THE NURSING FIELD CIRCA 1910

In order to best appreciate where we are in 2015, we begin our roughly 100-year retrospective with a period around 1910 which nurse historian Patricia Donahue terms “the era of the rise of organized nursing” (1996, p. 318). Ten years after the turn of the 19th century, William Howard Taft was the 27th president² of the United States. What was American life like in 1910?

The developments in nursing at this time, which included the 1910 time line of accomplishments mentioned in Chapter 2, would culminate with and then initiate the rise of nursing as a profession in the United States. As Donahue (1996) has noted, “nursing has made its greatest advances and notable achievements in connections with wars” (p. 352). World War I (WWI) broke out in June 1914 in Sarajevo, Serbia, when the archduke of Austria and his wife were killed (Gavin, 1997; Higonnet, Jenson, Michel, & Weitz, 1987). Nevertheless, just after the turn of the century, nursing was very difficult work and wages were variable. The average yearly salary was about $1,000 to $1,500, although some private duty nurses took work at whatever price they could get (Sussman, 1999; Wickwire, 1937).

The American Journal of Nursing (AJN), founded in 1900 with Sophia F. Palmer⁴ as its first editor, was the leading nursing journal at that time and still continues today (Mason, 1999). Table 15.1 provides the table of contents from April 1910, Volume 10, Issue 7. By examining these journal articles from 1910, what kinds of assumptions about nursing and the nursing discipline might you make?

The following excerpt is from the 1910 editorial comment:

What we find most interesting about this early issue of AJN is that already we have evidence of one of the earliest iterations of practice inquiry, which has been reawakened in a new framework in the nursing literature almost 100 years later by nursing scholars at the University of Washington (Magyary, Whitney, & Brown, 2006).

Thorton’s article on typhoid is a representative example. Typhoid fever was still a serious illness in 1910. It was an acute, life-threatening bacterial illness contracted by ingesting contaminated water or food. It was one of the most serious health problems in 19th- and early-20th-century America, particularly because the universal water supply in America was not adequately filtered and safe (Gaspari & Wolf, 1985). With an estimated population of 22,573,435 in the United States in 1910, there were 4,637 recorded deaths (there were likely many more undocumented) or a death rate of 20.54 per 100,000 from typhoid (American Journal of Public Health, 1940).⁶ Walton and Connelly (2005) describe the very expert care by trained nurses in the care of children with typhoid at the Children’s Hospital of Philadelphia between 1895 and 1910. They concluded: “Then, as now, expert nursing care and collaboration with medical colleagues ensured optimal outcomes. A better understanding of the historic importance of the professional bedside nurse may improve our ability to attract and retain nurses—so important today” (p. 74). These comments may also be apropos today as we prepare for a more highly educated advanced practice nurse workforce. Finally, these early writings also indicated that nurses were inquisitive and sought answers to the nursing and health issues of the day. Most importantly, by publishing their work so others might benefit, they were demonstrating scholarly inquiry and a commitment to the improvement of the field of nursing.

TABLE 15.1    Table of Contents, April 1910, 10(7), American Journal of Nursing

NURSING: A “FIELD” TECHNICALLY BECOMES A “PROFESSION,” CIRCA 1935

Some 25 years later in 1935, America was slowly emerging from the ravages of the 1929 to 1933 depression (Friedman, 2008). Despite the election of Franklin Delano Roosevelt in 1933 and his first real economic plans to defeat the depression (e.g., the 1935 Social Security Act), the Great Depression’s aftereffects would last until the end of World War II (WWII) (Goodwin, 1995). In 1935, American nursing also found itself ramping up for WWII. Japan invaded Manchuria in 1931⁷ and China later in 1937, and WWII exploded with the German invasion of Poland in September 1939 (Maddox, 1992). The United States would join WWII with the bombing of Pearl Harbor in December 1941. The national unemployment rate was 20.1%; among nurses (graduate, registered, and licensed), it was not until 1937 that nurses (those fortunate to be employed) would be relieved from working 12 hours a day and up to 70 hours per week to working only 8 hours a day and only 6 days a week (Byers, 1999; Kangas, 1997). This was the landscape that American nursing found itself in 1935.

