Profession and Society

Experiences of Pioneer Nurse Practitioners in Establishing Advanced Practice Roles

Marie Annette Brown, Mary Ann Draye
Purpose: To describe pioneers experience of establishing the nurse practitioner (NP) role, and their experiences in maintaining and building the NP role in the contemporary practice environment. Design: The study sample included 50 middle-aged women currently practicing in Washington State as licensed advanced practice nurses, who began the NP role during 1965-1979. Methods: This descriptive study included interviews and focus groups to gather data about the nurses early experiences. Interpretative methods of grounded theory were used in data collection and analysis. Findings: The central organizing theme, Advancing Autonomy to Make a Difference, was manifested through six broad themes: Breaking Free, Molding the Clay, Encountering Obstacles, Surviving the Proving Ground, Staying Committed, and Building the Eldership. Conclusions: Autonomy was requisite to practice to ones full potential and maintain commitment over time. The data findings show the evolution of advanced nursing practice in the United States and provide guidance for nurses who are working to establish advanced practice nursing in other countries.

JOURNAL

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NURSING SCHOLARSHIP, 2003; 35:4, 391-397. 2003 SIGMA THETA TAU INTERNATIONAL.

[Key words: nurse practitioners, autonomy, pioneers]

* hanges in the health care system, such as cost containment, productivity mandates, reimbursement mechanisms, and limitations on access to patients, have renewed concerns about the survival and growth of advanced nursing practice. In addition, the resurgence of proposals by organized medicine requiring physician supervision threatens the autonomous nature of advanced nursing practice (American Academy of Pediatrics [AAP], 2003). A critical step in addressing these challenges is to analyze the role of autonomy and to glean wisdom from past experiences of those who pioneered these roles. As Bigbee and Amidi-Nouri (2000) suggested, The historical trends of the older siblings can certainly provide guidance and support in terms of current and future strategies (p. 29). Given the projected worsening of the nursing shortage, examining factors that contribute to recruitment is also important. Furthermore, many advanced practice nurses enter retirement age without adequate replacements, identifying professional satisfactions that could enhance retention is needed. Finally, knowledge about the origins of advanced practice can lead to better understanding of this key milestone in the growth and development of nursing. One advanced practice role, the nurse practitioner (NP), originated in the 1960s and

* provided the opportunity to diagnose and treat a variety of health problems in ambulatory care. Building on their nursing expertise and additional education, NPs advanced their autonomy, assumed a central role in primary care, enhanced quality of care, and increased access for the underserved. The Office of Technology Assessment review (1986) of the NP role showed that NPs were especially valuable in improving access to health care services for people in rural areas, low-income people, minority populations, and people without health insurance. To date, research has yielded information about NP educational preparation, characteristics of NP practice (Draye & Pesznecker, 1979), utilization of NPs in various settings (Bigbee & Amidi-Nouri, 2000; Brykczynski, 2000), and

Marie Annette Brown, PhD, FNP, FAAN, Psi-at-Large , Professor, Mary Ann Draye, MPH, FNP, Psi-at-Large, Assistant Professor, both at University of Washington, School of Nursing, Seattle, WA. The authors acknowledge the National Organization of Nurse Practitioner Faculties for partial funding and the pioneer NP study participants for their enthusiasm and openness. Correspondence to Dr. Brown, Department of Family & Child Nursing, Box 357262, University of Washington, Seattle, WA 98195. E-mail: mabrown@u.washington.edu Accepted for publication September 15, 2002.

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effectiveness (Horrocks, Anderson, & Salisbury, 2002; Mundinger, 2000; Safriet, 1992; Office of Technology Assessment, 1986). However, with only anecdotal stories from leaders of the NP movement, detailed information about the evolution of advanced practice is limited. Therefore, the primary aims of this study were to: (a) describe pioneers experience of establishing the nurse practitioner role; and (b) describe pioneers experiences in maintaining and building the NP role in the contemporary practice environment.

