Duke's MSN in Advanced Clinical Nursing Practice

Nurse Thelma Ingles and the first MSN in Advanced Practice Clinical Nursing 

Through decades of role confusion and conflict between clinical nurse specialists, nurse practitioners and physicians assistants, little attention has been given to their mutual antecedent, a short lived (1958-1962) Master of Science in Nursing (MSN) program established at Duke University in Durham, NC.  Under the leadership of Nurse Thelma Ingles and Dr. Eugene Stead, a ground breaking plan to educate a new type of health care provider became a brief reality.  Until this Duke program, MSN degrees had been awarded either in the functional areas of education, supervision or administration, or in the specialized areas of anesthesia and psychiatric nursing1, 2.  This program marks the beginning of advanced clinical practice in medical surgical nursing. Ingles and Stead designed a unique curriculum to expand the scope of nursing practice to include skills such as taking a patient history and performing a physical examination.3 Ingles and Stead’s MSN program ultimately generated the Physicians Assistant (PA) profession and helped pave the way for the now familiar roles of Nurse Practitioner (NP) and Clinical Nurse Specialist (CNS).    

Thelma Ingles was born in Redfield, SD in 1909. From an early age, she was keenly interested in academics and developed goals of furthering her education, particularly in literature and nursing. After earning her first degree, a Bachelor of Arts in English Literature from UCLA (1931), she went on to receive a diploma in nursing from Massachusetts General Hospital (1935) and a Master of Arts in English Literature from Case Western Reserve (1941).  Having decided to focus her career on nursing, Ingles did post graduate studies at both Duke University in clinical nursing and the University of California at Berkley in public health nursing and sociology.  Her early academic appointments include Boston Nursery (1936), the University of Virginia (1941-1945) and Admiral Bristol Hospital in Istanbul (1945-1948).  In 1949, Ingles accepted a position as professor of medical-surgical nursing at Duke University School of Nursing.3   

Several mid twentieth century critical events set the stage for Duke’s advanced practice nursing program. Before World War II, 3-year hospital-based nursing schools served as the primary source of nursing education.  Physicians frequently owned small private hospitals and created nursing schools to ensure a supply of inexpensive labor.  The physicians taught the courses, and what they taught largely depended on the type of patients currently being treated in the hospital.  Responding to this haphazard approach to teaching, early nursing leaders formed the National League for Nursing Education (NLNE) to upgrade and standardize nursing education.  Having nurses create, teach and evaluate nursing school curricula was a key principle championed by the NLNE.  

At the same time advances in pharmacology, medicine and surgery during World War II increased the quantity and quality of services health care agencies offered after the war. To accommodate the increased number of hospitalizations, the US Congress passed the Hill Burton Act in 1946, which funded hospital expansion and construction across the nation and provided a funding mechanism for indigent care. The additional number of hospital beds coupled with the variety of services hospitals could offer led to increased number of hospitalizations. Concurrently health insurance coverage grew so more people were able to avail themselves of new inpatient services.5 Finally, in the 1950s, predictions of an impending shortage of physicians were discussed in conferences and the professional literature.  At a time when more people were seeking an increased amount of care there were not enough physicians to provide the care being sought.  Physician training could not keep up with the tremendous demand for care which created a need for addition health care professionals.4, 6

The nursing profession underwent tremendous change in the middle 1900s. Baccalaureate programs (BSN) grew in number and influence.  Two year community college, associate degree nursing (ADN) programs began and flourished. The role of Licensed Practical and Vocational Nurses (LPN/LVN) was expanding and soon nursing assistants appeared on the scene. The roles, responsibilities and interrelationships of these healthcare workers were hotly debated.  Nurses had yet to reach consensus on issues related to educational preparation and the best way to utilize nursing staff with varying credentials and years of schooling. Academic accrediting organizations and state Boards of Nursing had their hands full managing the changes in nursing education and practice in the 1940s and 50s.7 Against this already confusing backdrop, Ingles and Stead introduced yet another type of nurse, the advanced clinical practitioner. 

