Nurse Practitioners: An American Invention

Josephine Ensign (Bowdler then) at Cross-Over Clinic. From The Bon Secours Courier/St. Mary's Hospital June 1987.
Josephine Ensign (Bowdler then) at Cross-Over Clinic. From The Bon Secours Courier/St. Mary’s Hospital June 1987.

In celebration of the 50th Anniversary of the establishment of the role of nurse practitioners, I want to share an excerpt from my forthcoming book, Catching Homelessness (She Writes Press, August 9, 2016 publication date). Young people contemplating careers in nursing often ask me if I am happy I ‘became’ a nurse practitioner back in the early 1980s. My answer is always a qualified and honest, “yes, but it has not always been an easy role to work within–mainly due to the rigid medical hierarchy.” Yet of all the health care roles in existence today, if I had the chance to do it all again, I would–without any hesitation–become a nurse practitioner. We are a tough breed, willing to work on the medical margins, and we are here to stay.

Here is the excerpt from my book, in a chapter titled “Confederate Chess”:

“Nurse practitioners are an American invention, and specifically they are an invention of the American West. The nurse practitioner role was started by a Colorado nurse in the mid-1960s during President Johnson’s War on Poverty, when Medicaid and Medicare were established to extend health care to the poor and elderly. Even before this expansion of health care, there was a shortage of primary care physicians. At the same time there were many seasoned, capable nurses who were already providing basic health care to poor and underserved populations. A nurse-physician team developed the nurse practitioner role, adding additional course work and clinical training for nurses. With this, states began allowing nurse practitioners to diagnose and treat patients, including prescribing medications for common health problems.

Not surprisingly, the emergence of the nurse practitioner role met with the most resistance in states with higher physician to population ratios, and in states with more powerful and politically conservative physician lobbying groups. The nurse practitioner role was protested both within the medical and the nursing establishments. Physicians didn’t want nurses taking jobs from them, and nurses didn’t want other nurses having a more direct treatment role—more power and prestige—than they did. But the role caught on and spread throughout the country. Nurse practitioners didn’t get firmly established in Virginia until the mid-1980s when I completed my training.

Why nursing? I often asked myself, and people continued to ask me even after I became a nurse practitioner. It was as if any sane, intelligent, modern woman could not want to be a nurse. I had stumbled into nursing while a master’s student at Harvard University, studying medical ethics and taking courses in the School of Public Health. I was gravitating toward a public health degree, but was advised by one of my professors to go to either medical or nursing school first in order to get direct health care experience. I didn’t like the approach of mainline medicine, but also had a negative stereotype of nursing. The only nurses I knew worked in my rural family doctor’s office. They were stout, dull-witted, and wore silly starched white caps, overly-tight white polyester uniforms, and white support stockings that swished as their fleshy thighs rubbed together. But in graduate school at Harvard I sprained my ankle, and went to the student health clinic. I was seen by a kind and competent provider who spent time explaining what I should do to help my ankle recover. I was impressed and thought she was the best doctor I’d ever seen. Then she told me she was a nurse practitioner and explained what that was. My negative stereotype of nurses was challenged.”

Nurse Log: A Winter Solstice Gift of Quietude

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A decorated nurse log (stump) on Orcas Island, Washington. Photo credit: Josephine Ensign/2015

Recently, I spent a week ‘off the grid’ on a solo writing retreat at one of my favorite places on earth: Orcas Island in Washington State’s San Juan Islands. In my experience, going off grid, off e-mail, off social media, off any news is both deeply restorative and refreshingly loopy. Restorative, of course, because the electronic umbilical cord connection with the world creates a constant anxious buzz that is typically only apparent when it is absent. Refreshingly loopy because the cessation of that baseline buzz creates space for our brains to make sudden strange connections and leaps into uncharted territory.

