1910: FIRST A “FIELD”

The image of nurses and nursing is a complicated one. The identity of nursing is grounded in a historical caricature of both the public’s perception of nursing and nurses and the profession’s own internalized perceptions and beliefs about itself. In other words, the status and stature of nursing in 1910 were very different from the status and stature of nursing in 2015. For an examination of 1910, Sussman (1999) published an interview that was based on the recollections of a 101-year-old nurse about her early days in nursing school. Much of what is described subsequently is based on her interview and the commentary of Joan Lynaugh, a noted nurse historian:

Nursing practice in 1910 was certainly extremely different from what it is today. Ask yourself, was nursing a discipline yet? Or was it more of a field, a good description of what a discipline is in its formative, less-established, early stages (Hongcai, 2007)? A quick historical overview of what was happening in nursing around 1910 is as follows:

Nurse historian Donahue (1996) actually describes this era as the “rise of organized nursing” (p. 318). Our own particular interest among these events is on those that signal the rise of a discipline as it shifts and evolves from a field to a recognized discipline of study. We usually see this with the progression of a heritage of literature typical of a discipline described in Chapter 1. Examples include publication of the first nursing journal Nightingale in 1880, followed by The Trained Nurse and Hospital World in 1888 and The American Journal of Nursing in 1900, which is still in existence today (American Association of History of Nursing, 2008; Flaumenhaft & Flaumenhaft, 1989). The emergence of new schools of nursing also meant that there was great demand for nursing textbooks. The first nursing textbook was Clara S. Weeks-Shaw’s A Textbook of Nursing for the Use of Training Schools, Families, and Private Students in 1885; shortly thereafter, Isabel Adams Hampton Robb’s Nursing: Its Principles and Practice for Hospital and Private Use (1893) was published.

A closer examination of these historical landmarks during the rise of organized nursing in the late 20th and early 21st centuries indicates to us that nursing was in its formative stage as a field and had yet to fully emerge as a complete discipline. The practice orientation of the work of early American nursing students was also codified by very strict behavioral and moral guidelines for an overwhelmingly middle-class, female student population (Tomes, 1978).⁷ These principles, by which student nurses were socialized, meant that the mission of the first nursing schools in the late 1800s and early 1900s (and for many, many subsequent decades of nursing education) was to ensure each nursing school’s mission was “to establish and maintain a code of ethic [sic]” (Walker, 1900, pp. 203–207). Most academic disciplines in their evolution are not burdened in the public way practice disciplines are. Did the very visible, often unglamorous practice of nursing that was seen (and perceived) in the hospital ward, the settlement house, or the home (the domain of the private duty nurse) make it more difficult for the field to establish respect for its scientific base and to emerge as a discipline? Did the burden of nursing, being an occupation of women, also hamper its slow acceptance as a “proper academic discipline” as many have suggested (Thompson, 2009; Wuest, 1994)? Or was nursing’s early legitimacy as a discipline hampered more by its lack of advanced educational opportunities, which left it dangling at the door of the academy (Emerson & Records, 2005)?

1960s: A PRACTICE DISCIPLINE BEGINS TO EMERGE

If we shift 50 years later to 1960, we can take a brief glimpse into the state of the discipline as it emerges from the shadows of a field, and the first tangible signs of an emerging discipline appear. Largely because of the important public and recognized role nurses had in World War II (WWII), nursing’s image was certainly elevated, and the efforts to improve the status of nursing in society began to take place (Breakiron, 1995; Stevens, 1990). Famed nurse historian Beatrice Kalisch was quoted in her comments about the role of nurses during WWII that “There was a flow of wartime films showing heroic nurses; there were autobiographical films and books about nurses” (Schmidt, 2001, p. 1). The heroism of nurses both during WWI and WWII was also replicated with the war effort of nurses in the Vietnam War, where nurses first served as commissioned officers. Many women, including eight nurses, died in the Vietnam War and their heroism and service formed the basis for the Vietnam Women’s War Memorial commemorative statue erected in Washington, DC, in 1993 (Sheehy, 2007).

