Certainly, the bedside registered nurse engages in practice or nursing practice. Similarly, the master’s-prepared certified registered nurse practitioner (CRNP), certified nurse–midwife (CNM), certified registered nurse anesthetist (CRNA), and clinical nurse specialist (CNS) all engage in advanced nursing practice. Dreher and Montgomery (2009) have defined the practice of the Doctor of Nursing Practice (DNP)⁵ graduate as doctoral advanced practice nursing (or doctoral advanced nursing practice when the individual is not a CRNA, CRNP, CNM, or CNS). They further describe how it is (or should be) different from the practice of the advanced practice registered nurse (APRN) with the master’s degree. But before we explore these concepts in Chapter 2, we need to first explore the origins of the word practice and evaluate how it is defined and operationalized among various health professions.

Elementally, the word practice is both a noun and a verb. The earliest English derivation of the word is from the 14th century with the word’s etymology from the Middle English practisen; from Middle French practiser; from Medieval Latin practizare, alteration of practicare; from practica, practice, noun; from Late Latin practice; and from Greek praktikē, from feminine of praktikos (Merriam-Webster Online Dictionary, 2010). As a noun the Oxford American Dictionary (Ehrlich, Flexner, Carruth, & Hawkins, 1980) defines it as: (a) action as opposed to theory; (b) a habitual action, custom; (c) repeated exercise to improve the skill one has; and (d) professional work, the business carried on by a doctor or lawyer, the patients or clients regularly consulting these.⁶ As a verb it is defined as: (a) to do something in order to be skillful; (b) to carry out in action, to do something habitually; (c) to do something actively; and (d) to be actively engaged in professional work.⁷ Using these definitions, it is clear that the term practice indicates that it is action, habitual and repeated, and professional work. Nursing practice is also done to be skillful, is carried out actively, and pertains to professional work. Our view of these various definitions is that the word practice has a strong connection to professionalism and thus to professional disciplines.⁸

PRACTICE BOUNDARIES

It is incumbent on any professional discipline, particularly health profession disciplines, to define specifically what its disciplinary practice is and to establish boundaries within the domains of these definitions. Without such defined boundaries of practice, advanced practice nurses may find themselves accused of “practicing medicine,” for instance. One of the earliest cases of a nurse being accused of practicing medicine occurred in 1917 in Frank v. South, 175 Ky. 416 (Kentucky, 1917); Margaret Hatfield, a nurse anesthetist, was accused of practicing medicine. However, the court ruled that:

The court went on to note:

In a more recent case of the boundaries of professional practice, the attorney general of Illinois in 2009 ruled that physician assistants or advanced practice nurses (referred to as advanced practice clinicians) were legally able to dispense RU-486 (a drug that ends a pregnancy that is less than 7 weeks along) under the supervision of a physician (Olsen, 2010). This practice by nonphysicians, according to the Illinois Abortion Law of 1975 (the Abortion Law—720ICLS 510/), would not constitute the practice of medicine. Another contemporary controversy is over the boundaries of disciplinary practice includes, for example, whether nurse practitioners (NPs) can administer cosmetic services such as Botox independently (Buppert, 2006). Or similarly, whether dentists who can legally use Botox to treat temporomandibular disorders (TMD) or other dental problems in the dental office can also use it for cosmetic procedures (Bock, 2008).⁹ Complicating the complex question of the precise boundaries or domains of a professional practice is the issue of regulation and malpractice insurance. For any practitioner, although a respective state practice act may indeed indicate that the health professional is legally authorized to perform a specific procedure, it is perhaps equally important for the individual health professional to be certain that his or her malpractice insurance offers coverage for the procedure.

Ultimately, with 50 different state nurse practice acts (plus DC), the autonomy and authority of the advanced practice nurse to practice independently varies from state and state. According to the American Association of Nurse Practitioners (2015), 21 states (including DC) currently give NPs full authority to evaluate patients; diagnose, order, and interpret diagnostic tests; initiate and manage treatments; and prescribe medications—under the exclusive licensure authority of the state board of nursing; 18 provide for some restriction in practice, and 12 states have the most restrictive regulation of NPs.¹⁰ Therefore, although the Institute of Medicine in its October 2010 report on the nursing profession, The Future of Nursing: Leading Change, Advancing Health, called for advanced practice nurses to practice to the full extent of their education and training, progress has been made toward nurses practicing at a level to which they are educated, but the goal is far from complete.

