To understand the challenges facing advanced practice nursing today and determine a path for the future, it is essential to look to the past (see Box 1-1). This chapter presents some highlights of the history of advanced practice nursing in the United States, from the late nineteenth century to the present. It examines four established advanced practice roles—certified registered nurse anesthetists (CRNAs), certified nurse-midwives (CNMs), clinical nurse specialists (CNSs), and nurse practitioners (NPs)—in the context of the social, political, and economic environment of the time and within the context of the history of medicine, technology, and science. Legal issues and issues related to gender and health care manpower are considered. Although sociopolitical and economic context is critical to understanding nursing history, only historical events specifically relevant to the history of advanced practice nursing are included. The reader is encouraged to consult the references of this chapter for further information.

Box 1-1 Timeline

1751 Pennsylvania Hospital opens in Philadelphia

1820 Florence Nightingale born

1860 Notes on Nursing published in the United States

1861 Dorothea Dix appointed Superintendent of Female Nurses of the Union Army

1861 Catholic Sisters deliver chloroform anesthesia during American Civil War

1873 Bellevue Hospital Training School and Connecticut Training School founded

1879 Mary Eliza Mahoney, first black graduate nurse, completes training program

1880-1900 Rapid proliferation of hospital nursing schools, from 15 schools to more than 400

1881 Clara Barton and others establish American Red Cross

1893 Nightingale pledge first recited in Detroit

1893 American Society of Superintendents of Training Schools for Nurses (precursor to National League for Nursing [NLN]) founded at Chicago World’s Fair

1900 American Journal of Nursing first published

1901 Nurse Corps becomes permanent (became Army Nurse Corps in 1908)

1903 North Carolina passes first nurse registration law in United States

1908 National Association of Colored Graduate Nurses established

1910 Florence Nightingale dies

1910 Flexner Report criticizes quality of medical education

1912 National Organization of Public Health Nursing founded

1915 Lakeside Hospital School of Anesthesia opens in Cleveland, Ohio

1917 Frank v. South (Kentucky) upholds nursing anesthesia

1918-1919 Influenza epidemic and World War I

1922 Sigma Theta Tau formalized

1923 Goldmark Report criticizes quality of nursing education

1923 Yale School of Nursing becomes first autonomous school of nursing in the United States

1925 Kentucky Committee for Mothers and Babies, precursor to Frontier Nursing Service, founded

1931 American Association of Nurse Anesthetists (AANA) founded

1938 Chalmers Frances v. Nelson; practice of nurse anesthesia made legal

1943-1948 U.S. Cadet Nurse Corps supports nursing education to prepare nurses for military

1945 AANA develops and implements Certified Registered Nurse Anesthetists (CRNA) certification examination

1946 Hill Burton Act enacted, providing funds to construct hospitals

1947 Army-Navy Nurse Act secures commission status for military nurses

1950 NLN assumes responsibility for administering first national state board examination

1955 American College of Nurse-Midwives incorporated

1964 Nurse Training Act passed

1965 Medicare legislation enacted

1965 Pediatric Nurse Practitioner (PNP) certification program opens in Colorado

1975 American Nurses Association (ANA) holds ceremony to honor first certified nurses

1979 Nursing Doctorate (ND), first clinical doctorate program, established at Case Western Reserve University

1984 All states recognize nurse-midwifery

1985 American Academy of Nurse Practitioners (AANP) founded

1995 National Association of Clinical Nurse Specialists formed

2004 American Association of Colleges of Nursing recommends that all advanced practice nurses earn Doctorate in Nursing Practice (DNP)

A brief comment on terminology:

The use of the term specialist in nursing can be traced to the turn of the twentieth century, when it was used to designate a nurse who had completed a postgraduate course in a clinical specialty area or who had extensive experience and expertise in a particular clinical practice area. With the introduction of the NP role during the 1960s and 1970s, the terms expanded role and extended role were used, implying a horizontal movement to encompass expertise from medicine and other disciplines. The more contemporary term, advanced practice, which began to be used in the 1980s, reflects a more vertical or hierarchical movement encompassing graduate education within nursing, rather than a simple expansion of expertise by the development of knowledge and skills used by other disciplines. Since the 1980s, the term advanced practice nurse (APN) has increasingly been used to delineate CRNAs, CNMs, CNSs, and NPs. In the last decade, state nursing practice acts have increasingly adopted the term advanced practice registered nurse (APRN). These professional and regulatory influences served to unite the advanced practice specialty roles conceptually and legislatively, thereby promoting collaboration and cohesion among APNs.

