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Read the Learning Activity Case study on page 510 in your textbook ( Advanced Practice Nursing: Essentials for Role Development, Joel, 5th ed.) and answer the questions that follow it. Discuss the case study and the NP’s risk for liability.Provide 2 peer reviewed references that are < than 5 years old and from a professional advanced practice journal for your initial post.Make your initial post by 23:59 EST Wednesday of Week 6Respond to two other classmates' posts by 23:59 EST Sunday of Week 6 Provide 2 peer reviewed references per post. that are < 5 years old and from a professional advanced practice journal.-Identify which of the AACN essential(s) this assignment meets. Unformatted Attachment Preview 1 2 F.A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright © 2022 by F.A. Davis Company Copyright © 2022 by F.A. Davis Company. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Printed in the United States of America Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Publisher: Susan Rhyner Senior Content Project Manager: Amy M. Romano Design and Illustration Manager: Carolyn O’Brien As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up-to-date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs. Library of Congress Cataloging-in-Publication Data Names: Joel, Lucille A., editor. Title: Advanced practice nursing : essentials for role development / [edited by] Lucille A. Joel. Other titles: Advanced practice nursing (Joel) Description: Fifth edition. | Philadelphia, PA : F.A. Davis Company, [2022] | Includes bibliographical references and index. Identifiers: LCCN 2021040909 (print) | LCCN 2021040910 (ebook) | ISBN 9781719642774 (paperback) | ISBN 9781719642798 (ebook) Subjects: MESH: Advanced Practice Nursing | Nurse’s Role Classification: LCC RT82.8 (print) | LCC RT82.8 (ebook) | NLM WY 128 | DDC 610.7306/92--dc23 LC record available at https://lccn.loc.gov/2021040909 LC ebook record available at https://lccn.loc.gov/2021040910 3 Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F.A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.25 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 978-0-8036-6044-1/17 ≶ $.25. 4 Preface The content of this text was identified only after a careful review of the documents that shape both the advanced practice nursing role and the educational programs that prepare these individuals for practice. That review allowed some decisions about topics that were essential to all advanced practice nurses (APNs),* whereas others were excluded because they are traditionally introduced during baccalaureate studies. This text is written for the graduatelevel student in advanced practice and is intended to address the nonclinical aspects of the role. Unit 1 explores The Evolution of Advanced Practice from the historical perspective of each of the specialties: the clinical nursemidwife (CNM), nurse anesthetist (NA), clinical nurse specialist (CNS), and nurse practitioner (NP). This historical background moves to a contemporary focus with the introduction of the many and varied hybrids of these roles that have appeared over time. These dramatic changes in practice have been a response to societal need. Adjustment to these changes is possible only from the kaleidoscopic view that theory allows. Skill acquisition, socialization, and adjustment to stress and strain are theoretical constructs and processes that will challenge the occupants of these roles many times over the course of a career, but coping can be taught and learned. Our accommodation to change is further challenged as we realize that advanced practice is neither unique to North America nor new on the global stage. Advanced practice roles, although accompanied by varied educational requirements and practice opportunities, are well embedded and highly respected in international culture. In the United States, education for advanced practice had become well stabilized at the master’s degree level. This is no longer true. The story of our more recent 5 transition to doctoral preparation is laid before us with the subsequent issues this creates. The Practice Environment, the topic of Unit 2, dramatically affects the care we give. With the addition of medical diagnosis and prescribing to the advanced practice repertoire, we became competitive with other disciplines, deserving the rights of reimbursement, prescriptive authority, clinical privileges, and participation as members on health plan panels. There is the further responsibility to understand