In 1934, the final report by the Committee on Grading of Nursing Schools,⁸ Nursing Schools Today and Tomorrow, was published, and it reported on the state of nursing and nursing schools in the United States at the time (AJN, 1934).⁹ In describing findings from the document, Goodrich¹⁰ later wrote:

Goodrich further indicated that the League of Nursing Education in 1934 only identified 136 schools of nursing that were fully connected with universities, although many others (particularly Catholic-affiliated schools) had very loose connections (to colleges or universities) that she criticized as “but in name” (p. 767) only. She also envisioned the “field of nursing” (p. 768) moving quickly away from the outmoded classification of nursing as private duty, institutional, and public health nursing and more toward specialization in for example, pediatrics and obstetrics (1936).

On October 7, 1935, Harry L. Hopkins of the federal Work Progress Administration (WPA), wrote in a memo that nurses were reclassified from “skilled non-manual workers” to “Class 4 professional and technical workers” (AJN, 1935). Although nursing leaders had been working behind the scenes for years to accomplish this, this federal reclassification elevated the status of nursing and made nurses eligible for many federal WPA health projects (Lusk, 1997). In many ways, this important date has been lost in history; however, 1935 remains a landmark in the quest for nursing to be fully recognized as a profession, independent and away from the oppression of medicine. Among the most vocal and visible advocates for nursing at this time were two of nursing’s most important pioneers of the 20th century, Lavinia Lloyd Dock¹² and Isabel M. Stewart.¹³ In a confrontational way, almost unheard of due to the social mores still expected of women in the 1930s, they both wrote that nursing is not:

With a general worldview of the events occurring around 1935, we examined the February 1935 issue of the AJN—still considered the leading journal for American nursing in this period (Table 15.2). What kinds of topics were covered in comparison to the previous 1910 issue?

One observation we made is that there does not appear to be any significant movement to publishing research studies, which in many ways is further evidence that nursing was still a maturing field, and not yet a discipline. In 1935, the Association of Collegiate Schools of Nursing was founded with a mission to promote nursing education in the collegiate/university environment and away from the hospital-based programs (Williams, 1945). The principle aims of this new organization were: (a) to develop nursing education on a professional and collegiate level; (b) to promote and strengthen relationships between schools of nursing and institutions of higher education; and (c) to promote study and experimentation in nursing service and nursing education (Goodrich, 1936). This may have been the first highly visible policy record to encourage nursing research. You can see for yourself whether the research goals of nursing in 1935, “To promote study and experimentation in nursing service and nursing education” (Goodrich, 1936, p. 767), are the same or different today.

ON THE PRECIPICE OF A “DISCIPLINE” AND THE RISE OF MODERN NURSING, CIRCA 1960

Twenty-five years after 1935, America was about to undergo a decade of immense, significant social change. On November 8, 1960, in a very narrow election, John F. Kennedy¹⁴ was elected at age 43 as the youngest president. The Vietnam War, unlike previous wars, had no definitive beginning. The United States gradually began its involvement between 1950 and 1965, and America’s involvement escalated further during the early Kennedy administration (Rotter, 1999). Some 7,484 women (6,250 or 83.5% were nurses) served in Vietnam, and eight nurses died in that war, including one killed in action (Veterans Administration, 2010).¹⁵ Although nurses, such as Margaret Sanger¹⁶ and her sister Ethel Byrne, were involved in the earliest movements to support birth control and the rights of women, it would not be until 1965 that the Supreme Court would finally legalize birth control in all 50 states (Hampton, 2004; Reed, 1978; Sanger, Katz, Hajo, & Engelman, 2002).

In 1960, it was estimated that only 55.4% of trained nurses were actually employed (approximately 504,000),¹⁷ and it was surmised that a large number of qualified nurses were therefore married and not seeking employment actively (Cleland, 1967; U.S. Department of Health, Education, & Welfare, 1970). At this time, it was generally assumed that new professionals (nurses) who invested in professional education and training would remain an active part of the workforce (Bishop, 1970). However, these labor statistics indicated something very different for nursing. These qualified, but electively unemployed nurses were actually exacerbating the nursing shortage of the day (Fagin, 1980). Was marital status, perhaps, not the only factor contributing to these trained nurses forgoing full-time employment? Certainly, the working conditions of nurses described in 1935 had improved; however, evidence suggests not by much (Budd, Warino, & Patton, 2004). Further, the average annual salary for a general duty, hospital-based nurse reported in 1961 was $3,380/y in Atlanta and $4,628/y in Los Angeles, accounting for regional differences (AJN, 1961). It is in this chaotic social climate of nursing that the profession began to modernize itself.

