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Advanced Practice Nursing Essentials for Role Development, 4th edition

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Advanced Practice Nursing Essentials for Role Development Fourth Edition Advanced Practice Nursing Essentials for Role Development Fourth Edition Lucille A. Joel, EdD, APN, FAAN Disting... uished Professor Rutgers, The State University of New Jersey School of Nursing, New Brunswick–Newark, New Jersey F.A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright © 2018 by F.A. Davis Company Copyright © 2018 by F.A. Davis Company. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Printed in the United States of America Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Sponsoring Editor: Jacalyn Sharp Content Project Manager II: Amy M. Romano Design and Illustration Manager: Carolyn O’Brien As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up-to-date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs. Library of Congress Cataloging-in-Publication Data Names: Joel, Lucille A., editor. Title: Advanced practice nursing : essentials for role development / [edited by] Lucille A. Joel, EdD, APN, FAAN, Distinguished Professor, Rutgers, The State University of New Jersey, School of Nursing, New Brunswick-Newark, New Jersey. Description: Fourth edition. | Philadelphia, PA : F.A. Davis Company, [2018] | Includes bibliographical references and index. Identifiers: LCCN 2017023590 | ISBN 9780803660441 Classification: LCC RT82.8 .J64 2018 | DDC 610.7306/92--dc23 LC record available at https://lccn.loc. gov/2017023590 Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F.A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.25 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 978-0-8036-6044-1/17 + $.25. v Preface The content of this text was identified only after a careful review of the documents that shape both the advanced practice nursing role and the educational programs that prepare these individuals for practice. That review allowed some decisions about topics that were essential to all advanced practice nurses (APNs)*, whereas others were excluded because they are traditionally introduced during baccalaureate studies. This text is written for the graduate-level student in advanced practice and is intended to address the nonclinical aspects of the role. Unit 1 explores The Evolution of Advanced Practice from the historical perspective of each of the specialties: the clinical nurse-midwife (CNM), nurse anesthetist (NA), clinical nurse specialist (CNS), and nurse practitioner (NP). This historical background moves to a contemporary focus with the introduction of the many and varied hybrids of these roles that have appeared over time. These dramatic changes in practice have been a response to societal need. Adjustment to these changes is possible only from the kaleidoscopic view that theory allows. Skill acquisition, socialization, and adjustment to stress and strain are theoretical constructs and processes that will challenge the occupants of these roles many times over the course of a career, but coping can be taught and learned. Our accommodation to change is further challenged as we realize that advanced practice is neither unique to North America nor new on the global stage. Advanced practice roles, although accompanied by varied educational requirements and practice opportunities, are well embedded and highly respected in international culture. In the United States, education for advanced practice had become well stabilized at the master’s degree level. This is no longer true. The story of our recent transition to doctoral preparation is laid before us with the subsequent issues this creates. The Practice Environment, the topic of Unit 2, dramatically affects the care we give. With the addition of medical diagnosis and prescribing to the advanced practice repertoire, we became competitive with other disciplines, deserving the rights of reimbursement, prescriptive authority, clinical privileges, and participation as members on health plan panels. There is the further responsibility to understand budgeting and material resource management, as well as the nature of different collaborative, responding, and reporting relationships. The APN often provides care within a mediated role, working through other professionals, including nurses, to improve the human condition. Competency in Advanced Practice, the topic of Unit 3, demands an incisive mind capable of the highest order of critical thinking. This cognitive skill becomes refined as the subroles for practice emerge. The APN is ultimately a direct caregiver, client advocate, teacher, consultant, researcher, and case manager. The APN’s forte is to coach individuals and populations so that they may take control of their own health in their own way, ideally even seeing chronic disease as a new trajectory of wellness. The APN’s clients are as diverse as the many ethnicities of the U.S. public, and the challenge is often to learn from them, taking care to do no harm. The APN’s therapeutic modalities go beyond traditional Western medicine, reaching into the realm of complementary therapies and integrative health-care practices that have become expected by many consumers. Any or all of these role competencies are potential areas for conflict, needing to be understood, managed, and resolved in the best interests of the client. Some of the most pressing issues confronting APNs today are how to mobilize informational technology in the service of the client, securing visibility for their work, and thinking *Please note that the