Category Archives: Nurse practitioners

Remembering the Nurses of WW I (II)

“saving bits from the wreckage”

[The second of a series of essays about the gallant nurses of World War I commemorating the centennial of America’s entry into the war on April 6, 1917]

The term “blood bath” is always used metaphorically, even in its wartime sense of  a bloody massacre in which lives are lost.   Often it is used more loosely still, as in the crushing of opponents in sports or business or the purging of employees at a company.  “There Could Be a Bloodbath in Sports Media” reads one headline.[1]

For World War I nurses working in Casualty Clearing Stations (CCSs) and field hospitals on the Western Front, however,  blood bath could take on a startling literality.  Here is Beatrice Hopkinson writing in the fall of 1917 at the height of the fourth battle of Ypres (Passchendaele), after a general hospital close to her own took a direct hit.   She and an orderly began washing sheets and bedding of the bombed-out hospital in a big bath tub:  “Soon we seemed to be dabbling in a sea of blood.  When the lights were allowed on we looked at one another and we, too, looked as though we had been in a slaughterhouse.  Our clothing was blood stained up to our chins; arms and faces too.”  Things could be worse still in the operating room, which during major rushes became “a slaughter house,” a blood bath where ambulance drivers, aiding the exhausted nurses, “would seize a mop and pail and swipe up some of the blood from the sloppy floor, or even hold a leg or arm while it was sawn off.”[2]

Hours before the fate of wounded soldiers was decided, it was nurses – not emergency room physicians or combat-trained EMS providers – who triaged incoming wounded, determining which soldiers required emergency treatment for shock; which immediate surgery; which a ward bed to sleep and await treatment; and which quiet removal to the moribund tent to die.  Surgeons, who during battles might be operating 12-14 hours a day, had nothing to do with the process.  It fell to the trained nurses, the Sisters, to deploy what resources they had to do the sorting, and then to  stabilize as quickly as possible those wounded who could be stabilized.

What resources could they summon?  How, for example, did they identify wounded soldiers in shock?  Absent blood pressure meters and stethoscopes, much less lab studies and scans, they relied on their hands; their hands became instruments of differential diagnosis.  Here is Mary Borden’s powerful rendering of her work in the reception hut of a Belgium Casualty Clearing Station:

It was my business to sort out the wounded as they were brought in from the ambulances and to keep them from dying before they got to the operating rooms:  it was my business to sort out the nearly dying from the dying.  I was there to sort them out and tell how fast life was ebbing in them.  Life was leaking away in all of them; but with some there was no hurry, with others it was a case of minutes. . . . My hand could tell of itself one kind of cold from another.  They were all half-frozen when they arrived, but the chill of their icy flesh wasn’t the same as the cold inside them when life was almost ebbed away.  My hands could instantly tell the difference between the cold of the harsh bitter night and the stealthy cold of death.  Then there was another thing, a small fluttering thing.  I didn’t think about it or count it.  My fingers felt it.  I was in a dream, led this way and that by my cute eyes and hands that did many things, and, seemed to know what to do.[3]

Thus the hands-on method of recognizing what was termed, in the idiom of the time,  “wound shock.”  For soldiers who arrived off the battlefield in shock, it was nurses who sought to stabilize them by mastering the complicated procedure of pumping saline solution either subcutaneously or intravenously.  Why complicated?  The patients had to be kept warm, with saline kept at 120 degrees and air kept out of the tubes.  And the entire procedure had to be performed aseptically in huts or tents that, depending on the season, could be stifling or freezing.

Of course, soldiers off the Front might bleed out even before shock set in.  Blood transfusions were not available in WWI until the United States entered the war in 1917, bringing with it transfusion advocates like Boston’s Oswald Robertson, who was invited to British field hospitals to teach transfusion technique and also to show how citrated blood collected from Type O (universal) donors could be stored and shipped.  But even in large base hospitals, transfusion remained “a complicated job under the very best of circumstances.”[4]  It was never an option in most reception huts of CCSs and field hospitals.  So nurses managed hemorrhage with what they had:  artery compression, tourniquets, and a variety of constrictive bandages.  Skill and reaction time often determined whether soldiers even made it to the surgeons.  Following what stabilization the nurses could provide, surgical cases were rushed to the X-ray hut and then to the attached “theatre hut.” There surgeons relied on still other nurses, the “theatre sisters,” to assist them at the operating table.

Nurses’ role as surgical assistants usually continued  in the operating theatres of the  base hospitals to which survivors were subsequently sent for more extensive repair.  In the chaotic overflow of wounded that followed major battles, when as many as seven operating tables might be in continuous use around the clock for two weeks, they really had no choice.  “In ten days,” reported Helen Boylston from her front line field hospital in late March, 1917, “we have admitted four thousand eight hundred and fifty-three wounded, sent four thousand to Blighty [England], have done nine hundred and thirty-five operations.”  And then, with obvious pride,  “– and only twelve patients have died.”[5]

“One doctor and one nurse work at each table,” Julia Stimson wrote her parents from Base Hospital 21 near Rouen several months later,

and you can imagine what surgical work the nurse has to do, no mere handing of instruments and sponges, but sewing and tying up and putting in drains while the doctor takes the next piece of shell out of another place.  Than after fourteen hours of this, with freezing feet, to a meal of tea and bread and jam, and off to rest if you can in a wet bell tent in a damp bed without sheets, after a wash with a cupful of water.[6]

Even the auxiliary nurses were co-opted for surgical duty.  Kate Norman Derr, the well-off daughter of a former Medical Director in the U.S. Navy, was studying art in France when war broke out in 1914.  Resolved to aid the French cause, she volunteered at local hospitals before earning a nursing certificate from the French Red Cross.  In September, 1915 she reported to a French field hospital in the Marne Valley where, assigned to the operating ward, she assisted the surgeon in the 25 or more operations performed daily.  Horrified by the wounds she encountered, she nonetheless relished her newfound surgical identity.  “I think you would sicken with fright if you could see the operations that a poor nurse is called upon to perform,” she wrote her family, referring to “the putting in of drains, the washing of wounds so huge and ghastly as to make one marvel at the endurance that is man’s, the digging about for bits of shrapnel.  I assure you that the word responsibility takes a special meaning here.” For Derr, it was the struggle itself, “the sense that one is saving bits from the wreckage,” that shoved aside the sense of being “mastered by the unutterable woe.”[7]

