A Comparison of Changes in the Professional Practice of Nurse Practitioners, Physician Assistants, and Certified Nurse Midwives:  1992 and 2000

• Printer-friendly (Acrobat/pdf) (11.33MB)

This page: Preface | Executive Summary | Introduction | Key Findings | Discussion | Chapter 1.  Study Overview | Chapter 2.  Background and Context

Preface

The numbers of nurse practitioners (NPs), physician assistants (PAs), and certified nurse midwives (CNMs) increased dramatically in the 1990s. As of 2000 there were an estimated 95,000 NPs^[1], 40,000 PAs^[2], and 8,000 CNMs^[3] practicing in the U.S., an increase of about 160 percent from 1992. Over this period the three professions were also becoming more widely accepted by physicians, patients, and the general public as key members of the health care delivery team.

To document the extent to which the three professions experienced increased responsibilities over this period, and were helping to meet the health care needs of underserved populations, the Health Resources and Services Administration (HRSA) commissioned this study of the professional practice of NPs, PAs, and CNMs in the 50 States by the Center for Health Workforce Studies at the School of Public Health at the University at Albany. The study involved the compilation of a variety of data to explore these issues, including statutes and regulations from the 50 States, estimated numbers of practitioners, numbers of education programs and graduates, etc. These data were supplemented by field work and interviews conducted in seven States. This report represents a synthesis of all the components of the study.

The Center for Health Workforce Studies is a not-for-profit research center operating under the auspices of the University at Albany of the State University of New York and Health Research, Incorporated (HRI). The views expressed in this report are those of the authors and do not necessarily represent the views or positions of the State University of New York, the School of Public Health, HRI, HRSA, or the subcontractors.

Executive Summary

This chapter presents an overview of the study and this report. It includes the following sections:

• Introduction
• Key Findings
• Discussion

Introduction

Physician assistants (PAs), nurse practitioners (NPs), and certified nurse midwives (CNMs) play increasingly important roles in the health care system in the U.S.  The three professions now combine to form a group of practitioners that is rapidly approaching 20 percent of the size of the physician workforce. 

Since many of the NPs, PAs, and CNMs are recent graduates of their respective education programs and few are near retirement age, barring a major unexpected reduction in the respective education programs, the supply of new practitioners is almost certain to continue to grow substantially relative to both population and the supply of physicians for the foreseeable future.

A 1994 article on State practice environments of NPs, PAs, and CNMs by Sekscenski et al, concluded that the professional practice of NPs, PAs, and CNMs varies widely across the 50 States, and that favorable practice environments for the three professions are strongly associated with larger supplies of practitioners [1]. This report revisits this situation and

• documents changes in professional practice of the three professions between 1992 and 2000;
• creates new statistical professional practice indices for each of the three professions that more accurately reflect the respective practice environments across the 50 States in 2000;
• examines the nature of the relationship between the three professions, the professional environment in which they operate, and their physician counterparts;
• identifies salient factors that are related to changes in the three professions and their physician counterparts; and
• assesses the extent to which the three professions improved access to care for underserved populations in the 1990s.

The professional practice indices described in this report were designed to quantify the professional practice options, structural identity, and market recognition of the three professions in each of the 50 States. Higher scores on a professional practice index are generally associated with broader sets of tasks, more autonomous practice environments (i.e., less direct oversight by physicians), and greater opportunities to prescribe controlled substances.

No effort was made to develop an index that could be used to compare the professional practice across the three professions. Although there are similarities among the three professions, each has developed independently with different sets of legal, organizational, and clinical parameters, and it would be inappropriate to compare any single index across the three professions.

The study included: a review of the relevant literature, a systematic review of professional practice statutes and regulations in the 50 States, analysis of data on the three professions and related practice and environmental characteristics, field work in seven States (California, Illinois, New York, North Carolina, Ohio, Oregon, and Texas), and interviews and discussions with a wide range of informants and stakeholders.

