Brief History of theBrief History of theNurse PractitionerNurse Practitionerin the United Statesin the United States

Elaine Leinung DNP, FNP-BC, CNEElaine Leinung DNP, FNP-BC, CNEAssistant Professor,Assistant Professor,

New York City College of TechnologyNew York City College of Technology

President, Brooklyn/Queens Chapter, President, Brooklyn/Queens Chapter, Nurse Practitioner Association of NYNurse Practitioner Association of NY

What is a Nurse Practitioner?• RN with advanced education

– Master’s Degree– Doctor of Nursing Practice

When, Where & Why• 1965 - Dr. Loretta Ford EdD, RN, PNP FAANP

• University of Colorado

• Cost effective for first contact health care in rural regions

• Pediatric Nurses were the first NP’s

• Certificate Program, then MSN, now DNP

Scope of Practice• Diagnosing, treating, evaluating and managing acute and chronic

illness and disease (e.g. diabetes, high blood pressure)• Obtaining medical histories and conducting physical examinations• Ordering, performing, and interpreting diagnostic studies (e.g.,

routine lab tests, bone x-rays, EKGs)• Prescribing physical therapy and other rehabilitation treatments

• Prescribing pharmacologic treatments and therapies for acute and chronic illness (extent of prescriptive authority varies by state regulations)

• Providing prenatal care and family planning services

Scope of Practice• Providing well-child care, including screening and immunizations• Providing primary and specialty care services, health-

maintenance care for adults, including annual physicals• Providing care for patients in acute and critical care settings• Performing minor surgeries and procedures

– dermatological biopsies– Suturing– casting

• Counseling and educating patients on health behaviors, self-care skills, and treatment options

(cont.)

Practice Settings• Community clinics, health

centers, urgent care centers

• Health departments• Health maintenance

organizations (HMOs)• Home health care

agencies• Hospitals• Hospice care

• NICUs or PICUs• Nurse practitioner

practices/offices • Nursing homes• Private & public schools,

universities and colleges• Physician/private medical

practices• Veteran's administration

facilities

Legitimization Period • 1970’s

– Across the US, legislative initiatives to change state laws and nurse practice acts

• 1971– 1st Family Nurse Practitioner Program at

University of Washington

• 1973– 65 FNP programs

Certification1977 - The American Nurses Association• The first nurse practitioner certification

exams • Legitimized the role of NPs and led to more

standardized practice outcomes

1980 - 1990 Slow Steady Growth

Due largely to Federal Government funding NP education through grant programs administered by the United States Public Health Service, Division of Nursing.

1991-2000 New Expansion & Rapid Growth• In 2001, the number of NPs in the United States is

estimated to be 78,251 (Pearson, 2001, p. 26)

• Legislative victories lead to an increasingly independent role for the NP in practice:

– Third party reimbursement

– Prescriptive authority

• By the turn of the century, nurse practitioner programs had entered the mainstream of graduate education in nursing.

The PresentNP specialties have grown

• FNP (Family NP)• GNP (Geriatric NP)• HNP (Holistic NP; APN program)• NNP (Neonatal NP)• PMHNP (Psychiatric/Mental

Health NP)• APMHNP (Adult

Psychiatric/Mental Health NP)• FPMHNP (Family

Psychiatric/Mental Health NP) • OHNP (Occupational Health NP) • ONP (Oncology NP)

• ACNP (Acute Care NP)• ANP (Adult NP)

– Adult Cardiovascular Care NP

– Adult Primary Care NP– Adult Critical Care NP– Adult Acute Care NP

• ENP (Emergency NP)

• PA/CCNP (Pediatric Acute/Chronic Care NP)

• WHNP (Women's Health NP)

• BC-PCM (Board Certified - Palliative Care Management, disc’d by ANCC)

• BC-ADM (Board Certified - Advanced Diabetes Management)

• BC-ADM (Board Certified - Advanced Diabetes Management)

• ACHPN (Advanced Certified Hospice & Palliative Nurse)

The PresentNP specialties have grown• AONP (Adult Oncology NP)

• PONP (Pediatric Oncology NP)

• PCNP (Palliative Care NP; APN program)

• PNP (Pediatric NP)

• PCCNP (Pediatric Critical Care NP)

• ACPNP (Acute Care Pediatric NP)

THE END!

