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Copyright © 2005 by F. A. Davis.
Copyright © 2005 by F. A. Davis.
Advanced Practice Nursing:
Emphasizing Common Roles
Edition 2
Joan M. Stanley, PhD, RN, CRNP
Director of Education Policy
American Association of Colleges of Nursing
Washington, DC
F.A. Davis Company • Philadelphia
Copyright © 2005 by F. A. Davis.
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Copyright © 2005 by F. A. Davis Company
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Library of Congress Cataloging-in-Publication Data
Advanced practice nursing : emphasizing common roles / [edited by] Joan M. Stanley.—2nd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 0-8036-1229-X (hardcover : alk. paper)
1. Nurse practitioners. 2. Midwives. 3. Nurse anesthetists.
[DNLM: 1. Nurse Clinicians. 2. Nurse Practitioners. 3. Nurse Midwives. WY 128 A2445 2005] I.
Stanley, Joan M.
RT82.8.A37 2005
610.73′06′92—dc22
2004001938
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Copyright © 2005 by F. A. Davis.
This book is dedicated to my mother,
Lillian P. Stanley, forever a nurse!
Copyright © 2005 by F. A. Davis.
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Copyright © 2005 by F. A. Davis.
Foreword
With information overload a challenge in all of our lives, why should anyone
read this book? The answer is simple—this book is not only informative, cov-
ering the major issues facing advanced practices nurses (APNs), but it is also vital
to understanding the past, present, and future of advanced practice. This effort
weaves together historical views of APNs with present-day issues and trends. The
contributors have masterfully analyzed the issues so that the reader will come to
know both the larger policy issues facing APNs and how these issues translate into
day-to-day care of patients.
The critical examination of financing, values, politics, and intraprofessional
education and practice as well as interprofessional relationships combines to bring
APNs into sharp focus. The evolution of APNs has been a major event in the his-
tory of nursing. While each of the four APN disciplines—clinical nurse specialist,
nurse practitioner, certified nurse midwife, and nurse anesthetist—has a unique
history and place within nursing, the commonalities have established a force within
health care that has changed the way care is delivered and will continue to change
the system. In fact, the commonalities provide a critical basis for forging an even
more powerful coalition of APNs to tackle common challenges related to ensuring
patients get the best care possible. The social contract that nurses have with the
public is unique, and APNs have extended that contract to higher levels of service,
decision-making, and accountability.
This book captures the vitality of advanced practice nursing as an aggregated
entity. The label of APN is now widely used and recognized by policy makers
and patients alike. This represents unprecedented progress in nursing, when few
knew what a clinical specialist or nurse practitioner was. We are largely past the
days of having to prove the viability, utility, and safety of APNs. We are now con-
structively examining practice issues in order to advance patient care, not defend
the practice.
Each chapter presents perspectives that are useful resources unto themselves.
A valuable part of each chapter is the suggested exercises. Readers will appreciate
the challenge that these exercises afford them. Taking the time to think through the
questions will give APNs and others a chance to explore issues they may not have
thought to explore. Even though each chapter is a resource itself, the collection of
v
Copyright © 2005 by F. A. Davis.
•vi FOREWORD
chapters is so well orchestrated that the full picture is definitely greater than the
parts.
Whether this book is used by students, practicing APNs, policy makers, or
other health professionals, it will be an extraordinary resource.
Jean Johnson, PhD, FAAN
Senior Associate Dean and Professor
George Washington University Medical Center
Washington, DC
Copyright © 2005 by F. A. Davis.
Acknowledgments
As an APN for the past 30 years, more years than I want to count, I have made
many lasting and cherished friends among the APN community. A very heart-
felt thanks goes out to all on whom I called and who allowed me to cajole them into
contributing to this project. The collegiality of the APN community was truly
demonstrated.
I also am deeply indebted to all my friends and colleagues who provided sup-
port throughout this endeavor. Several people were particularly helpful in provid-
ing guidance and wisdom. A special thanks goes to Christine Sheehy and Marilyn
Edmunds, who shared their expertise and insight on editing a book. I also am in-
debted to my editor, Joanne DaCunha, for her patience and confidence through the
many stages of learning and production.
Finally, loving thanks go to my husband, Jack, and my two boys, Jonny and
Jeff, for their understanding, love, and support. And to my little sister, June, an
FNP, who has always been there for me when I needed a listening ear or a laugh:
thank you.
JMS
vii
Copyright © 2005 by F. A. Davis.
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Copyright © 2005 by F. A. Davis.
Contributors
Janet Allan, PhD, RN, NP, FAAN
Dean
University of Maryland School of Nursing
Baltimore, Maryland
Geraldine “Polly” Bednash, PhD, RN, FAAN
Executive Director
American Association of Colleges of Nursing
Washington, DC
Debra Bergstrom, MS, RN, FNP
Nurse Practitioner
Neighborhood Family Practice, PC
Linda A. Bernhard, PhD, RN
Associate Professor and
Associate Dean of Academic Affairs
The Ohio State University
Columbus, Ohio
Pier Angeli Broadnax, PhD, RN
Assistant Professor
Howard University
Washington, DC
Vicki L. Buchda, MS, RN
Director, Patient Care Resources
Mayo Clinic
Scottsdale, Arizona
Christine E. Burke, PhD, CNM
Clinical Practice
The Denver Health Authority
Denver, Colorado
ix
Copyright © 2005 by F. A. Davis.
•x CONTRIBUTORS
Linda Callahan, PhD, CRNA
Associate Professor
Department of Nursing
California State University
Long Beach, California
Dennis J. Cheek, PhD, RN, FAHA
Professor, Harris School of Nursing and
School of Anesthesia
Texas Christian University, Texas
Katherine Crabtree, DNSc, FAAN APRN, BC
Professor
Oregon Health and Science University
Portland, Oregon
Linda Lindsey Davis, PhD, RN
Professor, School of Nursing
Senior Scientist, Center for Aging
University of Alabama at Birmingham
Birmingham, Alabama
Julie Reed Erickson, PhD, RN, FAAN
Associate Professor
University of Arizona College of Nursing
Tucson, Arizona
Margaret Faut-Callahan, DNSc, CRNA, FAAN
Professor and Chair of Adult Health Nursing and
Director of the Nurse Anesthesia Program
Rush University College of Nursing
Chicago, Illinois
Linda Gibbs, BSN, RN, MBA
Assistant Professor of Clinical Nursing
Associate Dean for Practice Development
Columbia University School of Nursing
New York, New York
Catherine L. Gilliss, DNSc, RN, FAAN
Dean and Professor
Yale University
New Haven, Connecticut
Karol S. Harshaw-Ellis, MSN, RN, A/GNP, ACNP-CS
Consulting Clinical Associate
Durham Regional Hospital
Copyright © 2005 by F. A. Davis.
•CONTRIBUTORS xi
Practicing Acute Care Nurse Practitioner
Durham, North Carolina
Judy Honig, EdD, CPNP
Associate Professor of Clinical Nursing
and Associate Dean, Student Services
Columbia University School of Nursing
New York, New York
Betty J. Horton, CRNA, DNS
Immediate Past Director
American Association of Nurse Anesthetists Accreditation Council
Chicago, Illinois
Anita Hunter, PhD, RN, CNS, CPNP
Associate Professor and PNP
University of San Diego
San Diego, California
Lucille A. Joel. EdD, RN, FAAN
Professor
Rutgers—The State University of New Jersey, College of Nursing
Newark, New Jersey
Jean Johnson, PhD, FAAN
Senior Associate Dean and Professor
George Washington
University Medical Center
Washington, DC
Suzanne Hall Johnson MN, RN,C, CNS
Director, Hall Johnson Consulting, Inc
Editor Emeritus, Nurse Author & Editor and Dimensions
of Critical Care Nursing
Lakewood, Colorado
Mary Knudtson MSN, NP
Professor of Family Medicine
University of California,
Irvine, California
Pauline Komnenich, PhD, RN
Professor
Arizona State University College of Nursing
Tempe, Arizona
Copyright © 2005 by F. A. Davis.
•xii CONTRIBUTORS
Michael J. Kremer, DNSc, CRNA, FAAN
Associate Professor of Adult Health Nursing and
Assistant Director of the Nursing Anesthesia Program
Rush University College of Nursing
Chicago, Illinois
Brenda L. Lyon, DNS, FAAN
Professor, Adult Health Nursing
Indiana University School of Nursing
Indianapolis, Indiana
Mary Jeannette Mannino, JD, CRNA
Director, Anesthesia and Ambulatory Surgery
The Mannino Group
Washington, D.C.
Eileen T. O’Grady, PhD, RN, NP
Adjunct Assistant Professor
George Washington University School of Medicine
and Health Sciences and
George Mason University College of Nursing
and Health Science
Fairfax, Virginia
Mary Ann Shah, CNM, MS, FACNM
President, American College of Nurse-Midwives
Editor Emeritus, Journal of Midwifery & Women’s Health
White Plains, New York
Christine Sheehy, PhD, RN
Chief, Quality of Care and Program Monitoring for
Geriatrics and Extended Care in the Veterans Health Administration
Washington, DC
Michelle Walsh, PhD, RN, CPNP
Pediatric Nurse Practitioner
Columbus, Ohio
Marla J. Weston, MS, RN
Executive Director
Arizona Nurses’ Association
Phoenix, Arizona
Copyright © 2005 by F. A. Davis.
Consultants
Lynne M. Dunphy, PhD, FNP, CS
Associate Professor
Florida Atlantic University
Boca Raton, Florida
Laurie Kennedy-Malone, PhD, RN, APRN-BC, GNP
Associate Professor
Director of the Adult/Gerontological Nurse Practitioner Program
School of Nursing
The University of North Carolina at Greensboro
Greensboro, North Carolina
xiii
Copyright © 2005 by F. A. Davis.
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Copyright © 2005 by F. A. Davis.
Contents
Foreward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .V
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XIX
CHAPTER 1
The Evolution of Advanced Practice in Nursing . . . . . . . . . . . . . . . . . . . . . . . .1
Pauline Komnenich, PhD, RN
Certified Nurse Midwives, 4 33
Nurse Anesthetists, 14
Clinical Nurse Specialists, 22
Nurse Practitioners, 27
Joining Forces: Role Parameters and Concerns,
CHAPTER 2
Advanced Practice Nursing in the Current Sociopolitical Environment . . . . .46
Lucille A. Joel, EdD, RN, FAAN
The American People and Their Health, 48 56
The Health Care Delivery System: Origins of Change, 54
Dominant Trends in American Health Care, 55
The Advanced Practice Nurse and the Emergent Delivery System,
Barriers to Advanced Nursing Practice, 57
Summary, 66
CHAPTER 3
The American Health Care System: Implications for Advanced
Practice Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70
Mary Knudtson, MSN, NP
The American Health Care System, 72 90
Financing Health Care, 74
The Evolution of Managed Care, 88
Implications for Advanced Practice Nursing,
xv
Copyright © 2005 by F. A. Davis.