Obviously, over time and with the evolution of any discipline, countless numbers of questions arise as to what actions and skills constitute the practice or professional work of the practitioner. It is not surprising that competing health professions may also dispute the legitimacy or legal authority of one health professional to perform an act that he or she believes is in his or her domain of practice. At the beginning of the 20th century, prior to the advances in technology that have changed the landscape of health care, taking a blood pressure and pulse was in the domain of medicine. Today, these still important assessments are often performed by non-licensed assistive personnel. Controversy over the boundaries of a domain even happens within disciplines. With the invention of emergency ultrasound procedures, particularly abdominal radiography, for rapid use in the diagnosis, evaluation, and follow-up of abdominal distension, bowel obstruction, or non-obstructive ileus in the emergency room, a large battle began over who was qualified to administer this new procedure (Kendall, Blaivas, Hoffenberg, & Fox, 2004). Traditionally, this was the strict domain for radiologists, but soon emergency room physicians across the country were performing the procedure, and a dispute over who could perform the procedure, and thus get reimbursed for it, commenced (Cohen & Moore, 2004). In 2014, the diagnosis and treatment guidelines for this procedure were revised and it was formally determined that a physician not licensed as a radiologist could administer the procedure under certain specifications.¹¹

In nursing, there have been ongoing concerns over the issue of advanced practice nurses, especially NPs, practicing outside the boundaries of their specific specialty area or outside their scope of education and practice (Klein, 2005; Reel & Abraham, 2007). Examples include scenarios where the acute care NP is practicing primary care, the domain of the family NP, or where the pediatric NP is caring for neonates, the rightful domain of the neonatal NP. The National Council of State Boards of Nursing (NCSBN) has addressed these concerns and also the proliferation of new NP specialties/subspecialties in their Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education (NCSBN, 2008), which is now in widespread implementation. Although a detailed discussion of this document is perhaps better suited for a graduate role development course, we believe that the NCSBN has clearly instituted a very detailed regulatory model that is designed to establish more of a national standard for the APRN with less state-to-state variability in the various nurse practice acts. Their goal is to ensure that there is less ambiguity and more legal protection (and thus fewer malpractice claims) for advanced practice nurses and increased protection of the health of the public by enhanced regulation to promote safe advanced nursing practice. However, even that document and the results of its implementation need to be evaluated over time. One very visible question is whether their decision to eliminate the gerontologic NP role and merge it with the adult NP role (to form an adult-gero NP role) was a wise one, especially with our growing national aging population (Villars, 2012).

Moreover, the prescription of these new guidelines has one significant limitation—their regulatory model may very well threaten the innovation of new advanced practice roles or innovation within these formal roles. All four of them (CNM, CNS, CRNP, and CRNA) have their unique histories and they were encouraged to develop largely because the health care marketplace first recognized and then valued their contributions. The American Nurses Credentialing Center (ANCC, 2014), as a result of the Consensus Regulatory Model document, now only recognizes board certification for five NP specialties.¹² They have also announced the retirement of multiple NP and CNS specialties, including the adult and child psychiatric CNS, a still controversial decision especially because the psychiatric CNS was the first CNS in the profession founded by Dr. Hildegard Peplau of Rutgers University in 1955 (American Psychiatric Nurses Association, n.d.; Jones & Minarik, 2012; Schmidt, 2013).¹³ This leaves the profession with a number of “grandfathered” advanced practice clinicians whose numbers will never increase, but will eventually fade away. And while there may no longer be a national accreditation exam (at least one administered by the ANCC), for certain specialties, many states will continue to “grandfather” these programs and they will continue in one format or another. One program that now lies outside the Consensus Model document and ANCC certification is a CNS in holistic nursing and integrative health degree that has existed at one institution for more than 20 years.¹⁴ This content is more prevalent than ever in the media, and the presence of a National Institutes of Health (NIH) Center for Complementary and Integrative Health (previously the National Center for Complementary and Alternative Medicine until a name change was made in December 2014) actually provides at least a plausible argument that this particular CNS role has an evidence base and is needed by society.

Moreover, what if the marketplace needs a new kind of CNS—perhaps a CNS in care coordination, which is emerging as a possible new model of care that is led by a master’s-prepared nurse (not necessarily an NP; American Nurses Association [ANA], 2012). While both the RN and APRN have been traditionally involved in care coordination, the post–Affordable Care Act health initiatives and structures, where the “nurse” may be required to navigate optimal patient- and population-focused care by collaborating with managed care organizations, accountable care organizations, patient-centered medical home programs, coordinated care organizations, and various home health- or community-based organizations may require a nurse prepared at the master’s level. What kind of clinician or practitioner (or even administrator) will this role require? Should it be placed into a traditional ANCC board-certified APRN model? What if the ones available do not fit? And what about that new nursing specialty that lies in the future but that we cannot imagine today? How can the innovation emerge with these barriers?

