TESTBANK FOR ADVANCED PRACTICE NURSING 4TH EDITION

TESTBANK FOR ADVANCED PRACTICE NURSING 4TH EDITION 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 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 xv xvi CONTENTS 17 The Advanced Practice Nurse: Holism and Complementary and Integrative Health Approaches 251 25 Advanced Practice Registered Nurses: Accomplishments, Trends, and Future Development 387 Carole Ann Drick Jane M. Flanagan, Allyssa Harris, and Dorothy A. Jones 18 Basic Skills for Teaching and the Advanced Practice Registered Nurse 276 26 Starting a Practice and Practice Management 395 Judith Barberio 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 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 : Bibliography UNIT 1 The Evolution of Advanced Practice 1 Advanced Practice Nursing Doing What Has to Be Done Lynne M. Dunphy • Recognize the historical role of women as healers. • Identify the roots of professional nursing in the United States including the public health movement and turn-of-the-century settlement houses. • Describe early innovative care models created by nurses in the first half of the 20th century such as the Frontier Nursing Service (FNS). • Trace the trajectory of the role of the nurse midwife across the 20th century as well as the present status of this role. • Recognize the emergence of nurse anesthetists as highly autonomous practitioners and their contributions to the advancement of surgical techniques and develop- ments in anesthesia. • Describe the development of the clinical nurse specialist (CNS) role in the context of 20th-century nursing education and professional development with particular attention to the current challenges of this role. • Describe the historical and social forces that led to emergence of the nurse practi- tioner (NP) role and understand key events in the evolution of this role. • Describe the development of the doctor of nursing practice (DNP) and distin- guish this role from the others described in this chapter. • Describe the current challenges to all advanced roles and formulate ways to meet these challenges going forward. 2 Advanced practice is a contemporary term that has evolved to label an old phenomenon: nurses or women providing care to those in need in their surrounding communities. As Barbara Ehrenreich and Deidre English (1973) note, “Women have always been healers. They were the un- licensed doctors and anatomists of western history . . . they were pharmacists, cultivating herbs and exchanging the secrets of their uses. They were midwives, travelling from home to home and village to village” (p. 3). Today, with health care dominated by a male-oriented medical profession, advanced practice nurses (APNs) (especially those cheeky enough to call themselves “doctor” even while clarifying their nursing role and background) are viewed as nurses “pushing the envelope”—the envelope of regulated, standardized nursing practice. The reality is that the boundaries of professional nursing practice have always been fluid, with changes in the practice setting speeding ahead of the educational and regulatory environments. It has always been those nurses caring for persons and families who see a need and respond—at times in concert with the medical profession and at times at odds—who are the true trailblazers of contemporary advanced practice nursing. This chapter makes the case that, far from being a new creation, APNs actually predate the founding of modern professional nursing. A look back into our past reveals legendary figures always responding to the challenges of human need, changing the landscape of health care, and improving the health of the populace. The titles may change—such as a doctor of nursing practice (DNP)—but the essence remains the same. PRECURSORS AND ANTECEDENTS There is a long and rich history of female lay healing with roots in both European and African cultures. Well into the 19th century, the female lay healer was the primary health-care provider for most of the population. The sharing of skills and knowledge was seen as one’s obligation as a member of a community. These skills were broad based and might have included midwifery, the use of herbal remedies, and even bone setting (Ehrenreich, 2000, p. xxxiii). Laurel Ulrich, in A Midwife’s Tale (1990), notes that when the diary of the midwife Martha Ballard opens in 1785, “. . . she knew how to manufacture salves, syrups, pills, teas, ointments, how to prepare an oil emulsion, how to poultice wounds, dress burns, treat dysentery, sore throat, frost bite, measles, colic, ‘whooping cough,’ ‘chin cough,’ . . . and ‘the itch,’ how to cut an infant’s tongue, administer a ‘clister’ (enema), lance an abscessed breast . . . induce vomiting, assuage bleeding, reduce swelling and relieve a toothache, as well as deliver babies” (p. 11). Ulrich notes the tiny headstones marking the graves of midwife Ballard’s deceased babies and children as further evidence of her ability to provide compassionate, knowledgeable care; she was able to understand the pain and suffering of others. The emergence of a male medical establishment