•xvi CONTENTS
CHAPTER 4
Selected Theories and Models for Advanced Practice Nursing . . . . . . . . . . . .93
Michelle Walsh, PhD, RN, CPNP, Linda A. Bernhard, PhD, RN
Theories of Leadership, 96 113
Theories of Change, 102
Models of Health Promotion, 107
Models of Advanced Practice Nursing,
Summary, 119
CHAPTER 5
Primary Care and Advanced Practice Nursing: Past, Present,
and Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .122
Catherine L. Gilliss, DNSc, RN, FAAN, Linda Lindsey Davis, PhD, RN
Health Care in the Twentieth Century, 124
Health Care in the Twenty-First Century, 124
The Nature of Primary Care, 125
Primary Care Providers in the Twenty-First Century, 131
Policy Issues Influencing Advanced Practice in Emerging Primary
Care Systems, 137
Summary, 142
CHAPTER 6
Advanced Practice Nurses in Non-Primary Care Roles: The Evolution
of Specialty and Acute Care Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .146
Dennis J. Cheek, PhD, RN, FAHA, Karol S. Harshaw-Ellis, MSN, RN, A/GNP, ACNP-CS
Advanced Practice Nursing Roots in Acute Care, 148
Evolution of NPs in Neonatal and Acute Care, 149
Hospitalist/Acute Care Nurse Practitioner Model, 152
Non-Primary Care Roles: Growing Specialties, 154
Summary, 155
CHAPTER 7
Formulation and Approval of Credentialing and Clinical Privileges . . . . . . .158
Geraldine “Polly” Bednash, PhD, RN, FAAN, Judy Honig, EdD, CPNP, Linda Gibbs, BSN, RN, MBA
Regulation: Professional and Public, 160 174
Professional Certification for APNs, 169
Clinical Practice and Institutional Privileges,
Summary, 183
CHAPTER 8
Reimbursement for Expanded Professional Nursing Practice Services . . . . .187
Michael J. Kremer, DNSc, CRNA, FAAN, Margaret Faut-Callahan, DNSc, CRNA, FAAN
The Economic System, 191 199
Criteria for an Economic System in Relation to Health Care, 191
Types of Economic Systems, 192
Market Competition, 194
Disequilibrium, 196
Supplier-Induced Demand, 197
The Effects of Changes in Price, Supply, and Demand for Health Care,
Copyright © 2005 by F. A. Davis.
•CONTENTS xvii
Cost Considerations in Provision of Care and Reimbursement for Physicians and APNs, 201
Key Terms in Finance and Reimbursement, 210
Reimbursement for Specific APN Groups, 214
Summary, 223
CHAPTER 9
Marketing the Role: Formulating, Articulating, and Negotiating
Advanced Practice Nursing Positions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .226
Christine E. Burke, PhD, CNM
The Traditional Marketing Approach: The 4 Ps, 228
Knowledge of Personal Values, Professional Skills, and Practical Necessities, 230
Knowledge of Practice Regulations, 232
Knowledge of Existing Services, 232
Knowledge of Clients’ Health Care Needs and Desires, 233
Knowledge of the Target Population’s Understanding of the Role and Scope
of Practice of the APN, 234
Knowledge of the Utilization and Cost-Effectiveness of and Satisfaction with
APN Services, 234
Knowledge of Specific Marketing Elements, 235
Communication Skills, 237
Evaluation of Job Opportunities, 246
Close of the Deal, 248
Mentors and Career Advancement, 250
Summary, 252
CHAPTER 10
Caring for a Diverse Population: Ensuring Cultural Competency
in Advanced Practice Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .255
Pier Angeli Broadnax, PhD, RN
Diversity, 258 259
Commonly Used Culture-Related Terms,
Principles of Cultural Competency, 260
Cultural Assessment Models, 261
Healthy People 2010, 264
Culturally Sensitive Life Events, 264
Summary, 273
CHAPTER 11
Clinical Research in the Advanced Practice Role . . . . . . . . . . . . . . . . . . . . . .277
Julie Reed Erickson, PhD, RN, FAAN, Christine Sheehy, PhD, RN
APNs as Consumers of Research, 282
APNs as Researchers, 293
Summary, 297
CHAPTER 12
Publishing Scholarly Works . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .304
Suzanne Hall Johnson, MN, RN,C, CNS
Avoiding the “School Paper” Style Rejection, 307
Adapting the Thesis Style for Publication, 313
Summary, 320
Copyright © 2005 by F. A. Davis.
•xviii CONTENTS
CHAPTER 13
Legal and Ethical Aspects of Advanced Practice Nursing . . . . . . . . . . . . . . .322
Linda Callahan, PhD, CRNA, Mary Jeannette Mannino, JD, CRNA
Nurse Practice Acts, 324 327
Professional Negligence (Malpractice),
Malpractice Insurance, 331
The Patient and the APN, 332
Professional Ethics, 332
CHAPTER 14
Advanced Practice Nursing and Global Health . . . . . . . . . . . . . . . . . . . . . . . .351
Katherine Crabtree, DNSc, FAAN, APRN, BC, Anita Hunter, PhD, RN, CNS, CPNP
Global Health Challenges, 354 367
Globalization of Advanced Practice Nursing, 355
Education Competencies for NP Practice in the U.S. and Abroad, 357
Advanced Practice Nursing in Other Developed Nations, 361
Advanced Practice in Developing Nations, 364
Ethics and Spiritual and Cultural Competence in a Global Environment,
Opportunities for Advanced Practice Outside the United States, 367
Preparing APNs with a Global Perspective, 369
Summary, 371
CHAPTER 15
Advanced Practice Nursing and Health Policy . . . . . . . . . . . . . . . . . . . . . . . .374
Eileen T. O’Grady, PhD, RN, NP
Tensions Among Health Care Costs, Quality, and Access, 376
The American Health Policy Process, 379
The APN Health Policy Agenda, 384
APN Political Competence, 388
Important Health Policy Websites, 392
CHAPTER 16
Creating Excellence in Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .395
Marla J. Weston, MS, RN, Vicki L. Buchda, MS, RN, Debra Bergstrom, MS, RN, FNP
Attributes of Excellence, 398
Summary, 409
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .413
Copyright © 2005 by F. A. Davis.
Introduction
Joan M. Stanley, PhD, RN, CRNP
Joan Stanley, PhD, RN, CRNP, is currently Director of Education Policy at the
American Association of Colleges of Nursing (AACN), a position she has held
since 1994. She has served on many of the association’s task forces and commit-
tees, including the Task Forces on Essentials of Master’s Education for Advanced
Practice Nursing, Essentials of Baccalaureate Education for Professional Nursing
Practice, Hallmarks of Professional Nursing Practice, Quality Indicators for
Research-Focused Doctoral Programs, and Education, Regulation and Practice II.
She codirected the national project to develop consensus-based Primary Care
Competencies for Adult, Family, Gerontology, Pediatric and Women’s Health. She
has also served as the association’s representative to numerous advanced practice
nursing projects, including the American Nurses Association’s Task Force on the
Scope and Standards for Advanced Practice Nursing, The National Council of
State Boards of Nursing’ Advisory Committee for the Family Nurse Practitioner
Pharmacology Curriculum Project, and the first and second national task forces that
developed the Criteria for Evaluation of Nurse Practitioner Programs. In addition,
since 1991, Dr. Stanley has served as project director for a contract awarded to the
AACN by the National Health Service Corps and served on the NHSC Technical
Advisory Group on the Evaluation of the Effectiveness of the NHSC. She also main-
tains a practice as an adult nurse practitioner at the University of Maryland
Hospital Faculty Practice Office. Before joining the AACN, Dr. Stanley was assis-
tant professor at the School of Nursing at the University of Maryland and associate
director of Primary Care Nursing Services at the University of Maryland Hospital.
Dr. Stanley received her bachelor’s of science degree in nursing from Duke
University and her master’s of science in nursing and her doctorate in higher edu-
cation organization and policy from the University of Maryland.
One commonality undergirds all four advanced practice nursing roles–the dis-
cipline of nursing. At the same time, it is the unique combination of nursing knowl-
edge, science, and practice that differentiates each of the advanced practice nursing
roles from one another and from other health professional roles and practice. Now
is an exciting time for advanced practice nurses (APNs). After many decades, cost-
effectiveness and beneficial outcomes of advanced nursing practice are being widely
xix
Copyright © 2005 by F. A. Davis.
•xx INTRODUCTION
recognized by policy makers, other health professionals, and the public. Despite or
because of the increased recognition and advances made, APNs face many issues,
some recurrent and others emerging, related to education, certification, regulation,
and practice. Increasingly over the past 10 years, leaders in the APN community
have recognized the need and benefit to collaborate in addressing these common
concerns. Some of the most critical emerging and recurrent practice issues con-
fronting APNs include attempts to limit scope of practice, rising costs of malpractice
insurance premiums, establishing parity with other health professions, mainte-
nance of ongoing competence, and standardized recognition for reimbursement,
primary care status, and practice privileges. Current education issues facing the
APN community include concern over subspecialization, maintenance of quality
programs, and the exponential growth of scientific knowledge, technology, and role
expectations, all of which have increased credit requirements and length of educa-
tion programs. A comprehensive list of critical issues currently facing APNs could
probably be developed. However, the nuances, importance of, and interaction of
events affecting each of these issues are changing constantly. Just since beginning
work on this text, changes in economic and health policies, funding sources, and
even organizational policies are just of a few of the things that have significantly
impacted, both positively and negatively, APN practice and education. An overall
and ongoing awareness of these issues, and of others not yet evident, is what is im-
perative for each APN in order to navigate the current and future health care envi-
ronment successfully.
Four nursing leaders, each recognized for leadership and expertise in one of
the APN specialties, were asked to identify and briefly discuss the critical issues fac-
ing their APN specialty, now and in the near future. These perspectives represent
the individual’s opinion and personal thoughts and are presented here as a basis for
reflection and discussion.
THE CERTIFIED REGISTERED NURSE ANESTHETIST
ISSUES TODAY AND TOMORROW
Betty J. Horton, CRNA, DNSc
Immediate Past Director
American Association of Nurse Anesthetists (AANA)
Accreditation Council
Nurses were chosen by surgeons to administer anesthesia in the United States
shortly after the discovery of ether in the middle of the 19th century. In 1893, Isabel
Robb documented the education of nurses as anesthetists by including a chapter
on the administration of anesthesia in her nursing textbook. She indicated that
nurses needed the information because they were often asked to give anesthesia
to alleviate the pain and suffering of patients. Thus, Robb identified nurses as
the first professional group to provide anesthesia in the United States prior to the
establishment of anesthesiology as a specialty option for physicians following
World War II.
Copyright © 2005 by F. A. Davis.
•INTRODUCTION xxi
In the early 20th century, court decisions established that nurse anesthetists
were not practicing medicine but rather practicing nursing when they administered
anesthesia. These legal opinions paved the way for a current population of approxi-
mately 30,000 certified registered nurse anesthetists (CRNAs) to administer more
than 65 percent of the 26 million anesthetics given annually in 50 states and Puerto
Rico. CRNAs practice in all types of practice settings, from large urban centers to
more than two-thirds of rural hospitals where they are the sole anesthesia
providers. Fifty-eight percent of CRNAs are women, and 42 percent are men.i
There are many important education and practice issues facing CRNAs in the
early 21st century. Key issues in education include approval of schools, certifica-
tion, academic degrees, and continuing education. Key practice issues are changes
in the work environment, equitable reimbursement for services, continuing educa-
tion, maintaining a full scope of practice, and staffing shortages.
Education Issues
Nurse anesthetists recognized education as a top priority at the first meeting of the
National Association of Nurse Anesthetists (later renamed the American
Association of Nurse Anesthetists [AANA]) in 1931. This focus on education was
maintained throughout the 20th century with the establishment of educational
standards, accreditation of schools, certification of nurse anesthetists for entry into
practice, and a recertification process requiring mandatory continuing education.
