- Email: [email protected]
A deviant comes of age
A d e v i a n t c o m e s of a g e L o r e t t a C. Ford, RN, EdD, FAAN, Rochester, N.Y.
Reflecting on 30 years of sociopolitical and professional changes in health care, the cofounder of the nurse practitioner movement compares and contrasts enabling environments, past and present, with the introduction and growth of the nurse practitioner. Differing responses of individual groups and institutions and research thrusts are reported as health care reforms offer new opportunities for the introduction of the nurse practitioner in acute care services. (Heart Lung ® 1997;26:87-91)
eflecting on 30 years of social and professional changes that have influenced the growth and development of the nurse practitioner (NP) in community-based services leads to comparing and contrasting the factors and forces that influenced the advanced practice of nursing in the past with current trends and events. The advent of the NP in acute care is a case in point. In 1979 my prediction was that the deviant of yesteryear, the NP, would become the norm and then the tradition of tomorrow in all settings.~ The NP is at last coming of age as one model of advanced practice along with nurse-midwives, clinical nurse specialists, and nurse anesthetists. Lessons of the past might be instructive, enlightening, and encouraging for those who choose a path not yet trod, such as that of the acute care nurse practitioner (ACNP). Sociopolitical and professional environments, responses of individual groups and institutions, and the research data base are all factors and forces to consider in social changes that have an impact on health and nursing.
R
SOCIOPOLITICAL AND SIONAL ENVIRONMENTS
PROFES-
In 1965 when the NP was born, there were enabling social, political, and professional environments to welcome the birth. President Lyndon From the Schoolof Nursing, Universityof Rochester. Reprint requests:Loretta C. Ford, RN, EdD, Professorand Dean Emerita, School of Nursing, University of Rochester, 60I Elmwood Ave., Rochester,NY 14642. Copyright © 1997by Mosby-YearBook, Inc. 0147-9563/$5.00+ 0 2/1/79974 HEART & LUNG VOL 26, NO. 2
B. Johnson had declared war on poverty, introd u c e d social programs to assist d e p r i v e d and d e p r e s s e d populations, including Medicare and Medicaid, and s u p p o r t e d educational initiatives amidst turbulent social unrest and public dissension a b o u t the Vietnam war, civil rights, and social entitlements, including health care. The professional e n v i r o n m e n t s were no less chaotic. Medicine was experiencing a technologic and informational revolution, t r e m e n d o u s expansions of specialties and subspecialties, and criticism for the maldistribution of its resources, b y specialty and by geography. Although demands for generalized primary care rose, and rural areas and inner cities were underserved, educational programs for physicians in academic health centers responded all too slowly. Incentives in income, status, and lifestyle favored specialization. Nursing too was struggling to change. Practice was expanding rapidly because of technologic advances, the knowledge explosion, and specialization. Education for entry into practice, although declared by the American Nurses Association as the baccalaureate degree, was by no means universally accepted in the profession. Graduate education in nursing was beginning to focus on the profession's centrality of interest: investigation and attention in caring for the patient. Clinical specialties were born, and nursing education responded by designating fields of study: maternal and child care, public health nursing (community health nursing), psychiatric nursing, and medicaLsurgical nursing. Functional areas of supervision, administration, consultation, and education became minor content areas. The identification of clinical content in nursing specialties was a major 87
preoccupation of faculties in a group of western schools of nursing. 2 From this base in community health nursing, the pediatric nurse practitioner (PNP) program was created. It was a demonstration project to expand the nurse's role in well child care. Academic standards were maintained, nursing and public health values (health maintenance and prevention) emphasized, and the potential for integration of content and processes into collegiate programs studied. The PNP was not a substitute for the physician; their relationship was envisioned as collaborative and collegial. 3 The nursing profession's explorations delved into the identification of the nature of the field and the differentiation of caring from curing and the scopes of practice. These explorations, nursing's social mandate, and growing emphasis on clinical research guided the development of the NP concept. Examination of the health needs of children via surveys and interviews with families, public health nurses, and physicians provided the wellness framework that dominated the first PNP program. Determining a child's state Of health required a comprehensive physical, psychosocial, and developmental assessment. It was the basis for identifying deviations from wellness and needs for maintenance and emergency care. These social, political, and professional factors created an enabling environment to experiment, to demonstrate, and to introduce new ideas. RESPONSES OF INDIVIDUAL GROUPS AND INSTITUTIONS
Chaos is always opportunity, but the responses of individual groups and societal institutions to maintain the status quo were surprisingly negative. Perhaps it was a sign of the times: uncertainties, heightened suspicions, fear of the unknown, and threat of change. The immediate resistance to the PNP came from faculty colleagues in nursing education, especially graduate faculty, the power bloc in most schools. Certain questions, born out of suspicion and distrust, were raised. Was medicine not trying to co-opt nursing students and control nursing education and practice? Physicians as teachers and preceptors were anathema in nursing education, as was the expectation that faculty should be engaged in practice. Was it legal for nurses, except for public health nurses who were already engaged in the decision-making processes on health status, to make comprehensive physical appraisals, much less physical examinations? (Using the words physical examination was complete heresy.) Would patients and physicians accept PNPs?