terms advanced practice nurse (APN) and advanced practice registered nurse (APRN) are used interchangeably in this text according to the author’s choice. vi Preface through publication. The chapters in this section aim to introduce these competencies, not to provide closure on any one topic; the art of direct care in specialty practice is not broached. When you have completed your course of studies, you will have many choices to make. There are opportunities to pursue your practice as an employee, an employer, or an independent contractor. Each holds different rights and responsibilities. Each demands Ethical, Legal, and Business Acumen, which is covered in Unit 4. Each requires you to prove the value you hold for your clients and for the systems in which you work. Cost efficiency and therapeutic effectiveness cannot be dismissed lightly today. The nuts and bolts of establishing a practice are detailed, and although these particulars apply directly to independent practice, they can be easily extrapolated to employee status. Finally, experts in the field discuss the legal and ethical dimensions of practice and how they uniquely apply to the role of the APN to ensure protection for ourselves and our clients. This text has been carefully crafted based on over 40 years of experience in practice and teaching APNs. It substantially includes the nonclinical knowledge necessary to perform successfully in the APN role and raises the issues that still have to be resolved to leave this practice area better than we found it. Lucille A. Joel vii Patricia DiFusco, MS, NP-C, FNP-BC, AAHIVS Nurse Practitioner SUNY Downstate Medical Center Brooklyn, New York Caroline Doherty, AGACNP, AACC Advanced Senior Lecturer University of Pennsylvania School of Nursing Philadelphia, Pennsylvania Carole Ann Drick, PhD, RN, AHN-BC President American Holistic Nurses Association Topeka, Kansas Lynne M. Dunphy, PhD, APRN, FNP-BC, FAAN, FAANP Professor and Associate Dean for Practice and Community Engagement Florida Atlantic University Christine E. Lynn College of Nursing Boca Raton, Florida Denise Fessler, RN, MSN, CMAC Principal/CEO Fessler and Associates Healthcare Management Consulting, LLC Lancaster, Pennsylvania Eileen Flaherty, RN, MBA, MPH Staff Specialist Massachusetts General Hospital Boston, Massachusetts Cindy Aiena, MBA Executive Director of Finance Partners HealthCare/MGH Boston, Massachusetts Judith Barberio, PhD, APNC Associate Clinical Professor Rutgers-The State University of New Jersey School of Nursing New Brunswick-Newark, New Jersey Deborah Becker, PhD, ACNP, BC, CCNS Director, Adult Gerontology Acute Care Program University of Pennsylvania School of Nursing Philadelphia, Pennsylvania Andrea Brassard, PhD, FNP-BC, FAANP Senior Strategic Policy Advisor Center to Champion Nursing in America at AARP Washington, District of Columbia Edna Cadmus, RN, PhD, NEA-BC Clinical Professor and Speciality Director-Nursing Leadership Program Executive Director NJCCN Rutgers-The State University of New Jersey School of Nursing New Brunswick-Newark, New Jersey Ann H. Cary, PhD, MPH, FN, FNAP, FAAN Dean and Professor University of Missouri Kansas City, School of Nursing and Health Studies Kansas City, Missouri Contributors viii Contributors Phyllis Shanley Hansell, EdD, RN, FNAP, FAAN Professor Seton Hall University College of Nursing South Orange, New Jersey Allyssa Harris, RN, PhD, WHNP-BC Assistant Professor William F. Connell School of Nursing Boston College Boston, Massachusetts Gladys L. Husted, RN, PhD Professor Emeritus Duquesne University Pittsburgh, Pennsylvania James H. Husted Independent Scholar Pittsburgh, Pennsylvania Joseph Jennas, CRNA, MS Program Director Clinical Assistant Professor SUNY Downstate Medical Center Brooklyn, New York Lucille A. Joel, EdD, APN, FAAN Distinguished Professor Rutgers-The State University of New Jersey School of Nursing New Brunswick-Newark New Jersey Dorothy A. Jones, EdD, RNC-ANP, FAAN Professor, Boston College Connell School of Nursing Senior Nurse, Massachusetts General Hospital Boston, Massachusetts David M. Keepnews, PhD, JD, RN, NEA-BC, FAAN Dean and Professor Long Island University (LIU) Brooklyn Harriet Rothkopf Heilbrunn School of Nursing Brooklyn, New York Jane M. Flanagan, PhD, ANP-BC Associate Professor and Program Director Adult Gerontology Boston College Connell School of Nursing Chestnut Hill, Massachusetts Rita Munley Gallagher, RN, PhD Nursing and Healthcare Consultant Washington, District of Columbia Mary Masterson Germain, EdD, ANP-BC, FNAP, D.S. (Hon) Professor Emeritus State University of New York–Downstate Medical Center College of Nursing Brooklyn, New York Kathleen M. Gialanella, JD, LLM, RN Law Offices Westfield, New Jersey Associate Adjunct Professor Teachers College, Columbia University New York, New York Shirley Girouard, RN, PhD, FAAN Professor and Associate Dean State University of New York-Downstate Medical Center College of Nursing Brooklyn, New York Antigone Grasso, MBA Director Patient Care Services Management Systems and Financial Performance Massachusetts General Hospital Boston, Massachusetts Anna Green, RN, Crit Care Cert, MNP Project Manager Australian Red Cross Blood Service Melbourne, Australia Contributors ix Beth Quatrara, DNP, RN, CMSRN, ACNS-BC Advanced Practice Nurse–CNS University of Virginia Health System Charlottesville, Virginia Kelly Reilly, MSN, RN, BC Director of Nursing Maimonides Medical Center Brooklyn, New York Valerie Sabol, PhD, ACNP-BC, GNP-BC, ANEF, FAANP Professor and Division Chair Healthcare in Adult Population Duke University School of Nursing Durham, North Carolina Mary