1. Advanced Practice and Clinical Nurse Specialism

Advanced practice and the Clinical Nurse Specialist (CNS) has been in existence for many years and the diversity of their roles increasingly became recognised. The list of skills and roles required by the nurse working at specialist or advanced level evolves and adapts constantly [1-6]. It includes clinical specialist, educator, consultant, advisor, researcher, manager, administrator, collaborator, communicator, liaison person, change agent and innovator, to name but a few. The development of expertise, acquisition of new skills and formal education all go towards the development of specialist. Skill/ role combination is often required when functioning as CNS. For example, with research, the CNS may have read, studied or carried out research relevant to the nursing specialism, but it can require the skill of innovation to enable the transfer of such findings to clinical practice to benefit patients.

2. Development of Advanced Practice and Clinical Nurse Specialism

Clinical nurse specialism has developed over a number of years and its origins can be found in the past. Menard [7] states that the 'future of nursing has always been seen in the past'. Certainly the development of nursing and particularly clinical nurse specialism can be traced over many years, It is very interesting and informative to look back at the growth of specialist nursing. Clinical nurse specialism has strong roots in the USA and this can be seen in Menard's [7] work, which traces both the growth of clinical nurse specialism and the factors that influenced it, such as the formalisation of nurse training in the late 19th and early 20th centuries. Menard [7] credits Florence Nightingale with introducing some of the first role concepts of the CNS work. For example roles such education and administration/ management, details of which can be seen in Florence Nightingale's own writings [8]. Another influence that Menard [7] recognises as having an impact on the development of the specialist nurse role was the increasing formalisation of nurse training which occurred in parallel in the USA and Western Europe, starting in the latter half of the nineteenth century.

In the USA, the Nursing Bureau was established in 1864, with its main focus being the development of nurse training schools in principal cities [7]. At the same time, the Suffragette Movement was gathering momentum to promote women's rights and, as nursing was such a female-dominated profession, some overlap occurred between those active in nursing and those active in the political [9,10]. Lillian Wald is credited by Menard [7] as being strongly influential in the development of nursing in the USA. She is an example of a woman with this dual role – nursing and politics. She commenced nurse training in the New York Hospital School of Nursing and graduated in 1891 [11]. After a short, but unsatisfactory experience working in an institution, where she was frustrated in any attempt to contribute to nursing policy and development, a complaint which anecdotally we still hear today, Wald sought work elsewhere. Invited to run nursing classes in New York's poorer East Side (an early example of the educational component of the nurse's role), Wald recognised what she saw as a need for nurses to live and work in their area of practice. Obtaining some financial backing from a philanthropic source, she and a colleague from her New York nursing school, Mary Brewster, established a system that allowed them to live in the community and not only to care for the sick, but also to encompass reform in other areas such as health, industry, education, leisure and housing [11]. Wald coined the term 'public health nursing' to describe such work. Nurses working in these roles became known as Public Health Nurses, this title continues for many years and only recently as the tem community nurse come into being.

Wald should be remembered not just for her contribution to health in America and public health nursing in New York in particular, but also for her innovative and dynamic approach which significantly broadened the possibilities of a nurse's work and gave American nurses 'professional independence' [11, p.1781] and the ability to 'care with autonomy' [9] and such skills can be seen in the work of the clinical nurse specialist. Certainly Wald’s work paved the way for the development of specialist roles for nurses.

Other visionary nurses followed and by the early 20th century nurses had begun to 'specialise' in areas such as public health. This specialisation allowed them to develop their expertise and become leaders in their field. Areas such as tuberculosis, mental health, and infant, child and maternal health are all examples of the specialised fields that nurses chose to work in. In addition, these nurses started to write and contributed to the nursing literature [11]. Thus ensuring that nursing knowledge was shared.

