The Door of Last Resort: Memoirs of a Nurse Practitioner

The Door of Last Resort

Critical Issues in Health and Medicine

Edited by Rima D. Apple, University of Wisconsin–Madison, and Janet Golden, Rutgers University, Camden

Growing criticism of the U.S. health care system is coming from consumers, politicians, the media, activists, and healthcare professionals. Critical Issues in Health and Medicine is a collection of books that explores these contemporary dilemmas from a variety of perspectives, among them political, legal, historical, sociological, and comparative, and with attention to crucial dimensions such as race, gender, ethnicity, sexuality, and culture.

For a list of titles in the series, see the last page of the book.

The Door of Last Resort

Memoirs of a Nurse Practitioner

Frances Ward

Rutgers University Press

New Brunswick, New Jersey, and London

Library of Congress Cataloging-in-Publication Data

Ward, Frances, 1950–

The door of last resort : memoirs of a nurse practitioner / Frances Ward.

p. ; cm. — (Critical issues in health and medicine)

Includes bibliographical references and index.

ISBN 978–0–8135–6053–3 (hardcover : alk. paper) — ISBN 978–0–8135–6054–0 (e-book)

I. Title. II. Series: Critical issues in health and medicine.

[DNLM: 1. Ward, Frances, 1950– 2. Nurse Practitioners—United States—Autobiography. WZ 100]

610.73'72069092—dc23

[B]

2012023498

A British Cataloging-in-Publication record for this book is available from the British Library.

Copyright © 2013 by Frances Ward

All rights reserved

No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, or by any information storage and retrieval system, without written permission from the publisher. Please contact Rutgers University Press, 106 Somerset Street, New Brunswick, NJ 08901. The only exception to this prohibition is fair use as defined by U.S. copyright law.

Visit our website: http://rutgerspress.rutgers.edu

Manufactured in the United States of America

For Norbert

Contents

Preface

Chapter 1: Bread Is Not Sugar

Chapter 2: Health Care: Perspectives from the Street Level

Chapter 3: Nurse, Are You a Doctor?

Chapter 4: Protection of the Public or Creation of a Guild?

Chapter 5: Context, Data, and Judgment: When Is Enough, Enough?

Chapter 6: Barriers, Opportunities, and Militancy

Epilogue

About the Author

Preface

I was born a first-generation American to immigrant Scottish parents who settled in Kearny, New Jersey. From a diachronic perspective, my life as nurse and nurse practitioner was grounded in my early growth in this town. Maturing in a loving home shaped by the values of hard-working immigrant British parents, I enjoyed the luxuries of American higher education. As a student, I was a sponge. With education and experience, I immersed myself over time in unique events in distinct contexts, with dreams of an equitable health care system. Synchronically, certain tropes emerged in time, evidenced in behavioral outcomes; patterns of power relationships—equality, dualisms, reasoning, and valuing—evolved, invariably influencing what I live for. Perhaps more a blurred genre than either memoir or autobiography, my narrative recounts a life as a first-generation participant in the dismantling of medical autocracy in the United States—and the establishment of an alternative: the care of patients on their terms, in their context.

Over Time

The location of two Scottish manufacturers in Kearny—the Clark Thread Company and the Nairn Linoleum Company—cloaked the town in British values of hardiness, work productivity, and frugality. No one believed in the American dream more than my father. A highly skilled ship’s carpenter in Scotland, in his early years in the United States he was termed a Mick, mistaken as just another Irish immigrant looking for work. Once a member of the carpenters union, however, he had regular employment and benefits. Born in Dumbarton, Scotland, he was one of twelve children, completing the fifth grade in school. He married my mother, Frances, also from Dumbarton; but, as he wryly said, she was from the other side of the tracks. Also one of twelve, her family was engaged in the whiskey and liqueur trade; she completed high school and became a beautician. A British loyalist, she joined the Royal Army in World War II, becoming a front-line jeep driver. When the war ended, they came to the United States and married, eager for a new life.

