We’ve Come a Long Way…the Evolution of the Nurse Practitioner Role

By Terry Polanin, MSN, APRN, FPA, Family Nurse Practitioner

As I reflect upon the past 40 years as a family nurse practitioner and fulfilling my childhood dream of becoming an RN. It is hard to express the pride I feel having been a part of the pioneering efforts in “expanding the role of the nurse,” the courage it took to risk “stepping out of my box” into a man’s medical world…. and the joy I have received by the patients who trusted their care to me as a primary care provider.

I was not a physician—that was a hurdle we had to “jump.” Many times…and, we had to have risk-taking physicians willing to suggest to their patients that they see a “nurse practitioner” (who knew what that was?) rather than their physician for some of their care. Those were very special physicians that helped us pave the way. Their colleagues began to “see the light” as the years went by. And, we produced countless flyers and newsletter articles explaining our role in health care.
 

It was 1978. The women's movement was underway and the Viet Nam war had ended finally.

Things were changing in America. RNs were mostly female. MDs were mostly male (I knew of two female physicians then). Nurses “took orders” from doctors and patients as well as nurses “followed doctors orders.” We wanted to share some of the responsibility in providing health care. Not substitute for the physician, but “partner.”

A woman and a nurse partner? Physicians were not used to having partners and most were in independent, physician-owned practices, where the physicians made all of the decisions. (No hospital owned practices until about the later 80s) We wanted to be part of the healthcare “team” and thought we could provide primary care to “compliment” the physician. We could provide the preventive focus, patient /parent education, minor illness management (via protocols co-signed by the physician), staff development, women's health, etc.

A pediatric nurse/physician team in Colorado was establishing a model (Dr. Loretta Ford, PNP) at the time and other nurses (myself included) felt this was a viable model for health care. Especially in pediatrics in which many well child visits and parent education were needed.

I was teaching in the typical 3 year, hospital – based RN program at the time because I had a BSN (fairly new concept ) and considering a masters degree in nursing. University of Illinois was looking for nurses willing to initiate this new “role”, as U of I also saw viability in being a leader in this new concept for nursing. Six area nurses were accepted into the community health MSN program in downstate Illinois (Chicago was the only other site) and we decided to call this new entity, the Family Nurse Practitioner or Pediatric Nurse Practitioner. Upon graduating from the few graduate programs then in Illinois, we practice with our RN licensure and there was no certification yet for this specialty.

Most physicians were not in favor of nurses in this “expanded role” and therefore, this made acceptance challenging for patients. Much skepticism , outside of the few broad-minded physicians willing to incorporate an NP into their practice, mostly in the role of patient educator or for minor illnesses. We practiced with protocols and the physician co-signed our charts.

Keep in mind that there were no computers, no electronic medical records, no HIPPA laws, no “evidence based practice” data, many HMOs focusing on prevention of chronic diseases, and the nurse practice act under which we practiced was the Registered Professional Nurse “and all its specialties.” If needing to prescribe (mostly for minor acute illnesses), we signed the physician name and our initials.

We were “ghosts “ providing quality care. However, as time went on, patients grew to appreciate “the time with took with them”, the caring (nursing), our competent physical exam and assessment skills, and the listening skills that set us apart from other professionals. We were starting to evolve into respected members of the healthcare team. As more physicians realized our value, most physicians (and the hospitals that owned their practices by the late 90s) decided that the NP was someone that they wanted in their practices.  
 

Fast forward to 2002, with many “pioneers” such as Marie Lindsey and wonderful lobbyists, we were able to officially become APRNs, with the legal ability through our revised (several times) Nurse Practice Act to prescribe medications, based on our credentials, and sign our own names to the prescriptions.

I will never forget the day!

We had also adopted the Advanced Practice Nurse title legally, which encompassed not only nurse practitioners, but certified nurse anesthetists, nurse midwives, and clinical nurse specialists.

The Illinois Society of Advanced Practice Nurses was born and as a group, we worked tirelessly to continue evolving and protecting our role that we had worked so hard to achieve.

I was in an administrative and part- time practice position at the time as the Coordinator of the Nurse Practitioners at Methodist Medical Center in Peoria, IL. We were asked to include physician assistants in our group. We did agree to this (we had one PA in the group with 20 NPs at that point in the late 90s) and the medical administration wanted to call us “mid level providers”. A term I was not fond of—who were the low level and high level providers then???? I’ve always been proud of the name, “Advanced Practice Providers”, or APPs, as I suggested we be referred. I smile when I hear that title in other settings or even articles referring to the APPs…it seemed much more appropriate to me than “mid level providers”, though I have to say that took some negotiating with the medical administration to achieve that title.
 

Teamwork…we were finally a respected part of the healthcare team and patients even began to ask to see the NP. We had arrived!

The most recent hurdle, which I cannot say I was a part of…but appreciate those who “fought” for the APRN to have independent “full practice authority”. It has been in just the last few years , 2019 I believe, that we were given the legal privilege to apply for the FPA, if qualified with licensure, certification, and practice experience. Another milestone in the APRN evolution.

With the physician shortages, especially in rural and urban areas, many experienced APRNS , are filling vital roles providing health care independently and collaboratively. APRNs have expanded into critical care, emergency room care, hospice care, and other roles outside of the original primary care model. We are needed. And…finally many APRNs have earned the Doctorate of Nursing Practice. However, they are still at times negotiating that “Dr.” title in clinical settings. Keep negotiating. You earned that as have other professionals.
 

Be proud of that achievement and use it! 

Just a few additional thoughts appreciating the progress we have made from the “ghost” providers in the 70s- 80s to the respected, valued colleagues in health care today. I believe as nurses we went into this profession to help others, to help make this a better and safer world, and to be an integral part of health care teams.

We still have work to do.

I do have some concerns. Having just been through a pandemic with rippling effects on our health care system…healthcare is fragmented, weary , governed by insurances (or lack of), with masses of chronically ill patients, over-worked providers/staff, many seeking care at urgent care sites, the effects of social media (good and bad information out there ), online learning programs with less “hands on” practice, and physicians now overwhelmed with patients with significant chronic diseases/poly-pharmacy, and urging for support from us, whether we are prepared, ready… or not.

Be careful what you wish for… always remember your roots of nursing. Caring. Helping people prevent chronic diseases. Working within your domain of knowledge, education, and experience, licensure and certification. Don’t be pulled into the “medical model” or let others’ values or needs define you. Individualized, preventive, patient-focused, cost contained, collaborative nursing care is our roots and what will still define our very unique, hard-earned role today.

We have much to be proud of, but much continued work ahead to preserve and protect our distinct role into the health care of the 21st century—without sacrificing basic foundation of nursing care or the quality of care that we are known for. Be involved in your professional organizations, attend meetings with your colleagues, be part of the ISAPN , get involved politically if you can, and very importantly—practice healthy self care habits, so that we can continue to make a difference in healthcare in Illinois and our country.

“We’ve come a long way… but we’ve only just begun.”