56 ■ I: HISTORICAL AND THEORETICAL FOUNDATIONS FOR ROLE DELINEATION
Robinson (1946) has also written an outstanding text that focuses on the history of nurs-
ing globally, but it ends with nurses still active in World War II. This chapter, however,
is historical in its approach. What we wish to do differently is to trace the role of nurses
(their work) from its early American origins to the emergence of professional nursing
roles. Dreher reviews the meaning of role or work roles and discusses how the theoretical
aspects of role theory have influenced nursing as a profession. Uribe, a nurse historian,
will then trace the evolution of these roles (or work roles) in nursing from Nightingale
to just after the turn of the 20th century in the United States, and then through the evo-
lution of the “professional registered nurse” educated at the baccalaureate level in the
mid- 1960s. As we all know, the American Nurses Association’s (ANA’s) historic 1965
position statement, which called for all RNs to be educated at the baccalaureate level,
tragically was never realized (Donley & Flaherty, 2002). Despite the ANA’s reaffirma-
tion of that position in 1985, the majority of nurses in the United States is still not first
educated at the bachelor of science in nursing (BSN) level, with associate degree (AD)-
level nurses (and to lesser, but additive effect) predominating (Aiken, Cheung, & Olds,
2009; Dreher, 2008a; Health Resources and Services Administration, National Center for
Health Workforce Analysis, 2013; Kraus, 1980).^3 Linda Aiken et al., have long reported
better health- related outcomes for hospitals that deliver care by BSN- prepared nurses
over the care delivered by non- BSN- prepared nurses (Aiken et al., 2011, 2014; Aiken,
Clarke, Cheung, Sloane, & Silber, 2003). More recently, she and her new European col-
leagues indicated a 10% increase in the proportion of nurses with BSNs was associated
with a 7% decrease in patient deaths. Although trends point to increasing percentages of
all RNs attaining the baccalaureate degree, the question is whether there are forces that
can still undermine BSN education and thwart the new goals of the Institute of Medicine
report from 2010 The Future of Nursing: Leading Change, Advancing Health, which calls
for 80% BSN- prepared nurses by 2020. What is still driving AD nursing education? Is
it an issue of economics: A 2- year degree obviously costs less than a 4- or 5- year bac-
calaureate degree?^4 The Magnet® movement that encourages (some think they require
80% of the staff to have the BSN, but this cannot be verified) hospital- based RNs to pur-
sue higher education, probably is helpful. But does the public not view nursing as a
profession and, as a result, a significant number of potential nurses are steered toward
AD programs, which still predominate (approximately 1,100+ associate degree in nurs-
ing [ADN] programs versus 700+ BSN programs; American Association of Colleges of
Nursing [AACN], 2015)?
Whether this decades old issue over the entry level for basic professional nurs-
ing practice will ever be fully resolved is unknown. The politics behind the support
of AD (and thus Community College education) is enormous. Furthermore, a very
antiquated federal formula that funnels Medicare’s “pass- through” funds still favors
hospital- based (or hospital- connected) RN diploma, CRNA nurse anesthesia, and med-
ical education, over BSN and graduate nursing education (AACN, 2015; Aiken et al.,
2009). It is therefore not surprising that there is continuing controversy over whether the
doctorate will ever fully replace the master’s degree for entry- level advanced nursing
practice. Do you envision all 50 various state legislatures changing their respective
nurse practice acts to eliminate the master’s degree requirement in favor of the doctor-
ate? This is an interesting question.
Having defined what the roles of the professional nurse were through the mid-
1960s, Chapter 3 focuses on the evolution of what came to be known as “advanced practice
nursing” roles. The first iteration of advanced practice nursing began with the certifi-
cate pediatric nurse practitioner movement at the University of Colorado in 1965 and
culminated in the 1990s with the master’s of nursing science as the requirement for all
advanced practice nurses (Dreher, 2009; Ford & Silver, 1967). Finally, Chapter 4 builds