The 1960s began as a decade where nursing’s scholarship began to flourish. It was also the decade when the first real discussion took place about what kind of minimal educational preparation RNs should possess. In 1965, only 15% of RNs had been prepared in an academic program (this included RNs with an associate, baccalaureate, or higher degree), with 85% of all nurses still prepared in diploma programs. In response to this need to elevate the educational level of the profession, the American Nurses Association (ANA) proposed in 1965 to require the bachelor’s degree in nursing (BSN) degree for entry into professional nursing. With regard to higher education in nursing, this was still the era before the beginning of the advanced practice nursing movement. Advanced practice nursing would begin to evolve with the first certificate pediatric nurse practitioner (NP) program at the University of Colorado (Denver) in 1965 (Silver, Ford, & Steanly, 1967). At the beginning of the decade, there were only three nursing doctoral programs in existence—at Teacher’s College University (1924), New York University (1934), and the University of Pittsburgh (1954; Dreher, 2009a, 2009b; Robb, 2005). As mentioned in Chapter 1, a larger critical mass of nurse scientists was created through the Nurse-Scientist Training Program at the National Institutes of Health (Gortner, 1991). Formed early in the decade (i.e., 1961), it helped prepare competent nurse scientists who pursued doctorates in the basic sciences, physical sciences, and social sciences, with the goal of using this interprofessional knowledge to create nursing knowledge while maintaining a nursing identity (Gortner, 1986). In 1962, an experimental Division of Nursing Field Research Center was founded in San Francisco (Nursing Research, 1962). According to Gortner (1986), “The late 1960’s began an important reorientation of the Federal interest in nursing research with particular attention being given to studies that would be relevant to patient care issues and problems” (p. 124). She further indicated that, “Following establishment of the National Center for Health Services Research in 1967, some nursing research grant project investigators moved their research efforts into the field of health services research⁸ in general” (1986, p. 124).

The value of health services research, interestingly, has steadily increased over time and the standards and protocols of care and practice that are reported by the Agency for Healthcare Research and Quality (AHRQ) have become so important that funding decisions for health care at the federal level are often based on these expertly produced mostly multidisciplinary research studies. Unfortunately, aside from the brilliant nursing health services research work of Dr. Linda Aiken⁹ (also a sociologist), we see a decline in nursing health, sensitive health services research, and fewer nurse scientists; properly trained in these methods, Dr. Sean Clarke, a protégé of Dr. Aiken and now at Boston College, is one of the next generation of researchers in this area.¹⁰ This decline, which includes research that explores the cost effectiveness of nursing interventions (Lee, Moorhead, & Clancy, 2014; Shever et al., 2008; Spetz, 2005), will impact the practice of DNP graduates, who many indicate should be the leaders of evaluating and implementing best-practice protocols of care (American Association of Colleges of Nursing [AACN], 2006; Fitzpatrick, 2008).¹¹ This movement toward the study of the efficacy of nursing and nursing interventions, nevertheless, was indeed in its infancy in the late 1960s.

By the end of the decade, there would be three additional nursing doctoral programs founded nationally and many more in the early 1970s (Table 2.1).

These institutions would cement their reputations over time by producing the chief nursing science graduates who would help nursing crystallize itself as a practice discipline. It should be noted that Table 2.1 reflects three different doctoral nursing degrees—DNS (Doctor of Nursing Science), PhD, and DSN (Doctor of Science in Nursing). Much has been written about the origins of the DNS, DSN (first approved at the University of Alabama–Birmingham in 1975), and DNS (first approved at the University of Indiana in 1976) degrees. Unfortunately, much of the literature that has described these degrees, their purpose, and historical trajectory is very muddled and confusing. Joyce Fitzpatrick (2003), the former dean of the Frances Payne Bolton School of Nursing at Case Western Reserve University, makes this case quite nicely in her plea for nursing to embrace a clinical doctorate as a credible alternative to the PhD and the other multiple nursing research degrees. Essentially, the DNS, DSN, and DNS were all designed as clinical doctorate degrees for the nursing discipline. The first, the DNS at Boston University, founded in 1960 with the first graduate in 1963, was designed to focus on clinical practice and scholarship in psychiatric nursing. However, over time, all three of these degrees lost their original clinical doctorate mission, and most now agree that they indeed all became de facto research degrees, as did the PhD in nursing (AACN, 2006).