E. Samost, RN, MSN, DNP, CENP System Director Surgical Services Hallmark Health System Medford, Massachusetts Madrean Schober, PhD, MSN, ANP, FAANP President Schober Global Healthcare Consulting International Indianapolis, Indiana Robert Scoloveno, PhD, RN Director–Simulation Laboratories Assistant Professor Rutgers-The State University of New Jersey School of Nursing Camden, New Jersey Carrie Scotto, RN, PhD Associate Professor The University of Akron College of Nursing Akron, Ohio Dale Shaw, RN, DNP, ACNP-BC ACNP–Acute Care Neurosurgery University of Virginia Health System Charlottesville, Virginia Alice F. Kuehn, RN, PhD, BC-FNP/GNP Associate Professor Emeritus University of Missouri-Columbia School of Nursing Columbia, Missouri Parish Nurse St. Peter Catholic Church Jefferson City, Missouri Irene McEachen, RN, MSN, EdD Associate Professor Saint Peter’s University Division of Nursing Jersey City, New Jersey Deborah C. Messecar, PhD, MPH, AGCNS-BC, RN Associate Professor Oregon Health and Science University School of Nursing Portland, Oregon Patricia A. Murphy, PhD, APRN, FAAN Associate Professor Rutgers-The State University of New Jersey New Jersey Medical School Newark, New Jersey Marilyn H. Oermann, RN, PhD, FAAN, ANEF Thelma Ingles Professor of Nursing Director of Evaluation and Educational Research Duke University School of Nursing Durham, North Carolina Marie-Eileen Onieal, PhD, MMHS, RN, CPNP, FAANP Faculty, Doctor of Nursing Practice Rocky Mountain University of Health Professions Provo, Utah David M. Price, MD, PhD Founding Faculty Center for Personalized Education of Physicians (CDEP) Denver, Colorado x Contributors Caroline T. Torre, RN, MA, APN, FAANP Nursing Policy Consultant Princeton, New Jersey Formerly, Director, Regulatory Affairs New Jersey State Nurses Association Trenton, New Jersey Jan Towers, PhD, NP-C, CRNP (FNP), FAANP Director of Health Policy Federal Government and Professional Affairs American Academy of Nurse Practitioners Washington, District of Columbia Maria L. Vezina, RN, EdD, NEA-BC Chief Nursing Officer/Vice President, Nursing The Mount Sinai Hospital New York, New York Benjamin A. Smallheer, PhD, RN, ACNP-BC, FNP-BC, CCRN, CNE Assistant Professor of Nursing Duke University School of Nursing Durham, North Carolina Thomas D. Smith, DNP, RN, NEA-BC, FAAN Chief Nursing Officer Maimonides Medical Center Brooklyn, New York Mary C. Smolenski, MS, EdD, FNP, FAANP Independent Consultant Washington, District of Columbia Shirley A. Smoyak, RN, PhD, FAAN Distinguished Professor Rutgers-The State University of New Jersey School of Nursing New Brunswick-Newark, New Jersey Christine A. Tanner, RN, PhD, ANEF Professor Emerita Oregon Health and Science University Portland, Oregon xi Sheila Grossman, PhD, APRN, FNP-BC, FAAN Professor and Coordinator Family Nurse Practitioner Program Fairfield University Fairfield, Connecticut Elisabeth Jensen, RN, PhD Associate Professor School of Nursing York University Toronto, Ontario Canada Linda E. Jensen, PhD, MN, RN Professor Graduate Nursing Clarkson College Omaha, Nebraska Julie Ann Koch, DNP, RN, FNP-BC, FAANP Assistant Dean of Graduate Nursing DNP Program Coordinator Valparaiso University College of Nursing & Health Professions Valparaiso, Indiana Linda U. Krebs, RN, PhD, AOCN, FAAN Associate Professor University of Colorado Anschutz Medical Campus, College of Nursing Aurora, Colorado Nancy Bittner, RN, PhD Associate Dean School of Nursing Science and Health Professions Regis College Weston, Massachusetts Cynthia Bostick, PMHCNS-BC, PhD Lecturer California State University Carson, California Susan S. Fairchild, EdD, APRN Dean, School of Nursing Grantham University Kansas City, Missouri Cris Finn, RN, PhD, FNP Assistant Professor Regis University Denver, Colorado Susan C. Fox, RN, PhD, CNS-BC Associate Professor College of Nursing University of New Mexico Albuquerque, New Mexico Eileen P. Geraci, PhD candidate, MA, ANP-BC Professor of Nursing Western Connecticut State University Danbury, Connecticut Reviewers xii Reviewers Julie Ponto, RN, PhD, ACNS-BC, AOCN Professor Winona State University–Rochester Rochester, Minnesota Susan D. Schaffer, PhD, ARNP, FNP-BC Chair, Department of Women’s, Children’s and Family Nursing FNP Track Coordinator University of Florida College of Nursing Gainesville, Florida Beth R. Steinfeld, DNP, WHNP-BC Assistant Professor SUNY Downstate Medical Center Brooklyn, New York Lynn Wimett, EdD, APRN-C Professor Regis University Denver, Colorado Jennifer Klimek Yingling, PhD, RN, ANP-BC, FNP-BC Advanced Practice Nurse Faxton-St. Luke’s Healthcare SUNY Institute of Technology Utica, New York Joy Lewis, CRNA, MSN Interim Assistant Program Director Nurse Anesthesia Lincoln Memorial University Harrogate, Tennessee Laurie Kennedy-Malone, PhD, GNP-BC, FAANP, FGSA Professor of Nursing University of North Carolina at Greensboro School of Nursing Greensboro, North Carolina Susan McCrone, PhD, PMHCNS-BC Professor West Virginia University Morgantown, West Virginia Sandra Nadelson, RN, MS Ed, PhD Associate Professor Boise State University Boise, Idaho Geri B. Neuberger, RN, MN, EdD, ARNP-CS Professor University of Kansas School of Nursing Kansas City, Kansas Crystal Odle, DNAP, CRNA Director, Assistant Professor Nurse Anesthesia Program Lincoln Memorial University Harrogate, Tennessee xiii This book belongs to its authors. I am proud to be one among them. Beyond that, I have been the instrument to make these written contributions accessible to today’s students and faculty. I thank each author for the products of his or her intellect, experience, and commitment to advanced