The Nurse PractitionerThe Nurse Practitionerinin

New York StateNew York State

Dr. Elaine Leinung DNP, FNP-BC,CNEDr. Elaine Leinung DNP, FNP-BC,CNE

President of Brookyln Queens ChapterPresident of Brookyln Queens Chapter

Dorothy Grasso, MSN FNP-BCDorothy Grasso, MSN FNP-BC

Vice President B/Q ChapterVice President B/Q Chapter

License Requirements:Nurse Practitioner in New York State

• Graduate from approved program with minimum Master’s Degree (30 -30 credits above a BSN and 600 - 1000 practice hours)

• Infection control class (on line) • Child abuse reporting class (4 hours)• Obtain a DEA (Drug Enforcement Agency)

number • Obtain National Provider Identifier Number

• Can only practice & prescribe in your specialty • Establish a collaboration agreement with an MD

or DO and keep on file • Identify a protocol text to be used for patient care.

License Restrictions:Nurse Practitioner in New York State

NPs in New York StateNP title(s) used in this state: NP (nurse practitioner)

Number of NPs in state: 14,272

National certification required for recognition/practice? NO

BON sole state authority over NPs? Yes

Physician involvement required for any aspect of practice? Yes. For details, log on

to www.webnp.net

CE requirements for NP practice? No

“Doctor Nurse?”Q: Is there a statutory restriction against an NP with

doctorate being addressed as “Doctor?”

A: No, but, according to General Business Law statute, if you use the term “Doctor” when offering to perform health services, you must indicate the profession in which you hold a doctorate.

Additional limitations/prohibitionsto NP practice?

• Write home health personal aid services,• Act as medical inspectors• (In school districts) order respiratory therapy• Obtain limited test-site permits under CLIA• Declare an emergency in response to ordering

utilities turned back on after “shutoff” action• Prescribe non-patient-specific orders

– (certain) immunizations– Anti-anaphylactic agents– PPD tests– rapid HIV tests

NPs may:

NP Scope of Practice – Prescribing

• The practice agreement and protocols govern the prescribing of drugs.

• May prescribe drugs for treatment of patients within their specialty area of practice.

• In terms of CS, NPs may order drugs from Schedules II-IV without restriction.

• Drugs, immunizing agents, tests, devices, and procedures ordered by NPs do not require a co-signature from the collaborating physician.

Why an Nurse Practitioner?• NP’s Provide Patient Centered Care• NPs take the time to listen to patients'

concerns, health and otherwise.• NPs concentrate on preventative health

care.• NPs provide individualized, holistic (all

encompassing) care.

The NPA of New York State• The NPA was established in 1980 as a non-profit organization

under the name The Nurse Practitioner Association, Inc. Since 1980, the NPA has grown financially, programmatically and increased the visibility and credibility of NPs within the healthcare community, at both the national and State levels of government, and with consumers throughout New York.

• The NPA is the voice of Nurse Practitioners in New York State. We offer our members the tools, resources, and information to advance the NP profession, and an effective and successful advocacy program dedicated to advancing and protecting NPs in all of New York State.

Historical Overview of NPA 1980 – The Nurse Practitioner Association, Inc. was formed

1981 – Organized meetings begin in Syracuse, NY under the name of Coalition of Organized Nurse Practitioners Associations (COONPA)

1985 – First Annual Convention and Educational Conference in Albany, NY

1988 – Landmark legislation authorizing title and scope of practice for NPs

1988/1992 – Acquired prescriptive authority and ultimately full DEA prescriptive authority

1991 – The Coalition of Nurse Practitioners renamed New York State Coalition of Nurse Practitioners (NYSCONP)

Historical Overview of NPA 1992 – The American College of Nurse Practitioners (ACNP) established with

NYSCONP as a founding member with a seat on the Board

1993 – Education Law amended allowing referrals for physical and occupational therapy

1993 – Medicaid reimbursement at 100% of the physician’s rate enacted

1997 – Medicare reimbursement at 85% of the physician's rate enacted

1998 – NYSCONP forms a Political Action Committee (PAC)

1999 – NYSCONP hires its first full-time paid executive and professional staff and opens Albany office

2002 – NYSCONP begins doing business as The Nurse Practitioner Association New York State (The NPA)

2002 – The Practice Area Bill is passed, becoming Chapter 600 of the Laws of 2002

2003 – The Respiratory Therapy Bill enacted allowing Respiratory Therapists to accept orders from NPs

2004 – Clinical Lab Bill is passed

2005 – The NPA grows to 21 Chapters and 7 Regions with over 2,500 Members

2006 – Four bills introduced at the request of NPA pass both houses of the NYS Legislature:

Death Certificates Bill, Patient Restraints Bill, Handicap License Plates Bill, and the Medical Emergency Utility Services Bill.

