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Tracing the History of the Nurse Practitioner Profession in 2020, the Year of the Nurse

      The World Health Organization declared 2020 the Year of the Nurse and Midwife to honor the 200th birthday of the nursing advocate and pioneer Florence Nightingale. This designation celebrates and elevates the contributions of nurses and midwives, who the World Health Organization reports make up more than half of the national health work force in many countries.
      Coincidentally, 2020 celebrates the centennial birthday of another nursing maverick. When Loretta C. Ford, mother of the nurse practitioner (NP) profession and lifelong advocate of advanced nursing education, addresses audiences at speaking events, she often reminds them that she was born in 1920—the year American women won the right to vote. In doing so, she nods not only to her many years of experience but also to her work and struggle as a pioneer of the NP role and dedicated luminary of advanced practice clinical education in the face of a professional health landscape that was not always welcoming to the expertise of nurses. The Year of the Nurse and Midwife also marks 55 years since Loretta Ford and pediatrician Henry K. Silver united forces to establish the first NP program ().
      The advanced practice nursing movement originated during a period of shifting politics and social landscapes; as the Vietnam War's draft doubled, President Lyndon B. Johnson signed the Medicare Act of 1965 into law, which established Medicare and Medicaid. With elderly and low-income patients thus encouraged to use health care resources, the demand for high-quality primary and acute care skyrocketed and put pressure on the existing physician-led care model. It was also during 1965 that the American Nursing Association released their white paper “First Position on Education for Nursing.” A landmark publication in the nursing field, the paper encouraged a shift toward associate and baccalaureate education that emphasized both technical and practical learning and advocated for greater autonomy in nursing practice (
      • Donley R.
      • Flaherty M.J.
      Revisiting the American Nurses Association's first position on education for nurses.
      ).
      Nightingale wrote in 1860, “Were there none who were discontented with what they have, the world would never reach anything better” (
      • Nightingale F.
      Cassandra: Florence Nightingale's angry outcry against the forced idleness of Victorian women.
      ), and a little more than a century later, Ford, too, had her eyes set on “better.” She saw the opportunity posed by the shifting political and social landscapes to innovate and create quality clinical education content for public health nurses. In 1965, she partnered with Silver, a pediatrician who also saw a growing need for independent clinical practitioners, to grasp that opportunity. Together, in a move toward what they termed “role expansion,” Ford and Silver established the nation's first NP education program at the University of Colorado in 1965 with the goal of increasing the primary care workforce and, eventually, integrating the content into nursing master's programs. Ford, who was at the time the recently recused president of the Colorado Board of Nursing, went to the board with Silver to present their practices and get approval. (

      SUNY Polytechnic Institute (2013, May 1). Dr. Loretta Ford at SUNYIT NP teaching Day 2013 [Video file]. Retrieved from https://www.youtube.com/watch?v=34hZ5uvYWNM

      ). The first master's-level NP program was established at Boston College two years later in 1967.
      The NP profession and its dedication to elevating nursing clinicians proliferated, and by 1973 the United States offered more than 65 NP programs (). In that same year, the National Association of Pediatric Nurse Practitioners was established and became the first NP society and only professional organization dedicated to serving the needs of pediatric-focused advanced practice registered nurses (APRNs) and their patients. Over time, advanced NPs expanded into practice settings such as women's health and adult acute care.
      From the beginning of the NP movement and as the profession advanced, skeptics questioned the quality of care provided by the new advanced practice nurses graduating from the growing number of NP educational programs. In
      • Mundinger M.O.
      Advanced-practice nursing—Good medicine for physicians?.
      , Mary O'Neil Mundinger, founder of the first clinical nursing doctorate in the country and current dean emerita at the Columbia School of Nursing, answered the skeptics when she published “Advanced Practice Nursing—Good Medicine for Physicians” in The New England Journal of Medicine. The article explored the implications of early-1990s legislative decisions that allowed NPs to receive direct payment and prescribe medication and was a strong reinforcement of advanced practice providers’ ability to make primary care decisions “indistinguishable from their physician counterparts” (
      • Mundinger M.O.
      Advanced-practice nursing—Good medicine for physicians?.
      , p. 212). Mundinger also emphasized the particular strengths of NPs, including the level of expertise and experience they bring to patient-centered care.
      Ford frequently tells audiences that she dislikes the term “independent practitioner,” as she believes all practice requires teamwork and collaboration.
      • Mundinger M.O.
      Advanced-practice nursing—Good medicine for physicians?.
      , too, highlighted a “collaborative practice” (p. 211) model that emphasized a team orientation to make use of the various strengths of health care professionals. The designation of legal full practice authority to NPs, in whatever setting they practice, is nevertheless a move forward for the profession and its more than 270,000 members. As of 2020, 22 states grant full practice authority to advanced practice nursing professionals. In addition, the Department of Veterans Affairs established in a landmark 2016 move that most of its APRNs are authorized to practice “to the full extent of their education, training, and certification, without the clinical supervision of physicians,” regardless of state restrictions (

      Department of Veterans Affairs. (2016). Advanced Practice Registered Nurses. Washington, DC: National Archives. Retrieved fromhttps://www.federalregister.gov/documents/2016/12/14/2016-29950/advanced-practice-registered-nurses

      ).
      These strides, however, reveal the opportunity for greater acceptance of APRNs as practitioners who are capable and competent at serving patients on the front lines of health care. The designation of 2020 as Year of the Nurse and Midwife celebrates the accomplishments and high-quality health care that have moved the nursing field forward and encourage nurses to remember that, as Nightingale and Ford knew, there is always room for “better.”
      While National Association of Pediatric Nurse Practitioners honors our more than 9,000 members every day, we are pleased to be able to celebrate The Year of the Nurse and Midwife throughout 2020, especially during national Pediatric NP Week, March 23–29, 2020.

      References

      1. Department of Veterans Affairs. (2016). Advanced Practice Registered Nurses. Washington, DC: National Archives. Retrieved fromhttps://www.federalregister.gov/documents/2016/12/14/2016-29950/advanced-practice-registered-nurses

      2. American Association of Nurse Practitioners (AANP) (2019). Nurse practitioner timeline. Retrieved fromhttps://www.aanp.org/about/about-the-american-association-of-nurse-practitioners-aanp/historical-timeline

        • Donley R.
        • Flaherty M.J.
        Revisiting the American Nurses Association's first position on education for nurses.
        Online Journal of Issues in Nursing. 2002; 7 (Retrieved from)
        • Mundinger M.O.
        Advanced-practice nursing—Good medicine for physicians?.
        New England Journal of Medicine. 1994; 330: 211-214
        • Nightingale F.
        Cassandra: Florence Nightingale's angry outcry against the forced idleness of Victorian women.
        The feminist press at CUNY, New York, NY1979
      3. SUNY Polytechnic Institute (2013, May 1). Dr. Loretta Ford at SUNYIT NP teaching Day 2013 [Video file]. Retrieved from https://www.youtube.com/watch?v=34hZ5uvYWNM

      Biography

      Cate Brennan, Chief Executive Officer, National Association of Pediatric Nurse Practitioners, New York, NY