practice. Acknowledgments xv 8 The Kaleidoscope of Collaborative Practice 116 Alice F. Kuehn 9 Participation of the Advanced Practice Nurse in Health Plans and Quality Initiatives 143 Rita Munley Gallagher 10 Public Policy and the Advanced Practice Registered Nurse 158 Marie-Eileen Onieal 11 Resource Management 165 Eileen Flaherty, Antigone Grasso, and Cindy Aiena 12 Mediated Roles: Working With and Through Other People 184 Thomas D. Smith, Maria L. Vezina , Mary E. Samost, and Kelly Reilly Unit 3 Competency in Advanced Practice 203 13 Evidence-Based Practice 204 Deborah C. Messecar and Christine A. Tanner 14 Advocacy and the Advanced Practice Registered Nurse 218 Andrea Brassard 15 Case Management and Advanced Practice Nursing 227 Denise Fessler and Irene McEachen 16 The Advanced Practice Nurse and Research 240 Beth Quatrara and Dale Shaw Contents Preface v Contributors vii Unit 1 The Evolution of Advanced Practice 01 1 Advanced Practice Nursing: Doing What Has to Be Done 02 Lynne M. Dunphy 2 Emerging Roles of the Advanced Practice Nurse 16 Deborah Becker and Caroline Doherty 3 Role Development: A Theoretical Perspective 33 Lucille A. Joel 4 Educational Preparation of Advanced Practice Nurses: Looking to the Future 43 Phyllis Shanley Hansell 5 Global Perspectives on Advanced Nursing Practice 54 Madrean Schober and Anna Green Unit 2 The Practice Environment 91 6 Advanced Practice Nurses and Prescriptive Authority 92 Jan Towers 7 Credentialing and Clinical Privileges for the Advanced Practice Registered Nurse 100 Ann H. Cary and Mary C. Smolenski xvi Contents 25 Advanced Practice Registered Nurses: Accomplishments, Trends, and Future Development 387 Jane M. Flanagan, Allyssa Harris, and Dorothy A. Jones 26 Starting a Practice and Practice Management 395 Judith Barberio 27 The Advanced Practice Nurse as Employee or Independent Contractor: Legal and Contractual Considerations 418 Kathleen M. Gialanella 28 The Law, the Courts, and the Advanced Practice Registered Nurse 433 David M. Keepnews 29 Malpractice and the Advanced Practice Nurse 445 Carolyn T. Torre 30 Ethics and the Advanced Practice Nurse 474 Gladys L. Husted , James H. Husted , and Carrie Scotto Index 491 Available online at davisplus.fadavis.com: Bibliography 17 The Advanced Practice Nurse: Holism and Complementary and Integrative Health Approaches 251 Carole Ann Drick 18 Basic Skills for Teaching and the Advanced Practice Registered Nurse 276 Valerie Sabol , Benjamin A. Smallheer, and Marilyn H. Oermann 19 Culture as a Variable in Practice 295 Mary Masterson Germain 20 Conflict Resolution in Advanced Practice Nursing 328 David M. Price and Patricia A. Murphy 21 Leadership for APNs: If Not Now, When? 336 Edna Cadmus 22 Information Technology and the Advanced Practice Nurse 349 Robert Scoloveno 23 Writing for Publication 354 Shirley A. Smoyak Unit 4 Ethical, Legal, and Business Acumen 365 24 Measuring Advanced Practice Nurse Performance: Outcome Indicators, Models of Evaluation, and the Issue of Value 366 Shirley Girouard, Patricia DiFusco, and Joseph Jennas 1 Unit 1 The Evolution of Advanced Practice 2 1 Advanced Practice Nursing Doing What Has to Be Done Lynne M. Dunphy Learning Outcomes Learning outcomes expected as a result of this chapter: • Recognize the historical role of women as healers. • Identify the roots of professional nursing in the United States including the public health movement and turn-of-the-century settlement houses. • Describe early innovative care models created by nurses in the first half of the 20th century such as the Frontier Nursing Service (FNS). • Trace the trajectory of the role of the nurse midwife across the 20th century as well as the present status of this role. • Recognize the emergence of nurse anesthetists as highly autonomous practitioners and their contributions to the advancement of surgical techniques and developments in anesthesia. • Describe the development of the clinical nurse specialist (CNS) role in the context of 20th-century nursing education and professional development with particular attention to the current challenges of this role. • Describe the historical and social forces that led to emergence of the nurse practitioner (NP) role and understand key events in the evolution of this role. • Describe the development of the doctor of nursing practice (DNP) and distinguish this role from the others described in this chapter. • Describe the current challenges to all advanced roles and formulate ways to meet these challenges going forward. Chapter 1 •  Advanced Practice Nursing 3 Advanced practice is a contemporary term that has evolved to label an old phenomenon: nurses or women providing care to those in need in their surrounding communities. As Barbara Ehrenreich and Deidre English (1973) note, “Women have always been healers. They were the unlicensed doctors and anatomists of western history . . . they were pharmacists, cultivating herbs and exchanging the secrets of their uses. They were midwives, travelling from home to home and village to village” (p. 3). Today, with health care dominated by a male-oriented medical profession, advanced practice nurses (APNs) (especially those cheeky enough to call themselves “doctor” even while clarifying their nursing role and background) are viewed as nurses “pushing the envelope”—the envelope of regulated, standardized nursing practice. The reality is that the boundaries of professional nursing practice have always been fluid, with changes in the practice setting speeding ahead of the educational and regulatory environments. It has always been those nurses caring for persons and families who see a need