Patients at Risk

The Rise of the Nurse Practitioner and Physician Assistant in Healthcare

Niran (Rebekah) A Al-Agba (Bernard)

• Publisher: Universal-Publishers
• Year: 2020
• ISBN:
  9781627343176
• Topic: Medicine
• Subtopic: Health Policy

Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare exposes a vast conspiracy of political maneuvering and corporate greed that has led to the replacement of qualified medical professionals by lesser trained p

Chapter 1

Differences That Can Kill

Alexus Ochoa-Dockins was a healthy and vibrant 19-year-old girl from Oklahoma. A straight-A student and top-notch athlete, only an unfortunate injury to her knee—a torn anterior cruciate ligament—precluded her participation in Division 1 basketball during her first year of college. In September 2015, Alexus had just begun her sophomore year at Redland College in El Reno, Oklahoma. On Thursday, September 24, she began feeling unwell, but like most healthy teenagers, Alexus ignored her symptoms and went about her regular activities.

According to court records, Alexus and her boyfriend Cortez Wright drove home for the weekend to visit family and returned to El Reno on the afternoon of Sunday, September 27, 2015. Upon arrival at her college dormitory, Alexus began to experience chest pain. She told her boyfriend that she couldn’t breathe. Then, Alexus fainted.

Alarmed, her boyfriend called 9-1-1. An ambulance owned by the local hospital—Mercy El-Reno—responded to the call. The emergency paramedic who arrived on the scene immediately suspected that Alexus was suffering from a pulmonary embolism and called ahead to the emergency room to give her assessment. (A pulmonary embolism is a life-threatening medical condition, caused when a blood clot in the lungs interrupts the flow of oxygen to the rest of the body.) Without proper medication to dissolve the blood clot, patients are at high risk of death.

When Alexus arrived by ambulance at the Mercy El-Reno emergency room on September 27, nurse practitioner Antoinette Thompson met her to provide care. Thompson was an experienced health professional. She had worked for 15 years as a firefighter and paramedic before returning to school to become a nurse. She also worked for several years as an emergency room nurse before returning to school in 2012 to become a nurse practitioner. Thompson graduated from the University of South Alabama in 2014 with a master’s degree in nursing, where her curriculum was completed entirely online, other than the two weeks of classes she attended on-campus. In addition to her online training, Thompson was required to complete 500 hours of clinical experience. She earned these hours working at a county health department providing medical care to healthy, stable pregnant women.

On December 30, 2014, Thompson passed her nurse practitioner certification exam and applied for a job with the Mercy Health system. Although she had no nurse practitioner experience in an emergency room or urgent care setting, Thompson was hired a month later to work in the emergency room of Mercy-El Reno Hospital. On the day that Alexus was rushed to the emergency room, Thompson had been a nurse practitioner for only eight months. Alexus Ochoa’s life now rested in her hands.45

History of nursing

The first nurse practitioner program opened in 1965, and by 2019, more than 290,000 nurse practitioners were licensed to practice in the United States.46 This number has grown exponentially in recent decades, with the total number of nurse practitioners doubling between 2005 and 2019. Meanwhile, new physician graduates have remained relatively flat. How and why has the nurse practitioner model grown so rapidly?

The origin of professional nursing is generally attributed to Florence Nightingale, a British social reformer. In 1854, Nightingale, along with a team of 38 women, succeeded in significantly reducing mortality in a Crimean War hospital barrack by establishing standards for basic sanitation, the provision of medical necessities, and close attention to the psychological needs of the soldiers. Upon her return from the war, Nightingale started a School for Nursing in London and wrote the book “Notes on Nursing: What It Is and What It Is Not” (1859).

In the United States, a female physician—Susan Dimock, MD—established the first professional nursing school. Dimock studied medicine in Switzerland after her application was rejected from Harvard University, which refused to accept women at the time. After graduating from the University of Zurich with high honors, Dimock returned to the New England Hospital for Women and Children in Boston, where she developed a training program for nurses in 1872, including lectures on the study of anatomy. Linda Richards, a graduate of Dimock’s nursing program, became America’s first professional nurse and went on to establish nursing schools across the country.

