Brief History of the

Nurse Practitioner

in the United States

Elaine Leinung DNP, FNP-BC, CNE Assistant Professor, New York City College of Technology President, Brooklyn/Queens Chapter, Nurse Practitioner Association of NY

What is a Nurse Practitioner?

• RN with advanced education –

Master’s Degree

–

Doctor of Nursing Practice

When, Where & Why

• 1965 - Dr. Loretta Ford EdD, RN, PNP FAANP • University of Colorado • Cost effective for first contact health care in rural regions • Pediatric Nurses were the first NP’s • Certificate Program, then MSN, now DNP

Scope of Practice

• Diagnosing, treating, evaluating and managing acute and chronic illness and disease (e.g. diabetes, high blood pressure) • Obtaining medical histories and conducting physical examinations • Ordering, performing, and interpreting diagnostic studies (e.g., routine lab tests, bone x-rays, EKGs) • Prescribing physical therapy and other rehabilitation treatments • Prescribing pharmacologic treatments and therapies for acute and chronic illness (extent of prescriptive authority varies by state regulations) • Providing prenatal care and family planning services

Scope of Practice

(cont.) • Providing well-child care, including screening and immunizations • Providing primary and specialty care services, health maintenance care for adults, including annual physicals • Providing care for patients in acute and critical care settings • Performing minor surgeries and procedures – – –

dermatological biopsies Suturing casting

• Counseling and educating patients on health behaviors, self-care skills, and treatment options

Practice Settings

• Community clinics, health centers, urgent care centers • Health departments • Health maintenance organizations (HMOs) • Home health care agencies • Hospitals • Hospice care • NICUs or PICUs • Nurse practitioner practices/offices • Nursing homes • Private & public schools, universities and colleges • Physician/private medical practices • Veteran's administration facilities

Legitimization Period

• 1970’s –

Across the US, legislative initiatives to change state laws and nurse practice acts

• 1971 –

1st Family Nurse Practitioner Program at University of Washington

• 1973 –

65 FNP programs

Certification

• • 1977 - The American Nurses Association The first nurse practitioner certification exams Legitimized the role of NPs and led to more standardized practice outcomes

1980 - 1990 Slow Steady Growth

Due largely to Federal Government funding NP education through grant programs administered by the United States Public Health Service, Division of Nursing.

1991-2000 New Expansion & Rapid Growth

• In 2001, the number of NPs in the United States is estimated to be 78,251 (Pearson, 2001, p. 26) • Legislative victories lead to an increasingly independent role for the NP in practice: – Third party reimbursement – Prescriptive authority • By the turn of the century, nurse practitioner programs had entered the mainstream of graduate education in nursing.

The Present

• • •

NP specialties have grown

ACNP

(Acute Care NP)

ANP

– (Adult NP)

Adult Cardiovascular Care NP

–

Adult Primary Care NP

–

Adult Critical Care NP

–

Adult Acute Care NP ENP

(Emergency NP) • • • • • • • • •

FNP

(Family NP)

GNP

(Geriatric NP)

HNP

(Holistic NP; APN program)

NNP

(Neonatal NP)

PMHNP

(Psychiatric/Mental Health NP)

APMHNP

(Adult Psychiatric/Mental Health NP)

FPMHNP

(Family Psychiatric/Mental Health NP)

OHNP

(Occupational Health NP)

ONP

(Oncology NP)

The Present

• • • • • •

NP specialties have grown

AONP

(Adult Oncology NP)

PONP

(Pediatric Oncology NP)

PCNP

(Palliative Care NP; APN program)

PNP

(Pediatric NP)

PCCNP

NP) (Pediatric Critical Care

ACPNP

NP) (Acute Care Pediatric • • • • • •

PA/CCNP

Care NP) (Pediatric Acute/Chronic

WHNP

(Women's Health NP)

BC-PCM

Palliative Care Management, disc’d by ANCC) (Board Certified -

BC-ADM

(Board Certified Advanced Diabetes Management)

BC-ADM

(Board Certified Advanced Diabetes Management)

ACHPN

(Advanced Certified Hospice & Palliative Nurse)

THE END!

