I've been asked to talk about the evolution of a nurse practitioner and what I'll try to do today is to turn hindsight into foresight so that some of the experiences history will have meaning for you an understanding of change and it's sort of a saga of change when I look back on it and I was fifty years to look back on it's a it's quite a history of course I was born in the year that the women got the vote and we're still struggling to keep it we will and I've lived through that too though I'm only half M I'm more than because 7/8 there yet to celebrate the hundred now if I don't make it I expect you to celebrate it for me but it's amazing I haven't been shot so far so and there's one way not to get shot just run faster very hard to hit a running target so that you can think about that now I would caution you about reading the literature because some of the things that are published about the early days are myths rather than facts oh one of the myths that all going to after I tell you what the environment was like a little bit then was that we got into this business Henry silver a pediatrician and I because there was a shortage of physicians that was the first myth but if you look at the social context in which the nurse practioner was born you're looking into a very turbulent time in the sixties the social political and all kinds of professional changes going on the political situation of course this is the time that Johnson was president and there was a war on poverty the civil rights situation which also raised the rights to health care Lisa V healthcare of privilege some of us thought it was a right under the nation to why that and then of course the Vietnam War was raising many many questions and Commons and protests and also in the professions to the major concerns at that time was for in nursing particularly was the 1965 white paper on entry into practice which yeah and they had put out as the new policy orientation for nursing well now you can just no you can't even imagine the brouhaha that that raised in the nursing court unquote profession because the predominant preparation was through diploma schools which I'm a product of and the profession was trying to elevate the nursing technical really education to professional education through a khadeem but the predominant way for nurses to be prepared as registered nurses was the home schools and they out wind baccalaureate schools by generations of course so that brouhaha you know was festering urine in medicine there was also great concern because the general practitioners were dwindling for the preparation of specialists and there were more specialists than there were general was about thirty percent of the physicians prepared at that time were in general health and general medicine actually and all of us were going into specialties interesting you know fifty years later that has not changed anyway that's sort of a quick review of what was going on in society at the time and the political fights that were predominant in terms of our almond because Nursing was making major changes not only in the baccalaureate program requirement but also in the masters the master's degree at the time was dedicated to functional roles you went into the Masters in nursing for supervision administration teaching but there are not clinical roles however some psychiatric nurses have begun to develop clinical roles in for nurses at the advanced level well pretty soon the profession began to professional nursing group began to look at it in terms of saying we should have clinical specialists in nursing that on our clinical roles and not functional roles and so we were in the process we as faculty were in the process of trying to identify what was clinically appropriate for our particular major since I was in public nursing I was one of the four groups that had that challenge in the West and the challenges were to the Med surg group to the psych group to the pediatric group and the polar column nursing so these four groups were identified entity the content what was so special about public health nursing what was so special about pediatrics were they age related where they know the condition related or whatever so faculty were busy trying to identify content what do you know anything about a faculty and I don't know faculty here do the same thing but you divide at the time we devised faculty who we devised curriculum by faculty getting together and sitting around the table and challenging each other with ideas when we finally finally came up with an idea that we thought we all agreed when we write it down and the next time we came together we forgot what it was well we didn't agree or that wasn't the concept I was talking about I looked at them you know how shall I put it I'm trying to put things in ways that are not too truthful I look at them as you know psychiatrically oriented ossification sessions psychologically psychologically oriented session where we negotiated things and then of course conveniently forgotten by the next me so anyway that's how Cricklewood devised I are coming from practice by the way and I haven't rolled twelve years as a public health nurse in a rural area in Colorado in the mountains of Colorado where I was a lone ranger I was in whatever went on in that and health I was called I took care of well it was communicable disease or whatever school nursing tuberculosis I even made inspections of nursing homes as well was running all the clinics and school exams as well and we had clinics and crippled children's clinic we had TV clinics we had immunization cook anyway I was it so I was used to pretty independent practice and I knew pretty much what public health nurses needed to know and could learn more so when I became a faculty member and we had this challenge for clinical content in public health nursing I said well we should have a demonstration project there's something we did begin to have shortages of physicians who would run on well-baby clinics we ran baby clinics but what sometimes without physicians what when we had physicians they did what physicians do and they do physical exam we continue to do the education and the growth and development and so I came to the point where we didn't have as a sensor but I looked at it as an opportunity for developing a curriculum that was needed and preparing nurses for taking on that role that was oriented toward health it was not a clinic to diagnose medical problems but to define the health status of children and help parents with parenting and do developmental testing and all sorts of things what should we do anyway and so my reason for that was to say well if it works we'll integrate it into the content areas of Public Health nursing into the curriculum so the fact that the myth came up it was a shortage of physicians I drove me I was so in an effort to me because why would I a public