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Intraprofessional Conflict Over the Advanced Nurse Practitioner Role

Intraprofessional Conflict Over the Advanced Nurse Practitioner Role

Early Controversies in Educational Preparation

The role of the Advanced Nurse Practitioner (ANP) was not without significant intraprofessional controversy, particularly regarding educational preparation. Early on, certificate programs based on the Colorado project rapidly emerged. According to Ford (1991), some of these programs shifted the emphasis of ANP preparation from a nursing to a medical model, contrasting with the original University of Colorado demonstration project that stressed collaboration between nursing and medicine.

Major Areas of Academic Controversy

One of the major areas of controversy among academics was the fact that ANPs made medical diagnoses and wrote prescriptions for medications, essentially crossing the boundary between nursing and medicine outlined earlier in the century by the ANA. Because of this, some nurse educators and other nurse leaders questioned whether the ANP role could be conceptualized as being within the discipline of nursing, a profession historically ordered to care rather than cure (Reverby, 1987; Rogers, 1972).

Opposition from Nurse Theorists

  • Nurse theorist Martha Rogers, one of the most outspoken opponents of the ANP concept, argued that the development of the ANP role was a ploy to lure nurses away from nursing to medicine, thereby undermining nursing’s unique role in health care (Rogers, 1972).
  • Subsequently, nurse leaders and educators took sides for and against the establishment of educational programs for ANPs in mainstream master’s programs.

Formation of the National Organization of Nurse Practitioner Faculties (NONPF)

  1. In 1974, a group of pro-nurse practitioner faculty, already teaching in ANP programs, held their first national meeting in Chapel Hill, North Carolina.
  2. This meeting laid the foundation for the formation of the National Organization of Nurse Practitioner Faculties (NONPF).
  3. Over time, the standardization of ANP educational programs at the master’s level, initiated by the faculty who formed NONPF, would serve to reduce intraprofessional tension.

Support from Health Policymakers

While nursing professors debated the discipline’s responsibility to educate ANPs, the ANP role attracted considerable attention from health policymakers. Health policy groups, such as the National Advisory Commission on Health Manpower, issued statements in support of the ANP concept (Moxley, 1968). At the grassroots level, physicians accepted the new role and hired ANPs—they needed the help.

Government Initiatives and Support

  • Early in the 1970s, the US Department of Health, Education, and Welfare Secretary Elliott Richardson established the Committee to Study Extended Roles for Nurses.
  • This committee was charged with evaluating the feasibility of expanding nursing practice (Kalisch & Kalisch, 1986).
  • The committee concluded that extending the scope of the nurse’s role was essential to providing equal access to health care for all Americans.

The kind of health care Lillian Wald began preaching and practicing in 1893 is the kind the people of this country are still crying for. (Schutt, 1971, p. 53)

Recommendations from the Committee

  • Establish innovative curricular designs in health science centers
  • Increase financial support for nursing education
  • Standardize nursing licensure and national certification
  • Develop a model nurse practice law suitable for national application
  • Conduct further research related to cost-benefit analyses and attitudinal surveys to assess the effect of the ANP role

The committee’s report resulted in increased federal support for training programs for the preparation of several types of ANPs, including family ANPs, adult ANPs, and emergency department ANPs (Kalisch & Kalisch, 1986).

The Importance of Primary Care in the Mid-20th Century

The Importance of Primary Care in the Mid-20th Century

Introduction of the Advanced Nurse Practitioner Role

The concept of the Advanced Nurse Practitioner (ANP) emerged in the 1960s, a time when outpatient pediatric clinics began to formalize and implement this role. This initiative was partly a response to the shortage of primary care physicians. As medical specialization grew, many physicians moved away from primary care, leading to numerous areas in the country being underserved.

Challenges in Primary Care

  • The American Medical Association (AMA) and the Association of American Medical Colleges frequently reported a shortage of physicians in poor rural and urban areas (Fairman, 2002, p. 163).
  • During this period, there was a growing demand for accessible, affordable, and sensitive healthcare.
  • Healthcare delivery costs were escalating annually by 10% to 14% (Jonas, 1981).

The Birth of the Modern Advanced Nurse Practitioner Role

Key Milestone

The establishment of the first pediatric Nurse Practitioner (PNP) program by Loretta Ford, RN, and Henry Silver, MD, at the University of Colorado in 1965, marked the inception of the modern Advanced Nurse Practitioner role.