The Nurse Practitioner in

New York State

Dr. Elaine Leinung DNP, FNP-BC,CNE President of Brookyln Queens Chapter Dorothy Grasso, MSN FNP-BC Vice President B/Q Chapter

License Requirements: Nurse Practitioner in New York State • Graduate from approved program with minimum Master’s Degree (30 -30 credits above a BSN and 600 - 1000 practice hours) • Infection control class (on line) • Child abuse reporting class (4 hours) • Obtain a DEA (Drug Enforcement Agency) number • Obtain National Provider Identifier Number

License Restrictions: Nurse Practitioner in New York State • Can only practice & prescribe in your specialty • Establish a collaboration agreement with an MD or DO and keep on file • Identify a protocol text to be used for patient care.

NPs in New York State

NP title(s) used in this state: Number of NPs in state: National certification required for recognition/practice?

BON sole state authority over NPs?

Physician involvement required for any aspect of practice?

CE requirements for NP practice?

NP (nurse practitioner) 14,272 NO Yes Yes. For details, log on to www.webnp.net

No

“Doctor Nurse?”

Q: A: Is there a statutory restriction against an NP with doctorate being addressed as “Doctor?” No,

but,

according to General Business Law statute, if you use the term “Doctor” when offering to perform health services, you must indicate the profession in which you hold a doctorate.

Additional limitations/prohibitions to NP practice?

NPs may:

• • • • • •

Write

home health personal aid services,

Act

as medical inspectors (In school districts)

order

respiratory therapy Obtain limited test-site

permits

under CLIA

Declare

an emergency in response to ordering utilities turned back on after “shutoff” action

Prescribe

non-patient-specific orders – (certain) immunizations – Anti-anaphylactic agents – PPD tests – rapid HIV tests

NP Scope of Practice – Prescribing

• The practice agreement and protocols govern the prescribing of drugs. • May prescribe drugs for treatment of patients within their specialty area of practice.

• In terms of CS, NPs may order drugs from Schedules II-IV without restriction. • Drugs, immunizing agents, tests, devices, and procedures ordered by NPs do not require a co-signature from the collaborating physician.

Why an Nurse Practitioner?

•

NP’s Provide Patient Centered Care

• NPs take the time to listen to patients' concerns, health and otherwise.

• NPs concentrate on preventative health care.

• NPs provide individualized, holistic (all encompassing) care.

The NPA of New York State

• The NPA was established in 1980 as a non-profit organization under the name The Nurse Practitioner Association, Inc. Since 1980, the NPA has grown financially, programmatically and increased the visibility and credibility of NPs within the healthcare community, at both the national and State levels of government, and with consumers throughout New York. • The NPA is the voice of Nurse Practitioners in New York State. We offer our members the tools, resources, and information to advance the NP profession, and an effective and successful advocacy program dedicated to advancing and protecting NPs in all of New York State.

Historical Overview of NPA

1980 – 1981 – The Nurse Practitioner Association, Inc. was formed Organized meetings begin in Syracuse, NY under the name of Coalition of Organized Nurse Practitioners Associations (COONPA) 1985 – 1988 – First Annual Convention and Educational Conference in Albany, NY Landmark legislation authorizing title and scope of practice for NPs 1988/1992 – Acquired prescriptive authority and ultimately full DEA prescriptive authority 1991 – The Coalition of Nurse Practitioners renamed New York State Coalition of Nurse Practitioners (NYSCONP)

Historical Overview of NPA

1992 – 1993 – 1993 – 1997 – 1998 – 1999 – 2002 – The American College of Nurse Practitioners (ACNP) established with NYSCONP as a founding member with a seat on the Board Education Law amended allowing referrals for physical and occupational therapy Medicaid reimbursement at 100% of the physician’s rate enacted Medicare reimbursement at 85% of the physician's rate enacted NYSCONP forms a Political Action Committee (PAC) NYSCONP hires its first full-time paid executive and professional staff and opens Albany office NYSCONP begins doing business as The Nurse Practitioner Association New York State (The NPA)

Historical Overview of NPA

2002 – The Practice Area Bill is passed, becoming Chapter 600 of the Laws of 2002 2003 – The Respiratory Therapy Bill enacted allowing Respiratory Therapists to accept orders from NPs 2004 – Clinical Lab Bill is passed 2005 – The NPA grows to 21 Chapters and 7 Regions with over 2,500 Members 2006 – Four bills introduced at the request of NPA pass both houses of the NYS Legislature:

Death Certificates Bill, Patient Restraints Bill, Handicap License Plates Bill, and the Medical Emergency Utility Services Bill.

