essentials for role development

AdvAnced PrActice nursing

essentials for role development

F o u r t h E d i t i o n

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AdvAnced PrActice nursing

essentials for role development F o u r t h E d i t i o n

Lucille A. Joel, edd, APn, FAAn Distinguished Professor

Rutgers, The State University of New Jersey School of Nursing, New Brunswick–Newark, New Jersey

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Library of Congress Cataloging-in-Publication Data

Names: Joel, Lucille A., editor. Title: Advanced practice nursing : essentials for role development / [edited by] Lucille A. Joel, EdD, APN, FAAN, Distinguished Professor, Rutgers, The State University of New Jersey, School of Nursing, New Brunswick-Newark, New Jersey. Description: Fourth edition. | Philadelphia, PA : F.A. Davis Company, [2018] | Includes bibliographical references and index. Identifiers: LCCN 2017023590 | ISBN 9780803660441 Classification: LCC RT82.8 .J64 2018 | DDC 610.7306/92–dc23 LC record available at https://lccn.loc. gov/2017023590

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v

Preface

The content of this text was identified only after a careful review of the documents that shape both the advanced practice nursing role and the educational programs that prepare these individuals for practice. That review allowed some decisions about topics that were essential to all advanced practice nurses (APNs)*, whereas others were excluded because they are traditionally introduced during baccalaureate studies. This text is written for the graduate-level student in advanced practice and is intended to address the nonclinical aspects of the role.

Unit 1 explores The Evolution of Advanced Practice from the historical perspective of each of the specialties: the clinical nurse-midwife (CNM), nurse anesthetist (NA), clinical nurse specialist (CNS), and nurse practitioner (NP). This historical background moves to a contemporary focus with the introduction of the many and varied hybrids of these roles that have appeared over time. These dramatic changes in practice have been a response to societal need. Adjustment to these changes is possible only from the kaleidoscopic view that theory allows. Skill acquisition, socialization, and adjustment to stress and strain are theoretical constructs and processes that will challenge the occupants of these roles many times over the course of a career, but coping can be taught and learned. Our accommodation to change is further challenged as we realize that advanced practice is neither unique to North America nor new on the global stage. Advanced practice roles, although accompanied by varied educational require- ments and practice opportunities, are well embedded and highly respected in international culture. In the United States, education for advanced practice had become well

stabilized at the master’s degree level. This is no longer true. The story of our recent transition to doctoral preparation is laid before us with the subsequent issues this creates.

The Practice Environment, the topic of Unit 2, dra- matically affects the care we give. With the addition of medical diagnosis and prescribing to the advanced practice repertoire, we became competitive with other disciplines, deserving the rights of reimbursement, prescriptive author- ity, clinical privileges, and participation as members on health plan panels. There is the further responsibility to understand budgeting and material resource management, as well as the nature of different collaborative, responding, and reporting relationships. The APN often provides care within a mediated role, working through other profession- als, including nurses, to improve the human condition.

Competency in Advanced Practice, the topic of Unit 3, demands an incisive mind capable of the highest order of critical thinking. This cognitive skill becomes refined as the subroles for practice emerge. The APN is ultimately a direct caregiver, client advocate, teacher, consultant, researcher, and case manager. The APN’s forte is to coach individuals and populations so that they may take control of their own health in their own way, ideally even seeing chronic disease as a new trajectory of wellness. The APN’s clients are as diverse as the many ethnicities of the U.S. public, and the challenge is often to learn from them, taking care to do no harm. The APN’s therapeutic modalities go beyond traditional Western medicine, reaching into the realm of complementary therapies and integrative health-care practices that have become expected by many consumers. Any or all of these role competencies are potential areas for conflict, needing to be understood, managed, and resolved in the best interests of the client. Some of the most pressing issues confronting APNs today are how to mobilize informational technology in the service of the client, securing visibility for their work, and thinking

*Please note that the terms advanced practice nurse (APn) and advanced practice registered nurse (APrn) are used interchangeably in this text according to the author’s choice.

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vi PrEFacE

through publication. The chapters in this section aim to introduce these competencies, not to provide closure on any one topic; the art of direct care in specialty practice is not broached.

When you have completed your course of studies, you will have many choices to make. There are opportunities to pursue your practice as an employee, an employer, or an independent contractor. Each holds different rights and responsibilities. Each demands Ethical, Legal, and Business Acumen, which is covered in Unit 4. Each requires you to prove the value you hold for your clients and for the systems in which you work. Cost efficiency and therapeutic effectiveness cannot be dismissed lightly today. The nuts and

bolts of establishing a practice are detailed, and although these particulars apply directly to independent practice, they can be easily extrapolated to employee status. Finally, experts in the field discuss the legal and ethical dimensions of practice and how they uniquely apply to the role of the APN to ensure protection for ourselves and our clients.

This text has been carefully crafted based on over 40 years of experience in practice and teaching APNs. It substantially includes the nonclinical knowledge necessary to perform successfully in the APN role and raises the issues that still have to be resolved to leave this practice area better than we found it.

LuciLLe A. JoeL

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vii

Patricia DiFusco, MS, NP-C, FNP-BC, AAHIVS Nurse Practitioner SUNY Downstate Medical Center Brooklyn, New York

Caroline Doherty, AGACNP, AACC Advanced Senior Lecturer University of Pennsylvania School of Nursing Philadelphia, Pennsylvania

Carole Ann Drick, PhD, RN, AHN-BC President American Holistic Nurses Association Topeka, Kansas

Lynne M. Dunphy, PhD, APRN, FNP-BC, FAAN, FAANP Professor and Associate Dean for Practice

and Community Engagement Florida Atlantic University Christine E. Lynn College of Nursing Boca Raton, Florida

Denise Fessler, RN, MSN, CMAC Principal/CEO Fessler and Associates Healthcare Management Consulting, LLC Lancaster, Pennsylvania

Eileen Flaherty, RN, MBA, MPH Staff Specialist Massachusetts General Hospital Boston, Massachusetts

Cindy Aiena, MBA Executive Director of Finance Partners HealthCare/MGH Boston, Massachusetts

Judith Barberio, PhD, APNC Associate Clinical Professor Rutgers-The State University of New Jersey School of Nursing New Brunswick-Newark, New Jersey

Deborah Becker, PhD, ACNP, BC, CCNS Director, Adult Gerontology Acute Care Program University of Pennsylvania School of Nursing Philadelphia, Pennsylvania

Andrea Brassard, PhD, FNP-BC, FAANP Senior Strategic Policy Advisor Center to Champion Nursing in America at AARP Washington, District of Columbia

Edna Cadmus, RN, PhD, NEA-BC Clinical Professor and Speciality Director-Nursing

Leadership Program Executive Director NJCCN Rutgers-The State University of New Jersey School of Nursing New Brunswick-Newark, New Jersey

Ann H. Cary, PhD, MPH, FN, FNAP, FAAN Dean and Professor University of Missouri Kansas City, School of Nursing and Health Studies Kansas City, Missouri

contributors

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viii contributors

Phyllis Shanley Hansell, EdD, RN, FNAP, FAAN Professor Seton Hall University College of Nursing South Orange, New Jersey

Allyssa Harris, RN, PhD, WHNP-BC Helpant Professor William F. Connell School of Nursing Boston College Boston, Massachusetts

Gladys L. Husted, RN, PhD Professor Emeritus Duquesne University Pittsburgh, Pennsylvania

James H. Husted Independent Scholar Pittsburgh, Pennsylvania

Joseph Jennas, CRNA, MS Program Director Clinical Helpant Professor SUNY Downstate Medical Center Brooklyn, New York

Lucille A. Joel, EdD, APN, FAAN Distinguished Professor Rutgers-The State University of New Jersey School of Nursing New Brunswick-Newark New Jersey

Dorothy A. Jones, EdD, RNC-ANP, FAAN Professor, Boston College Connell School of Nursing Senior Nurse, Massachusetts General Hospital Boston, Massachusetts

David M. Keepnews, PhD, JD, RN, NEA-BC, FAAN Dean and Professor Long Island University (LIU) Brooklyn Harriet Rothkopf Heilbrunn School of Nursing Brooklyn, New York

Jane M. Flanagan, PhD, ANP-BC Associate Professor and Program Director Adult Gerontology Boston College Connell School of Nursing Chestnut Hill, Massachusetts

Rita Munley Gallagher, RN, PhD Nursing and Healthcare Consultant Washington, District of Columbia

Mary Masterson Germain, EdD, ANP-BC, FNAP, D.S. (Hon)

Professor Emeritus State University of New York–Downstate

Medical Center College of Nursing Brooklyn, New York

Kathleen M. Gialanella, JD, LLM, RN Law Offices Westfield, New Jersey Associate Adjunct Professor Teachers College, Columbia University New York, New York

Shirley Girouard, RN, PhD, FAAN Professor and Associate Dean State University of New York-Downstate