health nursing faculty in the School of Nursing be concerned because of the kind of you know physicians if they should they should prepare their own why should I prepare so I said nurses could do that and we weren't doing a lot of it anyway we could do it better and we'll try it out and see I thought it was a perfectly good thing to do it was the faculty moment you're supposed to expand the fund of knowledge pass on to students you're supposed to do research and demonstration projects and collect data and report it and all that sort of thing so that was my idea that we would do it and then reports as a profession and oh I thought naively and I was being a very sharp faculty member believe me I was not well I was not I was the most unpopular and quickly unpopular faculty member you could imagine because or you can't imagine because I worked with a physician closely that was out we were doing physical exams now it was okay to do physical assessment but you didn't do physical exams there were lessons and everything I'm telling you today and I'll get her to just a little later so the nursing process I thought I was doing the nursing process I thought I was doing independent practice which I was qualified to do that's what the profession said I should be doing they said we should collaborate we did without supervision of physicians which we did so I thought I was doing exactly is the profession rhetoric printed that was it well the great trouble was with my colleagues and the faculty who were very concerned that medicine was going to take over nursing education that physicians were teaching nurses that the things that we were teaching were medical techniques it was okay to have a stethoscope take the blood pressure's real nurse but if she moved that stethoscope a inches oh that was medicine they didn't know what we were doing at 3:00 a.m. in the hospitals believe me all you do what I do in the hospital when I was a hospital nurse I closed the drapes in the ward and I use that stuff scope in lots of places and a 3:00 a.m. I mean who'd like that could never figure out who they thought was making all these decisions at 3:00 a.m. when that wasn't around or 9:00 to 5:00 everybody was there that was fine so something you could call something but it's 3:00 a.m. and you're it you don't any more than I did and the Roy or is in Colorado so there were but it was I was so surprised naively surprised because I was a fairly new faculty member to and I didn't really realize the politics of tenured faculty and the power that they held and now the young faculty were all very interested in it the older faculty run the young physicians were threatened by it the older physicians thought it was great if medicine liked it nursing didn't and nursing liked it resident so trying to balance all these things was really quite a challenge and the only way I do it is that a heavy summer was a he was excellent in several ways personally it was a wonderful clinical teacher and I learned fair amount from him and he from me he learns a whole new language that you didn't say physical as a physical exam you said physical assessment and he had to learn nurse ease I do all the medical terms of course but we never used them because we didn't want the physicians to think we would take it you know I used to say that public health nursing was the freshman of Nursing and public health practice clandestinely to make the physician think he was a lord of health I didn't say that in public too often but in a way that's what we were doing we had our own language that we usually talk to physicians and we're careful to always not cross the line of diagnosis or something like that so that the control the faculty worried about the control then they worried about the legal aspects well in legal aspects what we did Henry silver and I went to the board's we're going to the Board of Medicine and we didn't go to the Board of Medicine for approval we went to tell them what we were doing we wanted to tell them what we were doing and then we went to the Board of Nursing and because I was the President of the Board of Nursing I recruited myself but anyway we also told them we're not coming to for approval we're coming to you to tell you what you're doing so you're informed we also got into publication very early describing what we were doing in medical journals and in the nursing journals and in that sense we were very transparent there was an old secret about what we were doing soon it got all over the place in terms of people wanting to come and visit us and just see for themselves one thing and so we had we really ended up organizing the visitors to come for conference one whole day so could learn about it the students were phenomenal they were all very highly qualified students and they were articulate they were mature they had came from practice and they were able then to articulate what they were doing in terms of deserves and and in the first student we had even had an art it was featured in Time magazine for this this new role in Nursing and so and we talked about the role in Nursing that the goals were healthful goals they were not goals to diagnose diseases but the diagnosed health stares they were oriented toward education of mothers and children pretty soon it got pretty difficult for others to oppose us and so then finally of course we began to have funding from the government from the Commonwealth Foundation and evaluation of the program we got money for that so that it was a movement that kept you know really taking on taking on now we have some constraints in terms of the what the students were going to do when they have they had four months of theory and about eight months of practice in the field and most of them were in either health departments or specialty clinics or schools or whatever because everybody began to have school nurses and began taking everything else but if we had waited for Colorado to move that to the master's program we were really disappointed because we had of our four-year project produced about sixty four nurses and were highly highly enthusiastic about it and speaking of our and going around not only visiting but demonstrating what they could do and how they could do it and I was invited to speak in many many places so there was a lot of national interest in it and other people were doing some things to Rochester soon have a continuing education program and people took it up the VA started to prepare their own military began to prepare their own and they were all continuing education programs because the agencies could not wait for the universities the university faculties to move - preparing people at the Masters level and it was a very tumultuous time it was difficult for me personally because I hadn't been relatively popular faculty members been well known to the faculty and everything here was sudden I was isolated