Key Findings

• The numbers of NPs, PAs, and CNMs increased significantly in virtually every State between 1992 and 2000. The overall increase was 160 percent over this 8 year period.
• The professional practice for all three professions expanded significantly between 1992 and 2000, that is, practitioners in each of the three professions were permitted to perform more procedures and were permitted to work with less direct supervision from physicians in 2000 than they were in 1992.
• None of the 50 States achieved an index score of 100 on the new professional practice indices for any of the three professions in 2000, indicating that even States with the most expansive practice environments have not yet achieved all practice options viewed as 'optimal' by the respective professions.
• While there remain differences in the scope index scores among the 50 States, the variation of the index  scores has declined since 1992, suggesting that the 1990s was a period of 'standardization' or 'convergence' of professional practice across the 50 States for all three of the professions.
• The professional practice indices were significantly positively correlated with the numbers of practitioners per capita for the respective professions in 2000. This suggests that a more positive legal environment for the professions encourages both improved practice options and greater number of practitioners in a State.
• The professional practice indices were significantly positively correlated with managed care penetration in the States in 2000. This suggests that managed care strategies do impact the regulatory environment of NPs, PAs, and CNMs. This is consistent with the significant increases in the numbers of graduates from professional education programs for NPs, PAs, and CNMs in the decade of the 90s, and the continuing success of new graduates in finding employment.
• No other exogenous factor (e.g., aggregate health care expenditures, health insurance rates) was significantly correlated with the new professional practice indices for the three professions in the States. It may be that a study of individual practitioners would reveal additional relationships, but the State-level analysis in this study did not.
• Despite anecdotes about tensions between physicians and the three professions, significant positive correlations between practitioner per capita ratios for NPs, PAs, CNMs, and physicians indicate that States with more physicians per capita also have more NPs, PAs, and CNMs per capita. This is an indication that the three professions supplement or support physicians rather than substitute for or supplant them.
• A critical factor for the three professions related to access to care is the distribution of practitioners. Although the three professions do provide services in areas in which physicians cannot set up viable practices, the penetration of NPs, PAs, and CNMs into shortage areas is often limited by the practice locations of their collaborating physicians.
• Although a majority of new NPs and PAs trained in US entering practice in the 1990s were trained in primary care specialties, many of them entered non-primary care specialties. Many NPs and PAs in specialty practices are assigned tasks generally considered to be 'primary care', e.g., histories and physicals.
• Study informants reported that the attraction of NPs, PAs, and CNMs in different clinical settings and organizations is driven by two key factors: the salary difference between physicians and the three professions, and the ability of the three professions to handle effectively a wide range of clinical tasks. If salaries of the three professions continue to increase relative to those of physicians, the demand for the three professions may fall off. This may be the case for primary care practices as the salaries of primary care physicians in many parts of the U.S. are only slightly higher than those of NPs, PAs, and CNMs.
• Whereas in the early 1990s the major professional practice concerns of NPs were prescriptive authority and legal relations with physicians, the key issue for NPs in recent years has been empanelment by managed care organizations and insurance carriers, that is, the ability to contract with and obtain their own provider numbers for reimbursement from third party payers. This issue is related to both access and visibility. Empanelment provides a major impetus for NPs to seek out patients in traditionally underserved communities and neighborhoods. Empanelment also permits appropriate counting of the services provided by NPs, which now are often reported as being provided by supervising physicians.
• Although the observed increases in both numbers of practitioners and professional practice indices are the basis for prima facie arguments that access to services increased, reliable estimates of the numbers of NPs, PAs, and CNMs practicing in shortage areas are not available in most States. Thus, definitive statistical evidence of improved access for underserved populations is not available. However, qualitative research conducted as part of the field work in this study strongly supported the claim that the three professions do improve access to care for underserved populations.
• The processes by which legal scopes of practice change in the 50 States are far from uniform, but the field work indicates that the following steps are present in most States: practice teams of physicians and one or more of the three professions work out ‘locally acceptable practice arrangements’, often based on local demonstration programs that permit innovative practices; then the practitioners seek changes in professional practice to permit these procedures and arrangements for all practitioners. If access to services is limited, public constituent groups and coalitions (e.g., Primary Care Agencies, advocacy groups) often lobby for changes in professional practice to improve access to needed services. The professional associations for the NPs, PAs, and CNMs also lobby actively for changes in professional practice.
• Reimbursement, i.e., compensation or remuneration for different professional activities and procedures, is critical to the acceptance of different practice and supervision arrangements. There will always be some practitioners who provide pro bono services to underserved populations, but provision of services to broad segments of the population that are underserved will happen only if appropriate compensation is available.