One of these loopy leaps for me happened through the nurse log. Anyone who has ever lived in or traveled through the soggy, glacial-scoured forests of the Pacific Northwest, is familiar with the term ‘nurse log’–an example of which I include in this post. Nurse log, as in a decaying part of an older tree (log, or stump, as in this photo) that provides the ideal environment of moisture and nutrients and even shelter from competition, for a new tree to start its life. An example of resilience, adaptation, and thriving in the face of adversity. An example of the circle of life.

A metaphor for where I am in my nursing and teaching career: on sabbatical, gone fishing, taking a break, lying fallow and untilled, at least from my usual clinical and teaching responsibilities. More time to study important things, like the state of homelessness, the role of narrative in health and healing, the history of charity health care–and the lifecycle of evergreen trees. More time for travel–not to faraway lands–but to places right here at home. More time to cultivate and appreciate quiet.

It strikes me that we don’t allow enough space and time for quiet. We now recognize the importance of quiet in hospitals to allow patients to heal from illness, trauma, and surgery–although actually providing this for patients is spotty at best. I was reminded by Health Care for the Homeless, Seattle/King County Public Health nurse Heather Barr recently that emergency and transition shelters for people experiencing homelessness are often chaotic and cacophonous places. She advocates the addition of quiet rooms and quiet hours when she works with shelter staff around implementing trauma-informed care. People who are struggling with PTSD are often triggered by noise. I’ve often observed the role of a healing quiet space in public libraries for homeless and marginalized people who otherwise don’t have such sanctuaries. As health care providers, as caregivers, as teachers we should remember the gift of stillness and of quiet.

The Importance of Being Human(ities)

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Restroom sign at the University of Washington’s Intellectual House. Photo credit: Josephine Ensign/2015

All of our current ‘wicked problems’ such as racism, homelessness, environmental issues, human gene editing, violence against women, mass murders, and terrorism, cannot be addressed constructively by science or technology. As the late Donald Schon wrote:

“In the varied topography of professional practice, there is a high, hard ground overlooking a swamp.  On the high ground, manageable problems lend themselves to solution through the use of research-based theory and technique.  In the swampy lowlands, problems are messy and confusing and incapable of technical solution.  The irony of this situation is that the problems of the high ground tend to be relatively unimportant to individuals or society at large, however great their technical interest may be, while in the swamp lie the problems of greatest human concern.” (Schon, D.A. “Knowing-in-action: The new scholarship requires a new epistemology,” 1995, Change, November/December, 27-34.)

In order to muck through the swampy wicked problem areas, we need–more than ever–the humanities. Before we continue down the path of denigrating the humanities (Rubio wanting more welders/less philosophers) and decimating university programs in the humanities, we need to ask ourselves if this is who we want to be–both individually and collectively. Where would we be without grounding in history, language, literature, comparative religion, philosophy, ethics, archeology, the theory/philosophy of law, and the criticism/theory of art? The excellent short (7 minute/ June 2013) video “The Heart of the Matter” by the American Academy of Arts and Sciences explores this question. “No humanities? No Soul,” George Lucas states. 

William ‘Bro’ Adams, Chairman of the National Endowment for the Humanities (NEH), gave a speech this past week at the University of Washington’s newly opened (and gorgeous) Native American center, called the Intellectual House. Adams reminded us that both the NEH and its sister organization, the National Endowment for the Arts, are 50 years old this year. In 1965, President Johnson signed the act designating both the NEH and the NEA, and he made them a central part of the Great Society.

Adams was, of course, ‘preaching to the choir’ in that most of the audience consisted of academic-types from the different disciplines traditionally considered the humanities. I didn’t recognize anyone else from the health sciences, and none of the audience members asking questions identified themselves as being from science or technology fields. This was disappointing, although not surprising. After all, even physically the UW’s Intellectual House is surrounded by buildings that house the humanities and is a far trek from health sciences or any of the science and technology buildings. But as Adams emphasized towards the end of his talk, there’s a great need to increase the intersection of the humanities with science/technology/medicine (health sciences more broadly). The humanities bring the important tools of reflection. Reflection on what it means to be human. Reflection of what it means to be a citizen.