budgeting and material resource management as well as the nature of different collaborative, responding, and reporting relationships. The APN often provides care within a mediated role, working through other professionals, including nurses, to improve the human condition. Competency in Advanced Practice, the topic of Unit 3, demands an incisive mind capable of the highest order of critical thinking. This cognitive skill becomes refined as the subroles for practice emerge. The APN is ultimately a direct caregiver, client advocate, teacher, consultant, researcher, and case manager. The APN’s forte is to coach individuals and populations so that they may take control of their own health in their own way, ideally even seeing chronic disease as a new trajectory of wellness. The APN’s clients are as diverse as the many ethnicities of the U.S. public, and the challenge is often to learn from them, taking care to do no harm. The APN’s therapeutic modalities go beyond traditional Western medicine, reaching into the realm of complementary therapies and integrative health-care practices that have become expected by many consumers. Any or all of these role competencies are potential areas for conflict, needing to be understood, managed, and resolved in the best interests of the client. Some of the most pressing issues confronting APNs today are how to mobilize informational technology in the service of the client, securing visibility for their work, and disseminating their thinking through publication. The chapters in this section aim to introduce these competencies, not to provide closure on any one topic; the art of direct care in specialty practice is not broached. When you have completed your course of studies, you will have many choices to make. There are opportunities to pursue 6 your practice as an employee, an employer, or an independent contractor. Each holds different rights and responsibilities. Each demands Ethical, Legal, and Business Acumen, which is covered in Unit 4. Each requires you to prove the value you hold for your clients and for the systems in which you work. Cost efficiency and therapeutic effectiveness cannot be dismissed lightly today. The nuts and bolts of establishing a practice are detailed, and although these particulars apply directly to independent practice, they can be easily extrapolated to employee status. Finally, experts in the field discuss the legal and ethical dimensions of practice and how they uniquely apply to the role of the APN to ensure protection for ourselves and our clients. This text has been carefully crafted based on over 40 years of experience in practice and teaching APNs. It substantially includes the nonclinical knowledge necessary to perform successfully in the APN role and raises the issues that still have to be resolved to leave this practice area better than we found it. Lucille A. Joel ______________________ * Please note that the terms advanced practice nurse (APN) and advanced practice registered nurse (APRN) are used interchangeably in this text according to the author’s choice. 7 Contributors Cindy Aiena, MBA Executive Director of Finance Massachusetts General Hospital Boston, Massachusetts Judith Barberio, PhD, RN-BC Pain, APNc, ANP-BC, GNPBC Clinical Associate Professor Rutgers, The State University of New Jersey School of Nursing Newark, New Jersey Andrea Brassard, PhD, FNP-BC, FAANP, FAAN Associate Professor University of Maryland School of Nursing Baltimore, Maryland Edna Cadmus, PhD, RN, NEA-BC, FAAN Clinical Professor and Specialty Director-Nursing Leadership Program Executive Director NJCCN Rutgers, The State University of New Jersey School of Nursing Newark, New Jersey Ann H. Cary, PhD, MPH, RN, FNAP, FAAN Dean and Professor Florida Gulf Coast University College of Health and Human Services Fort Myers, Florida 8 Mary Ann Christopher, MSN, RN, FAAN President/CEO Christopher STH Consulting Avon, New Jersey Basia Delawska- Elliott, MLIS, AHIP-S Education & Research Librarian Oregon Health & Science University Portland, Oregon Patricia DiFusco, MS, NP-C, FNP-BC Nurse Practitioner SUNY Downstate Medical Center Brooklyn, New York Carole Ann Drick, PhD, RN, AHN-BC Founder/Director Conscious Living Center Past President American Holistic Nurses Association Youngstown, Ohio Lynne M. Dunphy, MSN, PhD, APRN, FNP-BC Professor Emerita Christine E. Lynn College of Nursing Florida Atlantic University Boca Raton, Florida, and Director of Nurse Practitioner Education Visual DX Rochester, New York Denise Fessler, RN, MSN Principal/CEO Fessler and