Surgical technique was taught by surgeons who then relegated certain aspects of complex multi-wound operations to the nurses.  Shell fragments and shrapnel often lodged in different parts of a soldier’s body, in which case surgeons concentrated on the most penetrative, life threatening wounds while the nurses, forceps in hand, dealt with the more manageable, if far from minor, wounds.  The complex wound management that followed surgery, on the other hand, was almost entirely in the nurses’ hands.  It began once more in reception huts, where nurses determined which wounds required a surgeon’s attention and which they could handle themselves.  For smaller wounds – the term is relative – nursing care became surgical care:  nurses irrigated wound beds with saline solution and then debrided the wounds, using sterile probes to locate and remove shrapnel, bone fragments, embedded clothing, and debris.  Finally, they dressed the wound with the antiseptics then available – iodine, carbolic acid, hydrogen peroxide, perchloride of mercury, sodium hypochlorite, boracic acid, salicylic acid, chloride of zinc, potassium permaganate, either alone or in combination, in liquid or paste form.  Given the plethora of options and toxicity of the more effective antiseptics, choosing the optimal dressing for a particular soldier was no simple matter.

For soldiers with large and infected open wounds – the “gaping wounds” or “horribly bad wounds” or  “wounds so huge and ghastly of which the nurses wrote[8] – it was nurses who mastered the intricacies of the novel and highly effective Carrel-Dakin irrigation method, which saved countless lives and limbs.  Here a weak solution of sodium hypochlorite continuously circulated in the wound via a complicated setup in which a glass container fixed at the head of the bed fed tubes with four or five separate nozzles, each connected to another small rubber tube packed into a different part of the wound.  The whole affair was held in place with bandages and an adjustable clamp on the main tube to regulate the amount of antiseptic fed into the wound.[9]

Madame Carrel demonstrating the Carrel-Dakin method in a French field hospital in 1917

In cases of compound fracture, nurses themselves usually followed cleaning, irrigation, debridement, and wound dressings with splinting.  Back on the ward, with or without a surgeon’s assistance, they began Carrel-Dakin treatment and monitored the fractures, alert, for example, to obstructed circulation.  Taking these nursing activities in their totality, Christine Hallett has every reason to conclude that WWI nurses emerged from their European tours as wound care practitioners, adding that, in the rushes that  followed major battles, professional boundaries dissolved and their work merged with that of surgeons.[10]

Nurses of the Civil War were no less heroic, if in a different way.   They were heroic simply in overcoming the resistance of surgeons and military officers to their presence right off the battlefield, exposed to the naked bodies of wounded men.  They were heroic in battling corrupt quartermasters and stewards who withheld supplies and food parcels from the wounded, not to mention racist orderlies who brutalized the wounded, especially African-Americans.  And they were heroic in providing comfort care in the tradition of Florence Nightingale, struggling against the system to keep the wounded dry, warm, and adequately fed, “mothering” them with the same compassion as their granddaughters on the Front.

But Civil War nursing lacked the procedural underpinnings of Great War nursing.  There was no “scientific nursing” to do because scientific nursing only emerged after the war.  The authority they achieved was moral and occasionally administrative.  In the latter cases, when nurses became powerful Head Matrons and even founders of their own field hospitals, their authority was typically wrestled from surgeons and officers who never stopped hoping they would pack up and go home.  Nurses from elite families – Hannah Ropes, Sophronia Bucklin, Kate Cumming, Clara Barton – sounded off and got results.  But the results were moral, not professional, victories.  There was no system of triaging for nurses to implement; no protocol in place for cleaning and irrigating infected wounds with saline solution before dressing them with potent antiseptics.  Nor were Civil War nurses trained to perform minor surgery in reception tents or to assist surgeons in the operating tent.  Very occasionally, a Civil War nurse would rise above the morale-sapping gender prejudice of her camp and find herself alongside an operating surgeon, but she was the heroic exception to the rule.

The heroism of the nurses of WWI has to do with the manner in which they rose to their historical moment, bringing into their operational domain major developments in scientific medicine of the past half century.  Consider only the birth of bacteriology; the derivative understanding of antisepsis, asepsis, and sterilization; the development of antiseptics and serum therapy; and major advances in wound management and surgical technique.  These developments, conjoined in a combat workplace that relied on collegial staff relationships, enlarged nurses’ responsibilities in a procedural direction.  Unlike Civil War nurses, the nurses of World War I initiated medical treatments and performed medical procedures, and they did so without abandoning their traditional obligation to provide care that was calming, comforting, and reassuring.  Indeed, with the catastrophic wounding of body and mind made possible by World War I weaponry, the provision of comfort often deepened into supportive psychotherapy and end of life counseling.  Psychiatric nursing was born in the CCSs and field hospitals of WWI.  The well-trained nurse practitioners of today, empowered in many states to practice medicine (or is it “medicalized” nursing?) with little or no medical supervision, have nothing on their gallant forebears of a century ago.

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[1] http://thebiglead.com/2015/11/18/fanduel-draftkings-commercials-new-york-attorney-general.

[2] Beatrice Hopkinson, Nursing through Shot & Shell: A Great War Nurse’s Story, ed. Vivien Newman (South Yorkshire: Pen & Sword, 2014), loc 1434; N.A.,  A War Nurse’s Diary: Sketches from a Belgian Field Hospital (Cornwall, UK: Diggory, 2005), loc 805-820.

[3] Mary Borden, The Forbidden Zone (ed. H. Hutchison (London: Hesperus[1928] 2008), 95-96.