Discussion

The analyses, interviews, and meetings conducted as part of this study identify potential follow-up activities that could be pursued at some point.

1. Many informants suggested revisiting the professions every 4 or 5 years to track changes in professional practice of NPs, PAs, and CNMs, the growth in the numbers of practitioners, their demographic characteristics, their legal scopes of practice, their practice patterns, and their contributions to care, especially for underserved populations.
2. A pilot study in one or two States to count/estimate the numbers of NPs, PAs, and CNMs who work in Health Professional Shortage Areas and Medically Underserved Areas, and assess their roles in providing care to underserved populations in rural communities, urban neighborhoods, community health centers, and institutions serving special populations would permit a careful assessment of the contributions of the three professions to care for the underserved.
3. Improved financial incentives for NPs, PAs, and CNMs to practice in HPSAs and other shortage areas could significantly improve access to care for underserved populations. Options for these incentives include increased Medicare incentive payments (as with physicians) and educational loan forgiveness/repayment programs.
4. Increased Medicare reimbursement levels for CNMs from 65 percent of physician rate to 85 percent (as is the case for NPs and PAs) would and help to increase access to CNM services for populations with mental and physical disabilities who are insured by Medicare .
5. Evaluation of State programs that permit practice with remote supervision in more non-traditional settings, including schools, nursing homes, home health agencies, and prisons could ultimately improve access to care for the people in these settings, many of whom are underserved.
6. Practitioner data bases for NPs and CNMs comparable to those maintained by PAs and physicians would significantly enhance the possibilities of assessing the practice patterns of the professions and their contributions to access for underserved populations.
7. If managed care organizations were encouraged to empanel properly qualified NPs, PAs, and CNMs, so that they can provide services to their patients with greater professional autonomy, the result would be improved access to services and reduced costs of care. Empanelment would also provide a basis for more accurately counting the services of the three professions, whose services are often now significantly underestimated because they are recorded as being provided by their collaborating physicians.

Chapter 1.  Study Overview

This chapter presents an overview of the study and this report. It includes the following sections:

• Introduction
• Study objectives
• Study components
• Remainder of report

Introduction

Over the last decade, the numbers of Nurse Practitioners (NPs), Physician Assistants (PAs), and Certified Nurse Midwives (CNMs) in the U.S. have increased substantially. So have the numbers of education programs, new graduates, professional practice options, location of practice, visibility to patient consumers, and professional standing. Many factors have contributed to these increases in numbers and status, some environmental and some related to the professions.

The net result of these factors has been a decade of standardization, socialization, and professionalization of NPs, PAs, and CNMs. Although these processes were not the major focus of this study, their influences on the professions and on the environments in which they practice demand consideration and attention. When considering the reasons for the changes in professional practice experienced by the three professions, it is important to understand the underlying driving forces, which included:

• Pervasive concerns about the rising cost of health care and a growing recognition that the three professions that are subjects of this study, in particular, provide cost-effective, high quality care;
• Cost containment measures that have increased pressure for new economies in practice;
• Consumers who are better educated about health care diagnosis and treatment through a combination of print media, the Internet, television, and advertising, and who as a result demand more of the providers and health systems from whom they seek care, including more time and information;
• Increasing acceptance of the three professions by health care consumers and subsequently, wider use of them in mainstream health care settings.
• The greater roles of consumers in the purchase of health services, the utilization of services, and choice of care providers;
• The growing number of consumers willing to go beyond the traditional allopathic health care system to seek out homeopathic and holistic treatments to address health care problems;
• Growing numbers of uninsured and underinsured people in need of medical care and increased demand for the three professions to work in underserved areas;
• Increased interest and enhanced funding for women’s health care initiatives creating new opportunities for CNMs and NPs; and
• Increasing use of the three professions instead of medical residents (i.e., physicians in training), particularly in primary care, in some settings that has created expanded practice opportunities for NPs, PAs, and CNMs.

