Category Archives: Nursing and Gender

What Do Nurse Practitioners Practice?

Posted on August 22, 2014 | Leave a comment

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.

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Posted in Nurse practitioners, Nursing, Nursing and Gender, Nursing education, Primary Care

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Your Tool Touches Me

Posted on February 8, 2014 | Leave a comment

It is little known that René Laënnec, the Parisian physician who invented the stethoscope at the Necker Hospital in 1816, found it distasteful to place his ear to the patient’s chest.  The distastefulness of “direct auscultation” was compounded by its impracticality in the hospital where, he observed, “it was scarcely to be suggested for most women patients, in some of whom the size of the breasts also posed a physical obstacle.”[1]  The stethoscope, which permitted “mediate auscultation,” not only amplified heart and lung sounds in diagnostically transformative ways; it enabled Laënnec to avoid repugnant  ear to chest contact.

Many women patients of Laënnec’s time and place did not see it that way.  Accustomed to the warmly human pressure of ear on chest, they were uncomfortable when an elongated wooden cylinder was interposed between the two.  By the closing decades of the nineteenth century, of course, the situation was inverted:  The stethoscope, in its modern binaural guise, had become so integral to physical examination that patients  hardly viewed it as a tool at all.  It had become emblematic of hands-on doctoring and, as such, a sensory extender of the doctor.  Even now, the stethoscope virtually stands in for the doctor, especially the generalist or the cardiologist, so that a retiring physician will announce that he is, or will be characterized by others as, hanging up his stethoscope.[2]

It’s easy to argue for the “oneness” of the physician and his or her instruments when it’s a matter of simple tools that amplify sensory endowment  (stethoscopes), provide a hands-on bodily “reading” (of temperature or blood pressure), or elicit a tendon reflex (e.g., the reflex hammer).  And the argument can be extended without much difficulty to the more invasive, high-tech “scopes” used by medical specialists to see what is invisible to the naked eye.  Instruments become so wedded to one or another specialty that it is hard to think of our providers without them.  What is an ophthalmologist without her ophthalmoscope?  An ENT without his nasal speculum?  A gynecologist without her vaginal speculum?  An internist without his blood pressure meter?  Such hand-held devices are diagnostic enablers, and as such they are, or at least ought to be, our friends.

In “Caring Technology” I  suggested that even large-scale technology administered by technicians, and therefore outside the physician’s literal grasp, can be linked in meaningful ways to the physician’s person.  A caring explanation of the need for this or that study, informed by a relational bond, can humanize even the most forbidding high-tech machinery.  To be sure, medical machinery, whatever the discomfort and/or bodily bombardment it entails, is often discomfiting.  But it need be alienating only when we come to it in an alienated state, when it is not an instrument of physicianly engagement but a dehumanized object – a piece of technology.

Critical care nurses, whose work is both technology-laden and technology-driven, have had much to say on the relationship of technology to nursing identity and nursing care.  This literature includes provocative contributions that look at where nurses stand in a hospital hierarchy that comprises staff physicians, residents, students, administrators, patients, and patients’ families.

For some CCU nurses, the use of technology and the acquisition of technological competence segue into issues of power and autonomy and they, in turn, are linked to issues of gender, medical domination, and “ownership” of the technology.[3]  A less feminist sensibility informs interview research that yields unsurprising empirical findings, viz.,  that comfort with technology and the ability to incorporate it into a caring, “touching” disposition hinge on the technological mastery associated with nursing experience.  Student and novice nurses, for example, find the machinery of the CCU anxiety-inducing, even overwhelming.  They resent the casual manner in which physicians relegate to them complex technological tasks, such as weaning patients from respirators, without appreciating the long list of  nursing duties to which such tasks are appended.[4]  Withal, beginners approach the use of technology in task-specific ways and have great difficulty “caring with technology.”[5]   Theirs is not a caring technology but a technology that causes stress and jeopardizes fragile professional identities.

