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Advanced
Practice
Nursing
Essentials for Role Development
Fourth Edition
Jane M. Flanagan, PhD, ANP-BC Phyllis Shanley Hansell, EdD, RN, FNAP, FAAN
Associate Professor and Program Director Professor
Adult Gerontology Seton Hall University
Boston College College of Nursing
Connell School of Nursing South Orange, New Jersey
Chestnut Hill, Massachusetts
Allyssa Harris, RN, PhD, WHNP-BC
Rita Munley Gallagher, RN, PhD Assistant Professor
Nursing and Healthcare Consultant William F. Connell School of Nursing
Washington, District of Columbia Boston College
Boston, Massachusetts
Mary Masterson Germain, EdD, ANP-BC, FNAP, Gladys L. Husted, RN, PhD
D.S. (Hon)
Professor Emeritus
Professor Emeritus Duquesne University
State University of New York–Downstate Pittsburgh, Pennsylvania
Medical Center College of Nursing
Brooklyn, New York James H. Husted
Independent Scholar
Kathleen M. Gialanella, JD, LLM, RN Pittsburgh, Pennsylvania
Law Offices
Westfield, New Jersey Joseph Jennas, CRNA, MS
Associate Adjunct Professor Program Director
Teachers College, Columbia University Clinical Assistant Professor
New York, New York SUNY Downstate Medical Center
Brooklyn, New York
Shirley Girouard, RN, PhD, FAAN
Lucille A. Joel, EdD, APN, FAAN
Professor and Associate Dean
State University of New York-Downstate Distinguished Professor
Medical Center Rutgers-The State University of New Jersey
College of Nursing School of Nursing
Brooklyn, New York New Brunswick-Newark
New Jersey
Antigone Grasso, MBA Dorothy A. Jones, EdD, RNC-ANP, FAAN
Director Professor, Boston College
Patient Care Services Management Systems Connell School of Nursing
and Financial Performance Senior Nurse, Massachusetts General Hospital
Massachusetts General Hospital Boston, Massachusetts
Boston, Massachusetts
David M. Keepnews, PhD, JD, RN, NEA-BC, FAAN
Anna Green, RN, Crit Care Cert, MNP Dean and Professor
Project Manager Long Island University (LIU) Brooklyn
Australian Red Cross Blood Service Harriet Rothkopf Heilbrunn School of Nursing
Melbourne, Australia Brooklyn, New York
Alice F. Kuehn, RN, PhD, BC-FNP/GNP Beth Quatrara, DNP, RN, CMSRN, ACNS-BC
Associate Professor Emeritus Advanced Practice Nurse–CNS
University of Missouri-Columbia University of Virginia Health System
School of Nursing Charlottesville, Virginia
Columbia, Missouri
Parish Nurse Kelly Reilly, MSN, RN, BC
St. Peter Catholic Church Director of Nursing
Jefferson City, Missouri Maimonides Medical Center
Brooklyn, New York
Irene McEachen, RN, MSN, EdD
Associate Professor Valerie Sabol, PhD, ACNP-BC, GNP-BC, ANEF,
Saint Peter’s University FAANP
Division of Nursing Professor and Division Chair
Jersey City, New Jersey Healthcare in Adult Population
Duke University
Deborah C. Messecar, PhD, MPH, AGCNS-BC, RN School of Nursing
Associate Professor Durham, North Carolina
Oregon Health and Science University
School of Nursing Mary E. Samost, RN, MSN, DNP, CENP
Portland, Oregon System Director Surgical Services
Hallmark Health System
Patricia A. Murphy, PhD, APRN, FAAN Medford, Massachusetts
Associate Professor
Rutgers-The State University of New Jersey Madrean Schober, PhD, MSN, ANP, FAANP
New Jersey Medical School President
Newark, New Jersey Schober Global Healthcare Consulting International
Indianapolis, Indiana
Marilyn H. Oermann, RN, PhD, FAAN, ANEF