[4] Julia C. Stimson, Finding Themselves: The Letters of an American Army Chief Nurse in a British Hospital in France (NY: Macmillan, 1918), 123.

[5] Helen Dore Boylston, Sister: The War Diary of a Nurse (NY: Washburn, 1927), loc 497.

[6] Stimson, Finding Themselves, 142.

[7] Kate Norman Derr, “Mademoiselle Miss”:  Letters from an American Girl Serving with the Rank of Lieutenant in a French Army Hospital at the Front, preface by Richard C. Cabot (Boston: Butterfield, 1916), 33.  My great thanks to Alan Kohuth for sending me his original copy of Dere’s letters.

[8] For example, Edith Appleton, A Nurse at the Front:  The First World War Diaries, ed. R. Cowen (London:  Simon & Schuster UK, 2012), 161, 203; Helen Dore Boylston, Sister: The War Diary of a Nurse (NY:  Washburn, 1927), loc 463; Derr, “Mademoiselle Miss,” 33.

[9] The Carrel-Dakin method was devised by Alexis Carrel, a French surgeon, and Henry Dakin, an English chemist, who met in the lab of a field hospital near the forest of Compiegne in France in late 1914.  Carrel developed the solution and Dakin devised the apparatus to deliver it.  The components of the solution, incidentally, had to be combined in a precise ratio to provide wound sterilization without causing tissue irritation – another procedural feat of the WWI nurses, who prepared and tested every batch of solution from scratch.  Their task was greatly simplified in 1917, when Johnson & Johnson of New Brunswick, New Jersey began producing the components in sealed ampoules and vials in the prescribed ratios.  Successful use of the method was reported in several articles in the British Medical Journal during the final years of the war.  One in particular paid tribute to the Sisters, “whose careful attention to detail largely contributed to the success obtained in the use of the Carrel-Dakin method.”  J. S. Dunne, “Notes on Surgical Work in a General Hospital – With Special Reference to the Carrel-Dakin Method of Treatment,” BMJ, 2:283-284, 1918, quoted at 284.

[10] Christine E. Hallett, Containing Trauma:  Nursing Work in the First World War (Manchester: Manchester University Press, 2009), 56-59, 46.  Anyone writing about nursing in World War I owes an enormous debt to Hallett, whose two exemplary studies, Containing Trauma (op. cit.) and Veiled Warriors: Allied Nurses of the First World War (NY: OUP, 2014) provide far greater detail of each of the nursing activities I touch on here.

Copyright © 2017 by Paul E. Stepansky.  All rights reserved.  The author kindly requests that educators using his blog essays in their courses and seminars let him know via info[at]keynote-books.com.

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“Scope of Practice” Minefields

“. . . my clinical practice as a women’s health NP began in the mid-1970s.  My colleagues who had gone on to academic careers questioned my commitment to nursing and to nursing values.  A common question was ‘Are you a nurse, or are you a mini-doc?’  My answer was, is, and will always be:  ‘I am a nurse with primary care skills.  I take care of my patients within a nursing framework. . . . my values lie in nursing, not in the medical model.  I care for my patients as a fully prepared, primary care provider of women.” – Judith A. Berg & Mary Ellen Roberts, “Recognition, Regulation, Scope of Practice:  Nurse Practitioners’ Growing Pains” (2012)[1]

“We agree certified nurse practitioners can provide many core primary care services, but it is important that this not be misunderstood as suggesting that nurses are interchangeable with physicians in providing the full depth and breadth of services that primary care physicians provide.  The two professions are complementary but not equivalent.  For diagnostic evaluation of clinical presentations that are not straightforward and for the ongoing management of complex or interacting medical problems, the most appropriate clinician is the physician.” – J. F. Ralston & S. E. Weinberger, “Nurses’ Scope of Practice” (2011)[2]

Entering the debate on the “scope of practice” between nurse practitioners (NPs) and physicians is like parachuting onto a battlefield strewn with semantic landmines and decaying verbiage, while overhead the whistle of incoming word-tipped artillery fire grows louder.  For the opposing forces, the NPs and the MDs, negotiation about the scope of NPs’ provider activities has given way to incendiary propaganda and explosive metaphors.  It is all a matter of logistics, planning, grand strategy, tactical advance and retreat.

When the nursing historian Julie Fairman and her colleagues argue that “physicians’ additional training has not been shown to result in a measurable difference from that of nurse practitioners in the quality of basic primary care services,”[3]  they leave unexamined the meaning of basic.  Someone, after all, has to do the defining, and in so doing, to differentiate basic services from services that, in given circumstances, are not so basic.  Someone also has to stipulate how exactly “quality” is being assessed, qualitatively and quantitatively, in both the short- and long-term.

It is fine to make the commonsensical point that nurse practitioners should be permitted to practice “to the fullest extent of their skills and knowledge,” as recommended by the authors of the Institute of Medicine report of 2010, The Future of Nursing.[4]  But who decides what “fullest extent” actually means in relation to specific clinical contingencies and management challenges?  Is there even consensus on the meaning of NP “knowledge and competence” in contradistinction to the “knowledge and competence” of those who receive medical training?  Literally, then, what are Fairman and her colleagues talking about?

NP advocates make tactical use of the word “partnership” in framing debates about NP expansion.  And yes, certainly we need NPs and physicians to be collaborative partners in providing quality health care.  But the notion of “partnership,” as used by NPs, also subserves polemics.  Partnership, after all, does not entail parity among partners.  In law and business, for example, there are senior partners and junior partners, name partners and equity partners, voting partners and nonvoting partners.  In medicine, there are any number of  procedures (e.g., colposcopy, sigmoidoscopy, nasopharyngoscopy) that fall within the domain of adult primary care, but that many primary care physicians no longer perform, even if they are competent to do so, owing to issues of liability and lack of third party coverage.  This does not mean that primary care physicians, gynecologists, gastroenterologists, and ENTs are not “partners” in care, but rather that “partnership” does not abrogate the need for a division of labor, with the differing responsibilities, obligations, and entitlements that such  division entails.