Experienced CCU nurses, on the other hand, achieve a technological competence that lets them pull the machinery to them; they use it as a window of opportunity for being with their patients.[6]   Following Christine Little, we can give the transformation from novice to expert a phenomenological gloss and say that as technological inexperience gives way to technological mastery, technological skills become “ready-to-hand” (Heidegger) and “a natural extension of practice.”[7]

Well and good.  We want critical care nurses comfortable with the machinery of critical care – with cardiac and vital signs monitors, respirators, catheters, and infusion pumps – so that implementing technological interventions and monitoring the monitors do not blot out the nurse’s “presence”  in the patient’s care.   But all this is from the perspective of the nurse and her role in the hospital.  What, one wonders, does the patient make of all this technology?

Humanizing technology means identifying with it in ways that are not only responsive to the patient’s fears but also conducive to a shared appreciation of its role in treatment.  It is easier for patients to feel humanly touched by technology, that is, if their doctors and nurses appropriate it and represent it as an extender of care.  Perhaps some doctors and nurses do so as a matter of course, but one searches the literature in vain for examples of nurse-patient or doctor-patient interactions that humanize technology through dialogue.  And such dialogue, however perfunctory in nature, may greatly matter.

Consider the seriously ill patient whose nurse interacts with him without consideration of the technology-saturated environment in which care is given.  Now consider the seriously ill patient whose nurse incorporates the machinery into his or her caregiving identity, as in “This monitor [or this line or this pump] is a terrific thing for you and for me.  It lets me take better care of you.”  Such reassurance, which can be elaborated in any number of patient-centered ways, is not trivial; it may turn an anxious patient around, psychologically speaking.  And it is all the more important when, owing to the gravity of the patient’s condition, the nurse must spend more time assessing data and tending to machinery than caring for the patient.  Here especially the patient needs to be reminded that the nurse’s responsibility for machinery expands his or her role as the patient’s guardian.[8]

The touch of the physician’s sensory extenders, if literally uncomfortable, may still be comforting.  For it is the physician’s own ears that hear us through the stethoscope and whose own eyes gaze on us through the ophthalmoscope, the laryngoscope, the esophagoscope, the colposcope.  It is easier to appreciate tools as beneficent extenders of care in the safe confines of one’s own doctor’s office, where instrumental touching is fortified by the relational bond that grows out of continuing care.  In the hospital, absent such relational grounding, there is  more room for dissonance and hence more need for shared values and empathy.  A nurse who lets the cardiac monitor pull her away from patient care will not do well with a frightened patient who needs personal caring.  A parturient who welcomes the technology of the labor room will connect better with a labor nurse who values the electronic fetal monitor (and the reassuring visualization it provides the soon-to-be mother) than a nurse who is unhappy with its employment in low-risk births and prefers a return to intermittent auscultation.

In the best of circumstances, tools elicit an intersubjective convergence grounded in an expectation of objectively superior care.  It helps to keep the “objective care” part in mind, to remember that technology was not devised to frighten us, encumber us, or cause us pain,  but to help doctors and nurses evaluate us, keep us stable and comfortable, and enable treatments that will make us better, or at least leave us better off than our technology-free forebears.

My retinologist reclines the examination chair all the way back and begins prepping my left eye for its second intravitreal  injection of Eylea, one of the newest drugs used to treat macular disease.  I am grateful for all the technology that has brought me to this point:  the retinal camera, the slit lamp, the optical coherence tomography machine.  I am especially grateful for the development of fluorescein angiography, which allows my doctor to pinpoint with great precision the lesion in need of treatment.  And of course I am grateful to my retinologist, who brings all this technology to bear with a human touch, calmly reassuring me through every step of evaluation and treatment.

I experienced almost immediate improvement after the first such injection a month earlier and am eager to proceed with the treatment.  So I am relatively relaxed as he douses my eye with antiseptic and anesthetic washes in preparation for the needle.  Then, at the point of injection, he asks me to look up at the face of his assistant, a young woman with a lovely smile.  “My pleasure,” I quip, slipping into gendered mode.  “I love to look at pretty faces.”   I am barely aware of the momentary pressure of the needle that punctures my eyeball and releases this wonderfully effective new drug into the back of my eye.  It is not the needle that administers treatment but my trusted and caring physician.  “Great technique,” I remark.  “I barely felt it.”  To which his young assistant, still standing above me, smiles and adds,  “I think I had something to do with it.”  And indeed she had.