Thelma Ingles Professor of Nursing Robert Scoloveno, PhD, RN
Director of Evaluation and Educational Research Director–Simulation Laboratories
Duke University Assistant Professor
School of Nursing Rutgers-The State University of New Jersey
Durham, North Carolina School of Nursing
Camden, New Jersey
Marie-Eileen Onieal, PhD, MMHS, RN, CPNP,
FAANP Carrie Scotto, RN, PhD
Faculty, Doctor of Nursing Practice Associate Professor
Rocky Mountain University of Health Professions The University of Akron
Provo, Utah College of Nursing
Akron, Ohio
David M. Price, MD, PhD
Founding Faculty Dale Shaw, RN, DNP, ACNP-BC
Center for Personalized Education of Physicians ACNP–Acute Care Neurosurgery
(CDEP) University of Virginia Health System
Denver, Colorado Charlottesville, Virginia
Benjamin A. Smallheer, PhD, RN, ACNP-BC, Caroline T. Torre, RN, MA, APN, FAANP
FNP-BC, CCRN, CNE Nursing Policy Consultant
Assistant Professor of Nursing Princeton, New Jersey
Duke University Formerly, Director, Regulatory Affairs
School of Nursing New Jersey State Nurses Association
Durham, North Carolina Trenton, New Jersey
Thomas D. Smith, DNP, RN, NEA-BC, FAAN Jan Towers, PhD, NP-C, CRNP (FNP), FAANP
Chief Nursing Officer Director of Health Policy
Maimonides Medical Center Federal Government and Professional Affairs
Brooklyn, New York American Academy of Nurse Practitioners
Washington, District of Columbia
Mary C. Smolenski, MS, EdD, FNP, FAANP
Independent Consultant Maria L. Vezina, RN, EdD, NEA-BC
Washington, District of Columbia Chief Nursing Officer/Vice President, Nursing
The Mount Sinai Hospital
Shirley A. Smoyak, RN, PhD, FAAN New York, New York
Distinguished Professor
Rutgers-The State University of New Jersey
School of Nursing
New Brunswick-Newark, New Jersey
Nancy Bittner, RN, PhD Sheila Grossman, PhD, APRN, FNP-BC, FAAN
Associate Dean Professor and Coordinator
School of Nursing Science and Health Professions Family Nurse Practitioner Program
Regis College Fairfield University
Weston, Massachusetts Fairfield, Connecticut
xi
Joy Lewis, CRNA, MSN Julie Ponto, RN, PhD, ACNS-BC, AOCN
Interim Assistant Program Director Nurse Professor
Anesthesia Winona State University–Rochester
Lincoln Memorial University Rochester, Minnesota
Harrogate, Tennessee
Susan D. Schaffer, PhD, ARNP, FNP-BC
Laurie Kennedy-Malone, PhD, GNP-BC, FAANP, Chair, Department of Women’s, Children’s
FGSA and Family Nursing
Professor of Nursing FNP Track Coordinator
University of North Carolina at Greensboro School University of Florida College of Nursing
of Nursing Gainesville, Florida
Greensboro, North Carolina
Beth R. Steinfeld, DNP, WHNP-BC
Susan McCrone, PhD, PMHCNS-BC Assistant Professor
Professor SUNY Downstate Medical Center
West Virginia University Brooklyn, New York
Morgantown, West Virginia
Lynn Wimett, EdD, APRN-C
Sandra Nadelson, RN, MS Ed, PhD Professor
Associate Professor Regis University
Boise State University Denver, Colorado
Boise, Idaho
Jennifer Klimek Yingling, PhD, RN, ANP-BC,
Geri B. Neuberger, RN, MN, EdD, ARNP-CS FNP-BC
Professor Advanced Practice Nurse
University of Kansas School of Nursing Faxton-St. Luke’s Healthcare
Kansas City, Kansas SUNY Institute of Technology
Utica, New York
Crystal Odle, DNAP, CRNA
Director, Assistant Professor Nurse Anesthesia
Program
Lincoln Memorial University
Harrogate, Tennessee
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.