One question largely absent from the nursing literature is: Why did the early PhD programs at New York University and University of Pittsburgh not lead the way for more subsequent PhD programs instead of the DNSc? Some have declared that there was too little political support in many universities or among the standing faculty to support the awarding of a PhD in nursing (Veeser, Stegbauer, & Russell, 1999). Others reasoned that even many nursing scholars at the time did not consider nursing science mature enough to award the PhD (Carter, 2006). Aside from some of the leading nursing schools in the nation that first established DNSc degree programs instead of the PhD (Table 2.1), there were other nursing schools that began DNSc programs before converting to PhD programs:

Why did these first doctoral programs and those founded years later start DNSc degrees instead of the PhD? We believe that there has been a historical prejudice against the recognition of nursing as a legitimate discipline. We further surmise that many faculty in other disciplines historically were unable to accept that nursing scholarship was credible to award a PhD degree.¹² In rare cases, the university may not have initially had a state charter to award a PhD degree. For example, Widener University’s first doctoral degree was the DNSc, and the university was not permitted to award any PhDs until the charter was amended; however, this reason was indeed an anomaly. The question we are faced with now is whether nursing has sufficiently established itself as a discipline today and whether its scholars fully embrace its identity as a “practice discipline” or not. Furthermore, are our doctoral nursing graduates good stewards of the discipline, creating enough evidence to keep current with a rapidly changing, highly technological health care system? What do you think?

2015: NEW ENERGY, NEW TENSION—A DNP DEGREE SURGES

Now we arrive at 2015 and a new nursing doctorate, a practice doctorate, which has now been around formatively since 2005 and is around 10 years old, although the first DNP degree was founded at the University of Kentucky in 2001. Even though it is just 10 years old, there are more DNP programs than PhD programs, more DNP students than PhD students, and more DNP graduates than PhD graduates (AACN, 2005). Indeed, there is new energy in doctoral nursing education—as well as new tension. Can it be that the sudden, if not surprising, growth curve of new DNP programs will force nursing to revisit its origins as a practice field? Will scholars teaching in both DNP programs and PhD programs be challenged to reflexively and honestly examine how nursing, now as a more mature discipline, is going to generate the necessary practice knowledge it needs for the future? According to noted Emeritus Deans of Nursing Afaf Meleis (University of Pennsylvania School of Nursing) and Kathleen Dracup (University of California, San Francisco), “Practice drives knowledge development in nursing” (AACN, 2005, p. 1). With more than a decade of stagnant enrollments in PhD programs from 1996 to 2015 (with future stagnation in overall PhD enrollments and graduations likely on the horizon)¹³ and with surging enrollments in DNP programs, nurses with practice doctorates cannot be excluded from the knowledge-generating enterprise for a practice discipline (AACN, 2009; DeMarco, Pulcini, Haggerty, & Tang, 2009). Or can they? Moreover, if practice doctorate nurses are going to generate knowledge (or science) for the discipline, grounding in philosophy of science will be essential if the methods of inquiry are going to be reputable. Again, the issue for the future, we boldly predict, is not if the practice doctorate graduate will produce knowledge for the nursing discipline, but rather how this practice knowledge will be different from what is traditionally produced by the PhD graduate (Coghlan, 2007; Sheriff & Chaney, 2007; Smith Glasgow & Dreher, 2010). This important issue is addressed more fully in Chapter 16.