Methods
After approval from the universitys human subjects committee, flyers recruiting pioneer NPs were sent to all individuals licensed as advanced registered nurse practitioners (ARNP) practicing in the state of Washington. We solicited female NPs who initiated the role in the 1960s or 1970s and were in NP practice at the time of the study. The sample was limited to women to address potential gender issues. The 112 NPs who responded were invited to participate in focus groups. Thirty-three NPs attended one of four focus groups. An additional 17 NPs who were part of the original set of volunteers but who were not available for the focus groups participated in individual interviews with attention to expanding the ethnic and geographic diversity. The final sample included 50 NPs, who began in the NP role between 1965-1979. All participants were middle-aged women with 68% aged 50 and older and 26% aged 45-49 years. Despite focused recruitment for ethnic diversity, 94% of the respondents were Caucasian. The majority had practiced in Washington their entire NP careers in several different clinical sites. Forty-two percent of the respondents pioneered the NP role in either a health department or community clinic focused on care of underserved people. Four specialty groups were represented: family NPs, 54%; pediatric NPs, 22%; adult NPs, 14%; and womens health NPs, 10%. Fifty-four percent of the pioneers were practicing in urban areas and 44% in rural communities. The median length of NP practice was 22 years. The demographic characteristics of this sample closely approximated a recent state survey of Oregon health care providers in ethnicity and practice setting. However, participants were somewhat older (mean age=47 years) than the population of NPs in Oregon. All the pioneer NPs were female by study design whereas males comprised 8% of the NP population in Oregon (AHEC, 2001). Participant demographic characteristics were consistent with the most current Washington State NP Prescribing Practices Survey (Kaplan & Brown, 2002), indicating a predominance of middle-aged women and a majority of FNPs. Data collection and analysis were based on grounded theory methods (Glaser & Strauss, 1967; Strauss & Corbin, 1998). The approach to data gathering was identical for interview and focus groups, beginning with the initial open-ended question, What was it like for you starting out as a new NP in 19? Responses to this question elicited further in-depth
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description and clarified participants meanings. Interviews and focus groups were concluded with the questions: Describe your NP practice now compared to when you first began, and What advice do you have for new NPs? Interviews and focus groups were audiotaped and transcribed verbatim for data analysis. Data analysis followed multiple steps of open coding, axial coding, selective coding, and theoretical integration (Strauss & Corbin, 1998). Identification of initial conceptual categories was followed by more focused data collection to expand and verify themes (Charmaz, 2000). Data credibility was addressed by use of reflexive journals, prolonged engagement with the data, persistent observation, debriefing by peers, member checks, and review by nonparticipant NP pioneers. Independent audit trails were conducted by two of the investigators NP faculty colleagues and one nursing doctoral student on randomly selected transcripts to confirm categories and verify that sufficient data existed to support the study themes. During the final phases of analysis, study participants, NP faculty, and NPs who did not participate in the study were asked to review and critique the validity of the theoretical process and categories. Modifications of the theoretical presentation were based on feedback from these experts as well as consensus between the researchers. The categories derived during this study were validated using historical reviews found in texts commonly used to teach NP role development (Bigbee & Amidi-Nouri, 2000; Kommenich, 1998; Mezey & McGivern, 1993).

Results
A summary of the findings of the experiences of pioneering the NP role is outlined in the Table. The central organizing theme was advancing autonomy to make a difference. Data indicated that dedication to establishing autonomy became the quintessential issue of NP practice and endured over time. The intention of pioneers was to build on existing nursing autonomy and significantly expand it to accommodate their new role. This commitment to advance autonomy to make a difference in the quality of patient care was further understood in the context of six themes: (a) breaking free, (b) molding the clay, (c) encountering obstacles, (d) surviving the proving ground, (e) staying committed, and (f) building the eldership. These themes and their respective subthemes indicated multiple dimensions of the pioneers advancement of autonomy. Theme One: Breaking Free Breaking free refers to the process of leaving behind familiar, traditional nursing roles to explore previously unexplored territory. Although some pioneers were comfortable with their current nursing roles, many pioneers were frustrated by the circumstances of traditional nursing jobs or they were simply chomping at the bit to use their full expertise. These talented young professionals, primed for change, represented the first wave of the NP movement and were enticed by the promise of innovation and challenge. I like pushing the envelope; it fits my personality of being a little bit of a fighter, of wanting

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Table. Stages in Advancing Autonomy

