Blog Viewer

Advanced Practice Providers – A Historical Review

By Currents Editor posted 08-26-2021 14:14


Misti Tuppeny & Kelly A. Rath 

On Behalf of the NCS APP Leadership Section & NCS Ethics Committee:
Ethics Committee Chair/Chair Elect: Stephen Trevick, Jamie Nicole LaBuzetta
APP Leadership Section Chair/Chair Elect: Rachel Hausladen, Ana Kukulj 

Healthcare through the 20th and 21st centuries has seen significant change and growth, and through this evolution, the role of the advanced practice provider (APP) developed to fill a need for equitable access to quality patient care. The term advanced practice provider encompasses nurse practitioners (NPs), clinical nurse specialists (CNSs), physician associates/assistants (PAs), nurse anesthetists, and nurse midwives. APPs provide an emphasis on patient care management with a focus on outcomes, evidence-based practice, coordination of care, quality and safety metrics, as well as patient and staff satisfaction.1,2 

The International Council of Nurses defines a nurse practitioner as a registered nurse who has acquired a graduate education to expand their knowledge base in order to provide expert care, complex decision-making and competency for expanded practice.3 Nurse practitioners can diagnose and manage patients, and they hold prescriptive authority. The first NP program was developed in 1965 by Loretta C. Ford and pediatrician Dr. Henry K. Silver in Colorado in order to meet the healthcare needs of children, specifically in well-child care.4  In 1967, Boston College was one of the first to create a Master’s Degree Program 5 and after more than 50 years, the NP role continues to evolve with many nurse practitioners pursuing doctoral level education. Nurse practitioners nationwide are rallying for full practice authority (FPA), which would allow independent practice under their own license and state board without a collaborating physician. According to the American Academy of Nurse Practitioners, there are more than 325,000 nurse practitioners currently licensed in the U.S.6   

The clinical nurse specialist was first identified in literature as early as 1949, but not until 1969 was a formal educational process established. The CNS is a master’s-prepared advanced practice nurse whose function is to improve outcomes in patient care. The CNS is a clinical practice expert, an educator, a researcher, and a consultant with influences on patient care, nursing, and systems.7 The CNS provides expertise and support to the bedside nurses, drives practice change throughout organizations, and ensures best practices to achieve the best possible patient outcomes. The scope of the CNS may be defined by: population (e.g. stroke), patient care issues (e.g. wound care), unit-based, or disease-specific (e.g. diabetes). Presently there are 72,000 CNSs practicing within the United States.8 

Physician associates/assistants are defined by the American Academy of Physician Assistants as providers who can diagnose and treat illness and prescribe medications, (similar to NPs). PAs differ from NPs in that their undergraduate degrees may vary, and subsequently complete a 3-year graduate degree through an accredited PA program. The first program for PAs was championed by Eugene A. Stead Jr., MD at Duke University in 1965, with the aim of training persons who would assist physicians as medical providers. Early on, Vietnam War Veterans with battlefield medical experience were heavily recruited into the PA profession and later the PA influence spread outside the military.9  There are currently more than 125,000 PAs practicing in all 50 states and D.C.10 

Both the American Nurses Association and the American Academy of Physician Assistants recognize the role of advanced practice nurses and PAs in fulfilling the promise for equitable healthcare for all. The PA and Nursing Codes of Ethics recognize the need for mutual trust, respect, recognition, and open communication for all healthcare providers to improve health outcomes11,12 Through the years, APPs have served as instruments of social justice, to help meet the healthcare needs for patients of all backgrounds and all socioeconomic statuses. In the 1960s, Medicare and Medicaid programs extended coverage to include low-income individuals, which increased the demand for primary care providers, opening the door for APPs to fulfill a needed role in healthcare.13 In 2003, the Accreditation Council for Graduate Medical Education (ACGME) restricted resident duty hours to an 80-hour work week, providing another opportunity for APPs to demonstrate their value and benefit,14 including migration into the inpatient setting. It is projected that by 2030 there will be a major shortage of providers to care for the expanding and aging baby-boomer population, paving the way for ongoing influx of APPs into a number of clinical settings.15 

APPs have truly overcome many obstacles and barriers that have threatened to limit their practice, including legal restrictions preventing practicing to the full extent of their training, at times strained relations with physicians, lack of understanding of the role(s), reimbursement limitations, and restrictive local and state policies.16 Now, APPs practice in virtually every clinical setting and every medical and surgical specialty.17 Postgraduate training programs for APPs are also becoming more commonplace, further expanding training opportunities for APPs.18 Significant differences still exist between states surrounding FPA, and currently 22 states allow FPA for NPs.19 With time, the APP role will continue to evolve and flourish. 