in the 19th century marked the beginning of the end of the era of female lay healers, including mid- wives. The lay healers saw their role as intertwined with one’s obligations to the community, whereas the emerging medical class saw healing as a commodity to be bought and sold (Ehrenreich & English, 1978). Has this really changed? Are not our current struggles still bound up with issues of gender, class, social position, and money? Have we not entered a phase of more radical than ever splits between the haves and have-nots, with grave consequences to our social fabric? Nursing histories (O’Brien, 1987) have documented the emergence of professional nursing in the 19th century from women’s domestic duties and roles, extensions of the things that women and servants had always done for their families. Modern nursing is usually pinpointed as beginning in 1873, the year of the opening of the first three U.S. training schools for nurses, “as an effort on the part of women reformers to help clean up the mess the male doctors were making” (Ehrenreich, 2000, p. xxxiv). The incoming nurses, for example, are credited with introducing the first bar of soap into Bellevue Hospital in the dark days when the medical profession was still resisting the germ theory of disease and aseptic techniques. The emergence of a strong public health movement in the 19th century, coupled with the Settlement House Movement, created a new vista for independent and au- tonomous nursing practice. The Henry Street Settlement, a brainchild of a recently graduated trained nurse named Lillian Wald, was a unique community-based nursing practice on the lower east side of New York City. Wald described these nurses who flocked to work with her at Henry Street Settlement as women of above average “intellectual equipment,” of “exceptional character, mentality and scholarship” (Daniels, 1989, p. 24). These nurses, as has been well documented, enjoyed an exceptional degree of independence and autonomy in their nursing practice caring for the poor, often recent immigrants. In 1893, Wald described a typical day. First, she visited the Goldberg baby and then Hattie Isaacs, a patient with consumption to whom she brought flowers. Wald spent 2 hours bathing her (“the poor girl had been without this attention for so long that it took me nearly two hours to get her skin clean”). Next, she inspected some houses on Hester Street where she found water closets that needed “chloride of lime” and notified the appropriate authorities. In the next house, she found a child with “running ears,” which she “syringed,” showing the mother how to do it at the same time. In another room, there was a child with a “summer complaint”; Wald gave the child bismuth and tickets for a seaside excursion. After lunch she saw the O’Briens and took the “little one, with whooping cough” to play in the back of the Settlement House yard. On the next floor of that tenement, she found the Costria baby who had a sore mouth. Wald “gave the mother honey and borax and little cloths to keep it clean” (Coss, 1989, pp. 43–44). This was all before 2 p.m.! Far from being some new invention, midwives, nurse anesthetists, clinical nurse specialists (CNSs), and nurse practitioners (NPs) are merely new permutations of these long-standing nursing commitments and roles. NURSE-MIDWIVES Throughout the 20th century, nurse-midwifery remained an anomaly in the U.S. health-care system. Nurse-midwives attend only a small percentage of all U.S. births. Since the early decades of the 20th century, physicians laid claim to being the sole legitimate birth attendants in the United States (Dye, 1984). This is in contrast to Great Britain and many other European countries where trained midwives attend a significant percentage of births. In Europe, homes remain an accepted place to give birth, whereas hospital births reign supreme in the United States. In contrast to Europe, the United States has little in the way of a tradition of professional midwifery. As late as 1910, 50% of all births in the United States were reportedly attended by midwives, and the percentage in large cities was often higher. However, the health status of the U.S. population, particularly in regard to perinatal health indicators, was poor (Bigbee & Amidi-Nouri, 2000). Midwives—unregulated and by most accounts unprofessional—were easy scapegoats on which to blame the problem of poor maternal and infant outcomes. New York City’s Department of Health com- missioned a study that claimed that the New York midwife was essentially “medieval.” According to this report, fully 90% were “hopelessly dirty, ignorant, and incompetent” (Edgar, 1911, p. 882). There was a concerted movement away from home births. This was all part of a mass assault on midwifery by an increasingly powerful medical elite of obstetricians determined to control the birthing process. These revelations resulted in the tightening of existing laws and the creation of new legislation for the licensing and supervision of midwives (Kobrin, 1984). Several states passed laws granting legal recognition and regulation of midwives, resulting