My sister, Maureen, was born in 1948 and I was born in 1950. Living in Kearny with Scottish values, we were a close foursome. Schoolwork came first; phones were for business, not idle chatter; no television on weeknights; dinner at 4:30

P.M.

after my father came home from a construction site; and play was outside, with pinky balls, jump ropes, and adventures in the Meadowlands. I’d walk into Newark to my favorite bookstore, where I bought Russian novels with saved bus fare money. We spent summers on the beach in Ocean Grove, beginning the day after school closed until Labor Day; my father worked in Kearny during the week and joined us on weekends. Time for work, time for play—and the ethic creed: If something is worth doing, it is worth doing well. I watched my mother roll saved pennies once her change jar was full. While summers in Ocean Grove depleted their savings for a home, they wanted my sister and me to enjoy summers away from the city. Only in retirement did my parents purchase their small dream home in Florida. At the end, they had plants, a lemon tree, jalousie windows, and air conditioning. New Port Richey was their home until my father, James Francis Ward, died five years after their move.

Rutgers—Into Newark

After my Catholic grammar and high school education, my life seemed to take on limitless potential in 1968 when I entered Rutgers University College of Nursing in Newark. From a sheltered Scottish environment to the swirling chaos of Newark, one year after the race riots—amid activist efforts of Students for a Democratic Society, the National Organization of Women, civil rights, Black Power, and the anti-Vietnam War movement—I achieved a stellar academic record, all the while stringing love beads, painting peace symbols, and sympathizing with all efforts at equality on any front. My father, a quiet man with pro-freedom fighter, anti-Crown inclinations, had shaped my thinking. I watched and listened to all events on the Newark campus between 1968 and 1972, the year I graduated with my Bachelor of Science degree. At Rutgers I felt the value of America’s Declaration of Independence. Freedom of speech. Equality for all, including women and minorities. And health? Do not all Americans warrant quality health care?

Equally influenced by my stoic army mother, I obtained my first nursing position after graduation at the East Orange Veterans Administration Hospital (VAH) in East Orange, New Jersey. The reverence for veterans was paramount at the VAH; under the military ethos there, I was known as Nurse Ward. When I asked ambulatory patients on my oncology unit to help other less mobile patients with daily activities, I consistently heard a Yes, Ma’am! Embedded in an institution with a clear mission and exceptionally detailed scopes of practice for all employees, I learned how to care for patients as well as manage large, forty-bed units with minimal staff. Policies and procedures, numbered and unnumbered memoranda from Central Office in Washington were part of my day. My structured British background enabled me to fit into this system. Career advancement in nursing was available at the VAH; nursing positions were regularly published, each with educational and other requirements clearly outlined. In my early career, I enjoyed advancement from registered nurse in oncology, then on to intensive care; subsequently, I clicked into new roles as Clinical Nurse Specialist, and then, as Patient Education Coordinator. All actions at the VAH seemed to focus on one entity—duty to the veteran.

At the VAH I learned my drive to compete. Within six months at the VAH, I realized that to compete for advanced titles in the system, I needed more education. I looked to New York. Columbia University? No, too stodgy, too steeped in its own history. New York University? I was sold in one visit. Even the buildings exuded energy, color, vibrancy. I envisioned reading a book at the historic Washington Square Park, drinking my hot chocolate from the neighborhood Gristede’s grocery. At Rutgers, I was a very good student; at NYU, I learned to think. I became confident at NYU. There was no thought you couldn’t think; you simply crafted rationale to defend it. Faculty walked into classrooms and conversed with graduate students, who ardently absorbed the flavor and content of the discussions. Taking the PATH train from Harrison to New York City, I traveled from 1973 to 1981 earning a master’s and then enrolling in doctoral courses at NYU on a part-time basis and working full-time, first at the VAH and then at Seton Hall University College of Nursing in South Orange, New Jersey.

