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On March 11, 2020, the World Health Organization categorized the COVID-19 outbreak as a global pandemic.1 Less than a month later, nurse practitioners (NPs) in five US states were given emergency authority to do what NPs in 22 other states could already do: practice independently.2
Tennessee was one of those five: on March 19, 2020, Tennessee Governor Bill Lee signed an executive order that released NPs from the formal requirements of physician oversight.3 The executive order was of great relief to NPs like Renee Collins. Collins is a co-owner of a practice that provides home-based primary care to older adults in rural Tennessee. All of the providers she employs are NPs. But she has more than their salaries to worry about in her budget. She also has to hire a physician—not to see patients, but to meet the state requirement for physician oversight. What oversight means might be a surprise to many. In most cases, the physician never examines or speaks with any of the NPs’ patients. In states like Tennessee, the physician is required to visit an NP’s site of practice once a month and to retrospectively audit 20 percent of an NP’s charts.4 The physician collects a fee for this service, costing the practice not only in money but also in the time it takes to find, schedule, and manage an outside provider. Collins, and NPs across the state, hoped that the executive order would become permanent. But she was not optimistic. “We’re needed when there’s a crisis,” she told a reporter. “But when the crisis is over, we’re not needed anymore.”5
On the Frontlines of a Healthcare Crisis
And they have proven to be a solution with staying power. Because, unlike the pandemic, the healthcare crises they were created to address show no signs of abating. Demand for healthcare continues to soar, with a graying population helping to keep the need for services high. In 1950, just 8 percent of the US population was 65 or older. By 2019, it was 16.5 percent. And by 2050, it is projected to be 22 percent.7 While medical advances have made old age healthier, it remains a part of the life course that requires increased medical and supportive care. Likewise, the other crisis, the allure of physician specialization, has only gotten more serious. Between 1985 and 2011, the proportion of US medical students who chose primary care residencies declined by 24 percent; and in an especially dramatic drop, between 1999 and 2003, the proportion of internal medicine residents who went on to work in primary care plummeted from 54 to 20 percent.8 The result? In 1961, half of US physicians were in primary care, but by 2015, only a third were.9
In the wake of physician abdication of primary care, nursing’s footprint has grown.10 By 2017, the population of practicing NPs had swelled to about 190,000,11 with over 80 percent of recent NP graduates reporting they were going into primary care.12 There are still more physicians than NPs providing primary care in the United States,13 but with each passing year, more NPs than physicians are entering the primary care workforce.
Today, the NP as physician substitute is a fairly well-known story, at least within healthcare policy circles. What is less often considered is whether or not the problem they are addressing is only or even primarily about physician scarcity. Not everyone struggles to find a doctor; those with the least profitable conditions and the fewest resources are far more likely to have difficulty. As a consequence, NPs are more likely to treat populations whose care is often socially as well as medically complicated: people who are poor, are uninsured, receive Medicaid, and/or qualify for Medicare due to a disability.14 Far from being a simple substitute, NPs systematically care for different patients than physicians.
While some may believe NPs are best suited to provide “routine” care, the reality is that by becoming the provider to the socially marginal and medically vulnerable, NPs are often managing the most complicated patients. And the available evidence suggests they are up to the challenge. Fifty years of research on the safety and effectiveness of NP-led care supports the conclusion that their patients do at least as well as those who see physicians.15 This evidence suggests a possibility that few health policy experts have considered. Perhaps the utility of NPs is found not in their similarity to physicians, but in their difference from them. And maybe, just maybe, the problems NPs are a solution to have less to do with physician scarcity than with deeper questions of social inequality and how we choose to care for our most vulnerable citizens. These are the questions I brought with me as I spent two and a half years following a group of providers at a place I call Forest Grove Elder Services (a pseudonym).16
Forest Grove is best understood as a nursing home diversion program. All of its patients were eligible for nursing home care due to various physical or cognitive needs. In order to avoid institutional care, the Grove provides a comprehensive set of services that includes, but goes well beyond, medical care. In addition to primary care, the Grove provides physical and occupational therapy, recreational activities, and social work services. It also coordinates and manages the care its patients receive outside its walls, from specialist appointments to rehabilitation services. A dedicated fleet of accessible vans ferry patients to and from the Grove, as well as to these outside services.
