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50 years of NP excellence

Saver, Cynthia MS, RN

doi: 10.1097/01.NPR.0000463786.21636.47
Feature

Abstract: The nurse practitioner (NP) role is marking its 50th anniversary in 2015. This article explores the history and future of the role by talking with NP thought leaders.

Cynthia Saver is President, CLS Development, Inc., Columbia, Md.

The author has disclosed that she has no financial relationships related to this article.

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In her TEDx talk, “Rising from the Mud,” Debra Barksdale, PhD, FNP-BC, ANP-BC, CNE, FAANP, FAAN, describes the African Sankofa bird.1 As the bird flies forward, holding an egg in its mouth, it looks back. “San” means “reach,” “ko” means “to go,” and “fa” means to “look, seek, and take”. The image communicates the idea to “Reach back and get it” or “Go back and get what you have forgotten.”

“It symbolizes the gems of knowledge in the past,” says Dr. Barksdale, professor and director of the doctor of nursing practice program at Chapel Hill School of Nursing, University of North Carolina. Dr. Barksdale, a nurse practitioner (NP) since 1988 and former president of the National Organization of Nurse Practitioner Faculties, says “the bird teaches us to take what you need from the past and give back to the next generation.” As the NP profession marks its 50th anniversary, it seems a good time to reach back to the past and remember lessons learned as the role has evolved.

“Some people forget the fights that had to occur so NPs could be recognized as legitimate, necessary, and viable healthcare providers,” Dr. Barksdale says. “If we don't understand our history, we're likely to repeat some of the failures.”

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A turbulent start

“It was a turbulent, uncertain time, a very opportunistic time to bring about change,” says Loretta Ford, EdD, PNP, FAAN, of 1965, the year she and Henry Silver, MD, a pediatrician, started the first NP program at the University of Colorado. Dr. Ford is currently dean and professor emerita for the School of Nursing at the University of Rochester. “There were social, political, and organizational forces.”

The Vietnam War was raging, civil rights issues filled the airwaves, and President Lyndon Johnson had declared war on poverty. Many physicians were choosing specialty practice, leaving a dearth of general practitioners, and nursing was beginning to move away from a focus on tasks. The American Nurses Association's First Position on Education for Nursing was published at the end of 1965.2 The position paper, which defined technical (2 years) and professional (4 years) preparation divided the nursing community. “There was a great deal of rhetoric about what nursing should be in the future,” Dr. Ford says.

Perhaps most significantly, Medicare and Medicaid programs started providing healthcare coverage to low-income women, children, older adults, and individuals with disabilities, which increased the demand for primary care services.3 Many have credited the increased demand for care coupled with a physician shortage as the catalysts for creating the NP role, but Dr. Ford disagrees.

“We started this for the health needs of people, not because of a shortage of physicians,” Dr. Ford says. “I'm not the least bit interested in filling the physician role.”

Dr. Silver and Dr. Ford partnered to develop the NP role. “My strength was public health nursing and his was child care and development,” Dr. Ford says. “We brought different strengths to the partnership.” Dr. Ford, who by then had a decade of public health experience behind her, worked with Dr. Silver to study what services public health nurses were providing, what families needed, and what a nurse could do. “We developed a model and decided to test it and then integrate it into nursing programs,” she says.

The pair took a proactive approach to communicating their actions. “We decided on transparency in describing what we were doing,” Dr. Ford says. She and Dr. Silver met with the state boards of nursing and medicine to let them know what services the NPs were providing. In addition to publications, Dr. Ford and Dr. Silver responded to many requests to speak at conferences, even launching one of their own. “We tried to be open with what we were doing. Everyone wanted to learn about the program,” Dr. Ford says.

Unfortunately, these initial efforts were met with resistance, which puzzled Dr. Ford (see Nurses' perceptions of NPs). “I didn't see this as a great change,” she says. “I just thought it was nurses doing what they were already doing clandestinely in the field. We were pushing the boundaries of knowledge, evaluating, and reporting.” The resistance, primarily from nurse educators, “was a big surprise to me,” Dr. Ford says.

Fortunately, her students' reactions bolstered her confidence. “There was an enthusiasm for nursing and confidence once they got over the hump of taking on more responsibilities,” she says. “I was sure it was the right thing to do to help the patients we serve.” The students, experienced public health nurses with BSNs, joined Dr. Ford in the endeavor.