Gratitude for Mentors

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Dr. Lorna Mill Barrell (1931-2014), a nursing mentor of mine, after lunch in the Jefferson Hotel, Richmond, Virginia in 1996.

We now have the ‘science of gratitude’ to back what we’ve already known: gratitude is good for us, both individually and collectively. That we have a national holiday named for gratitude is something that–despite the complicated colonization and empire-building historical roots–I am thankful for.

Over the past four months, I have had the privilege of interviewing a variety of people in the Seattle area who work (or live) at the intersection of health and homelessness. These interviews are part of the oral history component of my ongoing Skid Road project, exploring the historical roots of ‘charity’ health care in King County, Washington (the county within which Seattle is located). One of the first open-ended interview questions I pose to people is, “Who or what has most influenced your work and life?”

People I interview typically pause for a moment after I ask this question, they gaze at some corner of the room as if seeing pleasant ghosts, and then they launch into detailed descriptions of people and events essential to who they are as people and to the work they do. Most people identify one or two key people in their lives who provided a sort of moral compass steering them in the direction of compassion–for their own humanity, as well as for other people. Parents. Teachers. Counselors or therapists. Professional mentors. They can easily tell a specific story of lessons they learned from these key people. And due to my use of snowball sampling–asking them to identify people I should try to interview–I have been able to complete oral history interviews on several generations of mentors.

These interviews have led me to reflect more deeply on the people in my life I am grateful for, people who have influenced who I am and what I do. I am also reminded of the wisdom of Rachel Naomi Remen, MD and her healing work with physicians, nurses, and other caregivers. I often introduce my students to her Heart Journal daily practice. For this, she advocates a 10-15 minute quiet time at the end of the day where you review your day, then write the first things that occur to you when you ask yourself three questions: 1) What surprised me today? 2) What moved me or touched my heart today?, and 3) What inspired me today?  Attention and gratitude.

As a nurse and a teacher, I remember two people who have had the most influence on my work, my life. One is Lorna Mill Barrell, RN, PhD who came into my life when I was seriously considering dropping out of nursing school. It was in November of 1983, my final year of the BSN program at MCV/VCU, and I had just been informed by my community health clinical instructor that she was giving me an ‘F’ on my final clinical rotation project paper. “I don’t see how this has anything to do with nursing,” she wrote across my project paper’s title, “The Health of Richmond’s Homeless Population.” I contested her grade and that’s how I met Lorna, who was the chair of the department my instructor worked in–she was my instructor’s boss.

I remember Lorna’s welcoming and nonjudgmental attitude towards me when I came into her office to meet with her about my grade. I’m sure I came across at first as indignant, haughty, and angry. At the time, I wasn’t just contesting my community health grade, I was also contesting my desire to be a nurse at all. She offered to read and re-grade my paper. Thanks to her intervention, I not only passed community health (she changed my paper grade to an ‘A’), but she helped convince me to finish nursing school and go straight into their master’s program for becoming a nurse practitioner. She was my thesis advisor and the co-author of my first published academic journal article. Within a year of graduating and starting my first job as a nurse practitioner working with homeless and marginalized patients at Cross-Over Clinic, Lorna hired me to teach a community health clinical course.

The other mentor I draw on as inspiration for my current work is another MCV/VCU teacher–from the medical school though–who I only remember as Chaplain Bob. During my first semester of the BSN program, fresh out of a brief stint in a MDiv medical humanities program, I convinced him to let me take his medical school elective course on death and dying. He approached this topic in our small seminar-style class, from a health humanities perspective, having us read and discuss Tolstoy’s The Death of Ivan Ilyich, among other works of art and literature. He also encouraged us to write our own poetry and short stories. I took that assignment seriously and wrote a chapbook-length collection of poetry. Chaplain Bob gave me an ‘Aa’ (not entirely sure what that grade really is) for the course, but he also enthusiastically encouraged me to continue my creative, reflective writing. I kept that chapbook. And here, impossibly at age twenty-two (meaning–not that it is great poetry but that is impossibly so long ago) , I wrote:

The Process

Sitting by the hour/ listening to the drone: “The Patient. The Client./And don’t forget the Significant Others./ By all means, keep in mind the Nursing Process.”