Nurse Anesthetists

The roots of nurse anesthesia in the United States can be traced to the late nineteenth century. During the 1860s, two key events converged—the widespread use of the newly discovered chloroform anesthesia and the demand for such treatment for wounded soldiers during the American Civil War (1861 to 1865). In 1861, except for Catholic sisters and Lutheran deaconesses, there were few professional nurses in the United States. There were only a handful of nurse training schools ¹ in the country and, for the most part, laywomen cared for families and friends when they were ill. When the first shots were fired on Fort Sumter and Civil War broke out, thousands of laywomen from the North and South volunteered to nurse. Because of social restrictions, these women actually did little hands-on nursing. Instead, they helped by reading to patients, serving them broths and stimulants such as tea, coffee, and alcohol, and assisting with the preparation of food in diet kitchens. Catholic sisters who nursed were given more freedom to provide direct care; their work included assisting in surgery, particularly with the administration of chloroform. Because the administration of chloroform was a relatively simple procedure in which the anesthetizer poured the drug over a cloth held over the patient’s nose and mouth, the nuns quickly mastered this technique, providing the surgeons with invaluable assistance during the war (Jolly, 1927; Wall, 2005).

In the decade following the Civil War, hospitals throughout the United States opened nurse training schools modeled according to Florence Nightingale’s school at St. Thomas Hospital in London. By the late nineteenth century, most U. S. hospitals used student nurses for staffing, rather than employing graduate nurses. One exception to this trend was the increasing use of graduate nurses as nurse anesthetists. Surgeons readily accepted them, valuing the fact that unlike the medical students who usually assisted them in giving anesthesia and spent much of the time observing the surgery itself rather than the patient’s response to anesthesia, nurse anesthetists concentrated on administering the chloroform and observing the patient.

Anesthesia at Mayo Clinic

At St. Mary’s Hospital in Rochester, Minnesota, Dr. William Worrall Mayo was among the first physicians in the country to recognize and train nurse anesthetists formally. In 1889, Dr. W.W. Mayo hired Edith Granham to be his anesthetist and office nurse. Subsequently, he hired Alice Magaw (later referred to as the “mother of anesthesia”; Keeling, 2007). Magaw kept excellent records of her results and, in 1900, published them in the St. Paul’s Medical Journal. Reporting her “Observations on 1,092 Cases of Anesthesia from January 1, 1899 to January 1, 1900,” she wrote:

In that time, we administered an anesthetic 1,092 times; ether alone 674 times; chloroform 245 times; ether and chloroform combined, 173 times. I can report that out of this number, 1,092 cases, we have not had an accident; we have not had occasion to use artificial respiration once; nor one case of ether pneumonia; neither have we had any serious renal results. Tongue forceps were used but once, the operation was on the jaw and it was quite necessary (p. 306).

Between 1899 and 1901, the Doctors Mayo added several other nurse anesthetists to their surgical teams. Soon, Mayo Clinic would become world renowned for its nurse anesthesia training program.

During the 1910s, nurse anesthetists faced obstacles and new opportunities. Early in the decade, as the specialty of anesthesia was on the rise, the medical profession began to question a nurse’s right to administer anesthesia, claiming that these nurses were practicing medicine without a license. In 1911, the New York State Medical Society argued (unsuccessfully) that the administration of an anesthetic by a nurse violated state law (Thatcher, 1953). A year later, the Ohio State Medical Board passed a resolution specifying that only physicians could administer anesthesia. Despite this resolution, nurse anesthetist Agatha Hodgins established the Lakeside Hospital School of Anesthesia in Cleveland, Ohio, in 1915. The challenge culminated in a lawsuit brought against the Lakeside Hospital program by the state medical society. This lawsuit was unsuccessful and resulted in an amendment to the Ohio Medical Practice Act protecting the practice of nurse anesthesia. However, medical opposition to the practice of nurse anesthesia continued in Kentucky and another lawsuit (Frank v. South) against nurse anesthetists was filed in 1917. In that case, the Kentucky appellate court ruled that anesthesia provided by nurse anesthetist Margaret Hatfield did not constitute the practice of medicine if it was given under the orders and supervision of a licensed physician (in this case, Dr. Louis Frank). The significance of this decision was that the courts declared nurse anesthesia legal but “subordinate” to the medical profession. It was a landmark decision, one that would have lasting implications for nurse anesthetists’ practice. Later in the century it would also affect all advanced practice nurses (Keeling, 2007).

Wartime Opportunities

Opportunities for nurse anesthetists increased when the United States entered World War I in 1917. That year, more than 1000 nurses were deployed to Britain and France, including nurse anesthetists, some of whom had trained at Mayo and Cleveland Clinics. The realities of the front were gruesome; shrapnel created devastating wounds and mustard gas destroyed lungs and caused profound burns (Beeber, 1990). The resulting need for pain relief and anesthesia care for the wounded soldiers created an immediate demand for nurse anesthetists’ knowledge and skills (Keeling, 2007).