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Forging ahead

Perhaps not surprisingly, NPs found a home caring for underserved patients. Many NPs worked in rural areas , which, in a pre-Internet era, meant they had to rely solely on their expertise. “The only GP (general practitioner) might by 60 miles away and the road to get there was closed in the winter,” says Michael Carter, DNSc, DNP, FAAN, FNP/GNP-BC, University Distinguished Professor in the department of advanced practice and doctoral studies at the University of Tennessee College of Nursing. Dr. Carter, an NP since 1973, is also a family NP for the Christian Health Center in Heber Springs, Arkansas.

Because of the focus on the underserved, Dr. Carter says the initial push back from physicians was muted. That changed as NPs ventured into caring for patients in higher socioeconomic classes and started to receive reimbursement.

“In the early 1970s, there were no states that enabled NP practice,” he recalls. Because state nurse practice acts said nurses could not diagnose or prescribe, the early NPs were technically in violation of the acts. “I would get calls from the Board of Pharmacy or Board of Medicine asking if we were practicing medicine,” says Dr. Carter, who worked at a primary care clinic in Marche, Arkansas. “We literally had to push and push to practice as we had been educated.”

It is easy to forget those early battles. “Sometimes they (NPs today) don't realize what mavericks we were back then,” says Jan Towers, PhD, NP-C, CRNP, FAANP, FAAN, a founder of and consultant for the American Association of Nurse Practitioners (AANP) who has been an NP since the 1970s. Dr. Towers recalls her days as a community health nurse when she would see a child crying and pulling at his or her ear. “You knew the child had otitis media but you couldn't look in the ear and you couldn't get anyone to see the child because the family was on Medicaid,” she says, adding that she remembers thinking, “We should be able to care for these people. We started sticking our necks out, pushing to get those doors open.” (See Patients' perceptions of NPs.)

The motivation to care for underserved patients remains strong today. “One of the things I saw pretty quickly in the hospital setting was the dearth of access to care that many people experience,” says Charity McClure, MSN, FNP-C, who, after 4 years as a nurse, became an NP in 2012. “I saw a number of patients who had poor outcomes from their chronic diseases because they didn't have access to primary care. I realized I wanted to work at the other end of the spectrum to prevent patients from getting to that point.”

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A growing force

Margaret Fitzgerald, DNP, FNP-BC, NP-C, FAANP, CSP, FAAN, DCC, president of Fitzgerald Health Education Associates, Inc., and a family NP at Greater Lawrence (MA) Family Health Center, has witnessed a tremendous increase in the NP profession since she started in 1986. “There were approximately 25,000 in the entire country. This is a very big country to spread 25,000 of any profession around,” she says. “We were mostly, as we are now, taking care of people who are disenfranchised, who are poorer, who are not on the healthcare radar screen in general, so we could practice as invisible entities. Part of that was good; there wasn't as much scrutiny of the practice, but as the profession matured, we needed more scrutiny to show what our outcomes were.”

This scrutiny, in the form of research studies, demonstrated the value and effectiveness of NPs. Many of the studies were published in physician journals, such as the landmark 2000 study by Mundinger and colleagues, which appeared in The Journal of the American Medical Association.4 By the 2000s, “We started having some really good studies saying NPs are as good as or better than physicians,” Dr. Carter says.

With the evidence and numbers, NPs surged to the forefront. “Now that we are pushing 200,000, we can no longer be ignored,” Dr. Fitzgerald says. “We are finally making our mark, and part of it is due to our strength in numbers.” She notes that some believe the market may be reaching saturation but disagrees with the premise. “I feel the higher numbers have brought us to our rightful place in contemporary healthcare where we are that disruption innovation, we are changing the status quo, and we are making a name for ourselves.”

As it has grown, the NP role has expanded from primary care into many specialty areas, including acute care. According to AANP, however, 89% of NPs are prepared in primary care, and more than 75% of actively practicing NPs provide primary care.5 Several key issues have threaded their way through the history of the NP role, including full practice authority, payment, education, and licensure.

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Full practice authority

The past few years have shown a rise in the number of states removing restrictions on NP practice by eliminating the need for physician collaboration or supervision. Susanne Phillips, MSN, FNP-BC, a clinical professor at the University of California in Irvine who has been an NP since 1996, credits the recent surge to passage of the Affordable Care Act. “It's really ramped up in terms of states moving towards full practice authority,” she says, adding, “The amount of legislation that will be passed in the next 5 to 7 years is going to be impressive.” As of 2014, 20 states allow full practice authority.6

Phillips credits NPs in all states with working to enact change. “There is a tremendous amount of work that goes on in every state that aren't the big ticket items,” she says. Even minor changes such as insurance empanelment and reimbursement help advance the NP role. Phillips has seen NPs become much more involved in legislative initiatives over the past 20 years. “More NPs attend lobbyist days, visit their legislative representatives, and support organizations advocating for NPs,” she says.