nobody would talk to me they would close their doors so I wouldn't visit with them and it was a kind of bullying you look at it it's bullying today it wouldn't be bullying because there was a lot of backstabbing and gossip about it and you know we were kind of challenged of medicine and doing medicines work Scott work and then wanted and all sorts of things and so but I did a lot of self searching you know Johnson said that adversity is the best time to get to know yourself because you have so few admirers at the time so I didn't love soul searching in terms of whether I wanted to stay in nursing had many opportunities to to go to schools and nursing or to go to other schools and nursing you know what I believed in it and the students were the ones that convinced me that they they this was something they wanted they were Suzy Asakawa they were professionals in their efforts and they to learn to write about their experiences and they were my saviors really because if it hadn't been for the student I doubt I'd be here talking to you today and other people began to you know see this as a vital thing and teams of physicians and nurses began to try things out in adult education no no they will all see eat programs but you know those cee programs were the savior of the whole movement because they kept the interest in the moving going the VA did the military did and Planned Parenthood even did now they did it for their services mostly and that was fine but it did specialized them a little bit they also did not maintain academic standards to a certain extent those nurses who were very excellent nurses most of them were diploma nursing still made a tremendous contribution to the survival of this role because it took the universities a few years to get off their Duff to faculty members and begin to train faculty to teaching these programs and develop them and they were helped by their wit Robert Wood Johnson Foundation because we've got them to put on a teacher training program and provided ways for faculty to become qualified to teach and to organize and run this petition program but it wouldn't have survived without those programs and unfortunately as I say the nurses that were in them were exploited once again because they didn't have the academic credentials so when they tried to run through accreditation stuff like that accreditation began to you know bring in certification and accreditation of programs and things like that they were not they didn't qualify academically for that and sometimes the schools were not as responsive to taking them on so I called Ronald was not one of the early schools to do it and he's sober and I got a letter on the Dean that said they could not support our continuance so doctor over me to Rochester who was ready to do some very innovative things including the nurse practitioner our Chester became quite famous for that and the unification model which worked which went together because it was obvious that there are many faculty who were not practicing and who were clinically incompetent to practice but we're teaching students well my view on that was these should go together that faculty who are in practice can find the seminal problems that need to be researched so they ought to be able to use practice integrated into the research efforts and try to one begin to make research relevant to the practice which was needed very badly and also that their competency gave them a lot of flexibility a lot of options that they didn't have before and I gave them were certain hiring a research material a book publication material and once they got onto the idea that this was a very useful thing we're seeing a lot more publications come out from faculty on very different areas of specialization and and they made a real contribution but it took them a little while to bear over the fact that we were working so closely with physicians and so high that so and physicians had a lot to learn about the professional nurse and to recognize some of their competencies as well so but Henry Henry silver did not have the resistance o that I experience in terms of a insisting that it comes out well there are wants to be learned from history and if you learn it well or listen to it or think about it in relation to today you'll learn some things that you might find useful one of them was you know your mother always told you watch your language or though she said watch your mouth ever hear your mother say that no you're too young but believe me language is very important about what you call thing because we had a great deal of problem the beginning being separated from the physician's assistant which there's also a program which was do any faculty remember Selma L at England English Velma England too young anyway so much English what worked with it instead at Duke University a Duke University and Salma Engels who was a very well-known nurse at the time I did a lot of international work for the Rockefeller Foundation and she and Dean Stan who was the father so to speak of the physician assistant movement work together and they tried to use nurses as and some of the same kinds of things we were doing but they made I think a big mistake in terms of calling it for physicians assistant because that didn't you don't over well at all the accreditation agency said no way we're gonna accredit professional nurses to be physicians assistant because they all hand me we're trying to get away from being the handmaiden to physicians and wanting independent practice or autonomy and so they were very few people who would support that on the other hand that's how the physician assistant came into being because the accreditation agencies in nursing would not allow the Selma and Salomon Engels and Eugene stead to have their program accredited but they had many of the element that we wanted was a master's degree integration and and you know assessment and all that but because the language is important language matters what you call things and if you use the words venison in terms of what you're trying to do in nursing you all will never be an acceptable kind of an idea because our role is not to say not to be a substitute or delegate or E to medicine you're our own profession and we carry with us certain kinds now that doesn't mean that we don't sometimes use the same tools even with a PA or that we don't use the same language in terms of some of the diagnostic things today but it does mean that if you start calling nurses physicians as extenders how would you like to be a hamburger helper a physician assistant physician associate position this or position that it's highly unacceptable and we never use those terms never also if you write the early now today you can say in physical exam but then you couldn't say physical exam which I explained earlier when any of the diagnostic terms that medicine held onto itself now the AMA