How Nurse Practitioners Obtained Provider Status: Lessons for Pharmacists

John Michael O'Brien


Am J Health Syst Pharm. 2003;60(22) 

In This Article

History of Nurse Practitioners

An overview of the nurse practitioner profession and its prescribing authority is provided in Appendix A.[4,5]

In the late 1950s and early 1960s, physicians began mentoring and collaborating with nurses who had clinical experience. In addition, increasing specialization in medicine led a large number of physicians out of primary care, creating a shortage of primary care physicians and leaving many areas, especially rural areas, medically underserved. In 1965, the Medicare and Medicaid programs provided health care coverage to low-income women, children, the elderly, and people with disabilities. The sudden availability of coverage increased the demand for expanded primary care services. Because physicians were unable to meet this demand, nurses "stepped into the breach."[4] Nursing leaders believed that nurses were qualified to expand their roles and meet the need.[6]

In 1965, Loretta Ford and Henry Silver, a nurse and a physician, created the first training program for nurse practitioners. The curriculum focused on health promotion, disease prevention, and the health of children and families.[7] According to Ford, society's demand for primary care services and nursing's potential to meet the need were the reasons for the development of nurse practitioners; the physician shortage merely provided the opportunity.[8,9] Others describe the physician shortage as the rationale for the expansion of nurse practitioner programs nationwide.[10,11]

Some nurses and physicians opposed the nurse practitioner model. Certain nursing leaders believed that nurse practitioners were no longer practicing nursing, that the title was "ambiguous and misleading," and that such training in primary care medicine would "control and devour nursing education and practice."[12] Organized medicine expressed opposition to the concept of a nurse "functioning in an expanded role not under [physicians'] direction," labeled the concept bad doctoring, and would concede only that these independent practitioners were physician extenders. Some in both nursing and medicine viewed this type of collaboration with alarm, suspicion, and distrust.

Nurse practitioners were created in an environment of informal training, a lack of credentialing processes, increasing sophistication of medical care, and opposition. In response to these challenges, nurse practitioners began to define and legitimize their profession. In the 1970s, they documented that they increased the availability of primary care services and that patients and physicians were satisfied with their care.[13,14,15,16,17,18] Health care faced new challenges in the early 1980s: The physician shortage became a surplus, and employers focused on controlling the skyrocketing cost of care. To address this, nurse practitioners conducted studies of increasing scientific rigor to establish their value.[19,20,21,22] A 1994 article in the New England Journal of Medicine concluded that, "When measures of diagnostic certainty, management competence, or comprehensiveness, quality, and cost are used, virtually every study indicates that the primary care provided by nurse practitioners is equivalent or superior to that provided by physicians.[23] Such articles and conclusions were vehemently disputed by many physicians, but nurse practitioners responded with still more data, including a randomized trial in the Journal of the American Medical Association supporting the hypothesis that primary care outcomes do not differ between nurse practitioner and physician delivery.[22] These findings spurred increasing utilization of nurse practitioners and would prove vital in establishing policies validating the profession.

Nurse practitioners continued to grow in number and autonomy in response to an expanding need for accessible, cost-effective care.[19,20] As their impact on health care increased, nurse practitioners sought greater professional and economic recognition. In an attempt to clarify the scope of practice and to meet federal regulations for reimbursement, advanced-practice nursing organizations began offering voluntary certifications and titles.[24] The result was a confusing list of titles and credentials that led to even more confusing scopes of practice and forms of reimbursement. The National Council of State Boards of Nursing ultimately defined advanced-practice nursing, established the master of science in nursing degree and licensure as a registered nurse as the minimum standards for certification, and recommended licensure as the preferred method for regulating the profession.[24,25,26]