Medical Center College of Nursing Brooklyn, New York

Antigone Grasso, MBA Director Patient Care Services Management Systems

and Financial Performance Massachusetts General Hospital Boston, Massachusetts

Anna Green, RN, Crit Care Cert, MNP Project Manager Australian Red Cross Blood Service Melbourne, Australia

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contributors ix

Beth Quatrara, DNP, RN, CMSRN, ACNS-BC Advanced Practice Nurse–CNS University of Virginia Health System Charlottesville, Virginia

Kelly Reilly, MSN, RN, BC Director of Nursing Maimonides Medical Center Brooklyn, New York

Valerie Sabol, PhD, ACNP-BC, GNP-BC, ANEF, FAANP

Professor and Division Chair Healthcare in Adult Population Duke University School of Nursing Durham, North Carolina

Mary E. Samost, RN, MSN, DNP, CENP System Director Surgical Services Hallmark Health System Medford, Massachusetts

Madrean Schober, PhD, MSN, ANP, FAANP President Schober Global Healthcare Consulting International Indianapolis, Indiana

Robert Scoloveno, PhD, RN Director–Simulation Laboratories Helpant Professor Rutgers-The State University of New Jersey School of Nursing Camden, New Jersey

Carrie Scotto, RN, PhD Associate Professor The University of Akron College of Nursing Akron, Ohio

Dale Shaw, RN, DNP, ACNP-BC ACNP–Acute Care Neurosurgery University of Virginia Health System Charlottesville, Virginia

Alice F. Kuehn, RN, PhD, BC-FNP/GNP Associate Professor Emeritus University of Missouri-Columbia School of Nursing Columbia, Missouri Parish Nurse St. Peter Catholic Church Jefferson City, Missouri

Irene McEachen, RN, MSN, EdD Associate Professor Saint Peter’s University Division of Nursing Jersey City, New Jersey

Deborah C. Messecar, PhD, MPH, AGCNS-BC, RN Associate Professor Oregon Health and Science University School of Nursing Portland, Oregon

Patricia A. Murphy, PhD, APRN, FAAN Associate Professor Rutgers-The State University of New Jersey New Jersey Medical School Newark, New Jersey

Marilyn H. Oermann, RN, PhD, FAAN, ANEF Thelma Ingles Professor of Nursing Director of Assessment and Educational Research Duke University School of Nursing Durham, North Carolina

Marie-Eileen Onieal, PhD, MMHS, RN, CPNP, FAANP

Faculty, Doctor of Nursing Practice Rocky Mountain University of Health Professions Provo, Utah

David M. Price, MD, PhD Founding Faculty Center for Personalized Education of Physicians

(CDEP) Denver, Colorado

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x contributors

Caroline T. Torre, RN, MA, APN, FAANP Nursing Policy Consultant Princeton, New Jersey Formerly, Director, Regulatory Affairs New Jersey State Nurses Association Trenton, New Jersey

Jan Towers, PhD, NP-C, CRNP (FNP), FAANP Director of Health Policy Federal Government and Professional Affairs American Academy of Nurse Practitioners Washington, District of Columbia

Maria L. Vezina, RN, EdD, NEA-BC Chief Nursing Officer/Vice President, Nursing The Mount Sinai Hospital New York, New York

Benjamin A. Smallheer, PhD, RN, ACNP-BC, FNP-BC, CCRN, CNE

Helpant Professor of Nursing Duke University School of Nursing Durham, North Carolina

Thomas D. Smith, DNP, RN, NEA-BC, FAAN Chief Nursing Officer Maimonides Medical Center Brooklyn, New York

Mary C. Smolenski, MS, EdD, FNP, FAANP Independent Consultant Washington, District of Columbia

Shirley A. Smoyak, RN, PhD, FAAN Distinguished Professor Rutgers-The State University of New Jersey School of Nursing New Brunswick-Newark, New Jersey

Christine A. Tanner, RN, PhD, ANEF Professor Emerita Oregon Health and Science University Portland, Oregon

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xi

Sheila Grossman, PhD, APRN, FNP-BC, FAAN Professor and Coordinator Family Nurse Practitioner Program Fairfield University Fairfield, Connecticut

Elisabeth Jensen, RN, PhD Associate Professor School of Nursing York University Toronto, Ontario Canada

Linda E. Jensen, PhD, MN, RN Professor Graduate Nursing Clarkson College Omaha, Nebraska

Julie Ann Koch, DNP, RN, FNP-BC, FAANP Helpant Dean of Graduate Nursing DNP Program Coordinator Valparaiso University College of Nursing & Health

Professions Valparaiso, Indiana

Linda U. Krebs, RN, PhD, AOCN, FAAN Associate Professor University of Colorado Anschutz Medical Campus, College of Nursing Aurora, Colorado

Nancy Bittner, RN, PhD Associate Dean School of Nursing Science and Health Professions Regis College Weston, Massachusetts

Cynthia Bostick, PMHCNS-BC, PhD Lecturer California State University Carson, California

Susan S. Fairchild, EdD, APRN Dean, School of Nursing Grantham University Kansas City, Missouri

Cris Finn, RN, PhD, FNP Helpant Professor Regis University Denver, Colorado

Susan C. Fox, RN, PhD, CNS-BC Associate Professor College of Nursing University of New Mexico Albuquerque, New Mexico

Eileen P. Geraci, PhD candidate, MA, ANP-BC Professor of Nursing Western Connecticut State University Danbury, Connecticut

reviewers

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xii rEviEwErs

Julie Ponto, RN, PhD, ACNS-BC, AOCN Professor Winona State University–Rochester Rochester, Minnesota

Susan D. Schaffer, PhD, ARNP, FNP-BC Chair, Department of Women’s, Children’s

and Family Nursing FNP Track Coordinator University of Florida College of Nursing Gainesville, Florida

Beth R. Steinfeld, DNP, WHNP-BC Helpant Professor SUNY Downstate Medical Center Brooklyn, New York

Lynn Wimett, EdD, APRN-C Professor Regis University Denver, Colorado

Jennifer Klimek Yingling, PhD, RN, ANP-BC, FNP-BC

Advanced Practice Nurse Faxton-St. Luke’s Healthcare SUNY Institute of Technology Utica, New York

Joy Lewis, CRNA, MSN Interim Helpant Program Director Nurse

Anesthesia Lincoln Memorial University Harrogate, Tennessee

Laurie Kennedy-Malone, PhD, GNP-BC, FAANP, FGSA

Professor of Nursing University of North Carolina at Greensboro School

of Nursing Greensboro, North Carolina

Susan McCrone, PhD, PMHCNS-BC Professor West Virginia University Morgantown, West Virginia

Sandra Nadelson, RN, MS Ed, PhD Associate Professor Boise State University Boise, Idaho

Geri B. Neuberger, RN, MN, EdD, ARNP-CS Professor University of Kansas School of Nursing Kansas City, Kansas

Crystal Odle, DNAP, CRNA Director, Helpant Professor Nurse Anesthesia

Program Lincoln Memorial University Harrogate, Tennessee

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xiii

This book belongs to its authors. I am proud to be one among them. Beyond that, I have been the instrument to make these written contributions accessible to today’s students and faculty. I thank each author for the products of his or her intellect, experience, and commitment to advanced practice.

Acknowledgments

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xv

8 the Kaleidoscope of collaborative Practice 116 Alice F. Kuehn

9 Participation of the Advanced Practice nurse in Health Plans and Quality initiatives 143 Rita Munley Gallagher

10 Public Policy and the Advanced Practice registered nurse 158 Marie-Eileen Onieal

11 resource Management 165 Eileen Flaherty, Antigone Grasso, and Cindy Aiena

12 Mediated roles: Working With and through Other People 184 Thomas D. Smith, Maria L. Vezina , Mary E. Samost, and Kelly Reilly

Unit 3 competency in Advanced Practice 203

13 evidence-Based Practice 204 Deborah C. Messecar and Christine A. Tanner

14 Advocacy and the Advanced Practice registered nurse 218 Andrea Brassard

15 case Management and Advanced Practice nursing 227 Denise Fessler and Irene McEachen

16 the Advanced Practice nurse and research 240 Beth Quatrara and Dale Shaw

contents

Preface v

contributors vii

Unit 1 the evolution of Advanced Practice 01

1 Advanced Practice nursing: doing What Has to Be done 02 Lynne M. Dunphy

2 emerging roles of the Advanced Practice nurse 16 Deborah Becker and Caroline Doherty

3 role development: A theoretical Perspective 33 Lucille A. Joel

4 educational Preparation of Advanced Practice nurses: Looking to the Future 43 Phyllis Shanley Hansell

5 global Perspectives on Advanced nursing Practice 54 Madrean Schober and Anna Green

Unit 2 the Practice environment 91

6 Advanced Practice nurses and Prescriptive Authority 92 Jan Towers

7 credentialing and clinical Privileges for the Advanced Practice registered nurse 100 Ann H. Cary and Mary C. Smolenski

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xvi contEnts

25 Advanced Practice registered nurses: Accomplishments, trends, and Future development 387 Jane M. Flanagan, Allyssa Harris, and Dorothy A. Jones

