sociology essay

ILR Press

Chapter Title: Introduction Book Title: More Than Medicine

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

Book Author(s): LaTonya J. Trotter

Published by: Cornell University Press; ILR Press

Stable URL: https://www.jstor.org/stable/10.7591/j.ctvq2w37q.5

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1

Introduction

At the beginning of each day, over one hundred older adults arrive at Forest

Grove Elder Services. Some are men; most are women; almost all are African

American. With the assistance of wheelchairs, walkers, and canes, they slowly

disembark from the Grove’s fleet of vans. For some, the day is organized by

bingo and crochet. For others, it is punctuated by medical exams and wound

care. But no matter how differently the hours unfold, everyone’s day will end in

the same way: the Grove’s vans will return everyone home. This is the promise of

the Grove. No matter how sick or frail you might be, the Grove will do its best to

keep you from the doors of the nursing home.

This is a difficult promise to keep. The Grove’s members have all been certi-

fied by the state as having needs suitable for nursing home placement. Whether

because of cognitive decline, physical disability, or medical complexity, every-

one requires a significant amount of care. The resources available to provide

this care are in short supply. All the Grove’s members qualify for Medicaid,

a marker of individual poverty and diminished family resources. The Grove’s

reliance on public payers is a sign of its own financial limitations in providing

this care.

But provide this care it does. Teams of NPs, physicians, social workers, occupa-

tional therapists, RNs, physical therapists, and nursing aides all work in concert

to provide the kind of comprehensive care that makes living in the community

possible. 1 Each provider has specific expertise; however, caring for a high-needs

population requires a level of coordination that does not happen spontaneously.

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2 INTRODUCTION

In most health care organizations, the person responsible for guiding group deci-

sions is a physician. At the Grove, that person is a nurse practitioner.

“Ms. Payne. Can you think of anyone else who could come by a few times

a day?” 2 Ms. Payne is eighty-six years old. Like most of the Grove’s members,

she lives with a litany of complaints: diabetes, arthritis, congestive heart failure.

Yet none of these are why she is sitting in NP Michelle’s office today. 3 In two

weeks, Ms. Payne is scheduled to have cataract surgery to improve her increas-

ingly cloudy vision. Michelle’s aim is to make sure Ms. Payne is prepared for the

operation. Cataract removal is a low-risk outpatient procedure, even for some-

one Ms. Payne’s age. The surgery is not the problem. The problem is what will

happen afterward.

I sit in the corner, trying to be unobtrusive in a room that seems full with

three people. I listen as Michelle reviews the surgeon’s postoperative instructions.

Ms. Payne will need to apply a series of prescription eye drops—four times a day

for four weeks—to control inflammation, prevent infection, and minimize com-

plications. There is nothing remarkable about their application. One would sim-

ply stretch an arm upward, tilt one’s head skyward, arch the arm over a selected

eye, grip the bottle with a personal selection of fingers, then squeeze with the

right amount of pressure. These coordinated steps, however, require a set of abili-

ties that not everyone possesses. Ms. Payne has rheumatoid arthritis, a condition

that not only inflames the joints but also often deforms them. This condition

has left her hands curled in on themselves like talons. As Michelle describes how

often the drops will need to be applied, all three of us look at these hands, our

eyes filling with doubt.

Michelle begins to interrogate these doubts by testing what Ms. Payne can

physically manage. She leaves the room and returns with a small plastic bottle

that approximates the size and shape of the problematic eye drop container.

She holds the bottle out to Ms. Payne and asks, “Do you think you can grasp it

with your right hand?” Ms. Payne’s right hand is the most visibly affected by her

arthritis, but it is also her dominant hand. Ms. Payne looks at the bottle. She takes

a few breaths before looking back at Michelle to say “No,” with a note of finality.

Michelle asks her to try with her left hand. Ms. Payne reaches out and successfully

picks up the bottle. Following Michelle’s prompts, she tries to reach her left arm

over her head. But Ms. Payne’s hand reaches its maximum height at just above

shoulder level. She lowers her arm, shrugs her shoulders, and the encounter ends.

Michelle’s work, however, is just beginning.

After Ms. Payne leaves, Michelle confers with Claudia, the RN stationed across

the hall, who assists Michelle and serves as her clinical sounding board. As they

talk, I learn why Michelle did not mention what seems to be the most obvious

solution: a home care aide. Every day, an army of aides takes medicine down from

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INTRODUCTION 3

shelves, removes pillboxes from drawers, and helps people maneuver hard-to-

open lids. What they do not do—at least not legally—is administer, or actively

give, medication. 4 In everyday life, when we cannot administer our own medica-

tion, parents, children, even a good friend might be enlisted to assist. This prac-

tice is both common and legal as long as it is done for free, which explains why

Michelle asks Ms. Payne whether she could think of anyone who might help.

Anyone would have sufficed. However, when payment enters the equation, the

universe of anyone shrinks considerably. In most states, only physicians and

nurses can administer medication. 5 This includes prescription eye drops. The

Grove would have had to pay for a much costlier RN to visit Ms. Payne four times

a day, every day, for four weeks. Michelle knew without asking that the Grove was

unlikely to approve such an expensive request.

Solving Ms. Payne’s problem would require more than medical knowledge.

It would require knowing how to navigate organizational systems both inside

and outside the Grove. It would require gathering and using knowledge about

Ms. Payne’s resources. And it would involve knitting these disparate forms of

knowledge together in a way that might be applied to the practical problem

at hand. Over the next two weeks, I watch as Michelle performs this knitting

together on Ms. Payne’s behalf. She experiments with adaptive equipment that

might make the task possible for Ms. Payne. When that is unsuccessful, she calls

the surgeon—again and again until she gets a response—to see where the flex-

ibility in the regimen might be. How frequently must the drops be given? Can

they get away with three times a day over the weekend when the Grove is closed?

Claudia meets with Ms. Payne separately to ask whether she is sure there isn’t

anyone who can assist her, even once a day. A cousin? A neighbor? Someone from

her church? She reminds Ms. Payne, gently but firmly, that not wanting to ask is

not the same thing as being unable to ask.

Michelle eventually crafts a plan that is one part neighbor, one part modi-

fied regime, and one part approval for two RN visits on weekends. Arriving at

this complex calculus takes more than a little time and a great deal of work. The

surgeon performs the technical miracle of curing the patient; Michelle performs

a miracle of her own in helping to ensure the best possible outcome. With Ms.

Payne’s eyesight improved, the odds are good she will be able to stay in her own

home for some time to come.

When I first arrived at the Grove, I was taken aback by the kind of intensive

management that happened in its exam rooms. Very little of the activity in the

clinic looked anything like what I expected to see within the medical encounter.

But after months of observation, my initial surprise had settled into expectation.

The case of Ms. Payne was not an outlier. Nor was Michelle an organizational

aberration. The knitting together she performed for Ms. Payne was emblematic

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4 INTRODUCTION

of the work of all the Grove’s NPs—not only for patients undergoing low-

risk surgeries but also for those living with end stage renal disease, struggling

through the uncertainties of multiple sclerosis, or dying from cancer. After

months of watching these NPs at work, I confess that I had started to take this

state of affairs for granted: this was the work these NPs did; this was the work

the Grove needed them to do. Michelle, however, may not have seen things in

quite the same way. As we ended our last conversation about Ms. Payne, Michelle

flashed a smile that was not really a smile and asked, “Now what part of all that

was medical care?” Her question shook me out of my analytical complacency

and, to a large extent, animates the questions at the heart of this account. How

should we understand the care that NPs provide? And whose problems are they

intended to solve?

From the ten-thousand-foot view of policy, the answers to both questions seem

fairly clear. The care NPs provide should, ideally, be the same as that of physi-

cians. Physician indignation notwithstanding, the scholarly consensus is that this is the case. Fifty years of research has demonstrated that patients who see NPs

largely have the same outcomes as those who see physicians; when there is a

discrepancy, it is usually in the NPs’ favor (Buerhaus et al. 2018; DesRoches et al.

2017; Horrocks, Anderson, and Salisbury 2002; Landsperger et al. 2016; Laurant

et al. 2004; Lenz et al. 2004; Martínez-González et al. 2014; Mundinger et al. 2000;

Naylor and Kurtzman 2010; Newhouse et al. 2011; Ohman-Strickland et al. 2008;

Ramsay, McKenzie, and Fish 1982; Stanik-Hutt et al. 2013). This robust evidence

of equivalence grounds our collective assumptions about what NPs are for: to fill

in for the missing physician.

Nurse practitioners were, in fact, intentionally created to deal with the grow-

ing scarcity of primary care physicians. In the 1960s, that scarcity was triggered

by increased demand for services caused by the baby boom and the creation of

public health insurance in the form of Medicare and Medicaid (Fairman 2008;

Silver, Ford, and Steady 1967). Today, that scarcity is exacerbated by our aging

population and the expansion of insurance through the Patient Protection and

Affordable Care Act. Meeting this growing demand comes with a cost for insurers

as well as health care organizations. That NPs are cheaper to train and less costly

to employ than physicians has led to their being championed by policy makers

and economists alike.

The NP as policy solution rests on a logic of substitution: when physicians

cannot be found or afforded, the NP is a reasonable facsimile. The story of Ms.

Payne suggests an alternate view of NP utility. Although paying for medical care

remains an issue for many, it was not one for Ms. Payne. Like most Americans,

she became eligible for Medicare when she reached the age of sixty-five. However,

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INTRODUCTION 5

despite having a payer for medical services, she did not always have access to

the full range of assistance she required. Ms. Payne needed help getting back

and forth to medical interventions such as her cataract surgery. She needed help

adhering to medical regimens such as her postoperative care instructions. Even

before any of this practical work commenced, she needed someone to help her

think through the help she needed and to coordinate with a range of people and

organizations to make it happen. None of this assistance is paid for by Medi-

care because none of it qualifies as medical care. Even if she qualified for pub-

lic or charitable programs to meet these needs, accessing and navigating those

resources would require both knowledge and time. Although much has been

made of the physician shortage, Ms. Payne’s hurdles equally arose from the scar-

city of supportive care.

Ms. Payne’s story is also an illustration of the intertwined problems of eco-

nomic and social precarity. Ms. Payne was not only a beneficiary of Medicare;

she was also a recipient of Medicaid. Because poverty is the primary eligibility

criterion for Medicaid, we often think of it as health care for the poor. However,

it might be more accurate to call it long-term care for the disabled. While long-

term care sometimes includes skilled nursing, it is primarily designed to assist

with the activities of daily living, such as bathing, dressing, eating, and toileting.

Because these services are excluded from Medicare, individuals and families have to pay for them on their own.

Few can shoulder these costs for years on end. In 2018, the yearly cost for

forty hours a week of home care assistance was just under forty-six thousand

dollars (Genworth 2018). These expenses are in addition to the mounting costs

of medical care. Even the insured are expected to pay some portion of the costs

of medications, hospitalizations, and provider visits. If nursing home placement

becomes necessary, these costs can increase exponentially. In 2018, the annual

cost of a semiprivate nursing home room was just over eighty-nine thousand

dollars (Genworth 2018). While some may enter older adulthood in poverty,

a great many others become poor as a consequence of failing health and mount-

ing costs. For adults, it is often the combination of poverty and disability that

results in eligibility for Medicaid. 6 As a consequence, Medicaid has become the

single largest payer for long-term care in the US. In 2015, Medicaid paid for

36 percent of all home health care and 31.7 percent of all nursing home care

(Burwell 2016).

Entering older adulthood intensifies not only economic needs but also social

needs. In addition to paid care, most older adults rely on the unpaid assistance

of family and friends (Freedman and Spillman 2014). Much of this assistance

is material, such as help with transportation, grocery shopping, or household

maintenance. Social support is also important. While aging itself does not

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6 INTRODUCTION

increase social isolation, the illness and disability that often accompany it do

(E. Y. Cornwell and Waite 2009a, 2009b; B. Cornwell, Laumann, and Schumm

2008). As one’s needs increase, the resources in one’s personal networks can

become strained and sometimes exhausted. Medical vulnerability is often exacer-

bated by economic and social vulnerability, which in turn can negatively impact

health and quality of life (Krause, Newsom, and Rook 2008; Newman 2003).

At the Grove, patients like Ms. Payne, faced with the interconnected problems

of aging, illness, and poverty, turned to their NPs for a kind of work that was

more than medical care. And at least some of the time, they found it. This book is

an on-the-ground account of how a group of NPs cared for four hundred African

American older adults living with poor health and limited economic resources.

I followed these NPs as they saw patients, met with colleagues, and spoke with

family. What I witnessed was less a facsimile of physician practices than a trans-

formation of them. These NPs expanded the walls of the clinic to include not just

medical complaints but a broad set of indigenous complaints. Patients presented

with serious medical problems, such as congestive heart failure and diabetes, but

they also brought a broader set of social and economic problems that, for them,

were of equal importance. In response, the NPs practiced a professional open-

ness to information and problems that are usually filtered out of the exam room.

In response to this openness, patients and their families turned to the clinic as

the place to get a diversity of needs met. Through this iterative cycle of open-

ness and turning to, both the encounter and the work performed within it were

transformed.

Clinic Work The proposition that NPs are doing different work from physicians is grounded

in a broader historical distinction between medicine and nursing. If physicians

are the iconic providers of medical work, nurses are the iconic providers of care

work. Broadly speaking, care work is defined as labor—paid and unpaid—that

cares for members of society who cannot care for themselves because of age,

illness, or disability (Duffy 2005; England 1992). While some scholars make fur-

ther divisions between types of care work, what fundamentally distinguishes care

work from other forms of labor is how it is performed and, often, who performs

it (Duffy, Albelda, and Hammonds 2013; England 2005). 7

Care work is based less on discrete services than on a general responsiveness

to the needs of a person. In this way, care work is inherently relational. To use

an example outside health care, kindergarten teachers are involved not just in

educational instruction but in helping their charges eat, visit the toilet, and learn

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INTRODUCTION 7

to socialize with one another. Moreover, how the work unfolds depends on the

quality of the relationships that form between students, teachers, and parents.

These features of the work cannot be separated from the fact that most care

workers are women. Care work often overlaps with labor historically performed

by women in the domestic sphere. Those who perform such work today continue

to be marked by gender and the lower status associated with “women’s work”

(Charles and Grusky 2005; England 2010; England, Budig, and Folbre 2002).

Despite the gendered devaluation that comes with seeing nursing as care work,

nurses continue to claim care as a category and relationship as a feature that dis-

tinguishes the practice of nursing from the practice of medicine (Apesoa-Varano

2007, 2016; Evans 1996; Radwin 1996; Tanner et al. 1993).

In this account, I advance the notion of clinic work to illustrate the ways in

which the Grove’s NPs brought care work into the medical encounter. I employ

this term for two reasons. First, it reflects the reality that the NPs’ work was dif-

ferent in both form and content from the medical work of their physician col-

leagues. This difference was a consequence not of formal role distinctions but of a

very different embodiment of what it meant to address patient complaints. When

family disagreements and economic challenges were allowed to enter the clinic as

part of the problem of disease management, what “disease management” meant

was fundamentally altered. The observation of this difference came not only from

me but also from the physicians—the providers best situated to evaluate what

medical work was and was not. However, the NPs did address bodily complaints.

Moreover, they were held to account by billing paperwork that required their

work be made visible as medical work. Because they were doing this work from

within the medical visit, this expansive form of clinic work had consequences

not only for constructions of NP work but also for changing expectations of the

medical encounter.

Second, I use clinic work to underline the ways in which the NPs’ work invoked

a different form of relationality—it was in deep relationship with the organiza-

tion or clinic in which it was located. The Grove’s NPs worked in a context orga-

nized around teams. The traditional boundaries one might draw between forms

of expertise were less apparent in this organizational context. For patients whose

problems were defined as much by poverty as by illness, and whose care was

as much a feat of coordination as one of curative treatment, the lines between

medical problems, social problems, and organizational problems were not easy

to draw. In order to understand the construction of clinic work, I had to account

for the ways in which some problems became NP problems while others did not.

I discovered that the transformation of the clinic encounter was about neither

the rearrangement of tasks nor the renegotiation of turf alone, but rather the

working out of much deeper questions about what these problems were, and

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8 INTRODUCTION

who was responsible for solving them. The organizational context in which this

working out occurred is as much a part of the story as the providers themselves.