[1] Quoted in J. Duffin, To See with a Better Eye: A Life of R. T. H. Laennec (Princeton: Princeton University Press, 1998), p. 122.

[2] Here are a few recent examples:  O. Samuel, “On hanging up my stethoscope,” BMJ, 312:1426, 1996; “Dr. Van Ausdal hangs up his stethoscope,” YSNews.com, September 26, 2013 (http://ysnews.com/news/2013/09/dr-van-ausdal-hangs-up-his-stethoscope);  “At 90, Gardena doctor is hanging up his stethoscope,” The Daily Breeze, October, 29, 2013 (http://www.dailybreeze.com/general-news/20131029/at-90-gardena-doctor-is-hanging-up-his-stethoscope);  “Well-known doctor hangs up his stethoscope,” Bay Post, February 8, 2014 (http://www.batemansbaypost.com.au/story/1849567/well-known-doctor-hangs-up-his-stethoscope)

[3] See, for example, A. Barnard, “A critical review of the belief that technology is a neutral object and nurses are its master,” J. Advanced Nurs., 26:126-131, 1997; J. Fairman & P. D’Antonio, “Virtual power: gendering the nurse-technology relationship,” Nurs. Inq., 6:178-186, 1999; & B. J. Hoerst & J. Fairman, “Social and professional influences of the technology of electronic fetal monitoring on obstetrical nursing,” Western J. Nurs. Res., 22:475-491, 2000, at pp. 481-82.

[4] C. Crocker & S. Timmons, “The role of technology in critical care nursing,” J. Advanced Nurs., 65:52-61, 2008.

[5] M. McGrath, “The challenges of caring in a technological environment:  critical care nurses’ experiences,” J. Clin. Nurs., 17:1096-1104, 2008.

[6] A. Bernardo, “Technology and true presence in nursing,” Holistic Nurs. Prac., 12:40-49, 1998;  R. C. Locsin,  Technological Competency As Caring in Nursing: A Model For Practice (Indianapolis: Centre Nursing Press, 2005);  McGrath, “The challenges of caring,” op. cit.

[7] C. V. Little, “Technological competence as a fundamental structure of learning in critical care nursing: a phenomenological study,” J. Clin. Nurs., 9:391-399, 2000, at pp. 398, 396.

[8] See E. A. McConnell, “The impact of machines on the work of critical care nurses,” Crit. Care Nurs. Q., 12:45-52, 1990, at p. 51; D. Pelletier , et al., “The impact of the technological care environment on the nursing role, Int. J. Tech. Assess. Health Care, 12:35     8-366, 1996.C

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

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Posted in Doctor-Patient Communication, Medical Instruments, Medical Technology, Old & New, Nursing, Nursing and Gender

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You Touch Me

Posted on December 12, 2013 | 3 comments

Etymologically, the word “touch” (from the old French touchier) is a semantic cornucopia.  In English, of course, common usage embraces dual meanings. We make tactile contact, and we receive emotional contact.  The latter meaning is usually passively rendered, in the manner of receiving a gift:  we are the beneficiary of someone else’s emotional offering; we are “touched” by a person’s words, gestures, or deeds.  The duality extends to the realm of healthcare:  as patients, we are touched physically by our physicians (or other providers) but, if we are fortunate, we are also touched emotionally by their kindness, concern, empathy, even love.  Here the two kinds of touching are complementary.  We are examined (and often experience a measure of  contact comfort through the touch)  and then comforted by the physician’s sympathetic words; we are touched by the human contact that follows from physical touch.

