NUR 6130 Module 6 Advanced Practice History Paper: The Nurse Practitioner From Colorado to Scope-of-Practice Debates Example

Making Room in the Clinic: How the Nurse Practitioner Role Was Built and Contested

Student Name

M.S. in Nursing, Thomas Edison State University

NUR-6130: History of American Nursing

Mentor Name

Month Day, Year

Making Room in the Clinic: How the Nurse Practitioner Role Was Built and Contested

Introduction

I plan to begin nurse practitioner study next year, and like many of my classmates I assumed the role was a modern invention. It is younger than most of nursing's institutions, but its roots are older than I expected, and its history has been contested from the start. This paper traces how the role was created, how nurses gained the authority to prescribe and why the scope of nurse practitioner practice is still debated.

Before the Nurse Practitioner

Keeling (2007) shows that nurses were giving medications on their own judgment long before the title nurse practitioner existed. Visiting nurses at Henry Street and similar agencies in the early twentieth century carried standing orders and supplies of common remedies and decided when to use them. Nurses in rural and frontier settings, including the nurse-midwives of the Frontier Nursing Service founded in Kentucky in 1925, managed illness and childbirth far from physicians. Keeling argues that the line between nursing and medical practice was always negotiated, often quietly, according to the needs of patients and the absence of doctors, and that formal authority usually followed practices nurses had already adopted.

Colorado, 1965

Fairman (2008) describes how Loretta Ford, a public health nurse, and Henry Silver, a pediatrician, created a pediatric nurse practitioner program at the University of Colorado in 1965. Concerned about children in rural communities without access to primary care, they prepared public health nurses to assess children, manage common illnesses and promote health. Fairman shows that the role grew from several forces at once: a perceived shortage of primary care physicians, federal interest in access to care and nurses' own expanding clinical knowledge. Programs spread quickly in the late 1960s and 1970s, many of them short certificate courses that later moved into master's programs.

Contested From the Start

Fairman's history emphasizes that the role was opposed from two directions. Some physicians and medical societies saw nurse practitioners as a threat to their authority and income, or accepted them only as physician extenders under close supervision. Some nursing leaders and educators worried that the role pulled nurses toward medicine and away from nursing's own knowledge. Nurse practitioners and the physicians who worked with them negotiated arrangements clinic by clinic, making room for a shared clinical space. Idaho in 1971 became the first state to change its law to recognize diagnosis and treatment by specially prepared nurses, and other states followed in different ways.

The Privilege of Prescription

Keeling traces how state legislatures, beginning in the 1970s, granted nurse practitioners authority to prescribe, at first with tight restrictions such as physician co-signature, limited formularies or exclusion of controlled substances. Over the following decades, states relaxed these limits unevenly, producing a patchwork in which a nurse practitioner's authority depended on where she practiced.

From Certificate to Doctorate

The early certificate programs, some only a few months long, gave way during the 1970s and 1980s to master's degree preparation, and national certification examinations gave the role a common standard across states. Federal training funds supported many programs. In 2004 the American Association of Colleges of Nursing recommended that preparation for advanced practice move to the doctor of nursing practice degree, a proposal still being carried out unevenly. Each step raised the role's educational standing, and each prompted fresh debate about cost and access for nurses seeking the role.

Evidence on Quality

As the role spread, researchers asked whether patients received care as good as physicians' care. Fairman and colleagues pointed to studies finding that nurse practitioners' care was comparable for the conditions examined, often with high patient satisfaction. That body of evidence has become central to scope-of-practice arguments, and it marks a change from the early years, when the role's defenders relied mainly on access and need.

Scope of Practice Today

Fairman et al. (2011), writing shortly after a major 2010 national report on nursing, argued that state scope-of-practice laws were a barrier to care. They noted that nurse practitioners in some states could practice and prescribe independently while those in others required physician supervision or collaboration agreements, differences they said reflected politics more than evidence. They cited research finding that care by nurse practitioners was comparable in quality to physicians' care for the conditions studied and urged states and federal programs to remove restrictions and update payment policies so that nurses could use the full range of skills their education had given them.

What the History Means for Me

The history changes how I see the arguments I hear at work. When colleagues debate whether nurse practitioners should practice independently, they are continuing a negotiation that began with visiting nurses carrying remedies in their bags. Knowing that Ford's program arose from concern for children without care reminds me that the role was built around patients' needs, not professional ambition.

Lessons for New Nurse Practitioners

The history suggests two habits for new nurse practitioners: knowing the law in one's own state and the reasons behind it, and building working relationships with physicians that rest on shared concern for patients rather than on rivalry.

Limits

This paper relies on secondary sources written largely by nurse historians, who may be sympathetic to the role's expansion. It focuses on nurse practitioners and leaves aside the related histories of nurse-midwives, nurse anesthetists and clinical nurse specialists. The narrator is invented.

Conclusion

Keeling shows that nurses exercised prescriptive judgment long before laws recognized it, Fairman shows how the nurse practitioner role was created in Colorado in 1965 and negotiated against opposition from physicians and from within nursing and Fairman and colleagues argue that today's uneven scope-of-practice laws reflect politics more than evidence. Nurses entering advanced practice inherit both the role and the argument.

References

Fairman, J. (2008). Making room in the clinic: Nurse practitioners and the evolution of modern health care. Rutgers University Press.

Fairman, J. A., Rowe, J. W., Hassmiller, S., & Shalala, D. E. (2011). Broadening the scope of nursing practice. New England Journal of Medicine, 364(3), 193-196. https://doi.org/10.1056/NEJMp1012121

Keeling, A. W. (2007). Nursing and the privilege of prescription, 1893-2000. Ohio State University Press.