Wald herself was not in full agreement with the increasingly specialised roles that public health nurses were developing, but her work had opened the door and specialised nurses became part of nursing [11]. The work of Wald and her colleagues, the formalisation of nurse training and the educational opportunities at higher levels becoming available to nurses were all factors that impacted on the development of nursing in specialised fields, particularly in the USA [7]. Similarly, at this time in Europe and particularly in the UK, nursing and nurse training were becoming more formalised. Florence Nightingale contributed greatly to this formalisation, but she was not alone. The Protestant Institute of Deaconesses near Düsseldorf, where Florence Nightingale spent a number of months early in her career, contributed the spirit of 'dedicated service' to the nursing profession [12]. However, it was the establishment of nurse training under the influence of Florence Nightingale that brought nursing from being a domestic duty to a vocation – and a 'respectable' vocation at that [12].

At the turn of the 19th century, Mrs. Bedford Fenwick, herself a trained nurse and former Matron of London's St. Bartholomew’s, started a movement for nurse registration. This was partly driven by her desire to see nurse training restricted to 'the daughters of the higher social classes' [12, p. 63]. The idea of registration had many objectors, not least Florence Nightingale who felt the focus on examinations could detract from the 'personal qualities' required in a probationer. Many people, particularly those running hospitals, feared the pool of probationer nurses would shrink if training was reserved for the higher social classes and therefore they largely supported Nightingale. The debate continued for some time. Then, the introduction of the midwives' register in 1902 in the UK gave weight to the idea of a nurses' register and in June 1904 a Select Committee was established to consider the registration of nurses. The Committee decided in favour of registration, but it was not until 1919 that the Nurses Registration Act was passed [12]. There followed a turbulent time as nursing bedded down and training became more standardised. As the century progressed, an increasing proportion of nurses' work was carried out in hospitals where 'specialised out-patient departments' allowed nurses to focus on, or specialise in, a particular area of nursing [12, p. 120]. Again, like in the USA, this offered opportunities for UK nurses to specialise in a particular area of practice. In many ways, Ireland mirrored the UK in the development of nursing, although unlike the UK, the first training schools were established in religious institutions.

St. Vincent's Hospital in Dublin (still in existence today) is an example of such an institution, run by the Congregation of the Irish Sisters of Charity and recognised for its quality of care in the 19th century [13]. The hospital started by training members of the religious community, only commencing training for lay people in the late 1850s[13]. Members of the Religious Orders sat on the Boards of Management in the institutions, and, since the members of the Orders traditionally came from middle and higher socio-economic backgrounds, this made nursing an attractive option for young women of similar backgrounds [14]. Again echoing the UK, calls came at the start of the 20th century to register nurses. The UK 1902 Midwives Act did not extend to Ireland and it was not until 1918 that the Midwives Act (Ireland) was passed. The Nurses Registration Act (Ireland), allowing for the registration of nurses, followed in 1919 [13].

3. Early examples of specialisation

When exploring clinical nurse specialism in Ireland, a few examples of early can be found, indicating that nurses were specialising from the late 19th century. As the range of areas of work for nurses grew, nurses increasingly became involved in a variety of roles and specialised in particular areas, such as in the X-ray Department of St. Vincent's Hospital [13]. Certainly, after World War 1 fever nursing or sanatoria nursing was recognised as a specialised area of work for nurses and specific training was identified as necessary to allow them to become competent in the area [14]. Another area of specialisation identified by Robins is occupational health nursing: with the appointment of the first occupational health nurse in Ireland, by Arthur Guinness and Company, the well-known brewery firm, recorded in 1890.

Certainly such an early example merited investigation which showed the appointment by Guinness of a nurse, or so-called 'Lady Visitor', revealed that the first record of an actual appointment in 1888. On 10th July 1888, the Board's Minutes record that 'in conjunction with the reorganisation of the Medical Department, it was resolved to appoint a midwife at a salary of £3 a month and free rooms in Belvue Buildings' [15]. The appointment of a midwife was first proposed in 1888 and appears to have occurred shortly afterwards. Mention of her duties and replacement are noted in the Minutes:

Provides details of numbers of women using the baths, policies regarding eligibility for use … frequency of use of midwife, her remuneration and replacement.

