This chapter provides a context for the subsequent discussion of professional practice indices for NPs, PAs, and CNMs. It includes the following subsections:

• Historical Context for the Three Professions
• Factors Related to Professional Practice Indices
• Professionalization
• Conclusions

The concepts of non-physician providers and physician “assistants” are not new, with medical tradition indicating the presence of these providers across cultures for hundreds of years. These practitioners often worked in locations where physicians were unavailable. However, their presence and acceptance in the United States has increased significantly in recent years.

Although the development of the three professions is rooted in the need for access to primary medical care for underserved populations, each of the three professions has an individual history and orientation that colors its present status. And although each has historical roots that reach into the past, in the United States, the professions have experienced their most rapid development in about the last 40 years, with considerable evolution over the last decade. Brief histories for the three professions are provided below.

In the 1960s, Dr. Henry Silver and Loretta Ford, PhD (a nurse educator) at the University of Colorado, created a program to educate nurses to respond to the need for primary care providers in rural areas. Dr. Silver and Dr. Ford established a pediatric practitioner program based on the nursing model.^[4] This was the first of the nurse practitioner programs that educated nurses to make medical diagnoses while providing care in a nursing model. The idea was revolutionary and initially not well accepted by the academic nursing profession.^[5]  The first graduates began to practice in the late 1960s.^[6] The program was at the master’s level requiring a nursing license and experience in patient care for admission. In subsequent years, several programs moved away from the master’s degree model to certificate programs but, more recently, the trend has again shifted to master’s education.^[7]

The nursing profession initially expressed skepticism with the educational process and the new identity of the nurse practitioner. Education that incorporated a medical model to create a physician “extender” was threatening to nursing’s roots and to its exclusive orientation to care. It was only as the NP profession evolved and the academic and training programs were clarified that the profession embraced the new roles for nurses.^[8]

Nurse practitioners function in a variety of roles in almost every conceivable health care setting. The care they provide is grounded in a nursing model which emphasizes treatment of illness in the context of a patient’s total well-being and encourages patient education.  Nurse Practitioners provide well care, diagnose and treat acute illness, and monitor chronic conditions. NPs are permitted to order, perform, and interpret certain laboratory tests and to prescribe medications.

In 2000, Nurse Practitioners were legally enabled to practice in every State and the District of Columbia. Practice varied considerably across States with different statutory and regulatory limitations on prescriptive authority, direct reimbursement, and the required legal relationship with physicians. Nurse practitioners were generally regulated by State Boards of Nursing, but in some States, Boards of Medicine were directly involved in regulation of the profession. In some States, agencies other than the Department of Health were involved in professional oversight activities for Nurse Practitioners. In 2000, NPs were not title protected in every State. In 49 States and the District of Columbia, NPs were provided with some form of prescriptive authority which varied from the ability to prescribe only legend drugs to full prescriptive authority including controlled substances. The educational requirements to obtain prescriptive authority varied widely across States. 

Many States required a master’s degree in order to be licensed in the State.  All but five States required national certification from a certifying body in order to qualify for licensure or registration as an NP. Examinations qualifying NPs for national certification were provided by the American Academy of Nurse Practitioners Certification Program (AANPCP), the American Nurse Credentialing Center (ANCC), the American Board for Pediatric Nurse Practitioners (PNCB), and the National Certification Corporation for the Obstetrical, Gynecologic, and Neonatal Nursing Specialties (NCC).

Nurse practitioners seek some professional autonomy in practice with formal collaboration being the general mode of cooperation with physicians. However, in some States supervision by physicians is a common form of practice.

In 2000, there were 321 institutions offering either master’s level NP and/or post-master’s NP programs.^[9] NP education programs  were accredited by the Commission on Collegiate Nursing Education, the National League for Nursing Accrediting Commission, and the National Association of Nurse Practitioners in Women’s Health which accredits NP programs in women’s health.^[10] Seventy-two percent of the graduates of the master’s programs in  2000 were family, adult, or pediatric nurse practitioners^[11] suggesting that primary care continues to be the focus  of the majority of NPs.

In 2000 there were approximately 95,000 NPs^[12] practicing in the U.S., up from about 28,000 in 1992. This represents an increase of more than 240 percent over the 8 year period.