26 starting a Practice and Practice Management 395 Judith Barberio

27 the Advanced Practice nurse as employee or independent contractor: Legal and contractual considerations 418 Kathleen M. Gialanella

28 the Law, the courts, and the Advanced Practice registered nurse 433 David M. Keepnews

29 Malpractice and the Advanced Practice nurse 445 Carolyn T. Torre

30 ethics and the Advanced Practice nurse 474 Gladys L. Husted , James H. Husted , and Carrie Scotto

index 491

available online at davisplus.fadavis.com: bibliography

17 the Advanced Practice nurse: Holism and complementary and integrative Health Approaches 251 Carole Ann Drick

18 Basic skills for teaching and the Advanced Practice registered nurse 276 Valerie Sabol , Benjamin A. Smallheer, and Marilyn H. Oermann

19 culture as a variable in Practice 295 Mary Masterson Germain

20 conflict resolution in Advanced Practice nursing 328 David M. Price and Patricia A. Murphy

21 Leadership for APns: if not now, When? 336 Edna Cadmus

22 information technology and the Advanced Practice nurse 349 Robert Scoloveno

23 Writing for Publication 354 Shirley A. Smoyak

Unit 4 ethical, Legal, and Business Acumen 365

24 Measuring Advanced Practice nurse Performance: Outcome indicators, Models of Assessment, and the issue of value 366 Shirley Girouard, Patricia DiFusco, and Joseph Jennas

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1

U n i t

1 The Evolution

of Advanced Practice

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2

1 Advanced Practice Nursing

Doing What Has to Be Done Lynne M. Dunphy

Learning Outcomes

Learning outcomes expected as a result of this chapter:

• Recognize the historical role of women as healers. • Identify the roots of professional nursing in the United States including the public

health movement and turn-of-the-century settlement houses. • Describe early innovative care models created by nurses in the first half of the

20th century such as the Frontier Nursing Service (FNS). • Trace the trajectory of the role of the nurse midwife across the 20th century as well

as the present status of this role. • Recognize the emergence of nurse anesthetists as highly autonomous practitioners

and their contributions to the advancement of surgical techniques and develop- ments in anesthesia.

• Describe the development of the clinical nurse specialist (CNS) role in the context of 20th-century nursing education and professional development with particular attention to the current challenges of this role.

• Describe the historical and social forces that led to emergence of the nurse practi- tioner (NP) role and understand key events in the evolution of this role.

• Describe the development of the doctor of nursing practice (DNP) and distin- guish this role from the others described in this chapter.

• Describe the current challenges to all advanced roles and formulate ways to meet these challenges going forward.

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Chapter 1 •  ADvAnceD PrActice nUrsing 3

Advanced practice is a contemporary term that has evolved to label an old phenomenon: nurses or women providing care to those in need in their surrounding communities. As Barbara Ehrenreich and Deidre English (1973) note, “Women have always been healers. They were the un- licensed doctors and anatomists of western history . . . they were pharmacists, cultivating herbs and exchanging the secrets of their uses. They were midwives, travelling from home to home and village to village” (p. 3). Today, with health care dominated by a male-oriented medical profession, advanced practice nurses (APNs) (especially those cheeky enough to call themselves “doctor” even while clarifying their nursing role and background) are viewed as nurses “pushing the envelope”—the envelope of regulated, standardized nursing practice. The reality is that the boundaries of professional nursing practice have always been fluid, with changes in the practice setting speeding ahead of the educational and regulatory environments. It has always been those nurses caring for persons and families who see a need and respond—at times in concert with the medical profession and at times at odds—who are the true trailblazers of contemporary advanced practice nursing.

This chapter makes the case that, far from being a new creation, APNs actually predate the founding of modern professional nursing. A look back into our past reveals legendary figures always responding to the challenges of human need, changing the landscape of health care, and improving the health of the populace. The titles may change—such as a doctor of nursing practice (DNP)—but the essence remains the same.

PRECURSORS AND ANTECEDENTS

There is a long and rich history of female lay healing with roots in both European and African cultures. Well into the 19th century, the female lay healer was the primary health-care provider for most of the population. The sharing of skills and knowledge was seen as one’s obligation as a member of a community. These skills were broad based and might have included midwifery, the use of herbal remedies, and even bone setting (Ehrenreich, 2000, p. xxxiii). Laurel Ulrich, in A Midwife’s Tale (1990), notes that when the diary of the midwife Martha Ballard opens in 1785, “. . . she knew how to manufacture salves, syrups, pills, teas, ointments, how to prepare an oil emulsion, how to poultice

wounds, dress burns, treat dysentery, sore throat, frost bite, measles, colic, ‘whooping cough,’ ‘chin cough,’ . . . and ‘the itch,’ how to cut an infant’s tongue, administer a ‘clister’ (enema), lance an abscessed breast . . . induce vomiting, assuage bleeding, reduce swelling and relieve a toothache, as well as deliver babies” (p. 11).

Ulrich notes the tiny headstones marking the graves of midwife Ballard’s deceased babies and children as further evidence of her ability to provide compassionate, knowledgeable care; she was able to understand the pain and suffering of others. The emergence of a male medical establishment in the 19th century marked the beginning of the end of the era of female lay healers, including mid- wives. The lay healers saw their role as intertwined with one’s obligations to the community, whereas the emerging medical class saw healing as a commodity to be bought and sold (Ehrenreich & English, 1978). Has this really changed? Are not our current struggles still bound up with issues of gender, class, social position, and money? Have we not entered a phase of more radical than ever splits between the haves and have-nots, with grave consequences to our social fabric?

Nursing histories (O’Brien, 1987) have documented the emergence of professional nursing in the 19th century from women’s domestic duties and roles, extensions of the things that women and servants had always done for their families. Modern nursing is usually pinpointed as beginning in 1873, the year of the opening of the first three U.S. training schools for nurses, “as an effort on the part of women reformers to help clean up the mess the male doctors were making” (Ehrenreich, 2000, p. xxxiv). The incoming nurses, for example, are credited with introducing the first bar of soap into Bellevue Hospital in the dark days when the medical profession was still resisting the germ theory of disease and aseptic techniques.

The emergence of a strong public health movement in the 19th century, coupled with the Settlement House Movement, created a new vista for independent and au- tonomous nursing practice. The Henry Street Settlement, a brainchild of a recently graduated trained nurse named Lillian Wald, was a unique community-based nursing practice on the lower east side of New York City. Wald described these nurses who flocked to work with her at Henry Street Settlement as women of above average “ intellectual equipment,” of “exceptional character, mentality and scholarship” (Daniels, 1989, p. 24). These nurses, as

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4 Unit 1 •  tHe evolUtion of ADvAnceD PrActice

regard to perinatal health indicators, was poor (Bigbee & Amidi-Nouri, 2000). Midwives—unregulated and by most accounts unprofessional—were easy scapegoats on which to blame the problem of poor maternal and infant outcomes. New York City’s Department of Health com- missioned a study that claimed that the New York midwife was essentially “medieval.” According to this report, fully 90% were “hopelessly dirty, ignorant, and incompetent” (Edgar, 1911, p. 882). There was a concerted movement away from home births. This was all part of a mass assault on midwifery by an increasingly powerful medical elite of obstetricians determined to control the birthing process.

These revelations resulted in the tightening of existing laws and the creation of new legislation for the licensing and supervision of midwives (Kobrin, 1984). Several states passed laws granting legal recognition and regulation of midwives, resulting in the establishment of schools of midwifery. One example, the Bellevue School for Midwives in New York City, lasted until 1935, when the diminishing need for midwives made it difficult to justify its existence (Komnenich, 1998). Obstetrical care continued the move into hospitals in urban areas that did not provide mid- wifery. For the most part, the advance of nurse-midwifery has been a slow and arduous struggle often at odds with mainstream nursing. For example, Lavinia Dock (1901) wrote that all births must be attended by physicians. Public health nurses, committed to the professionalizing of nursing and adherence to scientific standards, chose to distance themselves from lay midwives. The heritage of the unprofessional image of the lay midwife would linger for many years.

A more successful example of midwifery was the founding of the Frontier Nursing Service (FNS) in 1925 by Myra Breckinridge in Kentucky. Breckinridge, having been educated as a public health nurse and traveling to Great Britain to become a certified nurse-midwife (CNM), pursued a vision of autonomous nurse-midwifery practice. She aimed to implement the British system in the United States (always a daunting enterprise on any front). In rural settings, where doctors were scarce and hospitals virtually nonexistent, midwifery found more fertile soil. However, even in these settings, professional nurse-midwifery had to struggle to bloom.

Breckinridge founded the FNS at a time when the national maternal death rate stood at 6.7 per 1,000 live births, one of the highest rates in the Western world. More

has been well documented, enjoyed an exceptional degree of independence and autonomy in their nursing practice caring for the poor, often recent immigrants.