The regulation of health professions across the United States occurs both externally and internally and is intended to provide safeguards for the public, for the consumer, and for the professions themselves. Externally, State and Federal legislators and regulatory boards determine the legal parameters for professional practice and establish the rules for implementing those conditions. Internally, national professional organizations establish standards and core competencies which are to be met by the professionals within their purview and by the educational institutions which educate and train them. Such guidelines are intended to establish and maintain criteria for appropriate and competent practice.

Regulation of NPs, PAs, and CNMs has evolved considerably over the last decade. National professional organizations have been refining certification and education program requirements and establishing standards for proficient practice. During this period, many national associations have become effective at lobbying for legislation that accommodates the needs of the public and their members on both the State and national levels. Professional associations advocate for regulations that contribute to the professional standing of the group. Standards elevate a profession to a level of skill and competence which creates uniformity and engenders respect by both consumers and other professions.

State and Federal regulators have been actively engaged in altering and adjusting the legal environments in which these professions work to enable practice while maintaining standards to protect public safety. Achieving a balance in various legislative initiatives between the interests of the several professions is a dynamic process. Sustaining this delicate balance requires continual refinement and revision as health care practice, public preferences, and medical technologies evolve. Appropriate regulation can contribute to both efficient practice for the professions and effective care for patients.

In 1994 Edward Sekscenski and colleagues reported on a study that documented the practice environments for NPs, PAs, and CNMs in each of the 50 States for the year 1992 [Sekscenski et al, 1994]. They created three statistical indices that reflected the practice environments for the respective professions, based on the legal status of the professions, the possibilities for direct reimbursement of professionals for their services, and their authority to write prescriptions. The three indices were applied for each State to provide a basis for comparing the practice environments for the three professions across the 50 States and the District of Columbia.

Since that study, the numbers of NPs, PAs, and CNMs have increased dramatically, and their respective scopes of practice have expanded as well. For a variety of reasons many States began to look to non-physician clinicians (especially NPs, PAs, and CNMs) to address service gaps and shortage areas. To promote the use of non-physician clinicians in shortage areas, many State legislatures enacted expansions of their professional practice laws over the past decade with the objective of increasing the supply of medical services to the public, especially for those in officially designated physician shortage areas.

Study Goals and Objectives

The numbers of NPs, PAs, and CNMs increased dramatically in the 1990s, but questions remain: To what extent have the scopes of practice of the three professions increased in this period? Were the improvements in professional practice related to observed increases in numbers of practitioners? Have the overall increases in the numbers of practitioners also occurred in officially designated shortage areas? Has access to care increased in these areas?

The overarching goal of this study was to answer these questions, and to assess the impact of changing professional practice laws for NPs, PAs, and CNMs on access to health care for the underserved in the U.S. This goal was supported by five specific objectives:

1. Document changes in professional practice laws for NPs, PAs, and CNMs in the 50 States between 1992 and 2000, and assess the extent to which these scopes of practice are uniform across the States;
2. Replicate and update the scoring system for the professional practice indices for the three professions developed by Sekscenski, et al;
3. Compile data on the trends of the numbers of individuals licensed as NPs, PAs, and CNMs in each State between 1992 and 2000;
4. Compare the changes in the numbers of NPs, PAs, and CNMs for States with and without a significant change in professional practice for each of these professions, and assess whether there is a relationship between change in professional practice and change in the numbers licensed and practicing in each State; and
5. Assess the impact of changes in professional practice laws and regulations governing NPs, PAs, and CNMs on access to health care in underserved areas.