Civilian and military employers, insurers, and governments soon recognized the
value of the accreditation, certification, and recertification requirements as estab-
lished prerequisites for nurses as anesthetists to provide safe care to patients. The
maintenance of strong accreditation, certification, recertification, and continuing
education programs will continue to hold value and high priority for CRNAs.
Support of graduate education for nurse anesthetists has also been a key issue.
Following the move of all certificate nurse anesthesia programs into graduate edu-
cation to comply with a 1998 deadline set by the Council on Accreditation of Nurse
Anesthesia Education Programs, it is projected that every practicing CRNA will
possess a minimum of a master’s degree sometime in the first half of the 21st cen-
tury. Continued support for graduate education will undoubtedly increase knowl-
edge from research on education and practice.
Another key issue is the education of adequate numbers of students to meet the
increasing demands for anesthesia services. Nurse anesthesia programs have been
admitting more students as resources permit to meet a national need for increased
staffing. However, the recruitment and retention of more qualified faculty are vital
to meeting anesthesia personnel needs. Success in obtaining government funding
for education and payment for patient care services provided by CRNA clinical in-
structors will affect the availability of adequate resources necessary to continue ed-
ucating enough anesthetists in the future.
Practice Issues
Providing safe hands-on care to one patient at a time is the hallmark of nurse anes-
thesia care. Close patient contact is provided in an environment where major health
Copyright © 2005 by F. A. Davis.
•xxii INTRODUCTION
care reform has redefined how and where anesthesia care is to be provided, with
significant reduction in the amount of time nurse anesthetists can spend with pa-
tients. Changes in the practice environment have also included a tremendous ex-
pansion of knowledge and technology in recent decades. This requires that nurse
anesthetists use a great deal of technology in all kinds of practice settings whether
part of an anesthesia team or not. Complex services must be provided that require a
full scope of practice with a wide variety of anesthesia techniques, drugs, and equip-
ment. The need to keep abreast of changes within the field will continue to commit
CRNAs to continuing education and evidence-based practice throughout their ca-
reers.
The AANA and state nurse anesthesia organizations have made concerted
efforts to avoid reimbursement disincentives for the use of CRNAs. Although op-
posed vigorously by anesthesiologists, nurse anesthetists were the first nurses to ini-
tiate a successful lobbying effort resulting in direct reimbursement from Medicare
in 1989. Today, nurse anesthesia services are additionally reimbursed by various
states and federal programs plus some commercial insurance carriers. A proposal to
eliminate physician supervision as a condition of Medicare reimbursement was
deemed to be each state’s prerogative rather than a federal policy, which had been
strongly supported by nursing. A number of states have opted out of the require-
ment that tied reimbursement for CRNAs to physician supervision. Lobbying for
equitable reimbursement for services of civilian CRNAs and financial incentives for
military CRNAs will be ongoing. Contributions to political campaigns are an impor-
tant part of organized lobbying efforts. In 2002, the national political action com-
mittee, CRNA PAC, ranked 107 out of approximately 3,000 federal PACs.
In addition to equitable reimbursement for CRNAs, other critical practice is-
sues include the availability and affordability of liability insurance; the regulation of
clinical practice at the institutional, state, and federal levels; the maintenance of a
full scope of practice; and strained relationships between anesthesiologists and
nurse anesthetists at the national and state levels. Undoubtedly, lobbying, public re-
lations, and liaisons with other APN groups will continue to be at the forefront in
attaining successful resolution to these issues in the foreseeable future.
MIDWIFERY, A BLEND OF ART AND SCIENCE
Mary Ann Shah, CNM, MS, FACNM
President, American College of Nurse-Midwives (ACNM)
Editor Emeritus, Journal of Midwifery & Women’s Health
In 2005, the American College of Nurse-Midwives (ACNM) will celebrate its 50th
anniversary as the professional organization for certified nurse-midwives (CNMs)
and certified midwives (CMs). However, its historic roots date back to 1925 when
Mary Breckinridge sent public health nurses to Great Britain for midwifery train-
ing, and they returned to the Frontier Nursing Service of Kentucky, serving as the
first nurse-midwives in the United States. A few years later, the first formal nurse-
Copyright © 2005 by F. A. Davis.
•INTRODUCTION xxiii
midwifery education program within the United States was initiated in New York
City, and public health nurses were, once again, targeted for recruitment.
The ACNM has had a long and complex history with nursing. Nurse-
midwifery established itself as a profession in the 1920s, separate from but paired
with nursing; thus, its hyphenated name. During the mid-1940s, a section for
nurse-midwives was created within the National Organization of Public Health
Nurses (NOPHN). However, NOPHN was absorbed into the American Nurses
Association and the National League for Nursing a few years later, and subsequent
efforts to reestablish a niche specific to nurse-midwifery within these nursing orga-
nizations were unsuccessful. Thus, nurse-midwives were forced to seek their own
professional organization; in 1955, they incorporated in New Mexico as the
American College of Nurse-Midwifery (the name was modified to its current one in
1969). Today, midwives are licensed to practice under a variety of midwifery, nurs-
ing, medical, and/or other state regulatory agencies. Regardless of how they are
credentialed, it seems safe to say that the interrelationship between midwives and
nurses will always be a collegial and collaborative one.
The ACNM has also had an evolving relationship with the American College of
Obstetricians and Gynecologists (ACOG). Although formal recognition by ACOG
in the early 1970s helped bring midwifery care into hospitals, finding language that
supported autonomous decision-making has been difficult. This was finally
achieved in October 2002, when the current version of the Joint Statement of
Practice Relations was approved by both organizations. This document clearly es-
pouses mutual respect and collaboration between physicians and CNMs/CMs while
placing professional accountability where it rightfully belongs: on the individual
provider of care: “ACOG and ACNM affirm their commitment to promote appro-
priate standards for education and certification of their respective members, to
support appropriate practice guidelines, and to facilitate communication between
obstetrician-gynecologists and certified nurse-midwives/certified midwives.”ii
While the majority of today’s midwives have entered the profession through
nursing education and have received the CNM credential, a growing number are
gaining entry via an approved alternate, but equivalent, education pathway and are
qualifying for the CM credential. The ACNM currently represents over 7,100
CNMs and CMs, having certified the 10,000th midwife in 2002. The organization is
committed to maintaining the highest standards for the practice of midwifery, the
accreditation of education programs, and the certification of practitioners.
It must be underscored that, similar to their nurse peers, non-nurse applicants
to ACNM-accredited midwifery education programs must successfully complete
university-level prerequisite courses in biology, microbiology, anatomy and physiol-
ogy, pathophysiology, psychology, sociology, chemistry, human development, epi-
demiology or statistics, and nutrition. Furthermore, although the ACNM Division
of Accreditation did not mandate that all CNMs and CMs possess a minimum of a
baccalaureate degree until the 1990s, over 73 percent have earned an additional
master’s or higher degree. In addition, all must graduate from an accredited mid-
wifery education program that is affiliated with an institution of higher learning
and must pass the national certification examination administered by the ACNM
Certification Council, Inc.
Copyright © 2005 by F. A. Davis.
•xxiv INTRODUCTION
According to data released by the U.S. National Center for Health Statistics in
2001, CNMs attended 10 percent of all vaginal births in the United States, more
than tripling the number reported nationally since 1989. Most notably, 34.5 percent
of all vaginal births in New Mexico that same year were attended by CNMs, with
Georgia (23.5 percent), New Hampshire (22.1 percent), and Vermont (21 percent)
also setting remarkable records. Unfortunately, other aspects of midwifery practice
are more difficult to track.
The midwife’s scope of practice, as embodied within the ACNM’s standards,
promotes “individual rights and self-determination within boundaries of safety,”
comprises “knowledge, skills, and judgments that foster the delivery of safe, satisfy-
ing, and culturally competent care,” and is supported by the ACNM’s Hallmarks of
Midwifery,iii which espouse, among others, the following high ideals:
• Advocacy of nonintervention in the absence of complications, informed
choice, participatory decision-making, and the right to self-determination
• Incorporation of scientific evidence into clinical practice
• Promotion of family-centered/continuity of care, cultural competency, care
to vulnerable populations, and a public health perspective
• Recognition of the therapeutic value of human presence
• Empowerment of women as partners in health care
• Skillful communication, guidance, and counseling
• Health promotion, disease prevention, and health education
• Facilitation of healthy family and interpersonal relationships
• Familiarity with common complementary and alternative therapies
The ACNM’s Core Competencies for Basic Midwifery Practiceiii specifically de-
lineate the minimal expectations for CNMs and CMs upon entry into practice and
serve as the foundation on which all ACNM-accredited midwifery education pro-
grams base their curricula. They stipulate that the CNM/CM must be prepared to
independently manage—utilizing consultation, collaboration, and/or referral to ap-
propriate levels of health care services—all of the following:
• Primary health screening and health promotion of women from the perime-
narcheal through the postmenopausal periods
• Gynecologic and family planning interventions
• Human sexuality counseling
• Therapies for common health problems/deviations of essentially healthy
women
• Care of women during pregnancy, childbirth, and the postpartum period
• Care of the newborn during the first 28 days of life
The ACNM proudly proclaims that midwifery represents the ideal blend of art
and science, i.e. “the best of both worlds,” offering women “high-touch/low-tech
care with high-tech options,” and that midwives are “With women, for a lifetime®”.
As Hattie Hemschemeyer, ACNM’s first president, wrote in 1956: “The future
looks bright.”
Copyright © 2005 by F. A. Davis.
•INTRODUCTION xxv
CLINICAL NURSE SPECIALISTS: CURRENT
CHALLENGES
Brenda L. Lyon DNS, FAAN
Professor, Adult Health Nursing
Indiana University School of Nursing
Past President, National Association of Clinical Nurse Specialists
Over the years, there has been considerable confusion regarding the commonalities
and differences among the four different advanced practice nurse (APN) scopes of
practice and roles, particularly between those of the clinical nurse specialist (CNS)
and nurse practitioner (NP). Although there are some commonalities in competen-
cies and some common concerns across all APNs, each area of advanced practice
nursing is responsive to different societal needs for care.
CNSs are registered nurses (RNs) who have graduate (master’s or doctoral
degree) preparation as a CNS. The CNS is a clinical expert in the application of
theory and research-based knowledge in a specialty area of nursing practice.
Specialization is at the heart of all CNS practice. Today CNS specialties encompass
one or any combination of settings (e.g., critical care, home or community care),
general disease or injury categories (e.g., medical-surgical, trauma, neurology, on-
cology, diabetes, orthopedics, pulmonary, or perioperative), age (e.g., pediatrics or
gerontology), life processes (e.g., perinatal or genetic), disease stage (e.g., chronic
disease), and health-related phenomena (e.g., pain or stress). Areas of specialization
have evolved over time in response to societal needs for CNS services.
The CNS scope of practice encompasses three spheres of influence: patient/
client (direct care), nursing personnel (advancing the practice of nursing), and or-
ganization/network (interdisciplinary). The second and third spheres are often re-
ferred to as the indirect domains of CNS practice. The balance or focus of a CNS
practice in these three spheres varies based on client and employer need. Each
sphere of influence requires a unique set of core competencies regardless of
specialty area. The National Association of Clinical Nurse Specialists (NACNS)
Statement on Clinical Nurse Specialists Practice and Educationiv articulates core
CNS competencies in each of these spheres.
