Paving the Way

Responding to a Health Care Crisis: The NP Program that Blazed the Trail for CANP

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

By Celia Johnson
CANP Correspondent

As we continue to celebrate the 40th anniversary of the California Association for Nurse Practitioners, let’s look back to the program that paved the way for it all.

In 1977, a group of UC Davis students founded the California Coalition of Nurse Practitioners (which later became known as the California Association for Nurse Practitioners). They’d just graduated from UC Davis’s family nurse practitioner program, which was, in fact, the second of its kind in the country (the first NP program was a pediatric one in Colorado). To get that program off the ground and keep it running was no small feat. It took a mixture of courage, creativity, and stealth, along with a steadfast sense of humor.

Among the central figures were three people who each played different but important roles in establishing and sustaining UC Davis’s nurse practitioner program: founder, director, and faculty member Mary O’Hara-Devereaux, FNP, Ph.D; faculty member, and later director, Janet Mentink, FNP; and student affairs coordinator, and later faculty member, Lynda White, PA.

Launching the FNP Program

The program was founded in the late ‘60s. O’Hara-Devereaux had been working as a basic science researcher in the Veterinary School at UC Davis around that time. She was also the Director of Allied Health in the Department of Rehabilitation Medicine. She was volunteering, too, helping staff clinics for migrant workers in the Central Valley. She was recruited by Director of Student Health Services Dr. John Loofborough, who worked closely with Cesar Chavez. Dr. Loofborough was having trouble finding doctors to provide medical services. O’Hara-Devereaux's volunteer work included being trained by Dr. Loofborough to diagnose and treat common medical problems, although they both knew it was illegal. Within eight weeks of volunteering with him, she was seeing patients as an “FNP” with little consultation. “I realized that nurses, with a little more training and a change of mindset, could do so much more, and faster, to solve the primary health care crisis than physicians alone,” she says. 

The medical school at UC Davis was new. It had been created to focus on solving California’s dismal lack of primary care. O’Hara-Devereaux sought to launch a family nurse practitioner program in the new medical school. To be successful, the idea needed to have physicians involved collaboratively, to practice and to teach. Dr. William M. Fowler, Jr., who served as Chairman of the Department of Rehabilitation at UC Davis, where O’Hara-Devereaux was Director of Allied Health Services, supported the idea of NPs. It was a natural fit, actually, because a lot of non-physicians are involved with rehabilitation. Early on, there was a brief collaboration with the School of Public Health at UC Berkeley. The first-year students also got an MPH. The School of Nursing at UC San Francisco was approached as a collaborator, but they refused. The idea of nurses “becoming mini-doctors” was not looked on as progressive. 

The nurse practitioner program remained in the Department of Rehabilitation until 1970. Then they moved over to UC Davis’ newly launched Family Medicine Department, which was led by Dr. Hughes Andrus. He was an early supporter of nurse practitioners and physician assistants, and a leader nationally in primary health care. As the program grew and evolved under O’Hara-Devereaux’s and Andrus’s leadership, there was one overarching goal: to solve the primary health care crisis by training family nurse practitioners and physicians assistants to practice collaboratively, often remotely, with physicians in medically underserved areas.  

Opponents on All Sides

No one could argue against the need for more primary care practitioners in California, and still, as it went with this innovative and unorthodox profession, O’Hara-Devereaux faced a great deal of resistance against the FNP program. She recalls, “It was really amazing that it ever got started, because so many health professions, including physicians were so against it, including the nurses. I had as many nurses furious at me for starting the family nurse practitioner program as I did physicians. They were telling me that I’m not a nurse and that I’m violating the profession. There was opposition on all corners.”

Opponents questioned the legality of nurse practitioners. Letters were sent out to physicians, ordering them to cease and desist training NPs. Thankfully, not all physicians took the orders seriously, particularly those in underserved areas. Janet Mentink was training as an NP with a physician who offered a simple and colorful response to the letter. He said, “Who gives a f… !” That spirit of rebellion was essential, it seems, in those early days. Mentink’s husband, who was a police captain, warned her against joining a potentially illegal profession. She recalls, chuckling, “He said you’re going to get arrested!”

O’Hara-Devereaux took matters of legality up with the government. She notes, “We were illegal and people were after us, until we cut a deal with Senator (Alfred) Song to do an Experimental Health Manpower Act. It allowed us to practice with NPs and PAs under medical supervision” (this act passed in 1972). This was the first of several legislative acts that were completed to provide permanent support. 

Up and Running

Once the Department of Family Medicine was launched, they shifted the focus of the program. In order to fulfill the purpose of solving the primary health care crisis, they opened the program to all nurses. It was no longer just a Master’s program; they also enrolled non-degree and Bachelor’s degree students. 

O’Hara-Devereaux began to seek foundation funding in 1970 and was successful. The first grant was from the Robert Wood Johnson Foundation and it included funding for airplanes to fly nurses to Davis to attend training, from the Oregon border to Kern County. Each nurse had to have a physician preceptor. The program ran for 18 months and included substantial clinical training. Didactic training took place one a month.