The physician assistant profession is generally understood to have its roots in the military medic or corpsman model. Medics provided medical services teamed with physicians and nurses in wartime settings. In many cases these adjunct providers were highly trained members of the medical team who became experienced in providing care in very challenging and demanding circumstances. In the late 1960s during the Vietnam War, this group of trained providers became the focus of attention for some foresighted physicians in the United States.

There was growing concern about a potential shortage of generalist physicians due to the increasing numbers of medical students who were choosing specialty training. This fact, coupled with increased attention to populations that were poor and/or medically underserved in the United States, created concern that the supply of physicians was insufficient to meet the needs of the public.

As early as 1960, Dr. Charles Hudson, President of the National Board of Medical Examiners, spoke to a gathering of the AMA about the possibility of training these medical corpsmen to work with physicians in civilian medical settings.^[13] Several physicians, including Dr. Richard Smith, a Federal bureau director, and Dr. Hudson and Dr. Eugene Stead, a faculty member at Duke University, reiterated this suggestion in subsequent years^[14]. Dr. Stead, Dr. Harvey Estes, and Dr. D. Robert Howard, all of Duke University in North Carolina, introduced the idea of educating a health professional who would assist physicians in the provision of primary care services with special emphasis on educating new providers to enhance access to care in rural North Carolina. In the mid-1960s, they instituted a program at Duke that provided formal education and training for these professionals.

This extension of the military model into practice environments in the United States was conceived as a way to link underserved populations to the health care system. After the Vietnam War, the recognition of the potential to use highly trained and competent medics to meet the needs in rural areas gained popularity. Thus the physician assistant profession was born.

PAs traditionally practice under the supervision of physicians and this strong relationship with physicians has remained relatively unchanged as the profession has evolved. As the name suggests, Physician Assistants are closely associated with a medical model of care, one grounded in the diagnosis and treatment of illness. There were only 237 PAs practicing in the U.S. in 1970. By 2000 that number had increased to about 40,000,^[15] a 90 percent increase since 1992.

As of 2000, all States and the District of Columbia had statutes or regulations governing the qualification of practice for PAs. All jurisdictions required PAs to pass the Physician Assistants National Certifying Examination, administered by the National Commission on Certification of Physician Assistants (NCCPA) and open only to graduates of PA educational programs accredited by the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA), which is sponsored by the AMA, the American Academy of Family Physicians, the American College of Surgeons, the American Academy of Pediatrics, the American College of Physicians, the Association of Physician Assistant Programs, and the American Academy of Physician Assistants. Only those successfully completing the examination may use the credential “Physician Assistant-Certified (PA-C).”

PAs are educated in accredited programs located in academic medical centers, teaching hospitals, universities, and colleges. The PA curriculum, like medical school, provides a generalist education that promotes the development of skills in clinical problem solving and medical decision-making. Their medical education makes it possible for PAs to choose any medical or surgical specialty after graduation, something that is facilitated by the scope of their licenses.

In order to remain certified, PAs must complete 100 hours of continuing education every 2 years. Every 6 years they must pass a recertifying exam or complete an alternate program combining learning experiences and a take-home exam. [AAPA, 2001]

A Brief History of Certified Nurse Midwives

Nurse Midwives have a lengthy history when considered in an international context. The presence of the profession in the United States, particularly among immigrant populations, spans many generations. In fact, there is documentation suggesting that a nurse midwife delivered three babies on the voyage of the Mayflower.^[16] However, the formal education of nurse midwives in the United States began when Mary Breckenridge founded the Frontier Nursing Service in East Kentucky in 1925.^[17] This highly regarded program educates midwives to provide nursing services in remote areas with a focus on women and families. Nurse midwives who continue to be trained in this program are credited with significantly reducing infant mortality rates in the areas that they serve.^[18]This program eventually began to educate nurse practitioners as well and continues today to serve its mission of educating providers to work with underserved populations. The Frontier School of Midwifery and Family Nursing offers a distance-learning program that enables many students to be in their own communities working with local providers while being educated as midwives.^[19]

In 1931, a collaboration of the Lobenstine Clinic and the Maternity Center Association began educating nurse midwives in New York City to serve immigrant and indigent populations in the city. That program continues today as the SUNY Downstate Nurse Midwifery Program.^[20] By the 1950’s there were seven education programs for nurse midwives in the US. In 1955, Hattie Hemschemeyer, a public health nurse educator who had begun the Maternity Center education program in New York City, incorporated the American College of Nurse Midwifery in New Mexico. In 2000 there were over 8,000^[21] nurse midwives in the U.S., educated in 40 master’s degree programs and 5 post baccalaureate certificate programs.^[22]  Educational programs for the profession were accredited by the American College of Nurse Midwives Division of Accreditation.