88
All this despite the profession's proclamations that the nature of nursing was in caring for and about people in an accountable, autonomous way that required the use of the nursing process and clinical judgment. While maintaining the integrity of their discipline, nurses were expected to function collaboratively as team members with physicians. However, without the embrace, acceptance, and leadership of nurse educators to shape and institutionalize the role, demands for NP specialty programs were met by short-term, continuing education offerings by medical schools and service and voluntary agencies. Professional organizations, mired in rhetorical debates, bureaucratic structures, and internal dissension regarding entry into practice, were slow to respond to the growing groups of NPs for affiliation and recognition. NPs therefore began to build their own guilds, set standards, and even seek credentialing from other than the unresponsive nursing groups. RESEARCH
Additionally and defensively, studies of the NP, descriptive and otherwise, began to appear. For political reasons, the focus of these inquiries and descriptions was on comparing physician and NP practices. Myriad studies and reports on NP preparation, performance, placement, and potential have since been conducted over a 30-year period. Earlier doubts were finally laid to rest by the Office of Technology Assessment in 1986 in its comprehensive literature review, which concluded that NPs in primary and ambulatory care "within their areas of competence...provide care whose quality is equivalent to that of care provided by physicians" and are "more adept than physicians at providing services that depend on communication with patients and preventive action. ''4 Over 30 years, NP specialty programs have grown up in primary care services, demands have increased appreciably, and graduate nursing education finally responded. Changes are occurring, albeit slowly, in reimbursement, legislation, credentialing, and accreditation in nursing; in practice and prescription privileges; and in differentiation of practice in institutions. Although a bleak future was predicted for the NP in the first decade, 5,6 NPs rather quickly demonstrated that they were clinically skilled, safe, affordable, quality-oriented, collaborative practitioners. They served as consumer advocates and partners, teachers, counselors, and case managers along with other advanced practice nurses (APNs). Many generated knowledge and are
MARCH/APRIL1997 HEART & LUNG
now conducting clinical studies in the caring phenomenon. They have become a political force professionally, influencing education, practice, public policy, legislation, and leadership in professional organizations. Malpractice suits were and still are nil. Until the last few years, the introduction of the NP into acute care settings was highly individualized by institution. In the 1970s, hospitals employed NPs in neonatal intensive care, cardiothoracic surgery, and a few other specialties. 7,a Most of these NPs were either "home grown" or transferred from ambulatory services to inpatient. Few continuing education programs were available, and graduate programs, if they had NP offerings, were dedicated to primary and ambulatory care. CURRENT SOCIOPOLITICAL AND PROFESSIONAL ENVIRONMENTS Today, much like those early years, the sociopo~ litical and professional environments are turbulent, unsettled, and uncertain. Domestically, the national budget deficit is the driving force behind every social, political, and technologic decision and has an impact on the health care industry as well. Thirty years ago we argued about whether nurses could use otoscopes and stethoscopes to make clinical decisions. Now we have machines to collect, interpret, and transmit information on vital and other signs and symptoms. No longer submissive, patients are seeking second opinions by means of their own computers with access to medical libraries and information systems. Telediagnostic services are available from specialists around the world, and concerns for global health are escalating. 9 The hospital scene has changed appreciably as well. Only the very sick and complex patients are cared for within the acute care settings, and the demand for better-prepared nurses has skyrockete d - - n o t only to provide specialty care but also to replace physicians, residents, and house officers, who are no longer available or affordable. Availability of physicians is threatened by the maldistribution of specialists versus generalists, the cutbacks mandated by law in residents' clinical hours, the expense and time it takes to prepare physicians, and the dwindling federal support for medical education. The situation is not unlike that in the 1960s when a shortage of physicians and geographic and specialty maldistribution existed; it is often mistakenly reported that the PNP came into being to relieve this situation. Patently untrue, but the same condition in the mid-1960s did give
HEART & LUNG *COL.26, NO. 2
rise to the opportunity to introduce an expanded role for public health nurses. Currently, the rationale for needed changes in health care does have social and political concerns. The twenty-first century health professionals will experience the aging of the 76 million "baby boomers." This group is better educated, culturally diverse, and health conscious; they are independent thinkers, computer sawy, and wise in the ways the world and health care system work or do not work. They have high expectations and are not likely to be silent partners in the political processes that shape policy. In addition, more than 70 million people are without health insurance or underinsured, and there are complaints of high costs and maldistribution of health services. The economic response has been dramatic: in the hope of changing incentives and rewards while controlling costs, managed care (health maintenance organizations) has become the favored solution, creating a "paradigm shift." It is characterized by shifting services from inpatient to outpatient, from specialist care to primary care, from acute care to diagnosis and prevention, and from clinical technologies to information systems. ~° This trend is creating a "massive deployment of capital" to accommodate reallocations and differing types of population needs for health, not necessarily medical, services. Managed care is a familiar work environment to NPs who have been invisible providers in health maintenance organizations for almost 30 years. RESPONSES OF INDIVIDUAL GROUPS AND SOCIETAL INSTITUTIONS Now, the environments are once again amenable to change. The opportunities and demands for NPs in acute care have escalated. However, the responses of individuals and educational, service, and professional institutions to NPs in acute care are quite different from those 30 years ago. As hospitals experience severe reductions in occupancy, rising costs, competitive markets, and managed care constraints, they are once again turning to nurses, especially APNs, to help rescue their struggling institutions. Because NPs have amply demonstrated their success in primary care, it was no great surprise to learn of the hospitals' interest in using them to contain costs. (Although there is a paradox here as hospitals downsize and replace well-qualified registered nurses with unlicensed assistive personnel to care for the hospitals' most important product-patients. A short-term gain augurs well a long loss.