Nationally, the RN license authorizes the practitioner independently or au-
tonomously to diagnose (nursing diagnoses) and treat (nursing therapeutics/treat-
ments) health-related problems (symptoms and functional problems). In addition to
this autonomous nursing scope of practice, practice acts authorize RNs to imple-
ment delegated medical therapeutics via prescriptive delegation or protocol. Since
the 1970s, most CNSs have practiced at an advanced level within these scopes of
practice. Some CNSs have extended their practice outside the domains authorized
by the RN license, e.g., obtaining prescriptive authority. Important regulatory is-
sues need to be addressed regarding CNS prescriptive authority. Specifically, should
a second license be required for the CNS who prescribes medications as this prac-
tice activity is not authorized in the RN scope of practice?v
Copyright © 2005 by F. A. Davis.
•xxvi INTRODUCTION
Today there is a critical shortage of CNSs. The U.S. Department of Health &
Human Services (DHHS) estimated that there were approximately 54,000 CNSs in
2000.vi This number is lower than estimated in previous years, largely as a result of
a reduction in CNS academic programs and positions during the 1990s. Reductions
in reimbursements to hospitals in the early and middle 1990s created downward
pressures on both RN and CNS staffing. The East and West coasts were particu-
larly hard hit in the reduction of CNS positions. One of the factors contributing
to the loss of CNS positions was, unfortunately (despite having a positive impact
on outcomes and cost), the fact that most CNSs were documenting time spent in ac-
tivities rather than outcomes, cost savings, cost avoidance, or revenue generation.vii
Another factor was the almost exclusive attention placed by policy makers and
schools of nursing on the preparation and regulation of NPs.
In 2002, the NACNS received an increasing number of recruiter requests, at
least 25 to 50 per month, for open CNS positions. The pressure to increase the num-
ber of CNSs is evident in the fact that a 2001 NACNS survey found 183 CNS pro-
grams, whereas in 1997 only 147 CNS programs were reported.vii The DHHS
Division of Nursing, in recent years, has also renewed its priority to include train-
ing grants for CNS programs.
Current challenges facing CNSs as APNs arise primarily from the regulatory
and educational (academic and continuing professional learning) arenas.
Regulatory Challenges
In the regulatory arena, the challenges are particularly difficult. Specific regulatory
challenges include:
• Preventing the creation of credentialing requirements for CNS practice that
create unnecessary barriers to the public’s access to the full range of CNS
services
• Developing a legally defensible alternative to certification for regulatory
recognition when no certification examination is available in a CNS spe-
cialty
• Achieving a reasonable level of uniformity to the regulation of CNS practice,
thereby facilitating reciprocity across state lines
Unnecessary “overregulation” in credentialing CNSs is an immediate concern.
Credentialing for regulatory purposes is important to affirm the educational prepa-
ration of a CNS, to establish a defined scope of practice, and to ensure patient
safety. By 1999, 27 states recognized CNSs in statutes, providing title protection
with a defined scope of practice.viii The issue is not whether regulation is necessary
but what level of regulation is necessary. Some states require a second license; oth-
ers require registration or certification. When a CNS practices within the domains
authorized by the RN license, requiring a second license would create unnecessary
practice barriers. However, when a CNS chooses to obtain prescriptive authority or
expand the scope of practice, the need to acquire a second license authorizing prac-
tice beyond that of the RN license becomes clearer. Currently, state boards of nurs-
ing accept certification as a proxy for a second licensure examination. This is not a
Copyright © 2005 by F. A. Davis.
•INTRODUCTION xxvii
barrier to practice when there is a CNS certification examination available in a
CNS’s specialty area of practice. However, when no such examination exists, e.g.,
in orthopedics, perioperative care, or diabetes, the CNS is denied authorization to
practice, and the public is denied access to CNS services. Two possible resolutions
have been proposed, including the development of a CNS “core” competencies ex-
amination and the use of legally defensible portfolios.vii These possible solutions
currently are being jointly investigated by the NACNS and the American Nurses
Credentialing Center.
Currently, there is wide variation in both statutory recognition of CNSs and
regulations governing CNS practice across states. This variation for CNSs and other
APNs creates difficult, or even insurmountable, barriers to reciprocity for practice
across state lines. This lack of uniformity in regulating APNs must be addressed by
the profession as a whole.
Education Challenges
Challenges in the academic and continuing professional learning arena include:
• Implementing educational standards consistent with NACNS standards for
CNS academic programs and developing a mechanism to recognize programs
that meet these standards or incorporate these standards into accreditation
processes.
• Establishing a Web-based continuing education and mentoring network
• Determining whether there is a need for a practice-focused doctoral degree
for CNSs to expand knowledge and skill in such areas as action research,
e.g., to develop and test models for diffusion of knowledge, testing innova-
tions in practice; and testing the economics and cost-benefits of CNS prac-
tice.
The NACNS CNS Educational Standards document was released in early
2004. These standards help assure that CNS academic programs focus on the same
learning outcomes while not prescribing a uniform curriculum.
CNSs, like other APNs, are scattered across the country and practice in
many different types of settings. Future life-long learning needed for practice and
career development will best be met by Web-based continuing education and men-
toring.
Currently, there is considerable debate in the discipline about whether there is
a need for another doctoral degree; specifically, one focused on nursing practice.
The impetus for a practice doctorate is the perceived need to prepare nurses at a
higher level for practice as well as to prepare clinical nursing faculty. Currently,
many CNSs who seek the doctorate, a research-focused degree, do so because they
have been turned on to research and desire to increase their capacity to contribute
to knowledge development for the discipline. Questions related to the practice doc-
torate that must be examined by APNs, educators, and consumers of APN services
include what additional competencies are needed and will the market bear the in-
creased cost for a practitioner or APN who has these competencies.
The continuing evolution of CNS practice will be characterized by the sus-
Copyright © 2005 by F. A. Davis.
•xxviii INTRODUCTION
tained development and evaluation of evidence-based innovations in nursing prac-
tice and a substantial rise in CNS scholarly publications. There is an increasing
need for CNSs to publish scholarly works related to researchable nursing practice
problems, best practices, outcomes evaluation, and strategies to enhance diffusion
of knowledge into nursing practice. Likewise, there is a tremendous need for sys-
tematic evaluation of evidence-based innovations in nursing practice. The system-
atic demonstration of effectiveness of nursing interventions on patient outcomes
and cost-effectiveness will help assure the future inclusion of these activities in CPT
coding and therefore reimbursement of CNS autonomous nursing services.
THE NURSE PRACTITIONER: A LOOK AT THE FUTURE
Janet Allan, PhD, RN, NP, FAAN
Dean, University of Maryland School of Nursing
Past President, National Organization of Nurse Practitioner Faculties
A distinguished nursing dean once said, “Nurse practitioners (NPs) are the future
of nursing.” Time has substantiated this remark. In the nearly 40 years since the
NP role was first conceptualized and implemented, the development of the role has
in many ways revolutionized nursing education and clinical practice. Although pre-
dated by the three other major advanced practice nursing roles, the NP role has
served as the major catalyst for changes in education, practice, and policy. NP edu-
cation is the major component of graduate nursing, with nearly 53 percent of mas-
ter’s level students enrolled in NP programs offered in over 325 institutions.ix
Curriculum standards, preceptor guidelines, role competencies, and program stan-
dards for NP education have been accepted as mainstream in graduate nursing edu-
cation. NPs have established a well-recognized and respected advanced practice
guideline-based direct care role spanning primary care to tertiary care settings. NPs
have made a major contribution to improving the health care of vulnerable popula-
tions and populations experiencing a disproportionate number of health disparities.
By capitalizing on trends in the larger health care system, political activism, and
coalition-building, NPs have been able to implement a full primary care scope of
practice and receive reimbursement for their services. Despite these successes,
many challenges remain for NP education and practice.
I would like to comment briefly on five critical challenges and opportunities
facing NP education and practice in the next decade.
Educate the NP for the Future
NP faculty must continue to maintain high educational standards while continuing
to evolve curricula to respond to society’s needs and health care system changes.
There needs to be further elaboration of ways to implement quality improvement
methods and national standards. Better data systems need to be developed in order
to document and monitor educational outcomes. As the NP role continues to both
evolve and diversify from the initial primary care focus, there will be more blended
Copyright © 2005 by F. A. Davis.
•INTRODUCTION xxix
roles, more specialty roles, and further development of the NP scope of practice,
particularly within multidisciplinary teams. There needs to be an emphasis on
preparing the NP to function in an evolving health care system. Content on cost-
effectiveness, work systems, technological supports, quality assessment, leadership,
and team-building will need to be incorporated into current educational programs.
Develop Evidence-Based Practices
This has come about given the increasing emphasis on quality of care, guideline-
based productivity and evaluation, practice cost outcomes, and the use of evi-
dence-based guidelines to promote equity of care.x NPs must fully implement
evidence-based practices. NPs, regardless of practice setting, have the opportunity
to further develop standardized practice guidelines that integrate nationally ac-
cepted interdisciplinary guidelines and practices with nursing’s focus on health pro-
motion. Utilization of standardized guidelines provides a basis for evaluation of the
contributions of NPs to patient care in multidisciplinary practices. Given a variety
of scenarios about future numbers and the role of NPs and physicians in managed
care settings, there are opportunities for NPs to develop innovative models of care
that expand scope of practice and place the NP in a more dominant primary care
management role.
Use Technological Innovations and Practice Support Systems/
Resources to Better Deliver Care
Recent developments in technology and practice systems provide innovative ways
to remove barriers and enhance the delivery of care. NPs have the opportunity to
incorporate and tailor care support processes and resources to their practice setting
and population. Such systems are particularly helpful in primary care settings to
maximize the effectiveness of the provider/patient interaction for health behavior
change and counseling.xi NPs also have opportunities to explore the use of technol-
ogy to deliver health care to populations at remote sites.
Increase Research on NP Practice
Research on patient outcomes and cost-effectiveness of care is essential to docu-
ment the value of NP practice and to increase our knowledge base of effective
interventions and practice models. We need more knowledge to create effective in-
terventions for populations that differ by ethnicity, gender, and geographic location.
Demonstrating improvements in health outcomes and cost-effectiveness will be
more and more expected of NPs in the future. We need research on the effective-
ness of varying care support systems and technological innovations used to support
interventions. NPs in community-based practices need to form more research-based
practice networks similar to those of physicians in order to examine clinical prob-
lems and practice patterns.xii Such networks allow aggregation across many small
practices so that NPs can document outcomes of care and study important clinical
questions.
Copyright © 2005 by F. A. Davis.
•xxx INTRODUCTION
Move from Competition to Partnership
The dismal state of our health care system, the lack of consumer satisfaction with
health care, the growing elderly population, the growth in community-based care,
spiraling costs, and the continuing magnitude of certain populations experiencing
major health disparities afford NPs an opportunity to create partnerships, build
teams of professional and lay providers, and collaborate with target communities.
As a society, we will not be able to provide quality care for the aging population or
reduce health disparities effectively without major changes in the way we think
about and deliver care. NPs and other disciplines have the opportunity to develop
teams and models of care, with the patient at the center. There also is the opportu-
nity to explore interdisciplinary regulation and clinical integration to ensure high
standards of care.
