Societal forces have clearly influenced the development of advanced practice nursing. Gender issues have affected all the specialties to some degree because of the unique position of nursing as a female-dominated profession. The specialties of nurse anesthesia and nurse practitioner have been the exceptions, with more men entering these fields. Within nurse-midwifery, the status of women and women's health were powerful forces in the establishment and development of the specialty. Overall, war has served as a catalyst to the development of advanced practice nursing, education, and professional organizations. Finally, economic changes, particularly in relation to health care financing, have had a powerful effect on the development of advanced practice nursing. The dramatic growth of managed care systems in the 1990s, in particular, has presented new challenges and opportunities for APNs related to reimbursement, scope of practice, and
autonomy ( Safriet, 1998 ). Current efforts at health care reform mandated in the Patient Protection and Affordable Care Act (2010) may lead to more fundamental changes in health care financing and delivery. With unremitting changes in nursing and health care, it is apparent that APN specialties will continue to evolve and diversify. As new roles emerge, the history of advanced practice nursing continues to be written. Today, particularly in light of the DNP initiative, the profession is at a critical juncture in which it must decide whether it will mandate doctoral level preparation for all APN roles. Agreement on master's preparation for all APNs is relatively new and disagreements about the requirement of the doctorate ( Cronenwett, Dracup, Grey, et al., 2011 ) may continue to impede progress on the adoption of standardized educational criteria in the future. Undoubtedly, as law professor Safriet (1998) has argued, consistency in the definition of advanced practice nursing and in the criteria for licensure as an APRN is critical to autonomy in practice. Thus, what remains to be seen is whether the profession can unite on issues related to the definition of advanced practice nursing and standardized criteria for educational preparation to ensure that APNs are permitted to practice with the autonomy experienced by other professionals. If that can be done, as the recent Institute of Medicine Future of Nursing report (2010) suggested, APNs could make a significant contribution to the transformation of health care in the twenty-first century. References American Association of Colleges of Nursing: Enrollment and graduations in baccalaureate and graduate programs in nursing. 1999, Author, Washington, DC. American Association of Colleges of Nursing: Essentials of doctoral education for advanced practice nursing. 2006, Author, Washington, DC.
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