in the establishment of schools of midwifery. One example, the Bellevue School for Midwives in New York City, lasted until 1935, when the diminishing need for midwives made it difficult to justify its existence (Komnenich, 1998). Obstetrical care continued the move into hospitals in urban areas that did not provide mid- wifery. For the most part, the advance of nurse-midwifery has been a slow and arduous struggle often at odds with mainstream nursing. For example, Lavinia Dock (1901) wrote that all births must be attended by physicians. Public health nurses, committed to the professionalizing of nursing and adherence to scientific standards, chose to distance themselves from lay midwives. The heritage of the unprofessional image of the lay midwife would linger for many years. A more successful example of midwifery was the founding of the Frontier Nursing Service (FNS) in 1925 by Myra Breckinridge in Kentucky. Breckinridge, having been educated as a public health nurse and traveling to Great Britain to become a certified nurse-midwife (CNM), pursued a vision of autonomous nurse-midwifery practice. She aimed to implement the British system in the United States (always a daunting enterprise on any front). In rural settings, where doctors were scarce and hospitals virtually nonexistent, midwifery found more fertile soil. However, even in these settings, professional nurse-midwifery had to struggle to bloom. Breckinridge founded the FNS at a time when the national maternal death rate stood at 6.7 per 1,000 live births, one of the highest rates in the Western world. More than 250,000 infants, nearly 1 in 10, died before they reached their first birthday (U.S. Department of Labor, 1920). The Sheppard-Towner Maternity and Infancy Act, enacted to provide public funds for maternal and child health programs, was the first federal legislation passed for specifically this purpose. Part of the intention of this act was to provide money to the states to train public health nurses in midwifery; however, this proved short-lived. By 1929, the bill lapsed; this was attributed by some to major opposition by the American Medical Association (AMA), which advocated the establishment of a “single standard” of obstetrical care, care that is provided by doctors in hospital settings (Kobrin, 1984). Breckinridge saw nurse-midwives working as indepen- dent practitioners and continued to advocate home births. And even more radically, the FNS saw nurse-midwives as offering complete care to women with normal pregnan- cies and deliveries. However, even Breckinridge and her supporters did not advocate the FNS model for cities where doctors were plentiful and middle-class women could afford medical care. She stressed that the FNS was designed for impoverished “remotely rural areas” without physicians (Dye, 1984). The American Association of Nurse-Midwives (AANM) was founded in 1928, originally as the Kentucky State were 11,194 CNMs and 97 certified midwives. In 2014, CNMs or CMs attended 332,107 births, accounting for 12.1% of all vaginal births and 8.3% of total U.S. births (National Center for Health Statistics, 2014). CNMs are licensed, independent health-care providers with prescriptive authority in all 50 states, the District of Columbia, American Samoa, Guam, and Puerto Rico. CNMs are defined as primary care providers under federal law. CMs are also licensed, independent health-care providers who have completed the same midwifery education as CNMs. CMs are authorized to practice in Delaware, Missouri, New Jersey, New York, and Rhode Island and have prescriptive authority in New York and Rhode Island. The first accredited CM education program began in 1996. The CM credential is not yet recognized in all states. Although midwives are well-known for attending births, 53.3% of CNMs and CMs identify reproductive care and 33.1% identify primary care as main responsibilities in their full-time positions. Examples include annual exam- inations, writing prescriptions, basic nutrition counseling, parenting education, patient education, and reproductive health visits. NURSE ANESTHETISTS Association of Midwives, which was an outgrowth of the FNS. First organized as a section of the National Organi- zation of Public Health Nurses (NOPHN), the American College of Nurse-Midwives (ACNM) was incorporated as an independent specialty nursing organization in 1955 when the NOPHN was subsumed within the National League for Nursing (NLN). In 1956, the AANM merged with the college, forming the ACNM as it continues today. The ACNM sponsored the Journal of Nurse-Midwifery, implemented an accreditation process of programs in 1962, and established a certification examination and process in 1971. This body also currently certifies non-nurses as midwives and maintains alliances with professional midwives who are not nurses. As noted by Bigbee and Amidi-Nouri (2000), CNMs are distinct from other APNs in that “they conceptualize their role as the combination of two disciplines, nursing and midwifery” (p. 12). At their core, midwives as a group remain focused on their primary commitment: care of mothers and babies