50 years of the nurse practitioner profession

Since the profession began in 1965, NPs have become increasingly important in healthcare.
Since the profession began in 1965, NPs have become increasingly important in healthcare.

This year marks the 50th anniversary of the nurse practitioner (NP) profession, which currently includes more than 205,000 NPs licensed in the United States. As NPs are poised to take on an even more prominent role for meeting healthcare needs, here is a look back at just how far the profession has come since its inception in 1965.

In 1965, Medicare and Medicaid coverage expanded their coverage to low-income women, children, the elderly, and people with disabilities. With so many new people now qualifying for primary care coverage, the United States experienced a shortage in available physicians. The NP profession began in response to a dearth of primary care providers, particularly for children, in urban and rural areas in the United States.

The first NP program was founded in 1965 by Loretta Ford, EdD, PNP, FAAN, and Henry Silver, MD, at the University of Colorado.1 Initially, it was established as a certificate program, but it became a master's degree program in the early 1970s. Many of the earliest NP programs were either certificate or post-graduate programs.

NPs primarily worked in pediatrics at first, but in the 1970s many new NP specialties were created. One of the first family NP programs originated at the University of Washington in 1971, and several adult NP programs began during that same time. By 1973, the United States was home to more than 65 NP programs.

In 1974, the American Nurses Association (ANA) helped legitimize the role of NPs by establishing the Council of Primary Care Nurse Practitioners, which created an early description of an NP's duties. To further standardize the duties of NPs, the ANA began offering NP certification exams in 1977.

In 1985, the American Academy of Nurse Practitioners was established. By the end of its first year, AANP had accrued 100 members and had begun to develop a national database of NPs. To see how the number of NPs increased throughout the profession's history, see Table 1.

TABLE 1. Growth of the number of NPs in the United States1,2

Year Approximate number of NPs in the United States
1979 15,000
1983 23,000
1995 40,000
1999 68,000
2001 82,000
2003 106,00
2007 120,000
2009 130,000
2010 140,000
2011 148,000
2012 157,000
2013 171,000
2014 192,000
2015 205,000

The U.S. federal government began contributing money to NP education, with $100 million spent on programs by 1987. By 1989, 90% of NP programs were either a master's degree program or a post-master's degree program.2 The National Organization of Nurse Practitioner Faculties (NONPF) developed many publications on NP education, including documents on curricula, competency-based education, and a directory of programs. Among these publications were National Profile of NP and Midwifery Programs, Developing Competent Nurse Practitioners, Nurse Practitioner Faculty Practice Survey, Desired Competencies for Nurse Practitioners, and Advanced Nursing Practice: Curriculum Guidelines and Program Standards for Nurse Practitioner Education.

Even as the NP profession continued to grow, NPs did not have provider status in the eyes of the government and thus were not eligible for reimbursement. NP leaders worked with Congress to pass the Omnibus Reconciliation Act of 1989, which created limited reimbursement for NPs.3

Many other hospital-based roles suffered during the fiscal crisis in health care in the 1990s. As these roles declined, it led to rapid growth for the NP profession. The number of NPs increased from 40,000 in 1995 to more than 60,000 in 1999, and the number of NP education programs continued to outnumber all other nursing specialties. To standardize NP education, NONPF created the National Task Force on Quality Nurse Practitioner Education in 1995, which published the Criteria for Evaluation of Nurse Practitioner Programs.

During this decade, NPs continued to fight for legitimization of their profession. The Balanced Budget Act of 1997 granted NPs direct reimbursement, and by 2000, NPs were legally able to practice in all 50 states.

As the number of NP programs continued to grow, various NP organizations worked together to incorporate NP education standards into the nursing accreditation process. The Commission on Collegiate Nursing Education revised its Standards of Accreditation to include the Criteria for Evaluation of Nurse Practitioner Programs, which went into effect in January 2005.

In 2004, the American Association of Colleges of Nursing (AACN) began its initiative to require a Doctor of Nursing Practice degree for NPs, requiring that all current NP master's programs transition to DNP programs. The AACN hoped to reach this goal by 2015, but a document released in October 2014 by the AACN's Task Force on the Implementation of the DNP noted that fewer than one-fourth of NP programs had fully transitioned to DNP programs.4

Although the AACN missed its goal of requiring a DNP for all NPs by 2015, the number of DNP programs continues to increase. There are DNP programs in 49 states, and the DNP is widely recognized as the preferred degree for those pursuing an NP career.5 As more programs continue to transition to the DNP, the AACN hopes to better standardize curricula, program length, and practice requirements.

The role of NPs has become even more important as additional patients are covered under the Affordable Care Act and more states grant NPs full practice authority. Currently, NPs have full scope of practice in 21 states and the District of Columbia, and organizations such as AANP are working to increase this number. The NP profession is anticipated to continue its growth, with 244,000 NPs expected to be practicing by 2025.

References

  1. Historical Timeline. American Association of Nurse Practitioners website. https://www.aanp.org/all-about-nps/historical-timeline. Accessed November 6, 2015.
  2. Pulcini J, Wagner M. Nurse Practitioner Education in the United States: A Success Story. Clin Excell Nurse Pract. 2002;6(2):51-56.
  3. History of Nurse Practitioners in the United States (Slideshow). Simmons School of Nursing and Health Sciences website. Published November 13, 2014. https://onlinenursing.simmons.edu/nursing-blog/history-nurse-practitioners/. Accessed November 9, 2015.
  4. Auerbach DI, Martsolf G, Pearson ML, et al. The DNP by 2015: A Study of the Institutional, Political, and Professional Issues that Facilitate or Impede Establishing a Post-Baccalaureate Doctor of Nursing Practice Program. Rand Health. http://www.aacn.nche.edu/dnp/DNP-Study.pdf. Accessed November 9, 2015.
  5. Task Force on the Implementation of the DNP. The Doctor of Nursing Practice: Current Issues and Clarifying Recommendations. American Association of Colleges of Nursing. Published August 2015. http://www.aacn.nche.edu/aacn-publications/white-papers/DNP-Implementation-TF-Report-8-15.pdf. Accessed November 9, 2015.
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