Physician groups threatened by the legislative incursions of nonmedical providers like NPs are no better and even worse.  The Physicians Foundation is a nonprofit organization of medical groups formed to push back the nonmedical invaders, especially nurse practitioners.  Their report of November, 2012, Accept No Substitute: A Report on Scope of Practice, brims with military metaphors.  The authors, Stephen Isaacs and Paul Jellinek, write of “holding the line” on “expansionary forays” and summarize bulletins “fresh from the front lines.”  “What is the score so far?” they ask.  “Who is winning these scope of practice battles?”  And the military metaphors segue into sports metaphors, with the authors’ dour acknowledgment that physicians “are usually playing defense on scope of practice” brightened by occasional successes in eliminating nonphysician licensing.  In the latter cases, they exult, physicians “are in fact able to move the ball up the field.”[5]

What is one to make of such sophomoric posturing in the face of a serious and growing shortage of primary care physicians?  Where will we find the 51,880 additional primary care physicians that, according to recent published projections, we will need by 2025?[6]  It is easy to appreciate the exasperation of primary care NPs who face such opposition in the face of well-established facts.  To wit:   Only 20% of today’s medical students will choose a primary care specialty; NPs provide more cost-effective care than their physician counterparts; patient surveys reveal satisfaction with the care provided by NPs; and half of all physicians in office practice already work with NPs, certified nurse midwives, and/or physician assistants.  All such facts, be it noted, are ceded by the authors of The Physicians Foundation report.[7]

It is time for physicians to accept not only the reality, but also the socioethical desirability of nonphysician providers.  By the same token, it is time for nurse practitioners to accept the reasonableness of practice limits.  An expanded scope of practice is not a limitless scope of practice.  And, yes, self-evidently, the limits to which NPs are subject will not be identical to the limits imposed on physicians. There are indications for which physician consultation and supervision should be mandatory; there will be procedures that only physicians, including primary care physicians, are trained and legally authorized to perform. Establishing boundaries will always be shaped by power politics and economic self-interest, but it need not be deformed by them.  The process can be elevated by concern for public safety and prudent good sense.  By way of identifying two areas in need of further dialogue informed by complementary needs for patient access and patient safety, consider the topics of chronic disease management and prescriptive authority.

Nurse practitioner advocates tout the important role of NPs in managing chronic disease, and type 2 diabetes is typically given as a case in point.[8]  Certainly NPs can manage diabetics whose glucose levels must be monitored and insulin dosages adjusted.  There is also evidence that specialized NPs are highly effective in collaborative practice with primary care physicians, where they serve as diabetic care coordinators.[9]  What then is the problem?  It arises from the fact that management of chronic disease, especially among the elderly, is rarely a matter of managing a  stable disease entity.  In later life, diabetes, however well monitored and managed, typically leads to neuropathy, retinopathy, and/or kidney disease.

Are NPs trained to manage chronic diseases as independent providers when management ipso facto entails a plethora of intersystemic complications?  Consider another example.  Perhaps an NP-nephrologist can manage end-stage renal disease (ESRD), a chronic disease that can be stabilized for long periods with dialysis.  But what happens when such management, and the prolongation of life it entails, leads to diabetes and heart disease, as it often does?  Is such management still within the “knowledge and competence” of NPs?  As I wrote in “The Costs of  Medical Progress”:

Chronic disease rarely runs its course in glorious pathophysiological isolation.  All but inevitably, it pulls other chronic diseases into the running.  Newly emergent chronic disease is collateral damage attendant to chronic disease long-established and well-managed.  Chronicities cluster; discrete treatment technologies leach together; medication needs multiply.

Well-trained NPs no doubt bring much-needed talent to managing intercurrent disease in certain respects.  I am no expert here, but I am open to the possibility that independent management of chronic disease, particularly among the elderly, may not be commensurate with the discrete “skill set” that NPs acquire, even as this “set” is enlarged by the medley of nonmedical skills inculcated by “nursing education and its particular ideology and professional identity.”[10]  Management of chronic disease, that is, often entails complexity of a distinctly medical sort.  Scope of practice debates should be informed by the fact that diabetes, to keep to the example, is no longer a disease with a stable natural history.[11]  The same can be said of kidney disease and heart disease and many types of cancer.  So the question of what NPs can and cannot do needs to be fleshed out in a more clinically realistic manner:  We need to know whether NP-generalists are as capable as primary care physicians of managing chronic illness in the context of life span issues and specific dimensions of patient care.  Are they as capable as primary care physicians, for example, of prioritizing interventions among older patients with multiple chronic diseases?[12]

Another “fullest extent” problematic concerns prescribing privileges.  NPs and APRNs (advanced practice registered nurses) demand the same authorization to prescribe medications as physicians.  This insistence, globally formulated, masks the fact that prescriptive authority is always qualified in various ways. Perhaps physicians, NPs and APRNs, and legislatures should set the all-or-nothing rhetoric aside and wrestle with the real-world issue of “prescriptive authority of various levels” that gets codified in state law.[13]  Is it within the NP’s scope of practice, for example, to change antibiotics without physician consultation for a child who comes to the pediatrician with fever, sore throat, and pain, and whose symptoms have not abated with first-line antibiotics prescribed by the NP?[14]  To begin to get a handle on this kind of issue, one must at present read the law on NP “scope of practice” in a particular state, as NPs have in fact been enjoined to do.[15]

Here is the point: primary care NPs in all states deserve – and now have – “prescriptive authority,” but reasonable people may differ on the breadth of this authority.  Here is an issue that can be subject to empirical research and meaningful negotiation among all the stakeholders, including the public. To wit, what kinds of drugs are NPs trained to prescribe and, based on survey data, what kinds of drugs do they actually prescribe?  Several studies from the 1980s showed “that NPs prescribe a very limited number of relatively simple medications to predominantly healthy populations.”[16]  Perhaps these studies are badly dated and superseded by  recent studies attesting to the broadened range of drugs now prescribed by primary care NPs. Well and good.  Then the “prescriptive authority” granted to NPs by legislatures should be broader rather than narrower.