Organizational Care Work Forest Grove Elder Services is not an ordinary outpatient clinic. It is a federally

backed policy experiment to evaluate whether a comprehensive care model could

ameliorate the state’s economic burdens for long-term care. The pillars of the

Grove’s cost savings are coordination and capitation. The team model was its pri-

mary strategy for coordinating care. Each team consisted of a mandated mix of

providers who worked together not only to provide direct medical, nursing, and

supportive care but also to coordinate access to specialists, home care aides, and

a host of ancillary services. To pay for this care, the Grove received monthly per

capita or per member payments instead of fee-for-service reimbursements. This

system provided an incentive to control costs and incentivized preventive over

interventionist forms of care. Yet the Grove still operated under the quasi-market

logic of all US health care: if its members did not believe they were receiving

quality care, they could take their Medicaid and Medicare insurance elsewhere.

The Grove had to provide not just cheaper care, but care of sufficient quality to

successfully compete with other health care organizations.

In some ways, the Grove’s experimental objective was to figure out how to

deliver care work under the aegis of medical care. Its mission of intensive man-

agement and service coordination necessitated a layered understanding of each

patient that required it to be responsive to a broad and variable set of individual

needs. Even speaking of its patients as “members” was a nod to the expectation

of relationship and responsibility. How does an organization—whose payment

structure and regulatory environment still make it primarily accountable for

medical work—deliver on the promise of providing the kind of patient-centered

relationality required of care work?

At the Grove, the answer was through its NPs. One of the unique features

of the Grove was that the NP, rather than the physician, was the formal head of

the team. What it meant for the NPs to lead, however, was unclear. I observed

that NP leadership was often reworked as NP responsibility. The NPs became

solely responsible for ensuring that the Grove’s mission of coordination was

achieved. Within the expansive category of clinic work, the NPs were expected to

deal with a broad set of problems not only as a way of helping their patients but

also as a way of managing “difficult patients” for their employer. Doing so was

not a simple matter. Various departments inside the Grove had to work together

for member care, and the Grove had to communicate with a range of external

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INTRODUCTION 9

organizations and family members. Moreover, the work of coordination seemed

to generate as many problems as it solved. For the NPs, solving member problems

often involved helping them navigate the inefficiencies of the organizations in

which they sought care—including those at the Grove.

I argue that these NPs were not simply performing an expansive form of work

on behalf of their patients; they were also providing an expansive form of orga-

nizational care work for their employer. As the NPs put out a range of social and

organizational fires in the exam room, they were tasked with the invisible work

of caring for the organization as they cared for patients. Clinic work was not in

opposition to organizational demands but was partly constructed through the

NPs’ responsiveness to them. Problems not solved within the exam room became

organizational problems. Patients whose social problems were significant hurdles

to medical stability might transition to higher and more expensive forms of care.

Members who struggled to navigate the Grove’s inefficiencies might leave the

program, expressing their dissatisfaction with the Grove in a way that was vis-

ible to the state. The NPs’ performance of organizational care work made them

a different kind of provider to patients, as well as a different kind of worker for

their employer.

I entered the Grove attentive to the work of the NP. My main finding is that

their labor became the primary means through which the Grove embodied its

own mission of being a caring organization. How these NPs turned a broad set

of concerns into clinic concerns reflected the expectations of their colleagues and

employer as much as those of patients. I argue that these NPs were doing more

than practicing medicine sprinkled with nurse-branded empathy; they were

transforming the nature of the work itself.

Nursing’s Utility under State Retrenchment In exploring how these NPs solved problems for members and their employ-

ing organization, I had to grapple with the larger context in which these prob-

lems came into being. Physician scarcity is often treated as a naturally occurring

problem inherent to developed countries with high demand for medical care.

Yet this scarcity is not simply a consequence of consumer demand; it is a con-

sequence of inequality. Not everyone struggles to find a physician; those with

the least lucrative problems and the fewest resources are the most likely to have

trouble accessing physician care. Perhaps one might wish that physicians would

behave more altruistically. However, I argue that this uneven distribution of

workers and work is a consequence of state inaction rather than individual

career choices.

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10 INTRODUCTION

While the federal government has decried the physician shortage, it has largely

taken a noninterventionist approach in addressing it. The state may coax or con-

vince, but if physicians prefer dermatology to pediatrics, it will not compel. This

reticence to use state power is not matched by a reticence to provide state fund-

ing. In 2015, the federal government provided 14.5 billion dollars to support

medical residents working in teaching hospitals (Villagrana 2018). Even the eco-

nomic disincentives to working in primary care are a function of state inatten-

tion. The comparative lucrativeness of specialty care is partly a consequence of

unregulated prices. The federal government treats health care as a commodity

and largely declines to interfere in the medical marketplace.

It becomes impossible to understand the creation of NPs without placing

them within the context of what the state has decided not to do. In the years

since I began this research, I have often been asked how NPs in the US compare

to those in other parts of the world. The simple answer is that there is no other

country that uses NPs in quite the same way. Governments that are less reluc-

tant to directly control costs and personnel have less need for this new provider.

Some countries, such as Canada, the United Kingdom, and Australia, are in the

process of experimenting with NPs. Referencing the US as a model, they are

deploying NPs to counter physician shortages in medically underserved areas.

However, the NPs’ extensive use and level of practice autonomy is a uniquely

US phenomenon because the US is singular in having a hands-off approach to

health care while largely financing its provision. In 2013, the federal government

financed nearly two-thirds of all US health care (Himmelstein and Woolhandler

2016). In this context, the NP becomes a privatized, professional response to

a set of policy problems that the state has declined to address through other

means.

The pairing of state financing with privatized solutions has come to character-

ize not just health care policy but the US welfare state more broadly. Since the

1980s, the US has been the chief evangelist and implementor of neoliberal policy

reforms (Centeno and Cohen 2012). Most of these reforms have been directed

at deregulating money and labor; however, the general tenet of favoring markets

over state influence has had a significant impact on social policy. A move toward

smaller government has resulted in the downsizing and privatization of state and

federal safety-net programs (Morgen 2001; Smith and Lipsky 2009). The socially

and economically vulnerable have been the chief casualties of this approach. But

there have also been professional ones.

Social workers were once the professional foot soldiers of the welfare state.

In the early to mid-twentieth century, the robustness of professional social

work reflected prevailing ideas about the state’s role in addressing the symp-

toms and structural causes of poverty. As the government established relief

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INTRODUCTION 11

programs and national efforts such as the War on Poverty, it relied on social

workers to carry them out (Ehrenreich 1985). However, the use of state power

to address inequality has fallen out of favor. Many of the programs that social

workers once implemented have languished or disappeared. Those that remain

are increasingly privatized, with social work’s purview narrowed to policing

client eligibility rather than providing therapeutic assistance or community

development (Lipsky 1980; Schram and Silverman 2012; Smith and Lipsky

2009). With little to no state support, social work’s professional decline was all

but inevitable.

The story of social work’s falling fortunes is more than just an interesting

piece of occupational history. Its diminished status reflects the state’s disavowal of

any moral obligation to ameliorate social inequality. Although individual social

workers continue to fight on behalf of their clients (Aronson and Smith 2010;

Fabricant, Burghardt, and Epstein 2016), social work is in danger of becoming

a disciplining agent of the state rather than the agent of social change its pio-

neers envisioned it to be (Schram and Silverman 2012; Soss, Fording, and Schram

2011). How this shift occurred is a question best addressed by historical analysis.

But the logic of its reproduction can be understood through attention to the

work that social workers do, and don’t do, within the multidisciplinary environ-

ment of a health care organization.

The Grove was not unusual in employing NPs, but it was unusual in employ-

ing social workers. Social workers are a rarity in outpatient care because, usually,

there is no payer for their work in this setting. At the Grove, social worker inclu-

sion was required by the federal regulations that governed the program. Their

presence raised an important question: How did the clinic encounter, rather than

the social work encounter, come to be the appropriate location for the “sticky”

problems of coordination and social precarity? I found that the social workers

occupied a marginal position within an organization whose economic solvency

was based on the performance of medical work. The logic of medical necessity

that set priorities for the Grove’s resources led to an institutional disinvestment

in both the social workers and their realm of expertise. The social workers found

that what they thought of as real social work had been replaced by labor that was

largely in service to state-required paperwork and the regulatory requirements

of medical work.

Comparing the plights of the Grove’s NPs and its social workers revealed that

the appearance of social problems in the exam room was a function not just of

NP professional openness within the clinic encounter, but of the lack of resources

given to address these problems outside it. The federal government has largely

withdrawn itself as a payer for the problems of poverty even as its financing of

medical care has soared. I argue that the saliency of the NP is as much a story of

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12 INTRODUCTION

welfare state retrenchment as one of economic utility. The hurdles faced by the

Grove’s social workers illustrate the limitations of analyzing occupational strate-

gies without placing them within a larger political economy.

The NP as policy solution is based on the logic of substitution. Once we start

interrogating this logic, a new set of questions arises. As the sociologist Ever-

ett Hughes (1970) observed, experts do not just solve our problems; they shape

our conceptions of them. The NP might be the kind of solution that rearranges

the problem in new ways. Accordingly, the chapters that follow do more than

describe the work of a particular category of clinician. They provide a view, from

the ground up, of a broader reorganization of medical labor and its relation-

ship to the ever-shifting division between medical problems and social problems.

Nurse practitioners are often thought of as filling in for the absent physician.

Together, these pages make the case that NPs are just as often filling in for the

absent state.

The arguments I make in this book speak to broad changes in health care deliv-

ery. Although these arguments are far-reaching in their implications, they are

made through the materiality of Forest Grove Elder Services. The first chapters of

the book speak directly to the idea of NPs as a policy solution. In part I, I situate

the Grove as both a professional and an organizational solution to the problems

of health care, old age, and poverty. The Grove and its NPs do not exist in a

vacuum; they coexist in a policy environment in which both nursing and health

care organizations are seeking to capitalize on state support. I illustrate that the

expansion of nursing’s terrain is intertwined with changes in the organization

and provision of care for older adults.

I then describe the professional resources that these NPs used to construct a

notion of clinic work within this expanded terrain. In following the journey of

member problems—how they are generated, to whom they are brought, and who

fixes them—I reveal organizational logics about the type of expertise the Grove

collectively believed resided within the clinic. Part of the work of this section is

to reinterpret the clinical encounter as more than a meeting between a medi-

cal provider and the patient’s chief complaint, but as an institutionally situated

meeting of a range of complaints. I make the case for the NPs’ performance of

organizational care work by paying attention to the work they do and contrasting

it with the work the physicians do not.

In part II, I demonstrate how the new notion of clinic work effectively recon-

structs physician understandings of what constitutes medical work. I begin

by looking directly at the relationship between NPs and physicians. The NPs

I followed had three distinct views of who physicians were in relationship to

their own practice: consultants, captains, or teammates. These three framings

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INTRODUCTION 13

led to very different ways of being what each considered a competent NP.

I then investigate how the physicians reoriented their own domain of work in

the face of the NPs’ view of their role. I pay particular attention to the unease

experienced by physicians who found themselves working within NP-led teams,

as well as how that unease was managed through actively relocating physician

expertise outside the clinic. In doing so, I show that the NPs’ clinic work was

a relational concept that required adjustments in how physicians understood

their own work.

In part III, I consider how the expansion of clinic work is inextricably tied to

the shrinking domain of social work, both as a profession and as an orientation

to social problems. Empirically, I ground my analysis in the everyday work of the

Grove’s social workers, who are positioned at the margins of an expanding clinic.

I situate these observations within a broader view of social work’s precarious

professional position. Part of the challenge of claiming expertise for social work

is its location in the devalued world of social problems. In this section, I argue

that the legitimacy of the NP is related to the delegitimization of social work.

The different fates of these two professions do not simply represent a problem

of professional strategy; rather, they reflect an unwillingness, in policy and in

ideology, to recognize the economic and political character of social problems.

I end by questioning professionalization more generally as a privatized response

to collective concerns.

Through illustrating these arguments, this book is both a meditation on

and an empirical excavation of the possibilities NPs are forging within the con-

fines of the medical encounter. When NPs fill the space that physicians have

absented, they are embodying a different set of possibilities for what the health

care encounter could be. In doing so, they are positioned to make visible not

just the scarcity of physician labor but that of caring labor. Although sometimes

self-conscious of the claim, nursing still relies on care as the bedrock of its pro-

fessional identity and legitimacy. To care is not empty rhetoric; it is work. And

although it is usually seen as ancillary to the main stage of medical interven-

tions, health care organizations have never been more reliant on such work. The

Grove’s NPs may have been unique in the wealth of organizational resources

available to them as they embodied nursing expertise. However, I believe they

are not alone in being asked to solve different problems than their physician

colleagues.

I suggest that, as providers with different professional experiences and held

accountable to different expectations, NPs are opening the exam room to a dif-

ferent kind of clinical performance. Not only is this performance reshaping our

ideas about medical work, but it is also a mirror that reflects how we choose to

care for our most vulnerable citizens. In this account, I have avoided revisiting

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14 INTRODUCTION

the question of what kind of work NPs should or should not do. Rather, I provide

a closer look at the work they are actually doing, not just for their patients but for

the health care organizations that employ them and for the state, which chooses

to care in some ways but not others. In focusing on the work NPs do, I hope to

both illuminate and trouble the relationship between who we think should solve

our problems and what we understand those problems to be.

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Par t I

AN EXPANDED TERRAIN FOR NURSING

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17

1

NURSING’S EXPERTISE

NP Francesca worked part-time in the Grove’s clinic. The rest of her days were

spent teaching nursing students. Before I had permission to begin observing in

the clinic, one of the Grove’s administrators encouraged me to meet with Franc-

esca. Perhaps because she was an educator, the administrator believed Francesca

would have “an interesting perspective on the Grove.” Our meeting was sched-

uled at midday, when the clinic was closed for lunch. When I arrived at her office,

I had a quick preview of the woman I was to meet. There was a sign on the door

that read, “The Professor,” in cursive font. Underneath was a picture of an owl

who wore glasses and wielded an old-fashioned pointer. I cannot recall ever hear-

ing anyone call her the Professor, but it was a name she had earned.

Francesca had received a PhD in gerontologic nursing research. She was not

shy about describing herself as more academically than clinically oriented. By

her own admission, doing the work of an NP was not her forte. She had taken

the unusual route of getting her PhD before returning to school for the clinical

NP master’s degree. Along the way, she had developed a strong set of ideas about

the work of an NP. I asked her, as I eventually asked all the NPs, to describe what

being an NP meant. Her response was to take out a pen and teach.

“Medicine,” she said, “sees the relationship between nursing and medicine

like this.” Francesca drew two circles: a large circle to represent medicine with

a smaller circle for nursing contained inside it. “However, nursing has always

argued that the relationship looks more like this.” She then drew a second set

of equal-sized circles that overlapped in the middle. Pointing to the right-hand

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18 CHAPTER 1

circle, she said, “Medicine does many things that nurses can’t do.” As she pointed

to the overlapping section, she continued, “And some of the things NPs do are

also done by physicians.” Then she pointed to the left-hand circle and said, “Yet

nursing has things that only it does—knowledge that exists apart from medicine.”

Francesca’s sense of what nursing “has always argued” was informed by the

long arc of nursing’s history. But it was also shaped by her experience living

through its more recent past. Francesca entered nursing as an RN in 1978. It was

a time when neither nursing nor medicine was quite sure who NPs were. Nurses

were initially wary of those who seemed to want to trade in their nursing identity

for that of medicine (Fairman 2008). It was physician organizations, not nursing

organizations, that initially welcomed NPs into the fold. This welcome, however,

came with a risk. Physician organizations began arguing that NPs were no longer

really nurses and therefore medicine, not nursing, should train and govern NPs

(Fairman 2008).

The status and identity of the NP was not fully resolved until the mid-1980s.

This period of uncertainty partly explains Francesca’s somewhat circuitous

route to becoming an NP. Nursing did eventually rally around NPs, so that today

there is little question over which profession they belong to. However, Franc-

esca’s instruction underlines a reality that is often missing from debates about

the NP: the boundary between the two professions is as important to nursing as

it is to medicine. One of nursing’s most enduring threats—to its identity, work,

and governance—is that of being swallowed whole by medicine. To blur the line

between them is to risk trading in nursing’s diagram for medicine’s, which shows

nursing as a small island within the sea of medicine’s domain. One of my primary

claims is that NPs may be doing more than simply reproducing physician prac-

tices. That claim requires an understanding of the ways in which nursing’s iden-

tity is grounded in assertions of difference, not interchangeability. In this chapter,

I situate who the Grove’s NPs understood themselves to be within nursing’s larger

political and existential fight for an identity apart from medicine.

A Profession Apart Throughout the nineteenth century (and well into the twentieth), the family

home was the site of most sick care in the US. Carried out as a woman’s obligation

to her family, nursing the sick was not viewed as something that required much in

the way of knowledge or skill (Reverby 1987b). Whether a woman performed the

work herself or discharged the duty to a servant, nursing work was akin to that of

laundering clothes and scrubbing floors. The bonds of affection might imbue the

work with deeper meaning, but as an activity, it was mere drudgery.