The number of nursing professionals rapidly increased in the early 1900s as the number of hospitals in the U.S. grew from 149 in 1873 to 4,400 in 1910. With an increased demand for hospital nurses, nursing schools began to fall under hospital authority. This change shifted nursing training from the Nightingale-Dimock model of using books and lectures to a greater emphasis on clinical experience—a development considered by some nurses to be a clever disguise for cheap labor.

Nurses were also in demand outside the hospital. The growth of inner cities and crowded living arrangements led to greater numbers of patients being afflicted with tuberculosis and other communicable diseases. Community nurses were critical in the care of these patients. The importance of public health nursing was further bolstered by the 1918 flu pandemic.

During World War II, nurse volunteers served soldiers in the field and civilians at home. The war provided nurses with experience in leadership, which they utilized upon returning home to organize and lobby for better pay and working conditions. By the 1950s, most nursing schools moved out of hospitals and into universities. Anticipating the need for more nurses, the Federal Nurse Training Act of 1964 increased funding for nurse training.

The development of the nurse practitioner model

The designation of nurse practitioner was first described in 1964, when pediatrician Henry Silver and nursing professor Loretta Ford created a pediatric nurse practitioner program at the University of Colorado. The program opened its doors in 1965, with the goal of graduating advanced nurses who would work alongside physicians to provide well-childcare. Nurses were trained to perform well-child exams, administer immunizations, and provide education on disease prevention and health promotion.47 The new designation caught on, growing to 65 nurse practitioner programs in 1973. Rather than focusing simply on wellness, nurse practitioner programs began to train nurses on diagnosing and treating disease states.

This created a challenge: the scope of practice for a nurse practitioner now fell outside of the American Nurses Association’s 1955 definition of nursing, which emphasized that nurses did not diagnose or prescribe. To resolve this problem, the U.S. Department of Health, Education and Welfare (today’s Department of Health and Human Services) established a Committee to Study Extended Role for Nurses in the 1970s. The group concluded that extending nursing scope of practice was “essential to providing equal access to healthcare for all Americans,” and called for a national certification for nurse practitioners, as well as increased federal funding to train nurse practitioners.48 Private philanthropy played a large role in the development of the nurse practitioner model, with the Commonwealth Fund, Robert Wood Johnson Foundation, and the Carnegie Corporation of New York all donating large sums of money towards the effort.49

Idaho became the first state to recognize the nurse practitioner role in 1971. In an effort to increase healthcare in underserved areas, the Rural Health Clinic Act of 1977 authorized funding for nurse practitioners working in rural health centers. The law further required that 50% of all services provided by federally funded rural health clinics be provided by nurse practitioners or physician assistants. In 1989, the Omnibus Budget Reconciliation Act added reimbursement for rural nurse practitioners working under physician supervision outside of these clinic settings.50

While the goal of the first nurse practitioner program was for physicians and nurse practitioners to work together collaboratively, the tide began to shift as nurse practitioners sought more autonomy and independence. Up until this point, nurse practitioners were paid through their association with a physician or hospital, except in certain rural areas. In the 1990s, nurse practitioner leaders began a concerted campaign to make direct reimbursement a “top legislative priority.”51 They did this by bringing together 125 nursing leaders in 1993 for a leadership summit, which led to the formation of the National Nurse Practitioner Coalition. This Coalition combined eleven different organizations to form a powerful lobbying group that would later become the American College of Nurse Practitioners (ACNP).52

Members of the ACNP received training on political activism, attending lectures on how to effectively spread their message to legislators. The College released calls-to-action with specific instructions on how to communicate with policymakers—and their hard work paid off. As policymaker support for nurse practitioner legislation grew, nursing organizations “thanked their congressional advocates with awards and recognition at local, state, and national meetings, and worked within their membership to express gratitude at the district level.”53