From a funding perspective, what is unique about the Grove is the way it tries to manage costs. The state authorized the use of Medicare and Medicaid dollars to pay for these enhanced services as an experiment to test if providing comprehensive, community-based care could save money through averted hospitalizations and nursing home placement. But in the time I spent at the Grove, I found that what was truly unique about the organization is the way its NPs make this model work. Like many healthcare organizations, the Grove employs both physicians and NPs to provide medical care. However, what makes the Grove different from other collaborative environments is that its NPs are the formal leaders of the healthcare team. What it meant for NPs to lead was not just about decision making, but about fundamentally reshaping how care happens.
More Than Medicine
When I first met Michelle, she had been an NP for almost 20 years. But she had been a nurse for longer still. Like most NPs, she started her career as a registered nurse (RN); her first job was at the hospital bedside. She had already amassed over two decades of experience before she went back to school to become an NP. Maybe that is why when I spent time with Michelle, it became impossible to think of her as a substitute physician. To watch Michelle was to watch a nurse at work.
“Ms. Payne. Can you think of anyone else who could come by a few times a day?” Ms. Payne was 86 years old. Like most of the Grove’s patients, she lived with a litany of complaints: diabetes, rheumatoid arthritis, congestive heart failure. Yet none of these were why she was sitting in Michelle’s office on that day. In two weeks, Ms. Payne was scheduled to have cataract surgery to improve her increasingly cloudy vision. Michelle’s aim was to make sure Ms. Payne was prepared for the operation. Cataract removal is a low-risk outpatient procedure. The surgery was not the problem. The problem was what would happen afterward.
I sat in the corner, trying to be unobtrusive in a room that seemed full with three people. I listened as Michelle reviewed the surgeon’s postoperative instructions. Ms. Payne would need to apply a series of prescription eye drops—four times a day for four weeks—to control inflammation, prevent infection, and minimize complications. There is nothing remarkable about their application. One would simply 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, and then squeeze with the right amount of pressure. These coordinated steps, however, require a set of abilities that not everyone possesses. Ms. Payne had rheumatoid arthritis, a condition that not only inflames the joints but also often deforms them. This condition had left her hands curled in on themselves like talons. As Michelle described how often the drops would need to be applied, all three of us looked at these hands, our eyes filling with doubt.
In everyday life, when we cannot administer our own medication, parents, children, or even a good friend might be enlisted to assist. This practice is both common and legal as long as it is done for free, which explains why Michelle asked 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 outside of an institution. This includes prescription eye drops. Justifying the expense of paying for an RN to visit Ms. Payne four times a day, every day, for four weeks, might not have been impossible, but it certainly would not have been easy. Yet, sending her home after surgery with no plan for applying the eye drops bordered on medical malpractice.
Over the next two weeks, I watched as Michelle “knit together” a range of resources on Ms. Payne’s behalf. She called the surgeon to see if a simpler regimen might work on weekends. She asked an RN colleague to meet separately with Ms. Payne to go ask if she were sure that no one could assist her, even once a day. A cousin? A neighbor? Someone from her church? The nurse reminded Ms. Payne, gently but firmly, that not wanting to ask is not the same thing as being unable to ask.
With the RN’s help, Michelle eventually crafted a plan that is one part neighbor, one part modified regime, and one part approval for some nursing visits on weekends. Arriving at this complex calculus took more than a little time and a great deal of work. The surgeon performed the technical miracle of curing the patient; Michelle performed a miracle of her own in helping to ensure the best possible outcome. With Ms. Payne’s eyesight improved, the odds are good that she will be able to stay in her own home for some time to come.
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, coordinating care, and knitting together complex information is someone’s full-time job. Yet, 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 children. Moreover, this work is not unskilled; an adult’s availability does not necessarily signal possession of the knowledge or expertise to do what needs to be done. To categorize this as the work of daughters reveals it as the kind of invisible work that money cannot always buy, and for which insurers rarely reimburse.17 But if this work happens within the reimbursed medical visit, there is a greater chance that it might occur. The NPs I spent time with did this kind of work as part of the medical exam, making it not just an adjunct to medical work, but a transformation of it. And when they did it well, there was a good chance that their patients would experience fewer complications—and that the state would incur fewer costs.
The Hard Work of Being an NP
When I asked what made the work hard, she responded, “Let’s say you’re Mr. Smith. And you’re in the hospital right now. And the hospital calls one of our doctors [to get his medical history]. 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 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.… 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 to the problem.”