Associates Healthcare Management Consulting, LLC Lancaster, Pennsylvania Eileen Flaherty, RN, MBA, MPH Staff Specialist Massachusetts General Hospital 9 Boston, Massachusetts Jane M. Flanagan, PhD, ANP-BC, AHN-BC, FNI, FNAP, FAAN Associate Professor Boston College Chestnut Hill, Massachusetts Rita Munley Gallagher, RN, PhD Retired Nursing and Healthcare Consultant Washington, District of Columbia Mary Masterson Germain, EdD, ANP-BC, FNAP, D.Sc. (Hon) Professor Emeritus SUNY Downstate Health Sciences University [per https://www.downstate.edu/] Brooklyn, New York Kathleen M. Gialanella, RN, BSN, JD, LLM (Health Law & Policy) Nurse Attorney Kathleen M. Gialanella, Esq., P.C. Westfield, New Jersey Shirley Girouard, RN, PhD, FAAN Professor-Nursing/Co-director GWEP/Health Policy Consultant SUNY Downstate Health Sciences University [per https://www.downstate.edu/] Council of State Governments-East Brooklyn, New York Antigone Grasso, MBA Director Patient Care Services Management Systems and Financial Performance Massachusetts General Hospital Boston, Massachusetts 10 Phyllis Shanley Hansell, EdD, RN, FNAP, FAAN Professor Seton Hall University College of Nursing Nutley, New Jersey Allyssa L. Harris, RN, PhD, WHNP-BC Associate Professor and Department Chair WHNP Program Director William F. Connell School of Nursing Boston College Chestnut Hill, Massachusetts Joseph Jennas, CRNA, CCRN, FNYAM Staff CRNA NYP Columbia University Irving Medical Center New York, New York Lucille A. Joel, APN, EdD, FAAN Distinguished Professor Rutgers, The State University of New Jersey School of Nursing New Brunswick-Newark-Blackwood, New Jersey Dorothy A. Jones, EdD, APRN, FAAN, FNI Professor, Senior Nurse Scientist Boston College, Connell School of Nursing Yvonne L. Munn Center for Nursing Research Massachusetts General Hospital Boston, Massachusetts David M. Keepnews, PhD, JD, RN, NEA-BC, FAAN, ANEF Professor and Director, Health Policy DNP The George Washington University School of Nursing Washington, District of Columbia Alice F. Kuehn, RN, PhD, BC-FNP/GNP Associate Professor Emeritus Faith Community Nurse 11 University of Missouri-Columbia Sinclair School of Nursing Columbia, Missouri Parish Nurse St. Peter Catholic Church Jefferson City, Missouri Christina Leonard, DNP, APRN, FNP-BC, CNL Assistant Professor Duke University School of Nursing Durham, North Carolina Deborah C. Messecar, PhD, MPH, RN, AGCNS-BC, CNE Associate Professor Oregon Health and Science University Portland, Oregon Patricia Murphy, PhD, APN, FAAN, FPCN Associate Professor Rutgers, The State University of New Jersey New Jersey Medical School Newark, New Jersey Marilyn H. Oermann, PhD, RN, ANEF, FAANP Thelma M Ingles Professor of Nursing Duke University School of Nursing Durham, North Carolina Marie-Eileen Onieal, PhD, MMHS, RN, CPNP, FAANP Immediate Past Director, DNP Program Rocky Mountain University of Health Professions, Provo, Utah Past President American Association of Nurse Practitioners Former Health Policy Coordinator, Bureau of Health Care Quality Massachusetts Department of Public Health Boston, Massachusetts David M. Price, MDiv., PhD 12 Retired faculty, New Jersey Medical School, Newark, New Jersey Founding Faculty, PROBE, a program of CPEP Center for Personalized Education of Physicians (CDEP) Denver, Colorado Beth Quatrara, DNP, RN, CMSRN, ACNS-BC Assistant Professor University of Virginia School of Nursing Charlottesville, Virginia Kelly Reilly, MSN, RN, BC Director of Nursing Maimonides Medical Center Brooklyn, New York Valerie Sabol, PhD, ACNP-BC, GNP-BC, CNE, CHSE, ANEF, FAANP, FAAN Division Chair, Clinical Professor Duke University School of Nursing Durham, North Carolina Mary E. Samost, DNP, RN, CENP Executive Director Perioperative Services Assistant Professor, DNP Program Massachusetts General Brigham, Salem Hospital Salem, Massachusetts Madrean Schober, PhD, MSN, ANP, FAANP President Schober Global Healthcare Consulting International Indianapolis, Indiana Robert Scoloveno, PhD, RN, CCRN Director–Clinical Simulation and Associate Clinical Professor Seton Hall University College of Nursing Nutley, New Jersey Carrie Scotto, RN, PhD 13 Associate Professor The University of Akron College of Nursing Akron, Ohio Dale Shaw, RN, DNP, ACNP-BC Advanced Practice Nurse 3 University of Virginia Health System Charlottesville, Virginia Thomas D. Smith, DNP, RN, NEA-BC, FAAN Chief Nursing Officer and Senior Vice President Patient Care Services Maimonides Medical Center Brooklyn, New York Mary C. Smolenski, MS, EdD, FNP, FAANP Writer/Editor