Study Components

The Center for Health Workforce Studies at the University at Albany (SUNY) in collaboration with the four other Centers for Health Workforce Distribution Studies (at UC San Francisco, the University of Washington, the University of Texas San Antonio, and the University of Illinois at Chicago), the North Carolina Center for Nursing, the National Conference of State Legislatures, and the Health Policy Institute at the Medical College of Wisconsin examined the impact of changing professional practice laws for three professions on access to health care for the underserved. The specific tasks undertaken included:

1. Obtain and review previous and current professional practice statutes and regulations governing NPs, PAs, and CNMs in the fifty States (plus the District of Columbia) and document how the professional practice requirements changed between 1992 and 2000;
2. Replicate and update the scoring system for professional practice for these practitioners developed by Sekscenski, et al for the year 2000 and assess the extent of the changes that took place between 1992 and 2000;
3. Because the original index was shown to be insufficiently discriminating among the States for the year 2000, develop a new professional practice index for the three professions that reflected a larger number of criteria and used more detailed scoring criteria;
4. Compile data on the trends of the numbers of individuals licensed as NPs, PAs, and CNMs in each State over the past decade to provide a statistical perspective on the changing numbers of practitioners in the three professions;
5. Compare the changes in the number of NPs, PAs, and CNMs for States with and without a significant change in professional practice for each of these professions and assess whether there is a relationship between professional practice and the numbers licensed in each State;
6. Conduct field work in seven States to gather qualitative information about the professional practice of the three professions and access to services in underserved areas to supplement the data on the professional practice indices and numbers of practitioners gathered in other components of the study;
7. Prepare report(s) for HRSA and articles for peer-reviewed journals to disseminate the findings and conclusions of the study.

Remainder of the Report

• This report is presented in eight chapters, including this Study Overview. The remaining chapters address the following topics:

Chapter 2: Background and Context
Chapter 3: Professional Practice Indices
Chapter 4: Nurse Practitioners
Chapter 5: Physician Assistants
Chapter 6: Certified Nurse Midwives
Chapter 7: Factors Related to Professional Practice Indices
Chapter 8: Field Work in Seven States
Chapter 9: Access to Care

• Providing additional detail for interested readers are eight appendices, each providing information about some aspect of the study, the index calculations, or the field work.

Appendix A: Project Advisory Committee
Appendix B: Professional Organizations Related to the Three Professions
Appendix C: Details of the Calculations of the Original Practice Environment Indices
Appendix D: Details of the Calculation of the New PA Professional Practice Index
Appendix E: Details of the Calculation of the New NP Professional Practice Index
Appendix F: Details of the Calculation of the New CNM Professional Practice Index
Appendix G: Details About the Field Work in Seven States
Appendix H: References

Chapter 2.  Background and Context

This chapter provides a context for the subsequent discussion of professional practice indices for NPs, PAs, and CNMs. It includes the following subsections:

• Historical Context for the Three Professions
• Factors Related to Professional Practice Indices
• Professionalization
• Conclusions

Historical Context for the Three Professions

The concepts of non-physician providers and physician “assistants” are not new, with medical tradition indicating the presence of these providers across cultures for hundreds of years. These practitioners often worked in locations where physicians were unavailable. However, their presence and acceptance in the United States has increased significantly in recent years.

Although the development of the three professions is rooted in the need for access to primary medical care for underserved populations, each of the three professions has an individual history and orientation that colors its present status. And although each has historical roots that reach into the past, in the United States, the professions have experienced their most rapid development in about the last 40 years, with considerable evolution over the last decade. Brief histories for the three professions are provided below.

