APPs: A Long History of Meeting Patient Needs

Alicia Calacci, NP

Over the past several weeks we have been celebrating CVPH’s Advanced Practice Providers (APPs). Our Nurse practitioners (NPs), certified nurse-midwives (CNMs), certified registered nurse anesthetists (CRNAs) and physician assistants (PAs) play an integral role in the high quality patient care provided here and throughout the region.  These important members on your health care team each evolved to meet the needs of their patients and community – which is in keeping with our practice today.

Dating back as far as records allow, midwives have been attending births in the United States (US).  Prior to the 1920s, midwives learned their role through apprenticeship.  Meaning they learned by working with another midwife.  During this time, midwifery laws were widely varied from state to state.  Between 1910 and 1929, many events occurred that limited the role of the midwife.  In 1900, midwives attended nearly 50% of all births.  By 1935, they attended less than 15%.  In 1925, the Frontier Nursing Service was founded in Kentucky, creating formalized education for nurse-midwives.  The growth of certified nurse-midwifery education has continued.  As of 2019, there are 39 accredited nurse-midwife programs in the US, where graduates earn a Master or Doctoral degree.  In 2019 there were 12,218 CNMs in the US. As primary care providers for women, CNMs   specialize in pregnancy, childbirth, gynecologic and reproductive health through the life span. 

Certified registered nurse anesthetists specialize in administering anesthesia during surgery and procedures and some CRNAs receive further education to specialize in pain management.  The first formalized training program 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 relied upon to provide anesthesia which is one of the reasons that the CRNA programs flourished in the US.  As of 2019 there are 121 accredited CRNA programs in the US, where graduates earn a Master or Doctoral degree.  There are 43,520 CRNAs practicing in the US as of 2018.  

In the late 1950s and early 1960s there was growth in the specialty areas of medicine, which meant fewer physicians were working in primary care.  And, in the mid-1960s, Medicaid and Medicare were created which improved access to care for low income women, children, the elderly and those with disabilities.  This lead to two movements in our country, the creation of the physician assistant and nurse practitioner roles – both of which aimed at meeting growing demands for primary care.  

Loretta Ford, RN, a pioneer in creating the nurse practitioner role, recognized the need for and benefit of improved access to health care. She co-created the first nurse practitioner program at the University of Colorado in 1965.  Today, there are over 270,000 NPs in the US, and 350 accredited NP programs, where graduates earn a Master or Doctoral degree.  Nurse practitioner education specializes to specific populations: Neonatal, Psychiatric, Women’s Health, Pediatric, Family, Emergency, Adult Gerontology and 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. 

During the mid-1960s, Eugene Stead, MD of Duke University Medical Center began training Naval hospital corpsmen, who had received medical training while serving their country, in the first PA education program.  Today, there are 131,152 PAs in the US and 246 accredited PA programs where graduates earn a Master or Doctoral degree.  PAs provide physical examinations, order and interpret laboratory tests, diagnose and treat illness and coordinate healthcare services.  PAs work in primary care as well as many specialty areas like surgical services, emergency department, cardiology, women’s health, pediatrics and pulmonology to name a few.  Where NPs specialize during their education, PAs specialize once they are in the workforce.

At CVPH we have CNMs, CRNAs, NPs and PAs working in many different departments of the hospital. This includes: Oncology, Psychiatry, Interventional Radiology, Palliative Care, Infectious Disease, Primary Care, Pulmonology, Cardiology, Nephrology, Neurology, Hospitalist Inpatient Service, Vascular, Midwifery, Occupational Health, Electrophysiology, Surgical Services, Orthopedics, Emergency Department, Wound Care and in the Skilled Nursing Facility. Every day, patients benefit from their expertise, skill and compassion.  

References

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 Anesthetists.  (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/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.

https://onlinelibrary.wiley.com/doi/abs/10.1016/S1526-9523(03)00002-3

Dellabella, H. (2015).  50 years of the nurse practitioner.  Retrieved from https://www.clinicaladvisor.com/home/web-exclusives/50-years-of-the-nurse-practitioner-profession/

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/2018StatisticalProfileofCertifiedPhysiciaAssistants.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. https://www.aana.com/about-us/aana-archives-library/our-history

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://data.bls.gov/cgi-bin/print.pl/oes/current/oes291151.htm