and Consultant Lakewood Ranch, Florida Shirley A. Smoyak, RN, PhD, FAAN Distinguished Professor Emerita Rutgers, The State University of New Jersey School of Nursing New Brunswick-Newark, New Jersey Patricia A. Tabloski, PhD, GNP-BC, FGSA, FAAN Associate Professor William F. Connell School of Nursing Boston College Chestnut Hill, MA 02467 Christine A. Tanner, RN (ret), PhD, FAAN, ANEF Professor Emerita Oregon Health and Science University School of Nursing Portland, Oregon Carolyn T. Torre, RN, MA, APN, FAANP 14 Nursing Policy Consultant Advisory Board Member: Felician College School of Nursing Hackensack-Meridian APN Residency Program NJ Mandated Health Benefits Advisory Commission Trenton Psychiatric Hospital Board of Trustees Princeton, New Jersey Jan Towers, PhD, NP-C, CRNP (FNP), FAANP Director of Health Policy, Federal Government, and Professional Affairs American Academy of Nurse Practitioners Washington, District of Columbia Maria L. Vezina, RN, EdD, NEA-BC, FAAN System Vice President, Chief of Nursing Practice, Education, APN Credentialing and Labor Partnerships Mount Sinai Health System New York, New York 15 Reviewers Phyllis Adams, EdD, APRN, FNP-C, NP-C, FAANP, FNAP Clinical Faculty University of Texas Health Science Center Houston, Texas Ferrona Beason, PhD, APRN Assistant Professor Barry University Miami Shores, Florida Schvon Bussey, MSN, FNP-C, PMHNP-BC Assistant Professor Albany State University Albany, Georgia Carolynn DeSandre, PhD, APRN, CNM, FNP-BC, CSAP Interim Dean College of Health Sciences & Professions Institutional University of North Georgia Dahlonega, Georgia Joy Goins, DNP, CRNA Clinical Coordinator and Faculty Lincoln Memorial University Harrogate, Tennessee Cynthia Parsons, DNP, APRN, PMHNP-BC, FAANP Associate Professor University of Tampa Tampa, Florida Zelda Peters, DNP, FNP-C, RN 16 Assistant Professor, Graduate Clinical Coordinator Albany State University Albany, Georgia Barbara Wilder, PhD, CRNP Director of Graduate Programs Auburn University School of Nursing Auburn, Alabama 17 Acknowledgments This book belongs to its authors. I am proud to be one among them. Beyond that, I have been the instrument to make these written contributions accessible to today’s students and faculty. I thank each author for the products of his or her intellect, experience, and commitment to advanced practice. 18 Contents Unit 1 The Evolution of Advanced Practice 1 Advanced Practice Nursing: Doing What Has to Be Done Lynne M. Dunphy 2 Emerging Roles of the Advanced Practice Nurse Patricia A. Tabloski 3 Role Development: A Theoretical Perspective Lucille A. Joel 4 Educational Preparation of Advanced Practice Nurses: Looking to the Future Phyllis Shanley Hansell 5 Global Perspectives on Advanced Practice Nursing Madrean Schober Unit 2 The Practice Environment 6 Advanced Practice Nurses and Prescriptive Authority Jan Towers 7 Credentialing and Clinical Privileges for the Advanced Practice Nurse Ann H. Cary and Mary C. Smolenski 8 The Kaleidoscope of Collaborative Practice Alice F. Kuehn and Patricia Murphy 19 9 Participation of the Advanced Practice Nurse in Health Plans and Quality Initiatives Rita Munley Gallagher 10 Public Policy and the Advanced Practice Nurse Marie-Eileen Onieal 11 Resource Management Cindy Aiena, Eileen Flaherty, and Antigone Grasso 12 Mediated Roles: Working With and Through Other People Thomas D. Smith, Maria L. Vezina, Mary E. Samost, and Kelly Reilly Unit 3 Competency in Advanced Practice 13 Evidence-Based Practice Christine A. Tanner, Deborah C. Messecar, and Basia Delawska-Elliott 14 Advocacy and the Advanced Practice Nurse Andrea Brassard 15 Case Management and Advanced Practice Nursing Denise Fessler and Mary Ann Christopher 16 The Advanced Practice Nurse and Research Beth Quatrara and Dale Shaw 17 Holism and Complementary and Integrative Health Approaches for the Advanced Practice Nurse Carole Ann Drick 18 Basic Skills for Teaching and the Advanced Practice Nurse Christina Leonard, Valerie Sabol, and Marilyn H. Oermann 19 Culture as a Variable in Practice Mary Masterson Germain 20 Conflict Resolution in Advanced Practice Nursing 20 David M. Price 21 Leadership for APNs: If Not Now, When? Edna Cadmus 22 Information Technology and the Advanced Practice Nurse Robert Scoloveno 23 Writing for Publication Shirley A. Smoyak Unit 4 Ethical, Legal, and Business Acumen 24 Measuring Advanced Practice Nurse Performance: Outcome Indicators, Models of Evaluation, and the Issue of Value Shirley Girouard, Patricia DiFusco, and Joseph Jennas 25 Advanced Practice Registered