xiii
1
The Evolution
of Advanced Practice
Learning Outcomes
Learning outcomes expected as a result of this chapter:
Advanced practice is a contemporary term that has evolved wounds, dress burns, treat dysentery, sore throat, frost bite,
to label an old phenomenon: nurses or women providing measles, colic, ‘whooping cough,’ ‘chin cough,’ . . . and ‘the
care to those in need in their surrounding communities. itch,’ how to cut an infant’s tongue, administer a ‘clister’
As Barbara Ehrenreich and Deidre English (1973) note, (enema), lance an abscessed breast . . . induce vomiting,
“Women have always been healers. They were the un- assuage bleeding, reduce swelling and relieve a toothache,
licensed doctors and anatomists of western history . . . as well as deliver babies” (p. 11).
they were pharmacists, cultivating herbs and exchanging Ulrich notes the tiny headstones marking the graves
the secrets of their uses. They were midwives, travelling of midwife Ballard’s deceased babies and children as
from home to home and village to village” (p. 3). Today, further evidence of her ability to provide compassionate,
with health care dominated by a male-oriented medical knowledgeable care; she was able to understand the pain
profession, advanced practice nurses (APNs) (especially and suffering of others. The emergence of a male medical
those cheeky enough to call themselves “doctor” even establishment in the 19th century marked the beginning
while clarifying their nursing role and background) are of the end of the era of female lay healers, including mid-
viewed as nurses “pushing the envelope”—the envelope of wives. The lay healers saw their role as intertwined with
regulated, standardized nursing practice. The reality is that one’s obligations to the community, whereas the emerging
the boundaries of professional nursing practice have always medical class saw healing as a commodity to be bought
been fluid, with changes in the practice setting speeding and sold (Ehrenreich & English, 1978). Has this really
ahead of the educational and regulatory environments. It changed? Are not our current struggles still bound up with
has always been those nurses caring for persons and families issues of gender, class, social position, and money? Have
who see a need and respond—at times in concert with the we not entered a phase of more radical than ever splits
medical profession and at times at odds—who are the true between the haves and have-nots, with grave consequences
trailblazers of contemporary advanced practice nursing. to our social fabric?
This chapter makes the case that, far from being a new Nursing histories (O’Brien, 1987) have documented
creation, APNs actually predate the founding of modern the emergence of professional nursing in the 19th century
professional nursing. A look back into our past reveals from women’s domestic duties and roles, extensions of
legendary figures always responding to the challenges the things that women and servants had always done for
of human need, changing the landscape of health care, their families. Modern nursing is usually pinpointed as
and improving the health of the populace. The titles may beginning in 1873, the year of the opening of the first three
change—such as a doctor of nursing practice (DNP)—but U.S. training schools for nurses, “as an effort on the part
the essence remains the same. 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
PRECURSORS AND ANTECEDENTS the first bar of soap into Bellevue Hospital in the dark days
when the medical profession was still resisting the germ
There is a long and rich history of female lay healing with theory of disease and aseptic techniques.
roots in both European and African cultures. Well into The emergence of a strong public health movement
the 19th century, the female lay healer was the primary in the 19th century, coupled with the Settlement House
health-care provider for most of the population. The sharing Movement, created a new vista for independent and au-
of skills and knowledge was seen as one’s obligation as a tonomous nursing practice. The Henry Street Settlement,
member of a community. These skills were broad based and a brainchild of a recently graduated trained nurse named
might have included midwifery, the use of herbal remedies, Lillian Wald, was a unique community-based nursing
and even bone setting (Ehrenreich, 2000, p. xxxiii). Laurel practice on the lower east side of New York City. Wald
Ulrich, in A Midwife’s Tale (1990), notes that when the described these nurses who flocked to work with her
diary of the midwife Martha Ballard opens in 1785, “. . . at Henry Street Settlement as women of above average
she knew how to manufacture salves, syrups, pills, teas, “intellectual equipment,” of “exceptional character, mentality
ointments, how to prepare an oil emulsion, how to poultice and scholarship” (Daniels, 1989, p. 24). These nurses, as
has been well documented, enjoyed an exceptional degree regard to perinatal health indicators, was poor (Bigbee &
of independence and autonomy in their nursing practice Amidi-Nouri, 2000). Midwives—unregulated and by
caring for the poor, often recent immigrants. most accounts unprofessional—were easy scapegoats on
In 1893, Wald described a typical day. First, she visited which to blame the problem of poor maternal and infant
the Goldberg baby and then Hattie Isaacs, a patient with outcomes. New York City’s Department of Health com-
consumption to whom she brought flowers. Wald spent missioned a study that claimed that the New York midwife
2 hours bathing her (“the poor girl had been without this was essentially “medieval.” According to this report, fully
attention for so long that it took me nearly two hours to 90% were “hopelessly dirty, ignorant, and incompetent”
get her skin clean”). Next, she inspected some houses on (Edgar, 1911, p. 882). There was a concerted movement
Hester Street where she found water closets that needed away from home births. This was all part of a mass assault
“chloride of lime” and notified the appropriate authorities. on midwifery by an increasingly powerful medical elite of
In the next house, she found a child with “running ears,” obstetricians determined to control the birthing process.
