History in the Making

40 Years Ago, a Group of Pioneering Nurse Practitioners Looked Ahead

This article originally appeared in the September, 2017 edition of Connections

By Celia Johnson
CANP Correspondent

In June 1977, shortly after receiving their master’s degrees from U.C. Davis, a group of newly minted nurse practitioners gathered at a pool party. They were there to celebrate graduation, but rather than look back, they decided to focus on the road ahead. Except that road didn’t exist. They were taking on a role in the nursing/medical profession that had yet to be defined, and they faced resistance on many fronts. Founding member and U.C. Davis graduate Jennifer Hasselbach recalled, “We were sitting around at this pool party and decided there ought to be an organization for nurse practitioners.”

The idea for the California Coalition of Nurse Practitioners (now the California Association for Nurse Practitioners) sprung up poolside, but it had been germinating on campus for some time. The CCNP founders were part of a relatively new nurse practitioner program, launched in 1970 at U.C. Davis and supported primarily by federal funds. In 1973, Hughes Andrus, the original chair of the family practice department, helped secure a Robert Wood Johnson grant for $1.2 million. This grant significantly expanded the NP program, with a new directive to train people from rural areas of central and northern California. Mary Fenley (O’Hara-Devereaux) and Andrus were co-directors of the program at that time (they later married).

The CCNP founders graduated from U.C. Davis four years after the university received the Robert Wood Johnson grant. Ferd Mitchell was their main lecturer and an important instigator. “Ferd was a true inspiration. He encouraged everybody. It was out of the masters’ degree curriculum that we (CCNP) forged ahead,” noted Mary Margaret Baker, a U.C. Davis graduate, pool partygoer, and founding member. Andrus and Fenley were both staunch advocates of the group.

Five months after that pool party, the California Coalition of Nurse Practitioners became a reality.

In October, Baker had just returned from three months in Mexico. She’d barely adjusted to life back in California. She certainly didn’t expect to take on a new leadership role. A group of around 35 nurse practitioners had assembled October 8 for the first official meeting of CCNP, right back on the U.C. Davis campus. When it came time to elect a chairperson, there was no vote. Baker was nominated with unanimous support from the group. She accepted. Speaking about the surprise role, Baker recalled, “I take on a task and move forward.” And she did, without breaking stride. Just five short months later, CCNP hosted its first conference in Monterey.

The conference was a natural next step. The goal of CCNP was to bring together nurse practitioners from all over the state so that together they could initiate change. In fact, though the organization is now known as the California Association for Nurse Practitioners, the word “Coalition” was selected deliberately in those early days. At that time NPs identified strongly with their own group. “We didn’t want to offend anyone,” noted Baker. A coalition meant that any group – pediatric, family, and so on – could join. Founding member Shelly Stewart remembers those early years fondly. She observed, “We knew we were stronger together.” She added, “At the time nurse practitioners were seen as being "different,” sort of stepping out of the mold, and as such did not readily buy into joining or conforming. We were different and had to acknowledge those differences.”

It takes an overwhelming amount of work to pull off a successful conference, and it’s an even bigger challenge if you’re working from the ground up. First you need to galvanize the people you want to attend. This was the age of letters, and much of the early work of CCNP involved stuffing envelopes in someone’s living room. Baker assembled mailing lists from the California Nurses Association (CNA) and every other nurses group willing to share their list. UC Davis graduate Fiona Shannon was a key founding member of the group. She was there every step of the way, as Baker noted, “working tirelessly with me and the Sacramento group to get the first meetings, in 1977 and 1978, off the ground.”

CCNP hosted its first conference March 1978, in Monterey. Hasselbach was the CCNP Conference Chair in 1986, and she attended every conference from the beginning until 2002. Of the conference work in those early years, she said, “It was tough. We did it all. We’d get a small group together, and we were all working full time and trying to do this on the side.” And, if the planning wasn’t arduous enough, it was all done on a very tight budget. Baker recalls counting coffee pots at a hotel at one of the first conferences. She suspected that hotels padded their bills. Every pot cost around $15. Sure enough, the hotel charged for an extra 25 or so pots. Every penny counted!

The CCNP conferences moved from city to city and drew nurse practitioners from all over the state. Attendance didn’t always meet expectations. Many were disappointed when just 100 people showed up to one of the early conferences. U.C. Davis Doctor Walt Morgan offered sage advice, though, telling them, “Think of it this way, at least you have 100 people.”

In its second year, the CCNP focused on creating a legislative presence. “We were going through a lot of language with the BRN (California Board of Registered Nursing) on what is a nurse practitioner and how do we get qualifications. It was a really big thing at the time,” said Baker. NPs registering through the BRN, otherwise known as “holding out,” finally went through a few years later, when Donna Cannady was chairperson of CCNP, due to the continued efforts of the organization. Hasselbach recalls putting up a picture of herself in her office with a sign right beside it explaining what a nurse practitioner was. “That’s how it was at the time,” she said.

CCNP recruited lobbyists to help pursue their interests. They also became actively involved in politics. Fenley lobbied heavily and gave testimony to push for NPs to receive Medi-Cal reimbursement at 100 percent of the M.D. rate. It was a critical issue for NPs back then. In 1977 a California Health Manpower Policy Commission report stated, “The Commission is concerned that one barrier to proper utilization of primary care physician's assistants and primary care nurse practitioners in California is the lack of reimbursement for their services by the State's Medi-Cal program.” That same year, in December, President Carter signed a federal law that signaled promising change. The law stated that certified health clinics in rural California with NPs and Physician Assistant’s should receive reimbursement from Medicare and Medi-Cal.

Facing stubborn officials and bureaucracy, resourceful NPs soon realized that, if they couldn’t beat the government, they’d need to join it.

Elinor Peters became a member of CCNP in 1978, as a student at U.C. Davis, and she has been involved in the organization ever since. On attending a CCNP conference as a fledgling nurse practitioner, she observed: “The experience and connection with other NP leaders was so inspirational. I later went on to emulate those leaders by becoming legislative representative for the greater L.A. area/region.”

Peters remembers how difficult it was to alter the existing medical structure. She noted, “The California Medical Association fought us on all legislation. My first disappointment was when we were defeated on prescribing privileges.” Prescriptions were a major hurdle for NPs at the time. The CNA supported this move and put their weight behind it. NP early member Shari Kovner recalled treating an influx of patients who’d arrived from Vietnam. She’d have to hand over stacks of prescriptions for doctors to sign. Ultimately, prescribing privileges were, in 1986, under AB 4372, as Peters put it, “watered down to Furnishing License with its limitation.” Despite the loss, Peters was still somewhat satisfied. She said, “I was so glad to write my own prescriptions that it didn’t matter what the license was called.”

In the early years of CCNP, the members created a solid foundation. They launched a CCNP newsletter, so that members could stay on top of pressing issues. They drew up a phone tree, so that they could efficiently spread the word whenever they needed to approach the government about pending legislation as a united force.

CCNP offered NPs important support at the time. They recruited lawyers, who offered professional advice to members. Later, they offered members insurance. Michael Loughran, CEO of NSO (Nurses Service Organization), has helped NPs in the organization navigate insurance for decades.

Despite seemingly insurmountable odds, forty years later, the California Association for Nurse Practitioners is thriving. What began as an idea at a pool party is now an important mainstay, all because a group of pioneering NPs stuck with it. And they couldn’t have done it without champions at U.C. Davis and from other professional fields.