From Joanne’s perspective, the hard work that the NPs performed gave them a better relationship with their patients, which in turn gave them a better understanding of their clinical care. I pondered Joanne’s words for some time. To speak of relationship is usually to invoke the intangible world of emotions. Yet when Joanne illustrated this term, she did not describe an affective tie between NP and patient, but one born of deep, layered knowledge. Moreover, she was explicit in calling out the action required to cultivate that knowledge. For Joanne, this was not the result of an emotional attachment; it was the result of hard work. As I spent more time in the clinic, I began to understand how the NPs’ work might improve patient care.
One afternoon, I sat with Michelle as she met with Mr. George. His weight had gone up by seven pounds in less than two weeks. This was of particular concern to Michelle because 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. What Michelle knew for sure was that if Mr. George retained too much fluid, he might find himself struggling to breathe.
This was the kind of slow-moving emergency that Michelle faced on a daily basis. Because it was not just age that defined her patients; it was medical frailty. All of Michelle’s patients had multiple chronic conditions like diabetes, arthritis, and hypertension—as well as an array of physical and cognitive impairments that interfered with daily life. Her job as their primary care provider was not just to provide medical care, but to manage the full range of services upon which her patients depended. Mr. George saw a regular cardiologist for his heart failure. But if the problem could be treated without that level of care—and cost—it was Michelle’s job to make it happen.
As Michelle met with Mr. George, I recognized a technique that I had often seen her employ. When she wanted to understand a problem, either from a patient, family member, or colleague, she asked questions that did not reveal her own suppositions. Instead, she let the person to whom she was speaking give their own rendering of the facts. 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 questioning. 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. 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?” In the conversation that followed, Michelle learned that Mr. George was only taking half of 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 one of the medications that helped him manage his heart failure.
The case of Mr. George could be described as an issue of noncompliance or patient education—the kind of nonmedical problem you had to be neither an NP nor a physician to solve. But the nature of the problem was only apparent in hindsight. Michelle not only had to ask the right questions, she had to listen. If she had simply inquired, “Are you taking your medications?,” Mr. George may have reported—honestly, from his perspective—that he was. If she had sent him directly to the cardiologist, Mr. George might have had his medications changed or increased without addressing his underlying concern of side effects—the concern that had motivated him to modify his medications without understanding the risks. It was listening, conversation, and medical knowledge that led Michelle to the right conclusion and the best plan of action. What Joanne had described as “the hard work” of being an NP did not just make Mr. George feel listened to or cared for, it was a crucial part of keeping him medically stable and independent. When Michelle did this work well, she not only helped Mr. George but also saved his insurer from paying for a more expensive trip to the cardiologist.
But their conversation would have benefits beyond any single exam. Michelle’s questions were open-ended. Therefore, along with hearing what she might have thought was important, she heard information that was important to Mr. George. He had his own ideas about how each of his 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 a brand name to a generic version. And as they talked, Michelle learned just a little bit more about Mr. George. Such as how he reasoned about which pills to take and when. That despite not knowing which pills were for which condition, he was otherwise willing and compliant with taking them. She learned more about his relationship with a neighbor who came over to help him put groceries away and brought him dinner on Sundays. In addition to learning why he was retaining fluid, she learned more about his support network and personal resources. If she needed to help him address a different issue, she would have new information to draw from to make that happen.
The Nursing Model of Care
“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.” These were the words of Norah, an NP who worked alongside Michelle. These words were in response to a question I had asked about how NPs differed from physicians. For Norah, it was nursing’s whole-person orientation that allowed them to “hear things,” and to “identify needs” that a physician would not necessarily notice.
Norah was quick to make sure I did not misunderstand her. “Look,” she said. “There’s a lot of things that [the physicians] understand way better than I do.” However, for Norah, recognizing the physician’s expertise did not take away from her own. “NPs have really taken on that kind of responsibility,” she told me. “It’s the nature of the profession.” When I watched NPs like Michelle and Norah at work, I came to understand how that different responsibility looked in action. And why it mattered for patients.
