More Than Medicine

Nurse Practitioners and the Problems They Solve for Patients, Health Care Organizations, and the State

LaTonya J. Trotter

• Editorial: ILR Press
• Año: 2020
• ISBN:
  9781501748165
• Categoría: Medicina
• Categoría: Salud pública, administración y atención

In More Than Medicine, LaTonya J. Trotter chronicles the everyday work of a group of nurse practitioners (NPs) working on the front lines of the American health care crisis as they cared for four hundred African American older adults living with poor health and limited means. Trotter describes how these NPs practiced an inclusive form of care work that addressed medical, social, and organizational problems that often accompany poverty. In solving this expanded terrain of problems from inside the clinic, these NPs were not only solving a broader set of concerns for their patients; they became a professional solution for managing "difficult people" for both their employer and the state. Through More Than Medicine, we discover that the problems found in the NP's exam room are as much a product of our nation's disinvestment in social problems as of physician scarcity or rising costs.

Part I

AN EXPANDED TERRAIN FOR NURSING

1

NURSING’S EXPERTISE

NP Francesca worked part-time in the Grove’s clinic. The rest of her days were spent teaching nursing students. Before I had permission to begin observing in the clinic, one of the Grove’s administrators encouraged me to meet with Francesca. Perhaps because she was an educator, the administrator believed Francesca would have “an interesting perspective on the Grove.” Our meeting was scheduled at midday, when the clinic was closed for lunch. When I arrived at her office, I had a quick preview of the woman I was to meet. There was a sign on the door that read, “The Professor,” in cursive font. Underneath was a picture of an owl who wore glasses and wielded an old-fashioned pointer. I cannot recall ever hearing anyone call her the Professor, but it was a name she had earned.

Francesca had received a PhD in gerontologic nursing research. She was not shy about describing herself as more academically than clinically oriented. By her own admission, doing the work of an NP was not her forte. She had taken the unusual route of getting her PhD before returning to school for the clinical NP master’s degree. Along the way, she had developed a strong set of ideas about the work of an NP. I asked her, as I eventually asked all the NPs, to describe what being an NP meant. Her response was to take out a pen and teach.

“Medicine,” she said, “sees the relationship between nursing and medicine like this.” Francesca drew two circles: a large circle to represent medicine with a smaller circle for nursing contained inside it. “However, nursing has always argued that the relationship looks more like this.” She then drew a second set of equal-sized circles that overlapped in the middle. Pointing to the right-hand circle, she said, “Medicine does many things that nurses can’t do.” As she pointed to the overlapping section, she continued, “And some of the things NPs do are also done by physicians.” Then she pointed to the left-hand circle and said, “Yet nursing has things that only it does—knowledge that exists apart from medicine.”

Francesca’s sense of what nursing “has always argued” was informed by the long arc of nursing’s history. But it was also shaped by her experience living through its more recent past. Francesca entered nursing as an RN in 1978. It was a time when neither nursing nor medicine was quite sure who NPs were. Nurses were initially wary of those who seemed to want to trade in their nursing identity for that of medicine (Fairman 2008). It was physician organizations, not nursing organizations, that initially welcomed NPs into the fold. This welcome, however, came with a risk. Physician organizations began arguing that NPs were no longer really nurses and therefore medicine, not nursing, should train and govern NPs (Fairman 2008).

The status and identity of the NP was not fully resolved until the mid-1980s. This period of uncertainty partly explains Francesca’s somewhat circuitous route to becoming an NP. Nursing did eventually rally around NPs, so that today there is little question over which profession they belong to. However, Francesca’s instruction underlines a reality that is often missing from debates about the NP: the boundary between the two professions is as important to nursing as it is to medicine. One of nursing’s most enduring threats—to its identity, work, and governance—is that of being swallowed whole by medicine. To blur the line between them is to risk trading in nursing’s diagram for medicine’s, which shows nursing as a small island within the sea of medicine’s domain. One of my primary claims is that NPs may be doing more than simply reproducing physician practices. That claim requires an understanding of the ways in which nursing’s identity is grounded in assertions of difference, not interchangeability. In this chapter, I situate who the Grove’s NPs understood themselves to be within nursing’s larger political and existential fight for an identity apart from medicine.