Just about a decade before 1960, this unsigned editorial appeared in the AJN:

Three years later in 1952, the nursing profession had its first research journal—Nursing Research—under the inaugural editorship of Dr. Helen L. Bunge¹⁹ (Notter, 1970). The first issue’s main article was a very sophisticated and meticulous report (23 pages) titled “The Personal Adjustment of Chronically Ill Old People Under Home Care,” and was a summary of Margery J. Mack’s PhD dissertation from the University of Chicago in 1951 (1952). The journal was initially an enterprise of the American Journal of Nursing Company and struggled financially for many years. After 10 years of publication, Bunge (1962) reflected on the journal’s first decade and made a couple of assessments: (a) “the scarcity and sometimes paucity of manuscripts suitable for publication” (p. 137); (b) “many more manuscripts from the area of psychiatric nursing are submitted than manuscripts from other clinical fields” (p. 137);²⁰ and (c) persistent questions over who should be the journal’s audience, writing, “Shall it aim to appeal to students, to persons engaged in and sophisticated in research, or to persons comparatively unknowledgeable in research?” (p. 137).

Returning to 1960, in Chapter 2, we detailed how many modern developments in nursing emerged as the decade of the 1960s progressed. In 1960, though, nursing still appeared to be on the precipice of being a discipline. Only one doctoral nursing program, a PhD in Nursing at the University of Pittsburgh in 1954, had been added since 1935, and by the end of the 1950s only 39 doctoral degrees in nursing had been awarded (Nichols & Chitty, 2005; Parietti, 1990). Because the conduct of research in any discipline requires financial resources, without a source of funding nursing could not advance its scientific basis. One major development during this era was the founding of a research and fellowship branch in 1955 within the federal Division of Nursing Resources (founded in 1948), with the first applications received, reviewed, and first federal grants for nursing research awarded that fall (Gortner, 1986; Gortner & Nahm, 1977; Stevenson, 1987). The year 1960 also predated the majority of the early nursing theorists, although Dr. Faye Abdellah²¹ and colleagues published their book Patient-Centered Approaches to Nursing that year, which included Abdellah’s very influential list of “21 nursing problems.” An examination of the published titles in the Fall 1960 issue of Nursing Research in Table 15.3 reveals what new trends were observed from 1935.

With a new research journal in the field of nursing, it is interesting to note that these were the featured articles some 8 years into the journal’s history. Bunge’s (1962) earlier comment about the problem with publishing nonresearch articles in a research journal is evident here. There was great debate on the editorial board about this; however, it is important to note there was still a dearth of qualified submissions in the early days of the journal. Nevertheless, the idea that nurses could be scholars, conduct experimental research, have scholarly discourse, and critique another’s published work are clearly advances for the scientific development and maturation of a slowly emerging discipline. Nursing appears to be at a nexus here in 1960—perhaps no longer just a field, but not quite a fully fledged discipline.

TABLE 15.3    Table of Contents, Fall 1960, 9(4), Nursing Research

THE SCIENTIFIC DISCIPLINE OF NURSING EMERGES, CIRCA 1985

The 25-year span of nursing between 1960 and 1985 represented nursing’s definitive emergence as a discipline, even if there are retrospective analyses that question the overall contribution the voluminous early nursing theorists have made to the science of nursing today. The trajectory of what took place during the modern era of nursing (1960–1985) is far too extensive to cover in this chapter; however, some important landmarks in nursing did occur that set nursing on a different course. In January 1985, Ronald Reagan²² began his second term as president. In his first term, he slowly guided the country out of a short, but severe recession that lasted from 1981 to 1982 with a peak unemployment rate of 10.8% in November to December 1982 (Bandyk, 2009).²³ Reagan’s second term had more emphasis on foreign affairs and included the end of the Cold War, the bombing of Libya, and the Iran–Contra Affair. With the AIDS epidemic beginning in 1981, Reagan was criticized for being slow to respond to the epidemic at the federal level and for not mentioning the epidemic publicly until 1985 (Stinson, 2004).