I was thrilled to be a faculty member at Seton Hall. It was within walking distance from my home in the same town. Situated on a beautiful campus, with the Carolyn D. Swartz College of Nursing building constructed in 1973, Seton Hall nestled into its host community as a major face for South Orange, the Pirates commanding loyalty from local residents. It was a comfortable environment, but I was not matched well for it. As I increasingly questioned my world, fueled by my mentors at NYU, I became uncomfortable with the expected compliance demanded at this private, religious institution. It was a constraining environment, dogmatic in tone. When I left Seton Hall for a position at Rutgers University College of Nursing in Newark, I learned the culture of a public, research university.

In my five years at Rutgers University, I advanced from instructor to assistant professor, with an appointment to the Graduate School in Newark. My experiences at NYU deeply influenced my teaching at Rutgers: more constructs, less content; more inquiry, less dogma. A university for those who sought to excel, Rutgers was a road as diverged as any I had imagined. I learned the essence of the academy at Rutgers: the high stakes of tenure, the value of research and publications in the tenure process. As a young assistant professor, I taught students nursing care at Saint Michael’s Medical Center, just a few blocks from the university. Always passionate about clinical care, and very proud of my expertise in acute care, I worked part-time at the medical center to assure my continued competency. Weekends at Saint Michael’s, weekdays at Rutgers, evenings at NYU. It was a full life, with husband and children. I was awarded my PhD in nursing in 1982 while still an eager young assistant professor at Rutgers University. I was too busy for any ceremony of robes. During an evaluation session, my chairperson noted that I shouldn’t waste my time with students in the clinical courses. Couldn’t I find someone else to do my clinical coursework? I recall being angry. Nursing is a clinical discipline, and I was (and am) an expert clinician. I wanted to mentor my students at Saint Michael’s; I thought of this as the most important aspect of my work. A tenure-track faculty appointment—with its ultimate promise of the award of tenure—seemed contrary to the essence of my discipline. It was an uncomfortable reality, even as I was on my way to successfully achieving the coveted goal.

I resigned from Rutgers after five years to return to the VAH for a short period. Rutgers had been a home with clear goals and missions, but I had grown inquisitive in the past years and now was restless, even in an institution I greatly admired. After a while, a colleague at the VAH encouraged me to respond to an advertisement for the position of chairperson for the department of nursing at the School of Health Related Professions at the University of Medicine and Dentistry of New Jersey (UMDNJ) in Newark. Curious for years as to why UMDNJ did not have a nursing school as one of its units, given its status as the state’s only Academic Health Science University, I responded without hesitation. I was their only respondent—itself, a curious fact, but one that did not deter me from interviewing for the position. The president’s goal: to have all health-related professions as part of the university community. When he had become the university’s leader in 1970, he closed the hospital’s diploma school, founded in the mid-1880s. Since that time, he wanted to establish academic nursing programs, undergraduate, graduate, or both. It seemed a simple matter. He was correct. It was a simple matter, given his enthusiasm, the resources he committed, and the wide base of support he offered. Never imagining I would be writing about all this ages later, I took that road.

A Room of One’s Own

It was at UMDNJ that my Scottish work ethic singularly assured outcomes. While I gained confidence at NYU, I found my voice at UMDNJ. As a clinician in a health sciences university, I learned nursing’s contribution to health care delivery, primarily by comparison and contrast to the disciplines of medicine, dentistry, and the various allied health professions. My niche was clear; my profession had a necessary place in care delivery. I also learned about courage as I moved forward professionally. After establishing the University’s School of Nursing in 1992 and becoming its first dean, I matriculated in our nurse practitioner program and became an adult primary care nurse practitioner in 1998, working part-time in the University Hospital’s emergency department in addition to my administrative role. As a political as well as an academic institution, UMDNJ flourished through legislative efforts. As the nation’s shortage of primary care providers became pronounced in the late twentieth century, I became involved in legislation to name nurse practitioners as primary care providers. Through my relationship with New Jersey State Senator Wynona Lipman, I crafted language for her bill seeking prescriptive authority for nurse practitioners. My policy and administrative background informed my historical research into nursing’s history in New Jersey, an effort that informed my appreciation for the influence of power, politics, and legislation in nursing practice.