A Crisis of Care
Because we are not simply facing a crisis of cost or personnel; we are facing a crisis of care. For the Grove’s patients, the work of knitting together information, resources, and systems was not a luxury, it was a necessity. Certainly, not all NPs care for patients as ill as those the Grove served. But in becoming the primary care providers for people who are poor, disabled, or otherwise medically marginalized, NPs across the country are often asked to meet a fairly high bar of expertise. Moreover, while the expertise required includes that of medicine, it often goes beyond it. Because what ails patients like Ms. Payne and Mr. George is as much about inequality as illness. A lifetime of poverty and racial discrimination are known causes of poor health.18 These social conditions not only make it difficult to access quality healthcare, there is good evidence that they literally age the body and directly produce illness. The NPs who listen, advocate, and coordinate will not solve these problems. Nonetheless, they can and do serve as on-the-ground lifelines for patients navigating the interwoven terrain of organizational, medical, and social problems that all too often go unnamed and unaddressed.
This crisis, however, goes beyond the exam room. Because the scarcity at work is less about providers than policy. We should not forget that the creation of the NP is only one of many possible responses to the crises we face. Despite being organized as a private system, healthcare’s largest payer in the United States is the government.19 Given this reality, what might have happened if we, as a nation, had matched the weight of our financial investment with a cohesive, national healthcare policy? What if, when faced with the growing evidence that health disparities were caused by social inequality, we had invested in social policies to ameliorate the worst excesses of poverty? Or used the full weight of the law to eradicate entrenched forms of racial discrimination? These are paths we did not take. Instead, we unraveled the national safety net, leaving individual providers to knit together the last threads of what remained.
Many have argued that the pandemic has exposed the cracks in our healthcare system. I hope it also shines light on the workers who are often called upon—and feel a calling within themselves—to span those cracks. In the hours I spent watching NPs like Michelle and Norah at work, I came to the conclusion that it is often nurses who are left with the invisible work of holding healthcare together. Before, during, and after the pandemic, nurses do not only the visible work of patient care but also the invisible work of shoring up a healthcare system that is crumbling under the weight of social inequality. As of the writing of this article in the first months of 2021, most of the executive orders that expanded NP practice autonomy have already been rescinded, even as the pandemic rages on. NPs like Renee Collins are back to paying physicians for oversight. But her patients in rural Tennessee will never know the difference because Collins is clear in her purpose: “Nurses are not wanting to be doctors.… We are simply wanting to fill the gap for access.”20
LaTonya J. Trotter is a sociologist at Vanderbilt University who writes about how changes in the organization of medical work impact social inequality. In her book More Than Medicine: Nurse Practitioners and the Problems They Solve for Patients, Health Care Organizations, and the State, she considers how nurse practitioners are creating new possibilities for what the medical encounter could be, while demonstrating the depth of the crisis we face. Portions of this article were first published in More Than Medicine, © Cornell University Press 2020; adapted with permission.
Endnotes
1. World Health Organization, “WHO Director-General’s Opening Remarks at the Media Briefing on COVID-19—11 March 2020,” March 11, 2020, who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020.
2. M. Bachtel, R. Hayes, and M. Nelson, “The Push to Modernize Nursing Regulations During the Pandemic,” Nursing Outlook 68, no. 5 (September–October 2020): 545–47.
3. “Executive Order 15 of March 19, 2020, an Order Suspending Provisions of Certain Statutes and Rules and Taking Other Necessary Measures in Order to Facilitate the Treatment and Containment of COVID-19,” State of Tennessee Executive Order by the Governor, publications.tnsosfiles.com/pub/execorders/exec-orders-lee15.pdf; see also “Executive Order 28 of April 17, 2020, an Order Amending Executive Order No. 15 and Taking Other Necessary Measures to Facilitate the Treatment and Containment of COVID-19,” State of Tennessee Executive Order by the Governor, publications.tnsosfiles.com/pub/execorders/exec-orders-lee28.pdf.
4. “FAQ: Physician Supervision of PAs and APNs,” Tennessee Board of Medical Examiners, October 2016, tn.gov/content/dam/tn/health/documents/SUPERVISION_FAQs.pdf.
5. K. Horan, “Nurse Practitioners Praise Executive Order amid COVID-19 Outbreak,” NewsChannel 5 Nashville, April 7, 2020, newschannel5.com/news/nurse-practitioners-praise-executive-order-amid-covid-19-outbreak.