All of these factors contributed to a pivotal conversation between Ingles and Stead in 1957. As the professor of medical surgical nursing, Ingles interacted with Duke physicians and medical school faculty on a regular basis.3 One of those physicians was Dr. Eugene Stead, Chairman of the Department of Medicine at Duke. Stead chaired the Department of Medicine at Emory University Hospital, in Atlanta, Georgia during WWII.  Severe physician shortages during WWII meant that responsibilities of medical students and residents were expanded. They cared for more complex patients earlier in their careers than had previously been the norm.  The quality of care Emory medical students and residents provided to patients impressed Stead. He became convinced that much of the routine hospital care, then provided by physicians, could be taught and performed by a new type of health care provider.  Stead initially envisioned teaching nurses, already armed with significant knowledge and experience in taking care of patients, to fill this new role. It made sense that they could learn to accomplish many of the routine tasks carried out by physicians.  These nurses would expand the provision of health care to many underserved people in a cost efficient manner.8 

Serendipitously, during a meeting in the spring of 1957 attended by both Ingles and Stead, the topic of advanced nursing practice came up.  Ingles was taking a sabbatical in the academic year 1957-58 and she was thinking about ways to increase her clinical competence.  At that time, the roles of nurse practitioner and clinical nurse specialist had not been developed. Stead and Ingles agreed that Ingles would spend her sabbatical year as a student of Stead’s enhancing her knowledge about the bedside care of medical and surgical patients through collaboration with physicians, laboratory personnel, imaging staff and anyone else at Duke Hospital with the knowledge she wished to gain to improve patient outcomes.9 Many of Stead’s medical colleagues were unsure what to make of a nurse in an expanded role.  Ingles9 remembered: 

“… when I was studying neurology, for example … making rounds with Dr. Conkle who was chairman of that division, he didn’t exactly know how to treat me.  When I would ask him some questions, he would say this ‘I don’t think that has anything to do with the nursing realm.’ I’d say ‘It has something to do with the nursing realm because this nurse wants to know it’ … I was considered a ‘nurse intern’ but there wasn't really any protocol for this unheard of position.”                                                                                                               

By the end of the year Ingles9 thought: 

“I had learned a tremendous amount about clinical medicine.  I suppose I was as well prepared as anyone in the country in this field, and I thought this ought to be shared.  And I felt that this year that I had had with Dr. Stead was such a superb year that we ought to replicate it with a group of students and give them the same thing.  Obviously Dr Stead could not continue year after year to take one nurse, and that would have little effect.  But maybe we could have a group. So we began to talk about setting up a Master’s program in nursing …”  

Ingles and Stead continued their collaboration. They were able to secure a five-year, $250,000 grant (a sizable sum for that time period) from the Rockefeller Foundation to develop the first nursing clinical specialist program at the Master’s level 8, 9.  According to the 1960 Duke University catalog, the purpose of the MSN program was to:

“… increase the students’ information relative to the area of specialization, promote opportunities for learning through self directed activities, offer sustained experiences in the care of individual patients, to offer experiences in supervised teaching, and provide opportunities for personal and professional growth and development.”

The one-year program included 12 hours a week of theoretical classroom instruction, three hours a week of research and 30 hours a week in clinical rotations. The curriculum consisted of two semesters of each of the following courses: Advanced Medical Surgical Nursing; Seminar in Patient Care; Psychophysiological and Interpersonal Aspects of Nursing; Seminar in Nursing Research and from 1960-1962 a Seminar in Teaching, and nine units of elective credit (Duke, 1960 -1962)10. As Wilson11 notes: “During the early years, few nursing educators possessed the knowledge or skill to teach students the medical components of the new roles. Physicians and physician support were therefore essential to the development and success of the nurse practitioner role.” Duke’s Department of Medicine physicians contributed many lectures and assisted with classes, particularly the Advanced Medical Surgical Nursing course. 

