77chapter THREE
The Evolution of Advanced Practice
Nursing Roles
Marcia R. Gardner , Bobbie Posmontier , Michael E. Conti ,
and Mary Ellen Roberts
Nursing, as a discipline, has struggled since the Florence Nightingale era to articulate
the unique contribution of its practitioners to health and illness care. This tension comes
in part from its own history and in part from its link with, and historical dependence
on, other disciplines including medicine for certain types of scientific knowledge,
practice skills, and to a large degree access to patients. Functional skills (e.g., physical
examination) and functional knowledge (e.g., pharmacology, pathophysiology of dis-
ease, or psychology of illness) are shared with (some might say “borrowed” from) other
health disciplines. Mastery of higher level biomedical and pharmacological knowledge,
clinical reasoning, and clinical and/ or diagnostic skills has emerged as a hallmark of
advanced practice nursing as enacted by nurse practitioners (NPs), nurse anesthetists,
nurse- midwives, and clinical nurse specialists (CNSs). Yet, at the same time, nursing has
also labored to establish a distinctive knowledge and practice structure separate from
these shared domains.
Nursing’s scope in the United States has expanded, contracted, and re- expanded
in concert with, and in response to, a variety of social, political, technological, and theo-
retical forces such as:
- The influx of poor immigrants into overcrowded tenements at the turn of the
century, culminating in Lillian Wald’s creation of the Henry Street Settlement
(Keeling, 2009) - Congress’s establishment of the Army and Navy Nursing Corps in the early
1900s (Keeling, 2009) - The advent of World War I and the 1918 influenza epidemic (Buhler- Wilkerson,
2001; Wald, 1922) - The Great Depression of the 1930s, resultant closing of hospital nursing pro-
grams, and movement of graduate nurses into hospitals (Keeling, 2009) - Nursing’s shortage during World War II resulting in the Bolton Act that es-
tablished funding for basic nursing education and postgraduate education for
the preparation of certified nurse anesthetists, educators, and administrators
(Spalding, 1943)