“We’re training you to be/ Professionals./ We want you to think/ Independently./ Here, take this test/But don’t think too much/just fill in the dots/the computer will understand.”

We learn to forget,/ to not feel, to not know./ It will hurt too much,/ and it certainly won’t help /us to be professionals.

and…

Waiting 

Sitting on park benches/writing their hands/trying to forget the ill one inside/that hospital there/ the building you just stepped out of/ the one you walk by every day/ that structure that has become/ a part of the skyline/ seen from the window of a dorm room.

It is a lab/a place to practice/the proper way/to give drugs/ to make beds/to become a nurse.

But reflected in the eyes/of the park-bench individuals/ the building becomes/ one room/one bed/one person/one fear/one hope.

____   To all my mentors, named and unnamed (and in Bob’s case, half-named): thank you. Remember to pass it on.

 

 

 

Prostitution: The Oldest Oppression

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Gloria Steinem/Sponsored by Hedgebrook at Seattle’s Benaroya Hall, 11-8-15. Photo credit: Josephine Ensign/2015

Gloria Steinem reminds us that prostitution is not the oldest profession for women, but rather it is the oldest oppression of women. This is not just some catchy, smart play on words by a feminist icon. It contains powerful truths. It contains powerful truths that affect public health and policy. It contains powerful truths that affect all of us, even if we prefer to think that it doesn’t.

I’m writing this post the morning after TV actor Charlie Sheen publicly announced he is HIV positive, and linked his infection to his history of alcohol/drug use combined with his ‘use’ of prostitutes. (See NYT article “Charlie Sheen says he has HIV and has paid millions to keep it secret,” by Emily Steel, 11-17-15.) Considering the fact that ‘use’ of female prostitutes by heterosexual men is correlated with high scores for men on different masculine hostility measures, it strikes me as ironic that Sheen’s last–and now cancelled– TV series was titled Anger Management.

Hopefully, most people know that prostitution is not the twisted Cinderella Hollywood version Julia Roberts portrays in the movie Pretty Woman. But Pretty Woman was written and directed by two fairly macho men, and it was released in the dark ages of 1990. Surely the portrayal of prostitution is much improved today. But no. Even the women’s rights advocate, TV screenwriter and producer Shonda Rhimes, is woefully disappointing on this issue. I recently watched the first season of Scandal (which Rhimes wrote and produced) in which the main character–the professional ‘fixer’ played admirably by Kerry Washington–puts on her white hat/gladiator woman power suit and successfully defends a Washington, DC high-class escort/prostitution madame, allowing her to retire as a rich grandmother in Boca Raton, Florida.

In my thirty-plus years work as a nurse, I have worked with many young women involved in prostitution. I was always clear that it was sexual exploitation for underage girls, but within the progressive subculture of clinics/agencies I worked in, we called adult prostitution ‘sex work,’ and erred on the side of harm reduction: trying to help minimize the harms of prostitution to the patient and the public. In many ways–as I view it now–we were supporting their lifestyle, enabling it, and becoming part of the problem. I remain a strong advocate of harm reduction, especially as it pertains to drug/alcohol addiction, but not applied to prostitution.

I know prostitutes who call it a profession, who say they freely choose their work. I’d like to believe them because it would make my work easier. But so many prostitutes (female, male, transgender) have histories of previous sexual abuse as children. Their bodies are not their own; their bodies have been stolen from them. In such situations free choice is not possible. This, combined with the growing evidence that prostitution–even in countries where it is legal and regulated (including health screens/care)–is one of the most hazardous ‘jobs’ in the world, has led me to the conclusion that prostitution is the oldest form of oppression. Prostitution is part of violence against women.

