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Advanced Nurse Practitioner: Growth, Organization, and Legislation
By admin 0 Comments Advanced Practice Registered Nurses (APRN)

Advanced Nurse Practitioner: Growth, Organization, and Legislation

Significant Growth in Advanced Nurse Practitioners

The latter part of the 20th century witnessed substantial growth in the number of Advanced Nurse Practitioners (ANPs) and their national organizations. The ANP role diversified significantly, giving rise to new specializations such as:

  • Emergency Nurse Practitioner
  • Neonatal Nurse Practitioner
  • Family Nurse Practitioner
  • Acute Care Nurse Practitioner

By 1984, approximately 20,000 graduates from ANP programs were employed in various settings envisioned by the founders (Kalisch & Kalisch, 1986, p. 715):

  • Outpatient clinics
  • Health maintenance organizations
  • Health departments
  • Community health centers
  • Rural clinics
  • Schools
  • Occupational health clinics
  • Private offices

Expansion to Tertiary Care Centers

By the late 1980s, ANPs, particularly those with specialty training, were increasingly employed in tertiary care centers, reflecting their success in neonatal intensive care units (Silver & McAtee, 1988).

Organizational Development and Legislative Influence

The multiple roles of ANPs created competing interests, impacting their ability to unify on legislative issues. Key organizational developments included:

  1. Primary Health Care Nurse Practitioner Council – Established by the ANA to address legislative challenges.
  2. American Academy of Nurse Practitioners – Formed in 1985 as the first organization for ANPs across all specializations.
  3. American College of Nurse Practitioners – Created in 1995 to serve as a “SWAT team” on policy during President Clinton’s healthcare reform initiative, aiming to unite all ANP organizations.

Legislative Milestones in the Early 1990s

Federal legislation in the early 1990s, particularly the Controlled Substances Act, significantly impacted ANP prescriptive authority:

  1. DEA’s Initial Proposal (1991) – Proposed registration for “affiliated practitioners” with prescriptive authority tied to a collaborating physician’s number. This was criticized and revoked in 1992.
  2. DEA’s Amended Regulations (1992) – Introduced the category of “mid-level providers” (MLPs), allowing ANPs to receive individual DEA numbers starting with an M, provided they had state-granted prescriptive authority.

Key Outcomes

  • The MLP provision, effective in 1993, greatly expanded ANPs’ ability to prescribe controlled substances (DEA, 1993).

Through these organizational and legislative advancements, Advanced Nurse Practitioners solidified their role and authority in the healthcare landscape, ensuring broader access to healthcare services and enhanced professional recognition.

Resistance to the Advanced Nurse Practitioner by Organized Medicine
By admin 0 Comments Advanced Practice Registered Nurses (APRN)

Resistance to the Advanced Nurse Practitioner by Organized Medicine

Overview

Although physicians and Advanced Nurse Practitioners (ANPs) collaborated at the local level, organized medicine began to express its resistance to the ANP role. One of the most contentious areas of interprofessional conflict involved prescriptive authority for nursing.

Nurse Practitioners and Prescriptive Privileges

The fight for prescriptive authority for Advanced Nurse Practitioners (ANPs) spanned the latter decades of the 20th century.

Historical Context

  • 1983: Only Oregon and Washington granted ANPs statutory, independent prescriptive authority.
  • Other States: Required direct supervision by a licensed physician.

Prescription Handling

  • Physician Availability: Depended on the negotiated boundaries of the physician–ANP team and locality.
  • Remote Clinics: Physicians might countersign prescriptions weekly or pre-sign prescription pads for ANPs.
  • State Variations: Practices varied, with some states requiring physicians to write and sign prescriptions at the ANP’s request.

Legal and Regulatory Developments

  • 1971: Idaho recognized diagnosis and treatment as part of the specialty nurse’s scope of practice.
  • Drug Enforcement Act: Required practitioners to obtain DEA registration numbers to prescribe controlled substances.

Progress and Challenges

Throughout the 1980s, ANPs worked tirelessly to convince state legislatures to pass laws and establish reimbursement policies that would support their practice. Interprofessional conflicts with organized medicine and, to a lesser extent, with pharmacists, centered on control issues and the degree of independence the ANP was allowed. These conflicts intensified as ANPs moved towards a more autonomous model.

Seminal Legal Case

Sermchief v. Gonzales (1983)

  • Initial Ruling: Missouri medical board charged two women’s healthcare ANPs with practicing medicine without a license.
  • Appeal: Missouri Supreme Court overturned the decision, allowing the scope of ANP practice to evolve without statutory constraints.

Policy and Perception

In 1986, a government report concluded that ANPs and Certified Nurse-Midwives provided care equivalent in quality to that provided by physicians. However, the American Medical Association House of Delegates opposed empowering nonphysicians to become unsupervised primary care providers.