My twenty-three years at UMDNJ passed in a seeming blink of an eye. Once I had returned to the classroom from administration in 2002, I became restless again. While I found engagement with students rewarding, I also found myself dulled by the constancy and repetitiveness of teaching, even online teaching. And, although I have a robust research agenda that involved the establishment of reliable and valid instruments to measure learned helplessness and community living skills, I missed administration. When approached by Temple University College of Health Professions to serve in its David R. Devereaux endowed chair of nursing, I took a pied-à-terre in Philadelphia and moved into a new, old role.

Temple, a large comprehensive public research university, is located in North Philadelphia, surrounded by a host community marked by poverty and poor health indices. All over again, here was déjà vu. My experiences at establishing a school of nursing in New Jersey would be very valuable at Temple; at least, so I thought. Temple’s nursing program had its roots in a diploma program begun in 1893, the year of the Chicago World’s Fair, an exciting time of change and educational advancement. That was also the year when the American Society of Superintendents of Training Schools of Nursing, the predecessor to the current National League for Nursing, was organized. Once it was transitioned to a Bachelor of Science in Nursing degree program in 1967, however, nursing simply became one of several health profession programs constituted as departments in a newly established College of Health Professions. After an enthusiastic faculty agreed with me to implement a new shared faculty governance model, they subsequently revised curricula to stay ahead of the health reform curve, virtually transforming programs from a hospitalist orientation to a primary health care model.

I elected to retire from Temple in 2012. Telling all this with a sigh, I will now watch change there from a distance.

Tropes over Time

In fall 2011, my elderly father-in-law was hospitalized in Louisiana with a severe infection and renal failure after having had bilateral knee replacement surgery a few months earlier. His surgeon, a regionally acclaimed expert in orthopedics, left surgical rounds of his hospitalized patients to his nurse practitioner, Darlene. My husband and I were instructed to talk with her in the hospital when we wanted updates on my father-in-law’s status. My husband spoke with the charge nurse: Can you please page my father’s nurse practitioner for us? A quizzical look, a raised eyebrow. Her answer was delayed, as if by the strangeness of the request. We don’t page nurse practitioners. In fact, we don’t even know their names.

Louisiana, New Jersey, Pennsylvania. Irrespective of state, nurse practitioners have remained relatively invisible as primary care providers in the delivery system. Despite the widespread acclaim that nurse practitioners represent a critical solution to the inadequate number of primary care providers across the United States, not a great deal is known about their scope of practice, their education, and their philosophical orientation to primary care. As a branch of the profession of nursing, the largest single health care discipline in the country, nurse practitioners—advanced practice nurses—are recognized by health insurers as primary care providers. Significantly, indices of current popular books exploring problems of the U.S. health care system do not reference nurse practitioners. Equally significant, books written for popular audiences by nurse practitioners about nurse practitioner practice—advanced practice nursing—are rare. Two such books come to mind. Laurel Thatcher Ulrich, a Pulitzer Prize–winning early American historian, provided readers with an accounting of a midwife’s work and life in her 1990 study The Life of Martha Ballard, Based on Her Diary, 1785–1812. Julie Fairman, a nurse historian, provided a historical analysis of the nurse practitioner movement in Making Room in the Clinic: Nurse Practitioners and the Evolution of Modern Health Care (2008). One is a late-eighteenth-century documentary study, the other an early-twenty-first-century historical analysis. This is all we have. Nurse practitioners’ silence about themselves and their practice is patently obvious. It is a silence cloaked in nursing’s historical models and value dualisms.

