History always lends perspective


Vol. 3 • Issue 5 • Page 16

Role & Growth

It’s been nearly a half-century since the nurse practitioner and physician assistant roles were established. The creation of these two professions was notable in the evolution of American medicine and nursing, and it marked a significant advancement in the division of healthcare labor. Initially, this sociomedical innovation was known as the new health practitioner movement.1

Only Two Emerged

The new health practitioner movement began in the mid 1960s and featured the development of many educational programs intended to produce new types of healthcare professionals. Of the various professionals trained during this time, the two professions that became established were the NP and PA professions.

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A number of factors led to the development of the new health practitioner:

• demise of the general practitioner

• failure of medicine to meet the needs of American citizens

• post-World War II population growth

• a shortage of primary care providers

• a desire for experimentation in medical education

• expansion of existing nursing roles.

The first nurse practitioner program was established at the University of Colorado by Henry Silver, a pediatrician, and Loretta Ford, a nurse.2 The first PA program was started at Duke University by Eugene Stead, a physician. The designs of both programs drew from academic medical education. Of note, other PA programs began almost concurrently at the University of Colorado and at the University of Washington. At the University of Washington, Richard Smith began the MEDEX program, for which previous healthcare experience was a key element.

Differences Noted

The roots of the PA profession ironically included the failure of a master of nursing science program at Duke in the late 1950s. It was a venture that Stead had encouraged. Some argue that this program represented a missed opportunity for nurses to develop an enhanced relationship with physicians, a view that has largely gone unchallenged among nursing historians.3 (To read more about this MSN program, enter “Thelma Ingles” in the Search Articles box at www.advanceweb.com/NPPA.)

Clearly, the mutually distrustful positions of the American Nurses Association (ANA) and the American Medical Association (AMA) during the late 1960s contributed to the lack of understanding and respect between professional nursing groups and the promoters of PA programs. This morphed into a continuing professional jealousy, particularly as more nurse practitioner programs arose.

Revitalizing CNMs

The new health practitioner movement also included the revitalization of the nurse midwife.

When nursing roles began to expand, the Frontier Nursing Service, established in the 1920s, developed the first certificate program to prepare family NPs. In 1970, the name of the school was changed to the Frontier School of Midwifery and Family Nursing.4

Dozens more educational programs arose as a result of the new health practitioner movement, and they took on a wide variety of configurations and focus areas. The interesting phenomenon was the gradual and eventual coalescence of this broad range of disparate programs into the PA and NP professions, now well established in the health system.

The turbulent 1960s was a decade of change in many areas of U.S. society, and fundamental restructuring of the division of medical labor evolved at this time. The introduction of the PA and the NP, along with the rebirth of the CNM in North America, represented a major transformation in U.S. medical practice. The NP and PA professions were created to assume a scope of practice that includes medical tasks previously reserved for physicians, particularly in underserved and rural areas. NPs and PAs have gained widespread recognition in nearly all aspects of healthcare delivery in the United States, and the concepts have extended globally.


1. Sadler AM. Introducing a new professional: the health practitioner.

In: Lippard VW, Purcell EF, eds. Intermediate-Level Health Practitioners. New York, NY: The Josiah Macy, Jr. Foundation; 1973: 1-56.

2. Pollitt P, Reesman K. Back to the Beginning. The PA and NP Professions each got a nudge from an MSN program at Duke. ADVANCE for NPs & PAs. 2012;2(11):37-39.

3. Holt N. Confusion’s Masterpiece: the development of the physician assistant profession. Bull Hist Med. 1998;72(2):246-278.

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4. How FNS began. Frontier Nursing Service website. http://www.frontiernursing.org/History/HowFNSbegan.shtm. Accessed March 5, 2012.

James F. Cawley is a professor in the Department of Prevention and Community Health in the School of Public Health and Health Services at George Washington University in Washington, where he also is the interim chairperson for the department. He is the 2011 recipient of the American Academy of Physician Assistants Eugene A. Stead Jr. Award of Achievement.


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