In many ways, the relatively new DNP degree in nursing is perhaps best described as a third-generation practice doctorate in the nursing discipline. It has been noted earlier that the first generation of clinical doctorates¹⁴ (DNSc, DSN, and DNS) originally conceived in the 1960s and 1970s really never fully became clinical doctorates and ended up being very reputable de facto research doctorates equivalent to the PhD (AACN, 2006; Bellack, 2002; Dreher, Donnelly, & Naremore, 2005). The second-generation clinical or practice doctorate for the nursing profession was the Doctor of Nursing (ND) degree, founded at Case Western Reserve University in 1979 (Bellack, 2002; Dreher, 2009a; Sakalys & Watson, 1986). The ND was created as a professional doctorate, much like the MD degree, where any typical college graduate¹⁵ would complete 3 years of full-time study and exit as a RN with a clinical/professional doctorate. Unfortunately, whether this was indeed a visionary degree for the nursing profession or not is still up for debate—especially because the nursing profession had never even fully implemented the requirement for the BSN to be required for entry level (Donley & Flaherty, 2008). For some, even the suggestion that the nursing profession should move to doctoral-level entry in 1979 was preposterous. Nevertheless, the ND degree was a failure of innovation, with only four degree programs ever established: Case Western Reserve University, 1979; Rush University, 1987; University of Colorado at Denver, 1990; and the University of South Carolina, 1999 (Dreher, 2005; Mundinger, 2005). All four ND programs subsequently closed between 2004 and 2005 and converted to DNP programs (AACN, 2009). The real question for history is: Why did this second-generation practice nursing doctorate fail, although Lenz (2005) has indicated that it actually paved the way for the current and third-generation nursing practice doctorate—the DNP? Whether this new practice doctorate will stick and survive the test of time will be revealed to us in the next decades.

The emergence of the current practice doctorate for the discipline of nursing began with the work of Dean Mary Mundinger at the Columbia University School of Nursing in the late 1990s. In 2000, Mundinger et al. published a very provocative study in the prestigious Journal of American Medical Association (JAMA), where her team conducted a randomized trial of physicians (n = 510) and nurse practitioners (n = 806) in ambulatory care and reported that when “patients were randomly assigned to either nurse practitioners or physicians, and where nurse practitioners had the same authority, responsibilities, productivity and administrative requirements, and patient population as primary care physicians, patients’ outcomes were comparable”¹⁶ (Mundinger et al., 2000, p. 59).

This was the first study in the United States of its caliber to indicate that, under certain conditions, physician medical care and nurse practitioner care (with master’s of science in nursing [MSN] degrees, not doctorates!) were equivalent.¹⁷ These findings led Dean Mundinger to introduce the first Doctor of Nursing Practice (DrNP) degree program (DNP) at Columbia University in 2005 after first piloting the degree with a cohort of internal faculty in an intensive format in 2004 (Honig & Smolowitz, 2009). Described initially as a clinical doctorate, the Columbia DrNP program was created as a very clinically based 30-credit doctoral program that required a 1-year, full-time residency as well as a portfolio of case studies; however, no clinical research project or clinical dissertation was required (Mundinger, 2005). Despite its converting to a DNP program in 2008,¹⁸ the historical impact of Columbia University’s practice doctorate model has largely surpassed the impact of the first DNP program at the University of Kentucky in 2001.¹⁹ Although they were both DNP programs with different initials, the Kentucky DNP did not prepare clinicians or practitioners, but instead it prepared clinical executives. Furthermore, its creators never published their rationale indicating why their DNP model was superior to the established ND that had, by this time, largely become both an entry-level doctorate and postmaster’s degree model. Why the AACN declared support for the Kentucky DNP degree model, which did not prepare traditional advanced practice nurses, over the Columbia DrNP-degree model, which did, is a mystery to many to this day. This author hypothesizes that the politics behind this decision is likely to have contributed to the tortuous reality that some DNPs are actually direct care “practice” clinicians and others are not, something the practice doctorate was supposed to clearly resolve.