For nurses, caregiving as touching and being touched has been central to professional identity.  The foundations of nursing as a modern “profession” were laid down on the battlefields of Crimea and the American South during the mid-nineteenth century.  Crimean and Civil War nurses could not “treat” their patients, but they “touched” them literally and figuratively and, in so doing, individualized their suffering.  Their nursing touch was amplified by the caring impulse of mothers:  they listened to soldiers’ stories, sought to keep them warm, and especially sought to nourish them, struggling to pry their food parcels away from corrupt medical officers.  In the process, they formulated a professional ethos that, in privileging patient care over hospital protocol, was anathema to the professionalism associated with male medical authority.[1]

This alternative, comfort-based vision of professionalism is one reason, among others, that nursing literature is more nuanced than medical literature in exploring the phenomenology and dynamic meanings of touch. It has fallen to nursing researchers to isolate and appraise the tactile components of touch (such as duration, location, intensity, and sensation) and also to differentiate between comforting touch and the touch associated with procedures, i.e., procedural touch.[2]  Buttressing the  phenomenological viewpoint of Husserl and Merleau-Ponty with recent neurophysiologic research, Catherine Green has recently argued that nurse-patient interaction, with its “heavily tactile component” promotes an experiential oneness:  it “plunges the nurse into the patient situation in a direct and immediate way.”  To touch, she reminds us, is simultaneously to be touched, so that the nurse’s soothing touch not only promotes deep empathy of the patient’s plight but actually “constitutes” the nurse herself (or himself) in her (or his) very personhood.[3]  Other nurse researchers question the intersubjective convergence presumed by Green’s rendering.  A survey of hospitalized patients, for example, documents that some patients are ambivalent toward the nurse’s touch, since for them it signifies not only care but also control.[4]

After World War II, the rise of sophisticated monitoring equipment in hospitals pulled American nursing away from hands-on, one-on-one bedside nursing.  By the 1960s, hospital nurses, no less than physicians, were “proceduralists” who relied on cardiac and vital function monitors, electronic fetal monitors, and the like for “data” on the patients they “nursed.”  They monitored the monitors and, for educators critical of this turn of events, especially psychiatric nurses, had become little more than monitors themselves.

As the historian Margarete Sandelowski has elaborated, this transformation of hospital nursing had both an upside and a downside.  It elevated the status of nurses by aligning them with postwar scientific medicine in all its burgeoning technological power.  Nurses, the skilled human monitors of the machines, were key players on whom hospitalized patients and their physicians increasingly relied.  In the hospital setting, they became “middle managers,”[5] with command authority of their wards. Those nurses with specialized skills – especially those who worked in the newly established intensive care units (ICUs) – were at the top of the nursing pecking order.  They were the most medical of the nurses, trained to diagnose and treat life-threating conditions as they arose.  As such, they achieved a new collegial status with physicians, the limits of which were all too clear.  Yes, physicians relied on nurses (and often learned from them) in the use of the new machines, but they simultaneously demeaned the “practical knowledge” that nurses acquired in the service of advanced technology – as if educating and reassuring patients about the purpose of the machines; maintaining them (and recommending improvements to manufacturers); and utilizing them without medical supervision was something any minimally intelligent person could do.

A special predicament of nursing concerns the impact of monitoring and proceduralism on a profession whose historical raison d’être was hands-on caring, first on the battlefields and then at the bedside.  Self-evidently, nurses with advanced procedural skills had to relinquish that most traditional of nursing functions: the laying on of hands.  Consider hospital-based nurses who worked full-time as x-ray technicians and microscopists in the early 1900s; who, beginning in the 1930s, monitored  polio patients in their iron lungs; who, in the decades following World War II, performed venipuncture as full-time IV therapists; and who, beginning in the 1960s, diagnosed and treated life-threatening conditions in the machine-driven ICUs.  Obstetrical nurses who, beginning in the late 1960s, relied on electronic fetal monitors to gauge the progress of labor and who, on detecting “nonreassuring” fetal heart rate patterns, initiated oxygen therapy or terminated oxytocin infusions – these “modern” OB nurses were worlds removed from their pre-1940s forebears, who monitored labor with their hands and eyes in the patient’s own home.  Nursing educators grew concerned that, with the growing reliance on electronic metering, nurses were “literally and figuratively ‘losing touch’ with laboring women.”[6]