89
An institution's reputation and image of quality and caring once lost is hard to regain.) Schools of nursing are also responding positively. A recent study on NP education programs by Harper and Johnson for the National Organization of Nurse Practitioner Faculties shows that a "dramatic increase occurred between 1992 and 1995...with a 69% increase in the number of institutions offering NP clinical tracks, and 108% increase in the total number of clinical tracks offered."11 Shifts between NP primary care and NP specialty tracks are also noticeable as are the expansions in NP post-master's degree offerings for clinical specialists. Another stratagem used, although not universally agreed on, was the blending of the clinical nurse specialist role with that of the NP to produce master's graduates with "a common core of knowledge, skills and competencies, and professional attributes ''~2 Professional organizations, notably the American Association of Colleges of Nursing, the American Nurses Association, and NP specialty groups have responded with leadership strategies, such as Consensus Conferences, information gathering and research, and the setting of standards of practice, accreditation criteria, and credentialing to accommodate recognition and reward. These organizations also provide continuing education to maintain clinical competence and training for NPs to become a vital force in political and policy decisions. 13,14 There is still a great deal to do intraprofessionally to bring all organizations together so that they can speak with one strong voice politically. States' scope of practice laws and federal regulations in their current confused state serve very poorly the public or the practitioner. Preferably, APNs would be certified, as other professionals are, by their own professional associations rather than through state laws. Abolishing the current varieties of restrictive legislation will not be easy, but it must be done. The interest of the public and the profession are at stake. Attention to Safriet's ~ salient arguments on the role of advanced practice nursing could bring order out of this legislative chaos. Issues such as those the NPs of earlier years faced in reimbursement, legislation, practice and prescription privileges, and relationships with medical colleagues and hospital administrators are still challenging this newest group of ACNPs. Overcoming these barriers will require great political acumen, professional unity, and financial resources. RESEARCH
What should be the thrust of research as the NP moves into acute care? The first reaction has 90
been to compare "nonphysicians," for example, NPs, with medical residents, just as the early NPs were compared with physicians. ~3,16 Continuity and quality of care by NPs is demonstrable, and the costs, especially over time, appear to be reasonable. The professional nursing values and behaviors bring a dimension now missing in care by medical residents. Riportella-Muller et al. ~7 refer to this as role enhancement, and Daly ~8 defines several additional functions, such as efficiency in clinical skills, shepherding patients through the system, and quality improvement management. But medical practice outcomes are not the gold standard for nursing practice research. True, there are complementarities that lend themselves to interdisciplinary inquiry, and APNs should participate as coinvestigators with physicians and others in studying health outcomes of their collaborative efforts. However, advanced practice nursing, which is a preferable generic category NPs now join, must move beyond comparing its nursing expertise with the expertise of physicians, residents, and other medical personnel. As Ackerman et al. 19 demonstrate in their conceptual model of advanced practice, APNs must begin to study the structure, process, and outcome in the centrality of the profession's interest, concern, and values--the patient and family. In addition, APNs need to conduct sophisticated clinical and economic studies and inquiries into the system's policies and practices that affect the patient care outcomes. Longitudinal studies of outcome to include hospital lengths of stay, readmission rates, patient and family education, and resumption of functional status and work productivity should provide telling evidence of the efficacy, efficiency, economy, and patient-family satisfactions of the systems of care. Further, studies by the profession must address concerns for society's health work force needs and the quality and costs of the educational programs, the preparation of their faculties and NP preceptors, and the adequacy of clinical resources. In comparing and contrasting current APN trends with 30 years of change, we can only be encouraged and enlightened by history. Predictions for APNs in the twenty-first century are for a bright future in all settings. Perhaps Boodley says it best: The location of care has been less important to the success of the NP role than the fundamental philosophy and attributes of the practice. The keys to the successof the NP role have been the autonomous yet collaborative nature of the practice, accountability as a direct provider of h e a l t h care services, e m p h a s i s o n clinical d e c i s i o n making as a f o u n d a t i o n clinical skill, a focus on h e a l t h
MARCH/APRIL 1997 HEART & LUNG
and healthy lifestyles as a f o u n d a t i o n of practice and the cost-effective, accessible nature of the practice. These basic a t t r i b u t e s of the NP role a n d NP practice h o l d true regardless of setting or s p e c i a l t y focus. 2° The deviant
of yesteryear has indeed
come of
age. 1 t h a n k Professor M i c h a e l A c k e r m a n a n d g r a d u a t e s t u d e n t D i a n e M i c k of t h e U n i v e r s i t y of R o c h e s t e r and Director and Lecturer Deborah Chyun, A d u l t A d v a n c e d Practice N u r s i n g Program, a n d g r a d u a t e stud e n t Susan D a n i e l l of Yale U n i v e r s i t y for t h e i r assistance in g e n e r o u s l y sharing resources.