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NURSING’S EXPERTISE 19

The story of how nursing transformed from drudgery into the work of a

respected profession begins in the mid-1800s with the English reformer, Flor-

ence Nightingale. Nightingale has many accomplishments to her name, but she

is widely known as the first person to make the case that nursing work required

education (Reverby 1987a). She argued against the popular notion that women

knew how to nurse by instinct or intuition; she believed potential nurses had to

be both vetted and trained. Nightingale had an uphill battle. One of her primary

challenges was the need to allay the fears of physicians and hospital administra-

tors, who were suspicious of any new claimants to expertise over patient care.

While navigating these more powerful actors was a daunting political hurdle, the

cultural hurdle was just as formidable. In an era when even women of modest

economic means did not work outside the home, Nightingale had to make the

case that they could do so without losing their claims to respectability. Despite

these hurdles, Nightingale’s ideas came to fruition both in her native England

and in the US.

There are several explanations for Nightingale’s success, including savvy poli-

ticking. However, a key explanation lay in the decision to align her new ideas with

preexisting ones. Similar to other female social reformers of the time, she made

liberal use of a gendered, moral language to create a place for professional nurs-

ing (Ginzberg 1992; Kunzel 1995; Welter 1966). While members of the budding

women’s movement were beginning to argue that women should have some of

the same rights as men, Nightingale’s approach proved to be much more palat-

able. She argued for the extension of rights she believed women already held.

Nightingale drew heavily on the principle of separate spheres, a commonly

accepted principle of the Victorian era. This principle held that women and men

had fundamentally different natures that suited them for separate spheres of

action: women were suited to the domestic, private sphere, while men were bet-

ter suited to the public sphere. Nightingale contended that nursing was simply

an extension of women’s natural and rightful domain. Caring for the sick was

already a woman’s duty; she argued it could also be a woman’s work (Nightingale

1860; Reverby 1987a). Nightingale’s evocation of separate spheres quelled the

fears of those who threatened to stand in nursing’s way. Medicine would remain

the province of men; women would work in their own, separate realm. 1

Like most separate-but-equal doctrines, the principle of separate spheres

was grounded in a deeper logic of inequality. The construction of nursing as a

woman’s profession would legitimate nursing’s subordination to medicine for

decades to come. The creation of a space apart, however, produced the possibility

for nursing’s autonomy and the construction of independent value. Nightingale

was quite forthright in arguing that only nurses should control nursing work.

Although noting that nurses had a duty to obey physicians in medical matters,

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20 CHAPTER 1

she took great pains to argue for the necessity of separate chains of command

(Holton 1984; Nightingale 1865). For Nightingale, nursing’s autonomy was not

just for the good of the nurse; it was for the good of the patient. She strongly

believed that “medical therapeutics and ‘curing’ were of lesser importance to

patient outcomes and she willingly left this realm to the physician” (Reverby

1987b, 7). In Nightingale’s view, women were superior at nursing, and when it

came to promoting health and well-being, nursing was superior to medicine

(Holton 1984; Reverby 1987b). At a time when physicians were turning toward

science and away from direct patient care, nursing began creating a corps of edu-

cated women whose distinct role was to observe patients, respond to their physi-

cal needs, and be attentive to their mental and social needs. Physicians would

cure, but nurses would care—in a way that was skillful and that materially mat-

tered for patients.

This initial framing set the nursing profession apart from medicine, with

different work, different knowledge, and a different orientation to patient care.

However, maintaining this separation has taken active work on the part of nurs-

ing. At different times and places, both hospitals and professional medicine have

attempted to annex nurses into their own regimes (Fairman 2008; Reverby 1987a;

Rosenberg 1995). Nursing, however, has been successful at preserving its own

identity. In the US, twenty-first-century nursing maintains its own professional

organizations, educates its own workers, and upholds autonomous standards for

regulating its work. Nurses may not always have the same power as physicians,

but they have taken pains to be neither absorbed nor governed by them.

The work of the NP might seem to be the breaking point of nursing’s claims

of separation from medicine. Nurse practitioners are licensed to provide the kind

of care traditionally performed by physicians, such as assessing patients, making

diagnoses, and providing or directing treatment. In twenty-two states and the

District of Columbia, they can do so without physician oversight or involvement

(American Association of Nurse Practitioners 2018). The NP’s work and grow-

ing autonomy has arguably made the wall between medicine and nursing more

porous than it has ever been. Nursing’s original wariness of this new role illus-

trates the ways in which the NP was both an opportunity and a threat to internal

notions of what it uniquely means to nurse (Barnes 2015; Brown and Olshansky

1998; Cusson and Strange 2008; Fairman 2008; Heitz, Steiner, and Burman 2004;

Hill and Sawatzky 2011).

When I began my work on the NP, one of my first aims was to understand how

the separation between medicine and nursing fared as NPs learned to, ostensibly,

practice medicine. I turned my attention to a classic site of identity construction:

professional schooling. In 2009, I spent twelve months following a cohort of NP

students at Stanton School of Nursing. Stanton is highly ranked—what some

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NURSING’S EXPERTISE 21

might call elite. Elite schooling would not represent the modal experience; to be

elite is defined by the status of being set apart. Elites are, however, usually the

producers and chief circulators of group-level claims to legitimacy and status

(Granfield 1992; Khan 2012; Reverby 1987a; Schleef 2006). If I wanted to under-

stand how nursing fashioned and maintained an identity apart from medicine,

elite schooling was one place to look.

The first thing I learned about nursing education is that from a creden-

tialing perspective, every NP is a nurse. Prospective NPs must complete the

education and licensure to become RNs before they can go on to train as NPs.

When I spoke with Stanton’s NP students about the transition from RN to NP,

I expected to hear stories of “moving up” from nursing or of “getting through”

the RN program as a credentialing hurdle. Instead, these students felt that the

experience of being a nurse was fundamental to learning to be an NP (Trotter

2019). One student asserted that it was in being a nurse that he learned “to

not just see the patient as a medical diagnosis or a set of problems,” and that

his experience as an RN gave him “a unique perspective on [providing] pri-

mary care as an NP.” Another student shared: “It was in going through nursing

school [and working as an RN] that I realized that nurses weren’t just doctors’

flunkies . . . that they were the ones at the bedside making a real difference in

the patient’s life.” The time prospective NPs spent working at the bedside was

not just about experience but about learning to embody what it meant to be a

nurse. Even as they made their way through the NP curriculum, the salience of

being a nurse remained.

To risk stating the obvious, it is not only RN education that happens in nursing

schools but also NP education. Although ostensibly learning diagnostic medicine,

these students were being taught a curriculum created by nurses and delivered

by nursing faculty. Students were certainly cognizant that they were learning

skills that, to some extent, still belonged to medicine. Yet they told stories that

reframed much of this work as nursing work. Through educational narratives,

they reworked nursing’s traditional claims to “whole person care,” “knowing the

patient,” and “relational interaction” (Apesoa-Varano 2016; Benner and Tanner

1987; Evans 1996; Radwin 1996; Tanner et al. 1993) into NP-specific modes of

care (Trotter 2019).

It was at Stanton that I first began to realize that nursing’s need to main-

tain its border with medicine was not only about professional control but also

about claims to different expertise. Stanton’s students were not learning how to

be like physicians but were figuring out how to remain nurses. As nurses, they

were called to be practitioners of care—not as an affective orientation but as

an iconic form of care work marked by relationship and responsiveness (Duffy,

Albelda, and Hammonds 2013; England 2005). Nursing’s embodiment of care

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22 CHAPTER 1

also invoked a different terrain of knowledge. I listened to faculty tell students,

“doctors have their expertise, but you have your own.” And I listened carefully as

faculty and students narrated the location of that expertise: on the bodies of the

socially vulnerable. These NPs in training were being told that their expertise lay

in the very skills that medicine, in its turn toward specialization, had left behind.

And that their utility was in serving those whom society had left behind: patients

without health insurance, patients living in poverty, and patients struggling to

manage their health under stressful circumstances. In Stanton’s classrooms, the

skills of relationship and of seeing the whole person put NPs in a position to be

expert providers to those for whom economic and social precarity were daily

realities. This was not simply a matter of empathy or compassion; it was about

constructing a different kind of clinical problem to which they could apply nurs-

ing expertise (Trotter 2019).

I left Stanton with a firm sense of the kinds of stories, metaphors, and identi-

ties that NPs constructed to navigate their new role. At the same time, key ques-

tions remained about the relationship between what NPs said about themselves

and how they might actually practice. The possibility that these were not one

and the same was pointed out to me by a physician I knew who was complet-

ing a post-residency fellowship in pediatric anesthesiology. As I summarized my

findings from Stanton, he countered, “Well, med students also form ideas about

how they will practice. But then reality sets in.” Indeed, what would happen when

newly minted NPs brought their classroom-honed ideas to work—in a world

not of their own making, but negotiated with the expectations of colleagues,

employers, patients, and payers? To understand this more complex set of social

processes, I would need to leave the nursing school.

There were any number of places I could have gone to see NPs at work. I could

find NPs at a retail walk-in clinic, at a federally supported neighborhood health

clinic, or at a high-end specialty practice. Faced with such diversity, I initially

grasped at the idea of finding an average case. However, after months of conver-

sations with Stanton faculty and students, I had already begun to doubt whether

such a case existed. For providers whose role was in flux, organizational varia-

tion seemed to be more the rule than the exception (Fairman 2008). Students in

particular had developed a belief that an organization’s experience with NPs (and

its physicians’ attitudes toward them) was at least as important in shaping their

work as the setting.

If I could not reliably find an average portrait of NP practice, I made it my

mission to find one that was likely to represent nursing’s ideal vision for NP prac-

tice. In the US, there is a group of health care organizations that self-identify as

nurse-managed or nurse-led health care centers. Some are staffed by RNs trained

in community or public health nursing while others provide NP-led primary

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NURSING’S EXPERTISE 23

care. But all embrace a vision of nursing leadership and, in agreement with the

profession’s larger claims, all assert their value in serving vulnerable populations

and working to eliminate health disparities. Through a combination of word-of-

mouth and organizational networks, I found what I believed to be all seven of

such centers that provided primary care in one northeastern city. Each of these

centers allowed me to spend an afternoon or two observing clinic operations

and meet with at least one administrator, as well as the NPs. I learned about

each organization’s history, how it was financed, whom it served, and how it was

staffed.

My goal in these conversations was both to develop an understanding of what

being nurse managed meant and to investigate possibilities for fieldwork. This

was how I found myself back in the halls of Stanton, speaking with the school’s

dean of community practice. Forest Grove Elder Services was on that list of seven

because Stanton School of Nursing owned and operated it. Sitting across the desk

from the dean, I described my broader research and my reason for wanting to add

Forest Grove to my organizational tour. In response, she delivered what sounded

like a warning: “The Grove is more than just a clinic.” If I was looking for an ordi-

nary clinic, the Grove was probably not where I wanted to be. She did, however,

encourage me to visit the Grove, as an example of what nursing could and would

do if allowed to embody its own orientation to patient care. I took both her warn-

ing and her encouragement to heart. Ultimately the Grove’s uniqueness, rather

than its representativeness, convinced me to stay for the next two and a half years.

The Grove was one of many policy experiments in community-based forms

of long-term care. Its focus on comprehensive, coordinated care is fairly unique

in a landscape dominated by piecemeal service provision. However, with a nurs-

ing school as its fiscal and administrative manager, the Grove was as much a

demonstration of nursing leadership as an experiment in older adult care. For

Stanton, the Grove was a stage upon which to elevate both the nursing profession

and nursing work. While the Grove’s model of care was not a nursing creation,

Stanton often employed it as an exemplar of nursing expertise, professional mis-

sion, and nursing’s utility to policy makers. As a nurse-managed organization,

the Grove strove to embody a nursing approach to care even as it provided what

patients and payers would recognize as medical care.

More than a Clinic In 1998, Stanton opened the Grove with fewer than ten members. It was a humble

operation, housed within a small, three-story storefront. Even with this modest

start, Stanton knew it was potentially doing something big. Nursing does not

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24 CHAPTER 1

have the same entrepreneurial history as medicine; its denizens have mostly been

employees rather than owners. In a landscape where it remains uncommon for

nurses to operate their own health care organizations, the Grove was an oppor-

tunity for Stanton to move nursing into new terrain. It was not long before they

began having measurable success.

In less than five years, the Grove’s member population had grown so large

that it was able to open a second location. By 2005, membership had reached

250. The Grove was growing not just in size but in reputation. State and local

politicians began to take notice of a program that seemed to appeal to consum-

ers while also potentially lowering costs. In a nursing school newsletter, the dean

of the nursing school reported that state administrators were asking the Grove

to expand enough to accommodate five hundred members within the next two

years. If the Grove wanted to continue growing, however, it would have to find

a larger space.

Less than a mile from Stanton’s campus stood a vacant building that seemed

almost perfect. The building was four stories of chimney-red brick, containing

over seventy thousand square feet of useable space. Not only was it large enough

to consolidate the Grove’s current members into one location, but it also had

enough room to expand. The building seemed ideal in other ways. It had previ-

ously been a nursing home, giving it an optimal constellation of rooms and facili-

ties to offer medical services, meals, and social activities. There was also a sense

of poetic justice. Opening an alternative to institutional care on the grounds of a

former nursing home seemed almost karmic; the building’s story would eventu-

ally become a very satisfying one to tell. The space would also satisfy the needs of

a growing organization.

In 2007, the Grove celebrated the grand opening of its new home. The move to

a larger building was an aspirational one, not just for the organization but for the

nursing school. Stanton was heavily invested in the Grove. The Grove’s operating

expenses were well over thirty-one million dollars, representing 40 percent of the

nursing school’s operating budget. Although it was one of several community

practices that Stanton operated, the Grove’s size and scope dwarfed the others,

making it a unique and publicity-worthy achievement.

There were other ways in which the fortunes of Stanton and the Grove were

intertwined. Stanton’s nursing students routinely completed clinical rotations at

the Grove. For its nursing faculty, the Grove was a common place to undertake

gerontological nursing research. There were also links between Stanton and the

NPs I followed: all but one was a Stanton graduate. If we assume that professional

socialization is at least partly shaped by schooling, Stanton undoubtedly influenced

these nurses’ understanding of what it meant to be an NP (Becker et al. 1976; Fox

1957; Granfield 1992; Hafferty and Franks 1994). However, the ties between Stanton

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NURSING’S EXPERTISE 25

and the Grove were also about mission. In one Stanton newsletter, a board member

was quoted as calling the Grove “an active personification” of what nursing stands

for. The nursing school saw the Grove’s focus on coordination and management

as the organizational equivalent of nursing’s own calls for relational, whole person

care. For Stanton, the Grove was not just another clinic. It was a chance to showcase

nursing’s unique mission, leadership, and expertise.

Stanton’s aim to elevate nursing work included the Grove’s NPs. In and of

itself, there is nothing particularly groundbreaking about employing NPs. How-

ever, the Grove was unique in placing the NP in a leadership role. While medical

care was provided collaboratively by NPs and physicians, the NPs were explicitly

named by Stanton as the leaders of the interdisciplinary teams and were, admin-

istratively, the primary care provider of record. 2 This naming is more revolution-

ary than it first appears.

Increasingly, teamwork in healthcare has been touted as a way to improve coor-

dination, increase communication among providers, decrease medical errors, and

ultimately, improve patient outcomes (Baker, Day, and Salas 2006; Institute of

Medicine 2001; Rice 2000). However, critics have argued that the notion of team-

work is an illusion that masks entrenched forms of inequality (Apesoa-Varano

and Varano 2014; Finn 2008; Finn, Learmonth, and Reedy 2010). Physician orga-

nizations require no such subterfuge. The American Medical Association (AMA)

explicitly argues that the evocation of teams should not be employed as a leveling

device; physicians should remain the rightful leaders in health care, teams or no

teams (Permut 2016). At the Grove, however, this traditional hierarchy was turned

on its head. In naming them as the principal providers in the clinic, Stanton gave

the Grove’s NPs an opening to reorder what care meant.

Nursing’s Usefulness If the Grove was an aspirational resource for Stanton, its NPs were on the

front lines of nursing’s continuing battle to prove its unique utility. However,

at the level of clinical care, the Grove was also a testament to the contradic-

tions of that utility. The first NPs were trained in pediatrics. Created to meet

the demands of the baby boom, the pediatric NP was trained to provide “well

child care.” The expectation was that they would refer children with acute

or chronic conditions to a physician (Silver, Ford, and Steady 1967). Popu-

lar accounts of NPs continue to stress their ability to provide “routine” care.

Readers are asked to imagine yearly physicals, runny noses, and strep throat.

Little, however, was routine about the Grove’s members. No one knew that

better than the NPs who cared for them.

