INTRODUCTION

It is an extraordinary opportunity to be able to evaluate one's personal legacy in the context of our professional journey. In 2014, we celebrated the creation of the role of the nurse practitioner (NP), which began with Loretta Ford's vision for the pediatric NP (PNP). The purpose of this review is to describe the evolution of the NP role and discuss this history in the context of the development of the pediatric surgical NP role. In so doing, there will be an opportunity to recognize the importance of mentoring and advocacy.

The first PNP program was created in 1965 as a certificate program to meet the needs of the underserved in pediatrics. In 1967, Boston College initiated one of the first Master's degree programs. In 1973, the National Association of Pediatric Nurse Practitioners was created. By 1980, there were more than 200 NP programs and 15,000-20,000 NPs practicing in the United States. In 1985, the American Academy of Nurse Practitioners was created, and by 1999, 90% of the NP programs prepared students at the MS or post-Master's certificate level. In 2010, Advanced Practice Registered Nurse (APRN) organizations met with the White House Office of Health Reform to provide a voice to inform our government leaders about primary care, quality and safety, payment, and the need to recognize all providers as solutions to this health care crisis. In 2013, the American Academy of Nurse Practitioners and the American College of Nurse Practitioners combined to create the largest membership organization for NPs of all specialties. Today, there are 56,000 NPs practicing in the United States.

Over the last 50 years, PNPs advocated for the needs of children who did not have primary care access, mostly in low-income and rural areas. This trend continues. It is estimated that there will be a shortage of 50,000 physicians during a time when the NP work force continues to flourish. The NP workforce is expected to increase expected to increase by 94%, increasing by 6,000-7,000 NPs per year. Has the time come for NPs to be fully recognized as the primary profession to provide health care to Americans? Even as we get full practice authority in 23 states, there are still barriers to providing care. Most states still require a physician signature for home health care (skilled nursing visits), hospice care (despite that NPs can declare death and sign advanced directives), provide palliative care and to order durable medical equipment, postdischarge care and medical home care coordination. Who is better to provide this level of complex coordination? Other barriers to full practice include needing to ask physicians who are not actively involved in the care the care to authorize services for patients whom they don't know. Finally, payer policies need to support NP independent practices. Other barriers include lack of full practice authority, non NP-centric language in the Centers for Medicare and Medicaid Services (CMS) regulations, and a lack of business, billing and coding expertise. Insurance companies must credential and authorize NPs as primary care providers.

Currently, PNPs earn the highest salaries in the United States are in Texas and the northeast. Acute care PNPs are most highly utilized in Texas, Pennsylvania, and North Carolina. The top five areas of PNP practice include critical care, emergency department, cardiology, hematology/oncology, and general surgery.

During this same time historically, pediatric nurses and NPs who were committed to the care of children undergoing surgery began a journey of advocacy and legacy. The American Pediatric Surgical Nurses Association (APSNA) was started in 1991 when 17 nurses met during the American Pediatric Surgical Association meeting. Each year, APSNA has grown to new heights, boasts over 500 members, has published three textbooks, and has an online peer-reviewed journal. The list of accomplishments is endless. This organization has created a springboard for advocacy and mentorship. It is our legacy. APSNA exists to provide and share knowledge, ideas, evidence, and understanding to those who care for children with surgical diagnoses and to provide a community to those who are committed to this care. This is the purpose of our legacy: to contribute. Our daily work is forged by commitment to the care and love of children and their families. Our call to mentoring welcomes new colleagues, builds relationships, and invites innovation and change. As we advocate for the population and the role, I encourage you to love what we do and to be passionate about the work, the children and their families, and the role we play in their lives. I challenge you to inspire mentoring in the workplace and, in so doing, to create a legacy.

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