REFERENCES 1. Ford LC. A nurse for all settings: the nurse practitioner. Nuts Qutlook 1979;27:516-21. 2. Ford LC, Cobb M, Taylor M. Defining clinical content, graduate nursing programs, community health nursing. Boulder (CO): Western Interstate Commission on Higher Education, Western Interstate Council on Nursing Education, 1967. 3. Ford LC, Silver HK. Expanded role of the nurse in child care. Nuts Outlook 1967;15(9):43-5. 4. US Qffice of Technology Assessment. Nurse practitioners, physicians, assistants, and certified nurse midwives: policy analysis. Washington (DC): Government Printing Office, 1986:5. 5. Spitzer W. The nurse practitioner revisited--slow death of a good idea. N Engl J Med 1984;310:1049-52. 6. Weston Jb. Whither the "nurse" in nurse practitioner? Nurs Outlook 1975;12:148-52. 7. Schultz JM, Fioravanti J, Liptak G. Nurse practitioners' effectiveness in NICU. Nurs Manage I994;25(I0):50-3. 8. Davitt PA, Jensen LA. The role of acute care nurse practitioner in cardiac surgery. On the Scene: University of Rochester Medical Center, Nursing Administration Quarterly 198 I;5( 1): 16-9. 9. Feachem RGA. Global health. 2020 Vision, health in the 21st century. Washington (DC):institute of Medicine, 1996:37-44.
10. The Advisory Board Co., the Governance Committee. Vision of the future. Washington (DC): Advisory Board Co, 1993:57. I I. Harper DC, Johnson ]. NONPF workforce policy project technical report: nurse practitioner educational programs 19881995. NONPF: Washington DC, 1996. 12. Shuren AW. The blended role of the clinical specialist and the nurse practitioner. In: Hamric AB, Spross/A, Hanson CM, editors. Advanced nursing practice, an integrative approach. Philadelphia: WB Saunders, I996:375-94. 13. American Association of Colleges of Nursing. 199&I995 Special report on master's and post-master's nurse practitloner programs, faculty clinical practice, faculty age profiles, and undergraduate curriculum expansion in baccalaureate programs in nursing. Washington (DC): The Association, ~995. 14. American Nurses Association. News release. Washington (DC), 11 Mar I996. 15. Safriet BJ. Health care dollars and regulatory sense: the role of advanced practice nursing. Yale Journal of Regulation 1992;9:417-87. 16. Knickman JR, Lipkin M, Finkler SA, Thompson WG, Kiel J. The potential for using non-physicians to compensate for the reduced availability of residents. Acad Med 1992;67:429-38. 17. Riportella-Muller R, Libby D, Kindig D. Data watch. The substitution of physician assistants and nurse practitioners for physician residents in teaching hospitals. Health Aft (Millwood) 1995;14:181-9l. 18. Daly BJ. The acute care nurse practitioner: education, practice, certification. In: Role differentiation of the nurse practitioner and clinical nurse specialist: reaching toward consensus. American Association of Colleges of Nursing proceedings of the Master's Education Conference; 1994 Dec 8-10; San Antonio (TX):33-48. 19. Ackerman MH, Norsen L, Martin B, Wiedrich J, Kitzman H. Development of a model of advanced practice. Am J Crit Care 1996;5:68-73. 20. Boodley CA. Nurse practitioner educationaI guidelines: program standards, curriculum, and graduate outcomes. In: Role differentiation of the nurse practitioner and clinical nurse specialist: reaching toward consensus. American Association of Colleges of Nursing proceedings of the Master's Education Conference; 1994 Dec 8-10; San Antonio (TX/.