SUMMARY
Four nursing leaders have presented their unique perspectives on advanced practice
nursing. Similar, yet different, histories, themes, and issues pervade these presenta-
tions. APNs are responsible and accountable for practice outcomes. Likewise, we
must be accountable for our actions and decisions that influence the policies and
events that shape future APN practice. We cannot assume that others, particularly
those outside of advanced practice nursing, will assume responsibility for ensuring
the future of the profession. The topics addressed in Advanced Practice Nursing:
Emphasizing Common Roles provide a broad treatment not only of the history of
APN roles but also of key issues and events that have impacted the evolution of
APN education and practice and continue to present significant challenges to the
future of all APN roles.
REFERENCES
iAmerican Association of Nurse Anesthetists: Certified Registered Nurse Anesthetists, Nurse
Anesthetists at a Glance. http://www.aana.com/crna/ataglance.asp. Accessed 6/26/2003
iiAmerican College of Nurse Midwives & American College of Obstetricians and Gynecologists: Joint
Statement of Practice Relations, October 2002. http://www.midwife.org/prof/jointstate.cfm.
Accessed 11/30/2003.
iiiAmerican College of Nurse Midwives: Core Competencies for Basic Midwifery Practice, May 2002.
http://www.midwife.org/prof/display.cfm?id=137. Accessed 11/30/2003
ivNational Association of Clinical Nurse Specialists: Statement on Clinical Nurse Specialist Practice and
Education, Harrisburg, PA, National Association of Clinical Nurse Specialists, 2004.
vLyon, BL: The regulation of clinical nurse specialist practice: Issue and current developments. Clin
Nurse Specialist 16:239, 2002.
viU.S. Department of Health & Human Services: The Registered Nurse Population. 2000 Fact Sheet.
Findings from the National Sample Survey of Registered Nurses. Health Resources & Services
Administration. Rockville, MD, Bureau of Health Professions, Division of Nursing, 2001.
viiDayhoff, N, and Lyon, BL: Assessing outcomes of clinical nurse specialist practice. In Kleinpell, R.
(ed.): Outcome Assessment in Advanced Nursing, pp. 103–129. New York, Springer Publishing Co.,
2001.
viiiLyon, BL, and Minarik, P.: Statutory and regulatory issues for clinical nurse specialist practice:
Assuring the public’s access to CNS services. Clin Nurse Specialist 15:108, 2001.
ixBerlin, L, Stennett, J, and Bednash, G. 2002–2003 Enrollment and Graduations in Baccalaureate and
Copyright © 2005 by F. A. Davis.
•INTRODUCTION xxxi
Graduate Programs in Nursing. Washington, DC, American Association of Colleges of Nursing,
2003.
xInstitute of Medicine: Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.
Washington, DC, National Academies of Science Press, 2002.
xiSolberg, L, et al.: The case for the missing clinical preventive services systems. Effectiveness Clin Pract
1:33, 1998.
xiiGrey, M, and Walker, PH: Practice-based research networks for nursing. Nursing Outlook. 46:125,
1988.
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Copyright © 2005 by F. A. Davis.
CHAPTER 1
The Evolution of
Advanced Practice
in Nursing
1
Copyright © 2005 by F. A. Davis.
CHAPTER 1
Pauline Komnenich, PhD, RN
Pauline Komnenich, PhD, RN, is currently a Professor in the College of Nursing at
Arizona State University. She received her baccalaureate from Stanford University
and her master’s in nursing from the University of Washington. She also has a
master’s degree in anthropology and a doctorate in linguistics from the University
of Arizona, which she received through the Nurse Scientist Program.
During the past 40 years in nursing, Dr. Komnenich has made contributions
to nursing as an educator, researcher in women’s health and family caregiving for
frail elders in the home, and clinical practitioner in elder care and educational ad-
ministration. Her major contributions in nursing have been to research, research
development, and nursing education. She has provided leadership for care manage-
ment of the elderly and parish nursing. She has a broad background of experience
both nationally and internationally, having participated in nursing education and
research in Eastern Europe and primary health care in Argentina. Professor
Komnenich participated as a Fulbright Senior Scholar in the School of Health at
the University of Sarajevo, Bosnia-Hecegovina, in 1999 to develop a curriculum
for nurses and allied health professionals. During that time she also conducted a
collaborative study with two Bosnian physiatrists on the cross-cultural factors
influencing fall vulnerability in older adults.
Her most current work in the College of Nursing at Arizona State University
is expanding the nurse educator track to offer courses that are relevant to teaching
and learning in academic and practice settings that are technologically relevant.
Dr. Komnenich has conducted studies on the future of nursing, including
perceptions of nurse practitioners and clinical nursing specialists. Her experience
in nursing and in both quantitative and qualitative research provides a unique
background for a unique chapter on the historical context of advanced practice
nursing in four domains.
2
Copyright © 2005 by F. A. Davis.
The Evolution of
Advanced Practice
in Nursing
CHAPTER OUTLINE Sociopolitical Context
Influence of Government Agencies, a Private
CERTIFIED NURSE MIDWIVES
Historical Context Foundation, and Professional Associations
Sociopolitical Context Key Leaders
Influence of Government Agencies and Interface with Certified Nurse Midwives, Nurse
Professional Associations
Influence of Private Foundations, Colleges, Anesthetists, and Nurse Practitioners
and Universities
Forces Influential in Marketing and Effective NURSE PRACTITIONERS
Utilization Historical and Sociopolitical Context
Key Leaders Influence of Government Agencies
Interface with Nurse Anesthetists, Clinical Influence of Private Foundations, Colleges, and
Nurse Specialists, and Nurse Practitioners Universities
Forces Influential in Marketing and Effective
NURSE ANESTHETISTS Utilization
Historical Context Key Leaders
Sociopolitical Context Interface with Certified Nurse Midwives, Nurse
Influence of Government Agencies Anesthetists, and Clinical Nurse Specialists
Key Leaders
Interface with Certified Nurse Midwives, Clinical JOINING FORCES: ROLE PARAMETERS
Nurse Specialists, and Nurse Practitioners AND CONCERNS
CLINICAL NURSE SPECIALISTS SUGGESTED EXERCISES
Historical Context
CHAPTER OBJECTIVES
After completing this chapter, the reader will be able to:
1 Understand the evolution of advanced practice nursing within the historical context of each
of the four practice domains—nurse midwives, nurse anesthetists, clinical nurse specialists,
and nurse practitioners—by reviewing the written historical accounts and reflections of “the
lived experience” of six contemporary nursing leaders.
2 Identify and discuss the sociopolitical forces that stimulated the expanded role for nurses
in the four practice domains.
3 Evaluate critical trends in the educational preparation of nurses and the implications of
those trends in preparing nurses for advanced practice roles.
4 Distinguish those characteristics that influence the scope of knowledge and skills within the
practice domain.
5 Synthesize common or shared role parameters and concerns of advanced practice nurses
from a historical perspective. 3
Copyright © 2005 by F. A. Davis.
•4 CHAPTER 1
As Ford,1 an influential leader in the nurse practitioner movement, pointed out,
myths and fallacies surround any movement. Therefore, the opportunity to di-
rectly interview those individuals who participated in the specific efforts to change
the nursing profession provides a depth of understanding frequently not found in
other historical narratives and helps to dispel some of the myths and fallacies. Built
around the reflections of six contemporary nurses who have experienced firsthand
the evolving role of the certified nurse midwife (CNM), certified registered nurse
anesthetist (CRNA), clinical nurse specialist (CNS), and nurse practitioner (NP),
this chapter not only provides a written and verbal account of events but also inter-
jects the flavor and energy of the “lived experience” of these advanced practice
nurses.
The contributors were selected based on their reputations in their respective
practice domains as clinicians, educators, and leaders. Joyce Roberts, PhD, CNM,
FAAN, FACNM, and Betty Bear, PhD, CNM, FAAN, FACNM, have worked skill-
fully through professional organizations to advance nurse midwifery education and
professional development. John Garde, MS, CRNA, FAAN, assumed a major role
in the American Association of Nurse Anesthetists and continues to provide con-
sultation for the association since stepping down as executive director. Pamela
Minarik, MS, RN, FAAN, has practiced as a psychiatric clinical nurse specialist liai-
son for nearly 20 years. She has contributed to the professional development of the
CNS movement through her practice and scholarly publications on the application
of theory and research to practice as well as through her publications on political
and policy implications for the CNS. Irene Riddle, PhD, MSN, RN, is a professor
emeritus in nursing of children; her career as a pediatric nurse, master teacher,
scholar, and researcher has included the mentoring of numerous CNS students and
professional CNSs. Loretta C. Ford, EdD, MS, FAAN, professor and dean emerita of
the University of Rochester, Rochester, New York, is a national leader in the NP
movement and one whose contributions and vision of advanced practice for nurses
have improved the quality of health care.
Developed through the use of semistructured telephone interviews and docu-
mented histories, the chapter describes the evolution of each domain from the per-
spective of history and sociopolitics, identifies key leaders and events, and discusses
common role parameters. It concludes with a discussion of the common themes
and distinguishing characteristics of each specific practice domain as well as with
some thoughts on the future, drawn from information obtained during the personal
interviews.
CERTIFIED NURSE MIDWIVES
According to Dickerson,59 as of 2003 there were 45 accredited nurse-midwifery ed-
ucation programs in the United States. These programs included 41 master’s educa-
tion programs and 4 certificate programs. In addition to these programs, there are
two accredited midwifery programs, which prepare an individual as a certified mid-
wife who is not a nurse. The development of these programs in the United States
Copyright © 2005 by F. A. Davis.
•THE EVOLUTION OF ADVANCED PRACTICE IN NURSING 5
has a history dating back to the early 1900s. The period from 1900 to 1935 focused
on the extension of education of midwives to the growth of nurse midwifery pro-
grams, which occurred from 1935 to the present. This development occurred with
the placement of nurse midwifery education in post-nursing or post-baccalaureate
programs within institutions of higher education.3 The overall purposes of nurse
midwifery education, as stated in the Carnegie Foundation for the Advancement of
Teaching report,4 are the provision of better health care for mothers and babies and
the promotion of midwifery as “a quality profession, requiring emphasis on caring,
competence and public education” (p. 29).
Historical Context
While the established date for the inception of modern nursing is 1873, there are
records of midwifery practice in the North American colonies dating back to 1630
and of attempts to educate midwives dating back to early 1762.5,6 In these early
times, the provision of obstetric care was outside the purview of medical practice
and was the exclusive domain of midwives. According to Roberts,3 efforts to estab-
lish formal midwifery schools, such as that of William Shippen, Jr., in Philadelphia
in 1762, were unsuccessful, and throughout the 1800s, the native midwife was “self
or apprenticeship-taught and was isolated from medicine, nursing or the hospital”
(p. 123). Although interest in promoting education for midwifery practice renewed
with the immigration of European midwives and physicians to the United States in
the latter part of the nineteenth century, it was not sustained.
Many factors are considered by historians as contributing to the demise of mid-
wifery’s occupational identity. Of note is the fact that the medical specialty of ob-
stetrics7,8 arose against the backdrop of the lack of formal midwifery education5 and
the relatively inexact training requirements for midwives. Other social and eco-
nomic events contributed to the decline of the native midwife.9 Between 1900 and
1935, midwife deliveries dropped from 50 to 10 percent as the flow of immigration
decreased and the emigrant midwife clients became integrated into the dominant
society, as home deliveries were replaced with hospital deliveries, and as physicians
became increasingly critical of the midwife.