Breaking free Molding Leaving familiar roles Exploring uncharted territory Creating new relationships Blending two worlds Stretching one's limits Meeting resistance Being undermined Feeling invisible Establishing credibility Explaining oneself Choosing the battles Fighting for legitimacy Building networks Making a difference Relishing intimacy Paying the price Sharing the wisdom Sounding the alarm

Encountering obstacles

Surviving the proving ground

Three subthemes illuminating the process of molding the clay were: creating new relationships, blending two worlds, stretching ones limits. Creating new relationships. Pioneer NPs forged new relationships with employers, patients, physicians, and nurse colleagues. Previous relational norms and authority structures shifted as they took new responsibilities for diagnosis and treatment. Key support from influential colleagues or visionary supervisors strengthened the foundation of NP practice.
On my first day in clinic one resident said, Oh, youre here to help the doctors. And right away the Chief Nurse said, No, shes a nurse practitioner and shell have her own job. She was probably way ahead of her time.

Staying committed

Building the eldership

to go to the nth degree on things to be part of that from the beginning was so much fun. Dissatisfaction with previous RN roles arose from the constant need to obtain physicians orders before implementing their own interventions. Participants emphasized their struggle was not for autonomy for its own sake, but as a means to transcend limitations in the RN role. One pioneer NP said: Its been a tremendous satisfaction of autonomy of being that person on the front lines with the patient. I never quite felt I was able to do that in the more traditional role of a nurse. Pioneers were usually encouraged to pursue NP education by either physician colleagues or nursing faculty who recognized their outstanding potential. Despite their enthusiasm, few participants clearly understood the NP role before beginning their educational programs. Even fewer had ever seen an NP in practice. However, their beliefs about possibilities for this new role gave them hope that it would infuse their work with excitement and fulfillment. Theme Two: Molding the Clay Being a pioneer often means that the structure and composition of the path ahead is not well specified. Molding the clay portrays the process of developing the NP role from a somewhat ambiguous entity and creating its form and substance. The first creative endeavor often was the process of seeking employment, when the pioneers recognized unmet needs in the practice site, envisioned how their new role could meet these needs, and persuaded administrators about their potential contribution. One participant summarized the obstacle of being an unknown. When you went looking, they really didnt know what you were. I dont think they knew how to utilize you so I got turned down at first. Even when NPs found clinics and agencies willing to experiment with a new provider role, obstacles arose. Once hired, they had few signpostsno detailed job descriptions or role models to follow. Often they proceeded by trial and error, relying on what felt right as well as feedback from employers, colleagues, and patients.

Pioneer NPs sought to create a new kind of collegiality with physicians that facilitated peer level consultation, with shared information and responsibility, and collaborative clinical decision-making. As RNs they had tried to influence physician practice by suggesting management strategies or asking for permission to implement what they considered to be beneficial treatments. As NPs they consulted with physicians, but they maintained decision-making authority. Pioneer NPs also attempted to establish alliances and partnerships with RNs to maximize their complementary roles. Some participants described their pleasure in encouraging RN colleagues to become NPs or to seek further education. Generally patients adjusted quickly to receiving care from an NP. However, this change did not simply substitute the NP for a physician; NPs and patients together created a different kind of relationship characterized by reciprocal exchange and mutual decision-making. One participant said: I think its a peer level with the patient. Youre a little bit of an icon but also youre a bit of a peer. I think that its relational and whatever it is, I experience it and I love it. Blending two worlds. Pioneers did not view themselves as a blank slate when they entered primary care or urgent care practices. They described how an established identity as an RN and a holistic nursing perspective were foundations of the NP role. The blending of components of nursing and medicine was highlighted by one study participant: What I loved was the ability to blend what I liked best in nursing which was the teaching and counseling with what I like best about medicine which is diagnosing. I love the detective part, and the intellectual challenge of that. Some participants described how their initial clinical responsibilities as an NP were focused on health screening and health promotion, a domain familiar to them as nurses. Pediatric NPs in particular described how their initial practice consisted mainly of physical exams and well-child checks before incorporating illness management. Most noted, however, that their practices diversified when colleagues and supervisors recognized the breadth of NP expertise. Families, friends, and colleagues of pioneers often had difficulty in understanding this unique blending of nursing and medicine. Pioneers reported frustration with others tendency to focus on the medical components of the NP role instead of the blending of nursing and medicine. Some pioneers
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were accused of no longer being nurses and others were interrogated about why they did not choose to become physicians. One participant reported: A good friend kept saying to me, why dont you just be a doctor. I kept saying I dont need to be a doctor. I need to be a nurse practitioner. This is where I fit. Stretching ones limits. Most participants said that when they began practicing as NPs they had little idea of the type or extent of the difficulties they would face. They vividly recalled the challenge of coping with external pressures and internal anxiety while fulfilling multiple role demands. They reported an exponential learning curve while struggling with the self-doubt and anxiety characteristic of a novice. One experienced RN described her transition to becoming a primary care NP: The first couple of years I went home saying, What am I doing? And weeping and crying and just totally stressed. I was feeling pretty shakyI was doing what I wanted but I kept questioning Am I up to this? Am I really ok? The steep learning curve on the way to competence became a burden because participants felt the need to prove the worth of all NPs to the world. Without mentors and role models, the burden for these novice practitioners was intensified even more. Work challenges were often exacerbated by participants private lives. Many discussed how the primary care provider role with long hours often clashed with the parenting role in nurturing young families. Without system support and role models of professional women seeking to do it all, they became exhausted trying to meet both professional and family demands. One single parent participant said:
You have to be pretty dedicated to do this day after day because it takes its toll emotionally. How can you walk out the door and not let it creep in and interfere with your own personal life? You have your home life and the demands of that and youre only one person.