which she “syringed,” showing the mother how to do it These revelations resulted in the tightening of existing
at the same time. In another room, there was a child with laws and the creation of new legislation for the licensing
a “summer complaint”; Wald gave the child bismuth and and supervision of midwives (Kobrin, 1984). Several states
tickets for a seaside excursion. After lunch she saw the passed laws granting legal recognition and regulation of
O’Briens and took the “little one, with whooping cough” midwives, resulting in the establishment of schools of
to play in the back of the Settlement House yard. On the midwifery. One example, the Bellevue School for Midwives
next floor of that tenement, she found the Costria baby in New York City, lasted until 1935, when the diminishing
who had a sore mouth. Wald “gave the mother honey need for midwives made it difficult to justify its existence
and borax and little cloths to keep it clean” (Coss, 1989, (Komnenich, 1998). Obstetrical care continued the move
pp. 43–44). This was all before 2 p.m.! Far from being into hospitals in urban areas that did not provide mid-
some new invention, midwives, nurse anesthetists, clinical wifery. For the most part, the advance of nurse-midwifery
nurse specialists (CNSs), and nurse practitioners (NPs) are has been a slow and arduous struggle often at odds with
merely new permutations of these long-standing nursing mainstream nursing. For example, Lavinia Dock (1901)
commitments and roles. 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
NURSE-MIDWIVES distance themselves from lay midwives. The heritage of
the unprofessional image of the lay midwife would linger
Throughout the 20th century, nurse-midwifery remained for many years.
an anomaly in the U.S. health-care system. Nurse-midwives A more successful example of midwifery was the
attend only a small percentage of all U.S. births. Since the founding of the Frontier Nursing Service (FNS) in 1925
early decades of the 20th century, physicians laid claim to by Myra Breckinridge in Kentucky. Breckinridge, having
being the sole legitimate birth attendants in the United been educated as a public health nurse and traveling to
States (Dye, 1984). This is in contrast to Great Britain and Great Britain to become a certified nurse-midwife (CNM),
many other European countries where trained midwives pursued a vision of autonomous nurse-midwifery practice.
attend a significant percentage of births. In Europe, homes She aimed to implement the British system in the United
remain an accepted place to give birth, whereas hospital States (always a daunting enterprise on any front). In rural
births reign supreme in the United States. In contrast to settings, where doctors were scarce and hospitals virtually
Europe, the United States has little in the way of a tradition nonexistent, midwifery found more fertile soil. However,
of professional midwifery. even in these settings, professional nurse-midwifery had
As late as 1910, 50% of all births in the United to struggle to bloom.
