History of Advanced Practice Nursing

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In our past, lies our future

According to Hamric, advanced practice nursing is, “ the patient-focused application of an expanded range of competencies to improve health outcomes for patients and populations in a specialized clinical area of the larger description of nursing.” Advanced Practice Nurses (APN) includes Certified Nurse Anesthesiologists, (CRNA), Certified Nurse Midwives (CNM), Clinical Nurse Specialists (CNS) and Nurse Practitioners (NP). [ Hamric - 1]
In order to understand why and how advanced practice nursing evolved, it is necessary to understand the evolution of each practice area.

Nurse Administered Anesthesia

Chloroform anesthesia had been discovered in the 1830’s and along with Ether, come into use in surgery. In the Civil War (1860 – 1865) there was increased demand for anesthetics to care for the wounded. Chloroform was the anesthetic of choice because it was easily inhaled, acted quickly and was thus seen to be more efficient than ether Union records show that of more than 80,000 operations performed during the war only 254 were done without some kind of anesthetic. [2]

Due to the lack of formal schools of nursing, during the civil war professional nursing was provided by religious women – Catholic sisters and Lutheran deaconesses. When the civil war started, women from the North and South eagerly volunteered to help. In the North, minimal training was provided by Dorothea Dix, the newly appointed Superintendent of Army Nurses. In the South, the confederacy also relied on ‘healers’ among slaves who attended to illness and injuries.

Physicians , along with social restrictions of that day prevented direct, hands on care by females, so women volunteers helped by reading, writing letters and preparing and serving food. Even with these restrictions, a few women did assist physicians and surgeons. In 1861, Catherine S. Lawrence became the first nurse to provide anesthetics during the Civil War
After the war, Sister Mary Bernard in 1877 became the first nurse anesthetist at St. Vincent’s Hospital.

In 1893 Alice Magaw, known as the “Mother of Anesthesia”, began working for Drs. William J. and Charles H. Mayo at St. Mary’s Hospital. Alice Magaw wrote five articles between 1899 and 1906which were published in medical journals to detail the technical aspects of administering open drop ether anesthesia. Her research and clinical findings set new standards for safer delivery of anesthesia in those early days.[3]

Sister Mary Barnard and Alice Magaw “Mother of Anesthesia”

  1. Hamric, Ann B. , (2014). A Definition of Advanced Practice Nursing. Chapter 3 in Hamric, A., Hanson, C. M., Tracy, M.F. & Grady, E.T. Advanced Practice Nursing: An Integrative Approach

  2. https://nurseanesthetist57.wordpress.com/history-of-nurse-anesthetists

  3. https://sharing.mayoclinic.org/2015/01/26/celebrating-nurse-anesthetist-education-alice-magaw-1860-1928-mother-of-anesthesia

Certified Registered Nurse Anesthetists CRNA

Answering the Call: The Beginning of Nurse Anesthesia
You Tube Video
C;lick Here



1978 ADN Graduate of Springfield Technical Community College - excerpt from his oral hhistory

”I’m very happy that I became a nurse…very happy that I became a nurse anesthetist. I wouldn’t trade the career, I have never…I encourage the younger generation and I’m a clinical instructor for Duke’s program and I have students that come to me about four days a week. I enjoy working with them, I try and pass on the experiences that I have and encourage them to take everything from each nurse anesthetist and each nurse that they work with and take the good parts of them and make it…good parts of the people they work with and make it their style. I try not to tell them not to copy any one style but to copy them all, all the good parts because every person that you run into, every practitioner that you meet has some really good qualities that you admire and you try and take those qualities and put it in an amalgam and become that. So I encourage them to do that, that’s my goal for them and to learn even when they are working with people that are doing things poorly, to learn what not to do. That it’s important and that’s all part of your education as a practitioner and I think that’s equally true of RN’s as it is CRNA’s and I always consider myself a nurse first. I probably say that once a day if I don’t say it more, that that’s who I am. I’m a nurse first and then I’m an anesthesia provider who is granted the right to do anesthesia because I’m a nurse and I always introduce myself to patients as a…it took me a while to figure out exactly what to call myself because patients got confused and I always introduce myself as, I’m a nurse that does anesthesia, or a nurse from anesthesia, or a nurse that is going to give you your anesthesia and I leave out the…(inaudible) only because it’s too confusing to people. But the nurse is a big part of who I am and what I do and I always consider that my top priority.”