In 1972, they admitted non-baccalaureate nurses. They did want to offer Master’s degrees to FNPs. That meant creating a Master’s degree at UC Davis that didn’t exist before, which is typically a slow and laborious process.  

O’Hara-Devereaux moved quickly to persuade the Dean of Graduate Studies and the top administration in the Chancellors Office to create a new Master of Health Services for the program. Armed with foundation funding, she gave a convincing argument. The first MHS degrees were awarded in 1972. The program had two separate didactic tracks for Master’s and non-Master’s students. This simply meant additional classes for the Master’s students.  

O’Hara-Devereux also secured several faculty positions for the Department of Family Medicine. The decision-makers at the university saw the importance of the FNP program. It fit with the mission of the university. So they quickly reduced preexisting barriers. 

It’s worth pausing to list some of the key people who helped shape the program in its early years. Dr Andrus, the Chair of Family Medicine at UC Davis, lived and practiced in King City (Monterey County). He came from a rural place, so he naturally supported the idea of training people who were willing to provide primary health care in those underserved areas. His work became a model nationally for primary health care and family medicine. In 1972, O’Hara-Devereaux graduated from the program while leading it. In 1974, Mentink, Leona Judson, FNP, Elaine Chaykin, FNP, and Pat Joslin, FNP, graduated from the program, while serving as pioneering faculty members of the Department of Family Medicine at UC Davis. Physicians were critical faculty members, and they included Jane Halpern and Ron Singler in the early years. Later, in 1975, Walt Morgan, MD, joined as medical director. Lynda White, PA, became student affairs coordinator that same year. She later joined the faculty, in 1978, and became associate director in 1994, overseeing the PA training. Joann Trolinger, FNP, joined the faculty in 1977. Shelly Stewart joined the faculty in 1980. Many of the people in this core group stayed on for a long time, some for decades, each one helping overcome the many obstacles that lay ahead.

Reaching the Underserved

One of the biggest hurdles, beyond ongoing opposition from the political, medical, and nursing communities, was getting NPs to work and stay in rural towns. This was part of the central mission of the program, to deliver primary health care to underserved areas. Students from the city weren’t likely to move out to the country. As a solution, the program established preceptorships, or training sites, in rural locations, so that students could train there, and come into UC Davis once a week, or once a month, depending on where they were located. White recalls, “They developed these satellites. We had multiple sites all over the state where we trained nurse practitioners. We were finally approved by the American Medical Association's Committee on Allied Health Education and Accreditation (CAHEA) years later.”

Mentink spent many years on the road, recruiting students and physicians, and teaching at those satellites. It wasn’t unusual for her to drive over 30,000 miles a year. She joined the program after chatting with O’Hara-Devereaux (like many other talented candidates, it seems, including White). Mentink says, “We were in family medicine, which was a new discipline. We were looked down on because everyone else was specialized. There was a bit of a push for primary care, but it wasn’t popular with medicine. My nurse colleagues said, ‘Oh my god, what are you doing?’ They called me crazy.” But Mentink loved the work and, despite any original fears, grew to enjoy her expeditions.

Mentink was in charge of Northern California. “You had to work the community to get preceptors. There was a real art to it. It took me a while to figure it out. You can’t ship somebody from someplace else into Hoopa. It was to be a local person who they respect,” she recalls. Mentink spent a great deal of time working at the Hoopa Valley Indian Reservation in Humboldt County. She drove across mountain ranges in all seasons, visiting reservations and small towns.

On one trip, she took a physician with her to a tiny town called Happy Camp in Siskiyou County. They arrived four hours late. “Oh my god,” she recalls, “About half the town was waiting for us to get there.” There had been an accident involving people who were in the back of a truck. They hadn’t called anyone. They were waiting for Mentink and her companion. They assumed the physician would know what to do, but she was a pediatrician. Mentink notes, “Everyone was looking at the physician and she didn’t know squat. So it was up to me.”

In order for the UC Davis NP program to work, they needed to convince local physicians to become preceptors. Physicians, though, were resistant at first. White notes, “We had a full-time community developer who would go out and talk to physicians about training, telling them that it was going to be a partnership.” It didn’t help, either, that many people, including physicians, simply didn’t understand this new NP field. Also, a few catastrophes in the ER didn’t help. A few specialty NPs, who had trained elsewhere, made some big mistakes, and it damaged the public image of this new profession. Even though they hadn’t graduated from UC Davis, the university still had to handle the fallout. O’Hara-Devereaux notes, “I had every hospital administrator calling me as though it was my fault. I was saying, ‘Oh my god, did you check their credentials? You can’t put a pediatric NP in the ER!’ The physician thought they were all alike!”

Over time, physicians grew more comfortable with the NPs, in part due to the programming at UC Davis, with its in-depth clinical training. White says, “Those of us on the faculty then worked clinically in the residency programs, so the residents got used to us. We were in co-practice with them, and many of them went on to train and hire students.” FNP faculty who taught in Sacramento worked at the UC Davis Medical Center and Family Practice Clinic.