Program Objectives

  • Funded by the Commonwealth Foundation, the program aimed to prepare professional nurses to provide comprehensive well-child care and manage common childhood health problems.
  • The 4-month program educated certified registered nurses as PNPs without requiring a master’s degree, emphasizing health promotion and family inclusion.

Program Outcomes

  1. The study evaluating the project demonstrated:

    • PNPs were highly competent in assessing and managing 75% of well and ill children in community health settings.
    • PNPs increased the number of patients served in private pediatric practice by 33% (Ford & Silver, 1967).
  2. Positive findings from early nurse-midwife and nurse anesthetist studies supported this new nursing role.

Loretta Ford: Cofounder of the Pediatric Nurse Practitioner Role

Exemplar 1.4

  • In the 1960s in Colorado, nurse Loretta Ford and Dr. Henry Silver, a pediatrician, introduced the concept of the nurse practitioner.
  • Both recognized the potential of expanding access to healthcare by enabling nurses to practice to the fullest extent of their advanced nursing education.
  • The term “nurse practitioner” was coined to emphasize the clinical practice role (Jacox, 2002, p. 162).
  • According to Ford, nurse practitioners should diagnose and treat patients within the context of the patient’s health status, social qualities, physical characteristics, and economic realities.

The establishment and success of the first PNP program were pivotal in demonstrating the capability and importance of Advanced Nurse Practitioners. This role has continued to evolve, significantly contributing to healthcare accessibility and quality, particularly in underserved areas.

The Evolution of Primary Care: The Role of Advanced Nurse Practitioners

The Evolution of Primary Care: The Role of Advanced Nurse Practitioners

Early Roots of Primary Care

The concept of primary care services has deep roots in the late 19th-century urban areas of the Northeastern United States. Public health nurses played a pivotal role, visiting patients at home to assess and provide medical care.

Notable Early Initiatives

  • Boston: The Boston Instructive District Nurses cared for thousands of patients and their families.
  • Philadelphia: The Visiting Nurse Society addressed the needs of patients and their families.
  • New York: The Visiting Nurse Service of the Henry Street Settlement (HSS) catered to newly arrived immigrants on the Lower East Side.

The Henry Street Settlement: A Case Study

In 1893, Lillian Wald, a graduate nurse, established the Henry Street Settlement (HSS) House in Manhattan. The HSS nurses faced numerous challenges while addressing the needs of a disadvantaged immigrant community living in overcrowded, unsanitary conditions.

Challenges Faced by HSS Nurses

  • High infant mortality due to summer bowel complaints.
  • Children suffering from measles, ophthalmia, and vermin bites.
  • Adults with typhoid and tuberculosis.

Overcoming Interprofessional Conflicts

To resolve conflicts with physicians, HSS nurses obtained standing orders from local doctors to administer emergency medications and treatments. Despite the tensions, the HSS nursing service continued to provide essential care until the 1950s.

Frontier Nursing Service: Pioneering Primary Care

Nurses in rural America, such as those with the Frontier Nursing Service (FNS) in Leslie County, Kentucky, provided extensive primary care services, functioning in roles similar to modern-day Advanced Nurse Practitioners.

Services Provided by FNS Nurses

  1. Diagnosing and Treating: Nurses made diagnoses and provided treatments, including the administration of herbs and medicines.
  2. Emergency Care: Nurses handled emergencies, from gunshot wounds to burns and infectious diseases.
  3. Medication Dispensing: They dispensed a variety of medicines, including aspirin, ipecac, and morphine.

Nursing in Migrant Camps and Indian Reservations

During the 1930s, nurses provided critical care in migrant camps and Indian reservations, often acting autonomously due to the lack of access to physicians.

Farm Security Administration (FSA) Nurses

  • Staffed well-baby clinics and coordinated immunization programs.
  • Wrote prescriptions and dispensed drugs from the clinic formulary.
  • Provided emergency care and referrals as needed.

Bureau of Indian Affairs (BIA) Nurses

  • Conducted well-baby “nursing conferences” in the Navajo reservation, focusing on health promotion and disease prevention.
  • Provided primary care to children with common ailments, such as ear infections and sore throats.
The evolution of primary care highlights the significant contributions of Advanced Nurse Practitioners (ANPs). From urban settlements to rural frontiers, and migrant camps to Indian reservations, ANPs have consistently provided essential health services, demonstrating their crucial role in healthcare delivery.