Spring 2004
Vol.2 | No. 1

When the renowned Loretta Ford (above) came to the School of Nursing to speak to the Johns Hopkins medical community in October, her visit highlighted just how far the profession has matured since its inception nearly 40 years ago. (photo by Keith Weller)

“I’m seeing patients before and after surgery....We want to be part of the diagnosis and part of the plan.”

— Deb Baker, MSN, CRNP

“You don’t have to go far to see that the NPs are the glue in trauma service....When I talk to Debbie, I trust her judgment.”

—Edward Cornwell, MD

Rx: Nurse Practitioners

When it comes to the delivery of health care today, nurse practitioners are making their presence known. At Hopkins, the School of Nursing is meeting the intensifying need for NPs with innovative training programs that are setting the standard nationwide.

By Elizabeth Evitts

1965 was a pivotal year in America. A stunned nation still coped with Kennedy’s death, a sweeping Civil Rights Act had recently passed Congress, the Beatles appeared on Ed Sullivan, and Betty Friedan was conceiving the National Organization for Women. College campuses would soon become the proving ground for a generation opposed to war. At the University of Colorado, a visionary physician-nurse team rewrote the prescription for modern health care delivery. The need to deliver better services to rural and urban areas lacking primary care pediatric physicians drove Henry K. Silver and Loretta C. Ford to construct the first curriculum for the nurse practitioner (NP) and propelled the profession of nursing into a new realm.

Silver and Ford integrated the traditional roles of the nurse with advanced medical training and the community outreach mission of a public health official. The NP would provide care and patient education previously offered only through doctors.

When the renowned Loretta Ford came to the School of Nursing to speak to the Johns Hopkins medical community in October, her visit highlighted just how far the profession has matured since its inception nearly 40 years ago. In the last decade, the NP has blossomed into an indispensable member of the medical world, a highly skilled health care practitioner handling an increasingly diverse and complex patient load. In the community, NPs frequently run primary care practices, where they have the legal authority to diagnose, prescribe medicine, and order specialist referrals. (The State of Maryland recognized their increased capacity when it agreed in 2003 to list NPs as primary care HMO providers.) In the hospital setting, NPs are now working with doctors and residents in integrated team settings.

Today, the Johns Hopkins University School of Nursing offers one of the foremost training programs for nurse practitioners in a number of specialties. The school and Hopkins Hospital alike recognize the burgeoning role of the NP and understand that the participation of nurse practitioners is paramount to the success of team-focused patient care. Beginning this fall, a cutting edge curriculum at the School of Nursing will answer the intensifying demand for NPs in acute care arenas and will help set the standard for the next generation nurse practitioner.

The Evolution of a Profession
Julie Freischlag, MD, knows what it means to break new ground. The highly skilled vascular surgeon is the first woman ever to hold the positions of William Stewart Halsted Professor and director of the Department of Surgery at the Johns Hopkins School of Medicine and surgeon in chief of Johns Hopkins Hospital (and only the fifth woman nationwide to head up a surgery department). Freischlag has long been a proponent of the nurse practitioner. Before coming to Hopkins, she was the first physician at UCLA to hire a nurse practitioner to assist in a busy clinic setting. “When I was an intern, this woman was an ICU nurse, and she taught me everything I know about ICU care,” Freischlag says. The nurse pursued her advanced degree to become an NP, and when the time came, Freischlag hired her to help run a vascular clinic overseeing some 1,500 patients a month. “She took on her own patients and developed her own practice there,” Freischlag says. “She took charge.”

Until recently, however, Freischlag had not fully realized just how central the NP had become to acute care units. This past fall the doctor was called into the cardiac ICU to supervise the care of a woman who had undergone an extremely complicated heart procedure. A team had been watching the patient carefully to decide what to do about her eschemic leg. One day, Freischlag stopped by as morning rounds were in place and to her pleasant surprise, the team’s nurse practitioner was leading the discourse. “Three of my guys were sitting there taking notes from her!” Freischlag says. “[The NP] had been there every day, and they were discussing where they were going to go with this patient. Everybody was contributing, and it became clear that this was a very good thing. It was amazing to watch.”