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HEART & LUNG VOL. 26, NO. 2
91
Reflecting on 30 years of sociopolitical and professional changes in health care, the cofounder of the nurse practitioner movement compares and contrasts enabling environments, past and present, with the introduction and growth of the nurse practitioner. Differing responses of individual groups and institutions and research thrusts are reported as health care reforms offer new opportunities for the introduction of the nurse practitioner in acute care services. (Heart Lung ® 1997;26:87-91)
eflecting on 30 years of social and professional changes that have influenced the growth and development of the nurse practitioner (NP) in community-based services leads to comparing and contrasting the factors and forces that influenced the advanced practice of nursing in the past with current trends and events. The advent of the NP in acute care is a case in point. In 1979 my prediction was that the deviant of yesteryear, the NP, would become the norm and then the tradition of tomorrow in all settings.~ The NP is at last coming of age as one model of advanced practice along with nurse-midwives, clinical nurse specialists, and nurse anesthetists. Lessons of the past might be instructive, enlightening, and encouraging for those who choose a path not yet trod, such as that of the acute care nurse practitioner (ACNP). Sociopolitical and professional environments, responses of individual groups and institutions, and the research data base are all factors and forces to consider in social changes that have an impact on health and nursing.
R
SOCIOPOLITICAL AND SIONAL ENVIRONMENTS
PROFES-
In 1965 when the NP was born, there were enabling social, political, and professional environments to welcome the birth. President Lyndon From the Schoolof Nursing, Universityof Rochester. Reprint requests:Loretta C. Ford, RN, EdD, Professorand Dean Emerita, School of Nursing, University of Rochester, 60I Elmwood Ave., Rochester,NY 14642. Copyright © 1997by Mosby-YearBook, Inc. 0147-9563/$5.00+ 0 2/1/79974 HEART & LUNG VOL 26, NO. 2
B. Johnson had declared war on poverty, introd u c e d social programs to assist d e p r i v e d and d e p r e s s e d populations, including Medicare and Medicaid, and s u p p o r t e d educational initiatives amidst turbulent social unrest and public dissension a b o u t the Vietnam war, civil rights, and social entitlements, including health care. The professional e n v i r o n m e n t s were no less chaotic. Medicine was experiencing a technologic and informational revolution, t r e m e n d o u s expansions of specialties and subspecialties, and criticism for the maldistribution of its resources, b y specialty and by geography. Although demands for generalized primary care rose, and rural areas and inner cities were underserved, educational programs for physicians in academic health centers responded all too slowly. Incentives in income, status, and lifestyle favored specialization. Nursing too was struggling to change. Practice was expanding rapidly because of technologic advances, the knowledge explosion, and specialization. Education for entry into practice, although declared by the American Nurses Association as the baccalaureate degree, was by no means universally accepted in the profession. Graduate education in nursing was beginning to focus on the profession's centrality of interest: investigation and attention in caring for the patient. Clinical specialties were born, and nursing education responded by designating fields of study: maternal and child care, public health nursing (community health nursing), psychiatric nursing, and medicaLsurgical nursing. Functional areas of supervision, administration, consultation, and education became minor content areas. The identification of clinical content in nursing specialties was a major 87
preoccupation of faculties in a group of western schools of nursing. 2 From this base in community health nursing, the pediatric nurse practitioner (PNP) program was created. It was a demonstration project to expand the nurse's role in well child care. Academic standards were maintained, nursing and public health values (health maintenance and prevention) emphasized, and the potential for integration of content and processes into collegiate programs studied. The PNP was not a substitute for the physician; their relationship was envisioned as collaborative and collegial. 3 The nursing profession's explorations delved into the identification of the nature of the field and the differentiation of caring from curing and the scopes of practice. These explorations, nursing's social mandate, and growing emphasis on clinical research guided the development of the NP concept. Examination of the health needs of children via surveys and interviews with families, public health nurses, and physicians provided the wellness framework that dominated the first PNP program. Determining a child's state Of health required a comprehensive physical, psychosocial, and developmental assessment. It was the basis for identifying deviations from wellness and needs for maintenance and emergency care. These social, political, and professional factors created an enabling environment to experiment, to demonstrate, and to introduce new ideas. RESPONSES OF INDIVIDUAL GROUPS AND INSTITUTIONS
Chaos is always opportunity, but the responses of individual groups and societal institutions to maintain the status quo were surprisingly negative. Perhaps it was a sign of the times: uncertainties, heightened suspicions, fear of the unknown, and threat of change. The immediate resistance to the PNP came from faculty colleagues in nursing education, especially graduate faculty, the power bloc in most schools. Certain questions, born out of suspicion and distrust, were raised. Was medicine not trying to co-opt nursing students and control nursing education and practice? Physicians as teachers and preceptors were anathema in nursing education, as was the expectation that faculty should be engaged in practice. Was it legal for nurses, except for public health nurses who were already engaged in the decision-making processes on health status, to make comprehensive physical appraisals, much less physical examinations? (Using the words physical examination was complete heresy.) Would patients and physicians accept PNPs?