As the decade began, the American Nurses Association (ANA) published in 1980 its inaugural and controversial Nursing: A Social Policy Statement. Hobbs (2009) has written a superb paper on the prickly constituents who fought and debated the language of this document, especially because many of them feared the impact of its codification at all levels of nursing oversight. Hobbs described how the primary debate was not over the odd language of the newly revised definition of nursing²⁴ (though this was indeed one of the document’s controversies); rather, it was a debate over the definition of specialization. The burgeoning nurse practitioner movement in particular voiced displeasure about the final document permitting specialization without an advanced nursing degree and failing to be more explicit about the scope of the advanced practitioner to diagnose and treat disease and illness (Cronenwett, 1995; Hobbs, 2009).

Despite advances in the nursing profession, the ANA continued to struggle, although without much success, to enact a minimum educational requirement for professional nursing. The ANA’s “position paper” 1965 statement on the education of nurses called for a minimum of a bachelor’s degree for entry into professional nursing (Nelson, 2002). This call largely fell flat due to rising enrollments in associate degree in nursing (ADN) programs and the burgeoning political power and influence of those involved in ADN education and the still prevalent clout of those in diploma education (Donley & Flaherty, 2008). In 1978, the ANA House of Delegates reaffirmed the 1965 statement and endorsed two levels of nursing practice—professional and technical. In 1982, however, the move to formalize the bachelor of science in nursing (BSN) as minimum entry level to professional nursing was rebuffed permanently (Nelson, 2002). Joel (2002) has aptly written “The health care industry has traditionally ignored the advice of the nursing profession” (p. 1); this statement reflects the many congealed forces that have successfully defeated a universal upgrade in basic nursing education in the United States since the 1960s. As a consequence, one reason for nursing’s historical lack of influence, despite the modernization of the profession and its growing numbers, can be attributed to Domino’s assertion that nurses are the least educated of all the major health care professionals (2005). Although that assertion still has a degree of accuracy, the percent of nurses with a BSN degree or higher has risen in the last decade to somewhere between 55% and 61% (Budden, Zhong, Moulton, & Cimiotti, 2013; Health Resources and Services Administration, 2013). This number, in fact, does reflect the inclusion of RNs with advanced degrees that was 13.2% in 2008, which included nurses who had an initial BSN at 33.7% and initially an ADN at 45.4% (U.S. Department of Health and Human Services, Health Resources and Services Administration, 2010). Still, this is only a modest improvement from 1989 when the percent of RNs graduating initially with a BSN was around 30% according to the Division of Nursing (U.S. Department of Labor, Bureau of Labor Statistics, 1992).²⁵ The Institute of Medicine’s (IOM) goal of having 80% of RNs with BSNs by 2020 seems a lofty and perhaps unattainable goal (2010). The prevalence of access to RN licensure with a less expensive 2-year community college associate degree, and the economic forces that today still make returning for a BSN expensive, are likely to support this unattainable trend line (2010).

The formal recognition of advanced nursing practice was also quickly progressing. The advanced practice nursing movement first began in 1965 at the University of Colorado when Dr. Loretta Ford, a pioneer nurse educator, established the first pediatric nurse practitioner certificate program with Dr. Henry Silver, a pediatrician (Hoekelman, 1967). Congressional legislation enacted in 1971 provided federal support for primary care intervention recommendations for which nurses and physicians could share responsibility; thus, job opportunities for nurses as primary care providers grew (Sherwood, Brown, Fay, & Wardell, 1997). The Rural Health Clinic Services Act of 1977 was another landmark piece of legislation that permitted reimbursement to nurse practitioners and physician assistants for federal Medicaid and Medicare reimbursement to patients in underserved, rural areas; this move helped to further progress the nursing primary care movement (Silver & McAtee, 1978; Wriston, 1981). It would be several decades, however, before the master’s of science in nursing (MSN) would be required for advanced nursing practice for all four primary advanced practice specialties (Dreher, 2009). Now we have a new movement by the American Association of Colleges of Nursing (AACN) to require the doctorate instead (AACN, 2004). As it did not happen in 2015, do you think this will actually ever take place?