and respond—at times in concert with the medical profession and at times at odds—who are the true trailblazers of contemporary advanced practice nursing. This chapter makes the case that, far from being a new creation, APNs actually predate the founding of modern professional nursing. A look back into our past reveals legendary figures always responding to the challenges of human need, changing the landscape of health care, and improving the health of the populace. The titles may change—such as a doctor of nursing practice (DNP)—but the essence remains the same. PRECURSORS AND ANTECEDENTS There is a long and rich history of female lay healing with roots in both European and African cultures. Well into the 19th century, the female lay healer was the primary health-care provider for most of the population. Thesharing of skills and knowledge was seen as one’s obligation as a member of a community. Theseskills were broad based and might haveincluded midwifery, the use of herbal remedies, and even bonesetting (Ehrenreich, 2000, p. xxxiii). Laurel Ulrich, in A Midwife’s Tale (1990), notes that when the diary of the midwife Martha Ballard opens in 1785, “. . . she knew how to manufacture salves, syrups, pills, teas, ointments, how to prepare an oilemulsion, how to poultice wounds, dress burns, treat dysentery, sorethroat, frost bite, measles, colic, ‘whooping cough,’ ‘chin cough,’ . . . and ‘the itch,’ how to cut an infant’s tongue, administer a ‘clister’ (enema), lance an abscessed breast . . . induce vomiting, assuage bleeding, reduce swelling and relieve a toothache, as well as deliver babies” (p. 11). Ulrich notes the tiny headstones marking the graves of midwife Ballard’s deceased babies and children as further evidence of her ability to provide compassionate, knowledgeable care; she was able to understand the pain and suffering of others. The emergence of a male medical establishment in the 19th century marked the beginning of the end of the era of female lay healers, including midwives. The lay healers saw their role as intertwined with one’s obligations to the community, whereas the emerging medical class saw healing as a commodity to be bought and sold (Ehrenreich & English, 1978). Has this really changed? Are not our current struggles still bound up with issues of gender, class, social position, and money? Have we not entered a phase of more radical than ever splits between the haves and have-nots, with grave consequences to our social fabric? Nursing histories (O’Brien, 1987) have documented the emergence of professional nursing in the 19th century from women’s domestic duties and roles, extensions of the things that women and servants had always done for their families. Modern nursing is usually pinpointed as beginning in 1873, the year of the opening of the first three U.S. training schools for nurses, “as an effort on the part of women reformers to help clean up the mess the male doctors were making” (Ehrenreich, 2000, p. xxxiv). The incoming nurses, forexample, are credited with introducing the first bar of soap into Bellevue Hospital in the dark days when the medical profession was still resisting the germ theory of disease and aseptic techniques. The emergence of a strong public health movement in the 19th century, coupled with the Settlement House Movement, created a new vista for independent and autonomous nursing practice. The Henry Street Settlement, a brainchild of a recently graduated trained nurse named Lillian Wald, was a unique community-based nursing practice on the lower east side of New York City. Wald described these nurses who flocked to work with her at Henry Street Settlement as women of above average “intellectualequipment,” of “exceptional character, mentality and scholarship” (Daniels, 1989, p. 24). These nurses, as 4 Unit 1 •  The Evolution of Advanced Practice regard to perinatal health indicators, was poor (Bigbee & Amidi-Nouri, 2000). Midwives—unregulated and by most accounts unprofessional—were easy scapegoats on which to blame the problem of poor maternal and infant outcomes. New York City’s Department of Health commissioned a study that claimed that the New York midwife was essentially “medieval.” According to this report, fully 90% were “hopelessly dirty, ignorant, and incompetent” (Edgar, 1911, p. 882). There was a concerted movement away from home births. This was all part of a mass assault on midwifery by an increasingly powerful medical elite of obstetricians determined to control the birthing process. These revelations resulted in the tightening of existing laws and the creation of new legislation for the licensing and supervision of midwives (Kobrin, 1984). Several states passed laws granting legal recognition and regulation of midwives, resulting in the establishment of schools of midwifery. One example, the Bellevue School for Midwives in New York City, lasted until 1935, when the diminishing need for midwives made it difficult to justify its existence (Komnenich, 1998). Obstetrical care continued the move into hospitals in urban areas that did not provide midwifery. For the most part, the advance of nurse-midwifery has been a slow and arduous struggle often at odds with mainstream nursing. For example, Lavinia Dock (1901) wrote that all births must be attended by physicians. Public health nurses, committed to the professionalizing of nursing and adherence to scientific standards, chose to distance themselves from lay midwives. The heritage of the unprofessional image of the lay midwife would linger for many years. A more successful example of midwifery was the founding of the Frontier Nursing Service (FNS) in 1925 by Myra Breckinridge in Kentucky. Breckinridge, having been educated as a public health nurse and traveling to Great Britain to become a certified nurse-midwife(CNM), pursued a vision of autonomous nurse-midwifery practice. She aimed to implement the British system in the United States (always a daunting enterprise on any front). In rural settings, where doctors were scarce and hospitals virtually nonexistent, midwifery found more fertile soil. However, even in these settings, professional nurse-midwifery had to struggle to bloom. Breckinridge founded the FNS at a time when the national maternal death rate stood at 6.7 per 1,000 live births, one of the highest rates in the Western world. More has been well documented, enjoyed an exceptional degree of independence and autonomy in their nursing practice caring for the poor, often recent immigrants. In 1893, Wald described a typical day. First, she visited the Goldberg baby and then Hattie Isaacs, a patient with consumption to whom she brought flowers. Wald spent 2 hours bathing her (“the poor girl had been without this attention for so long that it took me nearly two hours to get her skin clean”). Next, she inspected some houses on Hester Street where she found water closets that needed “chloride of lime” and notified the appropriate authorities. In the next house, she found a child with “running ears,” which she “syringed,” showing the mother how to do it at the same time. In another room, there was a child with a “summer complaint”; Wald gave the child bismuth and tickets for a seaside excursion. After lunch she saw the O’Briens and took the “little one, with whooping cough” to play in the back of the Settlement House yard. On the next floor of that tenement, she found the Costria baby who had a sore mouth. Wald “gave the mother honey and borax and little cloths to keep it clean” (Coss, 1989, pp. 43–44). This was all before 2 p.m.! Far from being some new invention, midwives, nurse anesthetists, clinical nurse specialists (CNSs), and nurse practitioners (NPs) are merely new permutations of these long-standing nursing commitments and roles. NURSE-MIDWIVES Throughout the 20th century, nurse-midwifery remained an anomaly in the U.S. health-care system. Nurse-midwives attend only a small percentage of all U.S. births. Since the early decades of the 20th century, physicians laid claim to being the sole legitimate birth attendants in the United States (Dye, 1984). This is in contrast to Great Britain and many other European countries where trained midwives attend a significant percentage of births. In Europe, homes remain an accepted place to give birth, whereas hospital births reign supreme in the United States. In contrast to Europe, the United States has littlein the way of a tradition of professional midwifery. As late as 1910, 50% of all births in the United States were reportedly attended by midwives, and the percentage in large cities was often higher. However, the health status of the U.S. population, particularly in Chapter 1 •  Advanced Practice Nursing 5 than 250,000 infants, nearly 1 in 10, died before they reached their first birthday (U.S. Department of Labor, 1920). The Sheppard-Towner Maternity and Infancy Act, enacted to provide public funds for maternal and child health programs, was the first federal legislation passed for specifically this purpose. Part of the intention of this act was to provide money to the states to train public health nurses in midwifery; however, this proved short-lived. By 1929, the bill lapsed; this was attributed by some to major opposition by the American Medical Association (AMA), which advocated the establishment of a “single standard” of obstetrical care, care that is provided by doctors in hospital settings (Kobrin, 1984). Breckinridge saw nurse-midwives working as independent practitioners and continued to advocate home births. And even more radically, the FNS saw nurse-midwives as offering complete care to women with normal pregnancies and deliveries. However, even Breckinridge and her supporters did not advocate the FNS model for cities where doctors were plentiful and middle-class women could afford medical care. She stressed that the FNS was designed for impoverished “remotely rural areas” without physicians (Dye, 1984). The American Association of Nurse-Midwives (AANM) was founded in 1928, originally as the Kentucky State Association of Midwives, which was an outgrowth of the FNS. First organized as a section of the National Organization of Public Health Nurses (NOPHN), the American College of Nurse-Midwives (ACNM) was incorporated as an independent specialty nursing organization in 1955 when the NOPHN was subsumed within the National League for Nursing (NLN). In 1956, the AANM merged with the college, forming the ACNM as it continues today. The ACNM sponsored the Journal of Nurse-Midwifery, implemented an accreditation process of programs in 1962, and established a certification examination and process in 1971. This body also currently certifies non-nurses as midwives and maintains alliances with professional midwives who are not nurses. As noted by Bigbee and Amidi-Nouri (2000), CNMs are distinct from other APNs in that “they conceptualize their role as the combination of two disciplines, nursing and midwifery” (p. 12). At their core, midwives as a group remain focused on their primary commitment: care of mothers and babies regardless of setting and ability to pay. Rooted in holistic care and the most natural approaches possible, in 2015 there were 11,194 CNMs and 97 certified midwives. In 2014, CNMs or CMs attended 332,107 births, accounting