Students spent six weeks in four required clinical areas – respiratory, neurology, cardiac and gastrointestinal.  After successfully completing those areas, students could choose any other two areas (such as obstetrics, pediatrics or psychiatry) they wished or repeat areas they had previously taken.  In the Seminar in Teaching course, students were often in charge of teaching the classes based on their recent clinical experiences.  They were expected to explain the pathophysiology of the disease, discuss the disease process, and describe and demonstrate the nursing care the patient needed. Ingles9described the intent of the new program in an almost prophetic statement for that time:

“… we came out with the idea that the nurse was qualified to do a great many things in patient care that had not been seen as part of her role and this meant setting up a different kind of a master’s program, in which we would try to demonstrate that the nurse could have a tremendous input in the psychosocial aspects of care, but also could do quite a few things in the physical care that had not been done before.  We even went so far as to project into the future that we were going to have our graduates in the master’s program working in the clinic as responsible individuals in care, that patients would be told to come in and see ‘the nurse’.  And she would be paid a per-visit call same as the doctor.  We thought that this was particularly relevant to patients with chronic disease.  We saw her as having much greater input into the diagnosis and treatment and follow up than had ever been done in the past.  But we knew that we had to move slowly …”   

On another occasion Ingles9 remembered,

 “One of the things I told the students right from the inception was we are preparing you for a job that doesn’t exist because there are no jobs in hospitals for the clinical nurse practitioner.  This was a new kind of role.  But we have to prepare people before we can set up the role so that we have people who know what the role should be … there were no jobs in hospitals in 1960 for what we now call the Clinical Nurse Practitioner. As a consequence, graduates had to go into Nursing Education”.

Duke University officials approved the program and it began in 1958 with five students9.  When Ingles and the nursing department at Duke sought to obtain NLNE accreditation for the new program they were denied. Organized, professional nursing was not ready to accept the new role that Ingles and Stead envisioned for nurses.  The NLNE turned down accreditation on the grounds that the program lacked structure and it criticized the use of physicians as instructors 6,12.  In addition, Ingles9 noted that the NLNE indicated she did not have the credentials she needed to teach in an MSN program since her highest level of education in nursing was the Diploma.  In order to remedy the situation and comply with NLNE guidelines Ingles took a year off from teaching to study at the University of California at Berkley.  While she was in California, the Nursing Department at Duke again tried to get the MSN accredited but was again denied 9, 13.  It would not be until the 1970s that the ANA and NLN embraced advanced clinical practice in nursing 14, 15

As the result of not gaining accreditation, the program could not attract students and was closed in 1962.  Dr. Stead was still enthusiastic about the idea of creating a new sort of healthcare worker to do many of the routine functions usually performed by physicians.  In 1965 he admitted and taught the first class of Physicians Assistants at Duke University Medical Center.  Dr. Stead is credited with founding the profession of Physician’s Assistant and his birthday, October 6th, is National Physician’s Assistants Day. One wonders if the career of Physician Assistant would have come into being if the NLNE had accredited the Duke Nursing Clinical Nurse Practitioner program in 1958. Dr. Stead’s initial desire was to enhance the nursing role.  Only when the NLN twice declined accreditation to the MSN program did he select medical corpsmen to implement his mid level provider plans8.

 In 1965 the idea of an extended and enhanced clinical role for nurses took hold and grew when Nurse Loretta Ford and Dr. Henry Silver began the Pediatric Nurse Practitioner program in Colorado.  Within nine years over 1,000 nurses were practicing in practitioner roles11. That program began as a certificate (not degree granting) program, as did most of the early practitioner programs, thus bypassing the need for accreditation by the NLNE 14.  It took over a decade from the Duke program’s inception for the NLN to accredit the first MSN programs for Clinical Nurse Specialists and Nurse Practitioners. ANA came out with its first Scope and Standards of Advanced Practice Registered Nursing in 1995 and accrediting group the American Association of Colleges of Nursing (AACN) produced its first The Essentials of Master’s Education for Advanced Practice Nursing in 1996 2,11,16.