A Profession Apart

Throughout the nineteenth century (and well into the twentieth), the family home was the site of most sick care in the US. Carried out as a woman’s obligation to her family, nursing the sick was not viewed as something that required much in the way of knowledge or skill (Reverby 1987b). Whether a woman performed the work herself or discharged the duty to a servant, nursing work was akin to that of laundering clothes and scrubbing floors. The bonds of affection might imbue the work with deeper meaning, but as an activity, it was mere drudgery.

The story of how nursing transformed from drudgery into the work of a respected profession begins in the mid-1800s with the English reformer, Florence Nightingale. Nightingale has many accomplishments to her name, but she is widely known as the first person to make the case that nursing work required education (Reverby 1987a). She argued against the popular notion that women knew how to nurse by instinct or intuition; she believed potential nurses had to be both vetted and trained. Nightingale had an uphill battle. One of her primary challenges was the need to allay the fears of physicians and hospital administrators, who were suspicious of any new claimants to expertise over patient care. While navigating these more powerful actors was a daunting political hurdle, the cultural hurdle was just as formidable. In an era when even women of modest economic means did not work outside the home, Nightingale had to make the case that they could do so without losing their claims to respectability. Despite these hurdles, Nightingale’s ideas came to fruition both in her native England and in the US.

There are several explanations for Nightingale’s success, including savvy politicking. However, a key explanation lay in the decision to align her new ideas with preexisting ones. Similar to other female social reformers of the time, she made liberal use of a gendered, moral language to create a place for professional nursing (Ginzberg 1992; Kunzel 1995; Welter 1966). While members of the budding women’s movement were beginning to argue that women should have some of the same rights as men, Nightingale’s approach proved to be much more palatable. She argued for the extension of rights she believed women already held.

Nightingale drew heavily on the principle of separate spheres, a commonly accepted principle of the Victorian era. This principle held that women and men had fundamentally different natures that suited them for separate spheres of action: women were suited to the domestic, private sphere, while men were better suited to the public sphere. Nightingale contended that nursing was simply an extension of women’s natural and rightful domain. Caring for the sick was already a woman’s duty; she argued it could also be a woman’s work (Nightingale 1860; Reverby 1987a). Nightingale’s evocation of separate spheres quelled the fears of those who threatened to stand in nursing’s way. Medicine would remain the province of men; women would work in their own, separate realm.1

Like most separate-but-equal doctrines, the principle of separate spheres was grounded in a deeper logic of inequality. The construction of nursing as a woman’s profession would legitimate nursing’s subordination to medicine for decades to come. The creation of a space apart, however, produced the possibility for nursing’s autonomy and the construction of independent value. Nightingale was quite forthright in arguing that only nurses should control nursing work. Although noting that nurses had a duty to obey physicians in medical matters, she took great pains to argue for the necessity of separate chains of command (Holton 1984; Nightingale 1865). For Nightingale, nursing’s autonomy was not just for the good of the nurse; it was for the good of the patient. She strongly believed that “medical therapeutics and ‘curing’ were of lesser importance to patient outcomes and she willingly left this realm to the physician” (Reverby 1987b, 7). In Nightingale’s view, women were superior at nursing, and when it came to promoting health and well-being, nursing was superior to medicine (Holton 1984; Reverby 1987b). At a time when physicians were turning toward science and away from direct patient care, nursing began creating a corps of educated women whose distinct role was to observe patients, respond to their physical needs, and be attentive to their mental and social needs. Physicians would cure, but nurses would care—in a way that was skillful and that materially mattered for patients.

This initial framing set the nursing profession apart from medicine, with different work, different knowledge, and a different orientation to patient care. However, maintaining this separation has taken active work on the part of nursing. At different times and places, both hospitals and professional medicine have attempted to annex nurses into their own regimes (Fairman 2008; Reverby 1987a; Rosenberg 1995). Nursing, however, has been successful at preserving its own identity. In the US, twenty-first-century nursing maintains its own professional organizations, educates its own workers, and upholds autonomous standards for regulating its work. Nurses may not always have the same power as physicians, but they have taken pains to be neither absorbed nor governed by them.