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26 CHAPTER 1

When NP Norah first started working at the Grove, she was no novice. She

had already been an NP for fifteen years. The last seven were spent at a retire-

ment community. She knew older adults. She knew geriatric medicine. But

when she first started treating the Grove’s members, she recalls thinking, “Holy

crap! These people are bad!” She had to learn how to manage conditions at a

level of acuity she had rarely seen before. Norah was not alone. All the NPs

I followed spoke about the challenges they faced in their first few years of work-

ing at the Grove. Not only were they seeing members living in complex circum-

stances, but as providers within a nursing home diversion program, they were

also expected to stretch the limits of what is normally done in primary care.

NP Anne, who had spent most of her career in acute care settings noted, “In a

hospital, you refer everybody. Somebody’s creatinine goes up with renal failure,

you refer it to renal. You don’t mess with it.” At the Grove, things looked a little

different. Anne continued, “You might bring them in. You might give them

some fluids. Look at their med list. See if there’s something you can cut back

on.” What Anne was describing is not primary care everywhere, but is often

what it means to provide primary care for those with the highest burdens of

disease and disability.

If the NPs’ imagined patients are the vulnerable and underserved, the Grove

was a place where the imagined came to life. Norah opined, “We’re seeing people

who just didn’t have good health care throughout their lives.” We know that pov-

erty in particular and socioeconomic status in general play a significant role in

determining health outcomes throughout the life course (Adler and Newman

2002; Braveman et al. 2005; Braveman, Egerter, and Williams 2011; Marmot

2004). There is increasing evidence that socioeconomic status continues to mat-

ter for health even in old age (Huguet, Kaplan, and Feeny 2008; Lyu and Burr

2016; Sudano and Baker 2006; Yao and Robert 2008, 2011). Because the Grove’s

members had to be medically frail or have significant cognitive deficits to qualify

for enrollment, many had already borne years of costly medical interventions and

home care expenses prior to coming to the Grove. These unrelenting economic

stressors may have further worsened their health status.

Race was another factor that shaped the medical vulnerability of the Grove’s

members. In 2009, 96 percent of the Grove’s members were African American.

This was primarily by design. As a federal program, the Grove had a predefined

catchment area of twelve zip codes. In seven of these areas, African Americans

exceeded 70 percent of the population. Living as an African American in the US is

itself a kind of medical vulnerability. There is a growing body of evidence to sug-

gest that experiences of racial discrimination produce chronic stress that literally

wears down the body, leading to premature aging and the early onset of chronic

disease (Geronimus 1996; Geronimus et al. 2006; Williams 2012).

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NURSING’S EXPERTISE 27

Nurse practitioners may have been created to provide routine care, but in

becoming the providers of the poor, disabled, or otherwise medically margin-

alized, they have been asked to meet a fairly high bar of expertise (Buerhaus

et al. 2018; DesRoches et al. 2017). Of course, they are not usually tasked with

meeting this challenge alone. The vast majority of NPs work in a setting with

some level of physician contribution (Health Resource and Services Administra-

tion 2014). This was particularly true at the Grove. In 2010, the Grove employed

three full-time physicians and one part-time physician. In the Grove’s state, NPs

were required to establish a formal, documented relationship with a collaborat-

ing physician. The NP and MD signed written agreements that spelled out what

the NP could and could not do. This formal performance of oversight, however,

sometimes seemed to belie the level of independence expected of NPs in everyday

practice.

At every other nurse-managed site I visited, the physicians were largely invis-

ible. Once the collaborating agreement had been filed away, the physician’s only

responsibility was to be available for questions during the NP’s practice hours—

which usually translated to being available by telephone. These physicians had

other jobs and had their own patients to see; acting as a collaborating physi-

cian was mainly a side gig. At five of the seven nurse-managed sites I visited,

the physicians were not expected to ever appear in person. At the sixth site, the

collaborating physician had a schedule for clinic visitations, but he came outside

clinic hours to provide staff education, not to assist in patient care. The role of

these collaborating physicians was to serve as a resource for the NPs, not for their

patients.

This was not the situation at the Grove. The Grove’s physicians did not have

other jobs or other patients. The Grove was their full-time job, and they were

expected to participate directly in patient care. This reality was partly a reflec-

tion of the Grove’s organizational complexity. As a site within a larger federal

program, the Grove had an additional layer of guidelines regarding physician

presence. A physician was required to serve as medical director, and a physician

was a required member of each interdisciplinary care team. The Grove may have

been nurse managed, but it did not have the option of relegating physicians to

the margins.

What all these physicians did on this stage of nursing excellence was one of

the first questions I began asking at the Grove. Not everyone agreed upon the

answer. One of the first people I asked was Katherine, who was trained as both a

nurse and a social worker; at the Grove, her job was to plan and coordinate staff

education. She said, “The nurse practitioners really do handle most of the care.

We have physicians, but they are mostly consultants.” I heard what she said, but

I also heard how she said it. Even though we were alone in her office, she leaned

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28 CHAPTER 1

in slightly and lowered her voice before she spoke these words, almost as if she

were relaying a secret. I assumed what she was concealing was the role of the

NPs. However, as I got to know the Grove better, I began wondering whether it

was the role of the physicians she was trying to keep under wraps.

One of the initial formal interviews I completed was with the center’s chief

operating officer. I wanted to get her understanding of how the clinic was

organized. She began by describing the roles of the NPs, the primary care

nurses, and the wound care nurse. She then moved onto the appointment

clerks, medical assistants, and the clinic receptionist. I listened patiently as she

began to talk about the dental and podiatry services that the Grove provided

in-house. For more than half an hour, she talked in great detail about the

Grove’s clinical services, but the word “physician” did not voluntarily come

out of her mouth.

A similar silence around the physicians’ role also seemed to pervade the

clinic. In my first walk-through, I observed that outside each NP’s office there

was a printed list of clinical team members. The name of the full-time NP

topped the list, followed by that of the part-time NP who supported the team.

Then there was that of the primary care nurse and the team’s medication nurse.

The name of the home care coordinator and the home care nurse followed. The

list ended with the name of the appointment clerk. There was no mention of

the physicians.

The whispers, the silence, and the invisibility surrounding the physicians

revealed a general unsettledness, not about the place of nursing but about that

of medicine. In the world outside the Grove, it is the NP’s scope of practice that

is questioned. In that world, policy makers, insurers, nurses, and physicians

continue to argue over just how independently NPs should be able to care for

patients. But at the Grove, this question was turned on its head. In a nursing

organization, crowded with nurses of all kinds, what exactly should the physi-

cians be doing?

The Grove and its NPs were on the front lines of an enduring fight to both expand

nursing’s reach and maintain its separateness from medicine. While nursing has

not been above marshaling claims of interchangeability when it appeals to policy

makers, its advocates have also understood that its professional independence

depends upon nursing maintaining work and knowledge that exist apart from

medicine. The warning delivered by Stanton’s dean was not just about the sin-

gularity of the Grove as a policy experiment; it was about the rarity of placing

nursing’s view of care at the center rather than at the periphery.

I chose to stay at the Grove because of what that rarity allowed me to see. In

a site where nurses had more power to define their own work, I expected to see,

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NURSING’S EXPERTISE 29

in sharp relief, how NPs would embody professional difference from physicians

while working in medicine’s traditional domain. While much of the policy nar-

rative has focused on how well the NP can approximate physician labor, I argue

that it is their difference from, not likeness to, physicians that makes the NPs of

particular utility to patients, health care organizations, and state policy makers.

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30

2

FROM MEDICAL WORK TO CLINIC WORK

The Grove held morning meetings every day at eight forty-five a.m. Attendees

would hear a rundown of which members had gone to the ER, who was being

discharged from rehab, and who had died in the night. The meeting would begin

with the on-call report. Outside business hours, there was a telephone number

that members, families, and aides could use to relay questions and complaints.

The on-call report was a summary of each call and how it had been handled. On

most mornings, the reader of this report was NP Lori, one of the Grove’s gero-

psychiatric NPs. Once the meeting was called to order, she would stand, hold her

notes in her right hand, and read.

“The home care nurse called to say that Allison Jones wasn’t home yet.

I believe she went on vacation.”

NP Anne looked up when she heard Ms. Jones’ name. She frowned and asked,

“When was that? Because I went out last night to drop off medications.”

“It was at . . .” Lori scanned through her notes to check “. . . five forty-five last

night.”

Anne continued frowning. “Hmm. Well. Okay,” telegraphing through her

voice that this was unlikely to be the end of the story.

“At six p.m., Mr. Simmons called needing wound supplies. I told the home

care nurse. She is taking care of it.”

Lori flipped the page on her notes and continued to read. “I got a call

at ten p.m. Marlene Baker fell at home. I gave the message to Norah. She took

care of it.”

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FROM MEDICAL WORK TO CLINIC WORK 31

Without looking up from her notes, NP Norah confirmed, “It was taken

care of.”

“Stacey Ladner’s son called. He was very angry. They sent a male caregiver to

care for his mother last night. He wants a meeting.” Anne interrupted to add, “It’s

not the first time this has happened. That’s a grievance.”

“The Gardens called. Arline Moore is not coming in today. She still has a

cough and a sore throat.” Lori looked up from her notes and suggested, “Nurs-

ing should go out to visit her soon. She hasn’t been feeling well for a while.” Lori

addressed this suggestion to the room, but it was NP Michelle who wrote it down

on her list of things to do.

“Denise Franks called about her meds. She had run out.” Norah interjected,

“But I took care of that. I took care of all of her meds.” Lori shrugged. “Well,

I called them in for the weekend. Maybe they didn’t go through.” Sometimes pre-

scriptions did not go through, but Norah was certain that this had not happened

with Ms. Franks. “I know her meds were taken care of. I personally tied them to

her wheelchair before she left the center on Friday!”

On-call was the first item in a longer agenda. There were lists of which mem-

bers had specialist appointments to attend, which members were requesting

additional services, and whose families were lodging formal grievances. The

daily reading of lists was an illustration of the complexity of caring for mem-

bers whose problems appeared not just in exam rooms but in hospitals, nursing

homes, assisted housing, and family homes. But morning meeting was more than

an illustration of complex care provision; it was also a demonstration of how that

care happened.

The principal actors in this daily performance were the NPs. And it was they

who routinely disrupted this reading of facts. If there was a discrepancy between

what they heard and what they knew, they would contest or amend what the orga-

nization believed to be true. While other attendees might voice a concern during

the meeting, it was the NPs who actively performed the taking on of concerns.

Even when they were silent, everyone could see them, seated collectively in the

center of the room, responding to new information by making lists of their own.

Through words, actions, and sheer presence, they performed their commitment

to knowing about a wide range of member problems. Specialist appointments,

problems with medication delivery—every piece of member-related information

seemed to make it onto an NP’s list. Moreover, this performance was a public

one. Each NP’s professional sense of responsibility was on display for the entire

organization, from administrators to social workers to aides. We were there to

witness what the NPs knew about their members and what they believed they

needed to know. We also saw what they did with that information: they solved

member problems.

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32 CHAPTER 2

In this chapter, I illustrate how this work unfolded, through attention to how

certain problems arrived on the NPs’ lists of things to do and how this arrival

reflected both professional and organizational understandings of NP work. In

an organization structured around teams, many people had access to member

problems. From meetings to email exchanges, the NPs were joined by a host of

others in receiving member information. This information was not only about

disease processes but also about family relationships, community context, and

each member’s experience of the Grove’s system of coordination. Yet I found that

the NPs were singular in performing a professional openness to incorporating

such diverse information into their clinical view of members.

The NPs’ openness allowed them to cultivate a layered knowledge of each

member that was distinct from the understandings of other providers on the

team. More importantly, they were uniquely positioned to wield that knowledge

from inside the medical encounter. In a health care context, problems that could

be relocated to the clinic were treated with more urgency and more resources

than those located outside the clinic. The act of relocating a broad range of prob-

lems to the medical encounter was at the core of the NPs’ performance of what

I call clinic work. The NPs were still responsible for treating and managing disease.

However, their view of chief complaints was not limited to the biological body

but extended to the socially and organizationally embedded body. Situated in the

health care encounter, clinic work was not just added to traditional notions of

medical work, it was a reconfiguration of what it meant to practice medicine . . .

when it was practiced by nurses.

The Expanded Encounter Norah was the full-time NP who anchored her team. In that role, she was respon-

sible for the medical care of approximately one hundred members. When I first

met her, I was struck by how closely she embodied my unarticulated ideal of a

nurse. Demographically, she represents what nursing has looked like for most of

its professional history: she is white, she is female, and she is a married mother of

three. More than a confluence of demographic variables, Norah exuded a brand

of easy confidence that one hopes to find at the bedside. “I’m good with people,”

she told me—not once, but several times. She made this pronouncement less as a

boast than as a self-evident truth. “You’ve been here a while,” she offered by way

of explanation. “You know how I am.” This confidence extended to her work.

“I’m good at what I do. And I think the Grove appreciates that.”

The Grove, it turned out, did appreciate Norah. If organizations can be thought

of as having certain beliefs, the Grove believed that she was “one of the best” NPs.

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FROM MEDICAL WORK TO CLINIC WORK 33

I heard this assessment from the Grove’s aides, its administrators, and more than

a few of its clinicians. But what made Norah one of the best was not exactly

transparent. The Grove, like many outpatient organizations, did not systemati-

cally analyze patient outcomes by provider. When I asked Norah to describe her

understanding of how her work was assessed, she replied, “I don’t think there’s

really much to do with—which is funny—performance.” While there was some

attention given to the timeliness of regulatory paperwork, the NPs were not

held to account for chart audits or clinical benchmarks. Yet the Grove’s sense of

Norah’s competence was not a mirage; it was grounded in the solidity of everyday

experience. Norah was a problem solver. She seemed to take personal responsi-

bility for attending to anything that stood between her members and improved

health. For Norah, that meant expanding the terrain of the encounter beyond the

walls of the exam room.

When I began following Norah, the first thing I noticed was the prominence

of the telephone. Norah’s day seemed to begin and end with attending to its

demands. Each and every morning, she was greeted with the urgent blinking

of the voice-mail light. These messages were almost exclusively from members

and their families. There might be a call from Ms. Baker to report she had been

up all night coughing. There might be a message from Ms. Joyner’s daughter;

when her mother returned home last night, her purse did not return with her.

There might be a message from Mr. Rivers, who is concerned that his father has

been acting strangely. Or from the triage nurse downstairs, who needs to notify

Norah that a medication she was scheduled to administer has not arrived from

the pharmacy.

In this more intimate version of the on-call report, Norah would repeat the

same motions she had just performed in morning meeting: she would listen, and

she would make decisions about what needed her attention. Norah’s phone was

not just a queuing device for when she was out of the office; it sounded out for

attention throughout the day. The identity of these callers mirrored that of each

morning’s voice mails; they were usually members and their families. And more

than anyone wished, these were often calls of complaint.

During one of my mornings with Norah, I sat behind her while she looked

over her list of members for the day. When her phone rang, she answered with

a swiftness that undoubtedly came with practice. “Oh hi, Carol.” Carol is the

daughter of one of Norah’s members. Her mother was in a rehabilitation facil-

ity recovering from a hip fracture. Since her mother’s needs were largely being

taken care of at the facility, Carol had not called with a medical problem. She had

called with a different kind of problem. The Grove had arranged to transport her

mother from rehab to a follow-up appointment with the orthopedic surgeon.

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34 CHAPTER 2

However, no one at the Grove had notified the facility, and her mother was not

ready for transport when the driver arrived. Consequently, her mother missed

the appointment.

I listened as Norah made apologies to smooth over Carol’s frustration, detail-

ing what she would do to address the situation. “I’ll have the [appointment clerk]

reschedule the appointment. Next time, we’ll make sure the nursing home knows.”

Norah wrote down this new item on the to-do list she keeps by her phone. When

Norah said she’d contact the clerk, she meant that she would walk across the hall

and speak directly to the clerk, verbally emphasizing how important it was to

notify the nursing home “next time.”

Before Norah could get through the pleasantries of ending the call, she noticed

the clinic receptionist standing inside her doorway. During a routine vital sign

check, Ms. Robins had presented with an elevated blood pressure. Per protocol,

the receptionist came to alert Norah, asking, “Do you want to see her?” An ele-

vated blood pressure is not always cause for immediate concern; some members

have poorly controlled blood pressure, while others maintain a consistent blood

pressure that runs higher than normal. Whether Norah chose to see Ms. Robins

immediately was not solely dependent on the numbers, but on her particular

clinical history.

Talking partly to herself and partly to us, Norah announced that Ms. Robins’s

pressure “is never elevated,” and that yes, she would like to see her. Trying to be

helpful, I volunteered to escort Ms. Robins from the waiting room to Norah’s office.