It also created opportunities for research and physicians and nurses began investigating new methods of administering anesthesia. At the well-established Lakeside Hospital anesthesia program, Dr. George Crile and nurse anesthetist Agatha Hodgins experimented with combined nitrous oxide–oxygen administration. They also investigated the use of morphine and scopolamine as adjuncts to anesthesia. Also, as anesthesia practice became more complicated and scientific, physicians became interested in naming it as a medical specialty. As they did, some medical anesthesia groups again claimed that nurse anesthetists were practicing medicine without a license and once again initiated legal battles. Interprofessional conflict over disciplinary boundaries seemed inescapable.

After the war, opportunities for the employment of nurse anesthetists were mixed. For example, in 1922, Samuel Harvey, a Yale professor of surgery, hired Alice M. Hunt as an instructor of anesthesia with university rank at the Yale Medical School, a significant and prestigious appointment for a nurse (Thatcher, 1953). In contrast to Hunt’s experience, however, many other nurse anesthetists struggled to find practice opportunities. Medicine was becoming increasingly complex, scientific, and controlled by organized medical specialties. See Box 1-2 for information on the Goldmark report.

Box 1-2 Goldmark Report

As nursing and nurses’ training developed in the late nineteenth and early twentieth centuries, many accused the widely used apprentice system of lacking academic rigor. With mounting pressure to examine the state of nursing education, the Rockefeller Foundation supported the formation of the Committee for the Study of Nursing Education. Yale University public health professor Charles-Edward Amory Winslow chaired the committee on which six nurses served, including Adelaide Nutting, Annie Goodrich, and Lillian Wald. The committee’s secretary and survey research leader was social worker and author Josephine Goldmark.

The survey included a sample of 23 schools and was intended to be representative of the more than 1800 nurse training schools then in existence. In 1923, the committee released their findings, known as the Goldmark Report. The major recommendations included increasing educational standards in nursing schools, focusing student time on education rather than on providing labor for hospital wards, moving educational programs to universities, and requiring that nurse educators have advanced education (Goldmark, 1923).

Although some changes in nursing education became apparent after publication of the Goldmark Report, notably the establishment of Yale University’s autonomous nursing school, the hoped for widespread elevation of nursing education did not occur. Hospital administrators strenuously resisted elimination of the free labor that nursing students provided to hospitals. Physicians argued that nurses were overtrained to provide the services that nurses needed to give. Fueled by disagreements among nurses themselves, state laws setting out requirements for nursing education varied drastically. The continued variability in nursing education stood in contrast to the medical profession’s response to the Flexner Report, issued in 1910, which resulted in standardization of medical education at the postgraduate level.

It was soon clear that nurse anesthetists needed to organize and, in 1931, at Lakeside Hospital, Hodgins established the American Association of Nurse Anesthetists (AANA) and served as the organization’s first president. At the first meeting of the association, the group voted to affiliate with the American Nurses Association (ANA). However, the ANA denied the request, probably because the ANA was afraid to assume legal responsibility for a group that could be charged with practicing medicine without a license (Thatcher, 1953).

The ANA’s fears were not unfounded. During the 1930s, the devastation of the national economy made jobs scarce and the tension between nurse anesthetists and their physician counterparts continued, with more legal challenges to the practice of nurse anesthesia. In California, the Los Angeles County Medical Association sued nurse anesthetist Dagmar Nelson in 1934 for practicing medicine without a license; Nelson won. According to the judge, “The administration of general anesthetics by the defendant Dagmar A. Nelson, pursuant to the directions and supervision of duly licensed physicians and surgeons, as shown by the evidence in this case, does not constitute the practice of medicine or surgery….” (McGarrel, 1934).

In response, Dr. William Chalmers-Frances filed another suit against Nelson in 1936, which again resulted in a judgment for Nelson (Chalmers-Frances v. Nelson, 1936). In 1938, the physician appealed the case to the California Supreme Court, which again ruled in favor of Nelson. The case became famous. The courts established legal precedent—the practice of nurse anesthesia was legal and within the scope of nursing practice, as long as it was done under the guidance of a supervising physician.

While World War II provided opportunities for young nurses in Europe to learn the skills necessary to administer anesthesia, it also was the period in which anesthesia grew into a medical specialty (Waisel, 2001). In 1939, just before the United States entered the war, the first written examination for board certification in medical anesthesiology was given, but the specialty still sought legitimacy. Meanwhile, demands for anesthetists, advances in the types of anesthesia available, and continuing education in the field increasingly stimulated physicians’ interest in the specialty. The medical journal Anesthesiology, established in 1940, further strengthened medicine’s claim to anesthesia practice. In particular, the use of the new drug sodium pentothal required specialized knowledge of physiology and pharmacology, underscoring the emerging view that only physicians could provide anesthesia. In fact, the administration of anesthesia was becoming more complex, and anesthesiologists demonstrated their expertise not only in administering sodium pentothal but also in performing endotracheal intubation and regional blocks (Waisel, 2001). Clearly, medicine was strengthening its hold on the specialty.