A Brief History of Nurse Practitioners in the US

In the 1960s, Dr. Henry Silver and Loretta Ford, PhD (a nurse educator) at the University of Colorado, created a program to educate nurses to respond to the need for primary care providers in rural areas. Dr. Silver and Dr. Ford established a pediatric practitioner program based on the nursing model.^[4] This was the first of the nurse practitioner programs that educated nurses to make medical diagnoses while providing care in a nursing model. The idea was revolutionary and initially not well accepted by the academic nursing profession.^[5]  The first graduates began to practice in the late 1960s.^[6] The program was at the master’s level requiring a nursing license and experience in patient care for admission. In subsequent years, several programs moved away from the master’s degree model to certificate programs but, more recently, the trend has again shifted to master’s education.^[7]

The nursing profession initially expressed skepticism with the educational process and the new identity of the nurse practitioner. Education that incorporated a medical model to create a physician “extender” was threatening to nursing’s roots and to its exclusive orientation to care. It was only as the NP profession evolved and the academic and training programs were clarified that the profession embraced the new roles for nurses.^[8]

Nurse practitioners function in a variety of roles in almost every conceivable health care setting. The care they provide is grounded in a nursing model which emphasizes treatment of illness in the context of a patient’s total well-being and encourages patient education.  Nurse Practitioners provide well care, diagnose and treat acute illness, and monitor chronic conditions. NPs are permitted to order, perform, and interpret certain laboratory tests and to prescribe medications.

In 2000, Nurse Practitioners were legally enabled to practice in every State and the District of Columbia. Practice varied considerably across States with different statutory and regulatory limitations on prescriptive authority, direct reimbursement, and the required legal relationship with physicians. Nurse practitioners were generally regulated by State Boards of Nursing, but in some States, Boards of Medicine were directly involved in regulation of the profession. In some States, agencies other than the Department of Health were involved in professional oversight activities for Nurse Practitioners. In 2000, NPs were not title protected in every State. In 49 States and the District of Columbia, NPs were provided with some form of prescriptive authority which varied from the ability to prescribe only legend drugs to full prescriptive authority including controlled substances. The educational requirements to obtain prescriptive authority varied widely across States. 

Many States required a master’s degree in order to be licensed in the State.  All but five States required national certification from a certifying body in order to qualify for licensure or registration as an NP. Examinations qualifying NPs for national certification were provided by the American Academy of Nurse Practitioners Certification Program (AANPCP), the American Nurse Credentialing Center (ANCC), the American Board for Pediatric Nurse Practitioners (PNCB), and the National Certification Corporation for the Obstetrical, Gynecologic, and Neonatal Nursing Specialties (NCC).

Nurse practitioners seek some professional autonomy in practice with formal collaboration being the general mode of cooperation with physicians. However, in some States supervision by physicians is a common form of practice.

In 2000, there were 321 institutions offering either master’s level NP and/or post-master’s NP programs.^[9] NP education programs  were accredited by the Commission on Collegiate Nursing Education, the National League for Nursing Accrediting Commission, and the National Association of Nurse Practitioners in Women’s Health which accredits NP programs in women’s health.^[10] Seventy-two percent of the graduates of the master’s programs in  2000 were family, adult, or pediatric nurse practitioners^[11] suggesting that primary care continues to be the focus  of the majority of NPs.

In 2000 there were approximately 95,000 NPs^[12] practicing in the U.S., up from about 28,000 in 1992. This represents an increase of more than 240 percent over the 8 year period.

A Brief History of Physician Assistants

The physician assistant profession is generally understood to have its roots in the military medic or corpsman model. Medics provided medical services teamed with physicians and nurses in wartime settings. In many cases these adjunct providers were highly trained members of the medical team who became experienced in providing care in very challenging and demanding circumstances. In the late 1960s during the Vietnam War, this group of trained providers became the focus of attention for some foresighted physicians in the United States.

There was growing concern about a potential shortage of generalist physicians due to the increasing numbers of medical students who were choosing specialty training. This fact, coupled with increased attention to populations that were poor and/or medically underserved in the United States, created concern that the supply of physicians was insufficient to meet the needs of the public.