regardless of setting and ability to pay. Rooted in holistic care and the most natural approaches possible, in 2015 there Nursing made medicine look good. —Baer, 1982 Surgical anesthesia was born in the United States in the mid 19th century. Immediately there were rival claimants to its “discovery” (Bankert, 1989). In 1846 at Massachusetts General Hospital, William T. G. Morton first successfully demonstrated surgical anesthesia. Nitrous oxide was the first agent used and adopted by U.S. dentists. Ether and chloroform followed shortly as agents for use in anesthe- tizing a patient. One barrier to surgery had been removed. However, it would take infection control and consistent, careful techniques in the administration of the various anesthetic agents for surgery to enter its “Golden Age.” It was only then that “surgery was transformed from an act of desperation to a scientific method of dealing with illness” (Rothstein, 1958, p. 258). For surgeons to advance their specialty, they needed someone to administer anesthesia with care. However, anesthesiology lacked medical status; the surgeon collected the fee. No incentive existed for anyone with a medical degree to take up the work. Who would administer the anesthesia? And who would do so reliably and carefully? There was only one answer: nurses. In her landmark book Watchful Care: A History of America’s Nurse Anesthetists (1989), Marianne Bankert explains how economics changed anesthesia practice. Physician-anesthetists “needed to establish their ‘claim’ to a field of practice they had earlier rejected” (p. 16), and to do this it became necessary to deny, ignore, or denigrate the achievements of their nurse colleagues. The most intriguing part of her study, she says, was “the process by which a rival—and less moneyed—group (in this case, nurses) is rendered historically ‘invisible’” (p. 16). St. Mary’s Hospital, later to become known as the Mayo Clinic, played an important role in the devel- opment of anesthesia. It was here that Alice Magaw, sometimes referred to as the “Mother of Anesthesia,” practiced from 1860 to 1928. In 1899, she published a paper titled “Observations in Anesthesia” in Northwestern Lancet in which she reported giving anesthesia in more than 3,000 cases (Magaw, 1899). In 1906, she published another review of more than 14,000 successful anesthesia cases (Magaw, 1906). Bigbee and Amidi-Nouri (2000) note, “She stressed individual attention for all patients and identified the experience of anesthetists as critical elements in quickly responding to the patient” (p. 21). She also paid special attention to her patients’ psyches: She believed that “suggestion” was a great help “in pro- ducing a comfortable narcosis” (Bankert, 1989, p. 32). She noted that the anesthetist “must be able to inspire confidence in the patient” and that much of this depends on the approach (Bankert, 1989, p. 32). She stressed preparing the patient for each phase of the experience and of the need to “‘talk him to sleep’ with the addition of as little ether as possible” (p. 33). Magaw contended that hospital-based anesthesia services, as a specialized field, should remain separate from nursing service admin- istrative structures (Bigbee & Amidi-Nouri, 2000). This presaged the estrangement that has historically existed between nurse anesthetists and “regular” nursing; we see a nursing specialty with expanded clinical responsibilities developing outside of mainstream nursing. The medical specialty of anesthesiology began to gain a foothold around the turn of the 20th century, led largely wanted to replace them to establish their own controls. Different variants of this old power struggle echo today in legislative battles over the need for on-site oversight by an anesthesiologist. The American Association of Nurse Anesthetists (AANA) was founded in 1931 by Hodgins and originally named the National Association for Nurse Anesthetists. This group voted to affiliate with the American Nurses Association (ANA), only to be turned away. As early as 1909, Florence Henderson, a successor of Magaw’s, was invited to present a paper at the ANA convention, with no subsequent extension of an invitation to become a member of the organization (Komnenich, 1998). Thatcher (1953) speculates that or- ganized nursing was fearful that nurse anesthetists could be charged with practicing medicine, a theme we will see repeated when we examine the history of the development of the NP role. This rejection led the AANA to affiliate with the American Hospital Association (AHA). The relationship between nurse anesthetists and anesthesiologists has always been, and continues to be, contentious. Consistent with health-care workforce data in general, there is a maldistribution of MDs, including anesthesiologists, who frequently choose to practice in areas where patients can afford to pay or in desirable areas to live. Rural areas continue to be underserved as well as indigent areas in general. CRNAs pick up the slack, “doing what has to be done” to meet the needs of underserved patients. Complicating this picture is that there is an uneven supply of CRNAs