At the same time, World War II increased the demand for anesthetists on the battlefield. Despite profound shortages of anesthetists early in the war, the U.S. military would not grant nurse anesthetists a specific designation within the military, and experienced nurse anesthetists were required to accept general nurse status. Later, when shortages became even more severe, staff nurses were trained to administer anesthesia.

Exemplar 1-1 Nurse Anesthetists in the 8th Evacuation Hospital, Italy, 1942-1945

(Courtesy University of Virginia, Center for Nursing Historical Inquiry.)

During World War II, the University of Virginia sponsored the 8^th Evacuation Hospital, a 750-bed mobile hospital a few miles from the front lines in North Africa and Italy. Conditions were demanding and the work overwhelming; surgical teams sometimes operated round the clock despite air raids, heavy rains, and blackouts. There, Dorothy Sandridge Gloor, a young surgical nurse, was trained on the job to give anesthesia. The unit had only one trained anesthesiologist and two nurse anesthetists on staff, and it soon became apparent that more help was needed if the team was to keep up with the “endless stream of battle casualties requiring surgery” (Kinser, 2011, p. 11). Gloor and other nurse anesthetists worked side by side with the surgeons for 16-hour shifts, collaborating with their colleagues to save the injured soldiers. She learned new skills and the specialty knowledge necessary to deliver anesthesia, noting how she learned to start IVs and make critical observations of the patient on which to base the administration of anesthesia (Kinser, 2011). Working with patients to calm their fears prior to surgery, and explaining what would happen in the operating suite, Gloor and her colleagues demonstrated expertise in coaching the critically injured men; see Box 1-3.

Box 1-3 Growth of Hospitals, Scientific Nursing, and the GI Bill

In the period after World War II, optimism about the possibilities of research and scientific knowledge permeated the United States. Without a doubt, specialization and a scientific approach to medical care had captured the interest of Americans. These two factors would set the stage for dramatic changes in health care. Another important factor was economic as federally funded hospital construction reshaped the setting in which physicians and nurses practiced. In 1946, Congress passed the Hill-Burton Act, which provided large-scale funding to modernize aging hospitals and build new ones. The new hospital spaces changed how care was given because the sickest patients were grouped together in the ICU (Fairman & Lynaugh, 1998). This trend contributed to an increase in specialization in nursing while simultaneously accelerating nursing’s invisibility when the costs of nursing care were included with the room rate.

In addition to funding new hospitals, the federal government provided funds for nurse education in the postwar years. Nurses returning from World War II were eligible to pursue advanced education under the GI Bill and many took advantage of the opportunity to return to school. Prompted by the Brown Report of 1948, the National League of Nursing Education (NLNE) established a committee that catalogued all nursing programs, including those leading to a master’s degree, in a 1949 issue of AJN (Donahue, 1996).

After the war, the specialty of nurse anesthesia continued to take steps to increase its legitimacy. The AANA instituted mandatory certification for CRNAs in 1945. This formal credentialing of CRNAs specified the requirements that a nurse had to meet to practice as a nurse anesthetist, preceded credentialing of nurses in the other specialties, and marked a significant milestone. Meanwhile, during the 1950s, increasing numbers of physicians were choosing anesthesia as a specialty. However, nurse anesthetists were not to be deterred. In 1952, the AANA established an accreditation program to monitor the quality of nurse anesthetist education. Soon, the United States was once again at war, this time with Korea and, once again, war provided a setting in which opportunities abounded for nurse anesthetists, particularly for those who were male. By the end of the decade, the army had established nurse anesthesia education programs, including one at Walter Reed General Hospital, which graduated its first class in 1961—but this class consisted only of men. Later, the Letterman General Hospital School of Anesthesia in San Francisco also graduated an all-male class. This significant movement of men into a nursing specialty was unprecedented and would continue in the next decade when the United States entered the war in Vietnam.

As was the case in wars of other eras, the war in Vietnam (1955-1975) provided nurses with opportunities to stretch the boundaries of the discipline as they treated thousands of casualties in evacuation hospitals and aboard hospital ships. Not surprisingly, nurse anesthetists played an active role at the front, providing vital services in the prompt surgical treatment of the wounded. According to one account (Jenicek, 1967):

The nurse anesthetist suddenly became a part of a new concept in the treatment of the severely wounded. The Dust-Off helicopter brings medical aid to severely wounded casualties who formerly would have died before or perhaps during evacuation. … Very often it is a nurse anesthetist who first is available to intubate a casualty, and by so doing may avoid the need for tracheostomy (p. 348).