Nurses: Accomplishments, Trends, and Future Directions Allyssa L. Harris, Jane M. Flanagan, and Dorothy A. Jones 26 Starting a Practice and Practice Management Judith Barberio 27 The Advanced Practice Nurse as Employee or Independent Contractor: Legal and Contractual Considerations Kathleen M. Gialanella 28 The Law, the Courts, and the Advanced Practice Nurse David M. Keepnews 29 It Can Happen to You: Malpractice and the Advanced Practice Nurse Carolyn T. Torre 30 Ethics and the Advanced Practice Nurse Carrie Scotto Index 21 Available online at fadavis.com: Bibliography 22 UNIT 1 The Evolution of Advanced Practice 23 1 Advanced Practice Nursing Doing What Has to Be Done Lynne M. Dunphy Learning Outcomes Learning outcomes expected as a result of this chapter: • Recognize the historical role of women as healers. • Identify the roots of professional nursing in the United States • • • • including the public health movement and turn-of-the-century settlement houses. Describe early innovative care models created by nurses in the first half of the 20th century such as the Frontier Nursing Service (FNS). Trace the trajectory of the role of the nurse midwife across the 20th century as well as the present status of this role. Recognize the emergence of nurse anesthetists as highly autonomous practitioners and their contributions to the advancement of surgical techniques and developments in anesthesia. Describe the development of the clinical nurse specialist (CNS) role in the context of 20th-century nursing education 24 • • • and professional development with particular attention to the current challenges of this role. Describe the historical and social forces that led to the emergence of the nurse practitioner (NP) role and understand key events in the evolution of this role. Describe the development of the doctor of nursing practice (DNP) and distinguish this role from the others described in this chapter. Describe the current challenges to all advanced practice roles and formulate ways to meet these challenges going forward. 25 INTRODUCTION Advanced practice is a contemporary term that has evolved to label an old phenomenon: lay healers, usually women, providing care to those in need in their surrounding communities. As Barbara Ehrenreich and Deidre English (1973) note, “Women have always been healers. They were the unlicensed doctors and anatomists of western history … they were pharmacists, cultivating herbs and exchanging the secrets of their uses. They were midwives, travelling from home to home and village to village” (p. 3). Today, with health care still dominated by a medical model rooted in patriarchy and white privilege, advanced practice nurses (APNs) (especially those with Doctorates of Nursing Practice [DNPs] cheeky enough to call themselves “doctor” even while clarifying their nursing role and background) are sometimes viewed as “mere” nurses “pushing the envelope”—the envelope of regulated, standardized nursing practice. The reality is that the boundaries of professional nursing practice have always been fluid with changes in the practice setting often speeding ahead of the educational and regulatory environments. This phenomenon occurred again during the COVID-19 pandemic as scope-of-practice regulations in a number of states expanded in light of national need. It has always been those nurse healers caring for persons and families who see a need and respond—at times in concert with the medical profession and at times at odds with it—who are the true trailblazers of contemporary advanced practice nursing. This chapter makes the case that, far from being a new creation, APNs actually predate the founding of modern professional nursing. A look back into our past reveals legendary figures always responding to the challenges of human need, changing the landscape of health care, and improving the health of the populace. The titles may change—such as the DNP—but the essence remains the same. 26 PRECURSORS AND ANTECEDENTS There is a long and rich history of female lay healing with roots in both European and African cultures. Well into the 19th century, the female lay healer was the primary health-care provider for most of the population. The sharing of skills and knowledge was seen as one’s obligation as a member of a community. These skills were broad based and might have included midwifery, the use of herbal remedies, and even bone setting (Ehrenreich, 2000, p. xxxiii). Laurel Ulrich, in A Midwife’s Tale (1990), notes that when the diary of the midwife Martha Ballard opens in 1785, “… she