In 1893, Wald described a typical day. First, she visited the Goldberg baby and then Hattie Isaacs, a patient with consumption to whom she brought flowers. Wald spent 2 hours bathing her (“the poor girl had been without this attention for so long that it took me nearly two hours to get her skin clean”). Next, she inspected some houses on Hester Street where she found water closets that needed “chloride of lime” and notified the appropriate authorities. In the next house, she found a child with “running ears,” which she “syringed,” showing the mother how to do it at the same time. In another room, there was a child with a “summer complaint”; Wald gave the child bismuth and tickets for a seaside excursion. After lunch she saw the O’Briens and took the “little one, with whooping cough” to play in the back of the Settlement House yard. On the next floor of that tenement, she found the Costria baby who had a sore mouth. Wald “gave the mother honey and borax and little cloths to keep it clean” (Coss, 1989, pp. 43–44). This was all before 2 p.m.! Far from being some new invention, midwives, nurse anesthetists, clinical nurse specialists (CNSs), and nurse practitioners (NPs) are merely new permutations of these long-standing nursing commitments and roles.

NURSE-MIDWIVES

Throughout the 20th century, nurse-midwifery remained an anomaly in the U.S. health-care system. Nurse-midwives attend only a small percentage of all U.S. births. Since the early decades of the 20th century, physicians laid claim to being the sole legitimate birth attendants in the United States (Dye, 1984). This is in contrast to Great Britain and many other European countries where trained midwives attend a significant percentage of births. In Europe, homes remain an accepted place to give birth, whereas hospital births reign supreme in the United States. In contrast to Europe, the United States has little in the way of a tradition of professional midwifery.

As late as 1910, 50% of all births in the United States were reportedly attended by midwives, and the percentage in large cities was often higher. However, the health status of the U.S. population, particularly in

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Chapter 1 •  ADvAnceD PrActice nUrsing 5

than 250,000 infants, nearly 1 in 10, died before they reached their first birthday (U.S. Department of Labor, 1920). The Sheppard-Towner Maternity and Infancy Act, enacted to provide public funds for maternal and child health programs, was the first federal legislation passed for specifically this purpose. Part of the intention of this act was to provide money to the states to train public health nurses in midwifery; however, this proved short-lived. By 1929, the bill lapsed; this was attributed by some to major opposition by the American Medical Association (AMA), which advocated the establishment of a “single standard” of obstetrical care, care that is provided by doctors in hospital settings (Kobrin, 1984).

Breckinridge saw nurse-midwives working as indepen- dent practitioners and continued to advocate home births. And even more radically, the FNS saw nurse-midwives as offering complete care to women with normal pregnan- cies and deliveries. However, even Breckinridge and her supporters did not advocate the FNS model for cities where doctors were plentiful and middle-class women could afford medical care. She stressed that the FNS was designed for impoverished “remotely rural areas” without physicians (Dye, 1984).

The American Association of Nurse-Midwives (AANM) was founded in 1928, originally as the Kentucky State Association of Midwives, which was an outgrowth of the FNS. First organized as a section of the National Organi- zation of Public Health Nurses (NOPHN), the American College of Nurse-Midwives (ACNM) was incorporated as an independent specialty nursing organization in 1955 when the NOPHN was subsumed within the National League for Nursing (NLN). In 1956, the AANM merged with the college, forming the ACNM as it continues today. The ACNM sponsored the Journal of Nurse-Midwifery, implemented an accreditation process of programs in 1962, and established a certification examination and process in 1971. This body also currently certifies non-nurses as midwives and maintains alliances with professional midwives who are not nurses. As noted by Bigbee and Amidi-Nouri (2000), CNMs are distinct from other APNs in that “they conceptualize their role as the combination of two disciplines, nursing and midwifery” (p. 12).

At their core, midwives as a group remain focused on their primary commitment: care of mothers and babies regardless of setting and ability to pay. Rooted in holistic care and the most natural approaches possible, in 2015 there

were 11,194 CNMs and 97 certified midwives. In 2014, CNMs or CMs attended 332,107 births, accounting for 12.1% of all vaginal births and 8.3% of total U.S. births (National Center for Health Statistics, 2014).

CNMs are licensed, independent health-care providers with prescriptive authority in all 50 states, the District of Columbia, American Samoa, Guam, and Puerto Rico. CNMs are defined as primary care providers under federal law. CMs are also licensed, independent health-care providers who have completed the same midwifery education as CNMs. CMs are authorized to practice in Delaware, Missouri, New Jersey, New York, and Rhode Island and have prescriptive authority in New York and Rhode Island. The first accredited CM education program began in 1996. The CM credential is not yet recognized in all states.

Although midwives are well-known for attending births, 53.3% of CNMs and CMs identify reproductive care and 33.1% identify primary care as main responsibilities in their full-time positions. Examples include annual exam- inations, writing prescriptions, basic nutrition counseling, parenting education, patient education, and reproductive health visits.

NURSE ANESTHETISTS

Nursing made medicine look good. —Baer, 1982

Surgical anesthesia was born in the United States in the mid 19th century. Immediately there were rival claimants to its “discovery” (Bankert, 1989). In 1846 at Massachusetts General Hospital, William T. G. Morton first successfully demonstrated surgical anesthesia. Nitrous oxide was the first agent used and adopted by U.S. dentists. Ether and chloroform followed shortly as agents for use in anesthe- tizing a patient. One barrier to surgery had been removed. However, it would take infection control and consistent, careful techniques in the administration of the various anesthetic agents for surgery to enter its “Golden Age.” It was only then that “surgery was transformed from an act of desperation to a scientific method of dealing with illness” (Rothstein, 1958, p. 258).

For surgeons to advance their specialty, they needed someone to administer anesthesia with care. However, anesthesiology lacked medical status; the surgeon collected the fee. No incentive existed for anyone with a medical

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wanted to replace them to establish their own controls. Different variants of this old power struggle echo today in legislative battles over the need for on-site oversight by an anesthesiologist.

The American Association of Nurse Anesthetists (AANA) was founded in 1931 by Hodgins and originally named the National Association for Nurse Anesthetists. This group voted to affiliate with the American Nurses Association (ANA), only to be turned away. As early as 1909, Florence Henderson, a successor of Magaw’s, was invited to present a paper at the ANA convention, with no subsequent extension of an invitation to become a member of the organization (Komnenich, 1998). Thatcher (1953) speculates that or- ganized nursing was fearful that nurse anesthetists could be charged with practicing medicine, a theme we will see repeated when we examine the history of the development of the NP role. This rejection led the AANA to affiliate with the American Hospital Association (AHA).

The relationship between nurse anesthetists and anesthesiologists has always been, and continues to be, contentious. Consistent with health-care workforce data in general, there is a maldistribution of MDs, including anesthesiologists, who frequently choose to practice in areas where patients can afford to pay or in desirable areas to live. Rural areas continue to be underserved as well as indigent areas in general. CRNAs pick up the slack, “doing what has to be done” to meet the needs of underserved patients. Complicating this picture is that there is an uneven supply of CRNAs in different geographic areas. As CRNAs retire later, unwilling to give up lucrative positions, some regions experience intergenerational hostility as well.

Despite a brief period of relative harmony from 1972 to 1976, when the AANA and the American Society of Anesthesiologists (ASA) issued the “Joint Statement on Anesthesia Practice,” their partnership ended when the board of directors of the ASA withdrew its support of this statement, returning to a model that maintained physician control (Bankert, 1989, pp. 140–150).

The Certified Registered Nurse Anesthetist (CRNA) credential came into existence in 1956. At present, there are approximately more than 50,000 CRNAs (AANA, 2016),* 41% of whom are males (compared with the approximately 13% male population in nursing overall, a figure that has held steady for some time). CRNAs safely

degree to take up the work. Who would administer the anesthesia? And who would do so reliably and carefully? There was only one answer: nurses.

In her landmark book Watchful Care: A History of America’s Nurse Anesthetists (1989), Marianne Bankert explains how economics changed anesthesia practice. Physician-anesthetists “needed to establish their ‘claim’ to a field of practice they had earlier rejected” (p. 16), and to do this it became necessary to deny, ignore, or denigrate the achievements of their nurse colleagues. The most intriguing part of her study, she says, was “the process by which a rival—and less moneyed—group (in this case, nurses) is rendered historically ‘invisible’” (p. 16).

St. Mary’s Hospital, later to become known as the Mayo Clinic, played an important role in the devel- opment of anesthesia. It was here that Alice Magaw, sometimes referred to as the “Mother of Anesthesia,” practiced from 1860 to 1928. In 1899, she published a paper titled “ Observations in Anesthesia” in Northwestern Lancet in which she reported giving anesthesia in more than 3,000 cases (Magaw, 1899). In 1906, she published another review of more than 14,000 successful anesthesia cases (Magaw, 1906). Bigbee and Amidi-Nouri (2000) note, “She stressed individual attention for all patients and identified the experience of anesthetists as critical elements in quickly responding to the patient” (p. 21). She also paid special attention to her patients’ psyches: She believed that “suggestion” was a great help “in pro- ducing a comfortable narcosis” (Bankert, 1989, p. 32). She noted that the anesthetist “must be able to inspire confidence in the patient” and that much of this depends on the approach (Bankert, 1989, p. 32). She stressed preparing the patient for each phase of the experience and of the need to “‘talk him to sleep’ with the addition of as little ether as possible” (p. 33). Magaw contended that hospital-based anesthesia services, as a specialized field, should remain separate from nursing service admin- istrative structures (Bigbee & Amidi-Nouri, 2000). This presaged the estrangement that has historically existed between nurse anesthetists and “regular” nursing; we see a nursing specialty with expanded clinical responsibilities developing outside of mainstream nursing.