As early as 1960, Dr. Charles Hudson, President of the National Board of Medical Examiners, spoke to a gathering of the AMA about the possibility of training these medical corpsmen to work with physicians in civilian medical settings.^[13] Several physicians, including Dr. Richard Smith, a Federal bureau director, and Dr. Hudson and Dr. Eugene Stead, a faculty member at Duke University, reiterated this suggestion in subsequent years^[14]. Dr. Stead, Dr. Harvey Estes, and Dr. D. Robert Howard, all of Duke University in North Carolina, introduced the idea of educating a health professional who would assist physicians in the provision of primary care services with special emphasis on educating new providers to enhance access to care in rural North Carolina. In the mid-1960s, they instituted a program at Duke that provided formal education and training for these professionals.

This extension of the military model into practice environments in the United States was conceived as a way to link underserved populations to the health care system. After the Vietnam War, the recognition of the potential to use highly trained and competent medics to meet the needs in rural areas gained popularity. Thus the physician assistant profession was born.

PAs traditionally practice under the supervision of physicians and this strong relationship with physicians has remained relatively unchanged as the profession has evolved. As the name suggests, Physician Assistants are closely associated with a medical model of care, one grounded in the diagnosis and treatment of illness. There were only 237 PAs practicing in the U.S. in 1970. By 2000 that number had increased to about 40,000,^[15] a 90 percent increase since 1992.

As of 2000, all States and the District of Columbia had statutes or regulations governing the qualification of practice for PAs. All jurisdictions required PAs to pass the Physician Assistants National Certifying Examination, administered by the National Commission on Certification of Physician Assistants (NCCPA) and open only to graduates of PA educational programs accredited by the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA), which is sponsored by the AMA, the American Academy of Family Physicians, the American College of Surgeons, the American Academy of Pediatrics, the American College of Physicians, the Association of Physician Assistant Programs, and the American Academy of Physician Assistants. Only those successfully completing the examination may use the credential “Physician Assistant-Certified (PA-C).”

PAs are educated in accredited programs located in academic medical centers, teaching hospitals, universities, and colleges. The PA curriculum, like medical school, provides a generalist education that promotes the development of skills in clinical problem solving and medical decision-making. Their medical education makes it possible for PAs to choose any medical or surgical specialty after graduation, something that is facilitated by the scope of their licenses.

In order to remain certified, PAs must complete 100 hours of continuing education every 2 years. Every 6 years they must pass a recertifying exam or complete an alternate program combining learning experiences and a take-home exam. [AAPA, 2001]

A Brief History of Certified Nurse Midwives

Nurse Midwives have a lengthy history when considered in an international context. The presence of the profession in the United States, particularly among immigrant populations, spans many generations. In fact, there is documentation suggesting that a nurse midwife delivered three babies on the voyage of the Mayflower.^[16] However, the formal education of nurse midwives in the United States began when Mary Breckenridge founded the Frontier Nursing Service in East Kentucky in 1925.^[17] This highly regarded program educates midwives to provide nursing services in remote areas with a focus on women and families. Nurse midwives who continue to be trained in this program are credited with significantly reducing infant mortality rates in the areas that they serve.^[18]This program eventually began to educate nurse practitioners as well and continues today to serve its mission of educating providers to work with underserved populations. The Frontier School of Midwifery and Family Nursing offers a distance-learning program that enables many students to be in their own communities working with local providers while being educated as midwives.^[19]

In 1931, a collaboration of the Lobenstine Clinic and the Maternity Center Association began educating nurse midwives in New York City to serve immigrant and indigent populations in the city. That program continues today as the SUNY Downstate Nurse Midwifery Program.^[20] By the 1950’s there were seven education programs for nurse midwives in the US. In 1955, Hattie Hemschemeyer, a public health nurse educator who had begun the Maternity Center education program in New York City, incorporated the American College of Nurse Midwifery in New Mexico. In 2000 there were over 8,000^[21] nurse midwives in the U.S., educated in 40 master’s degree programs and 5 post baccalaureate certificate programs.^[22]  Educational programs for the profession were accredited by the American College of Nurse Midwives Division of Accreditation.

Midwives advocate a more homeopathic, natural approach to childbirth with less emphasis on the use of technological innovation.^[23] This approach to obstetrical care has been integrated into extended scopes of practice that enable nurse midwives to provide women’s well-care and other gynecological services to non-obstetrical patients in many States.