THE NATURE OF PRACTICE: AN EMPHASIS ON THE INTERPERSONAL

In 1986, Whan, a social work scholar, attempted to make a distinction between the notion of the practical and the technical. He argued that the practice of social work was one of practical, moral engagement, and not primarily a matter of technique. In some ways, this sounds very similar to the long, but ongoing discussion as to whether nursing is more an art or a science (Bishop & Scudder, 1997; Jasmine, 2009; Mitchell & Cody, 2002; Peplau, 1988). However, social work and nursing are different disciplines. Furthermore, the nature of practice is much more complex, and we favor an argument that practice is more interpersonal than artistic or merely scientific (or technical). It is the interpersonal skills of the professional¹⁵ (nurse, minister, physician, social worker, occupational therapist, etc.) that give rise to higher level expectations from the visible and measurable direct outcomes of their practice.

Part of the theoretical support for the primacy of interpersonal skills, which manifests as effective communication between health professional/patient (client) or in the therapeutic nurse–patient relationship, can be pooled from multiple disciplines. In nursing, Peplau’s Theory of Interpersonal Relations¹⁶ (1952, 1997) and Travelbee’s Human-to-Human Relationship Model¹⁷ (1966) are both particularly useful in conceptualizing that the practice of the professional nurse really flourishes (lives) or stagnates (dies) depending on the relationship between the nurse and the patient. Although Travelbee’s work was really articulated before the advanced nursing practice movement, both theorists’ works have application to advanced and doctoral advanced practice and implications for other health profession disciplines too.¹⁸ From medicine, the literature on the skills necessary for physicians to deliver bad news or “death notification” expertly and with compassion is an example of an interpersonal professional practice (Leash, 1994; Lord, 2008). Delivering bad news is a professional skill that requires enormous maturity (over time) as the medical student—then intern, perhaps resident, and then finally attending physician—learns what to say, what not to say, and how to best communicate sensitive and usually painful news to individuals and families (Ptacek & McIntosh, 2009; Rosenbaum, Ferguson, & Lobas, 2004). There is even a contemporary body of literature in dietetics that describes the importance of the dietician–patient relationship (Cant, 2009; Cant & Arroni, 2008). Because both professional nurses and advanced practice nurses often are challenged to successfully motivate patients to lose weight or follow a specific diet (Dreher, 2008), it is not surprising to note that a dietician’s interpersonal skills could be instrumental in this interprofessional intervention.

Ultimately, it is the nature of practice, what the professional says and does for others, that differentiates the work in health profession disciplines like nursing from the work of the aviator, banker, or chemist. We attest that it is also the emphasis on the interpersonal relationship the professional has with individual patients/clients and their families, more so than technical competency, that best distinguishes the practice of the professional. Dreher spent most of his early career in cardiovascular nursing. It was observed during graduate school that the CNSs in cardiac rehabilitation (working primarily with patients post–myocardial infarction [MI] and post–coronary artery bypass graft [CABG]) had distinct advantages over the master’s-prepared exercise physiologists who were performing the same work. What was the most obvious advantage? The CNSs appeared to have more advanced interpersonal skills and they were more comfortable talking to patients, building relationships, and likely motivating them. Were they perhaps as knowledgeable as the exercise physiologists about the technical content of the specialty? Without making assumptions, one objective difference would likely be that the exercise physiology curriculum has a greater emphasis on applied kinesiology, biomechanics, and motor learning, for example. Therefore, it is not unlikely that the exercise physiologist may have a greater knowledge base of the discipline on average. However, as described in Malcolm Gladwell’s influential and best-selling book Outliers (2008), success is not necessarily about having the most intelligence (or having the most knowledge), but having enough intelligence. Gladwell outlines the advantage practical intelligence can have over analytical intelligence and how other factors than mere IQ are correlated with success. One can only imagine a minister with no (or weak) interpersonal skills, or a psychiatric nurse with poor therapeutic communication techniques, or an advanced practice nurse who is merely average at encouraging successful behavioral changes in her patients.