 Certified Nurse Midwife

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In colonial times thru the eighteenth and early nineteenth century babies were delivered at home by lay midwives. Rarely, doctors, if available, might be called for a difficult birth. It wasn’t until hospital reform in the mid nineteenth centuries that the hospital deliveries were felt to be safer and the untrained midwife fell ‘out of favor’ in the city. Rural areas, lacking physicians and hospitals, continued to rely in midwives.

According to Rooks: [1]

“Midwives attended almost all births in the American colonies, practicing from their homes and passing the skills they had brought from Britain from one woman to another informally. West African midwives came to America as slaves and attended the births of both black and white women in the antebellum South. After emancipation, African-American midwives continued to take care of both black and white poor women in most rural parts of the South, where they were referred to as “granny midwives.””

“Between 1910 and 1920, nurse midwives fell out of favor. Two reports on medical education, published in 1910 and 1912, concluded that America’s obstetricians were poorly trained. To improve obstetrics training, one report recommended hospitalization for all deliveries and the gradual abolition of midwifery. Rather than consult with midwives, the report argued, poor women should attend charity hospitals, which would serve as sites for training doctors Where midwifery declined, the incidence of mother and infant deaths from childbearing or birth injuries generally increased..Nursing Service. In 1915 a leading obstetrician of that time, Dr. Joseph DeLee argued that” midwives were untrained and incompetent, that pregnancy is a dangerous condition requiring care available only from highly trained medical specialists, and that midwives’ clients—mainly poor women—were needed to provide the clinical experience for training doctors in obstetrics.” This practice changed with Mary Breckinridge and the Frontier Nursing Service.[1}

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In 1925 Mary Breckinridge, seeing the great need in Leslie County Kentucky, an Appalachian community and one of the poorest and most inaccessible areas of the United States with a population of fewer than 11,000and had one of the highest maternal and infant mortality rates in the country, very few physicians, and formidable distances and terrible road conditions, making it almost impossible for patients to access medical care in nearby towns.

Mary Breckinridge considered the geography of the area and realizing that there were no real roads, decided that the horse was the best way to reach the families living there, so she along with her nurse colleagues, traveled on horseback to deliver care and attend births in Kentucky’s rural Appalachian mountain.

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The nurse-midwife carried two leather saddlebags—one on each side of the horse connected by a strap. She had one pair of saddlebags for general health care, and one for home deliveries. Nearly all babies were delivered at home. These saddlebags are from the 1930s.

Mary Breckinridge’s’ nursing background included Public Health Nursing and she was able o put her experiences to work caring for the whole family. A cousin, Marvin Breckinridge Patterson, in 1931 produced a film - The Forgotten Frontier which told the story of the Frontier Nursing Service of , "a new kind of 'fotched-on' woman [an eastern Kentucky phrase meaning women fetched from other places to to work with the mountain people] first appeared in the wild Kentucky highlands." This "'fotched-on' woman" was a professional nurse-midwife (a registered nurse with training in midwifery). The silent film is available on You Tube: . Watch on YouTube. https://www.youtube.com/watch?v=PtK3QsFpm6M

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Nurse Midwife Story

A nurse midwife has her hands full with a complicated delivery as a couple gives birth to their second child. (You Tube - Produced by HealthcareHeroesTV in. 2010)


 Clinical Nurse Specialist

Pediatric Clinical Nurse Specialist

Pediatric Clinical Nurse Specialist

As nurses graduated from their basic programs, and began practicing, many started to focus on a particular specialty or area of nursing such as pediatrics, geriatrics, hospital nursing specializing in medical – surgical areas, orthopedics, or in the community as public health nurses on home health nursing, and industrial health (occupational health) just to name a few. While these nurses often had extensive experience in their chosen area, and might, because of their expertise, be referred to as ‘specialists’ they are not ‘clinical specialist’.s.