Thelma Ingles eventually left Duke but retained her enthusiasm for nursing excellence and her dedication to healthcare education. After Duke, Ingles joined the Rockefeller Foundation as a nurse consultant.  For twenty years she traveled widely giving advice and inspiration to nursing and health care programs around the globe. During her life she visited 52 countries and was active in improving nursing education everywhere she went. In Cali, Columbia, for instance, she established a Bachelor’s and Master’s Program in Nursing, creating a new career opportunity for nurses and improving the quality of patient care. As a consultant to the World Health Organization she visited nursing schools in places as diverse as Finland, India, Thailand, Russian and England. In addition, she worked with a variety of agencies such as Project HOPE, The Peace Corps and the Robert Wood Johnson Foundation, helping to bring quality healthcare to underserved patients in the furthest reaches of the globe.  Her belief that the care of patients was more important than the growth and prestige of the profession we belong to never wavered. To improve nursing education by establishing the advanced clinical practitioner role, as a way to deliver better quality healthcare no matter how poor or how privileged the setting remained consistent throughout her life time 9.  As always, we should be conscious of the past in order to live in the present for the sake of the future.  The story of Thelma Ingles and the first Master’s level nurse clinician program teaches us to be more open to new ideas, to be willing to try new experiences and to support each other in our efforts to improve our beloved profession of nursing.  

References

1.        Mick DJ, Ackerman MH. Deconstructing the myth of the advanced practice blended role: Support for role divergence. Heart & Lung. 2002;31:393-398.

2.        Morrison JD. Evolution of the perioperative clinical nurse specialist role. AORN Journal. 2000; 72(2): 227-232.

3.        Thelma M. Ingles Biography Page. Physician Assistant History Center. Accessed July 28, 2010.

4.       Kalisch PA, Kalisch BJ. American nursing: a history.4th ed. Philadelphia (PA): Lippincott Co.; 2004.

5.        Stanhope M, Lancaster J. Foundations of nursing in the community: Community-oriented practice. 3rd ed. St. Louis, MO: Mosby; 2008.

6.        Holt N. “Confusion’s Masterpiece”: The development of the physician assistant profession. Bull Hist Med. 1998; 72(2):246-278.

7.        Hughes EC, Hughes HM, Deaustcher I. Twenty thousand nurses tell their story. Philadelphia (PA): Lippincott; 1958.

8.        Laszlo, Neelon FA. The Doctor’s Doctor: E.A. Stead, Jr. M.D. Durham, NC: Carolina Academic Press; 2005.

9.        Ingles TM, Hara. Care from the heart. 2007. (Unpublished Manuscript)

10.    Carter R. From concept to reality: Evolution of the physician assistant concept at Duke University, 1964-1965.  (Unpublished manuscript found at Duke University Medical Center Archives)

11.    Wilson D. Nurse practitioners: The early years (1965-1974). The Nurse Practitioner. 1994; 19(12): 26, 28, 31, 35.

12.    Bliss A A, Cohen E. The new health professionals: Nurse practitioners and physician assistants. Frederick, MD: Aspen Publishers; 1977.

13.    Fisher DW, Horowitz S. The physicians’ assistant: Profile of a new health profession. In: Bliss AA, Cohen ED, ed. The New Health Professionals. Germantown, MD: Aspen Systems Corporation; 1977: 140.

14.    Fairman J. Making room in the clinic: Nurse Practitioners and the evolution of modern health care. Piscataway, NJ: Rutgers University Press; 2008.

15.    Fulton JS, Lyon BL, Goudreau. Foundations of Clinical Nurse Specialist Practice. New York (NY): Spring Publishing Co.; 2010.

16.  American Association of Colleges and Nursing. The essentials of baccalaureate education for professional nursing practice. Washington, DC: Author; 2008.