The medical specialty of anesthesiology began to gain a foothold around the turn of the 20th century, led largely by women physicians. However, these physicians were unsympathetic to the role of the nurse anesthetists; they *In some states, the title CRNA has been changed to APN-Anesthesia.

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In a 1943 speech, Frances Reiter first used the term nurse-clinician. She believed that “practice is the absolute primary function of our profession” and “that means the direct care of patients” (Reiter, 1966). The nurse-clinician, as Reiter conceived the role, consisted of three spheres. The first sphere, clinical competence, included three additional dimensions of function, which she termed care, cure, and counseling. The nurse-clinician was labeled “the Mother Role,” in which the nurse protects, teaches, comforts, and encourages the patient. The second sphere, as envisioned by Reiter, involved clinical expertise in the coordination and continuity of the patient’s care. In the final sphere, she believed in what she called “professional maturity,” wherein the physician and nurse “share a mutual responsibility for the welfare of patients” (Reiter, 1966, p. 277). It was only through such working together that the patient could best be served and nursing achieve “its greatest potential” (Reiter, 1966). Although Reiter believed that the nurse-clinician should have advanced clinical competence, she did not specify that the nurse-clinician should be prepared at the master’s level.

In 1943, the National League for Nursing Education advocated a plan to develop these nurse-clinicians, enlisting universities to educate them (Menard, 1987). Traditionally, advanced education in nursing had focused on “functional” areas, that is, nursing education and nursing administration. Esther Lucile Brown, in her 1948 report Nursing for the Future, promoted developing clinical specialties in nursing as a way of strengthening and advancing the profession. The GI Bill was also available. Nurses in the Armed Services were eligible to receive funds for their education.

It took the entrance of another strong nurse leader, Hildegard Peplau, to move these ideas forward to fruition. In 1953, she had both a vision and a plan: She wanted to prepare psychiatric nurse clinicians at the graduate level who could offer direct care to psychiatric patients, thus helping to close the gap between psychiatric theory and nursing practice (Callaway, 2002). In addition, as always there was a great need for health-care providers of all stripes in psychiatric settings. In her first 2 years at Rutgers University in New Jersey, Peplau developed a 19-month master’s program that prepared only CNSs in psychiatric nursing. In contrast, existing programs, such as that at Teachers College in New York City, attempted to prepare nurses for teaching and supervision in a 10-month program.

administer approximately 43 million anesthetics to patients each year in the United States according to the AANA 2016 Practice Profile Survey.

Interestingly, the inclusion of large numbers of males in its ranks has not eased the advance of this venerable nursing specialty; turf wars between practicing anesthesiologists and nurse anesthetists remain intense as of this writing, further aggravated by the incursion of “doctor-nurses” or “nurse-doctors.” Nonetheless, nurse anesthetists continue to thrive and have situated themselves in the mainstream of graduate-level nursing education, including a large portion of programs adapting curriculums leading to the DNP. Their inclusion in the spectrum of advanced practice nursing continues to be invigorating for us.

THE CLINICAL NURSE SPECIALIST

The role of the CNS is the one strand of advanced prac- tice nursing that arose and was nurtured by mainstream nursing education and nursing organizations. Indeed, one could say it arose from the very bosom of traditional nursing practice. As early as 1900, in the American Journal of Nursing, Katherine DeWitt wrote that the development of nursing specialties, in her view, responded to a “need for perfection within a limited domain” (Sparacino, 1986, p. 1). According to DeWitt, nursing specialties were a response to “present civilization and modern science [that] demand a perfection along each line of work formerly unknown” (Sparacino, 1986, p. 1). She argued that “the new nurse is more useful, at least to the patient himself, and ultimately to the family and community. Her sphere is more limited, but her patient receives better care” (Sparacino, 1986, p. 1).

Historically, nurses were trained and worked in hospitals that were structured for the convenience of the doctors around specific populations of patients. Early on, nurses initiated guidelines for the care of unique populations and often garnered a hands-on kind of intimacy, an expertise in the care of certain patients that was not to be denied. Caring day in and day out for patients suffering from similar conditions enabled nurses to develop specialized and advanced skills not practiced by other nurses. Think of the nurses who cared exclusively for patients with tu- berculosis, syphilis, and polio. Because these conditions are no longer common, any nursing expertise that might have been developed has been lost.

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had 24-hour responsibility for a patient area and who was on call. Laura Simms at Cornell University–New York Hospital School of Nursing developed a CNS role to provide consultation to more generalist nurses. As opposed to the nurse who might have been expert in procedures, these new clinicians were experts in clinical care for a certain population of patients. This development occurred across specialties and was seen in oncology, nephrology, psychiatry, and intensive care units (Sills, 1983).

Role expansion of the CNS grew rapidly during the 1960s because of several factors. Advances in medical technology and medical specialization increased the need for nurses who were competent to care for patients with complex health needs. Nurses returning from the battlefields of Vietnam sought to increase their knowledge and skills and contin- ued to practice in advanced roles and nontraditional areas (such as trauma or anesthesia). Role definitions for women loosened and expanded. There was a shortage of physicians. The Nurse Training Act of 1964 allocated necessary federal funds for additional graduate nursing education programs in several different clinical specialties (Mirr & Snyder, 1995).

The terms nurse-clinician, CNS, and nurse specialist, among others, were used extensively by nurses with ex- perience or advanced knowledge who had developed an expertise within a given area of patient care. There were no standards regarding educational requirements or experience. In 1965, the ANA developed a position statement declaring that only those nurses with a master’s degree or higher in nursing should claim the role of CNS (ANA, 1965). These trends continued into the 1970s. The number of academic programs providing master’s preparation in a variety of practice areas increased. Federal grants, including those from the Department of Health, Education, and Welfare, continued to provide funding for nursing education at the master’s and doctoral levels.

In 1976, during the ANA’s Congress on Nursing Practice, a position statement on the role of the CNS was issued. The ANA position statement read as follows (ANA Congress for Nursing Practice, 1976):

The clinical nurse specialist (CNS) is a practitioner holding a master’s degree with a concentration in specific areas of clinical nursing. The role of the CNS is defined by the needs of a select client population, the expectation of the larger society and the clinical expertise of the nurse.

The statement went on to elaborate that “by exercising leadership ability and judgment,” the CNS is able to affect

The field of psychiatric nursing was in the process of inventing itself. Before the passage of the National Mental Health Act in 1946, there was no such field as psychiatric nursing. It was the availability of National Institute of Mental Health funds to “seed” such programs as Peplau’s that allowed psychiatric nursing to begin and eventually to flourish.

In retrospect, Peplau would note that no encouragement was received from the two major nursing organizations of the day, the NLN and the ANA. She stated, “We were highly stigmatized. Any nurse who worked in [the field of mental health] was considered almost certifiable. . . . We were thoroughly unpopular, we were considered queer enough to be avoided” (Callaway, 2002, p. 229).

It should be emphasized that at this point in nursing history it was inconceivable that any nurse, under any circumstances, could become a specialist. The “received wisdom” of the day was the axiom, followed by the vast majority of nurses, that “a nurse is a nurse is a nurse,” opposing any differentiation between who was doing what among them. Peplau’s rigorous curriculum and clinical and academic program requirements expected that faculty would continue their own clinical practice, do clinical research, and publish the results (Callaway, 2002). This was a radical model for nursing faculty, few of whom were doctorally prepared in the 1950s. In 1956, only 2 years following the initiation of the first clinically focused graduate program, a national working conference on graduate education in psychiatric nursing formally developed the role of the psychiatric clinical specialist.

Most hospital training schools remained embedded in a functional method of nursing well into the 1960s. As originally conceptualized by Isabel Stewart in the 1930s, “nurses were trained and much of nursing practice was rule-based and activity-oriented” (Fairman, 1999, p. 42), relying heavily on repetition of skills and procedures. There was little, if any, scientific understanding of the principles underlying care. There was little, if any, intellectual content to be found in the nursing curriculum.

With the advent of antibiotics in the 1940s and the resulting decline of infectious diseases, nurses’ practice shifted to caring for patients with acute, often rapidly changing exacerbations of chronic conditions. Leaders such as Peplau, along with others such as Virginia Henderson, Frances Reiter, and later Dorothy Smith, began developing a theoretical orientation for practice. Students were being taught to assess patient responses to their illnesses and to make analytical decisions. Smith experimented with the idea of a nurse-clinician who

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the Council of Nurses in Advanced Practice (Busen & Engleman, 1996; Lincoln, 2000). Following the merger of the councils, several studies were published comparing CNS and NP roles, finding the education for practice generally comparable (Joel, 2011).