in different geographic areas. As CRNAs retire later, unwilling to give up lucrative positions, some regions experience intergenerational hostility as well. Despite a brief period of relative harmony from 1972 to 1976, when the AANA and the American Society of Anesthesiologists (ASA) issued the “Joint Statement on Anesthesia Practice,” their partnership ended when the board of directors of the ASA withdrew its support of this statement, returning to a model that maintained physician control (Bankert, 1989, pp. 140–150). The Certified Registered Nurse Anesthetist (CRNA) credential came into existence in 1956. At present, there are approximately more than 50,000 CRNAs (AANA, 2016),* 41% of whom are males (compared with the approximately 13% male population in nursing overall, a figure that has held steady for some time). CRNAs safely 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. administer approximately 43 million anesthetics to patients each year in the United States according to the AANA 2016 Practice Profile Survey. Interestingly, the inclusion of large numbers of males in its ranks has not eased the advance of this venerable nursing specialty; turf wars between practicing anesthesiologists and nurse anesthetists remain intense as of this writing, further aggravated by the incursion of “doctor-nurses” or “nurse-doctors.” Nonetheless, nurse anesthetists continue to thrive and have situated themselves in the mainstream of graduate-level nursing education, including a large portion of programs adapting curriculums leading to the DNP. Their inclusion in the spectrum of advanced practice nursing continues to be invigorating for us. THE CLINICAL NURSE SPECIALIST The role of the CNS is the one strand of advanced prac- tice nursing that arose and was nurtured by mainstream nursing education and nursing organizations. Indeed, one could say it arose from the very bosom of traditional nursing practice. As early as 1900, in the American Journal of Nursing, Katherine DeWitt wrote that the development of nursing specialties, in her view, responded to a “need for perfection within a limited domain” (Sparacino, 1986, p. 1). According to DeWitt, nursing specialties were a response to “present civilization and modern science [that] demand a perfection along each line of work formerly unknown” (Sparacino, 1986, p. 1). She argued that “the new nurse is more useful, at least to the patient himself, and ultimately to the family and community. Her sphere is more limited, but her patient receives better care” (Sparacino, 1986, p. 1). Historically, nurses were trained and worked in hospitals that were structured for the convenience of the doctors around specific populations of patients. Early on, nurses initiated guidelines for the care of unique populations and often garnered a hands-on kind of intimacy, an expertise in the care of certain patients that was not to be denied. Caring day in and day out for patients suffering from similar conditions enabled nurses to develop specialized and advanced skills not practiced by other nurses. Think of the nurses who cared exclusively for patients with tu- berculosis, syphilis, and polio. Because these conditions are no longer common, any nursing expertise that might have been developed has been lost. In a 1943 speech, Frances Reiter first used the term nurse-clinician. She believed that “practice is the absolute primary function of our profession” and “that means the direct care of patients” (Reiter, 1966). The nurse-clinician, as Reiter conceived the role, consisted of three spheres. The first sphere, clinical competence, included three additional dimensions of function, which she termed care, cure, and counseling. The nurse-clinician was labeled “the Mother Role,” in which the nurse protects, teaches, comforts, and encourages the patient. The second sphere, as envisioned by Reiter, involved clinical expertise in the coordination and continuity of the patient’s care. In the final sphere, she believed in what she called “professional maturity,” wherein the physician and nurse “share a mutual responsibility for the welfare of patients” (Reiter, 1966, p. 277). It was only through such working together that the patient could best be served and nursing achieve “its greatest potential” (Reiter, 1966). Although Reiter believed that the nurse-clinician should have advanced clinical competence, she did not specify that the nurse-clinician should be prepared at the master’s level. In 1943, the National League for Nursing Education advocated a plan to develop these nurse-clinicians, enlisting universities to educate them (Menard, 1987). Traditionally, advanced education in nursing had focused on “functional” areas, that is, nursing education and nursing administration. Esther Lucile Brown, in her 1948 report Nursing for the Future, promoted developing clinical specialties in nursing as a way of strengthening and advancing the profession. The GI Bill was also available. Nurses in the Armed Services were eligible to receive funds for their education. It took the entrance of another strong nurse leader, Hildegard Peplau, to move these ideas