When I called her name, Ms. Robins arose under her own power. Without benefit

of walker or cane, she walked slowly but easily beside me. Her physical abilities set

her apart from much of the Grove’s population. As we carried on a casual conver-

sation about the center, I saw no evidence of impaired cognition. However, my

assessment of her independence was misplaced. She was in fair physical health,

but she had dementia, which made her an unreliable reporter of her own rou-

tines. Consequently, Norah did not begin the encounter by eliciting a history from

Ms. Robins but by saying, “let’s see if we can get your daughter on the phone.”

Norah looked up the number in the electronic medical record and then dialed.

Putting the call on speaker for Ms. Robins’s benefit, she narrated her concern

to the daughter and asked, “Has anything changed about her diet or her rou-

tine?” This simple question often elicits information about a caregiver’s new job,

a change in who resides with the member, or a new reliance on high-sodium

frozen dinners. Today, Norah’s questioning led to a simpler explanation for the

elevated reading. According to the daughter, Ms. Robins had run out of blood

pressure medication. As a comprehensive care organization, medication delivery

was one of the things the Grove managed. Whatever had happened to Ms. Robins’s

medication was not the fault of an outside organization; it was the fault of the

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FROM MEDICAL WORK TO CLINIC WORK 35

Grove. Hiding her own exasperation, Norah confidently assured the daughter

that the medication would go home with her mother today. This was not an

empty promise. Norah did the work of making it a reality.

After ending the call, Norah turned to her computer and looked online at the

pharmacy records. Finding those for Ms. Robins, she verified that the prescrip-

tion was active and that the pharmacy did, indeed, fill it. Not content to trust the

pharmacy’s online system, Norah called the Grove’s third-floor medication room

to verify the order’s receipt. Speaking directly with the medication nurse, she

asked for confirmation that Ms. Robins’s medication refills would go home with

her on the van this afternoon. Before she hung up, she made a final request to the

med room nurse: “Can you come down and give [Ms. Robins] her regular dose

of Lasix [a blood pressure medication]? She missed it this morning.”

The traditional medical encounter does not usually contain these kinds of

problems. An assumed part of diagnostic thinking requires filtering a patient’s

diverse complaints until a singular, medically defined complaint remains. For

Norah, the problem, and therefore the solution, was more complicated than just

what the body was doing. Instead of a winnowing out of members’ indigenous

complaints, she expanded the encounter to include them. Addressing the prob-

lem meant helping members gain access to the right specialists for a successful

recovery. It meant dealing with the everyday difficulties of medication compli-

ance. She expanded the encounter to include family members—using the phone

to dissolve the time and distance between the clinic and what was happening at

home or rehab. She organized the action of the Grove’s institutional caregivers

such as the medication nurses, the appointment clerks, and the transportation

department. And just as importantly, she often smoothed over the frustrations

of members and their families, not by managing their emotions but by taking

responsibility for their problems.

For Norah, there was no contradiction between the work she performed and

her ideas about what NPs do. When I asked Norah to describe the NPs’ approach

to patient care, she responded, “The nursing model is much more holistic [than

the medical model]. You’re looking at the whole person. Yes, disease is part

of the person, but so is their environment, so is their mentation, their spirit, so is

their social environment. So I think instinctually we all—nurses—that’s how we

look at some things.” This professional orientation informed how she described

the role of the NP at the Grove. Norah described the NPs as “like the air traffic

controller of the members and their needs.” Although each team contained a

range of providers, she believed that the NPs were best positioned to “hear things

or identify [member] needs.” For Norah, this positioning was not an individual

orientation but a professional one. “NPs have really taken on that kind of respon-

sibility. It’s the nature of the profession .”

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36 CHAPTER 2

Norah may have been considered an exemplar of NP skill, but she was not

unique in expressing her belief that NPs had a distinct professional approach.

NP Alice was one of the Grove’s part-time NPs. She did not have her own team;

she saw members in support of the work of a full-time NP. When I asked her to

describe her role at the Grove, she replied, “I’m the gatekeeper that sends things

out, but yet I also try to manage [members’] medicines and overall health. That’s

my ‘big picture.’ But I’m also trying to coordinate all of the ancillary and other

people that help me keep them functional. My job is to keep them as functional

as long as possible. And that’s what I do.”

Similarly to Norah, Alice went on to contrast this orientation to that of the

medical model that physicians employed. “Of course a doctor would tell you

they do that too. But again, I doubt that they’re going to check to see what the

dentist had to say or what the optometrist had to say. Lots of times they don’t

even really—they don’t listen well.” It is notable that this was the experience

of a part-time NP. Even though the patients she saw were not, in an organiza-

tional sense, “her members,” Alice’s understanding of what NPs do nonetheless

shaped her sense of responsibility. Sometimes that care looked similar to that

of the physician—for example, managing medicines and making referrals. But

sometimes that work was in an arena that Alice put into the exclusive purview

of nursing. From the vantage point of the NPs, listening well to members was

one of the core ideals of what it meant to be a good provider. Listening well took

skill. It also took time.

Michelle was another full-time NP with her own panel of members. One

afternoon, I sat with her as she met with Mr. George. She was meeting with him

because his weight had gone up by seven pounds in less than two weeks. She

needed to figure out why. Mr. George had congestive heart failure. Rapid weight

gain from fluid retention is one of the classic signs that something is amiss. It

could be a worsening of his heart; it could be a change in his diet; it could be a

problem with his medication. This was the kind of slow-moving emergency that

the Grove’s NPs faced on a daily basis. If Mr. George retained too much fluid, it

might eventually move to his lungs. If Michelle could not figure out the problem

fairly quickly, he might find himself struggling to breathe.

Michelle often employed a style that could best be described as playing dumb.

When she wanted to understand a problem, either from a member, family, or

staff, she asked questions that seemed to conceal what she believed she already

knew. I watched as Michelle spent half an hour listening to Mr. George describe

how he took his medications and when. She was meticulous in her question-

ing. Because Mr. George was not conversant with the names of the medications

he took, she showed him pictures of each of his pills as she asked him when he

took them. Her questions were open-ended. Therefore, along with hearing the

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FROM MEDICAL WORK TO CLINIC WORK 37

information she may have been interested in, she also heard what Mr. George

was interested in. He had his own ideas about how each of the medications made

him feel. He asked questions of his own about why he was taking certain pills or

why the pharmacy had switched him from brand name drugs to generics. When

Michelle got to one of his last medications, he said, “This one I take halfways.” She

stopped and asked, “What do you mean by halfways?” After a bit of questioning,

Michelle learned that Mr. George was only taking half this pill; he was concerned

about side effects and believed he felt better when he took less of it. He did not

know that the pill he was taking less of was the medication that helped him man-

age his heart failure.

At the Grove, the expansion of the clinic encounter required a professional

openness to information from inside the exam room as well as from outside it.

Michelle learned a lot about Mr. George in this interaction. She learned how he

reasoned about which pills to take and when. She learned that despite not know-

ing which pills were for which condition, he was otherwise willing and compli-

ant with taking his medications. She learned more about his relationship with a

neighbor who sometimes came over to help him put groceries away. And she also

learned why Mr. George was retaining fluid.

The Epistemology of Professional Openness The position of leaving oneself open is in accordance with the stories nursing tells

about itself. Scholarship on nursing practices has identified “whole person care,”

“knowing the patient,” and “relational interaction” as unique to nursing forms of

care (Apesoa-Varano 2016; Benner and Tanner 1987; Evans 1996; Radwin 1996;

Tanner et al. 1993). Some nursing scholars have raised questions about the utility

of grounding nursing identity in a rhetoric of care rather than in knowledge or

technical know-how (Allen 2004; Dingwall and Allen 2001; Gordon and Nelson

2006; Nelson and Gordon 2006). Nursing, they argue, will never get its due as

long as it is associated with ephemeral qualities rather than concrete skills. In

spite of the arguments of professional advocates, care remains salient to practic-

ing nurses and continues to ground an identity that distinguishes their work

from that of physicians (Apesoa-Varano 2007).

Maintaining a separate identity is serious business. Nursing’s claims to its own

expertise have been key both to its early formation and to ongoing group cohe-

sion (Fairman 2008; Reverby 1987a). These claims continue to matter; they pro-

vide the cultural tools for NPs to forge not only a different kind of medical career

but also different notions of the medical encounter. When I interviewed Stanton’s

NP students, they uniformly spoke of a nursing model of care as separate and

distinct from the medical model. When I asked them what it means to care for

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38 CHAPTER 2

patients as NPs rather than as physicians, they distinguished nursing from medi-

cine with phrases such as “holistic,” “whole person care,” “relationship-based,”

and “not just seeing the patient as a medical diagnosis.” Even as they explicitly

noted that becoming NPs required them to learn new skills from medicine, they

had a persistent belief that as NPs, they would be employing these skills “like

nurses” rather than “like physicians” (Trotter 2019). These were not just the senti-

ments of untried students; they were mirrored in the words of NPs on Stanton’s

faculty who had decades of experience.

Nursing may claim NP difference; however, we know very little about how

such claims are embodied (or not) in the clinical encounter. 1 By contrast, we

know a great deal about the structure of physician-led encounters. Instead of

professional openness, physician encounters are marked by control (Mishler

1985; Waitzkin 1989). While there is conversation between patient and provider,

the rhythm and cadence of the encounter is governed by the physician (Frankel

1990; J. Katz 1984; West 1984). The physician asks questions of the patient as

well as the physical body, through tests and examinations. Through this ques-

tioning, the physician shapes the meaning of the encounter. Patients may come

with their own understandings of their problems, but the goal of the physician

is to construct a medical narrative out of patient accounts. This is the core of the

physician’s job: to tame chaotic and sometimes contradictory pieces of informa-

tion into an orderly diagnosis. While some scholars have critiqued the systematic

removal of patient experience and meaning during the medical exam (Mishler

1985), a chief reason why patients seek physician counsel is to be offered a dis-

tinctly medical explanation for their individual suffering (Freidson 1988b). The

power dynamic between them may be asymmetric, but patients and physicians

enact a largely shared expectation of both the encounter and the role that each

will play.

As a sociologist and a patient, this is the rubric of the medical encounter

I brought with me to the Grove. Yet I observed that the NPs’ encounters were seem-

ingly controlled as much by the members as by the NPs. I found that members

were able to assert the urgency of their own needs through the logic of medical

necessity. Even though the Grove is an outpatient organization, the assumption

of medical acuity legitimated access to most of its resources. At a fundamental

level, medical need was used to triage access to the center. Member attendance

schedules varied between one and five days a week. While these schedules were

sometimes based on member choice, determinations of medical necessity were

used to limit attendance. Socialization and well-being were assessed as part of the

members’ needs, but medical necessity was the primary argument that justified

center attendance. This logic was similarly used to prioritize access to services

within the center. Any of the center’s social activities could be supplanted by

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FROM MEDICAL WORK TO CLINIC WORK 39

medical need. Members might be asked to interrupt Bible study or a musical per-

formance in order to meet with an NP or the wound care nurse. The Grove did

its best to accommodate member preferences, but primacy was given to clinic-

based services. This primacy was not, however, only a logic that was imposed on

members; it was often a logic that members employed.

Members actively used this logic for their own purposes. The Grove’s aides

were not always able to stop what they were doing to accede to requests to be

taken to the first floor for bingo, but a request to go to the clinic was rarely

ignored. This open-door policy created a clinic that was as much a member

space as a clinician space. Members would enter the clinic with problems rang-

ing from chest pains to constipation. They would come in to complain that they

had missed lunch because they were out on an appointment and got back to the

center late. Sometimes, they came to share a picture of a grandchild or to enjoy

the relative quiet of the waiting room. The Grove’s members made their own

use of clinic resources.

Not everyone was supportive of this expansive use of the clinic. There was an

unresolved tension between meeting the needs of members and getting the clinic

to operate more like a standard medical office. But the NPs were reluctant to limit

member access to their attentions. The defining feature of the Grove’s members

was not age but illness. As one administrator noted, “these people can turn on a

dime.” For the NPs, this medical complexity was inextricable from an individual’s

social context. Norah opined, “It’s one thing if we’re all making a widget and it’s

supposed to look the same way over and over again. But when you’re dealing

with human beings, there’s so many other elements involved.” The NPs some-

times complained about their “frequent flyers,” but their doors remained open

nonetheless. From the perspective of the members, this openness worked out in

their favor. The clinic was the one part of the center where every member was

guaranteed a face-to-face conversation.

The logic of medical necessity kept the doors of the clinic open. When mem-

bers arrived, they found a matching level of openness among the NPs. This open-

ness effectively expanded the walls of the clinic, creating not just more frequent

encounters, but also encounters distributed across time and space. The NPs

not only saw members in exam rooms; they took calls and voice-mail messages

directly from members and families. They initiated their own calls to providers

both within and without the Grove. They even did short consultations in hall-

ways and waiting rooms. The Grove’s clinic was embedded within the larger day

center. Any time an NP left her office, she found herself interacting with member

needs. In addition to a few sociable “good mornings,” any NP who entered the

waiting room might hear someone call out, “Michelle!” or “Norah!” “All I need

is Lantus [a brand of insulin]. I’m out!” If their issues could be addressed with a

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40 CHAPTER 2

few short questions, the NPs were often inclined to act rather than wait. But being

responsive to members and their families was only half of clinic work. The other

half was being responsive to staff.

Caring for the Organization While members and their families relied on the telephone to communicate with

the NPs, their colleagues relied on email. Some emails were sent to individuals,

but almost all member-related emails were addressed to the team. When I first

began observing in the clinic, Norah asked me, “Are you on the team email lists?

If you’re not, you have to be. You won’t understand how we work unless you’re on

team email.” About her own team, Norah noted, “We solve a lot of our problems

by email. I think that’s partly what makes us so efficient. We come to an agree-

ment about things without formal, scheduled meetings.”

Whether email improved team efficiency was up for debate, but it was undis-

putedly the Grove’s primary way of communicating about members. The implicit

purpose of sending these emails was not just to share information but to spur

some kind of action; someone had identified a member problem that the team

needed to solve. Even when the sender of an email addressed a communication

to a specific person, it was common practice to cc the entire team. In theory, each

clinician would evaluate which emails belonged to his or her domain of expertise.

In practice, the question of appropriate expertise was unclear. Because the Grove

was a comprehensive care organization, the problems it addressed rarely fit dis-

cretely into a single category. Who addressed a concern often seemed less a matter

of licensure and more a matter of who took responsibility. Moreover, given the

prominence of email, this taking on of responsibility was publicly performed.

Not only team-based clinicians were on each email list but also administrators,

supervisors, and direct care workers who worked across teams. In this public

arena, when problems were handed off to the team, it was the NPs who often

responded.

If checking voice mails was the first thing the NPs did each morning, check-

ing emails was the second. One morning, I watched as Anne scanned through

her team emails. One of those messages was about Ms. Tyne, who was being

discharged from the hospital to home that morning. There was already an orga-

nizationally defined chain of events that happened when a member left the hos-

pital, starting with the member being brought to the center to be seen by an NP.

This chain of events was defined by protocol; the email sent to the team was not

intended to start a conversation, but as an FYI. However, for Anne, there was a

more immediate response required.

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FROM MEDICAL WORK TO CLINIC WORK 41

Less than half an hour prior, Anne had listened to the reading of member

appointments in morning meeting. In paying attention to this list, she possessed

information that might solve a problem that had not yet surfaced. Anne sent an

email to transportation, cc’ing her question to the team: “Is it still possible for

Ms. Tyne to get to her neurology appointment this afternoon? It took us months

to get her that appointment.” Minutes later, she got a response from transportation:

“We’ll see what we can do.” The team may have been the recipient of this infor-

mation, but it was Anne who had the knowledge to respond. More importantly,

she responded quickly enough that a potential problem was avoided.

At other times, emails were sent to the team with a defined problem. One

afternoon, Michelle received an email concerning Ms. Violet. That morning,

Ms. Violet had presented with symptoms of a possible retinal detachment. Unless

addressed quickly, this condition can permanently impair vision. Michelle had

completed the referral paperwork for an urgent visit with the ophthalmologist

and had arranged transportation through the Grove. A few hours later, Michelle

received a team email from transportation saying, “Ms. Violet has declined trans-

portation. She said she doesn’t want to go and sit around all day.”

Individuals do have the right to refuse medical care. The Grove’s members

had that right as well. However, the Grove’s providers could not always take

such refusals at face value. Their members had varying levels of medical literacy;

some might not clearly understand the implications of their refusal. There was

also the possibility of dementia-related confusion. Some members might very

well have forgotten why they were going to an appointment in the first place.

