Some states in Australia, such as Victoria, actually have required certification and recertification requirements to recognize NPs; others do not recognize NPs and have no certification process in place at all (M. Burley & A. Green, personal communication, ICN/APN Conference, June 2006). South Africa is in the process of revising its nursing laws and developing certification (Geyer, personal communication, ICN/APN Conference, June 2006).

Expanding, Initiative (Preschool) 

Holland also had a shortage of physicians and a change in the medical policies regarding physicians, so the NP role was instituted there in the mid 1990s. Today, NPs in Holland are in their early stages; the country only has 74 NPs, but the numbers are growing (Roodbol, personal communication, ICN/APN Conference, June 2006). The story is much the same in all countries that have NPs and that are developing the role. In Botswana, for example, most nurses are educated at the diploma level. While there are baccalaureate and masters-level education programs in Botswana, many of the NPs there actually have been educated in Western nations. The newly developed education programs for NPs vary widely, from continuing education after a diploma to continuing education after a master's degree. Much discussion is occurring regarding duplication of class work for NPs who have a Bachelor of Science in Nursing (BSN) degree or a Master of Science in Nursing (MSN) degree. Curricular development needs to be done to standardize the education of the advanced practice nurse there (C. Pilane, O. Seitio, & P. Ncumbe, personal communication, ICN/APN Conference, June 2006). Once the role is established, the need for a standardized curriculum becomes clear. In the United States, the original programs were post-basic RN level and were continuing education programs. There was even a time in the 1970s when specific guidelines were developed by the American Nurses Association delineating the necessary components of the continuing education programs (Health Education and Welfare, 1977, International Council of Nurses, 2008). Many years later in the United States, as a result of policy and regulatory changes, and with much controversy and frustration on the part of many people, the minimum education became the MSN. In many parts of the world, basic nursing education varies, and therefore education at the advanced practice level also varies.

Interestingly, although the role has been present in Taiwan for almost 20 years, it largely has been hospital based, unlike in many other parts of the world. Nonetheless, the educational curriculum is still developing much as it did in the United States and with much controversy and discussion. In Taiwan, the education was at the hospital training level and still is in many places, but enlightened educators began a masters-level NP program and have graduated one class. These classes were developed in collaboration with NPs from the United States using the National Organization of Nurse Practitioner Faculties (NONPF) guidelines. The first NPs in Taiwan will take a certification examination this year, and educational guidelines specifically for Taiwan are being developed now (Tang, personal communication, ICN/APN Conference, June 2006). There is one MSN program that has graduated one class.

Even the United States, the advanced practice role is in the process of expansion. Currently, the role of the acute care NP both in the pediatric setting as well as in the adult arena is evolving. The role was first suggested in the early 1990s in the United States, and schools began to educate NPs as acute care NPs for the adult population. These NPs managed patients in the hospital setting, which was very different from the original role concept in the United States (Daly et al., 1991, Spisso et al., 1990). The consolidation phase was yet to come. In the early 2000s, the acute care pediatric role was initiated. The National Association of Pediatric Nurse Practitioners (NAPNAP) evaluated the role and endorsed the new role for pediatric nurse practitioners, and the Pediatric Nurses Certification Board (PNCB) created a certification examination, all in a short period (Fabrey & Codgill, 2003; NAPNAP, 2005). The roles continue to evolve, and consolidation is in process.

Consolidation, Industry (School Age) 

In Korea, the advanced practice role has advanced further developmentally. The role has been present there for almost 20 years, and the role has been developed as a masters-level education from the start with a formal curriculum and a national certification program well under way (Kang, 2005). Additionally, the certification process is well organized, and there will be national certification for all NPs beginning this year, with very well-defined curricular guidelines and expectations for all NPs throughout the country (Kang). Regulatory issues also must be addressed at this point. According to Fadwa Affara, prior president of the ICN/APN, regulations define the profession and its members, determine the scope of practice, set standards of education and standards for ethical, competent practice, and establish some system of accountability (personal communication, ICN/APN Conference, June 2006). “The overriding purpose of statutory regulation of nursing is that of service to and protection of the public.… Benefits to the profession and individual practitioners are secondary, and although they may be significant, do not in themselves provide good reason for statutory regulation” (Styles & Affara, 1997).

Rebellion, Identity (Adolescence) 

In the United States in the mid 1970s, nursing educators began to meet to address the concerns voiced by those challenging the profession. NONPF was formed in 1980 largely to respond to the identified needs of NP education. The mission statement clearly sums up the role: “The mission of NONPF is to provide leadership in promoting quality nurse practitioner education at the national and international levels” (NONPF, 2008). NONPF has been proactive in developing very specific and comprehensive materials designed to promote consistent and strong curricula in NP programs. Other countries often have used the materials developed by NONPF, developed their own curricular guidelines based on the NONPF guidelines, or combined NONPF guidelines with their own materials (ICN, 2008). In the United Kingdom, probably because of its close ties to the United States, the education of the NP at the masters level has been occurring for 20-plus years, and the curriculum has paralleled that of curricular development in the United States (H. Ward, personal communication, ICN/APN Conference, June 2006).

As the role develops in different cultures and societies, there are always groups that resist the development of the new role and new portions of the role. When resistance occurs, current NPs justify their role by doing research in support of their position. In 2005 and 2006, the Australian Medical Society continued to “prevent legislation changes for advanced practice nurses that they see as eroding medical turf and threatening their control of the health care dollar” (Pearson, Dans, & Fina, 2002, p. S4). Despite their repeated attempts, the role continues to expand in Australia. Studies of safety and efficacy of NPs currently in practice were initiated to look at improved access to care when NPs are utilized (Pearson et al.). For cultures in which the role has recently begun, the research is usually focused on the successes that have occurred both in those jurisdictions as well as elsewhere. In Great Britain, recent challenges relate to the initiation of prescriptive privileges, research related to the prescriptive privileges that have occurred, and the appropriateness of the prescriptions that have been written. Latter and Courtnay, 2004, National Association of Pediatric Nurse Practitioners, 2005, National Organization of Nurse Practitioner Faculties. (2008), 2008 did a meta-analysis of the literature to support the concept of NP subscribing and the effectiveness of the role. Additionally, in 2005 the case was made for the standardization of policy and education in Great Britain to enhance the development of NP role development (Furlong & Smith, 2005).

Reaching Out, Generativity (Adulthood) 

The United States, the country that has the longest history of the NP role, is now in the stage of reaching out or generativity. Many NPs in the United States are traveling to other countries to consult on new NP programs. Additionally, many students from other countries are coming to the United States to learn the NP role. Sometimes these students come and actually earn a master's degree as an NP and then return to their home country to establish the role there. At other times, international nurses come for shorter times to see what the NP is learning and doing in the United States, and then they return and employ those skills in their own institutions.

Integrity (Older Adult) 

It is difficult to determine if any NP practitioner role has reached the stage of integrity. In some ways, perhaps, the role is getting there in the United States; however, it has not reached that level yet. The role still needs to develop and grow in many ways before integrity will have been achieved. It is a goal that continues to be elusive, as it often is for many adults.

Conclusion 

The growth and development of the NP role, which began in the United States in the mid 1960s, in many ways mirrors the growth and development of a person following the stages of Eric Erikson.