has always loved nurse practitioner if it is controlled by medicine but they do not accept I don't like to call it independent practice there's no independent practice of anybody autonomy in your own profession is a more acceptable thing because everybody is interdependent in some way the physician is interdependent on nurses in terms of choral work in earlier years carrying out is or where he's interdependent they have to we have to depend on each other it's it's also true and teamwork we know more about teamwork than anybody else does and now it's just been discovered just like population health we know more about population health but now nursing is beginning to talk about population health never did before it was always a denominator in terms of my work in public health but now they just discovered it I can remember being at a meeting in Seattle one time early and this is a bill that psychiatric nursing is announcing a big new deal new new role new something so I said well vote in that session I went to the session it was loaded with people I'm sitting in the back row so I'm waiting for them to announce what's gonna be this new role for psychiatric nursing psychiatric nursing was going into the community I jumped up and I said oh for God's sake I was so embarrassed it shocked me they just discovered the community I'm here we're here in the community so it's just amazing you know those around comes around and what's what's new is never really new to somebody but there are lessons to be learned from history and their lessons that you need to think about though what about the future I think there are several things in the future that we're really gonna have to I'd like to see us take advantage of and I think they're good genomic codes are really going to be a real point of practice education and research there's no getting around to it precision medicine is now coming in why we've had precision nursing for a long time but now possessing the may be discovered and done individuals are different from each other the other thing is that all this technology and that's coming in I have together drink talking so much I might vomit out just a minute okay two minutes all the technology that's coming out it's gonna do away with all the kinds of things we're spending a lot of time on learning and who's gonna be in charge the patients are you familiar with topples work have any of you read Eric Topol work you've got to read it he's a cardiologist from Scripps and you know I work in computer and computerization to collect physiological and psychological data by sensors and these sensors for on patients go over you are going to provide the patient with all this information about everything from blood pressure to God coma pressure from EKGs or ECGs everything you want to think of is being censored he hasn't used a stethoscope in three years doesn't need patience our son sir but who gets the information for the patient and he has to decide what to do with it what does that tell you he needs to be pretty smart and he needs to have a computer so I can look it up so he can look up what's going on and seek out sources of information and consultation you'll be on the list for that patient to call you and say my blood pressure is doing this my INR is this everything you can think of it's going to be censored in the body and in terms of giving you information Eric Topol his work and the first one was a creative destruction of Medicine the creative destruction of medicine the second book is called the patient will see you now the patient will see you now he will determine whether or not he needs to go to your office his work is very interesting because he's predicting what's going to happen in some of the institutions as well so this is I think we're going to see some huge changes in the future and I think as prepared as nurses are becoming today they need to think about some ways to get dirty prepared so yeah now it's the time I I'm not quite finished but I will take some questions that Nancy may be repeating them if you don't speak loudly enough but if you speak loudly enough she I can hear them between us the Doctor of Nursing Practice to me is a natural evolution and we're the last profession I think or next to the last profession who's going to use the Doctor of Nursing Practice a doctor of practice as a professional degree given by the universities and that earns you a doctorate in nursing what do you all just have it the pharmacists have it the social worker oh I don't know about the social worker physical therapy medicines had it for a long time so and it came about because nurse practitioners themselves wanted advanced education beyond the masters but not the PhD they didn't realize frankly not the research because because the PhD was supposedly purely researched they did not want to leave practice but what the DMT is going to be into is translational research working with PhDs and tons of clinical problems they're the ones that are going to identify the important clinical problems and those clinical problems are considerable and if they if they can work with PhDs on the methodologies collection you're all the sentiment ology that they really need to they will find an exciting and I think we're going to see a lot of DNP pH we'll end up with that it's like the md/phd right how are the farming tasty for people who were really interested in the in the practice and you know you the reasons a lot of people got into n pieces because they were they were like you know disgusted with nursing practice or unhappy with it or something and so they're finding that the nurse practitioner kind of or the advanced practice nursing role were more exciting more challenging intellectually and that these just comes naturally so I think that of course there's some there's a lack of enthusiasm for some emptiness in terms of the DMP because they forgot they had asked for it you know just be careful what you ask for you might get it right a little thing we're out of time for questions but we you wanted to ask the audience okay I want all of you to close your eyes I don't cheat close your eyes and think about what the future your future is going to be like not my future not Suzy's future next to you your future think about that in terms of what where you are where you want to be maybe five years maybe ten how you wanna get there and what what kinds of things it's going to take and I don't want any of this yes but I want you to think about that I want you to think about that very seriously because we don't spend enough time dreaming about you got a bucket list as a mile long and stop putting these things on your bucket list and when you finish you'll probably end up like this you know I have I have been credited and crucified I've been reviled and revered I've been kicked and kissed but I haven't been botoxed or detox thank you very much