Freischlag remembers when, not so long ago, physicians were not comfortable handing off care to anyone, let alone to a nurse practitioner. In the nascent years, the medical industry met this hybrid profession with suspicion and little leeway was afforded the NP. Many physicians served as thoughtful mentors to the advanced training nurses, but many also sought to control their charges, which created tension as NPs worked toward independence.

During the 1970s, new specialties evolved as patient needs heightened. The NP advanced from pediatric care to adult, family, primary, and critical care. This decade saw a concerted effort by the nursing industry to start regulating and formalizing NP training. The first NP curriculum at the University of Colorado was a certificate program that required enrollees to have at least a bachelor of science in nursing. By 1977, the American Nurses Association offered the first NP certification exams and by the late ’80s, the majority of NP programs required master’s degrees.

Today, NPs must procure a master’s and post-master’s education, which is supplemented by advanced medical and nursing training, certification in specialty areas, and intense clinical experience.

NPs in a primary care setting partner with a physician or a physician’s group and outline in writing their exact roles within the practice. These NPs focus on wellness and prevention and are able to treat minor illnesses and perform basic procedures, like splinting a fracture. If the illnesses become unstable, the NP then calls in the partnering physician or the necessary specialist.

“Each practice is very individual,” explains Janet Selway, DNSc, CRNP, clinical instructor at Johns Hopkins School of Nursing and NP at Johns Hopkins Hospital. “Physicians go to medical school for four years so they can learn to do very complicated diagnoses and procedures. [NPs] learn basic medicine and approach the patient with the eyes of a nurse. We do a lot of health counseling and teaching and that’s something the physician cannot always give.”

The Hopkins School of Nursing program, which began in 1994 with an adult program, currently offers certification in adult, pediatric, family, and acute and critical care. More than 60 students are enrolled and support a growing number of departments at Hopkins Hospital including surgery, emergency, oncology, and pediatrics.

While steady gains had been made in the first 25 years of the NP, the profession exploded in the last decade. In 1996, there were less than 40,000 NPs nationwide. By 2001, that number had grown to an estimated 78,251. With the growth of HMOs, which have an eye on the bottom line, NPs have emerged as a more cost-effective option for general patient care. “We help the patient to know how to manage their condition through change and lifestyle,” explains Selway.

Significant alterations in the acute care setting in hospitals also fueled increased demands. In 2002, when the resident and intern workweek was capped to 80 hours at training hospitals nationwide, the change opened the door for NPs to step up their participation. The NP is capable of doing more complex procedures than a regular nurse and can often triage critical patients and manage their recovery, jobs that were traditionally reserved for physicians and physicians-in-training. NPs do not rotate the way residents do, and are therefore providing an unprecedented level of continuity in patient care, note advocates.

“We’ve seen such a transition in the role of NPs and a lot of it comes out of necessity,” Freischlag says. “Twenty years ago if you asked if a physician would have an NP on the team, the answer would have been no.” Now her department has 43 NPs working in a number of arenas. “If you ask my faculty [today] who would want an NP, they would all say, ‘Me! I’ll take three!’”

Edward Cornwell, MD, chief of trauma at Johns Hopkins Hospital, agrees. “You don’t have to go far to see that the NPs are the glue in trauma service,” Cornwell says. He works in tandem with nurse practitioner Deb Baker, MSN, CRNP, who is also a clinical instructor at the school. “When I talk to Debbie, I trust her judgment.”

Says Baker, “I’m seeing patients before and after surgery, taking out staples, getting studies done, and handling problems.” She says NPs hunger for this level of participation. “We want to be part of the diagnosis and part of the plan.”

Even before the resident workweek was shortened, the number of acute patients in hospitals was growing as the number of residents was shrinking. “People began realizing that nursing could provide a continuity of care that medicine alone couldn’t,” says Theresa Pluth Yeo, PhD (c), MPH, MSN, CRNP, and assistant professor and coordinator of the school’s Acute Care NP Program. Yeo is also the current president of the Nurse Practitioner Association of Maryland and was one of the founders of the NP program at Hopkins in 1994.

In 1995 a national certification board exam for acute care NPs laid the groundwork for new curriculum programs. Today the Acute Care Program administered by Yeo includes 10 NPs in training who learn to provide bedside care and more complex procedures like chest tube insertion and ordering and administering intravenous drugs.