How do nurse practitioners think? How do they describe primary care? Do their answers to these two questions differ significantly from those of other providers? Jerome Groopman explored How Doctors Think in his popular 2007 book. Groopman explained physicians’ cognitive shortcuts—or heuristics—as the core of flesh-and-blood decision making. Physicians’ thoughts-in-action, their clinical reasoning patterns that determine diagnoses and treatment plans, are deemed by Groopman as evidence-based techniques that are the foundation for medical thinking. Medical education provides the patterns for recognition of diagnoses, if not the actual heuristics. Education is the foundation; time at task provides heuristics. As Michael Crichton noted about Groopman’s book in his article Where Does It Hurt? (New York Times, April 1, 2007), Groopman recognizes the value of patients’ stories and their involvement in care, yet medical education has regarded communication skills with an indifference that approaches contempt. It’s unscientific.

While a book with the title How Nurse Practitioners Think has yet to be published, nursing’s early roots in monasticism have cultivated a sentimental societal image of a nurse as the vehicle for nurturing activities attendant to the alleviation of suffering as mediated by the physician. With its embedded requirements of absolute obedience, constrained voice, and limited expertise, monasticism shrouded the discipline of nursing in invisibility. Over time, nurse has become synonymous with hospital, given that nurses are the workforce needed to provide care and assure hospital cost recovery. As noted by Charles Rosenberg in The Rise of America’s Hospital System (1995), nurses settled on a public image of devotion and sensitivity rather than discipline-specific cognitive skills in order to acquire public acceptance in the late nineteenth century. Such settling has resulted in a systemic failure so deep that even the classification in the Integrated Postsecondary Education Data System for my specialization—adult nurse practitioner—is misleading. The inclusion of adult nurse practitioner as an illustrative example under the title Adult Health Nurse/Nursing, rather than as a separate entity itself, creates noise in the signal.

Signs signify what resides in cultures. A sign links to that which it signifies. I posit that neither the word nurse nor the phrase nurse practitioner have signifiers that uniquely convey shared understanding among Americans. Without clearly unique scopes of practice appropriate to the level of education among those holding the registered nurse (RN) license, the sign RN defaulted to a cultural image of a caring, gentle female emulating mothering, nurturing behaviors. Bernice Buresh and Suzanne Gordon in their 2006 book, From Silence to Voice: What Nurses Know and Must Communicate to the Public, have described the image of nursing and how that image would be redefined, if nurses want to take an active role—and responsibility—in changing this image. Since nurse practitioners must be, first and foremost, nurses, the cultural ethos surrounding nurse practitioners—their roles and their cognition—are grounded broadly in our culture’s view of nursing. The earliest nursing model—that of virtue—signified nurse as a composite of values emanating from this paradigm that was firmly established in the late nineteenth century. The virtue model continues into the twenty-first century; however, its impact is diminishing, gradually having been replaced in the later twentieth century by transitional gumbo—virtue blended with discipline-specific functions consistent with our country’s focus on science, technology, engineering, and mathematics. Post-Sputnik, post–Admiral Rickover. Virtue was still necessary, but not sufficient.

How nurse practitioners think, their cognitive patterns involving their practice, is deeply influenced by their education as nurses. Undergraduate nursing curricula address the nursing care needs of societies as encompassing health needs, both physical and psychiatric, enmeshed, among other factors, in a rich interaction of cultural and spiritual beliefs, housing and other environmental factors, socioeconomic status, educational achievement, family support, and community resources. Undergraduate students are encouraged to assess patients’ needs, their resources, their desire for healthier lifestyles, and their capacity to achieve such improvements. Patients are at the center of nursing care, making decisions based on information given to them from providers, including nurses and nurse practitioners. Diagnoses belong to patients; once informed, their wishes for care are to be honored. Thus, the nurse practitioner’s heuristics, if they were explored under the title How Nurse Practitioners Think, emanate from graduate education providing foundations of clinical reasoning alongside courses in epidemiology, anthropology, perception, culture, and other disciplines that explore humans in the context of their environment. Conversations about patient-centered health homes versus physician-centered medical homes highlight the differences between nurse practitioner and physician thinking.