Theme Three: Encountering Obstacles Pioneer NPs reported resistance common to agents of change. Although patient acceptance came quickly, NPs experienced opposition from many sources, including physicians, other nurses, insurance carriers, and pharmacists. Three subthemes, meeting resistance, being undermined, and feeling invisible indicate the struggle to be recognized as legitimate providers. Meeting resistance. Many pioneers experienced antagonism in practice settings, within organizations, in regulatory bodies, and in the legislature. For example, one participant recalled verbatim testimony during a legislative hearing that NPs would become an uncontrollable nuisance: Nurse practitioners will become like Scotch broom, first introduced to beautify the highway system in the state of Washington, but now a weed. Participants believed that some of the resistance from physicians was a manifestation of fear of losing patients, money, and control. One participant recalled: I remember one physician saying to me you might be ok as long as you dont try to get prescriptive authority.
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Misinformation about the NP role limited acceptance and caused verbal attacks. NPs constantly encountered skepticism about their knowledge and skills. Sometimes skepticism and resistance escalated into overt hostility and verbal attacks, such as: The residents were quite hostile to me. I had people yelling at me, doors slammed, How dare you handle this kind of patient; you shouldnt be here. Resistance took many forms and came from a range of coworkers. Some participants said they were treated as second-class citizens compared to physicians and they were exposed to an appalling lack of respect. For example: One medical assistant had one of those little monsters on a stick if I worked too slowly (for her) she would crack open the door, stick in the little monster head and that meant work faster. Would she have ever done that to the MD? Participants noted, however, that resistance often decreased over time as colleagues came to know the NPs and trust their expertise. Physicians who were willing to work as collaborative partners also served as important mediators and sources of support. The physicians were freaked out save the one that was my preceptor. The physician I collaborated with saw me as valuable. Being undermined. Participants felt undermined by various health care personnel. For example, some pharmacists refused to fill NP prescriptions and clinic coworkers (nurses, medical assistants, and receptionists) characterized NP care as second rate to patients or even withheld patients from NPs. Coworkers sometimes refused to assist NPs in the ways they commonly assisted MDs (i.e., ordering lab work, drawing blood). Lack of trust from nursing colleagues was particularly disappointing for pioneer NPs: The RNs never questioned him [MD], didnt ask Did you learn that in school? But I always felt like I was on trial or always being questioned about my expertise. Particularly frustrating were those occasions when NPs sought physician consultation and received admonitions and accusations along with medical advice. Some study participants were told that they were nervy to assume this level of autonomy. One pioneer described the sarcastic response she received during a courtesy call to a physician before handling an emergent weekend situation in a rural clinic:
I called him [the MD] and said this child has a laceration and I can sew this up. I just wanted to let you know. And he says something very smart back to me like What do you think youre doing? Is this OK with the parents? I went ahead and sutured because the parents trusted me.