States were reportedly attended by midwives, and the Breckinridge founded the FNS at a time when the
percentage in large cities was often higher. However, national maternal death rate stood at 6.7 per 1,000 live
the health status of the U.S. population, particularly in births, one of the highest rates in the Western world. More
than 250,000 infants, nearly 1 in 10, died before they were 11,194 CNMs and 97 certified midwives. In 2014,
reached their first birthday (U.S. Department of Labor, CNMs or CMs attended 332,107 births, accounting for
1920). The Sheppard-Towner Maternity and Infancy Act, 12.1% of all vaginal births and 8.3% of total U.S. births
enacted to provide public funds for maternal and child (National Center for Health Statistics, 2014).
health programs, was the first federal legislation passed for CNMs are licensed, independent health-care providers
specifically this purpose. Part of the intention of this act with prescriptive authority in all 50 states, the District of
was to provide money to the states to train public health Columbia, American Samoa, Guam, and Puerto Rico. CNMs
nurses in midwifery; however, this proved short-lived. By are defined as primary care providers under federal law. CMs
1929, the bill lapsed; this was attributed by some to major are also licensed, independent health-care providers who
opposition by the American Medical Association (AMA), have completed the same midwifery education as CNMs.
which advocated the establishment of a “single standard” CMs are authorized to practice in Delaware, Missouri, New
of obstetrical care, care that is provided by doctors in Jersey, New York, and Rhode Island and have prescriptive
hospital settings (Kobrin, 1984). authority in New York and Rhode Island. The first accredited
Breckinridge saw nurse-midwives working as indepen- CM education program began in 1996. The CM credential
dent practitioners and continued to advocate home births. is not yet recognized in all states.
And even more radically, the FNS saw nurse-midwives as Although midwives are well-known for attending births,
offering complete care to women with normal pregnan- 53.3% of CNMs and CMs identify reproductive care and
cies and deliveries. However, even Breckinridge and her 33.1% identify primary care as main responsibilities in
supporters did not advocate the FNS model for cities their full-time positions. Examples include annual exam-
where doctors were plentiful and middle-class women inations, writing prescriptions, basic nutrition counseling,
could afford medical care. She stressed that the FNS was parenting education, patient education, and reproductive
designed for impoverished “remotely rural areas” without health visits.
physicians (Dye, 1984).
The American Association of Nurse-Midwives (AANM)
was founded in 1928, originally as the Kentucky State
NURSE ANESTHETISTS
Association of Midwives, which was an outgrowth of the
FNS. First organized as a section of the National Organi-
Nursing made medicine look good. —Baer, 1982
zation of Public Health Nurses (NOPHN), the American
College of Nurse-Midwives (ACNM) was incorporated Surgical anesthesia was born in the United States in the
as an independent specialty nursing organization in 1955 mid 19th century. Immediately there were rival claimants
when the NOPHN was subsumed within the National to its “discovery” (Bankert, 1989). In 1846 at Massachusetts
League for Nursing (NLN). In 1956, the AANM merged General Hospital, William T. G. Morton first successfully
with the college, forming the ACNM as it continues today. demonstrated surgical anesthesia. Nitrous oxide was the
The ACNM sponsored the Journal of Nurse-Midwifery, first agent used and adopted by U.S. dentists. Ether and
implemented an accreditation process of programs in 1962, chloroform followed shortly as agents for use in anesthe-
and established a certification examination and process tizing a patient. One barrier to surgery had been removed.
in 1971. This body also currently certifies non-nurses However, it would take infection control and consistent,
as midwives and maintains alliances with professional careful techniques in the administration of the various
midwives who are not nurses. As noted by Bigbee and anesthetic agents for surgery to enter its “Golden Age.”
Amidi-Nouri (2000), CNMs are distinct from other APNs It was only then that “surgery was transformed from an
in that “they conceptualize their role as the combination act of desperation to a scientific method of dealing with
of two disciplines, nursing and midwifery” (p. 12). illness” (Rothstein, 1958, p. 258).
At their core, midwives as a group remain focused on For surgeons to advance their specialty, they needed
their primary commitment: care of mothers and babies someone to administer anesthesia with care. However,
regardless of setting and ability to pay. Rooted in holistic anesthesiology lacked medical status; the surgeon collected
care and the most natural approaches possible, in 2015 there the fee. No incentive existed for anyone with a medical
APPENDIX XIII
GENEVA CONVENTION ACT, 1911
1 & 2 GEO. 5, CHAPTER 20
An Act to make such amendments in the Law as are necessary to
enable certain reserved provisions of the Second Geneva Convention
to be carried into effect.
[18th August 1911.]
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