Nor did the dilemma for nurses end with the pull of machine-age monitoring away from what nursing educators long construed as “true nursing.”  It pertained equally to the compensatory efforts to restore the personal touch to nursing in the 1970s and 80s.  This is because “true nursing,” as understood by Florence Nightingale and several generations of twentieth-century nursing educators, fell back on gendered touching; to nurse truly and well was to deploy the feminine touch of caring women.  If “losing touch” through technology was the price paid for elevated status in the hospital, then restoring touch brought with it the re-gendering (and hence devaluing) of the nurse’s charge:  she was, when all was said and done, the womanly helpmate of physicians, those masculine (or masculinized) gatekeepers of scientific medicine in all its curative glory.[7]  And yet, in the matter of touching and being touched, gender takes us only so far.  What then of male nurses, who insist on the synergy of masculinity, caring, and touch?[8]  Is their touch ipso facto deficient in some essential ingredient of true nursing?

As soon as we enter the realm of soothing touch, with its attendant psychological meanings, we encounter a number of binaries.  Each pole of a binary is a construct, an example of what the sociologist Max Weber termed an “ideal type.”  The question-promoting, if not questionable, nature of these constructs only increases their heuristic value.  They give us something to think about.  So we have “feminine” and “masculine” touch, as noted above.  But we also have the nurse’s touch and, at the other pole, the physician’s touch.  In the gendered world of many feminist writers, this binary replicates the gender divide, despite the historical and contemporary reality of women physicians and male nurses.

But the binary extends  to women physicians themselves.  In their efforts to gain entry to the world of male American medicine,  female medical pioneers adopted two radically different strategies.  At one pole, we have the touch-comfort-sympathy approach of Elizabeth Blackwell, which assigned women their own  feminized domain of practice (child care, nonsurgical obstetrics and gynecology, womanly counseling on matters of sanitation, hygiene, and prevention).  At the opposite pole we have the research-oriented, scientific approach of Mary Putnam Jacobi and Marie Zakrezewska, which held that  women physicians must be physicians in any and all respects.  Only with state-of-the-art training in the medical science (e.g., bacteriology) and treatments (e.g., ovariotomy) of the day, they held, would women docs achieve what they deserved:  full parity with  medical men.  The binary of female physicians as extenders of women’s “natural sphere” versus female physicians as physicians pure and simple runs through the second half of the nineteenth century.[9]

Within medicine, we can perhaps speak of the generalist touch (analogous to the generalist gaze[10]) that can be juxtaposed with the specialist touch.  Medical technology, especially tools that amplify the physician’s senses –  invite another binary.  There is the pole of direct touch and the pole of touch mediated by instrumentation.  This binary spans the divide between “direct auscultation,” with the physician’s ear on the patient’s chest, and “mediate auscultation,” with the stethoscope linking (and, for some nineteenth-century patients, coming between) the physician’s ear and the patient’s chest).

Broader than any of the foregoing is the binary that pushes beyond the framework of comfort care per se.  Consider it a meta-binary.  At one pole is therapeutic touch (TT), whose premise of a preternatural human energy field subject to disturbance and hands-on (or hands-near) remediation is nothing if not a recrudescence of Anton Mesmer’s “vital magnetism” of the late 18th century, with the TT therapist (usually a nurse) taking the role of Mesmer’s magnétiseur.[11]  At the opposite pole is transgressive touch.  This is the pole of boundary violations typically, though not invariably, associated with touch-free specialties such as psychiatry and psychoanalysis.[12]  Transgressive touch signifies inappropriately intimate, usually sexualized, touch that violates the boundaries of professional caring and results in the patient’s dis-comfort and dis-ease, sometimes to the point of leaving the patient traumatized, i.e., “touched in the head.”  It also signifies the psychological impairment of the therapist, who, in another etymologically just sense of the term, may be “touched,” given his or her gross inability to maintain a professional treatment relationship.