An exception to this pattern of declining midwifery use in the United States
existed among the Mormon pioneer midwives. During the late 1800s and early
1900s, the Mormons relied on midwives trained initially in their native lands and
then further educated in medical-obstetrics in the United States at that time.3 In
1874, women who were able to travel to study at the Women’s Medical College in
Philadelphia returned to Utah and established midwifery courses. Licensure for
practice was required in Utah from 1894 to 1932, during which time 208 midwives
were licensed in Salt Lake City.
According to Roberts,3 medical care in the early twentieth century was no
better than midwifery care. A 1912 survey, carried out by J. Whitridge Williams, a
professor of obstetrics at Johns Hopkins University in Baltimore, found that the
lack of preparation of obstetricians rendered their practices as harmful as those
of midwives, if not more so, and noted that more deaths occurred from improper
Copyright © 2005 by F. A. Davis.
•6 CHAPTER 1
operations than from infections at the hands of midwives. Carolyn van Blarcom’s
1914 report to the New York Committee for the Prevention of Blindness acknowl-
edged that women may have been better cared for by less educated midwives than
by the physicians who were responsible for the eye infections and the puerperal
septicemia that were occurring at that time.
Unfortunately, although major reform in medical education began to take place
subsequent to the Flexner Report of 1910, no similar efforts to improve the educa-
tion or preparation of the midwife took place. Roberts2,3 perceived that the lack of
education and opportunity for training further led to diminished opportunities for
midwives. Furthermore, because midwives perceived childbirth as a “normal” phe-
nomenon and within the female domain of competence, few of them sought formal
education. Moreover, the predominantly male physicians’ attitudes toward mid-
wifery were that midwives were unsafe and that no “true” woman would want to
learn the knowledge and skills needed for midwifery.3
Van Blarcom, instrumental in developing the Bellevue School for Midwives,
became known as the first nurse in the United States to be licensed as a midwife.10
She advocated the training, licensure, and control of midwives, while Williams,
ironically, recommended abolishment of midwives and better education for physi-
cians. Even though this controversy led to a decline in midwifery deliveries,
Roberts3 noted that “the negative indicators surrounding childbirth actually
rose with the decline of midwives” (p. 128). Lower maternal and infant mortality
rates existed only where midwives were retained, notably Newark, New Jersey,11
and New York.12 If one considers that midwives were attending to poor, higher-
risk women, these findings were even more impressive. Some of the poorer birth
outcomes attributed to medicine were thought to be due to physicians’ lack of
training and experience with childbirth and to the techniques they used to hurry
labor.
Fortunately, positive midwifery outcomes in Germany and England were
noted by some American nurses who, according to Roberts,2,3 believed that mid-
wives should play a role in maternity care. This view led to the integration of the
roles of the midwife and public health nurse into the preparation of the nurse mid-
wife. American nursing leaders in the early 1900s did not consider midwifery to be
a part of nursing preparation or practice. In 1901, Dock,13 in a report on nursing ed-
ucation, pointed out:
The nurse never takes up midwifery work and in private practice or district nursing
goes only to obstetric cases where a doctor is in attendance. (p. 485)
Because so many births were being carried out in the community, nurses in-
volved in the supervision of midwives worked predominantly in public health and
community nursing. During this time, nurses concerned with maternal-child health
care who tended to be actively involved in social and health reforms included
Lillian Wald, the founder of the New York Henry Street Settlement. One result of
these reform efforts was the formation of a federal Children’s Bureau. Established
between 1909 and 1912, the Children’s Bureau, according to Roberts,3 was a “major
force in health reforms and subsequent midwifery practice” (p. 130).
Copyright © 2005 by F. A. Davis.
•THE EVOLUTION OF ADVANCED PRACTICE IN NURSING 7
Sociopolitical Context
During World War I, the limited fitness of men for military service resulted in leg-
islative initiatives that were instrumental in leading to social and health care reform
and, eventually, to changes in maternity care.14 The poor physical condition of po-
tential recruits also captured the attention of physicians and public health officials,
who noted that if one-half of these men were properly cared for during childhood,
they would have qualified for military service. Interestingly, Tom14 noted that the
investment of state and federal funds into public health programs was not stimu-
lated by high maternal and infant mortality rates, but rather by the concern for a fit
fighting force to ensure the nation’s security. According to Tom:
For the first time, children were recognized as future members of the military and thus
deserving of federal funds. (pp. 4–13)
Childbearing women were considered to be producers of future fighting men;
therefore, their health became a national resource.
The need for better maternity services in the context of opposition to midwives
by physicians contributed to the controversy in nursing about the role of nurses in
the practice of obstetrics. In 1909, the American Society of Superintendents of
Training Schools for Nurses (ASSTSN) acknowledged that nurses’ training in
obstetrics should be included in the program, and in 1911 a resolution was passed
to support that position (see Roberts3 for more detail). However, the association
directed that the training be limited to preparing for emergencies, observing symp-
toms, and reporting problems to a more general practice. In 1911, the ASSTSN
passed another resolution to provide training for registration, licensure, and train-
ing in the practice of midwifery.
Around the same time, the Bellevue School for Midwives in New York City
initiated a program to educate midwives. This occurred largely through the efforts
of van Blarcom, who, as noted earlier, was a strong advocate for midwifery. Clara
Noyes, Superintendent of Training Schools, Bellevue, and Allied Hospitals, includ-
ing the School for Midwives, also supported the education of nurses as midwives.
The training program for midwives at Bellevue was supported by public monies
from 1911 until 1935, when the diminishing need for midwives made it difficult
to justify its existence.3 Basically, the movement of maternity care into the hospi-
tals excluded midwifery. The joint proposal of the Maternity Center Association
(MCA) in New York and the Bellevue School of Midwifery to educate nurse mid-
wives was opposed by medical and nursing leaders. Although the need for better
maternal-child health services and midwifery practice continued, such opposition
inhibited nurses from engaging in the practice of midwifery. Eventually, the contin-
uing need led to the advanced preparation of public health nurses who could super-
vise midwifery practice and eventually prepare nurse midwives.
In 1921, the controversial Sheppard-Towner Act was enacted to provide
money to states to train public health nurses in midwifery.3 Although there was a
major political effort to prohibit passage of the bill, according to Roberts,3 the joint
efforts of women represented “one of the most effective expressions of women’s
Copyright © 2005 by F. A. Davis.
•8 CHAPTER 1
political influence” (p. 131). However, in 1929, major opposition by the American
Medical Association (AMA) resulted in the lapse of the bill. Roberts3 attributed the
bill’s demise to the desire of the AMA to “establish a ‘single standard’ of obstetrical
care” (p. 131) and also to the AMA’s concern that governmental regulation of mid-
wifery would lead to regulation of medical practice.
According to Shoemaker,15 despite this opposition to midwifery in nursing, the
first school for nurse midwifery established in the United States was the Manhattan
Midwifery School in 1928. Apparently the school, which was started by Mary
Richardson, a public health nursing instructor who had taken a midwifery course
in England, was short-lived. Two of the graduates of the school, considered to
be the first “unofficial” school3 (p. 133), were identified as joining the Frontier
Nursing Service in 1928.3 Earlier, in 1925, Mary Breckenridge had brought nurse
midwives from England to help establish the Service. The Frontier Nursing Service
in Kentucky (service) in 1925 and the MCA (education) in New York City in 1932
were two public health–oriented agencies that characterized the midwifery prac-
tice area for public health nurses prepared in nurse midwifery. According to
Bear,16 the Lobenstine Midwifery Clinic was established in 1931 to prepare public
health nurses to be midwives. In contrast to the Manhattan School established by
Richardson, this clinic was the first recognized nurse midwifery school.
After the opening of the Lobenstine Midwifery Clinic, the School of the
Association for the Promotion and Standardization of Midwifery was established
in 1932. Priority for attendance in the school was given to nurses from states that
had high infant mortality rates and many lay midwives. The intent was for the
graduates to return to their home states to establish public health department
programs for training and supervising “granny midwives.”3 In 1934, the school
merged with the Lobenstine Clinic under the MCA and was known thereafter as
The Clinic.
A key figure in the education of nurse midwives was Hattie Hemschemeyer, a
public health nurse educator and graduate of the Clinic’s first nurse midwifery
class. She was later appointed as director of the Clinic, where the emphasis was on
the provision of care to women during pregnancy and childbirth in neighborhood
settings and staffed by public health nurses and physicians. The MCA, a prototype
of this type of service, developed about 30 centers in New York City in 1918.3
Nurse midwives began to provide services in these centers around 1931 and, hence,
the role of the public health nurse as a nurse midwife emerged. At the same time,
the role of the nurse in maternity care was evolving but appeared to be quite differ-
ent from those of midwifery and medical practice.
In 1937, according to Roberts,3 the National League for Nursing Education
(NLNE) description of the role of the midwife in obstetrics was the “overall promo-
tion of the health and comfort of the mother and baby” (p. 135). The obstetric
nurse, in contrast, was described as a “bedside assistant” and “teacher of health.”17
Although preparation of the nurse in obstetrics was relatively poor in the early part
of the twentieth century, development of programs in nurse midwifery during the
1940s demonstrated progress in the education for the role. According to Diers, as
cited by Roberts,3 nurse midwives have been described as
Copyright © 2005 by F. A. Davis.
•THE EVOLUTION OF ADVANCED PRACTICE IN NURSING 9
the oldest of the specialized practice roles for nurses [and as providing] an unusually
good example of the issues nurses face in addressing public policy considerations of
manpower, economics, costs of care, quality and access to care, and interprofessional
politics. (p. 136)
World War II had a significant impact on the development of nurse midwives.
As a consequence of the war, there was a diminished supply of nurse midwives;
thus, another education program, the second in the United States, was initiated
as part of the Frontier Nursing Service in Kentucky and was assisted by the MCA
in New York. The positive publicity received by the Frontier Nursing Service
brought nurse midwifery into public view. Interestingly, this recognition came
largely from a Metropolitan Life report describing the first 10,000 Frontier Nurs-
ing Service deliveries from its initiation up to World War II. Dublin, as cited by
Willeford in 1933,18 reported that the Frontier Nursing Service protected the life of
the mother and baby, saving 10,000 lives a year in the United States, preventing
30,000 stillbirths, and ensuring that there would be 30,000 more children alive at
the end of the first month of life. According to Roberts3:
There is an irony in the notion that an insurance company would serve to stimulate the
expansion of nurse-midwifery services. (p. 141)
The formalization of nurse midwifery as an extension of public health nursing
continued after World War II. With increasing professionalization in nursing and
health care services, the progress of nurse midwifery education went hand in hand
with the development of public health education, which was considered to be essen-
tial for nurse midwifery practice. With the advocacy of clinical nursing specializa-
tion within universities, the nurse midwife or advanced maternity nurse became
more qualified to work with physicians within a professional framework. Table 1–1
traces significant historical events that helped to shape the midwifery profession.
TABLE 1–1. Significant Historical Events in Midwifery
Year Event
1762
Unsuccessful attempt by William Shippen, Jr., was launched to establish formal
1874 midwifery schools in Philadelphia.
1892–1932 Mormon midwives who were trained at Women’s Medical College in Philadelphia
1911 returned to Utah to establish midwifery courses.
1921 License to practice midwifery was required in Utah.
1928 American Society of Superintendents to Training Schools for Nurses passed a
1929 resolution to provide for registration, licensure, and training in midwifery.
Sheppard-Towner Act was passed, providing money to states to train public health
nurses in midwifery.