The rapid surge in new DNP programs in 2005 (Table 2.2 lists the first DNP programs established as of August 2005) has led us to today where we indicate the number of reported AACN doctoral nursing programs in 2010 and 10 years later in 2015 (Table 2.3). Besides the surge in DNP programs noted in Table 2.3 there has also been a modest increase in the number of Doctor of Education (EdD) degrees in nursing education noted. Some of these are clearly offered by a respective school/college of nursing, and others are offered by a school/college of education, while marketed as an EdD in nursing education or EdD in education with a nursing education specialty track.²⁰

The implication for so many DNP programs appearing in the last decade or so is enormous, and its ultimate impact on the discipline is unknown.²¹ Unlike 2005 (when there were many articles both pro and con written about the degree), this surge in programs during the past 5 years has created a vacuum in which very few nursing scholars have publicly written or hypothesized about this degree’s impact on nursing science knowledge development.

A couple of developments with the DNP degree historically should be noted. Shortly after Columbia University commenced its DrNP in 2005, Drexel University also implemented a DrNP degree; however, Drexel’s degree model was a hybrid model (different from Columbia’s intensive clinical focus) that combined a focus on advanced practice with clinical research and included a requirement to complete a clinical dissertation (Dreher, Smith Glasgow, et al., 2005).²² The Drexel DrNP degree model was created to fall in between the PhD and DNP degrees with its graduates prepared to evaluate and disseminate evidence, and also to conduct practical, practice-grounded, clinically oriented research. Although the degree model had excellent 5-year outcomes, it subsequently had multiple changes in leadership, and eventually internal politics led to the degree being phased out in favor of the new DNP.

Overall, it appears that the AACN strategy has been successful, as it has prevented any school from implementing anything but a specific DNP degree. Their very early proclamation that they would not accredit any DNP program unless it used the DNP degree initials worked, even if it still appears in retrospect to have been a very arbitrary decision so early in the evolution of a brand new doctorate.²³ It may have even thwarted DNP innovation as Columbia and Drexel, as both ultimately chose to align with the mainstream. Finally, having two models of the DNP degree (DNP and DrNP) was in itself not without controversy, as some (particularly the AACN) had indicated that they thought it confusing and again feared the previously mentioned doctoral nursing degree alphabet conundrum (AACN, 2006; Fulton & Lyon, 2005, 2006). Nevertheless, nurse anesthesia has not embraced the idea of single practice doctorate for certified registered nurse anesthetists (CRNAs) and CRNAs may now pursue the DNP, the increasingly prevalent Doctor of Nurse Anesthesia Practice (DNAP) degree, Doctor of Management Practice of Nurse Anesthesia degree (DMPNA), or actually any kind of doctorate the individual chooses;²⁴ however, they must do so by 2025 (Council on Accreditation [COA], 2011; Gombkoto, 2014; Hawkins & Nezat, 2009).

A second issue impacting the degree is the profession’s inability to establish the DNP degree by 2015 for all new advanced practice nurses instead of the master’s degree as voted by the AACN in 2004 (2004b). Although the AACN passed this resolution in 2004 by a vote of 162 yes, 101 no, and 13 abstain, the question before 2015 was whether this ruling had any real authority (Dreher, Donnelly, et al., 2005).²⁵ The correct answer was no, but the pragmatic response today is that it remains an ongoing goal, now with no real deadline. In reality, in order for this to truly take place in the near future (n.b., 2015), several decisions must take place:

Fulton and Lyon (2005) have affirmed that every Nurse Practice Act will need to be modified if the master’s degree is no longer going to be required to sit for certification as an advanced practice nurse in any respective state.²⁶ For instance, in 2006, the Pennsylvania State Nurses Association published a position paper against the requirement that all APRNs obtain a DNP instead of MSN by 2015. Meanwhile, the Nurse Practice Act in that state was modified to permit new advanced practice nurses to have either a master’s or doctoral degree, instead of a previously required master’s degree (Vogel & Gobel, 2006). One good question to ask yourself is: What is the current language regarding the educational preparation of different advanced practice nurses in your state? The major advanced practice nursing organizations (American College of Midwives, National Association of Clinical Nurse Specialists [NACNS], American Association of Nurse Anesthetists [AANA], and a cadre of nurse practitioner organizations) all took different perspectives on the 2015 deadline. Now they are all examining the passing of this deadline and exploring what it means for their members and the discipline.