“We are truly autonomous healthcare providers,” Dr. Fitzgerald says of the NP role, but adds there is still work to be done. “More than two-thirds of all NPs continue to practice in states where we need to have a physician collaborator or supervisor to do a role that we have been educated to do autonomously.”

Autonomy does not mean independence, according to Dr. Fitzgerald. “There isn't a single one of us, whether we're NPs, PAs, or MDs, who practice independently. We are interdependent on one another, we rely on one another for second opinions and clinical consults.”

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Payment

A watershed moment in reimbursement came with passage of The Balanced Budget Act of 1997, which granted NPs provider status and the ability to bill Medicare directly for services.7 “It was a turning point and made us able to move forward,” Dr. Towers says. Dr. Carter also credits patients with pushing their insurers to reimburse NPs.

However, Dr. Towers adds that Medicare reimbursement also prompted physicians to challenge NPs more. “They became more hardball,” she says, noting that in the early years of the role, many physicians supported NPs. “People were willing to help us and didn't see us as a turf issue.”

NPs still struggle with payment issues. “Even now, there are regulatory rules that do not include NPs,” says Jamesetta Newland, PhD, APRN, FNP-BC, editor-in-chief of The Nurse Practitioner. Dr. Newland, who launched her NP career in 1986, adds that even when insurers reimburse NPs, they may do so at a lower rate than physicians. NPs have not negotiated rates as well as their physician colleagues, according to Dr. Newland. “NPs should seek expert guidance when negotiating rates with an insurer with a goal of 100% reimbursement,” she says.

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Education

NP education has evolved from a certificate to master's level to, most recently, doctoral preparation. Dr. Carter says the 1980s saw NP programs move to the master's level. Part of the stimulus was enrollment in master's programs was flagging at the time. “We saw a rapid proliferation of master's programs, sometimes without adequate faculty,” he says. “Almost every school created an NP program.” Ultimately, it became clear that the 30 credits typically associated with a master's program weren't enough to prepare the NP for their evolving role. “Programs kept getting longer and longer,” Dr. Carter says. “Some of us started saying we have to move to the doctorate—not the PhD, but a clinical doctorate.”

Dr. Barksdale adds that the DNP movement was partially prompted by the realization that NPs needed more education in finance, healthcare systems, and larger healthcare issues, topics that she says used to be included in some master's programs. “Somewhere along the way, we lost some of that content that we now realize is essential.”

Dr. Barksdale says there are pros and cons to the DNP. One rationale for requiring a DNP is to have parity with other professionals, but she says, “I don't think having a degree gives you parity. It's how you conduct yourself and how you are able to show your worth and influence change.” She is also not convinced that the DNP will lead to better compensation. Despite these concerns, Dr. Barksdale says, “I believe if done properly, there is incredible potential for DNP-prepared NPs.” She calls for more consistency in DNP programs and adds that the bottom line will be the impact that DNP-prepared NPs have on the healthcare system. “If you aren't making an impact, it doesn't make sense.”

In the future, Dr. Fitzgerald envisions the DNP being the requirement for entry into practice for NPs. “We should anticipate that our profession will go more and more to doctoral level study as the entry into practice.” Dr. Newland agrees that the profession is moving to the DNP as entry to practice and adds that DNP programs need to be standardized.

“The DNP program needs to be substantive and concrete and prepare students for practice as NPs,” says McClure. McClure's concern is that doctorate programs will not offer enough clinical experiences for students. She noted that some of today's future NPs are enrolling in direct-entry programs, so they have limited to no experience working as a nurse.

McClure completed a residency to help ease the transition from school to practice, but Dr. Barksdale cautions that legislatively requiring such programs for all NPs “disadvantages us.” These programs may allow those outside the profession to gain control over the role, which will reduce the number of NPs that can be prepared.

Dr. Barksdale says educators face challenges in teaching NP students. “We try to teach too much specific information that no one can keep up with because it changes so quickly. It's difficult to prepare students for a world we can't imagine so our default is to prepare them the way we have always prepared them.”

But technology and patient demands are forcing a change. “We're at a point that robots are diagnosing, so we are going to need more education in humans relating to humans,” Dr. Barksdale says. “NPs might not just be primary care providers, they may be life coaches.”