Manhattan Midwifery School, the first school for nurse midwifery, was established.
American Medical Association opposition allowed for the lapse of the Sheppard-
Towner Act.
Copyright © 2005 by F. A. Davis.
•10 CHAPTER 1
Influence of Government Agencies and Professional Associations
In the 1970s and 1980s, efforts of both government and professional associa-
tions continued to advance the development of nurse midwifery. The Children’s
Bureau (later known as the Maternal Child Health Bureau), with leadership from
Katherine (Kit) Kendall and Carmella Carvello, and the Division of Nursing,
Bureau of Health Professions Education, was instrumental in facilitating the nurse
midwifery movement by providing training grants.2,16 According to Bear,16 Senator
Daniel K. Inouye of Hawaii assisted with lobbying efforts on Capitol Hill and with
development of contacts between nursing and other key people. During the same
time, Senator Daniel Patrick Moynihan of New York sponsored the Civilian Health
and Medical Program for the Uniformed Services (CHAMPUS) in the Omnibus
Reconciliation Act of the Defense Appropriations Bill. These activities of both sen-
ators had a positive impact on legislation that influenced education and advanced
practice initiatives for nurses, nurse practitioners, and nurse midwives
During the mid-1940s, the National Organization of Public Health Nurses
(NOPHN) created a section for nurse midwives. This organization was dissolved
in 1952; it was absorbed into the American Nurses Association (ANA) and the
National League for Nursing (NLN). There was no provision to include nurse
midwives as a separate entity within these organizations. Nurse midwives were
assigned to the Maternal and Child Health–NLN Interdivisional Council, which
included obstetrics, pediatrics, orthopedics, crippled children, and school nursing.
The general concern of the membership was that the Council was too broad to
represent nurse midwifery, although the nurse midwives assumed much of the
leadership of the council. In spring of 1954 at the ANA convention, the Committee
on Organization was formed to explore the future organization for nurse mid-
wifery. Through a tedious process and consideration of four options, the Committee
voted unanimously to form the American College of Nurse Midwifery (ACNM).
The ACNM was officially incorporated in 1955 as an outgrowth of the recommen-
dations of the Committee on Organization.19 Helen Varney Burst was the first pres-
ident of the ACNM elected to serve two consecutive terms.2 This event was
particularly significant because her tenure occurred during a time when there were
no provisions for nurse midwives in federal programs. Therefore, consistent leader-
ship was needed to maintain intense lobbying efforts for key legislation that influ-
enced programs such as Medicare, Medicaid, and CHAMPUS. These lobbying
efforts opened the door for more autonomous nursing practice, the potential for
third-party reimbursement, and greater recognition of the CNM as a health care
provider.
The medical malpractice crisis was a key sociopolitical event that occurred
in 1985 to slow the growth of nurse midwifery. Insurance carriers, fearing finan-
cial drains associated with litigation, dropped malpractice coverage for nurse mid-
wives. This created a difficult challenge for the ANA, the ACNM, and the Nurse
Association of the American College of Obstetrics and Gynecology, all of which
stepped in and worked to assist the ACNM in getting the Risk Retention Act
passed. Passage of this law allowed independent carriers to provide malpractice in-
surance to individuals on a state-by-state basis.
Copyright © 2005 by F. A. Davis.
•THE EVOLUTION OF ADVANCED PRACTICE IN NURSING 11
Under Bear’s presidency,16 further movement toward professional develop-
ment occurred during 1987 to 1989, when the ACNM developed a Division of
Research.16 Joyce Thompson, who succeeded Bear and who was the second person
to serve two consecutive terms (1989 to 1993), oversaw marked growth in the
number and quality of educational programs. As the deputy director for the
International Confederation of Nurse-Midwives (ICNM),20 Thompson was also in-
volved in the international development of midwifery. During her term, a formal
liaison developed between the ICNM and the Royal College of Midwives in London,
England.
Among international organizations, the Agency for International Development
and the World Health Organization (WHO) were probably most influential in pro-
moting midwifery in developing countries. The ICNM,20 founded in Europe in
1919, also worked to advance education in midwifery, with the aim of improving
the standard of care provided to mothers, babies, and their families throughout
the countries of the world. The Confederation is the only international midwifery
organization that has official relations with the United Nations and works closely
with the WHO and the United Nations International Children’s Emergency Fund
(UNICEF) to achieve common goals in maternal and child care.
Although its activities were interrupted during World War II, the first World
Congress of Midwives began a new era and the start of a series of triennial meet-
ings. These meetings brought together midwives from all over the world to share
ideas and experiences and to improve knowledge in the field. The first triennial
meeting, hosted by the United States, was held in 1972 in Washington, D.C.16 dur-
ing the presidency of Lucille Woodville. Currently, there are nine other organiza-
tions that work with the confederation, including the International Council of
Nurses and the International Federation of Gynecology and Obstetrics.20
Influence of Private Foundations, Colleges, and Universities
The Carnegie Foundation served as a definite stimulus for the nurse midwifery
movement. Ernest Boyer, president of the Carnegie Foundation until his recent
death and whose wife was a nurse midwife, strongly supported nurse midwifery
programs. However, at an exploratory meeting convened by the Carnegie
Foundation in July 1989, he posed a critical and continuing question regarding the
issue of accreditation of a program designed for individuals who were not first edu-
cated as nurses. Basically, the ACNM responded by saying that accreditation of a
program for non-nurse midwives would require identification of all the relevant
knowledge, skills, and competencies that nurses bring to a nurse midwifery educa-
tion and would require that those essential competencies be acquired by completion
of the midwifery education program.
A key principle underlying the ACNM, Division of Accreditation (DOA) pro-
gram, was that3 the ultimate competencies attained in an ACNM-accredited mid-
wifery program for non-nurses would be the same as those required of graduates of
DOA-accredited nurse-midwifery programs (p. 151).
However, until recently, the mechanism for taking the ACNM Certification
Council (ACC) examinations has not been open to non-nurse midwives, the re-
Copyright © 2005 by F. A. Davis.
•12 CHAPTER 1
quirement being that those who took the ACC examination be a registered nurse
(RN) licensed in the United States. Now, that avenue is open for both nurses and
non-nurses. Although there is some concern by others regarding this issue, the
ACNM points out that only those individuals graduating with a minimum of a bac-
calaureate degree from an ACNM-accredited midwifery program are eligible to take
the ACC examination. As of 2003, there are two direct-entry programs, one a cer-
tificate and one a master’s degree program. Both programs require applicants to
hold a baccalaureate degree, but not in nursing, prior to admittance.59
Nurse midwifery programs have received notable and growing support from
a number of major colleges and universities throughout the United States. Support
for doctoral education for nurse midwives who hold positions within university-
based programs as well as for the preparation of leaders with the skills of scientific
inquiry, knowledge of health policy formulation, educational administration, and
research has also become increasingly important.
Forces Influential in Marketing and Effective Utilization
According to Bear,16 professional associations and legislative support have encour-
aged consumer use of nurse midwives. Although nurse midwives have been in-
volved in health maintenance organizations (HMOs) since 1980, consumer support
was probably the most influential in the marketing and effective utilization of their
services. Once the recipients of health care became aware of what nurse midwives
could do, earlier misconceptions about midwifery were dispelled. The benefits of
midwifery practice, especially among the underserved populations, were appreci-
ated and disseminated.
Key Leaders
There has been a long debate on the content and structure of the curricular content
that constitutes adequate education for nurse midwives and an effort by leaders
to maintain the quality of education and care of mothers and children. Notable
for their contributions to nurse midwifery practice and education were Mary
Breckenridge, inducted into the Women’s Hall of Fame in 1995,3,16 and Hattie
Hemschemeyer, the first president of the ACNM. These early leaders were dedi-
cated to improving the quality of education for nurse midwives and to establishing
institutions for monitoring midwifery care through the ACNM.2,16 For example, the
ACNM has been influential in formulating standards for education and practice
that currently reflect the major differences between nurse midwives and traditional
midwives.
More contemporary leaders in the discipline include Ruth Lubic, formerly gen-
eral director of the MCA in New York; Irene Sandvold in the Division of Nursing,
Bureau of Health Professions (BHPr), Department of Health and Human Services
(DHHS); Dorothea Lang, a former president of ACNM and director of maternal
and infant projects in New York City; Joyce Cameron Foster of the University of
Utah, who established a nurse midwifery graduate program and certified nurse mid-
wife licensure; Katherine (Kit) Kendall, who was with the Maternal Child Health
Copyright © 2005 by F. A. Davis.
•THE EVOLUTION OF ADVANCED PRACTICE IN NURSING 13
Bureau, DHHS; and Elizabeth Sharpe of Emory University and a graduate of Yale
University. Joyce Roberts remains an active leader who continues to address nurse
midwifery education and practice issues and the challenge to maintain the profes-
sional standards of midwifery practice that have been established through the
ACNM. Betty Bear is a past leader in nurse midwifery practice and education and
continued in this role until her retirement several years ago.62 Other prominent
players featured in the long-standing movement toward the professional status of
nurse midwives include Sister Mary Stella, past president of ACNM; Vera Keane, a
professor from Yale University who coauthored a book on the perception of pa-
tients and their obstetric care providers, Nurse Patient Relationships in a Hospital
Maternity Service; and Ernestine Weidenbach, author of Family Centered Maternity
Nursing. Joyce Cameron Foster and Judith Fullerton also were instrumental in de-
veloping the National Certification Examination for nurse midwives.16
As with every profession, there are many unsung heroes and heroines in the
nurse midwifery movement whose commitment, support, and leadership have con-
tributed to its success and are a part of the unwritten history. Among others who
worked steadfastly to establish a professional standard for nurse midwifery were
Sister Nathalie Elder and Sister Jeanne Meurer, faculty members in the School of
Nursing at St. Louis University, St. Louis, Missouri.
Interface with Nurse Anesthetists, Clinical Nurse
Specialists, and Nurse Practitioners
According to Roberts,2 the focus of the nurse midwife is primarily on maternal-
infant care within the context of the family and thus differs from the focus of
the women’s health nurse practitioner (WHNP), who is oriented more toward
women’s health. Nurse midwives probably identify more closely with nurse anes-
thetists, who have followed a similar path and positioned themselves within an area
of practice that allows them to maintain a degree of autonomy within the medical
community. Nurse midwives and nurse anesthetists also have followed a similar
avenue by developing specialized accreditation processes for the education pro-
grams; both of these APN specialties have traditionally required certification for the
practice of the specialty. In contrast, the CNS and NP have only recently begun to
examine the need to accredit education programs in addition to the specialized ac-
creditation given to the master’s program. Also, NP certification is required by an
increasing number of states for practice; however, this requirement is not universal.
Bear16 has noted that a blending of the roles of advanced practice nurses in ma-
ternity care is beginning to occur. Many agree that roles probably overlap, because
both the WHNP and the nurse midwife do primary care across the lifespan and
prenatal and postnatal care for women. However, the primary focus of the nurse
midwife extends from pregnancy through birth, with responsibility for the conduct
of the delivery. Nurse midwifery has developed into a professional discipline in
the United States and retains its identity as a specialty practice in nursing. In addi-
tion, the nurse midwife retains an identity with midwifery internationally,2 in
contrast with the other specialties that constitute advanced practice nursing. In
other words, APNs are identified only with a specialty with the general rubric of
Copyright © 2005 by F. A. Davis.