The work of the NP might seem to be the breaking point of nursing’s claims of separation from medicine. Nurse practitioners are licensed to provide the kind of care traditionally performed by physicians, such as assessing patients, making diagnoses, and providing or directing treatment. In twenty-two states and the District of Columbia, they can do so without physician oversight or involvement (American Association of Nurse Practitioners 2018). The NP’s work and growing autonomy has arguably made the wall between medicine and nursing more porous than it has ever been. Nursing’s original wariness of this new role illustrates the ways in which the NP was both an opportunity and a threat to internal notions of what it uniquely means to nurse (Barnes 2015; Brown and Olshansky 1998; Cusson and Strange 2008; Fairman 2008; Heitz, Steiner, and Burman 2004; Hill and Sawatzky 2011).

When I began my work on the NP, one of my first aims was to understand how the separation between medicine and nursing fared as NPs learned to, ostensibly, practice medicine. I turned my attention to a classic site of identity construction: professional schooling. In 2009, I spent twelve months following a cohort of NP students at Stanton School of Nursing. Stanton is highly ranked—what some might call elite. Elite schooling would not represent the modal experience; to be elite is defined by the status of being set apart. Elites are, however, usually the producers and chief circulators of group-level claims to legitimacy and status (Granfield 1992; Khan 2012; Reverby 1987a; Schleef 2006). If I wanted to understand how nursing fashioned and maintained an identity apart from medicine, elite schooling was one place to look.

The first thing I learned about nursing education is that from a credentialing perspective, every NP is a nurse. Prospective NPs must complete the education and licensure to become RNs before they can go on to train as NPs. When I spoke with Stanton’s NP students about the transition from RN to NP, I expected to hear stories of “moving up” from nursing or of “getting through” the RN program as a credentialing hurdle. Instead, these students felt that the experience of being a nurse was fundamental to learning to be an NP (Trotter 2019). One student asserted that it was in being a nurse that he learned “to not just see the patient as a medical diagnosis or a set of problems,” and that his experience as an RN gave him “a unique perspective on [providing] primary care as an NP.” Another student shared: “It was in going through nursing school [and working as an RN] that I realized that nurses weren’t just doctors’ flunkies . . . that they were the ones at the bedside making a real difference in the patient’s life.” The time prospective NPs spent working at the bedside was not just about experience but about learning to embody what it meant to be a nurse. Even as they made their way through the NP curriculum, the salience of being a nurse remained.

To risk stating the obvious, it is not only RN education that happens in nursing schools but also NP education. Although ostensibly learning diagnostic medicine, these students were being taught a curriculum created by nurses and delivered by nursing faculty. Students were certainly cognizant that they were learning skills that, to some extent, still belonged to medicine. Yet they told stories that reframed much of this work as nursing work. Through educational narratives, they reworked nursing’s traditional claims to “whole person care,” “knowing the patient,” and “relational interaction” (Apesoa-Varano 2016; Benner and Tanner 1987; Evans 1996; Radwin 1996; Tanner et al. 1993) into NP-specific modes of care (Trotter 2019).

It was at Stanton that I first began to realize that nursing’s need to maintain its border with medicine was not only about professional control but also about claims to different expertise. Stanton’s students were not learning how to be like physicians but were figuring out how to remain nurses. As nurses, they were called to be practitioners of care—not as an affective orientation but as an iconic form of care work marked by relationship and responsiveness (Duffy, Albelda, and Hammonds 2013; England 2005). Nursing’s embodiment of care also invoked a different terrain of knowledge. I listened to faculty tell students, “doctors have their expertise, but you have your own.” And I listened carefully as faculty and students narrated the location of that expertise: on the bodies of the socially vulnerable. These NPs in training were being told that their expertise lay in the very skills that medicine, in its turn toward specialization, had left behind. And that their utility was in serving those whom society had left behind: patients without health insurance, patients living in poverty, and patients struggling to manage their health under stressful circumstances. In Stanton’s classrooms, the skills of relationship and of seeing the whole person put NPs in a position to be expert providers to those for whom economic and social precarity were daily realities. This was not simply a matter of empathy or compassion; it was about constructing a different kind of clinical problem to which they could apply nursing expertise (Trotter 2019).