Clinical specialists require graduate education either at the Masters or Doctorate level DNP and certification in their area of specialty.
Cocerham and Keeling, state that the roots of the clinical nurse specialist role lie in the area of psychiatric nursing. In 1882 McLean Hospital in Massachusetts opened the first psychiatric school of nursing. In 1899 Linda Richards organized a school for the preparation of psychiatric nurses at Worcester Hospital for the Insane.[2]

According to the American Psychiatric Nurses Association website, the first clinical nurse specialist (CNS) program was started in 1955 at Rutgers University, by Dr. Hildegard Peplau with a grant from National Institute of Mental Health. “With a vision for nurses who had expert theoretical and practical knowledge to improve patient outcomes and change systems to promote quality care, psychiatric-mental health advanced practice psychiatric nurses (PMH-APRNs) were prepared to link nursing science and nursing practice. “ [3]

In 1973, the American Lung Association (ALA) offered a grant - the Clinical Nurse Specialty Program Award for competitive application. This program offered training grants to academic institutions for the development of graduate programs for adult clinical specialists in respiratory nursing. One of the first five programs and program directors was at the University of Arizona – where Gayle Traver had developed a Respiratory – also known as Pulmonary - Clinical Specialty program.. Beginning in 1974 (through 1984), ALA offered Nursing Fellowships of up to $9,000 each student, to provide funds for doctoral as well as master’s level education. [4]

Author’s Personal Note:
In 1976 I was working in an Intensive Care Unit in a Community Hospital as the Charge Nurse and was concerned about a patient with C.O.P.D who was dependent on mechanical ventilation when sleeping. As the medical surgical units could not accept him due to hospital policy, with no outside facility able to care for him and with his family unable to provide care at home he was ‘trapped’ and unable to be leave the ICU. This situation concerned me – as I saw the situation here was an alert, oriented person trapped in a room in the ICU. What was his quality of life? I had more questions than answers. How do we, as a society, care for people suffering from chronic pulmonary conditions? What is the role of nursing? Can patients be cared for at home? Some nurses did not feel comfortable caring for a patient dependent on a ventilator –how can we help these nurses?

After much research I learned about an American Lung Association Fellowship grant for graduate studies in pulmonary nursing. I applied for the Nursing Fellowship and, with the support of the hospital’s medical director, I was awarded a Fellowship. I applied and was accepted into the University of Rochester’s Master’s program. I graduated in 1978 and started work as one of the early clinical nurse specialists. “

In 1995, The National Association of Clinical Nurse Specialists was formed to advance and preserve the clinical nurse specialist role in health care. A visit to their website - https://nacns.org/ is helpful in understanding their role in clinical patient care.
“Clinical nurse specialists provide diagnosis, treatment, and ongoing management of patients. They also provide expertise and support to nurses caring for patients at the bedside, help drive practice changes throughout the organization, and ensure the use of best practices and evidence-based care to achieve the best possible patient outcomes”.

[2] Cocerham , Anne Z.and Arlene W.Keeling, 2014. Chapter 1,A Brief History of Advanced Practice Nursing in the United States in in Hamric, A., Hanson, C. M., Tracy, M.F. & Grady, E.T. Advanced Practice Nursing: An Integrative Approach. P.10

[3] There appears a discrepancy as to the date -The American Psychiatric Nurses Association date given as 1955 ; Cocerham and Keeling date the start as 1954.


Clinical Nurse Specialists: Influencing Clinical Care, Driving Value
Video From Clinical Nurse Specialist Website

A Conversation with Hildegard Peplau
An archived video from 1994 with Hildegard Peplau, who is often referred to as the "Mother of Psychiatric Nursing - Click Here

Living the History of Psychiatric-Mental Health Nursing through the Eyes of Grayce Sills

Click Here for You Tube Video

 Nurse Practitioner

Loretta C. Ford, EdD, RN, PNP, FAAN, FAANP; Co-founder of the nurse practitioner role in 1965.

Loretta C. Ford, EdD, RN, PNP, FAAN, FAANP; Co-founder of the nurse practitioner role in 1965.