6. J. Fairman, Making Room in the Clinic: Nurse Practitioners and the Evolution of Modern Health Care (New Brunswick, NJ: Rutgers University Press, 2008); and H. Silver, L. Ford, and S. Steady, “A Program to Increase Health Care for Children: The Pediatric Nurse Practitioner Program,” Pediatrics 39, no. 5 (May 1967): 756–60.
7. “Share of Old Age Population (65 Years and Older) in the Total U.S. Population from 1950 to 2050,” Statista Research Department, September 2020, statista.com/statistics/457822/share-of-old-age-population-in-the-total-us-population.
8. M. Schwartz, “Health Care Reform and the Primary Care Workforce Bottleneck,” Journal of General Internal Medicine 27, no. 4 (April 2012): 469–72.
9. J. Dalen, K. Ryan, and J. Alpert, “Where Have the Generalists Gone? They Became Specialists, Then Subspecialists,” American Journal of Medicine 130, no. 7 (July 1, 2017): 766–68.
10. J. Pohl et al., “Primary Care Workforce Data and the Need for Nurse Practitioner Full Practice Authority,” Health Affairs (blog), December 13, 2018, healthaffairs.org/do/10.1377/hblog20181211.872778/full.
11. D. Auerbach, P. Buerhaus, and D. Staiger, “Implications of the Rapid Growth of the Nurse Practitioner Workforce in the US,” Health Affairs 39, no. 2 (February 2020).
12. Pohl et al., “Primary Care Workforce Data.”
13. B. Japsen, “U.S. Primary Care Doctor Supply Has Improved but Not Everywhere,” Forbes, February 18, 2019, forbes.com/sites/brucejapsen/2019/02/18/u-s-primary-care-doctor-supply-has-improved-but-not-everywhere/?sh=28413e7a5c6b.
14. C. Everett et al., “Physician Assistants and Nurse Practitioners as a Usual Source of Care,” Journal of Rural Health 25, no. 4 (Fall 2009): 407–14, onlinelibrary.wiley.com/doi/abs/10.1111/j.1748-0361.2009.00252.x; and Nurse Practitioners: A Solution to America’s Primary Care Crisis (Washington, DC: American Enterprise Institute, September 18, 2018), aei.org/research-products/report/nurse-practitioners-a-solution-to-americas-primary-care-crisis.
15. M. Laurent et al., “Substitution of Doctors by Nurses in Primary Care,” Cochrane Database of Systematic Reviews, no. 2 (2005), cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001271.pub2/full; E. Lenz et al., “Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians: Two-Year Follow-Up,” Medical Care Research and Review 61, no. 3 (2004): 332–51; and C. Desroches et al., “The Quality of Care Provided by Nurse Practitioners to Vulnerable Medicare Beneficiaries,” Nursing Outlook 65, no. 6 (November–December 2017): 679–88.
16. All quotations and examples come from my observations during these two and a half years; for more information, see the discussion of methods in my book: L. Trotter, More Than Medicine: Nurse Practitioners and the Problems They Solve for Patients, Health Care Organizations, and the State (Ithaca, NY: Cornell University Press, 2020), 9–16.
17. Examining the gender dynamics of caregiving in more detail is outside the scope of this article, but it’s worth noting that adult daughters provide significantly more care to their elderly parents than adult sons do—according to one study, more than twice as much in terms of hours; see A. Grigoryeva, “Own Gender, Sibling’s Gender, Parent’s Gender: The Division of Elderly Parent Care Among Adult Children,” American Sociological Review 82, no. 1 (2017): 116–46; and More Than Medicine passim.
18. P. Braveman, S. Egerter, and D. Williams, “The Social Determinants of Health: Coming of Age,” Annual Review of Public Health 32 (April 2011): 381–98.
19. “KHN Morning Briefing: Government Now Pays for Nearly 50 Percent of Health Care Spending, an Increase Driven by Baby Boomers Shifting into Medicare,” KHN, February 21, 2019, khn.org/morning-breakout/government-now-pays-for-nearly-50-percent-of-health-care-spending-an-increase-driven-by-baby-boomers-shifting-into-medicare.
20. E. Glover, “Tennessee Nurses Association Pushing Law Makers to Pass New Legislation,” Fox 17 WZTV Nashville, February 5, 2020, fox17.com/news/local/tennessee-nurses-association-pushing-law-makers-to-pass-new-legislation.
[Illustrations by Jasu Hu]