This was the kind of uncertainty that made Michelle leave her office in search of

Ms. Violet. She found her in the first-floor dining room. She sat down next to

her and explained the urgency of the appointment. Michelle relayed the dangers

more directly than she had before. “Do you want to take the risk of going blind?

That’s what can happen.” Apprised of the potential seriousness of her symptoms,

Ms. Violet agreed to go. Michelle returned to her office and called transportation.

“The appointment,” she told them, “is back on.”

With the same urgency that drove their responses to calls from daughters

and sons, the NPs responded to the concerns of their colleagues. Acting as the

air traffic controllers of members’ needs, they read emails from transportation,

notifying them that Mr. Wells refused to get on the van that morning; from the

home care nurse, noting that Ms. Brown’s blood sugar was over two hundred;

or from a home care aide who observed that Ms. Lawrence’s refrigerator was

stockpiled with months’ worth of unused insulin. Everyone on the team received

these emails, but if it seemed a matter of medical necessity, the NP took up

the concern. In a population as acutely ill as the Grove’s, it seemed that almost

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42 CHAPTER 2

anything could qualify as a medical necessity. And it was to almost anything that

the NPs seemed to respond.

For many of the Grove’s staff, the NPs’ responsiveness was highly valued. One

of the appointment clerks expressed this quality as belonging uniquely to the

NPs. “If I need my nurse practitioner, I know where she is. Any four of them,

I know where they are. You know? If I need something, it’s done. And if they

need something, they know it’s done.” She compared the NPs to the physicians in

saying, “These nurse practitioners? They do some really amazing things. I guess

it’s the regulation that you have to have a doctor here. Okay, fine. But sometimes

nurse practitioners are much better than doctors.” The clerk was not equipped

to assess clinical effectiveness. She knew, however, what “better” meant for her.

“Better” was being available. This availability was partly about being physically

located in the clinic. But it also described an existential openness to recategoriz-

ing a broad range of concerns as clinic concerns such that if a member—or a

clerk—needed something, “it’s done.” The NPs’ openness encompassed all mem-

ber problems, whether they were presented by members or by staff.

The clerk’s words also conveyed reciprocity. If the clerk needed something, she

could count on the NPs. But if they needed something from her, she was there.

This reciprocity created possibilities for information sharing. The primary job of

each team’s clerk was to make and organize outside appointments for members.

This entailed more than just calling the rheumatologist or endocrinologist to set

up the appointment. The clerks were responsible for organizing all the small but

crucial details that made the appointment possible. They had to coordinate with

transportation over both the time and the necessary assistance required. They

faxed over preliminary test results. They called to remind members and family

caregivers of the appointment, explain the travel details, and to emphasize any

required preparation, such as fasting.

These were the components of the job, but in order to do the job well, the

clerks had to perform their own form of social triage. A good clerk knew that

Mr. Scheller always missed early morning appointments. A good clerk knew

which adult child or neighbor needed to be called to help Ms. Taylor remember

that she had an appointment on Wednesday. A good clerk knew which members

needed a few extra phone calls and some direct encouragement to get to medical

appointments. The importance of this information may have explained why the

NPs took on the responsibility of discussing appointments with their clerks—

either through email or direct conversation—on a weekly basis. It was during

these conversations that an NP had the opportunity to learn the kinds of things

that a good clerk knows.

Anne was an NP who preferred face-to-face discussions with her clerk. On any

given Monday, Anne might pick up the phone and call her clerk. “Stacey? Can we

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FROM MEDICAL WORK TO CLINIC WORK 43

talk about appointments?” On one such Monday, Stacey responded by appearing

in Anne’s doorway. “Well,” Stacey began, “Mr. Fromm has a derm appointment.

He already said he’s not going.” “What’s the appointment for?” Stacy shrugged

her shoulders. Anne looked up the request for consult in the medical records and

read aloud, “‘Mole on left temple.’ Okay. Well, whatever it is, it’s not urgent and he

doesn’t want to go. Cancel the appointment.” The two of them don’t discuss every

appointment, just the ones Anne has questions about. Including Ms. Stoke’s colo-

noscopy. “Have we made arrangements for an aide to go with her?” Ms. Stokes

had no family in the city. She also struggled with anxiety. Without someone to

go with her, she might not go through with the procedure. Stacey asked Anne,

“Do you think she needs anything else? For the anxiety?” Anne considered before

answering, “I think she’ll be okay with an aide.”

The clerks might not always know which appointments were medically cru-

cial, but the NPs might not always know which collection of resources would

be needed to get a member to an appointment. These conversations between

the clerks and the NPs provided an opportunity not just for the NP to share her

clinical knowledge with the clerk, but for the clerk to share information with the

NP. Both learned something in the exchange. What the NPs learned was ever-

more-detailed information about the lives of their members. And they learned

it not only by listening to complaints from members and their families but also

by leaving their doors open to an endless stream of clerks, RNs, and aides. This

information, too, became part of the expanded clinical encounter.

When I first witnessed the rhythms of each NP’s day, I characterized them

as beset with interruptions. I saw the phone calls, emails, and doorway visita-

tions as intrusions on the “real” medical encounters I expected to see. One of

my initial thoughts was that the NPs inhabited a slightly updated portrait of the

harried floor nurse—called to be responsive to everyone and everything with

little authority to say no. As I discuss in later chapters, there is an element of this

explanation that rings true. But I also began to understand that the NPs were not

just “doing everything.” In leaving themselves open to member information, they

were cultivating expertise.

Cultivating Expertise Each of the NPs had the support of an RN in a role the Grove called the primary

care nurse. One such nurse summed up her role as “a lot of computer work”

in creating care plans for the members, doing patient education, assisting with

wound care, and calling members at home to remind them about medications

or just to “check in” if the nurse decided that would be beneficial. The NPs had

a much more evocative way of describing the primary care nurse. For Anne, her

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44 CHAPTER 2

primary care nurse was “like my right arm.” This was particularly true for the

primary care nurse who worked with Norah. RN Joanne’s office was right across

the narrow hallway from Norah’s. With their doorways facing one another, they

could sit at their respective desks and hold entire conversations throughout the

day. Norah had a penchant for annotating her activities aloud. “Joanne!” she

might call out while doing billing paperwork. “Ms. Carnissi has twenty-one [bill-

able] problems!” From these conversations, Joanne came to know much of what

Norah knew about their members. But she also developed an understanding of

what it meant to do the work of an NP.

In spending time with Joanne, I learned that she was currently taking classes

for a master’s degree in business. She did not want to do the work of an RN for

the rest of her life. I asked, “Why business? Why not become an NP of some

kind?” she answered from the perspective of someone who had watched Norah’s

work for almost two years. “The NPs do the work. They do all the hard work.”

When I asked what the hard work was, she responded, “Let’s say you’re Mr. Smith.

And you’re in the hospital right now. And you call one of our doctors. Chances

are, they don’t know Mr. Smith like an NP knows Mr. Smith: his family situation,

including his financial situation; what’s going on, what hospital work we’ve done

in the past; what has worked for him in the past.” Joanne marshaled her own

empirical data to back up this claim.

You pull a physician note [from the medical record] and it’s empty.

Not empty, but there’s nothing in there but, you know, a few words. It’s

like, ‘oh, yeah, I’ve seen them; they’re fine.’ But you have the NP notes

going much deeper into what is found. You find the situation and the

conditions of daily living because they’re coming in from their nursing

background when you access all those things that you’re adding it to the

problem. It’s more holistic, you know. The physician goes, ‘oh, no chest

pain today’ . . . and that’s it. . . . The physician’s notes sometimes lack

that personal touch to it where you can tell that they do not have the

connections with people that the NPs have.

From Joanne’s perspective, the hard work that the NPs performed gave them

a better relationship with the members, which in turn gave them a better under-

standing of members. I pondered Joanne’s words for some time. To speak of

relationship is usually to invoke the intangible world of emotions. Nursing’s own

claim as a caring profession is itself evocative of the realm of feelings. Yet when

Joanne illustrated this term, she did not describe an affective tie between NP and

member, but one born of a deep, layered knowledge of patients. Moreover, she

was explicit in calling out the material action required to cultivate that knowl-

edge. For Joanne, this was not the result of an emotional attachment; it was the

result of hard work.

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FROM MEDICAL WORK TO CLINIC WORK 45

It was not, however, always easy to see how this work got done. There was

nothing inherent to the NPs’ organizational position that gave them access to

more or better information about members. The NPs were firmly ensconced in

the clinic; although some of the Grove’s staff did visit member homes, the NPs

did not routinely do so. Neither did their days, structured by nine-to-five clinic

hours, encourage family member visits. The Grove’s medical director was not

shy about describing this as a shortcoming in the way the NPs practiced. From

her own experience as a physician in community-based practice, she believed

that the NPs needed to have more face-to-face meetings with family if they

wanted to build relationships and include them in clinical decision-making.

However, the NPs’ view of their members was not as truncated as the medical

director believed.

From inside the clinic, the NPs gathered this information from members

and their families through patient exams, telephone calls, and emails from

administrators and clinical staff, as well as from support and caregiving staff

through direct conversation. The NPs often had the most complete picture of

their members, not just because of what they were privy to inside the medical

encounter but because of the ways in which they expanded the encounter to

include the view from outside it. They could describe the basic layouts of mem-

ber homes or the contents of a refrigerator, and knew whether a neighbor could

be called on in a pinch. They knew who lived alone, who had a difficult sister,

and who would never remember to reorder their meds. Acquiring information

about members was not a passive activity. It required an openness to sources

usually excluded from the medical encounter. In my observations, these NPs

gathered such information not in spite of, but because of, their expansion of

the clinical encounter.

Like Joanne, I also witnessed the NPs doing the “hard work” in the clinic.

But hard work is not quite the same thing as expert work. It would be tempting

to conclude that the NPs were enacting a division of labor in which the physi-

cians did the traditional work of making medical decisions while the NPs did a

somewhat expanded version of bedside nursing work: dispensing medications,

attending to bodily needs, and monitoring patients. This way of dividing up the

work would be in keeping with the traditional boundary between nursing and

medicine. As is seen in later chapters, the Grove’s physicians and NPs did per-

form different work. Yet the border that separated their activities did not align

so neatly with formal occupational distinctions. In part, both administrative and

clinical logics constrained the embodiment of nursing difference in the primary

care exam room.

Despite being a nurse-managed organization, the Grove did not have the

option of moving traditional nursing work from periphery to center. The core

reason for this limitation was financial. For any health care organization that

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46 CHAPTER 2

relies on third-party payment, what counts as medical work is not a matter of

ideology but of the predefined rules of reimbursement. Under these constraints,

the Grove had to economically justify NP work. In the case of the Grove, whose

funding came from Medicaid and Medicare, the cost of the entire operation, from

recreational activities to physical therapy, was legitimated by the documented,

reimbursable medical activities that happened inside the clinic. “Whether we like

it or not,” explained Norah, “it’s all about the money. Really, we can’t function

unless the money comes through. If [the NPs] don’t do our part of it and make

sure the money comes through, then it’s an issue.”

Making sure “the money comes through” meant attending to encounters that

resulted in new or updated billing codes such as enrolling new patients, docu-

menting new diagnoses, or correctly identifying the worsening of old ones. Bill-

ing codes are what determine what an insurer will pay for a visit or procedure.

Even under the Grove’s capitation system, these codes were part of the algorithm

that determined patient acuity, which was directly tied to the per capita rate the

Grove received. The Grove was also mandated to complete comprehensive assess-

ments that included an in-person medical exam every six months. Keeping on

top of these assessments was indirectly tied to reimbursement, since failure to

comply would result in losing the organization’s status for enhanced payments

as a federal demonstration project. This threat was not abstract. After a biannual

Centers for Medicare and Medicaid Services survey in April of 2011, the Grove

had its license downgraded to provisional status. Although there were several

documented deficiencies, the Grove’s failure to meet assessment deadlines and to

properly document those assessments became the primary focus of administra-

tive interventions. The NPs were pressured to do the kind of work that counted

on paper: medical work, not nursing work.

The clinicians at the Grove also had to keep in mind the preferences of their

patients. While the Grove had a limited number of acceptable reasons to remove

someone from its rolls, members had the unlimited right to leave the Grove

and join a different Medicare- or Medicaid-funded program. If current mem-

bers believed they were receiving something other than quality medical care,

they might disenroll. The state collected data on the reasons for member dis-

enrollment. The Grove was only one among many models that state and federal

funders were considering. High levels of disenrollment due to program dissatis-

faction would not bode well for its future.

But the need for competent care was not just a matter of customer satisfac-

tion; the Grove’s patient population had a high level of medical need. As NP

Francesca observed, “The acuity level here is ridiculously high.” Members and

their families came to the clinic not just with complaints about transportation

but with a long list of bodily complaints. They arrived with manageable, chronic

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FROM MEDICAL WORK TO CLINIC WORK 47

conditions such as hypertension and diabetes. But they also arrived with less

manageable chronic conditions such as renal failure, congestive heart failure, and

multiple sclerosis. Moreover, they remained susceptible to acute conditions such

as pneumonia, shingles, and urinary tract infections.

Whatever else the NPs chose to do, both payers and members expected them

to address traditional medical problems as their core activity. To do so, they drew

from the same well of interventions as physicians. In my fieldwork at Stanton

School of Nursing, I observed that NP students were trained to rely on the evi-

dence. While nursing’s attention to whole person care was a core part of the

curriculum, this professional axiom did not extend to substituting alternative

practices for evidence-based approaches. Published guidelines for treatment

decisions took center stage in the nursing classroom; these same guidelines were

at the core of NP practice at the Grove. The work of the NPs was not separate

from medical work, yet, their approach made it different from medical work.

This modification of the medical counter inevitably raised questions about the

work of the physicians.

Clinic Work as Nursing Difference Managing the care of members as a team could not be done by email alone. Each

team met weekly: Michelle’s team on Wednesdays, Anne’s team on Thursdays,

and Norah’s team on Fridays. Everyone on the core team was expected to attend:

NPs, primary care nurses, physicians, physical therapists (PTs), occupational

therapists (OTs), and social workers. The primary purpose of these meetings was

twofold. First, the Grove was federally mandated to provide and document com-

prehensive assessments of members every six months. The primary work of the

meeting was for each discipline to share its findings and make any adjustments

to the member’s plan of care. The other purpose of the meeting was to discuss

“member issues.” This was a residual category that contained a number of diverse

problems. It might be a member request for additional home care hours, a com-

plaint from transportation that a member was chronically late, or any problem

that any staff member wanted the team to address.

Every team meeting would begin with the six-month assessments. Each clini-

cian was asked to report on each member’s status from his or her disciplinary

perspective. Because this was the moment when everyone spoke from a specific

arena of expertise, it was the part of the meeting where I had expected to see the

most discussion, negotiation, and, perhaps, conflict. This expectation was almost

never met. In some ways, this part of the meeting echoed the reading of lists dur-

ing morning meeting. Everyone listened respectfully as the PT, social worker, and

OT summarized their findings. The notes from the medical exam—sometimes

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48 CHAPTER 2

performed by a physician, sometimes by an NP—were also quickly summarized.

In some teams, the written notes from the medical exam were simply read aloud,

often at a galloping pace that left no room for interruptions or conversation. In

cases where the physician presented the assessment, the NPs might ask about a

point of fact, but they neither questioned the assessment nor made suggestions.

When NPs presented, a physician did sometimes make a recommendation. On

these occasions, there would begin a carefully choreographed dance of civility.

The physician would practice restraint, phrasing a recommendation as a sugges-

tion rather than an order. “You may want to think about trying a different regi-

men for her hypertension,” or “I’ve heard that Paxil is good for uremic itching. It’s

worth a try.” The NPs replied with a practically jovial deference, with responses

such as, “Oh, that’s a good idea,” or even more explicitly, “See, that’s why you [the

physician] are here.”

The direct conflict over medical decision-making that I anticipated seeing

was almost entirely absent. Within this organization, nurse managed though

it was, physicians seemed to have uncontested authority over decisions that

everyone recognized as being wholly medical. This state of affairs was not

without some dissension. When I spoke with Francesca, she noted, “We have

twenty-five people on the team; twenty-four agree and the physician says no

and we still tend to go with the physician. So we’ve gotten into that authorita-

tive kind of thing.” For Francesca, this was part of a larger critique about the

ways in which the Grove failed to live up to its nurse-managed ideals. And, in

many ways, her observations matched my own. When a member problem was

structurally demarcated as distinctly medical, the NPs’ deference to physician

authority was absolute.