That means educators “will have to work harder to help students learn how to acquire, interpret, and apply information instead of just pouring information from our heads into theirs,” Dr. Barksdale says. Educators will also need to become savvier in evidence-based education. “Whether students like something is different than whether it helps them to learn,” she notes, saying that some research shows e-books are associated with more distraction and lower retention, for example.

Finally, the role of simulation in replacing clinical hours in NP education needs to be studied. “Clinical sites are becoming more difficult to obtain,” Dr. Barksdale says. “But I hope we don't get to the point that we have too many clinical hours substituted with simulation. That would give more ammunition for medicine to say NPs aren't prepared to care for real patients.”

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Licensure

In 2002, the National Council of State Boards of Nursing delegate assembly approved the APRN Licensure Compact.8 The compact is designed to create consistency in legislation related to NP practice and allow for mobility from state to state. “It makes no sense for me to need to practice with physician collaboration in Massachusetts, yet I could walk out the door to New Hampshire and practice autonomously,” Dr. Fitzgerald says.

Resistance to multistate licensure remains. Phillips speculates that part of the resistance is the potential loss of revenue from license fees, which could hinder the ability of boards of nursing to investigate possible practice infractions. Practical considerations stand in the way as well. “If a nurse is licensed in one state and commits an action that requires discipline in another state, who bears responsibility for that?” she says.

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Challenges for the future

NPs will continue to face challenges as they enter the next half-century of the role.

“The challenge is to not let the momentum slow down,” Dr. Fitzgerald says. “We are on a roll. We need to be poised to move forward to continue the battle for autonomy.” She adds that, “It will be a tough, long fight to update the practice act so that state to state we are autonomous healthcare providers.”

Dr. Carter also sees full practice authority as an ongoing challenge. “NPs still can't fully exercise their abilities (in some states) and that's criminal,” he says. Conflicts can arise if NPs are more experienced than their collaborating physicians. Dr. Carter also adds that patients don't expect practice to vary by state, so why should NPs?

An aging population has resulted in more people with chronic health problems. “We're all seeing patients who are sicker, more complex, who require a very high level of skill in order to properly take care of. We're all doing this at a time when we're expected to be faster, more comprehensive, and be able to address myriad health problems in a very short period of time,” Dr. Fitzgerald says, adding that the situation poses the question, “How can we do this job faithfully under the current pressures of contemporary healthcare?”

Dr. Newland agrees that patients have become more complex and says NPs are functioning as providers and case managers. “In the past, a lot of these patients would have immediately been shifted to a physician, but now NPs are managing them,” she says. NPs are coordinating specialty visits with patients returning to them for primary care. “Even NPs in specialties are managing more complex patients.”

The concept of a health home is likely to be another battleground, Dr. Newland says. Physicians are becoming the leaders of these homes, but she says, “An NP who has the education, training, and experience—particularly the administrative experience—should be able to lead a medical home not only with poor and marginalized patient populations but also with the well-educated and well-insured.” Despite NPs' skills, she says, “That's going to be a battle. Wherever there's money to be made, establishment wants to push us aside.”

Phillips says, “The biggest challenge remains the opposition from organized medicine.” The Robert Woods Johnson Foundation and the Future of Nursing Campaign are leading efforts to garner support from consumer groups for full practice authority for NPs. “The push by organized medicine to prevent passage of legislation granting full practice authority is not evidence based, it's about protecting turn and financial efforts, not about protecting patients,” Phillips says, citing 40 years of research about the effectiveness of the NP role. “There is no longer the debate as to whether NPs can do the job. The research is there.”

Perhaps the most important challenge is, as Dr. Newland says, “keeping the nurse part in NP, which distinguishes us from physicians.”

“We take a holistic approach,” Dr. Newland says. “When we see patients, we really listen to what is going on in their lives and incorporate that information into a plan of care.”

“The NP role has been very much more medicalized compared to the early models,” Dr. Ford says, noting that healthcare delivery, reimbursement, and outcomes are all predicated on a medical model. “If you're not careful, you'll lose the nurse,” she cautions. She is heartened by the Affordable Care Act's focus on prevention and sees treatment as a conduit to prevention. “When patients are tending to treatments, it's time to introduce ideas of prevention, promotion, and protection,” Dr. Ford says. “You have to bring in the nursing focus.”