88
All this despite the profession's proclamations that the nature of nursing was in caring for and about people in an accountable, autonomous way that required the use of the nursing process and clinical judgment. While maintaining the integrity of their discipline, nurses were expected to function collaboratively as team members with physicians. However, without the embrace, acceptance, and leadership of nurse educators to shape and institutionalize the role, demands for NP specialty programs were met by short-term, continuing education offerings by medical schools and service and voluntary agencies. Professional organizations, mired in rhetorical debates, bureaucratic structures, and internal dissension regarding entry into practice, were slow to respond to the growing groups of NPs for affiliation and recognition. NPs therefore began to build their own guilds, set standards, and even seek credentialing from other than the unresponsive nursing groups. RESEARCH
Additionally and defensively, studies of the NP, descriptive and otherwise, began to appear. For political reasons, the focus of these inquiries and descriptions was on comparing physician and NP practices. Myriad studies and reports on NP preparation, performance, placement, and potential have since been conducted over a 30-year period. Earlier doubts were finally laid to rest by the Office of Technology Assessment in 1986 in its comprehensive literature review, which concluded that NPs in primary and ambulatory care "within their areas of competence...provide care whose quality is equivalent to that of care provided by physicians" and are "more adept than physicians at providing services that depend on communication with patients and preventive action. ''4 Over 30 years, NP specialty programs have grown up in primary care services, demands have increased appreciably, and graduate nursing education finally responded. Changes are occurring, albeit slowly, in reimbursement, legislation, credentialing, and accreditation in nursing; in practice and prescription privileges; and in differentiation of practice in institutions. Although a bleak future was predicted for the NP in the first decade, 5,6 NPs rather quickly demonstrated that they were clinically skilled, safe, affordable, quality-oriented, collaborative practitioners. They served as consumer advocates and partners, teachers, counselors, and case managers along with other advanced practice nurses (APNs). Many generated knowledge and are
MARCH/APRIL1997 HEART & LUNG
now conducting clinical studies in the caring phenomenon. They have become a political force professionally, influencing education, practice, public policy, legislation, and leadership in professional organizations. Malpractice suits were and still are nil. Until the last few years, the introduction of the NP into acute care settings was highly individualized by institution. In the 1970s, hospitals employed NPs in neonatal intensive care, cardiothoracic surgery, and a few other specialties. 7,a Most of these NPs were either "home grown" or transferred from ambulatory services to inpatient. Few continuing education programs were available, and graduate programs, if they had NP offerings, were dedicated to primary and ambulatory care. CURRENT SOCIOPOLITICAL AND PROFESSIONAL ENVIRONMENTS Today, much like those early years, the sociopo~ litical and professional environments are turbulent, unsettled, and uncertain. Domestically, the national budget deficit is the driving force behind every social, political, and technologic decision and has an impact on the health care industry as well. Thirty years ago we argued about whether nurses could use otoscopes and stethoscopes to make clinical decisions. Now we have machines to collect, interpret, and transmit information on vital and other signs and symptoms. No longer submissive, patients are seeking second opinions by means of their own computers with access to medical libraries and information systems. Telediagnostic services are available from specialists around the world, and concerns for global health are escalating. 9 The hospital scene has changed appreciably as well. Only the very sick and complex patients are cared for within the acute care settings, and the demand for better-prepared nurses has skyrockete d - - n o t only to provide specialty care but also to replace physicians, residents, and house officers, who are no longer available or affordable. Availability of physicians is threatened by the maldistribution of specialists versus generalists, the cutbacks mandated by law in residents' clinical hours, the expense and time it takes to prepare physicians, and the dwindling federal support for medical education. The situation is not unlike that in the 1960s when a shortage of physicians and geographic and specialty maldistribution existed; it is often mistakenly reported that the PNP came into being to relieve this situation. Patently untrue, but the same condition in the mid-1960s did give
HEART & LUNG *COL.26, NO. 2
rise to the opportunity to introduce an expanded role for public health nurses. Currently, the rationale for needed changes in health care does have social and political concerns. The twenty-first century health professionals will experience the aging of the 76 million "baby boomers." This group is better educated, culturally diverse, and health conscious; they are independent thinkers, computer sawy, and wise in the ways the world and health care system work or do not work. They have high expectations and are not likely to be silent partners in the political processes that shape policy. In addition, more than 70 million people are without health insurance or underinsured, and there are complaints of high costs and maldistribution of health services. The economic response has been dramatic: in the hope of changing incentives and rewards while controlling costs, managed care (health maintenance organizations) has become the favored solution, creating a "paradigm shift." It is characterized by shifting services from inpatient to outpatient, from specialist care to primary care, from acute care to diagnosis and prevention, and from clinical technologies to information systems. ~° This trend is creating a "massive deployment of capital" to accommodate reallocations and differing types of population needs for health, not necessarily medical, services. Managed care is a familiar work environment to NPs who have been invisible providers in health maintenance organizations for almost 30 years. RESPONSES OF INDIVIDUAL GROUPS AND SOCIETAL INSTITUTIONS Now, the environments are once again amenable to change. The opportunities and demands for NPs in acute care have escalated. However, the responses of individuals and educational, service, and professional institutions to NPs in acute care are quite different from those 30 years ago. As hospitals experience severe reductions in occupancy, rising costs, competitive markets, and managed care constraints, they are once again turning to nurses, especially APNs, to help rescue their struggling institutions. Because NPs have amply demonstrated their success in primary care, it was no great surprise to learn of the hospitals' interest in using them to contain costs. (Although there is a paradox here as hospitals downsize and replace well-qualified registered nurses with unlicensed assistive personnel to care for the hospitals' most important product-patients. A short-term gain augurs well a long loss.