However, in team meetings, these clinical assessments seemed only the pro

forma prelude to what the meetings were really about: member issues. During

this second part of the meeting, the team would debate and discuss such con-

cerns as what to do about a member’s cockroach problem that prevented home

health care aides from providing regular care, or how to convince a member

who was blind and had limited feeling in his extremities that he should consider

moving into a supported living situation. These problems were rarely discrete or

simple; consequently, conversations about them were long and prone to narra-

tive exposition. Some team clinicians grumbled about the length and circuitous-

ness of these discussions. Nonetheless, there was a high degree of participation,

both through talking and through a posture of engaged listening from almost

everyone present.

This was also the part of the meeting where NP knowledge was on full dis-

play. In team meetings, the NPs were the key weavers of member narratives.

They shared information about their conversations with Mr. Whitmore’s niece.

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FROM MEDICAL WORK TO CLINIC WORK 49

They recounted information about how Mr. Stiles’s apartment used to look

before his girlfriend moved in. They spoke about how Ms. Neville “was a success

story” in terms of how difficult it had been to finally get her blood sugar under

control. The NPs did not just share stories; they solicited them. Just as they

opened the exam room to information that is usually filtered out of traditional

medical encounters, they opened team meetings to the kind of storytelling that

did not fit into the genre of case reports. The NPs displayed and added to their

knowledge of members through team meetings. Yet in the context of sharing

information, decisions were made. These decisions were not usually about med-

ications or procedures, but from the NPs’ perspective, they were important to

the management of member care. Yet there seemed to be no explicitly medical

decisions required.

The physicians, by their behavior, seemed to agree. During long conversa-

tions about member issues, the physicians normally multitasked by signing writ-

ten orders or doing clinical work through smartphones. When opinions flew

or stories were shared, the physicians’ attention was usually elsewhere—if they

were still at the meeting at all. Team meetings were usually rescheduled or can-

celled altogether if an NP could not attend. Physician presence was treated as

optional—by both the physicians and the team. When physicians’ time was in

short supply, they might arrive late, leave early, or skip the meeting entirely. In

choosing to not participate in conversations that were not wholly medical, the

physicians absented themselves from information sharing and decisions made

about member care. In spite of NP deference to medical authority, physician

authority was required for a shrinking proportion of member problems. As NP-

defined clinic problems expanded, physician-defined medical problems seemed

to contract.

Clinic Work as Expertise The fact that the NPs had a deep level of knowledge about their members may

have had an intangible value to members and their families. Perhaps this knowl-

edge fostered a deeper sense of relationship between some members and some

NPs. However, in the realm of medical care, such intangibles are rarely under-

stood as goods in themselves. Indeed, we often tell stories about how the absence

of such intangibles is in direct proportion to the more tangible rewards of better

outcomes. For example, in the US, the iconic surgeon is someone whose techni-

cal skill is seen as so rarified that a lack of bedside manner is viewed almost as a

consequence of that skill rather than a detriment to it. In comparison, bedside

nurses may be idealized as being more nurturing than physicians, but their work

is not thought to require much in the way of expertise. From this commonsense

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50 CHAPTER 2

understanding of the world, it would not, then, be surprising to observe that

NPs might have a more “nurturing” style of practice than physicians. We may be

glad that nurses care, but we’re not convinced it matters all that much for health

outcomes.

This view of the world, however, has very little to do with the actual evidence,

and a great deal more to do with gender. The historical division between medi-

cine and nursing is grounded upon gendered notions of both skill and value:

work done by women is seen as innate and therefore low skilled, while that done

by men is seen as requiring expertise and is more highly valued. Yet nursing work

is skilled work. Moreover, it requires a skill that study after study demonstrates is

important not just for how patients “feel,” but for whether patients thrive (Aiken

2014; Aiken et al. 2002; Blegen et al. 2013; Wong, Cummings, and Ducharme

2013). Similarly, the quantitative evidence suggests that the kind of care NPs pro-

vide is different not only in style from physicians but also in content and positive

impact on patient health (Buerhaus et al. 2018; DesRoches et al. 2017; Martínez-

González et al. 2014). My observations cannot speak to the impact of these NPs’

clinical performance on patient outcomes, but they do show that this work was

less about nurturing members than it was a distinctive approach to both seeing

and solving problems. The knowledge NPs developed about members allowed

them to cultivate a different form of expertise and to carry out a different form

of work.

Anne had been an NP for over twenty years before coming to the Grove, but

had spent most of that time in acute and institutional long-term care, rather than

primary care. She remembered distinctly that when she arrived at the Grove, she

had to hone not only her skills of diagnosis and treatment but also her approach

to patient care.

I mean, the first month I’m [at the Grove] and I get a lab result back;

the PTINR [a measure of the rate of blood clotting] was high. So we

needed to adjust the Coumadin dose. So you have to remember my

background. My most recent places are working in a hospital, right?

So I throw the order in the computer, I send it through to the nurse

upstairs, I don’t think twice about it. I get the next PTINR and it’s still

high. What happened? I forgot to call the family. You’ve got to do that in

primary care. Transitioning into primary care from a lifetime of being

in long-term care and acute care? It sucked. It sucked. There were just

stumbling blocks everywhere.

When I met her, Anne was finishing her third year at the Grove. From my

observations, she had clearly taken to heart the need to incorporate the family.

One Wednesday, I spent a day shadowing her. As we approached late afternoon,

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FROM MEDICAL WORK TO CLINIC WORK 51

Anne was taking a moment of quiet to catch up on her email and write up notes

for the electronic medical record. As was often the case, this small reprieve was

interrupted by the ringing of the telephone. The caller was Susie, the oldest

daughter of Ms. Gray. Susie described her mother as behaving nervously. Anne

reported to Susie that she had seen Ms. Gray last week with a blood sugar level of

four hundred. Ms. Gray had reportedly stopped taking her oral diabetes medica-

tion. Anne wondered aloud whether this sudden shift in behavior could be attrib-

uted to her diabetes and asked, “What’s her blood sugar?” Susie didn’t know but

suggested that Anne call her younger sister, Tanisha. Susie had been tasked with

calling Anne, but Tanisha was the daughter currently with Ms. Gray. Anne agreed,

hung up, and called Tanisha. From the moment the line connected, Anne could

hear why Ms. Gray’s behavior change had seemed so urgent. While Anne was

trying to speak with Tanisha, Ms. Gray was shouting so loudly in the background

that it was difficult to carry on a conversation. Although we could not hear

Ms. Gray’s words, the anger behind them was unmistakable.

In spite of the chaos happening in the background, Anne began to trou-

bleshoot what might be going on in order to piece together a plan of action.

Ms. Gray had just returned home from a short hospital stay. Her routine prior

to hospitalization was that when she did not attend the Grove’s center, a nurse

would make a home visit and administer her insulin injections. After some back

and forth with Tanisha, Anne figured out that these nursing visits were never

restarted after Ms. Gray returned home from her recent hospitalization. For most

populations, insulin is self-administered. However, many older adults struggle to

do so because of cognitive decline, fading memory, or just the difficulty of learn-

ing a new skill in later life. Although Ms. Gray had the support of two daughters,

she lived by herself. Having assistance with insulin was one of the key supports

that allowed her to live in her own home. Missing a few doses of insulin might

not have been the entirety of the problem, but it was a good place to start. Anne

ended the call by asking the daughter to try to check her mother’s blood sugar

and to call back with the result. While waiting for this new information, Anne

did not return to her email or charting; she continued with the case of Ms. Gray.

First, she sent off an email to the Grove’s home care department. The email was

only the first in a multistep process of both finding out why the nursing visits

were not restarted and attending to the problem at hand by arranging for a nurse

to make a home visit before the end of the day.

Anne’s response to Ms. Gray’s problem was an example of how the NPs’ expan-

sive notion of the clinical encounter involved taking members’ and families’ own

constructions of the problem seriously. Ms. Gray’s daughter had called as much

out of frustration over her mother’s rain of invectives as from a cool observation

of changed behavior. Anne’s openness to responding to this frustration was not

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52 CHAPTER 2

only useful for short-term problem-solving. It was also part of how Anne was

able to set the stage for longer-term management. To solve the problem, she reac-

quainted herself with both the medical record and the practicalities of Ms. Gray’s

care routines. Her approach to a clinical problem was to immerse herself in

Ms. Gray’s life, a life that included both domestic and organizational routines and

relationships. In the context of troubleshooting a sudden behavior change, Anne

found herself inside longstanding family dynamics and learning just a little more

about each daughter’s relationship to her mother. She also found herself solving

the communication problems between the clinic and the home care department.

Anne’s openness to unfiltered complaints from members and their families was

not just a reflection of an NP’s orientation to patient care, but was constitu-

tive of the NP’s expertise. It was through this openness to information that the

NPs became the resident experts of the Grove’s members. And it was through

that openness that they were able to marshal personal, family, and organizational

resources to address member concerns.

The Grove’s NPs had no interest in supplanting the expertise of the physicians.

When faced with distinctly medical problems, the NPs used a variety of resources

to make sure that they treated the concerns in the same ways a physician might.

However, what I observed was that the NPs often faced different problems from

those of their physician colleagues, not because they were leaving medical prob-

lems to the physicians, but because medical problems were often reconfigured as

clinic problems.

In order to cultivate the expertise necessary to address these problems, the

NPs paid attention to information from a range of sources. This attention was

not passive but required an active stance of openness to both member and staff

concerns. Through this openness, the NPs encountered clinical bodies that were

embedded in social and organizational contexts. These bodies suffered from bio-

logical conditions as well as the exigencies of everyday life. And it was these bod-

ies, rather than disease states, to which the NPs attended.

Clinic work made up the core of NP practice; it was also at the heart of the

Grove’s mission of coordinated care. Among elder care professionals, there is a

saying: “The best long-term care insurance is a daughter.” Even with Medicare

and Medicaid paying for services, navigating bureaucracies and coordinating

services is someone’s full-time job. To categorize this as the work of daughters

reveals it as the kind of invisible work that money does not easily buy. For

many, these idealized daughters are in short supply. Few families have access

to a physically healthy adult whose time is not taken up by work in the paid

labor market or by unpaid responsibilities such as caring for dependent chil-

dren. Moreover, the work of coordination is not unskilled labor; an adult’s

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FROM MEDICAL WORK TO CLINIC WORK 53

availability does not necessarily signal possession of the knowledge or skill to

do what needs to be done.

For many of its members, the Grove had become an organizational daughter.

Yet how good a daughter it proved to be seemed to depend largely on the work

of the NP. To the extent that coordination happened at all, it happened through

NP expertise. This observation is not to diminish the work of anyone else on the

team. I went on home visits with the OTs, watched the PTs work with members

in the gym, and sat in the offices of the social workers. Everyone did their part,

and everyone cared for members. However, the work of navigating hurdles and

coordinating care was carried out primarily by the NPs from inside the clinic.

It was their knowledge of members lives and of the organizational context that

positioned them as the providers who knew how to solve the problems that inevi-

tably arise when delivering so many different forms of care. The NPs remained

responsible for the treatment of member complaints. Whether these complaints

were a product of biological, social, or organizational ills, the NPs expanded the

medical encounter to include them. Their performance of clinic work was not

simply an addition to medical work; it was a transformation of it.

The transformative quality of clinic work puts it in conversation with the

well-studied concept of medicalization. Medicalization describes the processes

through which problems not previously amenable to medical work come to be

seen as such (Conrad 1992, 2007). The transformation of grief into depression

and of childhood unruliness into attention deficit disorder are both examples of

medicalization. To offer these examples is not necessarily to put forward a cri-

tique. For many, medicalization eases suffering, either through access to effective

treatments or simply by making suffering comprehensible. However, medicaliza-

tion has consequences beyond the scope of the individual patient. To define a

condition as a medical concern removes it from other realms of authority. When

grief becomes depression, it is no longer at home in the church or synagogue, but

is now most appropriately addressed in the offices of psychiatrists. Medicaliza-

tion not only changes the arsenal of solutions at our disposal; it also changes what

we consider our problems to be (Freidson 1988b; Hughes 1981).

I invoke medicalization more as sensitizing concept (Blumer 1954) than as

precise description. Since the original explication of medicalization, it has been

updated and amended with the observation that the process involves not only

physicians but also pharmaceutical companies, lawyers, payers, and patients.

Despite this ever-expanding list of the “engines” of medicalization (Conrad

2005), nursing has never been theorized as one. Nursing possesses neither the

generative power to create new conditions nor the constraining power to hold

medicine’s domain in check. Indeed, my descriptions of clinic work illustrate that

expansions of nursing authority in the medical encounter are seemingly matched

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54 CHAPTER 2

by the increasing power of patients and the health care organization. However,

a focus on what nursing is not doing within realms of knowledge obscures the

work it is doing inside organizations.

At the Grove, clinic work transformed local, organizational understandings of

what kinds of problems counted as medical problems. Members and families who

turned to the clinic with a broad set of concerns had them met. The responses of

the NPs reshaped their expectations about what kinds of problem could be solved

in the medical encounter. Staff too brought problems to the clinic, changing the

encounter from one solely between patient and provider to one that included the

organization. Although the NPs did not offer new diagnoses or treatments, their

responsiveness eased the suffering of their patients nonetheless. In widening the

clinic’s doors to new kinds of problems, the NPs were quite effective at expanding

everyday understandings of what was amenable to nursing expertise, as well as

what could be addressed in the medical encounter.

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159

Conclusion

We are living through a crisis of care. In 2014, one in seven Americans was over

the age of sixty-five. By 2060, that ratio will be closer to one in four (Colby and

Ortman 2015). While medical advances have made old age healthier, it remains

a part of the life course that requires increased support. The efficacy of preven-

tive and curative strategies has had an independent hand in reshaping patient

needs. Chronic conditions have increasingly replaced the acute in terms of mor-

tality and disease burden (Gaziano 2010; Olshansky and Ault 1986; Omran 1971,

1977). We have never been more in need of care-centric practices.

The care crisis, however, is not exactly the one that NPs were created to solve.

Although there are differences of opinion about what NPs should do, there has

been little disagreement about what they are for: to help patients and health

care organizations deal with physician scarcity. The NP is purported to be an

economical and flexible stand-in, needed to address the dearth of physicians

in an ever-expanding number of places. In this book, I have focused on their

original proving ground of primary care, yet NPs are increasingly being used in

a diversity of settings, from nursing homes to the acute care hospital. Moreover,

the NP is just one example of nursing stepping into the breach left by physicians.

Certified nurse midwives are taking on the work of obstetricians by provid-

ing prenatal care and attending vaginal births. Certified nurse anesthetists, one

of nursing’s oldest advance practice specialties, are helping hospitals deal with

the scarcity and expense of anesthesiologists. It seems that almost anywhere

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160 CONCLUSION

physician labor is of concern, nurses are stepping in to ease the burdens of orga-

nizations and the patients they serve.

Throughout the health care system, nurses of all kinds are being rhetorically

deployed as physician substitutes. It behooves us, however, to look underneath

what people say and to look more closely at what they do. The rubric of substi-

tution allows us to neatly fit the NP into equations of cost and personnel, but

the calculus of social life is rarely that simple. I began my own investigations by

trying to understand what the educators of NPs do to remake RNs into autono-

mous medical providers. I found that nursing educators were not attempting to

create physician substitutes; they were engaged in the radical proposition that

nurses can be skilled, independent providers without being like physicians. In

the classrooms of Stanton Nursing School, students were provided with a history,

orientation, and set of skills that served to distinguish the work of NPs from that

of physicians, even as they borrowed from the physician’s traditional toolkit of

diagnostic medicine (Trotter 2019). At the Grove, this narrative construction of

nursing difference had real-world consequences. The Grove’s NPs were univocal

in the belief that nurses possessed a distinct set of strategies that they brought

to the medical encounter. Their attention to nursing’s approach manifested in a

stance of professional openness. They all, in their own ways, found themselves

“doing what nurses do” by marshaling clinical, professional, and organizational

resources to address a broad set of patient problems. The space that had been set

aside for medical work soon became the site of clinic work.

In this book, however, I have endeavored to illustrate not just what NPs do,

but what others do with them. The Grove ostensibly hired its NPs for their medi-

cal expertise, but in practice, it deployed them as much more than substitute

physicians. In addition to the mandates of medical work, the Grove held its NPs

uniquely responsible for care coordination. On the ground, this responsibility

manifested as an obligation to “put out fires” for members and the organization

rather than as an affirmative embodiment of NP authority. The physicians in

particular withheld acknowledgment of NP expertise and therefore independent

authority in patient care. Given the vocal antagonism of the AMA, this is not

surprising. The physicians, however, were not the only ones. The Grove’s admin-

istrators, some of whom were nurses, either failed to see the breadth of NP work,

or failed to recognize that work as important to patient outcomes.