Two bills are signed into law:

The Medical Emergency Utility Services Bill, and the Handicap License Plates Bill.

• • • •

Bills NPA is Sponsoring Before NYS Legislature

Patient Access & Advocacy Act

A.765 (Gottfried)/S.2948 (Montgomery)- Removal of Statutory Collaboration & Reimbursement

Reimbursement Assurance

within their lawful scope A.6651 (Gottfried)/S4490 (Duane) - To assure health plans do not deny reimbursement for services rendered by nurse practitioners acting

Access Protection

opportunities for nurse practitioners by prohibiting health plans from excluding nurse practitioners from their provider networks and to insure that reimbursement rates are reasonable A.7877 (Gottfried)/S4491 (Duane) - To promote practice

NP Worker's Compensation Access Act

A.3704 (John)/S.3908 (Duane) Authorizing NPs to fully participate within and be reimbursed under the worker's compensation program in NYS as a legislative study bill

• • • •

Bills NPA is Sponsoring Before NYS Legislature

Immunization Bill

A.6654 (Gottfried)/S.4070 (Montgomery) - To add NPs to the category of persons legally qualified to certify that an immunization required by section 2164 of the public health law may be detrimental to a child's health

NPA License Plates

A.4829 (Morelle) - Adding a new Section 404-x to the vehicle and traffic law to provide for the issuance of distinctive plates for members of the NPA

Death Certificate Bill

sign death certificates A.2028-A (John)/S.2969 (Montgomery) - Authorizing NPs to

Do-Not-Resuscitate

(DNR) A.1719 (Gottfried)/S.2947-A (Hannon) - Authorizing NPs to issue orders not to resuscitate

Bills NPA is Sponsoring Before NYS Legislature

• • Other bills monitored for provider neutrality:

Timothy's Law

A.5301 (Morelle) - this legislation would make technical amendments to make the law "provider neutral" by adding language to include nurse practitioners.

Collaborative Drug Management Therapy

A.6848 (Canestrari)/S.3292 (LaValle) - Authorizes pharmacists to perform collaborative drug therapy managment with physicians in certain settings.

The Future

• Removal of collaborative Practice agreements in NYS (we hope!) • NP’s as Primary Care Providers on Major Insurance Carriers • Health Care for

all Americans

and • NP’s as

Primary Care Providers

• • • • •

External Links

American Academy of Nurse Practitioners (AANP)

http://www.aanp.org/AANPCMS2

American College of Nurse Practitioners (ACNP)

http://www.acnpweb.org/

The National Organization of Nurse Practitioner Faculties

http://www.nonpf.org/

The Nurse Practitioner Association of New York State

http://www.thenpa.org/

New York State Department of Health, Office of the Professions

http://www.op.nysed.gov/

References

• • • • • • • Berlin, L.E., Bednash, G.D. & Stennett, J. (2001). 2000-2001 Enrollment and graduations in baccalaureate and graduate programs in nursing. Washington, D.C.: AACN.

Carnegie Commission on Higher Education. (1968). Quality and equality: New levels of federal responsibility for higher education. NY, NY: Carnegie Commission.

Geolot, D. (1987). NP education: Observations from a national perspective. Nursing Outlook, 35 (1), 132-135.

Geolot, D. (1990). Federal funding of nurse practitioner education: Past, present and future. Nurse Practitioner Forum, 1 (3), 159-162.

Harper, D. & Johnson, J. (1996). NONPF Workforce policy project technical report (1997) Pearson, L. (2001). Annual legislative update. Nurse Practitioner, 26 (1), 7-57.

Pearsson L. (2009). The Pearson Report American Journal for Nurse Practitoners vol 13 no 6