Nurse midwives in the United States are generally educated in a nursing model of care. In many States nurse midwives are regulated in legislation as advanced practice nurses. Several States permit practice by non-nurse midwives who are separately licensed and regulated by the individual States. Many States require that non-nurse midwives pass a competency examination. The American College of Nurse Midwives presently offers this exam to these “direct-entry” or “lay” midwives.

Nurse Midwives are governed variously in the 50 States and the District of Columbia. Statutes and regulations addressing practice by nurse midwives is not uniform. Nurse midwives are mainly governed by State Boards of Nursing. In Utah, the profession is governed by a Certified Nurse Midwifery Board and in New York by a Board of Midwifery that regulates both nurse midwives and direct entry midwives. The profession is jointly regulated by the Board of Nursing and the Board of Medicine in 5 States and solely by the Board of Medicine in 2 States. Illinois has established an Advanced Practice Nursing Board that regulates  advanced practice nurses (APNs) including nurse midwives. The Board of Health oversees practice of nurse midwives in 3 States.

In 2000, certified nurse midwives had some form of prescriptive authority in 49 States and the District of Columbia. National certification through examination is required in 44 States and the District of Columbia. Since 1971, the American College of Nurse Midwives (ACNM) and subsequently, since 1991, the ACNM Certifcation Council (ACC) have provided competency testing for nurse midwives. In 1998, the ACC began providing certification for non-nurse midwives trained in accredited education programs.^[24] 

Nurse midwives operate under various practice relationships with physicians.  State regulation requires a range of supervisory, consultative, or collaborative arrangements with physicians.  In 11 States in 2000, there was no specific language addressing a required relationship between nurse midwives and physicians in statute or regulation.^[25]

There are over 8,000 nurse midwives in the United States providing care in many settings to a wide variety of women. Midwives provide a significant amount of care to women whose access is marginal. As many as 70 percent of the women receiving care from midwives are considered “vulnerable” in some aspect either by their demographic characteristics, their geographic location, or their socioeconomic status.^[26]

Factors Related to Professional Practice Indices

A great many factors have influenced the evolution and acceptance of the three professions in the U.S. Figure 2-1 presents a highly simplified schematic that suggests some of the relationships that have contributed to the increased status and professional practice for the three professions over the past several decades. The figure emphasizes factors related to the contributions to patient care and outcomes that can be traced back to the three professions and to their collaborating physicians. The discussion that follows identifies several key factors related to the professional practice of the three professions to suggest the richness that exists in the framework that defines professional practice options.

Barbara Safriet [2002] presents a much different perspective on professional practice of professionals like NPs, PAs, and CNMs. She argues that current professional practice statutes and regulations have generally resulted in significant gaps between “the abilities of non-physician providers and the activities government regulation allows them to perform. Dominant provider groups extensively lobby State legislators in order to obtain scope-of practice monopolies, which confer exclusive control over their areas of interest and exclude other equally-capable groups from performing such services. As a result, the excluded providers’ skills are under-used, creating a systemic inefficiency”[p. 301].

NPs, PAs, and CNMs have fared reasonably well in this sometimes hostile political environment. The net result of these and other factors has been increased acceptance of the three professions across the U.S. The response of the system has been dramatic with numbers of practitioners increasing, and the roles, responsibilities, and scopes of practice expanding.

Professionalization

NPs, PAs, and CNMs have undergone a process of “professionalization” over the past 30 years, and especially in the 1990s. Professionalization has been described by Hodson and Sullivan as the “effort by an occupational group to raise its collective standing by taking on the characteristics of a profession.”^[27] The professionalism process is characterized by several steps including:

• Formation of a professional organization and lobbying the government and the public for increased professional standing,
• Standardization of the body of knowledge through more uniform curriculum requirements and training, publication of journals, engagement in research, and creation of examination requirements for the profession, and
• convincing the public by creating certification requirements that the occupation possesses appropriate professional knowledge and by licensure through public agencies.^[28]

Conclusions