Dr. Ford adds that primary care, as it is currently practiced, “is a dying system. It's not fulfilling the needs of people and it's oriented to symptoms,” she says. “It's ridiculous that you have to have a symptom to get into primary care.” Instead, there should be a focus on primary health services.

With challenges come growth opportunities (see Growth opportunities). For instance, Dr. Ford says there is going to be a “tremendous shift” in healthcare, with responsibility in the hands of the patient. “The patient will be the first one to receive the information (not the provider),” she says. “He will first go to his computer, then other people who have the conditions, then reach out to a provider.”

Dr. Ford believes NPs are ideally positioned to be the “first responders” when those patients decide to reach out.

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The next generation

Fortunately, the new generation of NPs is ready to take on the task of meeting the future needs of patients and advancing the NP role. “I think a lot about how much further there is to go,” McClure says. “I have seen the different levels of autonomy in different states and the struggle for NPs to function to the full level of their skills. That battle is still being fought. I see the challenge for other NPs and me is to get involved in the fight, especially as healthcare needs increase with the aging population. I hope we can position ourselves well, be vocal, and expand our ability to practice as autonomously and collaboratively as possible.” (See In their own voice: NPs look down the road.)

At the same time, these NPs haven't forgotten their roots. When asked what she would say to Dr. Ford, McClure says, “I would probably thank her for her contributions to the field and tell her that I feel that what I do is really a privilege. I feel for the first time in my life I am doing the job I was meant to do. I really love it.”

“We all have to roll up our sleeves,” Dr. Towers says. “The more we support each other and keep our eye on the goal, the better chance we have for success.” Dr. Towers can still see the apple tree in her back yard, where NPs gathered to form local, state, and national organizations. “It's still there, ready for more planning.”

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Nurses' perceptions of NPs

“My experience was one of the most traumatic that I have had in my life,” Dr. Ford says about the reaction from nurses when she and Dr. Silver started the NP role. She experienced bullying, including “a lot of backstabbing, a lot of shunning, and a lot of silence” from nurse educators who were her colleagues. “I had not been so unpopular in my life.”

Ultimately, the group worked with a community activist who discussed change theory. “We all began to look at things a little differently,” she says. “I began to understand how threatened people were. They could see their work changing.” Educators also worried that physicians would gain control of nursing programs. Dr. Ford says it was important to reassure people that NPs were not physician assistants, another new role in its early stages of development.

“The hard part was our colleagues who weren't supportive,” says Jan Towers, PhD, NP-C, CRNP, FAANP, FAAN, a founder of and consultant for the American Association of Nurse Practitioners (AANP) who has been an NP since the 1970s. Nurses had just been recognized as not being handmaidens to physicians and, “here we were doing physician things.”

After this rocky start, nurses have come to embrace NPs. “RNs and LPNs now look at us as collaborators, consultants, and nursing experts who help them decipher some of the difficulties in the healthcare arena and how challenging it can be to take care of increasingly ill patients, particularly in the outpatient setting,” says Margaret Fitzgerald, DNP, FNP-BC, NP-C, FAANP, CSP, FAAN, DCC, president of Fitzgerald Health Education Associates, Inc., and an FNP at Greater Lawrence (MA) Family Health Center. She notes that the regard goes both ways, “I greatly respect my RN colleagues where I practice. I do not know how I could possibly do my job without them.”

Charity McClure, MSN, FNP-C, who works locum tenens in federally qualified health centers in Connecticut, adds, “I have a good relationship with the nurses I work with. I use them as a resource and I want them to see me as a resource. All nurses, not just NPs, should work at the top of their license.”

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Patients' perceptions of NPs

Patients might not have known what an NP was, but from the start, they liked what they did.

“Patients thought it was the greatest thing since sliced bread,” says Dr. Ford of patients' initial reaction. “I used feedback from patients to help promote the role.”

“Starting out in the 1970s, patients didn't know about NPs,” Dr. Carter says. “But everyone had heard of a nurse.” “Patients were so grateful that someone cared and listened,” he adds. “It was the nurse part, not the NP part, that they tied into.” He encourages NPs to get patients to speak out about their experiences with NPs. “Often patients say they go to a doctor, but they really see an NP and they like that. We need to have them say that.”

“When I first became an NP over 30 years ago, it was like, ‘You're a what?’” Dr. Fitzgerald says. “There was very little public recognition as to who we are and what we do. Now I have found, especially over the last 10 years, that far more often when I introduce myself to a member of the general public, I get the following reactions: ‘Oh, my wife sees an NP, my cousin is in school to become an NP, I see an NP.’ I don't have to educate them on what the role is. That's really exciting to see.”