knew how to manufacture salves, syrups, pills, teas, ointments, how to prepare an oil emulsion, how to poultice wounds, dress burns, treat dysentery, sore throat, frost bite, measles, colic, ‘whooping cough,’ ‘chin cough,’ … and ‘the itch,’ how to cut an infant’s tongue, administer a ‘clister’ (enema), lance an abscessed breast … induce vomiting, assuage bleeding, reduce swelling and relieve a toothache, as well as deliver babies” (p. 11). Ulrich notes the tiny headstones marking the graves of midwife Ballard’s deceased babies and children as further evidence of her ability to provide compassionate, knowledgeable care; she was able to understand the pain and suffering of others. The emergence of a male medical establishment in the 19th century marked the beginning of the end of the era of female lay healers, including midwives. The lay healers saw their role as intertwined with one’s obligations to the community, whereas the emerging medical class saw healing as a commodity to be bought and sold (Ehrenreich & English, 1978). Has this really changed? Are not our current struggles still bound up with issues of gender, class, social position, and money? Have we not entered a phase of more-radical-than-ever division between the haves and have-nots with grave consequences to our social fabric? Nursing histories (O’Brien, 1987) have documented the emergence of professional nursing in the 19th century from women’s domestic duties and roles, extensions of the things that 27 women and servants had always done for their families. Modern nursing is usually pinpointed as beginning in 1873, the year of the opening of the first three U.S. training schools for nurses, “as an effort on the part of women reformers to help clean up the mess the male doctors were making” (Ehrenreich, 2000, p. xxxiv). The incoming nurses, for example, are credited with introducing the first bar of soap into Bellevue Hospital in the dark days when the medical profession was still resisting the germ theory of disease and aseptic techniques. The emergence of a strong public health movement in the 19th century, coupled with the Settlement House Movement, created a new vista for independent and autonomous nursing practice. The Henry Street Settlement, a brainchild of a recently graduated trained nurse named Lillian Wald, was a unique community-based nursing practice on the lower east side of New York City. Wald described these nurses who flocked to work with her at Henry Street Settlement as women of above average “intellectual equipment,” of “exceptional character, mentality and scholarship” (Daniels, 1989, p. 24). And Wald herself was extraordinary in her abilities to coalition-build and raise funds from a variety of public and private sources to support her endeavors (Dunphy, 2011). The nurses of the Henry Street Settlement, as has been well documented, enjoyed an exceptional degree of independence and autonomy in their nursing practice caring for the poor, often recent immigrants. In 1893, Wald described a typical day. First, she visited the Goldberg baby and then Hattie Isaacs, a patient with consumption to whom she brought flowers. Wald spent 2 hours bathing her (“the poor girl had been without this attention for so long that it took me nearly two hours to get her skin clean”). Next, she inspected some houses on Hester Street where she found water closets that needed “chloride of lime” and notif ied the appropriate authorities. In the next house, she found a child with “running ears,” which she “syringed,” showing the mother how to do it at the same time. In another room, there was a child with a “summer complaint”; Wald gave the child bismuth and tickets for a seaside excursion. After lunch she saw the O’Briens and took 28 the “little one, with whooping cough” to play in the back of the Settlement House yard. On the next floor of that tenement, she found the Costria baby who had a sore mouth. Wald “gave the mother honey and borax and little cloths to keep it clean” (Coss, 1989, pp. 43–44). This was all before 2 p.m.! Far from being some new invention, midwives, nurse anesthetists, clinical nurse specialists (CNSs), and nurse practitioners (NPs) are merely new permutations of these long-standing nursing commitments and roles. 