Feeling invisible . Participants described various marginalizing experiences that made them feel invisible. Some told of sending out referrals but replies were returned to their physician colleague instead of to the NP, thus complicating their efforts at coordinating care. Others described times when their names were excluded from office directories, business cards, and prescription pads. Despite their active prescribing roles, pharmaceutical representatives often ignored NPs or excluded them from events open to other prescribers. Participants noted that these forms of neglect were as destructive as overt resistance.

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You would go to the meetings and they [MDs] would talk to you because you were dressed up and they thought you were a doctor. As soon as they found out you were a nurse practitioner, they would stop talking to you. You were invisible.

Theme Four: Surviving the Proving Ground All participants reported experiencing a proving ground where their performance was under constant scrutiny. In response, they developed the following survival strategies: establishing credibility, explaining oneself, choosing the battles, fighting for legitimacy, and building networks. By establishing credibility, pioneer NPs worked to maximize their competency to gain respect and to become more credible to skeptical colleagues. Explaining oneself involved repeatedly clarifying the NP role, skills, and philosophy of practice to patients, colleagues, and anyone who would listen. Choosing the battles required the insight to decide when to take on a fight and when to let it go. Fighting for legitimacy involved lobbying for legislative changes and structures to establish a legitimate foundation for NP practice. Building networks was essential as participants garnered support and acceptance for the NP role. Detailed presentation of these data and discussion of the survival strategies as lessons for change is found elsewhere (Draye & Brown, 2000). Theme Five: Staying Committed In addition to making a meaningful contribution, sustained commitment to practice yielded many rewards. These included increased confidence in nonprofessional arenas, enhanced selfesteem, and serving as role models for their own children. At the same time this long-term commitment required sacrifice. Two subthemes, making a difference and relishing intimacy indicate the rewards but the third subtheme, paying the price, details the sacrifices. Making a difference. The data indicated considerable pride among participants who believed they had made important differences in the lives of their patients by enhancing patients receptivity to health care, encouraging self-care, serving as a healing presence, and increasing access to the health care system. Some NPs were particularly proud of the confidence invested in them across generations. For example, patients they cared for as children became adults and sought the NP for caring for their own children. NPs described how positive feedback from patients kept them going despite adversity, helped them remain committed over time, and was the major source of satisfaction over more than 20 years of practice. Participants were delighted to report how they helped patients make important changes. Out of the blue somebody will say, You talked to me and I decided I should quit smoking and be healthy for my kids. I thank you. Pioneers repeatedly emphasized that their ability to make a difference arose from the autonomy to create a practice style consistent with their values. These values characterized a practice style of: (a) listening carefully, (b) encouraging questions, (c) providing in-depth explanations, (d) offering affirmation, and (e) facilitating patient empowerment.

Relishing intimacy. Participants described enormous satisfaction from meaningful connections and intimacy in their NP-patient relationships. Patient feedback about the value placed on intimate exchange encouraged them to safeguard the interpersonal emphasis in their practice. Particularly moving for the NPs were acknowledgements from patients who felt heard and cared about. Powerful and reinforcing rewards were described as the juice of intimacy which seemed to have a healing quality for both patients and NPs. As you get older you realize that all you have in life is caring for others. When you make real contact with somebody it makes the fabric of both your lives richer. Paying the price. Despite the rewards, participants also reported discouragement and frustration with the NP role; the most common was a lack of appropriate financial remuneration. Many resented salaries that were not commensurate with their advanced education, increased expertise, proven effectiveness, and major responsibility. They felt undervalued and exploited.
It bugs me. Ive got a couple of masters degrees and all these years experience and I dont make much money. Financially becoming a nurse practitioner has not been a big boon. That has been a disappointment for me.