How would you describe the nature of practice? How important do you think it is to properly conceptualize the context of practice to the discipline of nursing? Does society perceive or value the practice of the physician or the practice of the physical therapist or the practice of the advanced practice or doctoral advanced practice nurse differently? We contend that more emphasis should be given to the training of interpersonal skills of the professional practitioner and its central relationship to enhancing “practice.” Thus, the importance of practice knowledge is explored in Chapter 16.

 WHAT IS A DISCIPLINE?

A discipline is foremost a field of study. It is the generated knowledge of a collective of scholars/practitioners (usually residing in a university where the generation of knowledge and teaching and disseminating this new knowledge are the mission) that leads to the formation of a discipline. Some of the first scholarly discussions surrounding the meaning of an academic discipline began in the 1960s when Phenix (1962) indicated “The distinguishing mark of any discipline is that the knowledge which comprises it is instructive—that it is peculiarly suited for teaching and learning” (p. 58). Discipline is defined by the Oxford English Dictionary as “a branch of learning or scholarly instruction” (p. 244). King and Brownell (1966) further state, “Each discipline, at any time in history … is best described as a ‘community of discourse,’ a company of persons moving in modest disarray toward its own goal. There have been and are now many such companies, more all the time. We attempt to institutionalize them in schools, colleges and universities” (p. 62). Even today, the Carnegie Foundation for the Advancement of Teaching confirms this, forcefully emphasizing in Envisioning the Future of Doctoral Education: Preparing Stewards for the Discipline (Golde & Walker, 2006) that “Disciplines continue to change, as do universities, the job market, the character of professional work, and the student population” (p. 4).

The first degree-granting university in medieval Europe was the University of Bologna founded in 1088, followed in 1150 by the University of Paris (which later became La Sorbonne). Oxford (1167) and Cambridge (1209) were founded shortly thereafter. At the University of Paris and these early universities, there were faculties in only four disciplines: theology, medicine, Canon Law (Ecclesiastical or Catholic Church Law), and the arts (largely grammar, rhetoric, logic, arithmetic, music, and astronomy). Most modern academic disciplines have their roots in the mid- to late-19th-century secularization of universities. One example is the origin of the discipline of psychology (mostly attributed to Wilhelm Hundt¹⁹ and William James,²⁰ both of whom probably founded the first psychology lab around 1875), which evolved from integrating knowledge from medicine, physiology, neurology, and philosophy. Indeed, reminding ourselves how young psychology as a discipline is comparatively should give some comfort to nursing’s own struggles with being a young and still maturing discipline. As one nursing scholar has stated “While the practice of nursing is as old as humanity, the discipline of nursing is quite young” (O’Shea, 2001).

We know what a discipline is, but maybe the more important questions are: What defines a discipline? Are there criteria for what a discipline is? For instance, nursing began as a practice²¹ and evolved eventually into an academic discipline, but by what standards? King and Brownell’s 1966 book The Curriculum and the Disciplines of Knowledge has provided a classical list of criteria for what constitutes an academic discipline:

       1.  A discipline is a community: scholars, teachers, and learners form a specialized dynamic group.

       2.  A discipline is an expression of human imagination: There is almost a spontaneous generation of ideas that evolve as “germinal concepts” and “intellectual challenges” (p. 71) by various individual members.

       3.  A discipline is a domain: “that natural phenomenon, process, material, social institution, or other aspect of man’s concern on which members of the discipline focus their attention” (p. 74).

       4.  A discipline has a history and traditions: a record of discourse of its forebears and the evolutionary intellectual craftsmanship.

       5.  A discipline has a conceptual structure: the dynamic and developmental full set of ideas in a discipline at any one time.

       6.  A discipline has a syntactical structure (mode of inquiry): the interrelated ensembles of principles in a field of inquiry.

       7.  A discipline has a specialized language or other system of symbols: the vocabulary, common language, and representative accumulated connotative meanings of the field and its members.

       8.  A discipline has a heritage of literature and a communication network: “the working materials of the community of discourse are the heritage of writings, paintings, composition, musical scores, artifacts, recorded interviews, and other symbolic expressions of the membership” (p. 86).

       9.  A discipline is a valuative and affective stance: the capacity for a field of inquiry to move beyond its mere rational attributes and to reflect various characteristics of man, reflect emotional dynamism, and exhibit aesthetic qualities.

     10.  A discipline is an instructive community: a path for progression of learning in a discipline is created and communicated theoretically through curricula.