During this period, intense lobbying was taking place at the highest levels of nursing in Washington, DC. In April 1986, the first National Center for Nursing Research at the National Institutes of Health (NIH) was founded. Interestingly, the first acting director was a physician (Schlepp, 1987). Although not a full research institute, “center” status was considered the first step to an ultimate National Institute of Nursing Research (NINR; Merritt, 1987). In Chapter 2, we described the surge of new doctoral nursing programs in the 1970s. This growth continued into the 1980s with 34 new doctoral nursing programs established by 1985 (Boland & Finke, 2005). This total also included the first Doctor of Nursing (ND) degree established at Case Western Reserve University in 1979 (Fitzpatrick, Boyle, & Anderson, 1986). Although today some will refer to the ND as the first practice doctorate in nursing, that is clearly a revisionist view, as the concept of the practice doctorate was not in usage. It is better described as the first practice-oriented ND because it prepared students for entry into the profession²⁶ in the same way that the MD degree was intended for entry into the profession of medicine, after first being awarded an undergraduate degree in some field (Forni, 1989). Historically, this degree model never became widespread and only four programs were ever established.²⁷ Master’s-level nursing programs also thrived in the 1980s, although the focus of this text is on the doctoral nursing scholars who would be better positioned to advance the practice-oriented and theoretical knowledge of the discipline (Dunphy, Smith, & Youngkin, 2009).

Another sign of the maturing of the nursing discipline has been the proliferation of nursing specialty journals, not just in the United States, but worldwide. It is difficult to be precise about the number of nursing journals that began publication since 1960, but the numbers surged chiefly as more nurses sought higher education, and the audience for nursing scholarship grew precipitously. Another way to measure the growth and impact of nursing scholarship is by reviewing Garfield’s (1984) citation studies noted in Table 15.4, which identified the 10 most cited journals in 1983 (and their initial date of publication). The most cited journal article from 1966 to 1983 was Dr. M. V. Marston’s (Francis Payne Bolton School of Nursing, Case Western Reserve University) “Compliance With Medical Regimens: A Review of the Literature” published in Nursing Research in 1970 (Garfield, 1984).

Finally, one historical landmark that we would be remiss if we did not address is the contribution of the nursing theorists to the nursing discipline during this 25-year period. Although our purpose in this chapter or text is not to address their epistemological contribution to nursing (many other scholars have covered this topic exceptionally well),²⁸ our acknowledgment is more their intellectual contribution to framing the theoretical questions: What is nursing? and What do nurses do? Any discipline, even a practice-oriented discipline such as nursing, cannot avoid completely the theoretical discussions and debates, which may not have direct meaning for the common practitioner. To avoid this would be completely anti-intellectual. However, this is likely one of the faults of the theorists—the inability to convince lay nurses (whether technical, professional, or advanced) that nursing theory has real, direct application to their work. Nevertheless, from a historical perspective, Martha Rogers, Imogene King, Dorothea Orem, Sister Callista Roy, Rosemarie Parse, Jean Watson, Madeleine Leininger, and Helen Erickson (and others) have made a unique contribution to a profession that unfortunately overvalues the practical and the concrete and undervalues philosophizing, contemplation, reflection, and theorizing. It is quite likely, however, that the theory of transcultural nursing proposed by nurse anthropologist Madeleine Leininger,²⁹ and the theory of human caring, chiefly articulated by Jean Watson,³⁰ may be the grand theorists who will have the most lasting impact on contemporary nursing practice.

Another type of nursing theory, termed middle range theory, evolved in the latter half of this 25-year span in nursing. The term was initially coined or invented by Merton, a sociologist in 1964. According to Meleis, “Middle range theories deal with more specific phenomena” (2007, p. 213). One classic example of a middle range theory is Mercer’s (1981, 1985) Theory of Maternal Role Attainment, which appeared in the 1985 issue of Nursing Research (Table 15.5). These theories may have the most direct impact on nursing practice and practice knowledge development. Examine Table 15.5 and the articles listed for the 1985 issue of Nursing Research. What kind of assumptions can you make when comparing Nursing Research from 1960?

In reviewing these journal titles, one very visible sign of the emergence of nursing as a scientific discipline is that there no longer appears to be a scarcity of “true research” articles, an admission of the journal’s early editor and editorial board (Bunge, 1962). In great part, this can be attributed to the enormous number of new doctoral programs, an increase in funding sources for research as noted earlier, the growing sophistication of nursing scholars to oversee the conduct of scientific research, and the availability of a new generation of mentors for the new generation of nurse scientists. We suggest you procure one of the research articles in this table. How would you evaluate the researcher’s method(s) and findings in 1985 compared to contemporary nursing research found in any leading research-oriented nursing journal?