•14 CHAPTER 1
advanced practice nursing, whereas the certified nurse midwife identifies with ad-
vanced practice nursing through nurse midwifery as a specialty and identifies with
non-nurse midwifery through the focus of care of pregnant women and newborns.
NURSE ANESTHETISTS
Although midwifery as a vocation dates back to the 1600s, nurse anesthesia pre-
dates nurse midwifery as a specialty area of nursing in the United States. From the
perspective of world history, the history of women attending other women in labor
can be documented in pre-Christian times. Nurses attending patients in surgery to
administer anesthesia is more recent.
Historical Context
Anesthesia in the United States reportedly dates back to the mid-nineteenth cen-
tury, with rival claimants to its discovery. Allegedly, William T. G. Morton success-
fully demonstrated anesthesia in surgery on October 16, 1846, at a centennial event
held at Massachusetts General Hospital. This demonstration was followed by a
number of reported studies, all of which failed to mention any involvement of nurse
anesthetists. In response to this apparent oversight, Thatcher21 emphasized the role
of the nurse specialist in her book History of Anesthesia. In the preface to the book,
she stated:
If the place of the nurse as an anesthetist receives special emphasis in this history, it is
because she has been derogated or ignored. (p. 15)
Bankert23 also described the difficulty associated with identifying the first
nurse anesthetist and the limited recognition of the prominence of nurses in anes-
thesia.
According to Thatcher,21 church records of 1877 identify Sister Mary Bernard
as being called on to function as an anesthetist within a year of enrolling in St.
Vincent’s Hospital, in Erie, Pennsylvania. As a result of this record, Sister Bernard
has been recognized as the first nurse anesthetist to practice in the United States.
The further contributions of members of the religious orders to the development of
the field of anesthesia include those of Sister Aldonza Eltrich (1860–1920) and
certain religious nursing orders.
According to Bankert,23 the Hospital Sisters of the Third Order of St. Francis
managed five hospitals that served employees of the Missouri Pacific Railroad be-
tween 1884 and 1888. During this period, nuns from the order served as anes-
thetists for the five hospitals. In 1912, Mother Superior Magdalene Wiedlocher, an
anesthetist, developed a course in anesthesia for sisters who were graduate nurses.
In 1924, this course was made available to secular nurses. Based on Thatcher’s
research, Bankert23 has detailed the contributions of Catholic and Protestant nurs-
ing orders whose members served as nurse anesthetists since the 1850s, providing
poignant narratives of these committed women. Included in this group are Alice
Magaw, known as the “Mother of Anesthesia,” and Sister Secundina Mindrup
(1868–1951), both of whom were described as most “touching figures.”
Copyright © 2005 by F. A. Davis.
•THE EVOLUTION OF ADVANCED PRACTICE IN NURSING 15
The emergence of nurse anesthesia in the United States cannot be considered
outside the context of the development of nursing itself. In 1873, three nurse
training schools were established in New York, New Haven, and Boston. These
American schools were referred to as “Nightingale Schools” and were credited with
bringing the art of nursing into a more reputable view. At that time, there was
some controversy over the philanthropic desire to make nurses’ training attractive
to the middle-class American woman. Some physicians supported the idea, while
many did not. According to Starr, as quoted by Bankert,23 physicians were con-
cerned that
educated nurses would not do as they were told—a remarkable comment on the status
anxieties of nineteenth-century physicians. (p. 20)
Fortunately, women reformers paid little attention to these remarks and, like
Florence Nightingale, moved forward. The schools were established to attract re-
spectable women and were modeled after the Saint Thomas Hospital Training
School for Nurses founded in 1860 by Nightingale.
Eventually, physicians were forced to accept nurses who were trained to carry
out the more complex work that hospitals were assuming. Shyrock, as quoted by
Bankert,23 described this change in attitude toward nurses rather vividly:
All of this related to the public opinion of medical service in general, since the nurses
came into more continuous contact with the patient than did any other figure in the
whole range of medical personnel. Good nursing was invaluable from a technical point
of view. It might make all the difference in the outcome of the individual case, and pa-
tients sometimes realized this. Better nursing was an essential feature in the gradual im-
provement of hospitals, and this in turn modified the earlier popular attitude toward
these institutions. … The whole spirit of hospitals changed. (p. 21)
Baer, as quoted by Bankert,23 made yet a stronger statement when she asserted
that “nursing made medicine look good” (p. 21). She goes on to further illustrate
this point:
Medicine’s ultimate success, technological advances, and subsequent impressive social
power were achieved through hospitals, and nurses made those hospitals work. Nurses
made them reasonable choices for sick-care, providing the environment in which
patients felt safe enough to permit medical instrumentation to occur. The development
of medical practice, education, therapeutics, etc. proceeded from that point. Happily,
one prominent physician understood that and reminded his contemporaries in 1910:
“Now one must have some understanding of the value of the profession of nursing in
modern medicine. … It has changed the face of modern medicine: it is revolutionary
in its influence upon the progress of modern medicine.” (p. 21)
Sociopolitical Context
The advent of anesthetics occurred simultaneously with the acceptance and promo-
tion of asepsis and the emergence of nursing in hospital care23; thus, the elements
“were in place for a removal of the remaining obstacle in the path of the advance-
ment of surgery” (p. 22). Discussion concerning problems associated with anesthe-
sia delivery began at the time of Morton’s first successful induction and continued
Copyright © 2005 by F. A. Davis.
•16 CHAPTER 1
without resolution for some 40 years. Most anesthesia was given by novice interns
who were more interested in the surgery than in the safe administration of anesthe-
sia. In 1898, Saling, as quoted by Bankert,23 illustrated the rather nonchalant atti-
tude toward anesthesia characteristic of the times:
Unfortunately, in most hospitals one of the younger interns is, as a rule, selected to ad-
minister the anaesthetic. The operator accustomed to having a novice give chloroform
or ether for him is kept on the qui vive while performing the operation and watching
the administration of the anaesthetic. Such a condition of affairs is not conducive to the
best work of the surgeon. (p. 23)
One of the hospitals established by the Sisters of St. Francis played a particu-
larly noteworthy role in the development of anesthesia care. Established in 1889 as
St. Mary’s Hospital, it later became known as the Mayo Clinic. During the early
years at the Mayo Clinic, no interns were available to assist in surgery. Therefore,
the clinic relied on nurse anesthetists, initially as a matter of necessity and later as a
matter of choice.
The Mayo Clinic’s first nurse anesthetists were Dinah and Edith Graham, sis-
ters who had graduated from the school of nursing at the Women’s Hospital in
Chicago. To train the Graham sisters while continuing to support the work of the
clinic, five staff nurses took over the patient care nursing and housekeeping duties
while the Grahams administered anesthesia and did general office and secretarial
work. According to Bankert,23 Dinah’s career as a nurse anesthetist at the clinic
was brief, but her sister Edith continued there until she married William W. Mayo
in 1893. Edith was succeeded by Magaw (1860–1928), reported to be brilliant not
only as an anesthetist but also as a scholar and researcher.
Bankert23 noted that although Magaw “won more widespread notice than
that of any other member of the Rochester group apart from the [Mayo] brothers”
(p. 30), because she was a nurse she was not given membership in the medical soci-
ety. According to Garde,24 Magaw administered anesthesia, kept data, and wrote ar-
ticles. She was a meticulous data collector, and although her papers are not listed in
the Physicians of the Mayo Clinic Bibliography, one of her studies was included in
the Collected Papers by the Staff of St. Mary’s Hospital, Mayo Clinic, Rochester,
Minnesota, 1905–1909.22 A 1941 catalogue by Clapesattle of Magaw’s papers re-
vealed that her first comprehensive paper, reporting more than 3000 cases, was ti-
tled “Observations in Anesthesia” and was published in Northwestern Lancet
in 1899.22 In 1900, the St. Paul Medical Journal published Magaw’s update of
the year’s work, which included observations of 1,092 cases reported. In 1906,
Magaw published another review of more than 14,000 successful anesthesia cases.
According to Bankert,23 Magaw made numerous recommendations that shaped
contemporary anesthesia practice. She stressed individual attention for all patients
and identified the experience of the anesthetist as a critical element in quickly re-
sponding to the patient. Magaw’s success was also attributed to her attention to the
psychological dimension of the anesthetic experience. In her words, she believed
that “suggestion” was a great help “in producing a comfortable narcosis” (p. 32).
The model of nurse anesthesia at the Mayo Clinic drew the attention of med-
Copyright © 2005 by F. A. Davis.
•THE EVOLUTION OF ADVANCED PRACTICE IN NURSING 17
ical people from all over the United States and the world. The Mayo Clinic’s reputa-
tion gave credibility to the movement, and Magaw’s efforts provided a particular
advantage to careful documentation and publication. As Garde24 noted:
We lose so many opportunities in clinical areas because people do not take the time
to write articles that could be major contributions to the literature. [By her writing], …
Alice Magaw really made a name for the nurse anesthetists.
In 1936, Crile,25 hailed as one of America’s greatest surgeons, praised the nurse
anesthetist movement. In these nursing professionals, he found a special quality
of “finesse” for administration of anesthesia not present in medical interns. His
choice for the prototype nurse anesthetist was Agatha Cobourg Hodgins, a native
of Canada. According to Bankert,23 she “proved herself to be not only a brilliant
anesthetist, but a woman of vision” (p. 39) in her dedication to the development
of professional nursing and the establishment of a national nurse anesthesiology
association.
A graduate of the Boston City Hospital Training School for Nurses, at age 21,
Hodgins went to Cleveland to work as a head nurse at Lakeside Hospital. There she
was selected by Crile to administer anesthesia. She avidly read all she could about
anesthesia, and she “walked the wards” at night listening to sleeping patients’
breathing to detect subtle differences. According to Crile, as quoted by Bankert23:
Miss Hodgins made an outstanding anesthetist for she had to a marked degree, both the
intelligence and the gift. (p. 41)
Crile and Hodgins inaugurated the Lakeside School of Anesthesia, which at
once was recognized as an organized center for teaching anesthesiology, contribut-
ing to the education of nurse anesthetists and furthering the work of the graduates.23
Not surprisingly, World Wars I and II, the Korean conflict, and the Vietnam
War all had a significant impact on the development of anesthesia. Crile and
Hodgins were part of the Lakeside Unit at the American Ambulance at Neuilly in
1914.23 After 2 months, Crile returned to the United States to present a plan to the
U.S. Surgeon General for the creation of hospital units composed of doctors, nurses,
and anesthetists for service internationally. Hodgins stayed on in Neuilly to teach
nurses, dentists, and physicians how to administer anesthesia. She returned to
Cleveland to resume her work at the Lakeside School of Anesthesia. The first grad-
uating class consisted of 6 physicians, 2 dentists, and 11 nurses. After the formal
declaration of war by the United States on April 6, 1917, the Lakeside Hospital
Unit, Base Hospital No. 4, was mobilized. Hodgins did not accompany the unit at
the time, instead remaining as director of the school and engaging in training nurse
anesthetists for military service.
In addition to training at the Mayo Clinic, preparation of nurse anesthetists
was also occurring in other parts of the country.23 For example, Sophie Gran
Winton (1887–1989), a graduate of Swedish Hospital in Minneapolis, had trained
as an anesthetist. After garnering 5 years of anesthesia experience and having es-
tablished a record of more than 10,000 cases without a fatality, she joined the Army
Nurse Corps. Winton and other nurses from the Minneapolis Hospital Unit No. 26
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