Jamesetta Newland, PhD, APRN, FNP-BC, editor-in-chief of The Nurse Practitioner, adds that patients trust NPs. “They really do like seeing a nurse practitioner,” she says. Although some patients still call her a “doctor” because they believe they have similar skills, Dr. Newland says, “I try to stress that doctors and we are complementary. We work together.”

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Growth opportunities

The NP role is one of the fastest growing roles in the United States as new opportunities open up. According to an article in Kiplinger, the 10-year projected growth for NPs is 22%.9

NPs will see growing opportunities, particularly in the area of convenient care clinics, according to Dr. Carter. He says that NPs are ideally suited for these clinics “because we know that an illness can only be understood in the context of the patient living with it.” For instance, a patient with symptoms of a cold may also have diabetes that needs to be considered when deciding on treatment.

Another growth opportunity is long-term care facilities. “It's a travesty that NPs can't be medical directors of nursing homes,” Dr. Carter says. “A few studies have found that patients do better with an NP in charge.”

NPs are even making house calls, as patients demand great access and are willing to pay for it. Heidi Johnson, a pediatric nurse practitioner, charges $80 per visit and does not accept insurance.10 One family who used Johnson's services says her fee is comparable to their regular pediatrician (and they would need to go into the office) and to a local urgent care center. “If we can deliver prescriptions, why not deliver an NP to you?” Dr. Carter says.

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In their own voice: NPs look down the road

Here are how some of the NPs interviewed responded when asked about their hope for the role 5 to 10 years down the road:

“I would like to see more NPs as leaders in innovative delivery systems and involved in community health organizations and more sustainable nurse-managed centers.”

— Dr. Jamesetta Newland

“All NPs have full authority in all states and we continue to work with all healthcare professionals. One profession (such as medicine) doesn't have supervisory rights over another.”

— Susanne Phillips

“The role of all healthcare providers is going to change in the relatively near future because there is so much technology that allows individuals to assess health information without having a healthcare provider present. Our role is going to be bringing that human touch; to help people process that information.”

— Dr. Debra Barksdale

“We've got to get rid of agreements that tie us in any way to anyone else. We need full scope of practice in every state.”

— Dr. Michael Carter

“I would see NPs functioning at their full scope with no laws to limit that, no tethers. We would become the primary care provider in the United States.”

— Dr. Jan Towers

“They'll be counselors and advisors and involved in inventing things. We are always tinkering to get things better for patients, but then we give our ideas away. It's unfathomable as to how many opportunities there will be.”

— Dr. Loretta Ford

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REFERENCES

1. Barksdale D. Rising from the mud. TEDxUNC. 2014. https://www.youtube.com/watch?v=3HjIDEStfyI.
2. Donley R, Flaherty MJ. Revisiting the American Nurses Association's First Position on Education for Nursing: a comparative analysis of the first and second position statements on the education of nurses. Online J Issues Nurs. 2008;13(2). http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/vol132008/No2May08/ArticlePreviousTopic/EntryIntoPracticeUpdate.aspx.
3. O'Brien JM. How nurse practitioners obtained provider status: lessons for pharmacists. Am J Health Syst Pharm. 2003;60(22):2301–2307.
4. Mundinger MO, Kane RL, Lenz ER, et al. Primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trial. JAMA. 2000;283(1):59–68.
5. American Association of Nurse Practitioners. Nurse practitioners in primary care. http://www.aanp.org/images/documents/publications/primarycare.pdf.
6. Phillips SJ. 27th annual legislative update. The Nurse Practitioner. 2014;40(1):16–42.
8. Nurse Licensure Compact Administrators. APRN (advanced practice nurse) licensure compact. https://www.ncsbn.org/APRN_Compact_hx_timeline_April_2012_%282%29.pdf.
10. Lankford K. Pay cash for your health care. Kiplinger's Personal Finance. 2015. http://m.kiplinger.com/article/insurance/T027-C000-S002-pay-cash-for-your-health-care.html.
11. American Association of Nurse Practitioners. Historical timeline. http://www.aanp.org/all-about-nps/historical-timeline.
    12. National Council of State Boards of Nursing. Consensus model for APRN regulation: Licensure, accreditation, certification & education. July 7, 2008.
      13. National Organization of Nurse Practitioner Faculties. History and goals. http://www.nonpf.org/?page=1.
        Keywords:

        history; nurse practitioner

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