These differences shift power relationships. In nurse practitioner cognition, the patient has power. In physician cognition, the physician has control and power. Should a patient not conform to a physician’s plan of care, she may be viewed as noncompliant. Should a patient be unable to conform to a plan of care mutually agreed upon earlier by the patient and nurse practitioner, the plan is changed; the patient is not blamed for failure. In hospitals, nurses conform to rules generated by physicians and hospital administrators; there, nurses care for physicians by complying with medical orders. In primary care, nurse practitioners construct management plans consistent with patients’ needs, resources, capacity for adherence, and overall goals. All courses in a nurse practitioner’s broad undergraduate nursing education, as well as in graduate courses, are prerequisite for safe primary care delivery.

In the early twenty-first century, nurse practitioners blend virtue and something else in a transitional state. Currently, some nurse practitioners aim to practice as replacements for physicians; they emulate medicine’s model. Accepting and embracing the complexity of patients’ contexts, others practice differently. Acceptance of context is a line in the sand, a trope of an evolving nurse practitioner model. Context is an essential externality embedded in the practice of nurse practitioners. Patient-centeredness mandates the embrace of context. The simple recognition of a patient’s economic status influences a nurse practitioner’s prescribing practices. Prescriptions for generic medications, along with instructions to purchase medications at local pharmacies with low-rate monthly charges, are part of a practice cognizant of context. Discussions emerge on the value of continuing education in order to improve confidence, meet goals, improve self-worth, and alleviate depression. Ignoring context may create burdensome costs in care delivery, in that negative externalities—such as poverty, lack of knowledge, poor housing conditions, ignored addictions, and others—may delay positive health outcomes and impact quality of life. My patient with hypertension, anemia, and bipolar disease is reminded that she has a voice—and the privilege to use it.

As nurse practitioners move from the virtue model through the transitional model to a new heuristic of practice based on context, other tropes are noted. Shifting control to patients in a patient-centered, context-driven model is an act of disruption in a postmodern, global era. The modern-era medical practice—complete with centralized authority and illness orientation—may continue indefinitely until other tropes of a new heuristic are more universally endorsed. One such trope is self-efficacy. Albert Bandura, a prominent psychologist known for the development of social cognitive theory, defines self-efficacy as the belief that one has the capability to perform in a way that positively affects one’s life. As nurse practitioners embrace the new heuristic of practice based on context, the uniqueness of their primary care behaviors will become increasingly self-evident. No longer skirting a hazy, hybrid practice existing in the borderlands between medicine and nursing, their confidence is enhanced. Gloria Anzaldúa, a prominent scholar of Chicano cultural theory, described a borderland as an unusual place demanding hybridity—a conscious flexibility allowing invisible survival without legitimate power.

Abandoning the cloak of virtue in exchange for self-efficacy also involves abandoning the secondary gains attendant to either the virtue or transitional model. Hybridity can generate complacency, a conscious choice to have peaceful days without power, but great predictability. Walking away consciously from hybridity is a disruptive act. To be disruptive is to be accountable. Disruptive acts interfere with obligation dualism, the dualism that traps nurses in both the virtue and the transitional models to coexist within competing tensions of obligation to self (individualism) versus obligation to society (collectivism). Such competing tensions conspire to trap nurse practitioners in an oppressed, but comfortable, performance ethic of low risk. Nancy J. Hirschmann, a political scientist, suggested in her 1992 book, Rethinking Obligation: A Feminist Method for Political Theory, that postmodern duality structures a world of paired opposites that provide individuals with identities not of their own construction that are highly oppressive. Reflection on such value dualisms reveals the importance of a heuristic model of nurse practitioner practice based on context. In place of contemporary health care, a new scope of practice deeply embedded in patient-centeredness brings into play another trope: accountable self-regulation. As virtue and hybridity are replaced with the new heuristic, the hazy fog surrounding nurse practitioner practice lifts. A