Opportunity was not without cost. Of the 10 nurses killed in Vietnam, two were nurse anesthetists (Bankert, 1989).

At home in the United States, the 1970s proved to be a difficult decade for nurse anesthetists. In 1972, years after the inception of nurse anesthesia as a specialty role, only four state practice acts specifically mentioned them. Nevertheless, some progress was made in interprofessional relations that year. The AANA and the American Society of Anesthesiologists (ASA) issued a “Joint Statement on Anesthesia Practice,” promoting the concept of the anesthesia team. However, a few years later, in 1976, the ASA Board of Directors voted to withdraw support from the 1972 statement, endorsing one that explicitly supported physician control over CRNA practice (Bankert, 1989).

Education and Reimbursement

Later in the decade, with the new requirement that CRNAs have a master’s degree, the number of nurse anesthesia education programs declined significantly, largely because of the closure of many small certification programs. However, the new requirement that programs offer a graduate degree did, in fact, promote nurse anesthesia eduction. In 1973, the University of Hawaii opened the first master’s degree program for nurse anesthesia, moving the role forward in the evolving criteria of advanced practice nursing.

Reimbursement for CRNA practice was not as clear-cut. In fact, third-party payment had its own set of issues. Beginning in 1977, the AANA led a long and complex effort to secure third-party reimbursement under Medicare so that CRNAs could bill for their services. The organization would finally succeed in 1989. Meanwhile, the financial threat posed by CRNAs to physicians was the source of continued interprofessional conflicts with medicine. During the second half of the twentieth century, tensions escalated, particularly in relation to malpractice policies, antitrust, and restraint of trade issues. In 1986, Oltz v. St. Peter’s Community Hospital established the right of CRNAs to sue for anticompetitive damages when anesthesiologists conspired to restrict practice privileges. A second case, Bhan v. NME Hospitals, Inc. (1985), established the right of CRNAs to be awarded damages when exclusive contracts were made between hospitals and physician anesthesiologists. Undeniably, CRNAs were winning the legal battles and overcoming practice barriers erected by hospital administrators and physicians.

The 1990s saw a significant growth in CRNA education programs, although many of the programs were very small. As the decade opened, there were 17 master’s programs in nurse anesthesia; by 1999, there were 82 (Bigbee & Amidi-Nouri, 2000). As of 1998, all accredited programs in nurse anesthesia were required to be at the master’s level; however, they were not uniformly located in schools of nursing. Instead, they were housed in a variety of disciplines, including schools of nursing, medicine, allied health, and basic science, a fact that is still true today. Today, with the American Association of Colleges of Nursing (AACN) pushing for the Doctor of Nursing Practice (DNP), these programs face a new challenge—redesigning their curricula to meet the requirements for CRNAs set by AANA while simultaneously meeting those for DNP (AACN, 2006). Nonetheless, in 2007, the AANA affirmed its support that the Doctor of Nurse Anesthesia Practice (DNAP) be the entry for nurse anesthesia practice by 2025 (AANA, 2007).

Nurse-Midwives

Like nurse anesthesia, the origins of nurse-midwifery in America can be traced to the preprofessional work of women. Throughout the eighteenth and nineteenth centuries, lay midwives, rather than professional nurses or physicians, assisted women in childbirth. Midwives who were brought to the United States with the slave trade in 1619, and others who arrived later with waves of European immigration, were respected community members. In the late nineteenth and early twentieth centuries however, these untrained midwives would lose respect as scientific, hospital-based deliveries became the norm. Meanwhile, women in isolated communities throughout the country, particularly in rural settings, continued to employ lay midwives for deliveries well into the twentieth century.

In the early twentieth century, national concern about high maternal-infant mortality rates led to heated debates surrounding issues of midwife licensing and control; lay midwives would soon be blamed for the high maternal and infant mortality rates that plagued the United States. In 1914, Dr. Frederick Taussig, speaking at the annual meeting of the National Organization of Public Health Nursing (NOPHN) in St. Louis, proposed that the creation of “nurse-midwives” might solve the “midwife question” and suggested that nurse-midwifery schools be established to train graduate nurses (Taussig, 1914). Later in the decade, the Children’s Bureau called for efforts to instruct pregnant women in nutrition and recommended that public health nurses teach principles of hygiene and prenatal care to so-called granny midwives (Rooks, 1997). In 1918, responding to a study conducted by the New York City Health Commissioner that indicated the need for comprehensive prenatal care, the Maternity Center Association (MCA) was established. It soon served as the central organization for a network of community-based maternity centers throughout the city.