for 12.1% of all vaginal births and 8.3% of total U.S. births (National Center for Health Statistics, 2014). CNMs are licensed, independent health-care providers with prescriptive authority in all 50 states, the District of Columbia, American Samoa, Guam, and Puerto Rico. CNMs are defined as primary care providers under federal law. CMs are also licensed, independent health-care providers who have completed the same midwifery education as CNMs. CMs are authorized to practicein Delaware, Missouri, New Jersey, New York, and Rhode Island and have prescriptive authority in NewYork and RhodeIsland. The first accredited CM education program began in 1996. The CM credential is not yet recognized in all states. Although midwives are well-known for attending births, 53.3% of CNMs and CMs identify reproductive care and 33.1% identify primary care as main responsibilities in their full-time positions. Examples include annual examinations, writing prescriptions, basic nutrition counseling, parenting education, patient education, and reproductive health visits. NURSE ANESTHETISTS Nursing made medicine look good. —Baer, 1982 Surgical anesthesia was born in the United States in the mid 19th century. Immediately there were rival claimants to its “discovery” (Bankert, 1989). In 1846 at Massachusetts General Hospital, WilliamT. G. Morton first successfully demonstrated surgical anesthesia. Nitrous oxide was the first agent used and adopted by U.S. dentists. Ether and chloroform followed shortly as agents for use in anesthetizing a patient. One barrier to surgery had been removed. However, it would take infection control and consistent, careful techniques in the administration of the various anesthetic agents for surgery to enter its “Golden Age.” It was only then that “surgery was transformed from an act of desperation to a scientific method of dealing with illness” (Rothstein, 1958, p. 258). For surgeons to advance their specialty, they needed someone to administer anesthesia with care. However, anesthesiology lacked medical status; the surgeon collected the fee. No incentive existed for anyone with a medical 6 Unit 1 •  The Evolution of Advanced Practice wanted to replace them to establish their own controls. Different variants of this old power struggle echo today in legislative battles over the need for on-site oversight by an anesthesiologist. The American Association of Nurse Anesthetists (AANA) was founded in 1931 by Hodgins and originally named the National Association for Nurse Anesthetists. This group voted to affiliate with the American Nurses Association (ANA), only to beturned away. Asearly as 1909, Florence Henderson, a successor of Magaw’s, was invited to present a paper at the ANA convention, with no subsequentextension of an invitation to become a member of the organization (Komnenich, 1998). Thatcher (1953) speculates that organized nursing was fearful that nurse anesthetists could be charged with practicing medicine, a theme we will see repeated when weexaminethe history of the development of the NP role. This rejection led the AANA to affiliate with the American Hospital Association (AHA). The relationship between nurse anesthetists and anesthesiologists has always been, and continues to be, contentious. Consistent with health-care workforce data in general, there is a maldistribution of MDs, including anesthesiologists, who frequently chooseto practicein areas where patients can afford to pay or in desirable areas to live. Rural areas continue to be underserved as well as indigent areas in general. CRNAs pick up the slack, “doing what has to be done” to meet the needs of underserved patients. Complicating this picture is that there is an uneven supply of CRNAs in different geographic areas. As CRNAs retire later, unwilling to give up lucrative positions, some regions experience intergenerational hostility as well. Despite a brief period of relative harmony from 1972 to 1976, when the AANA and the American Society of Anesthesiologists (ASA) issued the “Joint Statement on Anesthesia Practice,” their partnership ended when the board of directors of the ASA withdrew its support of this statement, returning to a model that maintained physician control (Bankert, 1989, pp. 140–150). The Certified Registered Nurse Anesthetist (CRNA) credential came into existence in 1956. At present, there are approximately more than 50,000 CRNAs (AANA, 2016),* 41% of whom are males (compared with the approximately 13% male population in nursing overall, a figure that has held steady for some time). CRNAs safely degree to take up the work. Who would administer the anesthesia? And who would do so reliably and carefully? There was only one answer: nurses. In her landmark book Watchful Care: A History of America’s Nurse Anesthetists (1989), Marianne Bankert explains how economics changed anesthesia practice. Physician-anesthetists “needed to establish their ‘claim’ to a field of practice they had earlier rejected” (p. 16), and to do this it became necessary to deny, ignore, or denigrate the achievements of their nurse colleagues. The most intriguing part of her study, she says, was “the process by which a rival—and less moneyed—group (in this case, nurses) is rendered historically ‘invisible’” (p. 16). St. Mary’s Hospital, later to become known as the Mayo Clinic, played an important role in the development of anesthesia. It was here that Alice Magaw, sometimes referred to as the “Mother of Anesthesia,” practiced from 1860 to 1928. In 1899, she published a paper titled “Observations in Anesthesia” in Northwestern Lancet in which she reported giving anesthesia in more