forward to fruition. In 1953, she had both a vision and a plan: She wanted to prepare psychiatric nurse clinicians at the graduate level who could offer direct care to psychiatric patients, thus helping to close the gap between psychiatric theory and nursing practice (Callaway, 2002). In addition, as always there was a great need for health-care providers of all stripes in psychiatric settings. In her first 2 years at Rutgers University in New Jersey, Peplau developed a 19-month master’s program that prepared only CNSs in psychiatric nursing. In contrast, existing programs, such as that at Teachers College in New York City, attempted to prepare nurses for teaching and supervision in a 10-month program. The field of psychiatric nursing was in the process of inventing itself. Before the passage of the National Mental Health Act in 1946, there was no such field as psychiatric nursing. It was the availability of National Institute of Mental Health funds to “seed” such programs as Peplau’s that allowed psychiatric nursing to begin and eventually to flourish. In retrospect, Peplau would note that no encouragement was received from the two major nursing organizations of the day, the NLN and the ANA. She stated, “We were highly stigmatized. Any nurse who worked in [the field of mental health] was considered almost certifiable. . . . We were thoroughly unpopular, we were considered queer enough to be avoided” (Callaway, 2002, p. 229). It should be emphasized that at this point in nursing history it was inconceivable that any nurse, under any circumstances, could become a specialist. The “received wisdom” of the day was the axiom, followed by the vast majority of nurses, that “a nurse is a nurse is a nurse,” opposing any differentiation between who was doing what among them. Peplau’s rigorous curriculum and clinical and academic program requirements expected that faculty would continue their own clinical practice, do clinical research, and publish the results (Callaway, 2002). This was a radical model for nursing faculty, few of whom were doctorally prepared in the 1950s. In 1956, only 2 years following the initiation of the first clinically focused graduate program, a national working conference on graduate education in psychiatric nursing formally developed the role of the psychiatric clinical specialist. Most hospital training schools remained embedded in a functional method of nursing well into the 1960s. As originally conceptualized by Isabel Stewart in the 1930s, “nurses were trained and much of nursing practice was rule-based and activity-oriented” (Fairman, 1999, p. 42), relying heavily on repetition of skills and procedures. There was little, if any, scientific understanding of the principles underlying care. There was little, if any, intellectual content to be found in the nursing curriculum. With the advent of antibiotics in the 1940s and the resulting decline of infectious diseases, nurses’ practice shifted to caring for patients with acute, often rapidly changing exacerbations of chronic conditions. Leaders such as Peplau, along with others such as Virginia Henderson, Frances Reiter, and later Dorothy Smith, began developing a theoretical orientation for practice. Students were being taught to assess patient responses to their illnesses and to make analytical decisions. Smith experimented with the idea of a nurse-clinician who had 24-hour responsibility for a patient area and who was on call. Laura Simms at Cornell University–New York Hospital School of Nursing developed a CNS role to provide consultation to more generalist nurses. As opposed to the nurse who might have been expert in procedures, these new clinicians were experts in clinical care for a certain population of patients. This development occurred across specialties and was seen in oncology, nephrology, psychiatry, and intensive care units (Sills, 1983). Role expansion of the CNS grew rapidly during the 1960s because of several factors. Advances in medical technology and medical specialization increased the need for nurses who were competent to care for patients with complex health needs. Nurses returning from the battlefields of Vietnam sought to increase their knowledge and skills and contin- ued to practice in advanced roles and nontraditional areas (such as trauma or anesthesia). Role definitions for women loosened and expanded. There was a shortage of physicians. The Nurse Training Act of 1964 allocated necessary federal funds for additional graduate nursing education programs in several different clinical specialties (Mirr & Snyder, 1995). The terms nurse-clinician, CNS, and nurse specialist, among others, were used extensively by nurses with ex- perience or advanced knowledge who had developed an expertise within a given area of patient care. There were no standards regarding educational requirements or experience. In 1965, the ANA developed a position statement declaring that only those nurses with a master’s degree or higher in nursing should claim the role of CNS (ANA, 1965). These trends continued into the 1970s. The number of academic programs providing master’s preparation