Additional sources of frustration arose from the multiple demands of family life, long work hours, and the clinical responsibility of the NP role. Rural NPs in particular said they felt always on duty because at stores or community events they were often asked for advice and problem solving. Theme Six: Building the Eldership Elder is defined as an influential citizen whose advice is sought, respected (Webster, 1996). Pioneers functioned as elders because of the wisdom accumulated from struggle and years of experience. This expertise was sought by colleagues and less experienced NPs and is indicated in the following subthemes: sharing the wisdom and sounding the alarm. Sharing the wisdom. Participants reported that over the years they experienced the transition from seeking advice to being the ones from whom advice was sought. Many became preceptors for NP students. Although they were not always a formal part of the administrative hierarchy, participants believed that colleagues and administrators viewed them as leaders with insight and sought their feedback. They described how managers asked them for assistance when initiating change and in some cases appointed them to spearhead projects.
Im told by my supervisor that Im highly thought of because of my background and knowledge and I know what is going on, so when they start these things, Im always there, sometimes at the table, sometimes in the background.

In the role of elder, the pioneer NPs described their need to pass on wisdom gained from experience to the next generation. For example, the importance of balancing work and personal time was emphasized. Without such a balance, the pioneers considered burnout to be inevitable. You have to have some kind of balance so you can get your batteries recharged. Dont be like us pioneers who had little life of [our] own.
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Participants also emphasized the value of ongoing learning throughout ones career. Acknowledging that No one can ever know it all, participants urged new NPs to Look things up and dont be afraid to say you dont know. They also advised new NPs to develop business savvy to market themselves, develop resources, build cost-effective practices, and implement strategic productivity decisions. Nearly all participants agreed that NPs need to be more assertive about salary issues. Computer and technology skills were identified as important for working with electronic records, documenting NP practice outcomes, accessing resources, consulting, and building stronger networks. Sounding the alarm. When participants compared their early days of practice with their current practice environments, they recognized enormous progress. At the same time, they were concerned about the future. They feared the very things that had attracted them to the NP role might be lost. For example, they worried about loss of autonomy because of a health care system that obstructs their practice style. Shorter patient visits, constraints by insurers, and the current emphasis on patient numbers were viewed by pioneers as threats to autonomy. Shorter visits were viewed as threats to quality and safety of patient care. In response, many pioneers salvaged time for patients by working through lunch, staying late, and charting on their own time. So what happens to me is I spend every minute and then some with the patient and then do the dictation on my own time. Its ingrained in me to build those relationships with people. I cant feel good about myself if I just walk in and walk out. However, despite these coping strategies, some participants were sufficiently discouraged to consider leaving NP practice or retiring early rather than further compromising their standards. And finally, pioneers urged the next generation of NPs to address current threats to quality health care in general and to the NP role in particular.
A thing to tell those nurse practitioners is they got to step up to the plate. You know, we all took our turns and you cant keep it up, you burnout politically. They have to do that if we want to survive. Get involved in your professional organization at some level give back to your nurse practitioner community.

