Medical Work/Nursing Work: Negotiating the Nurse Practitioner in Primary Care

Abstract

The United States is struggling to provide health care in the face of ever increasing demand. As medical students continue their decades long march toward specialization, questions of how to provide generalist care become quickly intertwined with that of who will provide this care. One answer to this question is increased reliance on nurse practitioners. If a patient were to visit a primary care clinic, she may increasingly have her chief complaint addressed by a nurse practitioner rather than a physician. If we want to understand both the present and future of health care, we need to look more closely at these new clinicians, their practices, and the ways in which they may be creating spaces of difference for the delivery of medical care.

This dissertation addresses this need through a multi-sited ethnography of the nurse practitioner. To understand how nurse practitioners understand themselves as a profession, I used 12 months of ethnographic and narrative data from a nursing school, analyzing routine, formal talk about patient care. An essential finding was that talk about nursing practices emphasized skills of difference from physician practice. This was achieved through different constructions of patient problems and case complexity. In these accounts, patients were often socially, rather than medically complicated. I found that medical knowledge was assumed to be technically attainable, but that true nurse practitioner expertise required special knowledge of each patient.

In order to understand how nurse practitioners negotiated the meaning of their work in practice, I used data from 16 months of fieldwork at a community practice that used an interdisciplinary team model. In an organization with multiple layers of providers, the nurse practitioner became the manager of not only medical concerns, but was also called to troubleshoot both social and organizational concerns involving patients. Nursing's duty to care required the skillful clinician to become conversant with the organization's view of the patient. This specific translation of nursing care allowed for the construction of an organizationally recognized area of expertise.

Through a performance of difference, nurse practitioners are doing more than constructing professional expertise or a personal sense of worth, they are changing expectations about what kinds of problems get solved during primary care encounters. As nurse practitioners colonize the exam room with a different kind of clinical performance, they are potentially redefining what it means to care for the sick.