The 1990s was an era of health-care “reform.” Health-care costs were skyrocketing; hospital stays were shorter, with acutely ill patients being discharged quicker and sicker. Because of fiscal mandates, hospitals were decreasing the number of beds and personnel and the focus of health care shifted from hospital to ambulatory care within the community and home. The historically hospital-based CNS was considered too expensive and unproven. Thus, CNSs all over were losing positions.

In 1993, the American Association of Colleges of Nursing (AACN) met to discuss educational needs and requirements for the 21st century. At the AACN’s annual conference in December 1994, members voted to support the merging of the CNS and NP roles in the curricula of graduate education in nursing. Although the structure of the curricula suggested in the “Essentials of Graduate Education” (AACN, 1995) has been widely adopted, the lived reality of role adaptation and its implementation in the marketplace has been less uniform and more divi- sive. Sparacino (1990) defined the scope of the CNS as “client-centered practice, utilizing an in-depth assessment, practiced within the domain of secondary and tertiary care settings” (p. 8). The NP role is defined by Sparacino (1986) as being responsible for providing a full range of primary health-care services, using the appropriate knowledge base and practicing in multiple settings outside of secondary and tertiary settings. To some degree this has been the nature of these roles, though many exceptions can be observed today.

Scope of practice barriers continue in this area of advanced practice nursing. The latest setback occurred when the Standard Occupational Classification Policy Committee (SOCPC) announced its recommendations to the Office of Management and Budget for the 2018 Standard Occupational Classification on July 22, 2016. The SOCPC declined to include the CNS in a separate broad occupation and detailed occupation category, stating:

Multiple dockets requested a new detailed occupation for Clinical Nurse Specialists. The SOCPC did not accept this recommendation based on Classification Principle 2 which states that occupations are classified based on work performed and on Classification Principle 9 on collectability.

client care on the individual, direct-care provider level as well as affect change within the broader health-care system (ANA Congress for Nursing Practice, 1976).

The 1970s were a time of growth in academic CNS programs; the 1980s were years in which refinements occurred. In 1980, the ANA revised its earlier policy statement of 1976 to define the CNS as “a registered nurse who, through study and supervised clinical practice at the graduate level (master’s or doctorate) has become an expert in a defined area of knowledge and practice in a selected clinical area of nursing” (ANA, 1980, p. 23). This statement was significant because it was the first time that education at the master’s level had been dictated as a mandatory criterion for entry into expert practice.

The CNS role more than any other advanced nursing role was situated in the mainstream of graduate nursing education, with the first master’s degree in psychiatric and mental health nursing conferred by Rutgers University in 1955. The inclusion of clinical content in master’s degree education was an essential step forward for nursing’s ad- vancement. But the implementation and use of the CNS avoided easy categorization and their efficacy was elusive.

In February 1983, the ANA Council of Clinical Nurse Specialists met for the first time (Sparacino, 1990). The Council grew rapidly throughout the subsequent years, supporting and providing educational conferences for the increasing numbers of CNSs. In 1986, the Council pub- lished the CNS’s role statement. This statement identified the roles of the CNS as specialist in clinical practice and as educator, consultant, researcher, and administrator. This role statement by the Council depicted the changing role of the CNS, notably delegating and overseeing practice as its primary focus (Fulton, 2002). The year 1986 was also notable for the publication of the journal Clinical Nurse Specialist: The Journal for Advanced Nursing.

In 1986, the ANA’s Council of Clinical Nurse Specialists and the Council of Primary Health Care Providers pub- lished an editorial outlining the similarities of the CNS and NP roles. Discussion surrounding the commonalities of both specialties occurred throughout the decade. In 1989, during the annual meeting of the National Organization of Nurse Practitioner Faculty (NONPF), the 10-year-old debate regarding the merger of the two roles reached a crescendo without resolution (Lincoln, 2000). It remains an issue of contention to the present day. Despite this, the two ANA councils did merge in 1990, becoming

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Jacox, 2002). A lesser known story involves Dr. Eugene A. Stead, Jr., of Duke University, who in 1957 conceived of an advanced role for nurses somewhere between the role of the nurse and the doctor. Thelma Ingles, a nursing faculty member on a sabbatical, worked with Stead, accompanying the interns and residents on rounds, seeing patients, and managing increasingly ill patients with acumen and sensi- tivity. Ingles shared Stead’s ideas and returned to the Duke Nursing School to create a master of science in nursing program modeled on her experience with Stead. Stead was gratified and anxious to impart this expanded role to other nursing faculty, envisioning a new role for nurses, with, in his view, expanded autonomy. He was shocked at the “lukewarm” response of the dean of nursing at Duke and the unsupportive stance of several prominent nurses at the university. On top of that, the NLN, the school’s accrediting body, did not approve of Ingles’s new program for nurse clinical specialization and withheld the program’s accreditation. They found the program “unstructured” and criticized the use of physicians as instructors to teach courses for nurses in a nursing program. They disavowed the study of the esteemed discipline of medicine that Stead was so anxious to impart (Holt, 1998). Instead, they wanted the students to study “nursing.” Stead could not understand this. What was there in nursing to study? Rejected and disheartened, Stead eventually turned to military corps- men to actualize this new role, which he named physician Helpant. He insisted that they be male. In his view, nurse leaders were very antagonistic to innovation and change (Christman, 1998). In the view of some, this was a missed opportunity for organized nursing but one governed by historical circumstances when viewed on the broader stage of history. Fairman (2008), in an extensive study of Stead’s papers, offers the appraisement that “Stead’s difficulties went beyond his experiences with organized and academic nursing. They reflected his perceptions of the kind of help his physician colleagues needed” (Fairman, 2008, p. 98).

Stead’s original proposal was quite prescient. Gender roles were loosening as were hierarchical structures in general; nurses were better educated and well able to assume the role responsibilities that Stead envisioned. Yet it came at a time when nursing was merely a fledgling discipline, new to the university, new to development as an academic discipline, and new to doctoral education. Academic nursing was fixated on defining its own knowl- edge base and developing its own unique science. Along

In July 2014, the National Association of Clinical Nurse Specialists (NACNS) submitted an extensive filing on why the CNS should be included in the Standard Occupational Classification (SOC) as a “broad category.” This is the second time that the SOCPC did not accept the request to make the CNS a new detailed occupation in the SOC. Retaining CNSs in the RNs 2010 classifications is inconsistent with federal agencies, with nursing practice in the states, and with the larger nursing community, all of which distinguish CNSs as APRNs. Congress has accepted CNSs as APRNs for nearly two decades. The Balanced Budget Act of 1997 allowed CNSs to directly bill their services through the Centers for Medicare and Medicaid Services under Part B participation in Medicare. CNSs were recognized as eligi- ble for Medicare’s Primary Care Incentive Program in the Patient Protection and Affordable Care Act (PPACA, 2010).

CNSs prescribe medications, durable medical equip- ment, and medical supplies as well as order, perform, and interpret diagnostic tests including laboratory work and x-rays. Two unequivocal differences exist between CNSs and RNs: diagnosing patients and prescribing pharmaceu- ticals. CNSs can perform both; RNs are not authorized to perform either. The SOCPC’s recommendation to not recognize the CNS as a broad occupation and detailed occupation, similar to how other APRNs are categorized, skews the quality and utility of federal health-care policy data. Linking the CNS workforce data with the RN work- force does not allow CNS contributions to be differentiated from or compared with any other APRN data. Simply put, a database set up by any federal, state, regional, local, research, or private entity using the 2010 SOC categories has no data on the more than 72,000 CNSs in the United States (NACNS, 2016).

The “other side” of this story of advanced practice nursing—NP evolution—is addressed in the next section of this chapter. The futures of these various roles remain on some level intertwined and are further complicated by the emergence of a new model of educational preparation: the DNP.

THE EVOLUTION OF THE NURSE PRACTITIONER ROLE: “A DISRUPTIVE INNOVATION”

The history of the NP “movement” has been well docu- mented (Brush & Capezuti, 1996; Fairman, 1999, 2008;

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Ford states the following in an interview: “We looked at the nurse practitioner preparation not as a separate program but as integrated into a role that had already been designed at the graduate level” (Jacox, 2002, p. 155). Ford notes that the lack of organizational leadership in the profession coupled with a lack of responsiveness in academic settings caused a “bastardization of the model” (Jacox, 2002, p. 157). She had envisioned that our professional organization, as in other professions, would identify, credential, and make public advanced NPs. However, Ford was to discover that the “ANA in those early years was reluctant to stick its neck out and give some leadership to the NP groups that were growing rapidly” and that the lack of leadership in nursing education created “a patchwork quilt” of differently prepared NPs (Jacox, 2002, p. 157). Although clinically based programs were growing, there remained resistance to the NP model. Ford (Jacox, 2002, p. 155) says,

I understood that faculty members were supposed to be doing just that—push the borders of knowledge and publish their work. In my naiveté of faculty politics, I expected that since the NP model grew out of professional nursing and public health nursing—including primary, secondary, and tertiary prevention and community-based services—it was a perfectly legitimate investigation. Instead, it became a battleground, and even recently was labeled in the Harvard Business Review as a “Disruptive Innovation.” What a compliment!