A CRITICAL JUNCTURE FOR NURSING KNOWLEDGE DEVELOPMENT, CIRCA 2010

We finally arrived at the 100-year mark in 2010. Historical events since 1985 are more recent and need to be refreshed less. If we focus, however, on global health issues, we have the progression of HIV/AIDS as a global pandemic and the emergence of new infections like the 2003 severe acute respiratory syndrome (SARS) and H5N1 avian influenza (World Health Organization, 2004, 2010). SARS conclusively emphasized that the health of a single traveling citizen in one distant country could literally affect the health of anyone, anywhere on the planet (Dreher et al., 2004). These events alone indicate that the doctoral-prepared nurse, no matter the degree, needs more preparation in global health nursing and public health content. We would further suggest they also need real-world exposure to international health experiences including study abroad programs at the doctoral level (Dreher, Lachman, Smith Glasgow, & Ward, 2008). Since 1985, nurses also served admirably in the first Gulf War in the 1990s and the wars in Iraq and Afghanistan (Scannell-Desch & Doherty, 2010; Sheehy, 2007). Nurses and other first responders were also at the forefront of responding to the deadliest terrorist attack in the United States on September 11, 2001 risking their own lives and health (Pak, O’Hara, & McCauley, 2008; Ungvarski, 2002).

Assessing the current landscape of nursing education, the issue of entry level into professional nursing appears to have been abandoned permanently. An alternative movement (to meet some of the original goals of the ANA) is to instead require the BSN after 10 years of having an ADN. This movement is termed RN + 10 or BSN in 10 and appears to have the most likelihood of entry-level reform. This legislation continues to percolate primarily in New York, New Jersey, and Pennsylvania (and to some degree in Ohio) and is poised to pass in the New York Assembly and Senate in 2015 to 2016 after only being narrowly defeated in the 2014 to 2015 legislative year (Boyd, 2010; Dreher, 2008; Hilton, 2012; Ohio League for Nursing, 2011). The national median salary for the estimated 2.6 million RNs in 2008 was $62,450 and $69,790 in 2014 (U.S. Department of Labor, Bureau of Labor Statistics, 2009, 2015). Although the issue of entry level into professional nursing is now percolating in some modest form, the move to change entry-level education for advanced practice nurses has swelled.

In October 2004, the AACN voted narrowly to require the DNP degree instead of a master’s degree for entry level into advanced practice nursing (i.e., the nurse practitioner, nurse midwife, nurse anesthetist, and clinical nurse specialist roles) by 2015. As detailed earlier in this text, although this had been a goal of the AACN, no major advanced practice specialty organization has ever agreed to this final timetable. In fact, only in March 2010 did the ANA (2010a) submit their first draft statement for public comment on the DNP degree. In June 2010, the ANA (2010b) published its first position statement. In this document, the ANA essentially supported many of the recommendations proposed by the AACN in their 2004 document. Specifically, the ANA stated: (a) their support for both master’s and doctoral entry into advanced practice nursing at least “through a period of transition” (p. 9); (b) that they did not acknowledge support for the AACN recommendation that only the degree initials DNP be recognized; and (c) that they did not attest to what advanced nursing practice specialty would necessarily qualify to obtain the DNP, probably in deference to differences between the two nursing accrediting agencies that differed on the status of the nurse educator (and perhaps other roles too) as engaging in advanced nursing practice.³¹ The Collegiate Commission on Nursing Education (CCNE) has accredited BSN or higher degree nuring programs since 1996. In 2013, nursing’s other accrediting agency, which also accredits associate and diploma programs, changed its name from the National League for Nursing Accredting Commission (NLNAC) to the Accreditation Commission on Education in Nursing (ACEN).

Nevertheless, in 10 short years, there has been explosive growth in new DNP programs.³² The latest AACN data have indicated that there are at least 269 DNP and 134 research-focused, mostly PhD, nursing programs (Fang, Li, Arietti, & Trautman, 2015). Obviously, many current graduate and matriculating students opted not to wait for 2015; however, that deadline has now passed and another deadline is not on the horizon (except the 2025 deadline for new nurse CRNAs). Will this stall further momentum toward the DNP?