But, normatively speaking, should it be equivalent to the prescriptive authority of primary care physicians?  Should NPs be granted authority to prescribe controlled substances without collaborative arrangements with physicians and without limiting stipulations as to dosage and duration of use?  Here is another issue ripe for further negotiation informed by empirical research and considerations of patient safety.  I bring no special expertise to the table beyond noting that NPs, however great their knowledge and competence, do not receive the extensive training in physiology, pathophysiology, and pharmacology that physicians do. I do not find it unreasonable that NP-issued scripts should require some degree of physician involvement, as is now the case in 32 states.[17]

The power differential between organized medicine and organized nursing, including medical specialty societies and NP/ACRP societies, has made matters worse for highly trained nurse practitioners seeking to practice to the fullest extent of their knowledge and competence.  But it has also led some NP representatives to demonize medical groups that seek any drawing of lines, since the very act of drawing a line can only derive from the economic imperative to “hold the line” on NP rights.  Consider the reaction of the editor of Policy Politics Nursing Practice in 2006 to the insistence of medical groups that the difference between nurse practitioners with doctorates and physicians be clarified for the benefit of patients. “Does anyone,” he wrote, “seriously see it as part of a conspiracy to mislead patients by having APRNs refer to themselves as doctor? And are physical therapists (who are moving toward a requirement for doctoral-level education), psychologists, and pharmacists in on the conspiracy, too?”[18]

Well, no, hardly.  But the issue here, shorn of polarizing rhetoric, isn’t about willful misleading; it’s about the cultural valence of the title “doctor” and the everyday meanings people impute to it in connection with healthcare.  A patient who seeks treatment from a licensed primary care provider who is referred to and addressed as “doctor” will, absent some kind of a priori clarification, likely assume the “doctor” in question is a physician.  It is not unreasonable to suggest reasonable efforts at patient education to clarify the different roles and orientations of different kinds of providers.  And what prevents NP groups from adopting their own strategy of patient education?  What prevents them from developing and publicizing endorsements of the “doctor of nursing practice” degree that play to the latter’s  “doctoring” strengths in contradistinction to those of physicians?

If there is a conspiracy out there, it is one perpetrated on the public by both physicians and NPs.  It is a conspiracy of partial explanations.  It is the conspiracy among physicians who refuse to cede that nurse practitioners have arrived, that they are licensed clinical providers who are perfectly capable of providing a great deal of what has traditionally been the province of medicine, especially primary care medicine.  But it is also the conspiracy among NP advocates whose rhetoric masks important distinctions, viz., that “fullest extent” of NP/APRN practice is not coextensive with the typically full extent of care that primary care physicians are trained to provide.  This follows from various considerations, not least of which is that family physicians train a total of 21,000 hours whereas NPs train between 3,500 and 6,000 hours.[19]  There, I’ve done it again.  I’ve made a a series of claims that strike me as reasonable and will win me no friends in either warring camp.

__________________________

[1] J. A. Berg & M. E. Roberts, “Recognition, regulation, scope of practice:  nurse practitioners’ growing pains,” J. Amer. Acad. Nurse Pract., 24:121-123, 2012, at 121.

[2] J. F. Ralston & S. E. Weinberger, “Nurses’ scope of practice,” Correspondence, New Engl. J. Med., 364:281.

[3] J. A. Fairman, et al., “Broadening the scope of nursing practice,” New Engl. J. Med., 364:193-96, at 193.

[4] As quoted in J. A. Fairman & S. M. Okoye, “Nursing for the future, from the past: two reports on nursing from the Institute of Medicine,” J. Nurs. Ed., 50:305-311, 2011, at 309.

[5] S. Isaacs & P. Jellinek, Accept No Substitute:  A Report on Scope of Practice. White Paper for The Physicians Foundation, November, 2012 (http://www.khi.org/documents/2014/aug/26/accept-no-substitute-report-scope-practice/), pp. 1, 2, 3, 6.

[6] S. M. Petterson, et al., “Projecting US primary care physician workforce needs:  2010-2025,” Ann. Fam. Med., 10:503-509, 2012.

[7] Issacs & Jellinek, Accept No Substitute, pp. 8-13.

[8] G. C. Richardson, et al., “Nurse practitioner management of type 2 diabetes,” Permanente Journal, 18:e134-140, 2014;  M. J. Goolsby, “2006 American Academy of Nurse Practitioners diabetes management survey,” J. Amer. Acad. Nurse Pract., 19:496-98, 2007; Fairman, et al.,  “Broadening the scope of nursing practice,” p. 193.

[9] Richardson, “Nurse practitioner management of type 2 diabetes,” op cit.; K. G. Shojania, et al., “Effects of quality improvement strategies for type 2 diabetes on glycemic control:  a meta-regression analysis,” JAMA, 296:427-40, 2006; S. Ingersoll, et al., Nurse care coordination for diabetes:  a literature review and synthesis,” J. Nurs. Care Qual., 20:208-14, 2005.

[10] On the notion of clinical competence as acquisition of a “skill set,” see, e.g., J. Fairman, “Delegated by default or negotiated by need?:  physicians, nurse practitioners, and the process of clinical thinking,” in E. D. Baer, et al., Enduring Issues in American Nursing (NY: Springer Pub., 2002),  pp. 311-12 and J. Fairman, Making Room in the Clinic: Nurse Practitioners and the Evolution of Modern Health Care (New Brunswick: Rutgers, 2008), pp. 187, 190.

[11] Chris Feudtner terms it a “cyclical transmuted disease” in Bittersweet: Diabetes, Insulin, and the Transformation of Illness (Chapel Hill: North Carolina, 2003), p. 36.

