There is an ancient Oriental axiom that states:

"A Tree with Deep Roots Will Withstand the Storm."

The American health care system over many, many years has grown into a tall and mighty tree with luxurious foliage. Health care for the population of the United States became and is world class. People with means from other nations sought US health care when deeply concerned about their outcomes. Yet, although the "Health Care Tree" was splendid to look at, there was something lacking; the roots were not deep enough.

The nurse practitioner (NP) profession has celebrated its 54th anniversary this year and was commemorated by more than 270,000 NPs in the United States (American Association of Nurse Practitioners, 2019). Over the years, NPs have contributed to deeper roots and strengthened the tree's stability. Nurse practitioners are evidence-based practice health professionals whose primary objectives are to keep Americans healthy by proactively emphasizing health promotion and illness prevention. Nurse practitioners provide health care by combining the art and science of care and cure. Over the years, the inclusion of NPs and other advanced practice nurses (APN) into the health care spectrum significantly expanded the options for patients to be seen, diagnosed, treated, and restored to productive health. In many states, covenants with physicians were required for NP direct patient care. In other states, such covenants were not required. Regardless, NP inclusion and availability significantly increased choices for patients and became an icon of patient-centered care. Clinics staffed entirely of NPs came into neighborhoods and vastly underserved rural areas. Primary care offices, home health care, and 24-hour emergency clinics saw NPs shouldering the load with excellent outcomes.

Today and in the future, NPs will be the "go-to" health care authority in our vast underserved rural areas and communities and "go-to's" in our urban and inner-city areas. The demand for NPs will significantly increase because of the ease of access in primary care settings in addition to the NPs imbedded in the traditional health care system with physicians, other clinicians, hospitals, and clinics.

There were three aspects of APN professionalism that kept the "root growth" steady, but SLOW. First was the requirement to have collaborative agreements with physicians for NP practice. Although many states have now eliminated the requirement, allowing NPs to have full practice authority, there are still some states with restrictive practice. However, as more evidence of increased access and higher patient satisfaction with NP care emerges after removal of required collaborative practice agreements, it is likely that states with restrictive practice environments will decrease (Holmes & Waltman, 2019). According to Xue et al (2018), full scope of practice regulation is associated with higher supply of NPs in rural and primary care health professional shortage settings. Evidence in support of full practice authority has allayed public safety concerns (Martin & Alexander, 2019).

Second was the legal ability of NPs to prescribe controlled medications. Where this was lacking, it slowed the patient-centered care contribution of NPs. Over a period of several years, various states began to legally authorize NPs to prescribe under continuing covenants with physicians. In 2016, Florida became the last state to allow NPs to prescribe controlled substances (Florida Board of Nursing, 2016).

Third, until recently, NPs were prepared at the master's level and doctoral preparation was optional, even as the Doctor of Nursing Practice degree was envisioned. Now, because of an implicit mandate from the national advanced practice leadership organizations such as American Association of Colleges of Nursing (AACN) and National Organization of Nurse Practitioner Faculties (NONPF), the Doctor of Nurse Practice (DNP) degree is proposed to be required of all entry-level NPs by 2025 (National Organization of Nurse Practitioner Faculty, 2019). More schools are producing DNP-prepared NPs, and enrollment in these programs is continuing to rise (American Association of Colleges of Nursing, 2019). With the additional implementation of the practice doctorate, NPs are ready to take on the challenges of clinical complexity, responsibility, and patient care.

As more barriers to autonomous practice are eliminated and NPs are prepared at the doctoral level, NPs have become a fortifying "taproot" of our American health care tree, ensuring its future, growth, and quality. US health care, thanks to the establishment and expertise of NPs, is now truly a "Tree with Deep Roots."

References