The school is constantly working to improve these courses and to develop the program further to better serve the increased needs of the medical community. And the demands keep coming. When Freischlag came to Dean Martha N. Hill recently to ask for help, Yeo analyzed the existing curriculum and realized there could be a way to plug NPs into critical care settings, like emergency rooms and ICUs, at a faster rate. She devised an Accelerated Acute Care NP Program for master’s students. “If you are an adult or family NP, you already have a master’s degree,” Yeo notes. “We’ve developed a post-master’s curriculum that will have NPs board eligible for Acute Care within two semesters,” she says.

The new program—the first of its kind in the country—will allow NPs to enroll in the Acute Care program while working in the hospital on their clinical training. That paid experience will apply toward their Acute Care certification. Before the program was created, students had to work those hours in addition to their regular nursing jobs. The school’s curriculum committee approved the program in February and will enroll the first fast-track students this fall.

Fighting for the Future
According to many at Johns Hopkins, NPs have become an indispensable asset to doctors and nurses, providing an unequaled level of consistency in patient care, both in team settings and in private practice. Hopkins NPs reach into the community, servicing low-income and uninsured patients at homeless shelters and centers like the House of Ruth. They increase the quality and delivery of direct care, helping patients transition successfully from hospital or clinic to home. “Guiding people through the system, getting them out the door safely, and watching their follow-up is a big part of our job,” says Julie Stanik-Hutt, PhD, CRNP, acute care assistant professor and NP for Lung Transplant Service at Hopkins Hospital.

Beyond this basic delivery of service, NPs are also providers who care for the patient one-on-one. “Sometimes you can make a world of difference with something so little, like teaching a new mother how to take a temperature,” says Janet Selway. “We’re looking at the patient like a nurse, but we’re offering services like the family doctor,” she adds. “And we’re becoming a household name.”

While NPs are making positive gains in public perception and are earning respect on the hospital and clinic floor, much of their battle is still being actively waged on the floor of the State House. To date, a national regulatory system is not in place, and NPs in every state regularly struggle to win rights to advance their careers. Maryland is one of the more progressive states in terms of NP legislation. “We earned the right to prescribe medication in 1982, and last year the state passed a bill that allowed NPs to be listed as primary care providers,” says Yeo.

These state-by-state legislative battles concern NP co-founder Loretta Ford, EdD, RN, FAAN. “We have a miserable situation here,” Ford says quite bluntly. “Advance practice is dynamic, and it moves with every new bit of knowledge and technology. We cannot run and ask for permission every time we want to do something new. What other profession does that?”

Even issues as basic as what to officially call NPs are still being played out. Some refer to them as “physician extenders,” a term that raises much ire with any NP. “We’re not Hamburger Helper,” Ford quips.

As the profession moves forward, NPs should be careful not to become too narrowly focused in their approach to patient care, cautions Ford. “I fear the medicalization of the role,” she says. “The diseases of the month, the esoteric medical conditions, those are for medical school. We need to learn about them in terms of referrals; there is teamwork that needs to be done. But we have 41 million uninsured in this country.” Ford contends that the NP must continue to work to bring about patient empowerment and to teach about preventive care to a public with fewer and fewer health care options. “We have a big job to do,” she adds.

The co-founder of the nurse practitioner profession believes that Johns Hopkins has a solid formula for tackling these complex issues. During her visit to the School of Nursing in October, Ford was impressed with the university’s global approach to NP training. The pipeline between Hopkins Hospital, School of Nursing, and Bloomberg School of Public Health, the outreach of the NPs into the community at large, and the diversity of the staff and students breed success. “I have been impressed with the international level of the student body and the research that’s happening here,” Ford said. “You’re trying to understand other cultures and to serve them.” Before leaving the school, Ford quoted Aristotle to a room full of health care providers. “Where your talents and the world’s needs cross, there lies your vocation.”

The School of Nursing continues to revise the rules, to explore and to push the boundaries of the NP vocation in order to provide the best training for its students and the best care possible for its patients. And in doing so, these dedicated medical professionals advance the vision born by Ford and Silver and continue to rewrite the prescription for modern health care service.

Elizabeth Evitts is a freelance arts and culture journalist living in Baltimore. Her work appears regularly in Baltimore magazine and Style.

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