The NPs’ performance of organizational care work had become the corner-

stone of the Grove’s goal of comprehensive care provision. Yet it was equally clear

that the work and expertise required to meet this goal were largely unacknowl-

edged. The logic of interchangeability that has legitimated the expansion of nurs-

ing independence has simultaneously rendered invisible the material work that

nurses perform. According to the paperwork from payers, the balance sheets of

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CONCLUSION 161

organizations, and the mental logics of administrators, only medical work counts,

even when more than medical work is expected. Nurse practitioners are normally

studied to see how well they meet the gold standard of physician practice. But on

the ground, NPs are often held to a higher standard than physicians—asked to

medically attend to patients while also attending to the economic and coordina-

tion problems of patients and their employers.

Arlene Kaplan Daniels (1987) observed that much of the invisible work that

women perform could be described as the labor of making social institutions

work. In the domestic sphere, the invisible work of women holds families together

(DeVault 1994; Oakley 2018). In the public sphere, the invisible work of women

holds communities together through their unpaid work in schools as well as civic

and cultural organizations (Daniels 1987, 1988). Scholars studying the paid labor

market have shown how women, particularly women of color, make the econom-

ics of caregiving work (Diamond 1992; Glenn 1992; Stacey 2011). As physicians

hold fast to protecting their status as professionals, it is nurses who are often left

with the invisible work of holding health care together. They are doing so not

just by performing medical work, but by performing care work for patients and

organizations.

Although created as a solution to physician scarcity, the NP is just as often

working on the front lines of our crisis in care. Nurse practitioners’ work often

goes unrecognized, but their performance of it has the potential to transform

how patients experience the health care encounter. Some have quietly begun to

question the logic of reimbursing NPs’ labor at a lower rate than that of physi-

cians. Their clinical responsibilities are not always the same, but when they are,

one wonders whether paying NPs less violates the principle of equal pay for equal

work. The answer to this question will be worked out in political rather than

scholarly realms. But I will end with the observation that NPs are often not doing

the same work as physicians. I make no claims that they are necessarily providing

better care than physicians, but it is almost certainly more than medicine. In this

account, my aim is not only to reveal the hidden work of yet another location of

feminized labor but also to shine a light on the central importance of that work

for patients.

A Gendered Solution That more is expected of the NPs is not, I argue, limited to the particularities of

the Grove. It is a reality produced by the gendered constraints faced by nursing

as well as the gendered professional privilege held by medicine. The scarcity and

unequal distribution of physicians has never been just a question of economics;

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162 CONCLUSION

it is a question of power. To many readers, the high status of the US physician

may appear to be a given. Medicine’s prestige is something one assumes it has

earned through the acquisition of expert knowledge. History, however, shows us

that physicians’ status was not bestowed; it was won. In his sweeping historical

analysis, Paul Starr describes the political and cultural strategies through which

US physicians transformed themselves from a powerless collection of low-status

individuals into a powerful profession with authority over an increasing propor-

tion of social life (Starr 1984). In the contemporary moment, physician domi-

nance has undoubtedly taken a beating; yet physicians have managed to hang on

to many of the perquisites of professional status, including autonomy. Profes-

sional medicine has been able to wield that autonomy to largely protect physi-

cian work from the influence of health care organizations and the state, even as

individual physicians find themselves increasingly working within organizations

and remunerated by state payers.

By contrast, nursing has never attained this level of power. Nursing has suc-

cessfully expanded its domain of work and has significantly raised the status and

pay of its denizens. Nonetheless, it has mostly labored in the shadow of medi-

cine’s authority. Nursing’s inability to legitimately claim its own authority is one

reason why scholars have dismissed it as an analytically minor actor in health

care (Etzioni 1969; Freidson 1988a; F. E. Katz 1969). However, scholars who study

the experience of women in the labor market have questioned a normative read-

ing of occupational authority that erases the role of gender. These scholars have

argued that female-dominated occupations have had to rely on different strat-

egies from those adopted by male-dominated ones, because they do not have

the same access to formal centers of power (Bourgeault 2006; Witz 1990, 1992).

Without access to foundations, the higher education system, and political net-

works, women have historically relied more heavily on gendered appeals of moral

authority. The audience to whom these appeals are made consists of state and

organizational actors. As an occupation populated primarily by women, nurs-

ing’s access to organizational and state support has largely been achieved through

its responsiveness to employer and state concerns.

It is unlikely that NPs would have come into existence through arguments

of skill alone. The doors of the exam room were opened because someone was

in need. Patients needed providers; health care organizations needed medical

personnel; the state needed to meet its moral obligation to care for its citizens

while balancing the rising costs of care. Contrary to the prevailing narrative of

substitution, I argue that NPs were called into being precisely because they were

not physicians. Legitimated by professional authority, physicians could ignore

the problems of health care organizations and the state. Nursing’s reliance on

moral authority has called them to be responsive to these neglected clients.

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CONCLUSION 163

Nursing has a long history of doing so, from Nightingale in the late nineteenth

century to public health nursing in the early twentieth century (D’Antonio 2017;

Reverby 1987a). The NP is the newest addition in a long line of nursing solutions

intended to address organizational and social ills as well as bodily ones.

There may, however, be unrecognized consequences arising from the shape of

this solution. There is a robust literature that investigates the processes through

which social problems are constructed. Problems themselves are not objective or

quantitatively defined but are made through the rhetorical claims and political

actions of concerned groups and individuals (Best 2017; Blumer 1971; Spector

and Kitsuse 2017). Someone has to make the case that our attention and resources

should go here rather than there. A parallel process that has received somewhat

less scholarly attention is the construction and framing of solutions. Solutions

are no more objectively defined than the problems that precede them. More-

over, the solution put forward often serves to reshape our understanding of the

problem.

The NP is a reasonable solution to the problem of physician scarcity. I argue,

however, that a focus on numbers of workers is a misrecognition of the real prob-

lem at hand. The crisis of care is not just about changing demography. Nor is it

just about producing enough workers or figuring out the right calculus to pay for

them. This crisis is, above all, a reflection of our changing view of what kinds of

problems are amenable to public policy. When faced with the problems of physi-

cian scarcity and rising costs, the state had any number of choices at its disposal.

It could have declared health care a public good and matched the weight of its

financial investment with a more cohesive health care policy. When faced with

entrenched health disparities along the lines of socioeconomic status—problems

that have increasingly been traced to social structure rather than poor individual

choices—the state might have invested in social welfare policies to ameliorate

the worst excesses of living in poverty. When faced with the documented racial

inequalities that the women and men of the Grove faced throughout their lives,

the state might have chosen to put resources into eradicating entrenched forms

of discrimination. Instead, the state outsourced its moral obligations to the

private ministrations of a profession. In the personage of the NP, nursing has

stepped forward to solve a set of problems as a profession that the state has been

unwilling to address through social policy. In this account, I endeavor to reveal

the hidden work of NPs. Through doing so, I also hope I have shined a small light

on the hidden inaction of the state.

There are many things that ethnographic evidence cannot do. One of those things

is provide average portraits. I do not claim that the work these NPs did is exactly

like the work of their peers inside other organizations. The Grove is a single case,

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164 CONCLUSION

and a strange one at that. It is not lost on me that the Grove’s entire reason for

being is predicated on its uniqueness as an organizational form. The ability these

NPs had to reorder clinic work was almost certainly out of proportion to that of

other practice locations. The overlap between the Grove’s mission of compre-

hensive care and nursing’s claims of expertise over patient management was also

likely an amplification of how primary care unfolds elsewhere.

For the purposes of an ethnographer, however, this strangeness was useful.

Strange cases provide an analytical lens through which one can see, as if through

a magnifying glass, a set of social processes and cultural understandings that exist

elsewhere in less prominent forms. The Grove was unique, but the understand-

ings these providers and administrators used to negotiate their day-to-day work

were not entirely a local creation. Social life may be constructed, but the tools

we use to construct that life are shared. In attaining a magnified view of these

shared understandings, it was helpful that the Grove was strange in known and

systematic ways. The organization’s explicit commitment to nursing expertise made it easier to see the relationship between nursing ideals and practice, while

the presence of the social workers made it possible to see society’s disinvestment

in nonmedical renderings of social problems.

Equally consequential is the fact that the Grove, as aberrant as it was, was also

a real health care organization that operated under a field-level set of condi-

tions: the enduring presence of physicians, an insured patient population who

had some element of choice in how they accessed health care, and the dictates

of third-party payers. These conditions made it possible to trace connections

between realities on the ground and a particular set of structural realities having

to do with the shrinking welfare state, the rising needs of an aging society, and

the depth of the policy vacuum that nursing has stepped into.

The depth of that vacuum cannot be understated. In the face of shrinking

resources for social welfare programs, both community activists and state work-

ers are contemplating using health care funding to pay for a range of social ben-

efits from housing to nutrition (Abrams 2019). Any progress in providing the

socially vulnerable with basic needs would seem to require little justification.

But there are, perhaps, missed opportunities to recognize the solidity of social

problems as real problems. The relocation of what could be considered social,

political, or community concerns to the realm of the clinic may produce a payer,

but there may be unintended consequences for turning all problems into clinic

problems. The tools of medicine, no matter who wields them, allow for some

interventions and not others.

There are unanswered questions that an analysis of the NP makes visible.

These questions are about neither professional nor academic concerns. They

are inherently political questions about how to conceive of local and national

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CONCLUSION 165

solutions to social inequality. I have no answers of my own, but I will end this

account with an alternate vision of what kind of organization the Grove might

have been. I will ground that vision not by looking toward an imagined future,

but by looking at the documented past.

An Alternate Vision “This used to be a nursing home.” When people recounted the Grove’s history,

this was often how the telling began. The role of the nursing home in this story

needs little explanation. Nursing homes are instantly recognizable as an institu-

tional villain for whom no one cheers. That the Grove is literally inhabiting the

space of a former nursing home is ironic. It is karmic. It is a very satisfying story

to tell. But it’s not the only story. From 1978 to 2002, the building that Forest

Grove would eventually occupy was the home of the Nathaniel Turner Nurs-

ing Home (a pseudonym). At its inception, the Turner Home served a primarily

African American population. And that was a point of pride. It was created to be

a community institution, for and by black residents.

The community that birthed the Turner Home had a long history of institu-

tional building. The black southern migrants who streamed into northern cit-

ies in the early part of the twentieth century swelled the demographic footprint

of the African American community in ways that supported cultural and orga-

nizational growth, even under the constraints of segregation. By 1950, the city

that would later support the Turner Home already sustained a network of black

churches, small businesses, banks, and theaters. This rich institutional life was

both an adaptive response to exclusion from white institutions and a positive

choice for community building.

By 1970, however, the death knell of black institutions was resounding through-

out northeastern and midwestern cities. State-enforced urban renewal destroyed

the architectural fabric of black life as families and business were forced out

through government-backed projects of “slum clearance,” freeway construction,

and real estate projects that benefited white businesses at the expense of existing

black occupants (Massey and Denton 1993). The gains of the Civil Rights Move-

ment had also made the promise of racial integration into at least a partial reality.

As African Americans began to have access to previously white institutions, the

practical need to maintain separate institutions waned.

It was in this historical moment that the Turner Home was conceived. Built

from the ground up, the Turner Home cost 3.5 million dollars to construct. Its

board members spent years securing financing from local and national banks,

eventually receiving additional support from the state and from the federal

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166 CONCLUSION

government’s housing and urban development fund. The facility was described

as state-of-the-art with an eye toward efficiency; it was, in the words of the board

president, an attempt to provide “the best [care] for the most.” But the vision of

its founders was about more than simply providing health care. Although explic-

itly a nursing home, the Turner Home had a larger, intergenerational vision of

community uplift. In addition to nursing home services, the founders hoped that

the Turner Home would provide short-term material assistance for older adults

who lived in its community. The board of directors looked toward a future when

the Turner Home might eventually incorporate educational training for young

black men and women in the health professions. Their vision was of an institu-

tion that would serve a broad spectrum of interconnected community needs.

From its very beginnings, it was an ambitious project. Perhaps too ambitious.

By the late 1970s, opening a black institution of this scale seemed almost anach-

ronistic. But the needs of the community were hard to deny. Despite the rhetoric

of integration, African Americans still experienced segregated fortunes in hous-

ing, education, and health care. The long shadow of racial discrimination had a

particular influence on the care and treatment of older adults. By the 1970s, nurs-

ing home care had become an increasingly viable option as a result of the pas-

sage of Medicare and Medicaid legislation. This legislation slowly transformed a

sector that had previously been funded by private monies into one increasingly

funded by public monies.

Despite public funding, African Americans were less likely than white Ameri-

cans to access this kind of care. This was true in the 1970s and it remains true today.

This racial difference has been long noted, but its explanation is not straightfor-

ward (Akamigbo and Wolinsky 2007; Cagney and Agree 1999; Smith et al. 2007;

Thomeer, Mudrazija, and Angel 2015; Wallace et al. 1998). It has become almost

a truism in health policy circles to point to cultural differences between white and

black Americans. African Americans, scholars opine, think differently about fam-

ily. But direct and structural discrimination bear at least as much consideration

as love of family. Hospitals that wanted to receive Medicare and Medicaid reim-

bursements were forced to abide by the 1964 Civil Rights Act and desegregate

their wards. However, it would be many more decades before federal funding was

a significant portion of what was still a relatively small nursing home industry.

Most white-only nursing homes relied on private-pay residents; attempts to open

their doors to African Americans would have driven away their customers (Smith

1990). The federal government was also reluctant to enforce integration in spaces

considered intimate or private, such as residential facilities (Smith 1990). There is

also the much more straightforward reality of racial bias in nursing home admis-

sions (Falcone and Broyles 1994; Institute of Medicine 1981). African Americans

who found they needed nursing home care often struggled to find it.

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CONCLUSION 167

In this context, the Turner Home was to be a place where black elders could

receive the kind of care they were denied elsewhere. As the physical embodiment

of an older vision of community and self-help, the Nathaniel Turner Nursing

Home was to be an exemplar of what black institutions could still be. There was

so much promise at its inauguration. One might be inclined to hope that it did

at least some of what it set out to do—until the moment when we know that it

did not. In 1998, investigations of the Turner Home found several deficiencies

in patient care. The Turner Home was part of a growing number of nursing

homes that were found wanting in quality. While this could be blamed in part

on unscrupulous operators, there were also larger changes in the industry that

challenged the entire sector. The “gold rush” of federal money into nursing home

care created demand, but it also increased the cost. With federal money came

federal regulation—the expense of which pushed many smaller nursing homes

out of the market. For example, compliance with federal fire and safety codes was

impossible for mom-and-pop facilities operating out of converted residential

homes (Hawes and Phillips 1986).

As a response to legal action by the federal government and the challenges of

running a smaller facility, the Turner Home permanently closed its doors in 2002.

The building was emptied of residents and would stand vacant for the next four

years. Eventually, the property went into foreclosure. City tax records contain

a photograph that documents the building’s fate: an empty parking lot, letters

missing from the nursing home’s sign, and windows that had been boarded up

in defeat. The building that cost 3.5 million to build in the 1970s was bought by

a developer for less than half a million in 2003.

It is unclear exactly when the dream of a community institution died. But per-

haps when Stanton investigated the property in 2005, it recognized something of

that original spirit. But Stanton had a somewhat different vision of what kind of

institution the Grove would be. Like the Turner Home before it, the Grove served

an almost exclusively African American population. But it was not to be a black

institution. It was to be a nursing institution. As a practice of Stanton School of

Nursing, its mission was not about racial uplift but about caring for the medically

underserved. Stanton hoped it could still be a place to experience community.

However, this vision of community formation was confined to the organizational

apparatus of a health care organization.

Despite the best of intentions, the Grove sometimes struggled to make itself

part of the community in ways that went beyond service provision. NP Franc-

esca made this point to me in one of our interviews. She noted that the Grove

“had the potential to be an ideal community practice, although it’s not there

yet.” She provided an example of the kind of community partnership that would

move the Grove closer to this ideal. “What if we opened a small training program

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168 CONCLUSION

here for community members who wanted to learn to be nursing assistants

so that they could go out and make money? They could come here; we could

teach them; they could do their practicum right here with our members. . . . I’ve

brought this up a couple times and haven’t gotten any place. But it’s like, how

great could that be?”

SW Yvonne also questioned the impermeability of the walls that seemed to

have grown between the Grove and the community outside. In one of our con-

versations, she noted that the Grove was so keen on “re-creating community” within the center that it seemed to have forgotten that members were already part

of communities. She wondered what would happen if the Grove moved beyond

medical definitions of therapeutic socialization and instead worked in tandem

with neighborhood organizations to strengthen the bonds of community. The

mutual visions of Francesca and Yvonne, an NP and a social worker, may seem

idealistically utopian. But perhaps it would be easier to imagine these visions

in a different terrain. The alternatives they imagined may be impossible for a

health care organization, but they might not be inconceivable for a community

organization—one that saw its role as an agent of change rather than as a pro-

vider of services.

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