Two bills are signed into law:

The Medical Emergency Utility Services Bill, and the Handicap License Plates Bill.

Historical Overview of NPA

Bills NPA is Sponsoring Before NYS Legislature

• Patient Access & Advocacy Act - A.765 (Gottfried)/S.2948 (Montgomery)- Removal of Statutory Collaboration & Reimbursement

• Reimbursement Assurance - A.6651 (Gottfried)/S4490 (Duane) - To assure health plans do not deny reimbursement for services rendered by nurse practitioners acting within their lawful scope

• Access Protection - A.7877 (Gottfried)/S4491 (Duane) - To promote practice opportunities for nurse practitioners by prohibiting health plans from excluding nurse practitioners from their provider networks and to insure that reimbursement rates are reasonable

• NP Worker's Compensation Access Act - A.3704 (John)/S.3908 (Duane) - Authorizing NPs to fully participate within and be reimbursed under the worker's compensation program in NYS as a legislative study bill

Bills NPA is Sponsoring Before NYS Legislature

• Immunization Bill - A.6654 (Gottfried)/S.4070 (Montgomery) - To add NPs to the category of persons legally qualified to certify that an immunization required by section 2164 of the public health law may be detrimental to a child's health

• NPA License Plates - A.4829 (Morelle) - Adding a new Section 404-x to the vehicle and traffic law to provide for the issuance of distinctive plates for members of the NPA

• Death Certificate Bill - A.2028-A (John)/S.2969 (Montgomery) - Authorizing NPs to sign death certificates

• Do-Not-Resuscitate (DNR) - A.1719 (Gottfried)/S.2947-A (Hannon) - Authorizing NPs to issue orders not to resuscitate

Other bills monitored for provider neutrality:• Timothy's Law - A.5301 (Morelle) - this legislation would make technical

amendments to make the law "provider neutral" by adding language to include nurse practitioners.

• Collaborative Drug Management Therapy - A.6848 (Canestrari)/S.3292 (LaValle) - Authorizes pharmacists to perform collaborative drug therapy managment with physicians in certain settings.

Bills NPA is Sponsoring Before NYS Legislature

The Future• Removal of collaborative Practice agreements in

NYS (we hope!)• NP’s as Primary Care Providers on Major Insurance

Carriers

• Health Care for all Americans and

• NP’s as Primary Care Providers

External Links• American Academy of Nurse Practitioners (AANP)

http://www.aanp.org/AANPCMS2

• American College of Nurse Practitioners (ACNP) http://www.acnpweb.org/

• The National Organization of Nurse Practitioner Faculties http://www.nonpf.org/

• The Nurse Practitioner Association of New York State http://www.thenpa.org/

• New York State Department of Health, Office of the Professions http://www.op.nysed.gov/

ReferencesReferences• Berlin, L.E., Bednash, G.D. & Stennett, J. (2001). 2000-2001 Enrollment and

graduations in baccalaureate and graduate programs in nursing. Washington, D.C.: AACN.

• Carnegie Commission on Higher Education. (1968). Quality and equality: New levels of federal responsibility for higher education. NY, NY: Carnegie Commission.

• Geolot, D. (1987). NP education: Observations from a national perspective. Nursing Outlook, 35 (1), 132-135.

• Geolot, D. (1990). Federal funding of nurse practitioner education: Past, present and future. Nurse Practitioner Forum, 1 (3), 159-162.

• Harper, D. & Johnson, J. (1996). NONPF Workforce policy project technical report (1997)

• Pearson, L. (2001). Annual legislative update. Nurse Practitioner, 26 (1), 7-57.

• Pearsson L. (2009). The Pearson Report American Journal for Nurse Practitoners vol 13 no 6