[12] For exemplary instances of how clinical judgment – and not a clinical “skill set” – enters into the prioritizing of treatment interventions among concurrent chronic diseases, see K. C. Stange, et al., “The value of a family physician,” J. Fam. Pract., 46:363-69, 1998; K. C. Stange, “The generalist approach,” Ann. Fam. Med., 7:198-203, 2009, and E. J. Cassell, Doctoring: The Nature of Primary Care Medicine (NY: Oxford University Press, 1997).

[13] Of course, the issue of  levels of prescriptive authority pertains not only to physicians and NPs, but also to physician assistants, dentists, optometrists, osteopaths, and podiatrists. For the concrete manner in which the state of Florida spells out prescriptive levels for each of these professions, see http://www.thehealthlawfirm.com/resources/health-law-articles-and-documents/prescribing-in-florida.html).

[14] M. Crane, “Malpractice risks with NPs and PAs in your practice,” Medscape, Jan 3, 2013 (http://www.medscape.com/viewarticle/775746).

[15] E.g., C. Buppert, “Scope of practice,” J. Nurse Pract., 1:11-13, 2005.

[16] C. D. DeAngelis, “Nurse practitioner redux,” JAMA, 271:868-71, 1994.  The studies  DeAngelis cites are:  P. Repicky, et al., “Professional activities of nurse practitioners in adult ambulatory care settings,” Nurse Pract., 4:27-40, 1980; D. Munroe, et al., “Prescribing patterns of nurse practitioners,” Am. J. Nurs., 82:1538-40, 1982; J. Resenaur, “Prescribing behavior of primary care nurse practitioners,” Am. J. Public Health., 74:10-13, 1984.

[17] “Nurse Practitioner Prescribing Authority and Physician Supervision Requirements for Diagnosis and Treatment” (http://kff.org/other/state-indicator/nurse-practitioner-autonomy/).

[18] D. M. Keepnews, “Scope of practice redux?,” Policy, Politics & Nurs. Prac., 7:84-86, 2006, at 84.

[19] D. Marbury, “Scope of practice debate,” Med. Econ., September 10, 2013, 26-30, at 27 (http://medicaleconomics.modernmedicine.com/medical-economics/news/scope-practice-debate?page=full).

Copyright © 2014 by Paul E. Stepansky.  All rights reserved.

What Do Nurse Practitioners Practice?

What should the nurse practitioner’s “scope of practice” be  and how autonomously should she or he be allowed to practice within that scope?  A half century after the first advanced training programs brought nurses into the ranks of clinical providers, these two questions continue to bedevil nursing, medicine, insurance companies, and state legislatures.  The crucial role of nurse practitioners in modern health care delivery, their ability to provide primary care, and the satisfaction of patients who receive this care – these facts are well-established and, for me at least, beyond dispute.

But questions of scope of practice and practice prerogatives (including prescribing privileges) remain contentious, and different state legislatures have codified different answers.   I have no desire to enter debates that will likely continue at medical, nursing, and legislative levels for some time to come.  But let me offer one historian’s perspective on a few aspects of these knotty issues.

The expansion of nursing’s role in the direction of specialized clinical expertise occurred in an amazingly brief stretch of time.  In 1955, The American Nurses Association (ANA) approved a legal definition of nursing practice that prohibited “acts of diagnosis and prescription of therapeutic or corrective measures,” and it was only seven years later, in 1962, that it held its first clinical sessions at its annual convention.[1]  Even then, until 1968, the ANA’s Code for Professional Nurses framed the nurse’s professional responsibilities in terms of the nurse’s relationship to physicians.[2]  Yet, by the mid-60s, spearheaded by reforms in nursing education then underway, the term “nurse practitioner” came into use.  It conveyed a nurse with “specialized expertise,” often in hospital settings, that grew out of additional training beyond the three years of hospital-based training that led to state licensure as a Registered Nurse.

“Specialized expertise” is an evocative but imprecise term.  In nursing, it initially conveyed expertise in one or another aspect of hospital-based care.  In the early 1900s, nurses acquired expertise as x-ray technicians and microscopists, and then again in the 1930s, they “specialized” in monitoring polio patients in their iron lungs.  During World War II, nurses both on the front lines and in stateside hospitals began to perform venipunctures to administer fluids intravenously; after the war, they continued to do so, and some  became specialized IV  therapists, performing and monitoring  IVs all along their units.

But in postwar America it was especially the new technologies brought to bear in treating acutely ill patients that elicited nurse specialization.  Self-evidently, we needed critical care nurses, obstetrical nurses, and dialysis nurses able to exercise independent judgment and initiate (or discontinue) treatments in exigent circumstances, in what the historian Margaret Sandelowski terms “emergent life-threatening conditions.”  By the 1960s, as Sandelowski observes, the new “machinery of care” had fostered a more collegial and collaborative relationship between physicians and nurses.[3]  But this machinery  – vital function monitors, cardiac monitors, electronic fetal monitors, and the like – was integral to medical care in the hospital.  These monitors were not invented by nursing scientists as extensions of nursing care; they were instruments of improved hospital care whose design, manufacture, and intended use fell within the domain of physicians and the medical model.

The nomenclatural challenge proved even greater when advanced nursing practice left the hospital setting and became office-based, especially in the realm of primary care.  Historians of nursing such as Julie Fairman tend to collapse the distinction between hospital-based specialty nursing and independent “nursing practice” in a global narrative of nursing’s coming-of-age in the four decades following the end of World War II.  The storyline of professional self-becoming involves new forms of collegial collaboration between individual nurses and physicians, which, over time, empowered the nursing profession to liberate itself from the bondage of organized medicine, with its long-held belief in the subordinate role of nurses as physician extenders.  What tends to be glossed over is the phenomenology of “expertise” in relation to different professional activities.  Expertise in the implementation of technologically driven, hospital-based monitoring – with the diagnostic and treatment prerogatives associated with it – is not the same as the expertise that inheres in being a “practitioner” of medicine.

