Evolution of Advanced Practice Nursing (APN)

S Spencer

Nursing History Video

http://www.youtube.com/watch?v=Noaqf-

JE3UI

Nursing Care

Florence Nightingale, 1855The Granger Collection, N. Y.

1952, A child receiving TB vaccine at a school in BulacamUNICEF/ICEF-2539

Surgery Perioperative nurses Robert Llewellyn Corbis

Physicians & nurses examine children with clef palate & lipat the Xion Jingxi HospitalChina Photos/Getty Images

1960’s-Establishment of Medicare & Medicaid programs→ ↑ demand for geriatric nursing

Pediatric nurses care for infants, children, and adolescents/Sean Justice—The Image Bank/Getty Images

U.S. Army Nurse Corps recruitment poster from World War II/National Library of Medicine, Bethesda, Md.

Nurse Anesthetist

Stock Photo - Nurse Anesthetist in Operating Room

42-16080493 Corbis Royalty Free Photograph

Nurse Anesthetist (CRNA) TIMELINE

1800s 1910-30s 1940s 1950s 1970-1990s

♦Traced to Catholic sisters administering chloroform during civil war

♦ After civil war,

graduate nurses used as Nurse Anesthetists

♦ 6 mo Nurse Anesthetist program

♦ Alice Magnaw, mother of anesthesia

♦ Nurse anesthetists’ right to administer analgesic by physicians questioned

♦ #s’ ↑ during WWI

♦Great

Depression

era, physicians & nurses

anesthetists

compete

for same jobs

♦ WWII defined anesthesia as a medical specialty

♦Anesthesiologists became board certified

♦ Certified as CRNAs

♦ Role expand due to physician shortage in military

♦↑ #s

of males

choosing

Anesthesiologist & CRNA

positions

♦↑ demand

because of the Korea

& Vietnam

War

♦ Building credibility & defending practice

♦ CRNAs could bill for services

♦ ↓ financial support

♦ ↑ physician pressure

♦ Overcome barriers to reimbursement

♦ Master degree required

Nurse Midwife

Nurse Midwife (NM) Timeline1600s 1900s 1950s 1970s 1990s

♦ Nurse midwives brought to US with the slave trade & European immigration

♦ Well respected during this period

♦ Nurse midwives blamed for high maternal & infant mortality

♦ Established schools for midwifery

♦ ↓usage in urban areas & ↑ usage in poor & European communities

♦ ↑ demand because of high birth rate & post war

♦ Hospitals opened its doors to midwives

♦ ↑ # of master degree programs

♦ Among 1st to advocate graduate education

♦ ↑ demand

♦ shortage of OB physicians

♦↑ funding

♦ Physicians supported certified NM

♦ Medical team continues to supervise their practice

♦ ↑ demand

♦Role expanded

♦ Recognized by every state

♦ Granted prescriptive privileges & 3rd party reimbursement

♦ Master degree preferred but not required

Clinical Nurse Specialist

Clinical Nurse Specialist (CRNA) Timeline1900-30s 1940-1950s 1960-70s 1980s 1990s

♦ Specializa-tion in nursing began (anesthesia, TB, lab, OR, dietetics, public health, and

psychiatric )

♦ ↑ demand for psychiatric nurses

♦ ↑ funding because soldiers returned from WWII with medical problems

♦ CNS role development

♦↑# s of CNSs

♦ Defined as expert practitioners & change agents,

♦ Master

prepared

♦ Early 80s,

represented 42% of APN

♦ Late 80s, ↓ #s of CNS due to cost constraints

♦ Role shift from clinical to education

♦ Considered clinical expert & should not be doing patient care

♦↓

employment

opportunities

♦ ↓ master level enrollment because of ↑NP, intro of acute care nurse practitioners, & hospitals’ financial challenges

♦ A # of CNS

also prepared

& worked as NP

Nurse Practitioner

Nurse Practitioner (NP) Timeline

1800-1960s 1970s 1980s 1990s 21st Century

♦ Psychiatric

Nursing 1st

specialty ♦ Nurse clinician defined as nurse with advance knowledge

♦ NPs not afforded the same status as cardiac CNS (can not diagnose & treat)

♦ ↑ demand due to physicians specialization

♦ NP operated & prescribe medication under the direction of the physician

♦ NP role perceived as enticing nurses to switch to medical side

♦ Supported by physicians ♦ Confronted with ↑ resistance by organized medicine

♦ Conflict between NPs & CNS by ANA

♦ AMA opposed any attempt to empower non physicians

♦ NPs fight for prescriptive authority & reimbursement

♦ Assumed

multiple roles

♦ Master degree required

♦ Gained prescriptive authority for narcotics prescription

♦ ↑ demand

♦ Multiple groups developed to represent PN ( ANCC, AANP, etc.)

♦ Battle over prescriptive authority

♦ Full recognition by insurers & health care organizations

♦ Doctorate NP (DNP) degree proposed by AACN to standardize the practice

Physician Assistant

Physician Assistant (PA) Timeline

1900s 1920s 1960s 1990s Current

♦ 1903, state licensure registration

♦ Goldmark study resulted in the establishment of collegiate nursing vs. hospital based schools

♦ Curriculum founded on nursing education

♦ Missed opportunity for professional nursing (slow to respond)

♦ PA role developed

♦ College degree not required

♦ PAs worked under the director of a license preceptor

♦ Created tension with the role of NP

♦ Trained according to the medical

model.

♦ Degree requirement varies (associate, baccalaureate, or master)

Conclusion

A brief synopsis of the history of ANP reveals several themes:

• Throughout the century, APNs have been permitted to provide care to the underserved poor communities and in rural areas.

• significant resistance from organized medicine occurred whenever nursing care competes with physicians’ reimbursement.

•  Documentation of outcomes of practice continues to be critical to the survival of APN practice.

•  Efforts of national professional organizations, national certification, and the move toward graduate education requirement for advanced practice have been critical in establishing the credibility of APN.

•  Intra-professional and inter-professional resistance to expanding the boundaries of the nursing discipline continue to recur.

•  Societal forces (i.e. wars, economic climate, and health care policies) have influenced APN history.

Reference

Brucker, M. C. & Reedy, N. J. (2000). Nurse Midwifery: Yesterday, Today, and Tomorrow. MCN, The American Journal of Maternal/Child Nursing. November/December 25(6), 322.

Hamric, A. B., Spross, J. A. & Hanson, C. M. (Eds.), Advanced practice nursing: An integrated approach. (3rd ed.). Elsevier Saunders. St. Louis MO. 

Hodson, D. M. (1998). The evolving role of the nurse practitioner in

surgery. Retrieved June 5, 2005 from

http://findarticles.com/p/articles/mi_m0FSL/is_n5_v67/ai_20601099/pg_2/

Kristi, H. K. The history and evolution of the APN role: The impact on

healthcare. Retrieved July, 27, 2009 from:

http://dynamicnursingeducation.com/class.php?class_id=86&pid=18

Northouse, P. G. (2003). Leadership theory and practice. (3rd ed.).

Sage Publications, Thousand Oaks, CA.

Nursing. In Encyclopedia Britannica online encyclopedia. Retrieved August 2, 2009, from

http://www.britannica.com/EBchecked/topic-art/422718/11075/Stephen-Girard-lithograph-by-A-Newsam-after-a-portrait-by%20on%20August%202