This course is designed to give an overview of the history and role development of the Nurse Anesthetist (CRNA), Nurse Practitioner (NP), Clinical Nurse Specialist (CNS), Certified Nurse-Midwives (CNM) and the Nurse Executive (CNO). Focus will be placed on how the evolution of these roles has influenced the development, transition and implementation of today’s Advanced Practice Nurse.
Course Objectives:
Upon completion of this course the student will be able to:
Discuss the early history of the Advanced Practice Nurse
Describe the early role of the Nurse Practitioner
Explain how the role of the Advanced Practice Nurse has evolved
Discuss the role of today’s Advanced Practice Nurse
A Brief History of the Advanced Practice Nurse:
Nurse Anesthetist (CRNA):
The American Civil war in 1861 can be credited for the development and initial implementation of the Advanced Practice Nurse (APN).
Because there were no professional nurses at the time, Catholic sisters served as nurses and assisted surgeons with the administration of chloroform.
In reviewing the history of the APN, this assistive act is considered to be the first reporting of the Nurse Anesthetist (CRNA).
As the role of the APN continued to develop, other nursing specialties emerged.
Even though the American Civil War is where the establishment of the first APN is documented, it was with the increase of immigration and the trend towards the industrialization and urbanization of America at the turn of the 20th century, that the nursing profession made significant progress.
During the early 1900’s the Nurse Anesthetist faced barriers as the medical profession began to question the rights of nurses to administrate anesthesia, making claims that they were practicing out of their scope.
In 1917, it was legislation in Kentucky (Frank vs. South), that ruled nurses administrating anesthesia were not practicing medicine “without a license”. Unfortunately it was also with this courts decision that Nurse Anesthetists were labeled as “subordinate” to the medical profession.
This decision has had a long lasting affect on the specialty of advanced practice nursing. In 1931, the American Association of Nurse Anesthetists (AANA) was established and in 1945, they instituted mandatory certification for CNRA’s.
Nurse Practitioner:
The term “Nurse Practitioner” may not have been officially coined until the 1960’s, but traces of this role also extend back to the 1800’s.
The role of the Nurse Practitioner in this era focused more on what we know today as a “Case Manger” approach to healthcare.
The Nurse Practitioner provided primary care for poverty stricken immigrants in New York City.
During World War II, more opportunities became available for the Nurse Practitioner (when it was convenient).
When physicians were overwhelmed and too busy to care for all of the wounded, the Nurse Practitioner was given the right to go beyond the realm of caring and move on to the role of “curing”.
When physicians had the time however, the NP was supposed to step back into a more supportive role.
Clinical Nurse Specialist:
The history of the Clinical Nurse Specialist came about in the mid 1800’s and was focused on the care and management of the psychiatric patient.
The emphasis at that time was to provide “moral treatment” or in other words, gentle methods of social control in a domestic setting.
It was not until the 1960’s that the role of the CNS took a more modern turn.
Clinical Nurse Midwife (CNM):
Similar to the Nurse Anesthetist, the roots of the Clinical Nurse Midwifery (CNM) can be traced to pre-professional time.
In the late 1800’s and early 1900’s it was midwives rather then nurses who assisted with the child birth process.
In 1910, there was considerable debate about the need for nurse midwives to become licensed in order to continue practicing.
Though the medical profession objected, several states passed laws that granted recognition to midwifery as a profession.
In the mid 1920’s a class distinction for the use of midwives developed, with the upper class using obstetrics and delivering babies in the hospital, and leaving the midwifery to the poor.
While World War II pressed on in the 1940’s, so did the progression of midwifery. In 1941 the formal establishment of the American Association of Nursing Midwives (AANM) was erected.
Nurse Executive:
The starting point of official nursing leadership is difficult to trace.
Some will list “Florence Nightingale” as the first nursing leader.
In 1908 the Navy Nurses were able to establish the “Navy Corp of Nursing” which is thought to have given nursing administration and leadership a big boost.
Nurses in the Navy Corp earned were given deserved rankings such as Major, Colonel and Brigadier General.
Early advancement efforts for the Advanced Practice Nurse:
In the 1950’s and 1960’s, social, professional and political factors (namely the implementation of Medicare in 1965), contributed greatly to a new evolution for the APN.
With the implementation of managed care, hospitals were forced to develop and implement a new model of healthcare delivery.
Managed care has also put great pressure on hospital organizations to reduce the length of time patients stay.
