A Closer Look at Advanced Practice Providers at CVPH

Recognizing Advanced Practice Provider Week

Alicia Calacci, NP

This week we celebrate Advanced Practice Providers, or APPs, at CVPH. Every one of our APPs plays a vital role in the teams that care for our patients, and I wanted to pull back the curtain to give you a glimpse of what we do and how our roles started.

To begin, APPs include nurse practitioners (NPs), certified nurse-midwives (CNMs), certified registered nurse anesthetists (CRNAs) and physician assistants (PAs).

When you hear about certified nurse-midwives (CNMs), pregnancy and childbirth might be the first things that come to mind. They do much more than that, specializing in gynecologic and reproductive health for women of all ages. Dating back as far as records allow, midwives have been attending births in the U.S. Prior to the 1920s, midwives were educated and trained through apprenticeship, meaning they learned their role by working with another midwife. During that time, midwifery laws varied widely from state to state. Between 1910 and 1929, many events occurred that limited the role of the midwife, and that was reflected in the number of births participated in. At the beginning of the century, midwives attended nearly 50 percent of all births. By 1935, they attended less than 15 percent. In 1925, the Frontier Nursing Service was founded in Kentucky, creating formalized education for nurse-midwives. The growth of nurse-midwifery education has continued. As of 2019, there are 39 accredited nurse-midwife programs in the U.S., where graduates earn a Masters or Doctoral degree.  In 2019, there were 12,218 CNMs across the country.

Certified registered nurse anesthetists (CRNAs) can be a key part of your care team. They are the ones who administer anesthesia to you during surgeries and procedures. Some CRNAs receive further education to specialize in pain management.  The first formalized training program for CRNAs opened in Portland, Oregon in 1909. Prior to this, anesthesia was provided by medical students, house officers, nurses and orderlies and didn’t require any formal training.  In hospitals and during wars, nurses were often the consistent people providing anesthesia, which is one of the reasons that CRNA programs flourished in the U.S. As of 2019, there were 121 accredited CRNA programs in the country, where graduates could pursue a master’s or doctoral degree. There were 43,520 CRNAs practicing in the U.S. as of 2018.

In the late 1950’s and early 1960’s, there was growth in the specialty areas of medicine, which meant fewer physicians were working in primary care. In the mid-1960’s, Medicaid and Medicare were created, which improved access to care for low-income women, children, the elderly and those with disabilities. This led to two movements within the U.S.: the creation of the physician assistant and the nurse practitioner roles.

Loretta Ford, RN recognized the need for improved access to health care.  She co-created the first nurse practitioner (NP) program at the University of Colorado in 1965. Today, there are more than 290,000 nurse practitioners in the U.S. and 400 accredited NP programs, where graduates earn a master’s or doctoral degree. Nurse practitioner education is specialized to specific groups of people:

  • Neonatal
  • Psychiatric
  • Women’s health
  • Pediatric
  • Family
  • Emergency care
  • Adult gerontology
  • Acute care

Nurse practitioners focus on health promotion, disease prevention, education and counseling.  They provide physical examinations, order and interpret laboratory tests, diagnose and treat illness and coordinate healthcare services.

The initial physician assistant (PA) program was created by Eugene Stead, MD at Duke University Medical Center in 1965. The first students were Navy Hospital Corpsmen who had received medical training during their military service. As of 2019, there were 131,152 PAs in the U.S. and 246 accredited PA programs in the country, where graduates earn a master’s or doctoral degree. Physician assistants provide physical examinations, order and interpret laboratory tests, diagnose and treat illness and coordinate healthcare services. Physician assistants work in primary care as well as many specialty areas like surgical services, the emergency department, cardiology, women’s health, pediatrics and pulmonology. While NPs begin their specialization during their education, PAs begin specializing once they are in the workforce.

At CVPH, we have CNMs, CRNAs, NPs and PAs working in 19 different departments of the hospital.  These include: oncology, psychiatry, interventional radiology, palliative care, infectious disease, primary care, pulmonology, cardiology, nephrology, hospitalist inpatient service, vascular, midwifery, occupational health, electrophysiology, perioperative area, emergency department, wound care and in the skilled nursing facility.

Throughout Advanced Practice Provider week, you’ll hear from other colleagues giving insight into what they do and share their experiences as an APP.


Accreditation Review Commission on Education for the Physician Assistant, Inc.  (2019). ARC-PA. Retrieved from http://www.arc-pa.org/accreditation/accredited-programs/

American Academy of Physician Assistants. (2019). History of the PA profession. Retrieved from https://www.aapa.org/about/history/

American Association of Nurse Anesthetist. (2019). Certified registered nurse anesthetists fact sheet. Retrieved from https://www.aana.com/membership/become-a-crna/crna-fact-sheet

American Association of Nurse Practitioners.  (2019a). Nurse practitioners.  Retrieved  from https://storage.aanp.org/www/documents/NP-Infographic.pdf

American Association of Nurse Practitioners. (2019b). NP certification.  Retrieved from https://www.aanp.org/student-resources/np-certification

American Association of Nurse Practitioners. (2019c). Planning your NP education.  Retrieved from https://www.aanp.org/student-resources/planning-your-np-education

American College of Nurse-Midwives. (2019). Fact sheet: Essential facts about midwives.Retrieved from    http://www.midwife.org/acnm/files/ccLibraryFiles/Filename/000000004838/EssentialFactsAboutMidwives1214.pdf

Dawley, K. (2003).  Origins of Nurse-Midwifery in the United States and its Expansion in the 1940s. Journal of Midwifery & Women’s Health, 48(2), 86-95. Doi: 10.1016/S1526-9523(03)00002-3.

National Commission on Certification of Physician Assistants. (2018). 2018 Statistical profile of certified physician assistants. Retrieved from http://prodcmsstoragesa.blob.core.windows.net/uploads/files/2018StatisticalProfileofCertifiedPhysicianAssistants.pdf

O’Brien, J. M. (2003). How nurse practitioners obtained provider status: Lessons for pharmacists. American Journal of Health System Pharmacy, 60(22).

Ray, W. T., & Desai, S. P. (2016). The history of the nurse anesthesia profession.  Journal of Clinical Anesthesia, 30, 51-58.

Rooks, J. P. (2012). The history of midwifery. Retrieved from https://www.ourbodiesourselves.org/book-excerpts/health-article/history-of-midwifery/

U.S. Bureau of Labor Statistics. (2018). Occupational employment and wages. Retrieved from https://www.bls.gov/oes/current/oes291151.htm