These criteria are reexamined in the next chapter as we analyze whether nursing as a maturing discipline, and particularly as a practice discipline, has met these criteria. Dorothea Orem (a noted nurse theorist),²² however, has documented that, historically, neither King and Brownell nor Phenix had yet conceptualized the term a practice discipline in the 1960s, and it was not until October 7, 1967, that Dickoff and James introduced the term relative to nursing at a “Theory Development in Nursing” symposium at Case Western Reserve University (Orem, 1988).

DISCIPLINARY BOUNDARIES

Disciplinary boundaries are similar to the description of practice boundaries in our previous discussion. However, in many ways, the disciplinary boundaries of a practice discipline are more fluid than in nonpractice disciplines. In this discussion, we examine disciplinary boundaries in two different but important contexts: (a) Who is a legitimate member of the discipline? and (b) Who can legitimately produce knowledge for the discipline?

Who Is a Legitimate Member of a Discipline?

At first glance, this is an easy question, but in reality it is not. Members of a discipline have the responsibility to determine the qualifications for students to enter their program, the course of study to obtain a degree in the discipline, the requisite level of knowledge, necessary psychomotor skill acquisition (where applicable), and socialization to graduate from the program. Individual university faculties are ordinarily replete with members with degrees in the respective discipline. However, there are often faculty with terminal degrees in other disciplines who are duly members of a respective department. In any given divinity school, for example, there are usually faculty in moral theology who have doctorates in philosophy or biomedical ethics, but who are not necessarily ordained and do not belong to a ministerial profession. In nursing, the faculty might include nurses who may have a graduate degree in nursing, but who have doctorates in non-nursing fields. Furthermore, in nursing, some faculty may indeed actually be trained pharmacologists or physiologists who teach the pharmacology and anatomy and physiology courses or they could also be based in their home disciplinary department, too.²³ These persons, however, do not have the educational background or socialization as part of the discipline of nursing. Del Favero (2010) has suggested, perhaps more radically, that a legitimate member of a discipline is simply one who professes primary allegiance to a discipline. Nevertheless, we would contend that graduates with at least a baccalaureate degree in a specific discipline should be considered the de facto members of that discipline. But whether individuals with a graduate degree in one discipline, but a terminal doctorate in another, are properly positioned to receive advanced knowledge in their non-doctoral discipline is another question.

Who Can Legitimately Produce Knowledge for the Discipline?

After discussion of membership, the next important argument is who can legitimately produce knowledge for the discipline or who is best positioned to do so? Golde and Walker (2006) take a very traditionalist approach and state that “we believe that PhD recipients bear responsibility for the integrity of their discipline” (p. 10). However, it is with certainty, in light of the relatively new DNP movement, that doctoral graduates bear the responsibility for the integrity of the discipline. In many ways, those who are both a member and who generate the knowledge for a discipline are very much aligned. In other cases, it is not. For instance, it would be highly uncommon (if not outright unacceptable in many cases) that a student in a typical university sociology class be taught by someone without a doctorate in sociology (but another field). The point here is not to disparage individuals who have an identity as a member of a discipline, but a doctorate in another. It is to emphasize that the formal members in any given discipline are the ones most credible to advance disciplinary knowledge and establish the disciplinary boundaries. In this example, the assumption is that the guardians of knowledge for the discipline of sociology are logically faculty with a doctorate in that discipline, and not another.²⁴

First, distinctions have to be made between new disciplines, maturing disciplines, or traditional, established disciplines. For instance, the discipline of knowledge management is only 20 years old (Stankovsky, 2005). Male studies (as opposed to men’s studies, which has been around since the 1970s) is even newer and was just proposed in 2009 at Wagner College in New York (Epstein, 2010). As reported in the first edition of this book, it was intended that this new discipline would formalize itself with the first International Conference on Male Studies in 2010 and the launch of a Male Studies Journal, but these events did not happen (Elam, 2010). Despite focused symposia in male studies sponsored in collaboration with the New York Academy of Medicine (2011), the Lounsbery Foundation (2012), and dialogue at an annual American Public Health Association meeting (2013), this emerging “discipline” (described as such on their Foundation for Male Studies website)²⁵ has struggled to evolve and really may be a new field. Indeed, some controversy has surrounded this new discipline, and Goudreau reports from one of the new discipline’s founders:

“This came out of the contentious business of gender studies,” according to Lionel Tiger professor of anthropology at Rutgers University. “It’s not men’s studies as contrasted with women’s studies. It’s a study of males without all the ideology and self-righteousness of feminists about turning over patriarchy.” (Goudreau, 2010, p. 1)

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