89
An institution's reputation and image of quality and caring once lost is hard to regain.) Schools of nursing are also responding positively. A recent study on NP education programs by Harper and Johnson for the National Organization of Nurse Practitioner Faculties shows that a "dramatic increase occurred between 1992 and 1995...with a 69% increase in the number of institutions offering NP clinical tracks, and 108% increase in the total number of clinical tracks offered."11 Shifts between NP primary care and NP specialty tracks are also noticeable as are the expansions in NP post-master's degree offerings for clinical specialists. Another stratagem used, although not universally agreed on, was the blending of the clinical nurse specialist role with that of the NP to produce master's graduates with "a common core of knowledge, skills and competencies, and professional attributes ''~2 Professional organizations, notably the American Association of Colleges of Nursing, the American Nurses Association, and NP specialty groups have responded with leadership strategies, such as Consensus Conferences, information gathering and research, and the setting of standards of practice, accreditation criteria, and credentialing to accommodate recognition and reward. These organizations also provide continuing education to maintain clinical competence and training for NPs to become a vital force in political and policy decisions. 13,14 There is still a great deal to do intraprofessionally to bring all organizations together so that they can speak with one strong voice politically. States' scope of practice laws and federal regulations in their current confused state serve very poorly the public or the practitioner. Preferably, APNs would be certified, as other professionals are, by their own professional associations rather than through state laws. Abolishing the current varieties of restrictive legislation will not be easy, but it must be done. The interest of the public and the profession are at stake. Attention to Safriet's ~ salient arguments on the role of advanced practice nursing could bring order out of this legislative chaos. Issues such as those the NPs of earlier years faced in reimbursement, legislation, practice and prescription privileges, and relationships with medical colleagues and hospital administrators are still challenging this newest group of ACNPs. Overcoming these barriers will require great political acumen, professional unity, and financial resources. RESEARCH
What should be the thrust of research as the NP moves into acute care? The first reaction has 90
been to compare "nonphysicians," for example, NPs, with medical residents, just as the early NPs were compared with physicians. ~3,16 Continuity and quality of care by NPs is demonstrable, and the costs, especially over time, appear to be reasonable. The professional nursing values and behaviors bring a dimension now missing in care by medical residents. Riportella-Muller et al. ~7 refer to this as role enhancement, and Daly ~8 defines several additional functions, such as efficiency in clinical skills, shepherding patients through the system, and quality improvement management. But medical practice outcomes are not the gold standard for nursing practice research. True, there are complementarities that lend themselves to interdisciplinary inquiry, and APNs should participate as coinvestigators with physicians and others in studying health outcomes of their collaborative efforts. However, advanced practice nursing, which is a preferable generic category NPs now join, must move beyond comparing its nursing expertise with the expertise of physicians, residents, and other medical personnel. As Ackerman et al. 19 demonstrate in their conceptual model of advanced practice, APNs must begin to study the structure, process, and outcome in the centrality of the profession's interest, concern, and values--the patient and family. In addition, APNs need to conduct sophisticated clinical and economic studies and inquiries into the system's policies and practices that affect the patient care outcomes. Longitudinal studies of outcome to include hospital lengths of stay, readmission rates, patient and family education, and resumption of functional status and work productivity should provide telling evidence of the efficacy, efficiency, economy, and patient-family satisfactions of the systems of care. Further, studies by the profession must address concerns for society's health work force needs and the quality and costs of the educational programs, the preparation of their faculties and NP preceptors, and the adequacy of clinical resources. In comparing and contrasting current APN trends with 30 years of change, we can only be encouraged and enlightened by history. Predictions for APNs in the twenty-first century are for a bright future in all settings. Perhaps Boodley says it best: The location of care has been less important to the success of the NP role than the fundamental philosophy and attributes of the practice. The keys to the successof the NP role have been the autonomous yet collaborative nature of the practice, accountability as a direct provider of h e a l t h care services, e m p h a s i s o n clinical d e c i s i o n making as a f o u n d a t i o n clinical skill, a focus on h e a l t h
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and healthy lifestyles as a f o u n d a t i o n of practice and the cost-effective, accessible nature of the practice. These basic a t t r i b u t e s of the NP role a n d NP practice h o l d true regardless of setting or s p e c i a l t y focus. 2° The deviant
of yesteryear has indeed
come of
age. 1 t h a n k Professor M i c h a e l A c k e r m a n a n d g r a d u a t e s t u d e n t D i a n e M i c k of t h e U n i v e r s i t y of R o c h e s t e r and Director and Lecturer Deborah Chyun, A d u l t A d v a n c e d Practice N u r s i n g Program, a n d g r a d u a t e stud e n t Susan D a n i e l l of Yale U n i v e r s i t y for t h e i r assistance in g e n e r o u s l y sharing resources.