These binaries invite further scrutiny, less on account of the extremes than of the shades of grayness that span each  continuum.  Exploration of touch is a messy business, a hands-on business, a psycho-physical business.  It may yield important insights but perhaps only fitfully, in the manner of – to invoke a meaning that arose in the early nineteenth century – touch and go.

[1] See J. E. Schultz, “The inhospitable hospital: gender and professionalism in civil war medicine,” Signs, 17:363-392, 1992.

[2]  S. J. Weiss, “The language of touch,” Nurs. Res., 28:76-80, 1979; S. J. Weiss, “Psychophysiological effects of caregiver touch on incidence of cardiac dysrhythmia,” Heart and Lung, 15:494-505, 1986; C. A. Estabrooks, “Touch in nursing practice: a historical perspective: 1900-1920,” J. Nursing Hist., 2:33-49, 1987; J. S. Mulaik, et al., “Patients’ perceptions of nurses’ use of touch,” W. J. Nursing Res., 13:306-323, 1991.

[3] C. Green, “Philosophic reflections on the meaning of touch in nurse-patient interactions,” Nurs. Phil., 14:242-253, 2013; quoted at pp. 250-251.

[4] Mulaik, “Patient’s perceptions of nurses’ use of touch,” pp. 317-318.

[5] “Middle managers” is the characterization of the nursing historian Barbara Melosh, in “Doctors, patients, and ‘big nurse’: work and gender in the postwar hospital,” in E. C. Lagemann, ed., Nursing History: New Perspective, New Possibilities (NY: Teachers College Press, 1983), pp. 157-179.  

[6] M. Sandelowski, Devices and Desires:  Gender, Technology, and American Nursing (Chapel Hill: University of North Carolina Press, 2000), p. 166.

[7] On the revalorization of the feminine in nursing in the Nursing Theory Movement of the 70s and 80s, see Sandelowski, Devices and Desires, pp. 131-134.

[8] See R. L. Pullen, et al., “Men, caring, & touch,”  Men in Nursing, 7:14-17, 2009.

[9] The work of Regina Morantz-Sanchez is especially illuminating of this binary and the major protagonists at the two poles.  See R. Morantz, “Feminism, professionalism, and germs: the thought of Mary Putnam Jacobi and Elizabeth Blackwell,” American Quarterly, 34:459-478, 1982, with a slightly revised version of the paper in R. Morantz-Sanchez, Sympathy and Science: Women Physicians in American Medicine (Chapel Hill: University of North Carolina Press, 2000 [1985]), pp. 184-202.

[10] I have written about the “generalist gaze” in P. E. Stepansky, The Last Family Doctor:  Remembering my Father’s Medicine (Montclair, NJ: Keynote Books, 2011), pp. 62-66, and more recently in P. E. Stepansky, “When generalist values meant general practice: family medicine in post-WWII America” (precirculated paper, American Association for the History of Medicine, Atlanta, GA, May 16-19, 2013).

[11] Therapeutic touch was devised and promulgated by the nursing educator Delores Krieger in publications of the 1970s and 80s, e.g., “Therapeutic touch:  the imprimatur of nursing,” Amer. J. Nursing, 75:785-787, 1975; The Therapeutic Touch (NY: Prentice Hall, 1985); and Living the Therapeutic Touch (NY:  Dodd, Mead, 1987).  I share the viewpoint of Therese Meehan, who sees the technique as a risk-free nursing intervention capable of potentiating a powerful placebo effect (T. C. Meehan, “Therapeutic touch as a nursing intervention,” J. Advanced Nursing, 1:117-125, 1998).

[12] For a fairly recent examination of transgressive touch and its ramifications, see G. O. Gabbard & E. P. Lester, Boundary Violations in Psychoanalysis (Arlington, VA: Amer. Psychiatric Pub., 2002). 

Copyright © 2013 by Paul E. Stepansky.  All rights reserved.

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