The midwife problem was not easily solved, however. The use of midwives varied along ethnic, geographic, race, and class lines. With the rise in scientific medicine, many upper and middle class urban white women began to use obstetricians to deliver their babies in hospital delivery rooms (Rinker, 2000). However, nationality and other issues continued to influence women’s choices. For example, many urban European immigrants continued to employ midwives to deliver their babies at home. Geographic location and access to physicians’ services also played a part. For example, in rural southern states such as Mississippi, in which 50% of the population was black, most women (80% of African American and 8% of white women) relied on African American granny midwives to deliver their babies (Smith, 1994). Soon, a pattern could be identified: physicians delivered women of higher socioeconomic status in hospitals. Midwives attended the poor in the women’s homes.

Exemplar 1-2 The Frontier Nursing Service

A New Model for Nurse-Midwifery

(Courtesy Frontier Nursing Service.)

In 1925, nurse-midwife Mary Breckinridge founded the Frontier Nursing Service (FNS) in an economically depressed, rural mountainous area of southeastern Kentucky. British nurse-midwives and American public health nurses provided midwifery and nursing care through a decentralized network of nurse-run clinics (Breckinridge, 1981; Rooks, 1997). Because there were few roads in the mountainous region, the nurses traveled by horseback to attend births, carrying their supplies in saddlebags. One FNS nurse described the bags and their standing orders, or Medical Routines, whereby a physician committee supervised their practice:

The whole of the district work of the FNS in the Kentucky mountains is done with the aid of two pairs of saddle-bags … In these bags we have everything needed for a home delivery …. In one of the pockets we carry our Medical Routines which tells us what we may—and may not—do. A very treasured possession! (pp. 1183-1184).

From the outset, FNS nurses carefully maintained records of their work and their outcomes were stellar. Reflecting on her work in later years, Breckinridge (1981) noted that “trained statisticians were to come later, through a grant from the Carnegie Corporation, but from the start we had records and report sheets and kept them carefully” (p. 166). When the Metropolitan Life Insurance Company analyzed the findings in 1951, they found that FNS staff members had attended 8596 births, with 6533 of those occurring in patients’ homes, since 1925. More importantly, the FNS maternal mortality rate of 1.2/1000 was significantly lower than the national average of 3.4/1000 during the same period (Varney, 2004). Throughout the service’s existence, the FNS nurses’ documentation of the outcomes of their care would serve to advance their cause.

Despite exemplary clinical outcomes of the FNS, by midcentury, nurse-midwives were experiencing some of the same tensions with physicians that nurse anesthetists had faced. Changes in leadership on the advisory board, an increase in medical knowledge, the rapid development of new drugs, and a changing economic climate all played a part in accounting for these stricter controls over FNS nursing practice. The FNS medical advisory board reinforced traditional disciplinary boundaries on nursing’s scope of practice (Keeling, 2007).

Nurse-Midwifery Education and Organization

Aside from two tiny, short-lived, nurse-midwifery schools, about which little is documented (Manhattan Midwifery School in New York City and Preston Retreat Hospital in Philadelphia), the earliest school to educate nurse-midwives was the School of the Association for the Promotion and Standardization of Midwifery (APSM) in New York City (Burst & Thompson, 2003). Affiliated with the Maternity Center Association (MCA), the APSM opened in 1932. More commonly known as the Lobenstine Midwifery School, in honor of Ralph Waldo Lobenstine, chairman of the MCA’s medical board, the APSM graduated its first class in 1933. In 1939, the entry of Britain into World War II proved to be the catalyst for the establishment of the second major school for nurse-midwifery in the United States, the Frontier Graduate School of Midwifery (FGSM). That year, the Kentucky FNS lost many of its British nurse-midwives when they returned to England to work; in response, FNS leader Mary Breckinridge established the FGSM (Buck, 1940; Cockerham & Keeling, 2012).²

While the United States was at war, nurse-midwives continued their work on the home front. Key to their development in the 1940s was the establishment of a formal organization of practicing nurse-midwives, the American Association of Nurse-Midwives (AANM), which incorporated in 1941 under the leadership of Mary Breckinridge. By July 1942, the AANM had a “membership of 71 graduate nurses” who had specialty training in midwifery (News Here and There, 1942, p. 832). Three years later, in 1944, the National Organization of Public Health Nurses established a section for nurse-midwives³ within their organization.

This group prepared a roster of all midwives in the country and defined their practice, making it clear that nurse-midwives would continue to practice under physician authority.