The collaboration between NP and physician has been analyzed and debated since the advent of the NP role, in- cluding the relationship between Ford and Silver (Fairman, 2002, 2008). The sticking point of collaboration is that it has included the heavy implication of supervision and thus control. In truth, in the early 1970s both NPs and physicians had to give up their traditional roles, tasks, and knowledge to establish this new provider role, often in the face of organizational and societal opposition. Jan Towers describes the growth of her own NP practice as follows: “The area that I perhaps most feared turned out to be the least troublesome, after some initial adjustments between the physician with whom I was working and me were made” (Towers, 1995, p. 269). What would often be impossible on an organizational level was more easily resolvable among professionals with a shared interest and commitment: the good of the patient.

Prescriptive authority was a major issue, and it was either delegated from the medical practice act and carried out under physicians’ standing orders or protocols or it

with expanded opportunities for women came ideas of an autonomous nursing role separate and distinct from medicine. Stead’s deeply rooted gender-role stereotyping no doubt further inflamed nursing resistance to “his” new role. Other settings—such as the University of Colorado, where Henry Silver, a pediatrician, and Loretta Ford, a master’s-prepared public health nurse, founded a part- nership rooted in collaboration—provided more fruitful results. All these factors were in play when the first NPs emerged in the 1960s.

However, the NP was not really a new role for nurses. Examining our history, it is apparent that nurses func- tioned independently and autonomously before the rise of organized medicine. If medicine was ambivalent about the emergence of this new role, nursing itself was no less conflicted.

In 1978, the following statement appeared in the American Journal of Nursing (Roy & Obloy, 1978, p. 1698):

The nurse practitioner movement has become an issue in nursing, a topic on which there is no consensus. One question about the movement is whether the development of the nurse practitioner role adds to, or detracts from, the development of nursing as a distinct scientific discipline.

This statement was issued more than 13 years after the initiation of the first NP program at the University of Colorado. If, as Sparacino (1990) spells out, the domain of the CNS is situated in the secondary and tertiary setting, the domain of the NP originally arose as a role situated in primary care.

Loretta Ford and Dr. Henry Silver designed a graduate curriculum for pediatric nurses to provide ambulatory care to poor rural Colorado children. The goal of this program was to bridge the gap between the health-care needs of children and the family’s ability to access and afford primary health care (Ford & Silver, 1967; Silver, Ford, & Stearly, 1967). This program was situated in graduate education and included courses such as patho- physiology, health promotion, and growth and develop- ment, with the intent of the student understanding the principles of healthy child care and patient education. Nurses would then be able to provide preventive nursing services outside of the hospital setting in collaboration with physicians. Students had to have a baccalaureate degree and public health nursing experience to be ad- mitted to the program.

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Government and private groups rapidly developed funding support for educational programs (Hamric, Spross, & Hanson, 2013). According to Marchione and Garland (1997), “The traditional role of humanistic caring, com- forting, nurturing and supporting was to be maintained and improved by the addition” of new primary care functions that the Department of Health, Education, and Welfare approved: total patient assessment, monitoring, health promotion, and a focus that encompassed not only disease prevention but health promotion and maintenance, treatment, and continuity of care.

The Division of Nursing of the Department of Health, Education, and Welfare tracked the development of the NP role from 1974 to 1977. During that time, the number of NP programs rose from 86 to 178 across the country, with significant governmental support through the Nurse Training Act to advanced practice nursing education programs of all types. Although nurse educators by this time wanted NP education standardized, in 1977 most NP programs awarded a certificate with some still using continuing education models and accepting less than a baccalaureate degree for entry. However, the number of NP graduates of master’s programs did increase from 20% in 1975 to 26% in 1977, again largely encouraged by the availability of federal funds for support. The education of NPs was the rallying cry for the formation of the NONPF in 1980, dedicated to defining curriculum and Assessment standards as well as pioneering research and development related to NP practice and teaching-learning methodologies. The political voice for NPs was enhanced with the formation of the American Academy of Nurse Practitioners (AANP) in 1985 and the American College of Nurse Practitioners (ACNP) in 2003.

The Nurse Training Acts of 1971 and 1975 were critical in providing federal funding to support NP programs. By 1979, more than 133 programs and tracks existed, and approximately 15,000 NPs were in practice. By 1983 and 1984, NP graduates numbered approximately 20,000 to 24,000; they were primarily employed in sites that served those in greatest need: public health departments, community health centers, outpatient and rural clinics, health maintenance organizations, school-based clinics, and occupational health clinics (Hamric et al, 2013; Kalisch & Kalisch, 1986; Pulcini & Wagner, 2001). NPs were typically providing care for health promotion, disease prevention, minor acute problems, chronic stabilized illness, and the

came directly from the nursing practice acts. Nurse histo- rian Arlene Keeling has argued that far from being a new realm of nursing practice, the “prescribing”—or use—of a variety of techniques and substances for therapeutic effect has always been a dimension of nursing practice (Keeling, 2007). The states of Oregon and Washington allowed nurses the freedom to prescribe independently in 1983 (Kalisch & Kalisch, 1986). Some of the fiercest turf battles have heated up over prescriptive privileges. By 1984, nurses were accused of practicing medicine, although they were practicing well within the scope of their expanded role. Physicians remained ambivalent. They pushed NPs to function broadly but did not usually support legislation that authorized an increased scope of practice, especially in the area of prescriptive privileges. Joan Lynaugh, nurse historian, describes NPs as looking for an “exam room of their own”—essentially a clinical space in which to provide nursing care (Fairman, 2008, p. 7). This space is indeed a crowded one (Fairman, 2008, p. 200, note 9). Prescriptive authority is discussed in greater detail in Chapter 6.

The Great Society entitlement programs significantly influenced the need for NPs to care for people who were covered under Medicare and Medicaid. Predominant social movements—women’s rights, civil rights, antiwar protest, consumerism—had a profound impact on the need for groups to assert their place in the society of the 1960s and early 1970s. Nurses were not immune to the forces unleashed in these years and took advantage of the opportunities to work with physicians “in relationships that were entrepreneurial and groundbreaking, and to engage in a kind of dialogue that supported new models of care” (Fairman, 2002, p. 165). These nurses were pioneers, rebels, and renegades treading on uncertain ground.

The National Advisory Commission on Health Manpower supported the NP movement (Moxley, 1968). The Committee to Study Extended Roles for Nurses in the early 1970s recommended that the expanded role for nurses was necessary to provide the consumer with access to health care and proposed the inclusion of highly developed health assessment skills (Kalisch & Kalisch, 1986; Leininger, Little, & Carnevali, 1972; Marchione & Garland, 1997). Although the Committee did stop short of providing a definitive scope of practice statement, it recommended support for licensure and certification for advanced practice, recognition in the nursing practice act, further cost-benefit research, and surveys on role impact.

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the National Council of State Boards of Nursing (NCSBN) gave direction for gains in legal authority, prescriptive priv- ilege, and reimbursement mechanisms across the 50 states and the District of Columbia. Current NPs have achieved a higher degree of autonomy in practice and associated prestige (Phillips, 2011) with the mandate for continued advancement contained in the IOM report, The Future of Nursing (2011). More victories than failures provide evidence of success, but, as in the late 1970s, today’s NP is still battling for autonomy and consumer recognition in practice, especially in states with many physicians. Veterans’ Health Affairs (VHA) Advanced Practice Registered Nurses Proposed Rule (81 Fed.Reg.33155, May 25, 2016) to the Federal Register is under siege. Opponents, as noted earlier, are still trying to block implementation of this policy and are reaching out to members of Congress to delay the proposal through legislation that extends ex- piring benefits for our nation’s veterans. New legislation was introduced late in 2016, the Veterans Affairs Expiring Authorities Act (HR 5985).

As early as 1985, Hayes stated, “No role in nursing, or for that matter, in any field has been so debated in the literature, and possibly no other nursing function has ever been so obsessed about by those performing it as has been the NP role” (Hayes, 1985, p. 145). Yet, as Hayes asserts, there has been an avalanche of support from satisfied consumers of NP services.

THE CONSENSUS MODEL

In an effort to bring some clarity to and standardization of advanced practice nursing roles, in 2008 the APRN Consensus Model, also referred to as a regulatory model, was published by the APRN Consensus Work Group and the NCSBN APRN Advisory Committee with extensive input from a larger APRN stakeholder community. The nomenclature APRN was adopted, and four APRN roles were defined in the document: CNMs, CRNAs, CNSs, and certified nurse practitioners (CNPs). An APRN is further defined as an RN who has completed a graduate degree or postgraduate program that has prepared him or her to practice in one of these four roles. The acronym LACE—standing for “licensure, accreditation, certifica- tion, and education”—demonstrates alliances across these spheres for implementation of the APRN Consensus

full range of teaching and coaching that nurses have always provided for patients and families.