REFERENCES 1. Ford LC. A nurse for all settings: the nurse practitioner. Nuts Qutlook 1979;27:516-21. 2. Ford LC, Cobb M, Taylor M. Defining clinical content, graduate nursing programs, community health nursing. Boulder (CO): Western Interstate Commission on Higher Education, Western Interstate Council on Nursing Education, 1967. 3. Ford LC, Silver HK. Expanded role of the nurse in child care. Nuts Outlook 1967;15(9):43-5. 4. US Qffice of Technology Assessment. Nurse practitioners, physicians, assistants, and certified nurse midwives: policy analysis. Washington (DC): Government Printing Office, 1986:5. 5. Spitzer W. The nurse practitioner revisited--slow death of a good idea. N Engl J Med 1984;310:1049-52. 6. Weston Jb. Whither the "nurse" in nurse practitioner? Nurs Outlook 1975;12:148-52. 7. Schultz JM, Fioravanti J, Liptak G. Nurse practitioners' effectiveness in NICU. Nurs Manage I994;25(I0):50-3. 8. Davitt PA, Jensen LA. The role of acute care nurse practitioner in cardiac surgery. On the Scene: University of Rochester Medical Center, Nursing Administration Quarterly 198 I;5( 1): 16-9. 9. Feachem RGA. Global health. 2020 Vision, health in the 21st century. Washington (DC):institute of Medicine, 1996:37-44.
10. The Advisory Board Co., the Governance Committee. Vision of the future. Washington (DC): Advisory Board Co, 1993:57. I I. Harper DC, Johnson ]. NONPF workforce policy project technical report: nurse practitioner educational programs 19881995. NONPF: Washington DC, 1996. 12. Shuren AW. The blended role of the clinical specialist and the nurse practitioner. In: Hamric AB, Spross/A, Hanson CM, editors. Advanced nursing practice, an integrative approach. Philadelphia: WB Saunders, I996:375-94. 13. American Association of Colleges of Nursing. 199&I995 Special report on master's and post-master's nurse practitloner programs, faculty clinical practice, faculty age profiles, and undergraduate curriculum expansion in baccalaureate programs in nursing. Washington (DC): The Association, ~995. 14. American Nurses Association. News release. Washington (DC), 11 Mar I996. 15. Safriet BJ. Health care dollars and regulatory sense: the role of advanced practice nursing. Yale Journal of Regulation 1992;9:417-87. 16. Knickman JR, Lipkin M, Finkler SA, Thompson WG, Kiel J. The potential for using non-physicians to compensate for the reduced availability of residents. Acad Med 1992;67:429-38. 17. Riportella-Muller R, Libby D, Kindig D. Data watch. The substitution of physician assistants and nurse practitioners for physician residents in teaching hospitals. Health Aft (Millwood) 1995;14:181-9l. 18. Daly BJ. The acute care nurse practitioner: education, practice, certification. In: Role differentiation of the nurse practitioner and clinical nurse specialist: reaching toward consensus. American Association of Colleges of Nursing proceedings of the Master's Education Conference; 1994 Dec 8-10; San Antonio (TX):33-48. 19. Ackerman MH, Norsen L, Martin B, Wiedrich J, Kitzman H. Development of a model of advanced practice. Am J Crit Care 1996;5:68-73. 20. Boodley CA. Nurse practitioner educationaI guidelines: program standards, curriculum, and graduate outcomes. In: Role differentiation of the nurse practitioner and clinical nurse specialist: reaching toward consensus. American Association of Colleges of Nursing proceedings of the Master's Education Conference; 1994 Dec 8-10; San Antonio (TX/.
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