Innovative Curriculum and Programming

Typically, when you launch a new program in a university, you can model the curriculum on what others have done in the past. However, if you’re a pioneer, you have to create a curriculum, basically from scratch. O’Hara-Devereaux and the faculty had to figure out what to test and how to do it. White notes, “Mary did an incredible job putting this all together in a way that made it all ultimately work. She was the brains behind it. She knew what it would take to make these things happen.”

The curriculum evolved along the way, which is a nod, too, to one of the primary reasons why the program was successful. There was a consistent willingness from those involved to adapt, improve, and improvise. Mentink observes, “I got pretty creative myself, and that was kind of the fun of it. We had not only the medical establishment, but also the nursing establishment, who really were not for it. We had to make it work in the schools of medicine and the universities.”

In 1977, UC Davis and the Stanford Primary Care Associate Program joined forces. PAs registered at Stanford and FNPs registered at Davis. O’Hara-Devereaux and Virginia Fowkes, then director of the PA program at Stanford, were the masterminds behind this collaboration, and it was a true innovation. PAs studied at the satellites, and sometimes had the same curriculum as the NPs. Generally, the NPs had more clinical experience than the PAs coming into the program. White noticed that the more hands-on patient care that people had coming into the program, the more easily they absorbed the material. She says, “I think the ones who did the best were previously medical assistants in internal medicine or family practice, where they saw a broad spectrum of things. They had context for the things we were studying.”

One advantage for UC Davis NPs who came from this collaboration was that they could become doubly credentialed as PAs. This gave them broader opportunity, as PAs in some areas had more latitude for practice. All they had to do was put in the clinical hours required of the PA and attend a class on professional development for PAs. The program ran for a limited time, from 1977 to 1980, with funding from a Robert Wood Johnson Grant. After that three-year period, they were able to use what they’d learned to incorporate different tracks at both schools (NPs at Stanford and PAs at UC Davis).

In 1972, White shared a lab at with O’Hara-Devereaux. White left for a year, and when she came back she wasn’t working. She couldn’t find a lab that was a good fit. O’Hara-Devereaux said to her, “You can’t do nothing. You’ve got to come in here and see if you like it.” So, White joined the NP program at UC Davis as coordinator of student affairs. White recalls, “I thought, I’ll do this until I find a research position, but once I was there for just a few months, I realized I liked dealing with the students, the faculty, and the administration. It was much better than the isolation of the lab.”

When White came on as student affairs coordinator in 1975, they hadn’t been able to qualify the program as a certificate program. Ideally, students without a bachelor’s degree would receive a certificate. To get official certificates would mean jumping through many hoops. So White decided, she recalls, “I’m not going to do it that way. I went over to Medical Illustration and had them print up a bunch of certificates.” There were no dead ends, it seems, for the faculty and administration of this new program.

Always Remembering to Laugh

One common thread among all those interviewed for this series has become apparent through the course of those interviews: they are all fun-loving. The work was hard. They had to make things up as they went along. But it was also fun.

White recalls how she and other faculty from UC Davis and Stanford, went down to Esalen, a retreat center, to learn about teaching behavioral science. O’Hara-Devereaux had put the Director of Esalen, Dr. Julian Silverman, on the faculty. He was a brilliant psychologist, and already on Stanford’s clinical faculty. White notes, of Esalen, “It is a counter-culture kind of place. They had steam baths, fed by hot springs, out on a cliff looking out over the ocean. People didn’t wear their bathing suits to go to those things.” White laughs as she tells about a fellow faculty member who went into the steam bath after much hesitation. But as this faculty member sat in there, the steam dissipated, and there was no way to discreetly leave. She sat there until she was faint, trying to figure out how to get out without everyone seeing her! And, of course, everyone thought it was hilarious.

Through hard work, determination, and laughter, the NP program at UC Davis helped legitimize the profession in California, and enabled NPs to deliver much-needed primary health care to people who desperately needed it. This program paved the way for the CANP, and for generations of NPs to follow.

O’Hara-Devereaux left UC Davis in the mid-eighties to lead a global primary health care program in the School of Medicine at the University of Hawaii, with noted primary care leader Dr. Richard Smith. The program was supported by many foundations worldwide. Their goal was to create family nurse practitioner programs, like the once she launched at UC Davis, in underdeveloped countries around the globe. She stayed there for ten years and worked in many different countries. She went on to become an economic forecaster in Silicon Valley and ultimately founded her own company, Global Foresight.

She notes today, “I actually thought we would get someplace and transform health care. It became clear to me at the beginning of the 90’s that we weren’t going to make it, that we had really tried hard to turn the tide and we weren’t winning the war.” In 2017, she points out, we have worse access to health care than the 1970s, in addition to excessive specialization.

Wherever we stand today, with all of the challenges that face the health care field, it is worth celebrating the visionary people who sought out big solutions years ago, and whose contributions continue to inspire change.