Most NP organizations have taken a progressive stance that approves of DNP education without diminishing or marginalizing current master’s-level NP education; however, they did not explicitly endorse the 2015 implementation date. A 2008 consensus statement endorsed by multiple NP organizations²⁷ stated the following.

Similarly, the American College of Nurse-Midwives (ACNM) attested in 2007, 2009, and revised in 2012, stated: “The Doctor of Nursing Practice (DNP) may be one option for some nurse-midwifery programs, but should not be a requirement for entry into midwifery practice” (ACNM, 2012, p. 1). In June 2007, the AANA board of directors unanimously adopted the position of supporting doctoral education for entry into nurse anesthesia practice by 2025. In doing so, nurse anesthesia became the first national APRN specialty to eventually require the doctorate for entry-level practice, although specifically not the DNP. In 2014, they adopted standards for the nurse anesthesia practice doctorate. In 2009, the NACNS published the following as part of their Position Statement on the Nursing Practice Doctorate.

Finally, because the AACN DNP model of practice also included the executive role, it is worth noting that the most recent statement by the American Organization of Nurse Executives (AONE, 2007) attested that “AONE supports the Doctorate of Nursing Practice (DNP) as the terminal degree option for practice-focused nursing. However, AONE, at this time, believes nursing master’s degree programs in both specialty and generalist courses of study should be retained” (p. 3). One of the prime reasons for the AONE position was their belief that there was a lack of analysis and support that a doctoral-educated manager/executive was needed across all aspects of the care continuum.

Overall, despite the cautious endorsements of the DNP degree by the major APRN organizations, it remains evident that with 269 current DNP programs and supposedly 100 or more in the program consideration stage, the degree is going to continue to evolve and proliferate. It is also apparent that the AACN is moving away from another targeted date,²⁸ and instead, the AACN is studying barriers and facilitators to programs not converting or converting to the entry-level DNP instead of a master’s degree. Just this year the RAND Corporation and the AACN published their findings (2014)²⁹ to essentially explore what happened. Why has the movement to the DNP in nursing education not been swifter, despite the impressive number of new programs? A full exploration of the factors RAND identified are more detailed than possible to present in this chapter, but the facilitators and barriers are multifactorial.²⁹ This author has also observed a swing away from the entry-level BSN to DNP, as the global recession had seriously diminished the number of health care institutions offering tuition reimbursement for advanced nursing education. Furthermore, although many health care agencies today may have an incentive for RNs to achieve the BSN (e.g., to achieve Magnet status) and may even be interested in supporting their RNs’ growth with the master’s degree, most still prohibit tuition reimbursement for doctoral study. Finally, skipping the master’s and going directly for the doctorate requires more time and more money, and again these are disincentives to nurses in an economy that has been in a slow recovery and still has serious wage stagnation. The growth in DNP programs still is among the postmaster’s DNP programs, which many still believe is more appropriate than an aggressive strategy toward the entry-level DNP (Cronenwett et al., 2011; Dreher et al., 2012).

Its ultimate success, however, will be in the measurable outcomes of the graduates, their direct impact on the health care delivery system, and the overall reception of the new degree by the health care marketplace and important stakeholders—including academia. We must remember that the permanence of advanced practice nursing from the earliest certificate movement to the requirement of the master’s degree took some 40 years to come to fruition (Dreher, 2008).³⁰ Furthermore, and perhaps even more astonishing, we have never resolved even the minimal educational entry-level question for basic nursing practice (Donley & Flaherty, 2008). Thus, current DNP students should not despair as the profession and public (and health care system) try to figure this new degree out. What a critical mass of DNP graduates ultimately accomplish individually and on the discipline itself will ultimately determine whether this innovation was indeed timely and a benefit to the multitude of health care stakeholders. Whether the health of this nation and the public does advance with more educated advanced practice nurses remains a question that cannot be answered simply or quickly.