Discussion
These pioneers broaden the discourse on the historical development of advanced practice by including individual pioneer NP experiences and by drawing implications for continued evolution of the role. The findings about experiences of pioneers in their clinical practice settings and professional lives contain five important contributions: (a) analysis of autonomy in the development of the NP role as essential to stabilizing this advanced practice role; (b) elaboration of autonomy as a flashpoint for conflict from individual to organizational level; (c) documentation of the magnitude of the effort required to implement an advanced practice role; (d) analysis of how autonomy allows NPs to make a difference and enhances role commitment; and (e) elaboration of
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interpersonal connection and intimacy as key factors in commitment. Study findings are consistent with previous work about the significance of autonomy, which for decades has been recognized as a fundamental criterion of a profession (Davis, 1966). Struggles for autonomy have been central to the evolution of the entire nursing profession across specialties, including advanced practice (Bigbee & Amidi-Nouri, 2000). Pioneer NPs broadened nursing practice, altered state nurse practice acts and moved beyond the intermediary role of implementing physicians orders. NP practice heightened professional accountability and authority, escalating the shift away from physicians sole control over patient care. The expansion of autonomy with advanced practice involved risk taking to push professional limits and often resulted in rejection (Christman, 1992; Woodrow & Bell, 1971). Understandably however, the emergence of an unknown and poorly defined role, sometimes overlapping with roles of physicians, triggered skepticism and misunderstanding within and between professions. As nurses in advanced practice continue to struggle for autonomy, the salience for the profession remains (Dempster, 1994; Gilliss, 1996). Many NPs throughout the US continue to face legal barriers that restrict autonomous practice (Pruitt et al., 2002; Safriet, 2002). These restrictions raise important yet politically sensitive issues. For some NPs these barriers serve as a call to action similar to the responses of the pioneers in this study. NPs in more legally dependent relationships may be concerned about the repercussions of seeking full autonomy. Other NPs, comfortable with their situations, might view autonomy as a threat to collaborative practice rather than a foundation for it. Professional autonomy and collaborative practice are not mutually exclusive. Brush & Capezuti (1997) emphasized that NPs and physicians have distinct but overlapping areas of clinical practice. The pioneer NPs also emphasized that autonomy served as the basis for them to create collegial rather than adversarial relationships with physicians. Professionals with autonomous control of their practice can more effectively engage in peer level consultation. Resistance to change remains a common challenge in the implementation and survival of advanced practice roles. As Safriet (1992) emphasized, [Professional] ability cannot be demonstrated if practice is restrained. Advanced practice nurses can and should create a unified response to address the internal and external threats to autonomous practice while continuing to foster collegial relationships with practitioners in other disciplines. Themes about obstacles and sources of satisfaction for pioneer NP practice also were consistent with other reports. The data theme, encountering obstacles, elaborates on other work describing resistance to the NP role (Bigbee, 1996; Campbell, 1998; Doyle & Neurer, 1983; Draye & Brown, 2000). The findings show how small but significant actions, such as omitting NP names from office rosters, undermine autonomy. Consequently, attending to the day-to-day work environment, where much of the resistance occurs in these seemingly small acts of exclusion, is important.

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In addition to the significant obstacles reported in this study, pioneers also identified two important sources of satisfaction that sustained their commitment to the role over time: relishing intimacy and making a difference. The experience of relishing intimacy is consistent with Murray and Zentners (2001) assertion that Communication is the heart of the nursing process and health care ( p. 187) as well as the literature describing the centrality of relationships in womens lives (Gilligan, 1982; Kaplan, 1991; Miller, 1987). Given the high value placed on the relational aspect of the role, the findings that mutuality, shared decision-making, and personal connections were hallmarks of NP practice and job satisfaction were not surprising. The data further showed that these relationships were satisfying for patients and were a foundation for consumer satisfaction with NPs. Replication of this study with other advanced practice specialties is indicated. Information about day-to-day, indepth experiences with other advanced practice roles would provide a more complete understanding of the evolution of autonomy in the profession. Another contemporary outgrowth of this study would be an analysis of the organizational variables that constrain or facilitate NP autonomy in the practice setting. Finally, the results of this study are relevant not only for nursing in the US, but they also have particular salience for countries in which nurses are currently developing advanced practice nursing. Although cultural variations exist, these data offer anticipatory guidance that might be useful in addressing the difficulties inherent in pioneering new roles. Moreover, the findings indicate the importance of autonomy in practice for NPs to make a difference for patients.

Conclusions
Pioneers indicated that autonomy enabled them to use their expertise to develop a relationship-focused practice style through which they could enhance the lives and health of their patients. Meaningful relationships with patients and the experience of making a difference were necessary components of practitioner satisfaction. To retain advanced practice nurses, institutional leaders need to create an organizational culture that preserves the opportunity for these sources of satisfaction.
References American Academy of Pediatrics Policy Statement. (2003). Scope of practice issues in the delivery of pediatric health care [Electronic Version]. Pediatrics, 111(2), 426-435. Area Health Education Centers Program, Oregon Health Workforce Project. (2001). Composition and characteristics of Oregons health workforce: A comparison of six health professions. Retrieved March 4, 2003, from http://www.ohsu.edu/ahec/research/compare.pdf Bigbee, J.L., & Amidi-Nouri, A. (2000). History and evolution of advanced nursing practice. In A. Hamric, J. Spross, & C. Hanson (Eds.), Advanced nursing practice: An integrative approach (2nd ed., pp. 3-32). Philadelphia: Saunders. Brush, B.L., & Capezuti, E.A. (1997). Professional autonomy essential for nurse practitioner survival in the 21st century. Journal of American Academy of Nurse Practitioners, 9(6), 265-270.