Whatever the consequence, it is not likely that the AACN or other nursing leaders would have projected this momentous rise in an alternative to the PhD degree. Moreover, neither did they anticipate the DNP’s real impact on nursing knowledge development, particularly with the very labile enrollment and graduation rates from PhD programs that are not keeping pace with nursing faculty retirements.³³ It is not surprising that the PhD degree is in a state of crisis. In the past decade, the University of Washington’s Re-envisioning the PhD (Nyquist & Wilff, 2000) project was highly critical of contemporary PhD degree programs and offered solutions for reform. Subsequently, the Carnegie Foundation for the Advancement of Teaching affirmed this and called for more PhD degree reform in Envisioning the Future of Doctoral Education: Preparing Stewards of the Discipline (Golde & Walker, 2006). In reality, it should not be surprising that the PhD in nursing/nursing science degree is experiencing difficulty, particularly with all the national attention on the DNP degree (Dreher, 2009; Fontaine & Dracup, 2007; O’Sullivan, Carter, Marion, Pohl, & Werner, 2005). Figure 15.1 indicates the sluggishness of the PhD in nursing over a recent 10-year period (1996–2006), despite the 59% increase in overall number of PhD programs during that period.

FIGURE 15.1    New programs, enrollments, and graduations in research-focused doctoral programs, 1996 to 2006.

Data from AACN, 1996 to 2006, and analyzed by H. M. Dreher. Figure reprinted with permission from F. A. Davis from Joel (2009).

Since 2006, findings from 2009 to 2010 data are mixed with a 5.1% increase in total number of PhD in nursing students and only a 2.2% increase in graduations (Fang, Tracy, & Bednash, 2010). Full-time³⁴ postdoctorate enrollment (a large gauge of the future nurse scientist pool) was down 3.4% (Fang, Tracy, & Bednash). Similar data from 2015 have indicated that between 2010 and 2015 there were an average of 45 more PhD graduates per year; however, this was not a statistically significant increase from year to year. As mentioned earlier, if retirements of senior faculty are factored into this scenario, it is likely even these slightly optimistic numbers will not be enough to replace those exiting the profession. Impacting these flat enrollments and graduations is the discouraging, lengthy 8.3-year average it takes a nurse to obtain a PhD after the awarding of the MSN (Valiga, 2004). Reliable data on the time to completion of the PhD are very difficult to acquire. Even though this author has heard anecdotal reports that some PhD programs are trying to decrease the time to graduation, other anecdotal reports are that some PhD students are being dismissed based on their exceeding the allowable time to complete the PhD, normally 7 to 9 years.³⁵

Part-time PhD enrollment is also problematic because it contributes to these lengthy times to the award of the PhD degree; full-time graduate enrollment is usually not an option for working nursing professionals. Full-time PhD enrollment actually fell 1.0% from 2013 to 2014 (Fang et al., 2015). What is more worrisome than the actual numbers of PhD graduates per year is that this number (despite the rosy projections from the upper echelons in nursing about healthy PhD enrollments) is being overwhelmed by the retiring senior PhDs (and EdDs) and that the replacement pool for full-time faculty positions is actually quite diminished.

It is likely that the tensions between the PhD degree and DNP degree will continue as the profession debates what each degree needs to best contribute to the discipline in the next 20 years or more. The profession needs both nurse scientists and doctoral-educated practitioners/clinicians as stewards of the discipline. The debate of today and the future will be around the nature of this stewardship.

CONTEMPORARY NURSING SCIENCE MEETING THE HEALTH NEEDS OF A NATION

The advancement from center status to full institute status at the NIH was finally achieved in 1993 with the signing of the NIH Revitalization Act of 1993. A long-standing vision to house a nursing research enterprise, the NINR, at the NIH became a reality (Hurd, 1995). In 2000, the Council for the Advancement of Nursing Science (CANS) was formed within the prestigious American Academy of Nursing (AAN; founded in 1973), which has a mission to support “the preparation and use of knowledge in guiding nursing practice and shaping health policy” (Hinshaw & Holzemer, 2000, p. 240). CANS mostly replaced the function of: (a) the ANA Council of Nurse Researchers founded in 1971, which disbanded in the 1990s, and (b) the ANA Cabinet on Nursing Research founded in 1970, which was phased out in the 1980s (See, 1977). Despite this new support for nursing research (and other private sources), nursing research continues to be seriously underfunded, especially considering that nursing is the largest health profession and that the nursing care needs for America’s estimated 308.4 million residents in 2010 are so vast (Schlesinger, 2009).³⁶ In 2005, Aaronson pointed out that the NINR was the lowest funded of the 27 NIH institutes and centers with only $139 million requested for fiscal year 2006. It remained only slightly more funded than the National Center for Complementary and Alternative Medicine (NIH, 2005), renamed the National Center for Complementary and Integrative Health by President Obama in 2014.³⁷ According to data distributed by the AACN:

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