The NP at 50
It was a concept whose time had clearly come.
In the 1960s and 1970s, several distinct forces converged to drive the idea of nurse practitioners (NPs) forward: the social justice and women’s movements, President Lyndon B. Johnson’s Great Society programs, and massive federal funding for health programs and healthcare professionals. A national consensus had grown around the concept of healthcare as a right, and the 1965 enactment of Medicare and Medicaid connected more people with services. Within nursing, the NP role met the growing demand for patient care. Once introduced, it quickly gained traction.
NPs had "No hospital privileges then. There was no prescriptive authority . . . what we in fact did was figure out ways around the rules and the regulations and the law. Practice always goes ahead of the law."Barbie Dunn (MSN `74, PNP `74), a graduate of UVA's first pediatric NP master's program
By the late 1960s, NP programs rapidly proliferated across the nation, and UVA was no exception. “The federal money made a world of difference to our program and every nurse practitioner program in the country,” recalled Barbara Brodie, professor emerita, who arrived in 1970 to establish masters-level NP programs. “This was an extraordinarily exciting, productive time.”
Newly minted NPs were exhilarated to be diagnosing, treating, and managing patients, but they also faced a host of barriers as they explored the boundaries of their role. Depending on geography, a confusing spectrum of rules governed their practice. Even today, NPs’ autonomy varies by state, as does the scope of their prescriptive authority. For UVA’s first NPs, it felt like a game of cat and mouse.
Recalled Barbie Dunn (MSN ’74, PNP ’74)—a graduate of UVA’s first pediatric NP master’s program—“there were no hospital privileges then. There was no prescriptive authority . . . what we in fact did was figure out ways around the rules and the regulations and the law.”
“Practice,” added Dunn, “always goes ahead of the law.”
“If all healthcare professionals practice at the top of their license, then a better, more capable healthcare system is available to patients.”Reagan Thompson (BSN ’03, MSN ’06), a family NP at UVa Health
Despite the restrictions, NPs like Denise Geolot Sherer (BSN ’70, ENP ’75)—who, with Dr. Richard Edlich, headed the emergency NP program in 1975—filled a desperately needed niche in environments with too few physicians. One study at the time found that 30% of rural hospitals had no physicians in their ERs; most were managed by nurses with on-the-job training.
“At that time, the ER was the buffer for all the inequalities in the healthcare system,” explained Sherer. “There was a real need for the role of the nurse practitioner because so many of the people that were in the ER were seeking primary healthcare services.”
By 1976, 32 UVA students were enrolled across four established programs: Adult NP, Family NP, Pediatric NP, and the Emergency NP program. By 1977, the American Nurses Association authorized the first NP certification exams; by 1979, 15,000 NPs were working across the United States.
These days, what NPs do is much better understood than it was even a decade ago, according to Reagan Thompson (BSN ’03, MSN ’06), a family NP at UVA, who recalled “spending a lot of time describing the role of an NP to patients early in my career.” But the foundational victories won by earlier generations of NPs are not lost on Thompson and alumnus Joe Montoya (MSN ’94, FNP ’96, DNP ’08), who had prescriptive authority when he began working as a family NP in 1996 but, with his fellow NPs, continued to struggle for full autonomy at the local, state, and national levels.
Though Montoya recently gained recognition as a licensed independent practitioner by the Veteran’s Administration, affording him full privileges within the federal government’s health systems, there remain barriers to topple. But he celebrates the bigger picture—the positive impact NPs have on patients, families, communities—and the nursing profession.
Thompson, whose practice is focused on vulnerable, marginalized groups—from LGBTQ+ patients and migrant farmworkers to refugees—finds enduring satisfaction in helping people overcome barriers that, in the past, made good health “only a dream.”
“We still struggle with challenges regarding license recognition,” Thompson acknowledged, but becoming an NP has been worth the hurdles crossed. “If all healthcare professionals practice at the top of their license, then a better, more capable healthcare system is available to patients.”