 THE NATURE OF DISCIPLINARY NURSING PRACTICE

While this text is written largely for graduate nursing students (and chiefly for DNP and PhD students) and for the general community of interested nursing scholars, some comments about the diverse nature (and complexity) of disciplinary nursing practice should be made.

BASIC AND PROFESSIONAL NURSING PRACTICE

As Nelson (2002) has noted, with the arrival of the associate degree nursing (ADN) programs (first conceived by Dr. Mildred Montag³¹ of Adelphi University) in 1958, the resulting designation of two separate educational levels of nursing education did not ultimately differentiate practice between technical (ADN) and professional (BSN) nursing (Haase, 1990). Dr. Montag, however, never conceived that the ADN-prepared technical nurse would have absolute parity with the BSN-prepared professional nurse; however, due to the shortage of nurses after WWII and with a bustling postwar economy, this is exactly what happened. According to Nelson:

The ANA position in 1965 was later supported by a resolution in 1978 by the ANA House of Delegates in which the requirement was set forth that by 1985 the minimum preparation for entry into professional practice would be the baccalaureate degree. (2002, p. 1)

What this designation did was essentially to affirm and attempt to codify two levels of nursing practice, professional and technical. Nevertheless, over time, the technical nurse label has never really been affixed to the RN prepared at the associates or even diploma level, despite there being a plethora of published literature that has described how the technical nurse and professional nurse are inherently different. In many ways, the three types of basic nursing preparation have morphed over time (unfortunately) into “a nurse is a nurse is a nurse.”

Returning to Chapter 1, this has complicated the professionalism of nursing practice and nursing as a discipline. In 1998, Christman noted that nurses as a whole remain among the least educated health care professionals at the point of care. In 2000, BSN-prepared nurses represented only approximately 30% of all RNs, with nurses with associate degrees representing around 60% of all RNs (Gosnell, 2002). Almost a decade later from Christman’s observation, not much had changed. In 2007, in California (our largest state), nurses with associate degrees were noted to be 70% of the total nurse workforce (National League of Nursing [NLN], 2007). In 2009, Aiken et al. reported on data that indicated that BSN-prepared nurses had increased to 45% of the nursing workforce nationally, and the Robert Wood Johnson Foundation reported that the number had grown to approximately 50% in 2013. Although the ANA is no longer actively pushing the BSN as the required minimal entry-level degree for nursing, it is noted that one current innovation is the “RN +10” movement, which would require registered professional nurses to earn a BSN within 10 years of their initial basic nursing licensure (Dreher, 2008).³² This legislation passed the New York State Assembly in 2014, but narrowly did not pass the Senate. It is poised to be reintroduced and perhaps passed in 2015 to 2016 (Greater New York Hospital Association, 2014).

Where, then, are we left with this endless discussion point: Is nursing a profession?³³ Also, are all nurses professional nurses? Can the discipline ever fully mature with so many entry-level issues, both in professional and advanced practice, left in limbo or unresolved? Will these issues further impact nursing science and nursing knowledge development?

A DISTINCTION: ADVANCED PRACTICE NURSING VERSUS ADVANCED NURSING PRACTICE

Unquestionably, today, if graduate nursing students are pursuing a career goal in advanced practice as nurse practitioners, nurse midwives, nurse anesthetists, or clinical nurse specialists (CNSs; all traditional advanced practice roles), they are either pursuing these advanced practice roles as part of a formal accredited master’s degree, a post-master’s DNP, or as an entry-level DNP degree after completing a BSN. There are also DNP “advanced nursing roles” (different from traditional “advanced practice roles”) encompassing the roles of the clinical executive, public health,³⁴ integrative health and healing,³⁵ informatics,³⁶ lifestyle therapeutics,³⁷ and even nursing educator, under the “educational leadership” DNP track title (all “indirect role functions”) where students are also pursuing a practice doctorate.³⁸ Although there may be other DNP degree programs, this author is unaware of them.