Or is it the expertise that inheres in being a “practitioner” of nursing?  In her illuminating history of the nurse practitioner movement in America, Fairman delineates the inter-professional tensions congealed in this question.  Even  Loretta Ford and Henry Silver, she points out, who collaboratively developed the first (pediatric) nurse practitioner training program at the University of Colorado in the mid-1960s, used different, politically laden terminology to describe exactly what kind of nonmedical practitioner they were training.  For the pediatrician Silver, the new provider would be a “nurse associate”; for the nurse educator Ford, she or he would be a “nurse practitioner.”[4]

And the linguistic-cum-political tension was played out in different pairs of descriptors.  Nurse practitioners saw themselves as “taking on” diagnostic and treatment activities traditionally reserved for physicians, whereas physicians saw themselves as “delegating” certain medical tasks to nurses.[5]  The need to define the nurse specialist’s prerogative to diagnose and treat illness as  something other than “medical”  was at the heart of the American Nurses Association’s need to distance itself from another nonmedically trained practitioner who emerged at this same moment in  American history:  the Physician Assistant.  PAs were precisely what newly empowered clinical care nurses, at least in the eyes of their professional organization, did not want to be: a Physician Assistant rather than an autonomous Nurse Practitioner.[6]

In the realm of independent practice, this claim is highly problematic, since diagnosis and treatment of illness is not nursing “practice” in any historically meaningful sense of the term; rather, diagnosis and treatment have always fallen to the physician, as the word “physician” has been understood since the beginning of the thirteenth century, when Anglo-Normans gathered the Latin “physicus” and the French “physic” into the English “physic,” from which the word  “physician” as a medical practitioner came in to use later in the century.  It is easy to see how nursing practice can envelop sophisticated technological skills that are teachable and learnable.  But the art of diagnosis and treatment – and the qualities of learned judgment[7] that fall to this task – have always been the province of medicine.

The historical claim enfolds an epistemic claim, a claim about the nature of different kinds of knowledge.  Nursing knowledge, as codified in Florence Nightingale’s Notes on Nursing: What It Is and What It is Not (1859) and the British and American training programs that adopted her model in the 1870s and thereafter, has never been coextensive with medical knowledge.  For  Nightingale and her cohort of nursing educators, it remained a “gendered” (read: womanly) knowledge of comfort care; such care drew on sanitary science and scientifically informed  bedside observation, both infused with a maternalistic sensibility.[8]  Whether or not the knowledge base that subtends such patient-centered caring is something other than medical knowledge (as Nightingale believed) or a neglected subset of medical knowledge, is beside the point. And the point is this:  The kind of “knowledge and skills”[9] that enter into independent clinical practice – “knowledge and skills” that, to be sure, nurse practitioners and other nonmedical providers can acquire to some extent  – are by their nature medical.  This is why the struggle of nurse practitioners to obtain state licensure that permits them to “practice” without medical supervision has been halting and may never succeed entirely.

It is not simply a matter of power in the sense of Foucault, of organized medicine’s ability to withhold, control, and/or regulate entry into the world of practice.  It is because the science of clinical evaluation, diagnosis, and treatment that emerged in postbellum America was vested in the medical profession, not in the nascent nursing profession.  In the final three decades of the nineteenth century, we behold the paradigm shift in medicine that historians endlessly write about:  Medicine became scientific medicine, and this shift, with its associated educational and organizational changes, coincided with the emergence of a “profession” in the modern sense of the term.  The physician, not his (then) helpmate nurse, was part of the profession vested with the scientific understanding of illness and the cultural authorization to act on this understanding by diagnosing and treating it.[10]

The foregoing helps explain why, in retrospect, the ANA’s insistence that pediatric nurse practitioners retain the prerogative to delineate their own scope of practice was foredoomed.  ANA leaders sought to contest a notion of “practice” that, by the early 1970s, was incontestable.  And the pediatric nurse practitioners knew as much.  Like their nurse anesthetist forebears, who formed the National Association of Nurse Anesthetists in 1932,[11] they walked away from the ANA and formed their own professional association, the National Association of Pediatric Nurse Associates and Practitioners (NAPNAP) in 1973.  And the NAPNAP, without further ado, accepted affiliation with the American Academy of Pediatrics, realizing that the ANA’s insistence on complete autonomy for nursing was self-defeating.  The pediatric nurses, if not the ANA leaders, realized that such insistence militated against the idea of team practice, of a pediatrician, pediatric nurse practitioner, and nurse working together, and it contravened the reality that, in all such cases, the pediatrician would be the leader of the team.[12]

The dilemma for nurse practitioners is that they have spent  over a half century trying to define themselves by what they are not.  They are not physicians.  They are not physician assistants or associates.  They are not general nurses who lack advanced postgraduate training and specialty licensure.  So what exactly are they?

In the late 1950s and 1960s, nurse educators like Esther Brown and Hildegard Peplau sought to fill in the lacuna by articulating a new basis for nurse practitioner expertise.  In so doing, they adopted the same orientation as the founders of the “family practice” specialty movement during the same time.  That is, they sought to equate the nurse practitioner’s “expert clinical practice”  with a psychosocial sensibility and an ability to provide holistic psychotherapeutic care.  Social science course work and psychodynamic training, they hoped, would move the nursing practitioner away from medicine and toward this new kind of nursing expertise.