in a variety of practice areas increased. Federal grants, including those from the Department of Health, Education, and Welfare, continued to provide funding for nursing education at the master’s and doctoral levels. In 1976, during the ANA’s Congress on Nursing Practice, a position statement on the role of the CNS was issued. The ANA position statement read as follows (ANA Congress for Nursing Practice, 1976): The clinical nurse specialist (CNS) is a practitioner holding a master’s degree with a concentration in specific areas of clinical nursing. The role of the CNS is defined by the needs of a select client population, the expectation of the larger society and the clinical expertise of the nurse. The statement went on to elaborate that “by exercising leadership ability and judgment,” the CNS is able to affect client care on the individual, direct-care provider level as well as affect change within the broader health-care system (ANA Congress for Nursing Practice, 1976). The 1970s were a time of growth in academic CNS programs; the 1980s were years in which refinements occurred. In 1980, the ANA revised its earlier policy statement of 1976 to define the CNS as “a registered nurse who, through study and supervised clinical practice at the graduate level (master’s or doctorate) has become an expert in a defined area of knowledge and practice in a selected clinical area of nursing” (ANA, 1980, p. 23). This statement was significant because it was the first time that education at the master’s level had been dictated as a mandatory criterion for entry into expert practice. The CNS role more than any other advanced nursing role was situated in the mainstream of graduate nursing education, with the first master’s degree in psychiatric and mental health nursing conferred by Rutgers University in 1955. The inclusion of clinical content in master’s degree education was an essential step forward for nursing’s ad- vancement. But the implementation and use of the CNS avoided easy categorization and their efficacy was elusive. In February 1983, the ANA Council of Clinical Nurse Specialists met for the first time (Sparacino, 1990). The Council grew rapidly throughout the subsequent years, supporting and providing educational conferences for the increasing numbers of CNSs. In 1986, the Council pub- lished the CNS’s role statement. This statement identified the roles of the CNS as specialist in clinical practice and as educator, consultant, researcher, and administrator. This role statement by the Council depicted the changing role of the CNS, notably delegating and overseeing practice as its primary focus (Fulton, 2002). The year 1986 was also notable for the publication of the journal Clinical Nurse Specialist: The Journal for Advanced Nursing. In 1986, the ANA’s Council of Clinical Nurse Specialists and the Council of Primary Health Care Providers pub- lished an editorial outlining the similarities of the CNS and NP roles. Discussion surrounding the commonalities of both specialties occurred throughout the decade. In 1989, during the annual meeting of the National Organization of Nurse Practitioner Faculty (NONPF), the 10-year-old debate regarding the merger of the two roles reached a crescendo without resolution (Lincoln, 2000). It remains an issue of contention to the present day. Despite this, the two ANA councils did merge in 1990, becoming the Council of Nurses in Advanced Practice (Busen & Engleman, 1996; Lincoln, 2000). Following the merger of the councils, several studies were published comparing CNS and NP roles, finding the education for practice generally comparable (Joel, 2011). The 1990s was an era of health-care “reform.” Health-care costs were skyrocketing; hospital stays were shorter, with acutely ill patients being discharged quicker and sicker. Because of fiscal mandates, hospitals were decreasing the number of beds and personnel and the focus of health care shifted from hospital to ambulatory care within the community and home. The historically hospital-based CNS was considered too expensive and unproven. Thus, CNSs all over were losing positions. In 1993, the American Association of Colleges of Nursing (AACN) met to discuss educational needs and requirements for the 21st century. At the AACN’s annual conference in December 1994, members voted to support the merging of the CNS and NP roles in the curricula of graduate education in nursing. Although the structure of the curricula suggested in the “Essentials of Graduate Education” (AACN, 1995) has been widely adopted, the lived reality of role adaptation and its implementation in the marketplace has been less uniform and more divi- sive. Sparacino (1990) defined the scope of the CNS as “client-centered practice, utilizing an in-depth assessment, practiced within the domain of secondary and tertiary care settings” (p. 8). The NP role is defined by Sparacino (1986) as being responsible for providing a full range of primary health-care services, using the appropriate knowledge base and practicing in multiple settings outside of secondary and tertiary settings. To some degree this has been the nature of