3: THE EVOLUTION OF ADVANCED PRACTICE NURSING ROLES ■ 85degree and by 2025 a practice doctorate, DNP, or a doctor of nurse anesthesia practice
(DNAP), have a long history of providing quality, cost- effective patient care with posi-
tive patient outcomes
■ DEVELOPMENT OF THE NP ROLE
The NP’s role has been prominent in terms of controversies, visibility in public and
social policy, and scope of practice considerations, particularly in the role’s unique-
ness and overlap with medical practice. The history of the NP movement can be
seen as another exemplar for advanced practice nursing’s developmental journey.
The NPs step beyond the range of extended health care services, including education,
direct care, chronic illness management, and community services that public health
nurses had been providing since the 1920s. Formal NP practice was “birthed” in 1965
through the joining of primary care pediatrics and public health/ family- community
nursing. This was the vision of Dr. Henry Silver, a pediatrician associated with the
University of Colorado, School of Medicine, and Dr. Loretta Ford from the University
of Colorado School of Nursing. The NP role emerged at a time when pediatric medi-
cine was struggling to extend care to underserved populations during a shortage of
health care professionals. At the same time, nursing was also struggling to expand its
scope beyond hospital care to develop autonomous practice, to fully embed nursing
education in higher education, and to professionalize as a workforce (Bullough, 1976;
Ford, 1975; Richmond, 1965).
The new breed of pediatric care providers in the original University of
Colorado program were baccalaureate- prepared clinicians with: (a) advanced
clinical and diagnostic skills and knowledge; (b) the ability to monitor child
health, growth, and development; and (c) the ability to provide guidance to fami-
lies, manage minor acute health problems in pediatric primary care, and function
within health care teams— particularly for medically underserved populations.
The program involved 4 months of university- based education, followed by clini-
cal training in underserved rural community/ primary care pediatric settings.
Dr. Ford subsequently argued strongly for embedding NP education fully within
a graduate nursing education framework; both Ford and Silver were instrumen-
tal in communicating the effectiveness of this pediatric NP model and in ensur-
ing its replication (Ford, 1975; Mason, Vaccaro, & Fessler, 2000; Silver, Ford, &
Day, 1968).
A comparable brief pediatric NP program for the care of children from under-
served urban families developed soon after at the Massachusetts General Hospital in
Boston. In addition, other academic medical care settings also developed NP programs
that would similarly extend the skills of public health nurses, address access to care for
urban underserved children, as well as serve the needs of children in underserved rural
areas (Murphy, 1990).
In the following decade, NP certificate training programs began to proliferate
across the country. Most of these had a particular emphasis on pediatrics and/ or fam-
ily health, and on extending primary care to underserved urban and rural children,
and families in a time of expanding health care needs, and growing recognition of
disparities in access to care (Davidson et al., 1975; Mason et al., 2000). Most required a
short- time commitment (less than 1 year), and not all required a bachelor’s degree for
entry (Mason et al., 2000). The scope of NP practice expanded to include family plan-
ning and women’s health within 10 years after Ford and Silver’s innovation (Lewis,