29 NURSE-MIDWIVES Throughout the 20th century, nurse-midwifery remained an anomaly in the U.S. health-care system. Nurse-midwives attend only a small percentage of all U.S. births. Beginning in the 19th century, physicians laid claim to being the sole legitimate birth attendants in the United States, although it took them until the early years of the 20th century to achieve true dominance (Dawley, 2001; Dye, 1984). This is in contrast to Great Britain and many other European countries where trained midwives still attend a signif icant percentage of births. In Europe, homes remain an accepted place to give birth, whereas hospital births reign supreme in the United States. In contrast to Europe, the United States has little in the way of a tradition of professional midwifery. Once again, our crisis with the COVID-19 pandemic raised questions about this. Why not, in such times and with such stress on our health-care system, deliver babies at home, surrounded by friends and family? Would not this be far safer? (Kline & Hayes-Klein, 2020) As late as 1910, 50% of all births in the United States were reportedly attended by midwives, and the percentage in large cities was often higher. However, at that time, the health status of the U.S. population, particularly in regard to perinatal health indicators, was poor (Bigbee & Amidi-Nouri, 2000). Midwives— unregulated and by most accounts unprofessional—were easy scapegoats on whom to blame the problem of poor maternal and infant outcomes. New York City’s Department of Health commissioned a study that claimed that the New York midwife was essentially “medieval.” According to this report, fully 90% were “hopelessly dirty, ignorant, and incompetent” (Edgar, 1911, p. 882). There was a concerted movement away from home births. This was all part of an assault on midwifery by an increasingly powerful medical elite of obstetricians determined to control the birthing process. These revelations resulted in the tightening of existing laws and the creation of new legislation for the licensing and supervision of 30 midwives (Kobrin, 1984). There was need for the “professionalizing” of the nurse-midwife, more grounding in scientif ic advances through education and regulation. Several states passed laws granting legal recognition and regulation of midwives, resulting in the establishment of schools of midwifery. One example, the Bellevue School for Midwives in New York City, lasted until 1935, when the diminishing need for midwives made it diff icult to justify its existence (Komnenich, 1998). Obstetrical care continued the move into hospitals in urban areas that did not provide midwifery. For the most part, the advance of nurse-midwifery has been a slow and arduous struggle often at odds with mainstream nursing. For example, Lavinia Dock (1901) wrote that all births must be attended by physicians. Public health nurses, committed to the professionalizing of nursing and adherence to scientif ic standards, chose to distance themselves from lay midwives. The stigma of the unprofessional image of the lay midwife would linger for many years. A more successful example of midwifery was the founding of the Frontier Nursing Service (FNS) in 1925 by Mary Breckinridge in Kentucky. Breckinridge, having been educated as a public health nurse and traveling to Great Britain to become a certif ied nurse-midwife (CNM), pursued a vision of autonomous nurse-midwifery practice. She aimed to implement the British system in the United States (always a daunting enterprise on any front). In rural settings, where doctors were scarce and hospitals virtually nonexistent, midwifery found more fertile soil. However, even in these settings, professional nurse-midwifery had to struggle to bloom. Breckinridge founded the FNS at a time when the national maternal death rate stood at 6.7 per 1,000 live births, one of the highest rates in the Western world. More than 250,000 infants, nearly 1 in 10, died before they reached their first birthday (U.S. Department of Labor, 1920). The Sheppard-Towner Maternity and Infancy Act, enacted to provide public funds for maternal and child health programs, was the first federal legislation passed for specif ically this purpose (Cockerham & Keeling, 2012). Part of the intention of this act was to provide money to the states to train 31 public health nurses in midwifery; however, this proved shortlived. By 1929, the bill lapsed; this was attributed to some opposition by the American Medical Association (AMA), which advocated the establishment of a “single standard” of obstetrical care, care that is provided by doctors in hospital settings (Kobrin, 1984). Breckinridge saw nurse-midwives working as independent practitioners and continued to advocate home births. And even more radically, the FNS saw nurse-midwives as offering complete care to women with normal preg