Another early appointment by the same company was that of 'Mrs. Goodman, Lady Visitor'. Aptly named, Mrs. Goodman was mentioned in the Board's Minutes of 1909 and her position as a nurse had a clear job description, with roles identified:

Details individual cases requiring attention by the Board relating to work undertaken by Mrs. Goodman (Lady Visitor) in attending to welfare of widows, pensioners and orphans, as extension of work of Medical Department.

Examination of the Minutes shows that the midwife was involved in confinements and referrals to hospitals when required. The 'Lady Visitor' was involved in assessments, chiefly relating to the families of employees rather than the employees themselves. By 1920, the duties appear in more detail in the Minutes and include:

proposed duties and analysis of benefits;
terms of employment of nurses and requirements for same;
medical attendance for employees at trade stores;
consideration of present and proposed arrangements for provision of treatment;
arrangements for treatment of pensioners;
arrangements for treatment of Tuberculosis sufferers at sanatoria;
arrangements for provision of massage to employees – particularly increase of requirements due to influx of wounded soldiers;
assessment of health of casualties from First World War;
contracts with drug suppliers;
arrangements with hospitals to provide beds for Brewery employees.

The Guinness examples appear to be the first formal record of specialised appointments for nurses and midwives in Ireland. The list of duties also identifies various roles, ranging from a clinical role in assessment of post war casualties, a liaison and collaboration role arranging admission to hospital, through to an administrative role in dealing with drug suppliers [17]. As mentioned, it is interesting that not only a nurse but also a midwife was appointed to a specialised role, laying the template for what was to follow in Ireland over 100 years later.

However support, in the form of education for these specialised occupational nursing posts, did not occur until much later. In fact, it was not until well into the 20th century that an occupational health course was formally recognised by An Bord Altranais [14]. Yet, those nurses working in Guinness and Co. had job descriptions and clearly identified roles, and can thus be considered an early example of nursing specialisation. As nursing and nurse training became more standardised and regulated, nurses explored ways to develop and improve practice.

While as acknowledged clinical nurse specialism has strong roots in the USA. Menard [7] traces its growth and factors that influenced it during the late 19th and early 20th centuries. She credits Florence Nightingale with introducing some of the first role concepts of the CNS job, while acknowledging that although the actual term 'specialism' in nursing began with Peplau in the 1940s, the role had existed for many years before that. However, it was not until the mid-20th century that the title 'clinical nurse specialist' (CNS) first appeared [18,7].

Clinical nurse specialism and advanced practice is now well recognised in nursing in the 21st century. It is now recognised that nurses will focus on and specialise in, particular areas of nursing care. The USA led the way in this field, followed closely by the UK and the rest of Europe, followed, in turn, by Australia and Asia. This has led to a proliferation of nurses working in specialised areas and advancing nursing practice, both nationally and internationally.

4. Conclusions

Looking back can show how nursing grew and developed. The formalisation of nurse training which gave standards and consistency helped nursing to develop into specialised and advanced practice. While there was debate as this happened, the register of nurses and midwives did help to ensure that all those recognised as nurses has formal training. Interestingly as we look at the situation today, registers of clinical nurse specialists and advanced practice nurses are only starting to develop, perhaps echo’s of a hundred years ago. Another aspect of interest which Buhler-Wilkerson, [11] highlights is the contribution of nurses to nursing literature. This skill is still developing, as we move to higher levels of education for nurses, particularly for those working in advanced and specialised roles, such nurses carry out research and publish. There is still plenty of room for growth in this area. Currently the role of the clinical nurse specialist/advanced practitioner continues to grow and develop [19,20]. Looking back can sometime help us look and move forward. We can learn what works and works well but also what does not work and what to avoid. This can help ensure that we do not repeat the costly mistakes which have negative impacts on our patients but rather focus on developing and further improving patient care.

Competing Interests

The author declare that there is no competing interests regarding the publication of this article.