Even nurse practitioner students were encouraged to participate in the political process. “Political advocacy is built into nurse practitioner programs,” said Dara Grieger, MD, a former nurse practitioner-turned-physician, who attended political events during her nurse training program. “If there was an important vote pending and they needed our support, class would be canceled for the day. You needed to be there to make an impression on the legislature.” In 1994, on the day of the final vote granting nurse practitioners prescribing privileges in Tennessee, Grieger recalls, “our entire class was taken by faculty to the state capital to sit in the chamber.”54

To take their agenda to the next level, the ACNP hired a full-time lobbying firm in 1996, which would prove to be a highly strategic decision. The very next year, President Bill Clinton signed the Balanced Budget Act, recognizing nurse practitioners as “providers” by Medicare and Medicaid, and authorizing direct payment for their services in any setting.

The Robert Wood Johnson Foundation

The increase in nurse practitioner autonomy has been influenced by major funding from advocacy groups, most importantly, the Robert Wood Johnson Foundation (RWJF). Robert Wood Johnson was the founder of the company Johnson & Johnson, one of the world’s largest manufacturers of health products. Today, the RWJF is considered the United States’ largest health-focused philanthropy, with $11.4 billion in assets reported in 2017.55 The Foundation has shown a particular interest in nursing, contributing $674 million since 1972 to promote the work of nurses across the country.56

The RWJF has been instrumental in advocating for an expanded role for nurse practitioners. Since 1997, the organization has spent $41.2 million to fund Executive Nurse Health Policy Fellowships intended to “prepare a select cadre of outstanding nurse executives for leadership roles in clinical service, education, and public health.”57 The RWJF chose Shirley Chater, PhD, RN, FAAN, a nurse with political experience, as the fellowship’s founding chair. Chater previously served as commissioner of the U.S. Social Security Administration under President Bill Clinton.58 According to the Foundation, the fellowship offers “exclusive, hands-on policy experience with the most influential congressional and executive offices in the nation’s capital.”59 Nurse fellows “spend a year in Washington, D.C., working on health-related legislative and regulatory issues with members of Congress and the executive branch. They … also engage in seminars and discussions on health policy and participate in leadership development programs.60

Through this program, more than a dozen RWJ nurse fellows participated in congressional committees responsible for crafting healthcare legislation and formed powerful relationships with legislators.61 Of the 300 nurse fellows produced by the RWJF, more than 30 were later appointed to health committees and task forces. Six were appointed to high-level positions in local, state, and federal government programs, including the Commission of Veterans Affairs and the National Institutes of Health. Twenty-seven RWJ fellows and alumni participated in the Institute of Medicine’s influential 2010 Future of Nursing initiative.62

These opportunities led to politically important connections for nurses. In 1989, Congress named Nurse Carol Ann Lockhart, PhD, RN to its 13-member Physician Payment Review Commission, a group tasked with providing advice on reforming payments to physicians.63 Based on the Commission’s recommendations, the Omnibus Budget Reconciliation Act of 1989 granted reimbursement to rural nurse practitioners, established Medicaid payments for primary care nurse practitioners, and mandated a study of Medicare payments for non-physician practitioners.64

Another politically influential nurse, Sheila P. Burke, RN, MPA, became the chief of staff for Senate Majority Leader Robert Dole. In 2000, Burke was appointed as a member of the Medicare Payment Advisory Commission, which would ultimately recommend that nurse practitioners receive direct payment for services.65 The plan to place nurses into positions of leadership was so successful that in 2014, nurse practitioner groups announced it as a national strategy: to put 10,000 nurses on boards by the year 2020.66

Future of Nursing Report

In 2009, the RWJF gave $4.2 million to the Institute of Medicine (now the National Academy of Medicine) to develop policy recommendations for nursing. The Institute’s Future of Nursing comm...