Exemplar 1-3 Jean Fee

Public Health Nurse, Nurse-Midwife, and Nurse Practitioner

(From Frontier Nursing University)

Jean Fee, born in rural Alberta, Canada, arrived in Hyden, Kentucky, in 1958 eager to become a district nurse and pursue her passion to do public health work. Dismayed to find that only those with nurse-midwifery training were permitted to work on [sic] the districts, Fee enrolled in the Frontier Graduate School of Midwifery. She soon discovered the excitement and fulfillment of combining public health nursing and nurse-midwifery. Fee recalled, “I absolutely detested obstetrics in [nursing] training. I did the midwifery course [at Frontier] in self-defense so that I could work on the district, and in the meantime I learned that midwifery was a whole different ball game, much more up my alley” (Cockerham, 2012). After graduation from the midwifery training program in 1959, Fee remained in Kentucky, serving as district nurse-midwife for several different districts for 18 months. During that time, Fee demonstrated her expertise in clinical practice as she traveled around the districts on her horse, attending births and caring for the health needs of entire families. Several decades after leaving the FNS, and having worked in a variety of capacities in different areas, Fee wanted to apply for a family nurse practitioner position but needed official recognition of her preparation in primary care of families during her time at Frontier. According to Fee (Cockerham, 2012):

I had found ways to challenge the exam for nurse practitioner … My English midwifery instructor, Molly Lee, still at FNS … she got up into the attic and found the curriculum for the year that we were there. At FNS we did full care; we didn’t just do midwifery and we were primary care nurse practitioners from 1925 on. The title hadn’t been thought up at the time, but the job description was there and we had it! I won the right to sit that exam. In 1980, I was able to certify as a Family Nurse Practitioner.

Move Toward Natural Childbirth

The renewed public interest in natural childbirth that stemmed from the women’s movement was particularly beneficial to the practice of nurse-midwifery in the 1970s; the demand for nurse-midwifery services increased dramatically during that decade. In addition, sociopolitical developments, including the increased employment of CNMs in federally funded health care projects and the increased birth rate resulting from baby boomers reaching adulthood, converged with inadequate numbers of obstetricians to foster the rapid growth of CNM practice (Varney, 2004). In 1971, only 37% of CNMs who responded to an American College of Nurse-Midwives (ACNM) survey were employed in clinical midwifery practice. By 1977, this number increased to 51%. Not surprisingly, the earlier pattern continued; most CNMs practiced in the rural underserved areas of the Southwest and southeastern United States, including Appalachia.

At the national level, physician support for CNM practice became official. In 1971, the ACNM, the American College of Obstetricians and Gynecologists, and the Nurses’ Association of the American College of Obstetricians and Gynecologists issued a joint statement supporting the development and employment of nurse-midwives in obstetric teams directed by a physician. The joint statement, which was critical to the practice of nurse-midwifery, reflected some resolution of the interprofessional tension that had existed through much of the twentieth century. However, it did not provide for autonomy for CNMs. Later in the decade, the ACNM revised its definitions of CNM practice and its philosophy, emphasizing the distinct midwifery and nursing origins of the role (ACNM, 1978a, b). This conceptualization of nurse-midwifery as the combination of two disciplines, nursing and midwifery, was unique among the advanced practice nursing specialties. It served to align nurse-midwives with non–nurse midwives, thereby broadening their organizational and political base. Philosophically controversial, even within nurse-midwifery, the conceptualization created some distance from other APN specialties that saw advanced practice roles as based solely in the discipline of nursing. This distinction would continue to isolate CNMs from some APNs for the next several decades.

By the 1980s, the public’s acceptance of nurse-midwives had grown, and demand for their services had increased among all socioeconomic groups. By the middle of 1982, there were almost 2600 CNMs, most located on the East Coast. “Nurse-midwifery had become not only acceptable but also desirable and demanded. Now the problem was that, after years during which nurse-midwives struggled for existence, there was nowhere near the supply to meet the demand” (Varney, 1987, p. 31).

Meanwhile, conflict with the medical profession increased as obstetricians perceived a growing threat to their practices. The denial of hospital privileges, attempts to deny third-party reimbursement, and state legislative battles over statutory recognition of CNMs ensued. In particular, problems concerning restraint of trade emerged. In 1980, Congress and the Federal Trade Commission (FTC) conducted a hearing to determine the extent of the restraint of trade issues experienced by CNMs. In two cases, one in Tennessee and one in Georgia, the FTC obtained restraint orders against hospitals and insurance companies attempting to limit the practice of CNMs (Diers, 1991), in essence ensuring that CNMs they could practice. Third-party reimbursement for CNMs was a second issue. In 1980, CNMs, working under the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS; now Tricare) for military dependents, were the first to receive approval for reimbursement. Third-party payment for CNMs was also included under Medicaid. Statutory recognition by state legislatures was a third problem that would be addressed in the 1980s. By 1984, all 50 states had recognized nurse-midwifery in their state laws or regulations (Varney, 1987).