To accomplish this; hospitals needed to alter current practice and develop new models of care which included collaboration, patients being part of the “healthy” process, and a mutual interdisciplinary goal to return patients back to their highest functioning standard of health.
This new focus in care required additional resources, and the collaborative roles of the APN, were just what the Doctor ordered.
Bringing the APN Role into the 21st Century:
Similar to the unique history and evolution of the Nurse Anesthetist (CRNA), Nurse Practitioner (NP), Clinical Nurse Specialist (CNS), and Certified Nurse-Midwives (CNM), the transition and implementation of these roles into the 21st century is has proven as well to be unique.
(CNRA):
For example, the role of the CNRA today is no longer considered to be a “subordinate” role.
Though the CRNA works in conjunction with an anesthesiologist, their responsibilities are both collaborative as well as independent.
The role of the CRNA which has been for the most part related to operative procedures has expanded to include being part of what many hospitals are calling a “pain management team”.
Because Joint Commission of Accreditation of Healthcare Organizations (JCAHO), has mandated that all hospitals have pain management system in place, now affords the CRNA and opportunity to not only participate on these teams, but also to play an integral role in patient care activities that are related to pain.
(NP):
From inception to present day, the advancement of the Nurse Practitioner has also greatly improved.
As healthcare has become more evolutionary so have the opportunities for the NP.
Moving from the promotion of health and management of chronic illness to acute illness, the role of the NP has largely expanded.
The academic setting is also another 21st century change for the NP. As laws have limited resident physicians to working no more then 80 hours a week, most academic centers are employing NP’s to help with the inpatient work load. Effectiveness of the NP in the Emergency Department as well as the Intensive Care setting is also being explored.
(CNS):
The role of the CNS has certainly exploded into the 21st century, as evidenced by the sheer numbers of nurses who are currently practicing in this capacity.
In 1995 it was estimated that there were 40,000 CNS’s practicing in the United States and today estimations are well over 80,000.
Though the premise of the role has remained similar over the past couple of decades, there has been great emphasis placed on the CNS to assure that practice is evidenced based and that nursing training and education remain in touch with the latest trends and technology.
(CMN):
Major changes in the role of the CMN relate less to the actual clinical role and more to the credentialing of the role. According to an article posted in “The American Journal of Maternal/Child Nursing 2004”, many midwives do not want their role to be considered an APN because they fear this title will require them to get Master Degree’s.
The journal also goes on to estimate that as of the year 2002, approximately 7% to 10 % of all live vaginal births were CNM attended births.
(Nurse Exec):
Though the Nurse Executive (NE) is not under the umbrella of the current APN structure, their goals and objectives are very similar.
While the Nurse Executive is often accountable for positive outcomes he/she relies heavily on the APN regardless of specialty to assist with this success.
Today’s NE is a graduate prepared nurse who is responsible for overseeing all aspects of nursing services and assures that the environment of care is one that is optimal for the delivery of quality care.
From an organizational level, the NE promotes an interdisciplinary approach that maximizes positive patient outcomes.
It is the role of the NE to be able to work effectively with other organizational executives to assure that this type of environment exists.
References
Hodson, Denise, M. (1998). The evolving role of the nurse practitioner in surgery. Retrieved June 5, 2005 from:
Howie, Jill, N. (2002). Acute care nurse practitioners: Creating and implementing a model of care for an inpatient general medical service. Retrieved June 4, 2005 from:
Keeling, Arlene, W. & Biglee, Jeri, L. (2005). The history of advanced practice in nursing in the United States. A. B. Hamric, J. A. Spross, & C. M. Hanson (Eds.), Advanced practice nursing: An integrated approach. (3rd ed.) (Chap.1). Elsevier Saunders. St. Louis MO.
Northouse, Peter, G. (2003). Leadership theory and practice. (3dr ed.). (pp 8-15). Sage Publications, Thousand Oaks, CA.
Nurse Midwifery: Yesterday, Today, and Tomorrow. MCN, The American Journal of Maternal/Child Nursing. November/December 2000;(25)6:322.
Ray, G., L. (1995). Advanced practice nursing. Retrieved June 5, 2005 from:
Spross, Judith, A. & Lawson, Marjorie, Thomas. (2005). Conceptualizations of advanced nursing practice. A. B. Hamric, J. A. Spross, & C. M. Hanson (Eds.), Advanced practice nursing: An integrated approach. (3rd ed.) (pp. 47-58). Elsevier Saunders. St. Louis MO.
Tunajet, Sandra. (2004). Quiet revolutions: The CNRN scope of practice. Retrieved June 6, 2005 from:
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