That Brown and Peplau spearheaded this effort in nurse education is hardly surprising, given their respective backgrounds.  Brown, a social anthropologist on the staff of the Russell Sage Foundation, authored Nursing for the Future (1948), a Foundation report that advocated university-based nurse training schools in the service of a vague psychosocial vision of nursing care.  The nurse of the future, she wrote, would “complement the patient by supplying what he needs in knowledge, will, or strength to perform his daily activities and also to carry out the treatment prescribed for him by the physician.”  Peplau, the founder of psychiatric nursing, followed an M.A. at Columbia’s Teachers College, where she completed the first course in advanced psychiatric nursing, with psychoanalytic training at New York’s William Alanson White Institute.[13]  She believed that psychiatric nurses should function as psychotherapists, and, implicitly, that all nurses should bring a broad psychosocial, really a psychotherapeutic, orientation to their work.  Were Brown, Peplau, and their associates successful in reforming nursing training in a manner that subserved a new kind of nursing identity?   No, certainly not in the manner they envisioned.  And further, at the time their educational reforms were introduced in the nursing schools of large public universities, there were serious problems: Graduates overfed with the new social science curriculum were simply unprepared to assume the responsibilities of nursing practice.[14]

_______________________

 My father, William Stepansky, whose remarkable postwar career in family medicine has been woven into many of these essays, was a pharmacist before he was a physician.  He entered Philadelphia College of Pharmacy and Science in 1940, but his education was interrupted by induction into the army in March, 1943, several months before he completed his junior year.  He had not begun pharmacy college with the intention of attending medical school – this seemed an utterly far-fetched dream for the son of poor Russian émigrés who fled the Pogroms in 1921 and struggled to raise a family in the Jewish enclave of South Philadelphia.  His own mother thought him foolish for entering college and crazy (meshuga) when he mentioned his interest in medicine.  In 1946, after two years of service as a surgical technician on the battlefields of France, Belgium and Germany and an additional six months as a laboratory technician in Pilzen, Czechoslovakia, he returned to Philadelphia, where he completed his pharmacy training in 1947.  Only then, with the G.I. Bill in place, did he allow himself to envision a career in medicine, and following an inventive series of initiatives, he gained admittance to Jefferson Medical College, where he joined the freshman class in the fall of 1948.[15]

My father not only retained an active pharmacy license throughout his career, but actually “practiced” pharmacy out of his Trappe office.  He maintained an impressive inventory of basic and not-so-basic drugs, and he concocted, among other things, the marvelous “red medicine” of which I have written.  He became a staff research clinician for McNeil Labs and later participated in clinical drug trials with the Psychopharmacology Research Unit of the University of Pennsylvania.  Pharmacy training certainly proved helpful to him and his rural patients, but it was not at the core of his professional identity.  He was not a “pharmacist practitioner” or an “advanced practice pharmacist.”  He was a physician, a general practitioner of medicine.

Perhaps it is time for the nurse practitioner profession to dispense with the “nurse” appellation altogether.  These men and women are not professional nurses as the notion of nurse professionalism took shape over 150 years, even though they come to  medical “practice” through nursing training and the patient-centered values it instills.  But additional clinical training of several years duration beyond the R.N. or B.S.N. level, I suggest, takes them out of the realm of nursing practice altogether.   So, with a nod to perduring intra- and inter-professional politics, let’s cast aside the terms “medical,” “physician,” “nurse,” and “nursing” altogether, and come up with something more accurate.  Advanced practice nurses should henceforth be designated “licensed clinical providers” or “licensed clinical practitioners,” with the appropriate specialty designation appended to their licenses, e.g., “licensed clinical provider – primary care” or “licensed clinical provider – nephrology” or “licensed clinical provider – oncology.”  There, I’ve said it.  These designations are accurate and neutral and therefore certain to please no one.

 __________________

[1] J. Fairman, Making Room in the Clinic:  Nurse Practitioners and the Evolution of Modern Health Care (New Brunswick:  Rutgers University Press, 2008), pp. 119-21.

[2] L. Freitas, “Historical roots and future perspectives related to nursing ethics,” J. Prof. Nurs., 197-205, 1990, at 202.

[3]  M. Sandelowski, Devices and Desires:  Gender, Technology, and American Nursing (Chapel Hill: University of North Carolina Press, 2000), pp. 127-28.

[4] Fairman, Making Room in the Clinic, p. 91.

[5] J. Fairman, “Delegated by default or negotiated by need?:  physicians, nurse practitioners, and the process of clinical thinking,” in E. D. Baer, et al., Enduring Issues in American Nursing (NY:  Springer Pub., 2002), pp. 309-333, at p. 323.

[6] Fairman, Making Room in the Clinic, pp. 95ff.

[7] N.B. I do not understand “clinical judgment,” with its reliance on mentoring and tacit knowing, in the same way Fairman understands “clinical thinking,” viz., as a process or skill set. See Fairman, “Delegated by default,” pp. 311-12 and Making Room in the Clinic, p. 187.

[8] For a wonderful popular exposition of  Nightingale’s vision of the nurse transposed to the Bellevue Hospital Training School in the early 1880s,  see F. H. North, “A new profession for women,” The Century, 25:30-37, 1882.

[9] Fairman, “Delegated by default,” p. 323.

[10] These brief remarks allude to, without doing justice to, the brilliant analysis of Thomas Haskell on the emergence of modern professions in postbellum America.  See T. L. Haskell, The Emergence of Professional Social Science:  The American Social Science Association the the Nineteenth-Century Crisis of Authority (Baltimore: John Hopkins, 2000 [1977]), pp. 68-74, 91-121, and passim.

[11] K. Koch, “Agatha Hodgins, Lakeside Alumnae Association, and the founding of the AANA,” AANA Journal, 73:259-62, 2005.

[12] Fairman, Making Room in the Clinic, pp. 175-80.

[13] On Peplau’s graduate training at Teacher’s College and the William Alanson White Institute, see B. J. Callaway, Hildegard Peplau: Psychiatric Nurse of the Century (NY:  Springer Pub., 2002), pp. 167-91.

[14] Dominique Tobbell documents the perceived deficiencies of 1960s graduates of the UCLA and University of Minnesota nursing schools, where the new curriculum was implemented,  in “’Coming to grips with the nursing question’:  the politics of nursing education reform in 1960s America,”  Nurs. Hist. Rev., 22:37-60, 2014.

[15] This paragraph is culled from my memoir of my father’s life and career, P. E. Stepansky, The Last Family Doctor:  Remembering My Father’s Medicine (Montclair, NJ:  Keynote, 2011).

Copyright © 2014 by Paul E. Stepansky.  All rights reserved.