78 ■ I: HISTORICAL AND THEORETICAL FOUNDATIONS FOR ROLE DELINEATION
- Post– World War II development of the acute care hospital system (Fairman &
Lynaugh, 1998) - The Brown Report of 1948, funded by the Carnegie foundation, advocating the
transition of nursing education from hospital- based diploma programs into
colleges and universities, and recruitment of men and minorities (Donahue,
1996) - Explosions in scientific, biomedical, and pharmaceutical knowledge, as well as
related technologies (Keeling, 2009) - President Johnson’s “Great Society” legislation in 1964 enacting Medicare and
Medicaid (Keeling, 2009) - The growth of the third- party payment system in 1965 (Keeling, 2009)
- Economic pressures and expanding costs of health care and health care cover-
age (Keeling, 2009) - The need to fill the “provider gap” in rural and underserved geographic areas
(Keeling, 2009) - Title VIII funding for advanced practice nursing education through the Health
Resources and Services Administration (HRSA; American Nurses Association
[ANA], n.d.) - Creation of the National Center for Nursing Research in 1985 and the National
Institute of Nursing Research (NINR) in 1993 (National Institute of Health
[NIH], n.d.), providing greater opportunities for funded research helping to
document outcomes associated with advanced nursing practice, among other
issues - Publication of the Institute of Medicine (IOM)’s “Future of Nursing” Report in
2010 (IOM, 2010) - Approval and implementation of the federal Affordable Care Act (ACA),
beginning in 2010
In the midst of these social and scientific changes (and possibly in response to
them), nursing leaders and innovators in the mid- 20th century embraced a growing
theoretical and practice focus on individuals and their experiences, rather than on med-
ical diagnoses and treatment (Fairman, 1999). This disciplinary, cognitive shift offered
a means to recognize and consolidate nursing’s distinctive knowledge and practice
methods, to break away from a purely medicalized approach to patient care, and to
situate nursing as an independent, collaborative health care discipline with a differ-
entiated knowledge base, focus, skill set, and language— particularly differentiated
from medicine. Such efforts led to the development, articulation, and scientific testing
of conceptual models and related descriptive grand theories for the understanding of
human responses to health and illness, such as Orem’s Self- Care Framework, the Roy
Adaptation Model, or Rogers’s Science of Unitary Human Beings. Other crucial devel-
opments included elucidation of the generally accepted meta- paradigm for nursing
practice, research, and theory construction: human/ person, environment, health, nursing ,
and synthesis and testing of midrange and other theories to guide practice (Baer, 1987;
Fawcett & Alligood, 2005; Phillips, 1996). These efforts were integral to and important in
the examination and expansion of nursing’s knowledge and practice structures, includ-
ing its taxonomy, processes, strategies for knowledge generation, scope of practice, and
practice strategies (Blegen & Tripp- Reimer, 1997; Fawcett & Alligood, 2005; Moorhead,
Head, Johnson, & Maas, 1998; Roy, 2007). Knowledge and clinical practice set the stage
for the more recent evolution of, and revolution in, nursing advanced practice roles and
scope of practice. The four advanced practice nursing roles, addressed subsequently,
include the nurse- midwife, nurse anesthetist, NP, and CNS, all of whom contributed via