The Neurocritical Care Society’s Statement on Standards for Neurocritical Care describes APPs as having multiple duties, which include expert clinical consultation, leading quality improvement and evidence-based practice initiatives, providing education, and research initiatives. Furthermore, APPs are described as providers who should be involved in team rounding, with many training opportunities such as post-graduate fellowships, advanced orientations, and specific procedural training.20 During the 2020-2021 SARS-CoV-2 pandemic, APPs from multiple settings showed dedication and flexibility in the care of critically-ill patients.21 The Neurocritical Care Society has also seen great contributions by its APP members, including a recent NCS President, and more APPs than ever with the Fellow of Neurocritical Care Society designation. During the upcoming months, we recognize the contributions of our APPs during National Clinical Nurse Specialist Week (September 1-7), National PA Week (October 6-12), and National NP Week (November 7-13). We are proud of the contributions of our APP members, and as APPs we are grateful for the support of our multidisciplinary colleagues.  


An APP Prepares for a Point-of-Care Ultrasound Examination

APPs Networking at the Neurocritical Care Society Annual Meeting      

An APP Leads a Conference for Rotating Residents


  1. Davidson PM, Rahman A. Time for a Renaissance of the Clinical Nurse Specialist Role in Critical Care? AACN Advanced Critical Care 2019;30:61-4.
  2. Kleinpell RM, Grabenkort WR, Kapu AN, Constantine R, Sicoutris C. Nurse Practitioners and Physician Assistants in Acute and Critical Care: A Concise Review of the Literature and Data 2008–2018. Critical Care Medicine 2019;47:1442-9.
  3. Network ICoNAPN. Definition and characteristics of the role.
  4. Ford LC. Reflections on 50 years of change. J Am Assoc Nurse Pract 2015;27:294-5.
  5. McComiskey CA. The Role of the Nurse Practitioner: A 50-Year History: What Is Our Future? Journal of Pediatric Surgical Nursing 2018;7:1-2.
  6. National Nurse Practitioner Database. 2021.
  7. What is a CNS? (Accessed July 20, 2021, at
  8. Wetzel C, Kalman M. Critical Care Clinical Nurse Specialist: Is This the Role for You? Dimensions of Critical Care Nursing 2010;29:29-32.
  9. Cawley JF, Cawthon E, Hooker RS. Origins of the physician assistant movement in the United States. Jaapa 2012;25:36-40, 2.
  10. Assistants AAoP. 2020.
  11. Guidelines for Ethical Conduct for the PA Profession. In: Assistants AAoP, ed.2013.
  12. Code of Ethics for Nurses with Interpretive Statements. In: Association AN, ed.2015.
  13. Saver C. 50 years of NP excellence. The Nurse Practitioner 2015;40:15-21.
  14. Iglehart JK. Revisiting Duty-Hour Limits — IOM Recommendations for Patient Safety and Resident Education. New England Journal of Medicine 2008;359:2633-5.
  15. Angus DC, Kelley MA, Schmitz RJ, et al. Current and Projected Workforce Requirements for Care of the Critically Ill and Patients With Pulmonary DiseaseCan We Meet the Requirements of an Aging Population? JAMA 2000;284:2762-70.
  16. Schirle L, Norful AA, Rudner N, Poghosyan L. Organizational facilitators and barriers to optimal APRN practice: An integrative review. Health Care Manage Rev 2020;45:311-20.
  17. Moote M, Krsek C, Kleinpell R, Todd B. Physician assistant and nurse practitioner utilization in academic medical centers. Am J Med Qual 2011;26:452-60.
  18. Cappiello J, Simmonds K, Bamrick K. A Survey of Characteristics of Transition to Practice Nurse Practitioner Programs. The Journal for Nurse Practitioners 2019;15:241-4.e1.
  19. State Practice Environment. 2021. (Accessed July 8, 2021, at
  20. Moheet AM, Livesay SL, Abdelhak T, et al. Standards for Neurologic Critical Care Units: A Statement for Healthcare Professionals from The Neurocritical Care Society. Neurocrit Care 2018;29:145-60.
  21. Brissie MM, L. Advanced Practice Provider Assessment and Response to COVID-192021.  

Lauren Koffman, DO, MS As a member of the Educational Products Committee, one of many committees within the Neurocritical Care Society, I was recently asked to review A Guide to Traumatic Brain Injury: The Intensive Care Unit . This guide was written several years ago by Dr. David Y. Hwang and ...
Jenna Gonillo Davis, MS, ACNPC-AG, CCRN Angie Murkins, FNP-BC Ana Kukulj, FNP-C, MSN, BSN, RN Advanced practice providers (APPs) have become the ever-present providers in critical care departments. They act as a stabilizing force for intensive care units (ICU) where residents and ...
Gantner D, Wiegers E, Bragge P, Finfer S, Delaney A, van Essen T, Peul W, Maas AIR, Cooper DJ. Decompressive Craniectomy Practice following Traumatic Brain Injury in Comparison with Randomized Trials: Harmonized, Multi-Center Cohort Studies in Europe, the United Kingdom, and Australia. J Neurotrauma. ...