Nurse Practitioner

Because of the significant demand for physicians that could not be met by medical training programs currently in place, a new position, the physician assistant (PA) was introduced into the U.S. health care system. In this role registered nurses and retired Army Medical Corps personnel took on certain medical functions. Physician assistants were trained on the medical model, and practiced medicine with a great deal of autonomy—often in geographically isolated regions—while remaining under the supervision of a licensed physician. PAs continue to flourish in the United States, with an estimated twenty-six thousand in practice as of 1996. The average PA program consists of two years of intensive training offered within a medical school curriculum.

As in the United States, Canada experienced a physician shortage in the 1970s and 1980s. However, rather than introducing a totally new type of health care worker into the system, it was decided to expand the scope of registered nursing practice to meet the primary health care needs of Canadians. The new role was established as the nurse practitioner (NP) or expanded role nurse (ERN).

NP education did not develop within the usual university setting because of the urgent demand for NP/ERNs. Moreover, attitudes within many universities fostered skepticism about what was seen as a mixed medical and nursing role rather than a pure nursing role. Thus the NP role was initially perceived to be an extension of the registered nurse role emphasizing many of a physician's responsibilities: histories and physicals, medical diagnoses, ordering and interpreting laboratory and diagnostic tests, prescribing medications, and developing treatment plans in collaboration with a physician. As such, the NP was often compared to the PA. NP courses quickly proliferated in such subspecialties as pediatrics, occupational health, and geriatrics, and their graduates often worked in sparsely populated areas of northern Canada and the western United States that could not attract physicians.

As early as the 1940s a version of the NP, the clinical nurse specialist (CNS), was emerging in both Canada and the United States as a response to nurse educators' concerns for improving nursing care. The CNS specializes in a particular population or disease, emphasizing teaching, role modeling, nurse-to-nurse consultation, education and staff development, and research. The CNS uses specifically developed clinical expertise (e.g., in geriatrics or cardiovascular disease) to guide and mentor nursing staff in improving patient care.