So, what to do about it? In my hometown of Seattle, we have begun to adopt the ‘Nordic Model’ of intervention: decriminalizing (and diverting to supportive care, including housing, health care, counseling, job training) prostitution for the women/transgender people involved, and stepping up criminalization efforts directed towards the customers–or ‘Johns’–and the pimps/BackPages/brokers in whatever forms they take. And along with stepping up legal ramifications for the buyers and the brokers, Seattle has innovative programs, such as OPS: The Organization for Prostitution Survivors. OPS has a drop-in center for women, survivor support groups, art workshops for survivors, as well as community-based service provider trainings, and the new Stopping Sexual Exploitation: A Program for Men (SSE).

Last week I visited OPS and talked with OPS co-founder (with survivor/activist Noel Gomez) Peter Qualliotine. Peter has taken the lead in designing and facilitating the SSE workshops. He explained that the SSE program was designed and piloted for two years and then began full operation in January 2015. He receives self-referrals as well as court referrals, and he’s hoping to be able to move it more heavily towards referrals. As he put it “8,000 men a day in King County are customers on BackPage,” so waiting for men to be ‘caught’ by either their wives/partners or the police and referred in to a ‘John’s School’ such as SSE, will not be very effective.

The SSE consists of a telephone intake conversation that Peter has with the men. He uses a motivational interviewing technique and asks the men, “How has this been a challenging time for you?” He said that with the rare exception of a man with psychopathic tendencies (my term here), the vast majority of men soliciting sex feel at least some qualms about it and also suffer negative consequences (sexually transmitted infections, guilt, relationship/legal/money issues).

The SSE program is based on the social-ecological model of violence prevention, and includes information and role-play on gender socialization and manhood training. It’s a support group model of three hour sessions over eight weeks, and is purposefully limited to ten men at a time. So far this year they have had sixty men complete the program, with some of the men so positively affected/changed by it that they have volunteered to help with further advocacy. (Stay tuned, because local and national news coverage on SSE is coming soon.)

Meanwhile, I know many people who work within public health realms in Seattle/King County who continue to advocate for legalizing prostitution, as if it is similar to ‘legalizing’ marijuana. And the otherwise admirable social justice/human rights organization, Amnesty International, is also advocating this stance–although they cleverly call it “protecting the human rights of sex workers.”

White People Have Culture

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“Mauri” or life principle, illustration by Nancy Nicholson in Dr. Rangimarie Turuki Pere’s book, te wheke: A celebration of infinite wisdom. Awareness Book Company, 1997.

The word ‘culture’ is misused and abused. We often use the word ‘culture’ as some strangely polite code word for race and ethnicity, for people who are somehow ‘not like us.’ And those of us white people, part of the dominant culture, typically don’t even believe that we have our own culture–like racism, we can’t see it because of our own power and privilege.

Within health care, we have trainings, courses, (and silly multiple-choice tests) on ‘cultural sensitivity’ and ‘cultural competence.’ As if being sensitive to or competent in this thing called ‘culture’ is possible, and if possible, as if it is a good thing. When what we should be doing is teaching to cultural humility and its Kiwi sister, cultural safety: building in self-reflection, life-long learning, and work to see/undo institutional racism.

I’ve written about different aspects of this issue in previous blog posts: “Cultural Competence, Meet Cultural Humility” (8-16-11), “Cultural Humility Redux” (2-2-14)  and “Cultural Safety: A Wee Way to Go” (3-12-14). Until recently, I much preferred the name/concept of ‘cultural humility’ over the name/concept of ‘cultural safety,’ mainly because I didn’t comprehend the need for the word ‘safety.’ My white privilege comfortable blindness there. But the escalating, deeply disturbing litany of racist violence in our country has forced me to see–duh!–the need for ‘safety.’ My recent return to New Zealand, the birthplace of the term ‘cultural safety,’ also opened my eyes to deeper layers of nuanced meaning of this term, of this work.