than 3,000 cases (Magaw, 1899). In 1906, she published another review of more than 14,000 successful anesthesia cases (Magaw, 1906). Bigbee and Amidi-Nouri (2000) note, “She stressed individual attention for all patients and identified the experience of anesthetists as critical elements in quickly responding to the patient” (p. 21). She also paid special attention to her patients’ psyches: She believed that “suggestion” was a great help “in producing a comfortable narcosis” (Bankert, 1989, p. 32). She noted that the anesthetist “must be able to inspire confidence in the patient” and that much of this depends on the approach (Bankert, 1989, p. 32). She stressed preparing the patient for each phase of the experience and of the need to “‘talk him to sleep’ with the addition of as little ether as possible” (p. 33). Magaw contended that hospital-based anesthesia services, as a specialized field, should remain separate from nursing service administrative structures (Bigbee & Amidi-Nouri, 2000). This presaged the estrangement that has historically existed between nurse anesthetists and “regular” nursing; we see a nursing specialty with expanded clinical responsibilities developing outside of mainstream nursing. The medical specialty of anesthesiology began to gain a foothold around the turn of the 20th century, led largely by women physicians. However, these physicians were unsympathetic to the role of the nurse anesthetists; they *In some states, the title CRNA has been changed to APN-Anesthesia. Chapter 1 •  Advanced Practice Nursing 7 In a 1943 speech, Frances Reiter first used the term nurse-clinician. She believed that “practice is the absolute primary function of our profession” and “that means the direct care of patients” (Reiter, 1966). The nurse-clinician, as Reiter conceived the role, consisted of three spheres. The first sphere, clinical competence, included three additional dimensions of function, which she termed care, cure, and counseling. The nurse-clinician was labeled “the Mother Role,” in which the nurse protects, teaches, comforts, and encourages the patient. The second sphere, as envisioned by Reiter, involved clinical expertise in the coordination and continuity of the patient’s care. In the final sphere, she believed in what she called “professional maturity,” wherein the physician and nurse “share a mutual responsibility for the welfare of patients” (Reiter, 1966, p. 277). It was only through such working together that the patient could best be served and nursing achieve “its greatest potential” (Reiter, 1966). Although Reiter believed that the nurse-clinician should have advanced clinical competence, she did not specify that the nurse-clinician should be prepared at the master’s level. In 1943, the National League for Nursing Education advocated a plan to develop these nurse-clinicians, enlisting universities to educatethem (Menard, 1987).Traditionally, advanced education in nursing had focused on “functional” areas, that is, nursing education and nursing administration. Esther Lucile Brown, in her 1948 report Nursing for the Future, promoted developing clinical specialties in nursing as a way of strengthening and advancing the profession. The GI Bill was also available. Nurses in the Armed Services were eligible to receive funds for their education. It took the entrance of another strong nurse leader, Hildegard Peplau, to move these ideas forward to fruition. In 1953, she had both a vision and a plan: She wanted to prepare psychiatric nurse clinicians at the graduate level who could offer direct care to psychiatric patients, thus helping to close the gap between psychiatric theory and nursing practice (Callaway, 2002). In addition, as always there was a great need for health-care providers of all stripes in psychiatric settings. In her first 2 years at Rutgers University in New Jersey, Peplau developed a 19-month master’s program that prepared only CNSs in psychiatric nursing. In contrast, existing programs, such as that at Teachers College in New York City, attempted to prepare nurses for teaching and supervision in a 10-month program. administer approximately 43 million anesthetics to patients each year in the United States according to the AANA 2016 Practice Profile Survey. Interestingly, theinclusion of large numbers of males in its ranks has noteased the advance of this venerable nursing specialty; turf wars between practicing anesthesiologists and nurse anesthetists remain intense as of this writing, further aggravated by the incursion of “doctor-nurses” or “nurse-doctors.” Nonetheless, nurse anesthetists continue to thrive and have situated themselves in the mainstream of graduate-level nursing education, including a large portion of programs adapting curriculums leading to the DNP. Their inclusion in thespectrum of advanced practice nursing continues to be invigorating for us. THE CLINICAL NURSE SPECIALIST The role of the CNS is the one strand of advanced practice nursing that arose and was nurtured by mainstream nursing education and nursing organizations. Indeed, one could say it arose from the very bosom of traditional nursing practice. As early as 1900, in the American Journal of Nursing, Katherine DeWitt wrote that the development of nursing specialties, in her view, responded to a “need for perfection within a limited domain” (Sparacino, 1986, p. 1). According to DeWitt, nursing specialties were a response to “present civilization and modern science [that] demand a perfection along each line of work formerly unknown” (Sparacino, 1986, p. 1). She argued [Show More]

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