Midwives advocate a more homeopathic, natural approach to childbirth with less emphasis on the use of technological innovation.^[23] This approach to obstetrical care has been integrated into extended scopes of practice that enable nurse midwives to provide women’s well-care and other gynecological services to non-obstetrical patients in many States.

Nurse midwives in the United States are generally educated in a nursing model of care. In many States nurse midwives are regulated in legislation as advanced practice nurses. Several States permit practice by non-nurse midwives who are separately licensed and regulated by the individual States. Many States require that non-nurse midwives pass a competency examination. The American College of Nurse Midwives presently offers this exam to these “direct-entry” or “lay” midwives.

Nurse Midwives are governed variously in the 50 States and the District of Columbia. Statutes and regulations addressing practice by nurse midwives is not uniform. Nurse midwives are mainly governed by State Boards of Nursing. In Utah, the profession is governed by a Certified Nurse Midwifery Board and in New York by a Board of Midwifery that regulates both nurse midwives and direct entry midwives. The profession is jointly regulated by the Board of Nursing and the Board of Medicine in 5 States and solely by the Board of Medicine in 2 States. Illinois has established an Advanced Practice Nursing Board that regulates  advanced practice nurses (APNs) including nurse midwives. The Board of Health oversees practice of nurse midwives in 3 States.

In 2000, certified nurse midwives had some form of prescriptive authority in 49 States and the District of Columbia. National certification through examination is required in 44 States and the District of Columbia. Since 1971, the American College of Nurse Midwives (ACNM) and subsequently, since 1991, the ACNM Certifcation Council (ACC) have provided competency testing for nurse midwives. In 1998, the ACC began providing certification for non-nurse midwives trained in accredited education programs.^[24] 

Nurse midwives operate under various practice relationships with physicians.  State regulation requires a range of supervisory, consultative, or collaborative arrangements with physicians.  In 11 States in 2000, there was no specific language addressing a required relationship between nurse midwives and physicians in statute or regulation.^[25]

There are over 8,000 nurse midwives in the United States providing care in many settings to a wide variety of women. Midwives provide a significant amount of care to women whose access is marginal. As many as 70 percent of the women receiving care from midwives are considered “vulnerable” in some aspect either by their demographic characteristics, their geographic location, or their socioeconomic status.^[26]

A great many factors have influenced the evolution and acceptance of the three professions in the U.S. Figure 2-1 presents a highly simplified schematic that suggests some of the relationships that have contributed to the increased status and professional practice for the three professions over the past several decades. The figure emphasizes factors related to the contributions to patient care and outcomes that can be traced back to the three professions and to their collaborating physicians. The discussion that follows identifies several key factors related to the professional practice of the three professions to suggest the richness that exists in the framework that defines professional practice options.

Barbara Safriet [2002] presents a much different perspective on professional practice of professionals like NPs, PAs, and CNMs. She argues that current professional practice statutes and regulations have generally resulted in significant gaps between “the abilities of non-physician providers and the activities government regulation allows them to perform. Dominant provider groups extensively lobby State legislators in order to obtain scope-of practice monopolies, which confer exclusive control over their areas of interest and exclude other equally-capable groups from performing such services. As a result, the excluded providers’ skills are under-used, creating a systemic inefficiency”[p. 301].

NPs, PAs, and CNMs have fared reasonably well in this sometimes hostile political environment. The net result of these and other factors has been increased acceptance of the three professions across the U.S. The response of the system has been dramatic with numbers of practitioners increasing, and the roles, responsibilities, and scopes of practice expanding.

NPs, PAs, and CNMs have undergone a process of “professionalization” over the past 30 years, and especially in the 1990s. Professionalization has been described by Hodson and Sullivan as the “effort by an occupational group to raise its collective standing by taking on the characteristics of a profession.”^[27] The professionalism process is characterized by several steps including:

• Formation of a professional organization and lobbying the government and the public for increased professional standing,
• Standardization of the body of knowledge through more uniform curriculum requirements and training, publication of journals, engagement in research, and creation of examination requirements for the profession, and
• convincing the public by creating certification requirements that the occupation possesses appropriate professional knowledge and by licensure through public agencies.^[28]