Advanced
Practice
Nursing
Essentials for Role Development
Fourth Edition
Advanced
Practice
Nursing
Essentials for Role Development
Fourth
... [Show More] Edition
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 requirements 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, dramatically 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 authority, 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 professionals, 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.
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
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
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
Assistant 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 Assistant 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
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
Assistant 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 Evaluation 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
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
Assistant 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
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
Assistant 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
Assistant 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
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
Assistant 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 Assistant 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, Assistant Professor Nurse Anesthesia
Program
Lincoln Memorial University
Harrogate, Tennessee
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
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
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 Evaluation, and the Issue of Value 366
Shirley Girouard, Patricia DiFusco, and Joseph Jennas
1
Unit
1
The Evolution
of Advanced Practice
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 developments 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 practitioner (NP) role and understand key events in the evolution of this role.
• Describe the development of the doctor of nursing practice (DNP) and distinguish 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.
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 unlicensed 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. Thesharing
of skills and knowledge was seen as one’s obligation as a
member of a community. Theseskills were broad based and
might haveincluded midwifery, the use of herbal remedies,
and even bonesetting (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 oilemulsion, how to poultice
wounds, dress burns, treat dysentery, sorethroat, 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 midwives. 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, forexample, 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 autonomous 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
“intellectualequipment,” of “exceptional character, mentality
and scholarship” (Daniels, 1989, p. 24). These nurses, as
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 commissioned 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 midwifery. 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 littlein 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
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 independent practitioners and continued to advocate home births.
And even more radically, the FNS saw nurse-midwives as
offering complete care to women with normal pregnancies 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 Organization 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 practicein Delaware, Missouri, New
Jersey, New York, and Rhode Island and have prescriptive
authority in NewYork and RhodeIsland. 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 examinations, 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, WilliamT. 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 anesthetizing 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
6 Unit 1 • The Evolution of Advanced Practice
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 beturned away. Asearly as 1909, Florence
Henderson, a successor of Magaw’s, was invited to present a
paper at the ANA convention, with no subsequentextension
of an invitation to become a member of the organization
(Komnenich, 1998). Thatcher (1953) speculates that organized nursing was fearful that nurse anesthetists could
be charged with practicing medicine, a theme we will see
repeated when weexaminethe 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 chooseto practicein 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 development 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 producing 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 administrative 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.
Chapter 1 • Advanced Practice Nursing 7
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 educatethem (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, theinclusion of large numbers of males in
its ranks has noteased 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 thespectrum 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 practice 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 [Show Less]