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With the introduction of Diagnosis Related Groups in 1983 as an attempt by the U.S Federal Government to rein in Medicare costs, the number of hospitalized patients decreased, but their acuity (level of illness) went up. Around the same time, the Human Immunodeficiency Virus (HIV), the cause of Acquired Immunodeficiency Syndrome (AIDS), emerged as a new and terrifying disease. Caring for patients infected with HIV caused nurses to examine their courage and their ethical beliefs in a way that was new in modern nursing. Modern scientific treatments, such as vaccines and antibiotics, had lulled nurses and others into a false sense of safety in their work. HIV was different because it was fatal. Barbara Fassbinder was a Wisconsin nurse who looked after a very ill patient admitted to the emergency room on a busy night in 1986. Because of that care, Fassbinder was later identified as the first nurse to contract AIDS from a patient. Fassbinder died in 1994 (Lusk, 1997).

Increased patient acuity, exacerbated by shorter hospital stays, demanded that nurses have further education in specialized fields. Of the currently accepted Advanced Practice Nursing Roles (Nurse Midwife, Nurse Anesthetist, Clinical Nurse Specialist, and Nurse Practitioner (NP)), nurse midwifery and nurse anesthetist have the longest history. In the U.S., many nurses at the start of the twentieth century frowned upon nurse midwives. Clara Noyes, a noted nurse leader, wrote in 1912: “The word ‘midwife’, in America, at least, is one to which considerable odium is attached and immediately creates a mental picture of illiteracy, carelessness and general filth” (Noyes, 1912, p. 466). At the same time, in the early twentieth century, the medical profession in the U.S. was growing in prestige and flaunted its expertise. Physicians were eager to join with early nurse leaders in disparaging midwives as ignorant and dangerous. Childbirth evolved as a medically lucrative pathology rather than a natural event. Yet many women were unable, due to geographical location or cost, to obtain medical care and relied upon the local untrained but experienced midwife. Within a few decades, during the 1930s and 1940s, nurse midwifery schools opened. The public's interest in natural childbirth during the 1970s supported further growth in nurse midwifery (Lusk, Cockerham, & Keeling, 2019).

The story for nurse anesthetists started more abruptly with the discovery in the mid‐nineteenth century of gases that induced anesthesia. Isabel Adams Hampton, in her 1893 nursing textbook, gives instructions to nurses on how to administer both ether and chloroform (Hampton, 1893). However, in these early days, nurses primarily gave anesthesia in situations where no physicians were present except for the surgeon. The first specific nurse anesthesia training was probably given by Dr. William Worrell Mayo during his surgeries in the late 1890s at St. Mary's Hospital in Rochester, Minnesota. Nurse Alice Magaw, sometimes referred to as the “mother of anesthesia,” worked for Dr. Mayo and wrote of her anesthesia “observations” of over a thousand cases in 1900 (Lusk et al., 2019).

The Clinical Nurse Specialist role had its foundation in psychiatric nursing. Indeed, the woman known as the first trained nurse in the U.S., Linda Richards, an 1870s graduate, organized a nursing school for the preparation of nurse specialists in psychiatric nursing (Richards, 1911). NPs, the fourth type of Advanced Practice Nursing role, include diagnosis and treatment in their nursing care. Forerunners of today's NPs were nurses who treated patients who were often too poor to obtain medical care. Such a nurse was Rose Hawthorne.

Teacher's College, Columbia University, instituted the first doctoral degree for nurse educators, granting the education doctorate in 1924 (Robb, 2005). By 1949, there were 24 doctoral programs open to nurses in the U.S., 75% of which were in education. Twenty years later, this number had grown to over 300 with 10% of these doctoral programs in nursing and 21% in the social sciences and the remainder in education (Grace, 1978). Over the ensuing years, doctoral nursing education acquired such titles as Doctor of Nursing Science (DNSc) and the Doctor of Science in Nursing (DSN). Today we have primarily the titles of Doctor of Philosophy (PhD), a research doctorate, and the Doctorate in Nursing Practice (DNP), a clinical doctorate. In 2016, there were just under 5,000 nursing students enrolled in research focused doctoral programs compared with over 25,000 nursing students in DNP programs (American Association of Colleges of Nursing (AACN), 2017).