I left Stanton with a firm sense of the kinds of stories, metaphors, and identities that NPs constructed to navigate their new role. At the same time, key questions remained about the relationship between what NPs said about themselves and how they might actually practice. The possibility that these were not one and the same was pointed out to me by a physician I knew who was completing a post-residency fellowship in pediatric anesthesiology. As I summarized my findings from Stanton, he countered, “Well, med students also form ideas about how they will practice. But then reality sets in.” Indeed, what would happen when newly minted NPs brought their classroom-honed ideas to work—in a world not of their own making, but negotiated with the expectations of colleagues, employers, patients, and payers? To understand this more complex set of social processes, I would need to leave the nursing school.

There were any number of places I could have gone to see NPs at work. I could find NPs at a retail walk-in clinic, at a federally supported neighborhood health clinic, or at a high-end specialty practice. Faced with such diversity, I initially grasped at the idea of finding an average case. However, after months of conversations with Stanton faculty and students, I had already begun to doubt whether such a case existed. For providers whose role was in flux, organizational variation seemed to be more the rule than the exception (Fairman 2008). Students in particular had developed a belief that an organization’s experience with NPs (and its physicians’ attitudes toward them) was at least as important in shaping their work as the setting.

If I could not reliably find an average portrait of NP practice, I made it my mission to find one that was likely to represent nursing’s ideal vision for NP practice. In the US, there is a group of health care organizations that self-identify as nurse-managed or nurse-led health care centers. Some are staffed by RNs trained in community or public health nursing while others provide NP-led primary care. But all embrace a vision of nursing leadership and, in agreement with the profession’s larger claims, all assert their value in serving vulnerable populations and working to eliminate health disparities. Through a combination of word-of-mouth and organizational networks, I found what I believed to be all seven of such centers that provided primary care in one northeastern city. Each of these centers allowed me to spend an afternoon or two observing clinic operations and meet with at least one administrator, as well as the NPs. I learned about each organization’s history, how it was financed, whom it served, and how it was staffed.

My goal in these conversations was both to develop an understanding of what being nurse managed meant and to investigate possibilities for fieldwork. This was how I found myself back in the halls of Stanton, speaking with the school’s dean of community practice. Forest Grove Elder Services was on that list of seven because Stanton School of Nursing owned and operated it. Sitting across the desk from the dean, I described my broader research and my reason for wanting to add Forest Grove to my organizational tour. In response, she delivered what sounded like a warning: “The Grove is more than just a clinic.” If I was looking for an ordinary clinic, the Grove was probably not where I wanted to be. She did, however, encourage me to visit the Grove, as an example of what nursing could and would do if allowed to embody its own orientation to patient care. I took both her warning and her encouragement to heart. Ultimately the Grove’s uniqueness, rather than its representativeness, convinced me to stay for the next two and a half years.

The Grove was one of many policy experiments in community-based forms of long-term care. Its focus on comprehensive, coordinated care is fairly unique in a landscape dominated by piecemeal service provision. However, with a nursing school as its fiscal and administrative manager, the Grove was as much a demonstration of nursing leadership as an experiment in older adult care. For Stanton, the Grove was a stage upon which to elevate both the nursing profession and nursing work. While the Grove’s model of care was not a nursing creation, Stanton often employed it as an exemplar of nursing expertise, professional mission, and nursing’s utility to policy makers. As a nurse-managed organization, the Grove strove to embody a nursing approach to care even as it provided what patients and payers would recognize as medical care.

More than a Clinic

In 1998, Stanton opened the Grove with fewer than ten members. It was a humble operation, housed within a small, three-story storefront. Even with this modest start, Stanton knew it was potentially doing something big. Nursing does not have the same entrepreneurial history as medicine; its denizens have mostly been employees rather than owners. In a landscape where it remains uncommon for nurses to operate their own health care organizations, the Grove was an opportunity for Stanton to move nursing into new terrain. It was not long before they began having measurable success.

In less than five years, the Grove’s member population had grown so large that it was able to open a second location. By 2005, membership had reached 250. The Grove was growing not just in size but in reputation. State and local politicians began to take notice of a program that seemed to appeal to consumers while also potentially lowering costs. In a nursing school newsletter, the dean of the nursing school reported that state administrators were asking the Grove to expand enough to accommodate five hundred members within the next two years. If the Grove wanted to continue growing, however, it would have to find a larger space.

Less than a mile from Stanton’s campus stood a vacant building that seemed almost perfect. The building was four stories of chimney-red brick, containing over seventy thousand square feet of useable space. Not only was it large enough to consolidate the Grove’s current members into one locatio...