During the 1990s, increasing demand for CNM services resulted in the gradual expansion in the scope of nurse-midwifery practice. CNMs began to provide care to women with relatively high-risk pregnancies in collaboration with obstetricians in some of the nations’ academic tertiary care centers (Rooks, 1997). During this decade, two practice models emerged, the CNM service model, in which CNMs were responsible for the care of a caseload of women determined to be eligible for midwifery care, and the CNM-MD team model. Nurse-midwives continued making progress in establishing laws and regulations needed to support their practice. However, the struggle for prescriptive authority continued until 2007, when Pennsylvania’s nurse-midwives, the last in the country, finally received the right to prescribe (ACNM, 2007).

Clinical Nurse Specialists

The roots of the clinical nurse specialist role lie in the area of psychiatric nursing, which had its origins in the Quaker reform movement initiated earlier in mid–nineteenth century England. In the United States, these Quaker reformers challenged the brutal treatment of the insane and advocated “moral treatment,” emphasizing gentler methods of social control in a domestic setting (D’Antonio, 1991, p. 411).

The first American training program for psychiatric nurses was founded in 1880 at McLean Hospital in Massachusetts (Critchley, 1985). According to Linda Richards, a 1873 graduate of the New England Hospital School of Nursing, the McLean Hospital maintained high standards and demonstrated “the value of trained nursing for the many persons afflicted with mental disease” (Richards, 1911, p. 109). Richards served as superintendent of nurses at the Taunton Insane Hospital for 4 years, beginning in 1899. She subsequently organized a nursing school for the preparation of psychiatric nurses at the Worcester Hospital for the Insane and finally went to the Michigan Insane Hospital in Kalamazoo, where she remained until 1909 (Richards, 1911). Because of this work, Richards is credited with founding the specialty of psychiatric nursing.

The first decades of the twentieth century witnessed growth in all specialties, including the area of psychiatry. During this period, Harry Stack Sullivan’s classic writings and the work of Sigmund Freud changed psychiatric nursing dramatically. The emphasis on interpersonal interaction with patients and milieu treatment supported the movement of nurses into a more direct role in the psychiatric care of hospitalized patients.

Because of an increased public awareness of psychiatric problems in returning soldiers, (Critchley, 1985), World War II influenced the specialty of psychiatric nursing. During the 1940s, new treatments were introduced for the care of the mentally ill, including the widespread use of electroshock therapy. The new treatments would require the assistance of nurses who had specialized knowledge and training in the area. According to a 1942 American Journal of Nursing (AJN) article, “Only the nurse skilled in her profession and with additional psychiatric background has a place in mental hospitals today” (Schindler, 1942, p. 861). By 1943, three postgraduate programs in psychiatric nursing had been established. As nurse educator Frances Reiter later reflected on her career, she recalled having first used the term nurse clinician in a speech in 1943 to describe a nurse with advanced “curative” knowledge and clinical competence committed to providing the highest quality of direct patient care (Reiter, 1966). In 1946, after Congress passed the National Mental Health Act designating psychiatric nursing as a core discipline in mental health, federal funding for graduate and undergraduate educational programs and research became available, and programs in psychiatric and mental health were included in schools of nursing throughout the United States. Psychiatric nursing knowledge was now widely accepted as essential content in the nursing curriculum. Psychiatric nursing was also becoming established as a graduate level specialty, one that would lead the way for clinical nurse specialization in the next decade.

Psychiatric nursing blossomed as a specialty in the 1950s. In 1954, Hildegarde E. Peplau, Professor of Psychiatric Nursing, established a master’s program in psychiatric nursing in the United States at Rutgers University in New Jersey. Considered the first CNS education program, this program, and the growth of specialty knowledge in psychiatric nursing that ensued, provided support for psychiatric nurses to begin exploring new leadership roles in the care of patients with mental illness in inpatient and outpatient settings. Scholarship in psychiatric nursing also flourished, including Peplau’s conceptual framework for psychiatric nursing. Her book, Interpersonal Relations in Nursing: A Conceptual Frame of Reference for Psychodynamic Nursing (1952), provided theory-based practice for the specialty. Clearly, the link between academia and specialization was becoming stronger and the psychiatric specialty was leading the way.

The 1960s are most often noted as the decade in which clinical nurse specialization took its modern form. Peplau (1965) contended that the development of areas of specialization is preceded by three social forces: (1) an increase in specialty-related information; (2) new technologic advances; and (3) a response to public need and interest. In addition to shaping most nursing specialties, these forces had a particularly strong effect on the development of the psychiatric CNS role in the 1960s. The Community Mental Health Centers Act of 1963, as well as the growing interest in child and adolescent mental health care, directly enhanced the expansion of that role in outpatient mental health care.

Psychiatric nursing was not the only nursing specialty developing after mid–twentieth century. After the enactment of the 1964 Nurse Training Act, numerous CNS master’s programs were created. These new, clinically focused graduate programs were instrumental in developing and defining the CNS role.