Working as a public health nurse in rural Colorado during the 1940s and ’50s, Loretta Ford saw firsthand how a shortage of physicians often left children and families without access to care. To fill the gap, she envisioned a solution in which nurses received advanced education in both clinical care and research so they could better meet the needs of patients as well as practice to the full extent of their capabilities. Working with Dr. Henry K. Silver at the University of Colorado Medical Center in 1965 they co-developed the nurse practitioner model she co-developed expanded the scope of practice in public health nursing and led to the creation of the first pediatric nurse practitioner model of advanced practice.

In 1965 the University Of Colorado School Of Nursing on the Anschutz Medical Campus initiated the first Nurse Practitioner program. Although it took advantage of the physician shortage, the purpose was to reclaim a role that was historically a part of nursing e.g. public health and to develop graduate level education for nurses.
In 1972, Dr. Loretta Ford became Dean of the University of Rochester and established the School of Nursing, as an independent school. She continued to lead the nurse practitioner movement when she became Dean. The nurse practitioner model flourished at the University of Rochester due to the collaborative and progressive environment at the Medical Center and in the community.

Dr. Loretta Ford’s work a half century ago thrust the nursing profession in a new direction and transformed the health care system. In 2005, AANP celebrated 40 years of NPs with a look at the history and historical context that gave rise to the role of the Nurse Practitioner Link to History Nurse practitioners. and hear Dr. Ford speak (You Tube Link)

Historical Timeline Nurse Practitioners
Click Here

 Advanced Practice Nurse
Concepts and Competences

Conceptual Definition of Advanced Practice Nursing
• Evidence based practice
• Leadership
• Collaboration
• Ethical decision making

“Advanced practice nursing is the patient-focused application of an expanded range of competencies to improve health outcomes for patients and populations in a specialized clinical area of the larger description of nursing.” Hamric, Ann

Core Competencies of Advanced Practice Nursing[
• Direct clinical practice.-central to all the other competencies
• Guidance and coaching
• Consultation

Advanced practice registered nurses are licensed independent practitioners who are expected to practice within standards established or recognized by a licensing body. Each APRN is accountable to patients, the nursing profession, and the licensing board to comply with the requirements of the state nurse practice act and the quality of advanced nursing care rendered; for recognizing limits of knowledge and experience, planning for the management of situations beyond the APRN’s expertise; and for consulting with or referring patients to other health care providers as appropriate

The Advanced Practice Registered Nurses (APRN or APN)* is a nurse:

1. Who has completed an accredited graduate-level education program preparing him/her for one of the four recognized APRN roles;

2. Who has passed a national certification examination that measures APRN, role and population-focused competencies and who maintains continued competence as evidenced by re certification in the role and population through the national certification program;

3. Who has acquired advanced clinical knowledge and skills preparing him/her to
provide direct care to patients, as well as a component of indirect care; however, the defining factor for all APRNs is that a significant component of the education
and practice focuses on direct care of individuals;

4. whose practice builds on the competencies of registered nurses (RNs) by demonstrating a greater depth and breadth of knowledge, a greater synthesis of data, increased complexity of skills and interventions, and greater role autonomy;

5. Who is educationally prepared to assume responsibility and accountability for health promotion and/or maintenance as well as the assessment, diagnosis, and management of patient problems, which includes the use and prescription of pharmacologic and non-pharmacologic interventions;

6. Who has clinical experience of sufficient depth and breadth to reflect the intended
license; and

7. Who has obtained a license to practice as an APRN in one of the four APRN roles: certified registered nurse anesthetist (CRNA), certified nurse-midwife (CNM),
clinical nurse specialist (CNS) or certified nurse practitioner (CNP).

*APN – Advanced Practice Nurse – has recently replaced the earlier title of APRN or Advanced Practice Registered Nurse and currently (2019) has been used interchangeably with the earlier title depending on the age of the article or author. [personal experience /comment on the difficulty with titles. [ D.Michaels, website author.]

(Summary Article with References) History Advanced Practice Nursing in America (Word) Click Here