A precursor to “advanced nursing roles” may be what the ANA in 1980 affirmed as specialization, but specialization and advanced nursing practice are different. “Specialization involves concentration in a selected clinical area within the field of nursing” (Hamric, Spross, & Hanson, 1996, p. 43), but does not assume necessarily the requirement for an advanced degree. Cronenwett (1995) indicated that, in 1980, during discussions of the first ANA social policy document, there was no language proposed to define advanced practice! However, in the revision of the social policy document published in 1995, advanced practice nursing was finally characterized and defined as clinical practice that included specialization, expansion, and advancement (Lyon, 1996). From the ANA’s 1995 Nursing’s Social Policy Statement, “Expansion³⁹ refers to the acquisition of new practice knowledge and skills, including knowledge and skills legitimizing role autonomy within the areas of practice that overlap the traditional boundaries of medical practice” (p. 14). However, “Advancement⁴⁰ involves both specialization and expansion and is characterized by the integration of theoretical, research-based, and practical knowledge that occurs as a part of graduate education in nursing” (p. 14).

In 2003, the Drexel doctoral nursing faculty explored this tension (or the technical language) between advanced practice nursing and advanced nursing practice when they were developing their practice doctorate model and having discussion about who would be included: What population of nurses should properly undertake a practice doctorate? Certainly, the AACN was also struggling with this differentiation too in their Draft Position Statement on the Practice Doctorate in Nursing (2004a), which stated that “others have broadened the definition of advanced nursing practice to include both direct clinical practice and areas of practice that support clinical practice” (p. 7); however, they had not yet included the clinical executive role in the DNP degree. However, 9 months later, the AACN adopted the Position Statement on the Practice Doctorate in Nursing (2004b) where three new recommendations were added including “Recommendation 10: The practice doctorate be the graduate degree for advanced nursing practice preparation, including but not limited to [emphasis added] the four current APN roles: CNS, nurse anesthetist, nurse midwife, and nurse practitioner” (p. 13). Again, although not made explicit, the language was created, and ultimately the AACN made the actual (and monumental) decision to include the clinical executive role, termed the “Aggregate/Systems/Organizational Focus” (p. 1) and the “Advanced Practice Nursing Focus” (p. 1) or practitioner role⁴¹ as both appropriate for the DNP degree in the Essentials of Doctoral Education for Advanced Nursing Practice document, which has become the template for all DNP programs’ accreditation (AACN, 2006).⁴²

At that time, the presumed inclusion of the executive role with the practitioner role under the rubric advanced nursing practice (AACN, 2004a, p. 13) was controversial (Mundinger, 2005).⁴³ Dean Mary Mundinger (Columbia University School of Nursing) even later indicated that it was the inclusion of the nondirect care role in the DNP degree that led to the need to develop the Diplomate in Comprehensive Care examination⁴⁴ (the still controversial DNP certification examination) by the American Board of Comprehensive Care as “a national standard that distinguishes DNPs who have an advanced clinical knowledge from those who have an emphasis in research, administration or systems management” (Croasdale, 2008, p. 1). Others have alternatively argued, if the practice of nursing administration can be considered advanced nursing practice or even advanced practice nursing, why is the practice of nursing education excluded and not acceptable by the AACN as an appropriate role track for DNP degree programs too (Butler, 2009; Wittmann-Price, Waite, & Woda, 2011)? The NLN (2015), however, countered the AACN by affirming academic nursing education “as a specialty area of practice and an advanced practice role within professional nursing” (p. 1). So which organization (AACN or NLN) is correct or most consistent and coherent on this issue of the domain of advanced practice nursing with regard to the DNP degree? The Drexel doctoral nursing faculty working group first defined clinical nursing practice as:

The dynamic implementation of either professional or advanced nursing research-guided interventions, tasks, and responsibilities using competencies (knowledge, skills and attitudes) that support critical thinking and sound decision-making, ensure quality patient/client outcomes, uphold safety, and support the optimal promotion of health of diverse individuals, families, and communities. (Dreher, Smith Glasgow, et al., 2005, p. 28)

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