Access to Cost-Effective, Quality Health Care for All Americans

Key Findings

  • 1986 Government Report: Concluded that ANPs provided care equivalent in quality to physicians within their areas of competence.

Opposition

  • American Medical Association: Passed a resolution to oppose any attempt at empowering nonphysicians to become unsupervised primary care providers and be directly reimbursed.

Summary

The evolution of prescriptive authority and practice autonomy for Advanced Nurse Practitioners has been marked by significant legislative and legal challenges. Despite resistance from organized medicine, ANPs have achieved recognition and expanded roles, contributing to accessible and high-quality healthcare.

The Concept of Advanced Nurse Practitioner
By admin 0 Comments Advanced Practice Registered Nurses (APRN)

The Concept of Advanced Nurse Practitioner

Defining Advanced Nurse Practitioner in the 1980s

During the 1980s, the concept of Advanced Nurse Practitioner (ANP) began to be defined and discussed extensively in the literature. In 1983, Harriet Kitzman, an associate professor at the University of Rochester, explored the interrelationships between Clinical Nurse Specialists (CNSs) and Nurse Practitioners (NPs). She used the term “advanced practice” throughout her discussion, applying it not only to advanced education but also to CNS and NP practice. Kitzman noted:

“Recognition for advanced practice competence is already established for both NPs and CNSs through the profession’s certification programs. … advanced nursing practice cannot be setting-bound, because nursing needs are not exclusively setting-restricted” (Kitzman, 1983, pp. 284, 288).

In 1984, Joy Calkin, an associate professor at the University of Wisconsin–Madison, proposed a model for advanced nursing practice. She specifically identified CNSs and NPs with master’s degrees as Advanced Practice Registered Nurses (APRNs).

Organizational Efforts and Integration

During the 1980s, significant efforts were made to explore the commonalities between the roles of CNSs and NPs:

  • The Council of Primary Health Care Nurse Practitioners and the Council of Clinical Nurse Specialists began examining their shared roles.
  • In 1988, these councils conducted a survey of all NP and CNS graduate programs, identifying considerable overlap in curricula.
  • Between 1988 and 1990, discussions about a merger took place, leading to the formation of the Council of Nurses in Advanced Practice in 1991.

Key Developments

  1. 1988-1990: Discussions and survey about merging roles.
  2. 1991: Formation of the Council of Nurses in Advanced Practice.

Despite the short-lived merger due to the restructuring of the American Nurses Association (ANA) in the early 1990s, this was a pivotal step in the organizational coalescence of advanced practice nursing.

Evolution of Advanced Nurse Practitioner Terminology

By the mid-1990s, the nursing literature increasingly used the term Advanced Nurse Practitioner to reflect an integrative vision of advanced practice. The first edition of this textbook, published in 1996, included Certified Registered Nurse Anesthetists (CRNAs) and Certified Nurse Midwives (CNMs) under the umbrella of advanced practice nursing.

Important Milestones

  • 1996: Publication of the first edition of the textbook, including CRNA and CNM roles.
  • Late 1990s: Increasing use of the term Advanced Nurse Practitioner in the literature.

The evolution of the Advanced Nurse Practitioner concept highlights the ongoing development and integration within the nursing profession.

Support From Physicians for Advanced Nurse Practitioners
By admin 0 Comments Advanced Practice Registered Nurses (APRN)

Support From Physicians for Advanced Nurse Practitioners

Increasing Acceptance Among Physicians

Despite resistance within the nursing profession, physicians have increasingly accepted Advanced Nurse Practitioners (ANPs) in individual healthcare practices. In these local practices, ANPs and MDs established collegial relationships, negotiating work boundaries and reaching agreements about their collaborative practice.

Negotiations in the ANP-MD Dyad

In the ANP-MD dyad, negotiations centered on the ANP’s right to practice essential parts of traditional medicine, including:

  • Performing physical examinations
  • Eliciting patient symptoms
  • Creating diagnoses
  • Formulating treatment options
  • Prescribing treatment
  • Making decisions about prognosis

(Fairman, 2002, pp. 163–164)

Importance of Proximity and Supervision

The proximity of a supervising physician was considered key to effective practice, and on-site supervision was the norm. Grassroots acceptance of the ANP role depended on tight physician supervision and control of the protocols under which ANPs practiced. This supervision benefitted newly certified, inexperienced ANPs. According to Corene Johnson:

“Initially, we had to always have a physician on site. … I didn’t resent that. Actually, I needed the backup” (Fairman, 2002, p. 164).

Intraprofessional Conflict Over the Advanced Nurse Practitioner Role
By admin 0 Comments Advanced Practice Registered Nurses (APRN)

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
By admin 0 Comments Advanced Practice Registered Nurses (APRN)

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
By admin 0 Comments Advanced Practice Registered Nurses (APRN)

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.