A hindrance to practice in rural areas was finding ap- propriate physician backup. By 1987, the federal govern- ment had spent $100 million to promote NP education, primarily through the U.S. Public Health Service Division of Nursing (Pulcini & Wagner, 2001). By the 1980s, the master’s degree was viewed broadly as the educational standard for advanced practice (Geolot, 1987; Sultz et al, 1983), and by 1989, 90% of programs were master’s and post-master’s level (Pulcini & Wagner, 2001). NONPF thrived in the 1980s, developing curriculum guidelines and competencies, surveying faculties, and studying role components.

An interorganizational task force to identify criteria for quality NP educational programs occurred as an outgrowth of the work to unify certification. This work, begun in 1995 by NONPF and the NLN, was the beginning of the development of a model curriculum for NP educa- tion that would be used nationally and provide the basis for certification eligibility (Hamric et al, 2013). At that time, the NLN was the only accrediting body for nursing graduate programs, and program standards, curriculum guides, and domains and competencies for NP education from NONPF were often used by the NLN in the accred- itation process. In 1998, the Commission on Collegiate Nursing Education, an accreditation arm of the AACN, was formed to provide an alternative to the NLN as a source of accreditation to schools offering baccalaureate and higher degrees in nursing. The thrust of the 2001 meeting of the NP task force when it reconvened was for accrediting bodies to move toward the approval of NONPF guidelines and standards as the reigning accepted standards for accreditation of programs preparing NPs (Edwards et al, 2003). In addition, the APRN Consensus Model (see later section) spells out specific criteria for preapproval and accreditation of APRN education.

There is a cautionary note to this perception of prog- ress. Despite clear statutes in some states, credentialing by insurers for NPs may still lag, providing additional barriers to care. Scope of practice, a primary focus of the 2011 Institute of Medicine (IOM) Future of Nursing recommendations, remains a contested battleground for control of professional practice and reimbursement.

In 2008, the adoption of the Consensus Model for Advanced Practice Registered Nurse (APRN) Regulation by

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14 Unit 1 •  tHe evolUtion of ADvAnceD PrActice

The case can also be made that APNs across the coun- try have been expanding their skills, both formally and informally. One example is the role of “intensivist” in the hospital, which is being assumed by many NPs and CNSs (Mundinger, 2005). This is consistent with nurs- ing’s lengthy history of moving where the need in health care surfaces—always “doing what had to be done.” The aging of the population, the increased acuity of patients with multiple comorbidities, the complexity of care, the continuation of a dwindling number of primary care physicians, and the decreased hours for residents in the hospital because of legislative and accreditation criteria have fostered the need for these nurses to move well beyond the primary care arena. For example, when Columbia University School of Nursing was asked by Presbyterian Hospital to establish two new ambulatory care clinics to meet the growing demand for primary care among the underserved immigrant populations, the faculty accepted. They also proposed conducting a randomized trial com- paring independent NPs and primary care physicians. To reduce the variability among roles and strengthen the study, the faculty requested that the hospital’s medical board grant the faculty NPs admitting privileges. Mundinger (2005) describes this evolution at Columbia: “Several physician(s) . . . provided additional training for our faculty nurse practitioners in dermatology, radiology, and cardiology and helped mentor them through the process of admitting, and co-managing patients and conducting emergency room Assessment” (p. 175).

The results of the randomized trials, with excellent patient care outcomes achieved by NPs on a par with primary care physicians, were published in the Journal of the American Medical Association (Mundinger et al, 2000). This contributed to a change in hospital bylaws and granted faculty NPs hospital admitting privileges. Mundinger sees the level of service delivered by these faculty NPs as beyond that achieved by colleagues with the traditional master’s degree preparation for practice. Based on these observations comes the call for a formal and standardized curriculum leading to a doctoral degree consistent with the practice needs for advanced competencies and increased knowledge. Mundinger (2005) states, “We know that thousands of nurses aspire to this level of education and schools are responding by developing the new degree. We know that the research degree is asynchronous with these goals, and we know from every other profession that

Model, thus promoting uniformity and standardization of the APRN role for the safety of the consumer of health care. The target date for model implementation was 2015, with an alignment of current certifying examinations with educational program offerings and subsequent licensure. By December 2016, according to the NCSBN, 15 states were in full compliance with the LACE model and most others were in some stage of change. This is amazing given the continued strength of states’ rights and the opposition of organized medicine.

YET ANOTHER “DISRUPTIVE INNOVATION”: THE DOCTOR OF NURSING PRACTICE

The future contains clouds on the horizon as well as sunshine. Fairman (1999) cautions that although local negotiations between individual physicians and nurses may have been, in some cases, easily traversed in the interest of the good of the patient, on the professional level hierarchical relationships and power are at stake. As noted at the start of this chapter, within this hotly competitive health-care environment, with the still controversial implementation of the PPACA (2010), the entire health-care sector continues to face hurdles, challenges, and assaults.

In October 2004, the members of the AACN en- dorsed the Position Statement on the Practice Doctorate in Nursing, which called for the movement of educational preparation for advanced practice nursing roles from the master’s degree to the doctoral level by 2015. Though this target date has not been achieved, there has been much movement in this direction. This “new” doctorate is a “practice” doctorate in contrast to the doctor of philoso- phy (PhD)—the traditional research degree—and is not intended to “replace” the PhD. There are many reasons for this development. Some master’s programs for APNs had become very lengthy, without any change in the cre- dential awarded at the completion of studies. The number of credits, in many cases, approaches what is required for a doctoral degree. And many educators believe this is necessary to ensure clinical competency. Furthermore, other practice disciplines such as pharmacy, physiotherapy, and occupational therapy have moved on to doctoral-level preparation. The debate continues.

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Chapter 1 •  ADvAnceD PrActice nUrsing 15

RN, DrPH, FAAN. This report was presented in November 2010. The far-reaching impact of the report’s recommen- dations are just now beginning to be fully absorbed. Key recommendations begin with the assumption that “nurs- ing can fill . . . new and expanded roles in a redesigned healthcare system” (IOM, 2011, p. xi). We will need our renegades, rebels, and trailblazers more than ever.

CONCLUSION

The boundaries of practice are always malleable. They are always subject to myriad external forces—political, economic, social, and cultural—and are interpreted in different ways by different practitioners. APNs are a mixed breed; each trajectory under the umbrella of advanced nursing practice has evolved differently and under variable circumstances. This leads to vigor, strength, and diversity. The struggles documented within this chapter have aimed to strengthen each variant of the nursing advanced practice role. The struggles are not over; in many ways, they are just beginning. It is our hope that nursing will continue to produce rebels, renegades, and trailblazers motivated by concern for patients, concern for community, and concern for humanity. We have no doubt that we will continue to take on new and challenging roles using creative and diverse strategies. Nursing continues to lurch forward; progress is sometimes slow, sometimes variable, sometimes unsteady—but, as always, continuing to find opportunity in chaos, motivated, as ever, by commitment to patients, families, and communities, to human need and suffering.

when you reach the competency associated with doctoral achievement, one should receive a doctorate not another MS degree” (p. 175).

As part of the APRN Consensus Model, 2015 was targeted as the year anyone seeking to sit for certification as an APRN would need a DNP. Although the DNP degree has spread and prospered since 2008, there have always been vocal detractors. Recently, opposition to this mandate was voiced by a significant cohort of national nursing leaders in a paper titled “The Doctor of Nursing Practice: A National Workforce Perspective” ( Cronenwett et al, 2011), making the case that the need for care pro- viders should take precedence over a professionalizing agenda. Significant retrenchment of the 2015 mandate has occurred, with moves to preserve existing master’s programs producing APRNs. See Chapter 4 for more discussion on this issue.

THE INSTITUTE OF MEDICINE ISSUES ITS 2010 REPORT: THE FUTURE OF NURSING: LEADING CHANGE, ADVANCING HEALTH

This dramatic, evidence-based report presents the results of 2 years of study by the Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing at the IOM. This committee was chaired by Donna Shalala, PhD, FAAN, long-time nurse advocate, former head of the U.S. Department of Health and Human Services (1992–2000), and now University of Miami president, in concert with Nursing Vice Chair Linda Burnes Bolton,

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16

2 Emerging Roles of the Advanced

Practice Nurse Deborah Becker and Caroline Doherty

Learning Outcomes

Learning outcomes expected as a result of this chapter:

• Describe the advanced practice registered nurses (APRN) Scope of Practice and the Consensus Model.

• Describe the clinical nurse specialist (CNS) role and discuss how their contributions contribute to cost savings and implementation of evidence-based practice.

• Identify role highlights of the nurse practitioner (NP) in primary care with adult and pediatric populations, in various community settings, in psychiatric and mental health care, in women’s health/gender-related care and transitional care, an