Brykczynski, K. (2000). Role of the nurse practitioner in primary health care. In P. Meredith & N. Hogan (Eds.), Adult primary care (pp. 3-25). Philadelphia: Saunders. Campbell, L. (1998). The wisdom of the willow: Capturing the spirit of the nurse practitioner, nursing in the new millennium (Vol. I). Littleton, CO: The Inside Story Multimedia Publications. Charmaz, K. (2000). Grounded theory: Objectivist and constructive methods. In N. Denzin & Y. Lincoln (Eds.), Handbook of qualitative research (pp. 509-536). Thousand Oaks, CA: Sage. Christman, L. (1992). Advanced nursing practice: future of clinical nurse specialists. In L. Aiken & C. Fagin (Eds.), Charting nursings future: Agenda for the 1990s (pp. 108-120). New York: Lippincott. Davis, F. (1966). The nursing profession. New York: Wiley & Sons. Dempster, J. (1994). Autonomy: a professional issue of concern for nurse practitioners. Nurse Practitioner Forum, 5(4), 227-232. Doyle, E., & Neurer, J. (1983). Missouri legislation and litigation: Practicing medicine without a license. The Nurse Practitioner, 8, 4144. Draye, M., & Brown, M. (2000). Surviving the proving ground: Lessons in change from pioneer nurse practitioners. The Nurse Practitioner, 25(10), 1-8. Draye, M., & Pesznecker, B. (1979). Diagnostic scope and certainty: An analysis of FNP practice. The Nurse Practitioner, 4(1), 15, 42-43. Gilligan, C. (1982). In a different voice: Psychological theory and womens development. Cambridge, MA: Harvard University Press. Gilliss, C. (1996). Education for advanced practice nursing. In J. Hickey, R. Ouimette, & S. Venegoni (Eds.), Advanced practice nursing: Changing roles and clinical applications. New York: Lippincott. Glaser, B., & Strauss, A. (1967). The discovery of grounded theory. New York: Aldine de Gruyter. Horrocks, S., Anderson, E., & Salisbury, C. (2002, April 6) Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. British Medical Journal, 324, 819823. Kaplan, A. (1991). Womens growth in connection: Writings from the Stone Center. Wellesley, MA: The Stone Center. Kaplan, L., & Brown, M.A. (2002) Prescribing practice barriers for advanced registered nurse practitioners. Paper presented at Annual Pacific Northwest Conference in Acute and Primary Care, Seattle, Washington. Kommenich, P. (1998). The evolution of advanced practice nursing. In C. Sheehy & M. McCarthy (Eds.), Advanced practice nursing: emphasizing common roles. Philadelphia: FA Davis. Mezey, M.D., & McGivern, D.O. (1993). Nurses, nurse practitioners: Evolution to advanced practice. New York: Springer. Miller, J. (1987). Toward a new psychology of women. Boston: Beacon Press. Mundinger, M.O. (2000). Primary care outcomes in patients treated by nurse practitioners: A randomized trial. Journal of the American Medical Association, 283(1), 59-68. Murray, R.B., & Zentner, J.P. (2001). Health promotion strategies through the lifespan (7th ed.). Upper Saddle River, NJ: Prentice Hall. Office of Technology Assessment. (1986). Nurse practitioners, physicians assistants and certified nurse midwives policy analysis. Washington, DC: U.S. Government Printing Office. Pruitt, R., Wetsel, R.H., Smith, K.J., & Spitler, H. (2002) How do we pass NP autonomy legislation? The Nurse Practitioner, 27(3) 56-65. Safriet, B. (1992). Health care dollars and regulatory sense: the role of advanced practice nursing. Yale Journal of Regulation, 9, 417-487. Safriet, B. (2002) Closing the gap between can and may in health care providers scope of practice: A primer for policy makers. Yale Journal of Regulation, 19, 301-309. Strauss, A., & Corbin, J. (1998). Basics of qualitative research: Techniques and procedures for developing grounded theory. Thousand Oaks, CA: Sage. Webster, M. (1996). Websters encyclopedic unabridged dictionary. New York: Random House. Woodrow, M., & Bell, J. (1971). Clinical specialization: Conflict between reality and theory. Journal of Nursing Administration, 1, 23-27.

Journal of Nursing Scholarship

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