Jim Diers, MSW and I co-led an international service-learning study abroad program, “Empowering Healthy Communities,” on the North Island of New Zealand this past summer. We had a group of twenty-two engaged university students, across a range of health science and ‘other’ academic disciplines, and from a rich diversity of self-identified race/ethnicities. As many of them pointed out in their final written reflections, they learned as much from living with our group for five weeks as they did from interactions with New Zealanders. We spent a lot of our time working alongside and listening to community members on various Maori marae (villages), as well as Pacific Islander and other marginalized groups in New Zealand. We learned of their strengths, considerable community non-monetary assets, of their hopes for the future–as well as their challenges and historical traumas…the subtext being the need for cultural safety within health care, as well as within all other New Zealand institutions.

As part of a traditional Maori greeting, people introduce themselves–not by our typical name and credentials/work/university, but rather by details of where you are from: the names of the mountain and river of the land of your family/tribe. So for many members of our group, it was “My mountain is Rainer (or Tahoma as local tribes call it) and my river is the Duwamish (currently an industrial dump/Superfund site..).” And “My people are from Italy, England, Nepal, Mexico, the Philippines (and wait–why ‘the’ with Philippines?–important history lesson of oppression there), China, Israel….” Lovely diversity, except that none of us, unfortunately, could claim Native American/Indian ancestry. We were always asked about that by our Maori hosts–another important history lesson that wasn’t lost on our students. Through participating in this seemingly simple ritual of greeting, we all learned about our own cultures.

At the end of our study abroad program, we received an amazingly powerful talk on cultural safety from Denise Wilson, RN, PhD, a Maori New Zealand nurse and Director of the Taupua Waiora Centre for Māori Health Research at AUT School of Public Health and Psychosocial Studies here in Auckland. She talked to the students about her work with cultural safety in New Zealand–about the need for the ‘cloak’ of cultural safety. She told the story of well-intentioned Pakeha (white/European New Zealander) nurses asking their Maori or Pacific Islander patients, “What are your cultural practices,” and being met with polite, blank stares. “Because that’s our language, our terms, not theirs,” she added. She gently admonished our students to get to know themselves, their own cultures and biases, and to practice humility when working with people they perceive as ‘different’ from themselves–to listen, and “really listening takes time.”

Her closing quote, from Dr. Rangimarie Turuki Pere, whose book I reference in the photo caption in this post, was this:

“Your steps on my whariki (mat)/Your respect for my home/opens my doors and windows.”

Words to live and work by.

BE Uncomfortable

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Sliding doors/front entrance to the Nelson Public Library, South Island, New Zealand. Photo credit: Josephine Ensign/2014

“BE uncomfortable. That’s how you learn!” was one of the final exhortations to our students by Pepe Sapolu Reweti at the conclusion of our”Empowering Healthy Communities” study abroad in New Zealand program this past summer. She was describing the fact that there are many Pakehas (‘white’/European descent New Zealanders) who do not personally know any Maori people, much less ever been on a Maori marae (‘meeting place’ similar to our U.S. Indian ‘reservation’ except that it is the ancestral home of the Maori iwi, or tribes), much much less ever have been in a Maori home. She pointed out that our students had all been on a marae (several, in fact) and had been inside a Maori community meeting house, and had shared ‘kai’ (a meal–several, in fact). That’s an honor and a privilege and something for us to learn from, to take back home–to apply in our own country, in our own daily lives. If the students learned nothing else from this study abroad experience, I hope they learned this.

I was reminded of Pepe’s words this past week as I listened to Ta-Nehisi Coates talk about his latest book Between the World and Me, written in the form of a letter to his son about being a black man in the deeply scarred and racist modern day America. His talk was in the sold-out 2,900 seat McCaw Hall at the Seattle Center, as part of the Seattle Arts and Lectures literary series. The interviewer asked Coates about his article “The Case for Reparations” in the June 2014 edition of The Atlantic, and why he thought it had ‘gone viral’ and been so popular among white people. He replied that he thinks people like the fact he doesn’t sugar-coat things, that “It’s a sign of respect the way I talk directly about things.” And he added, “Reality is uncomfortable. Period.”

Looking around the packed auditorium in one of the whitest cities in America, I wondered how many of us white audience members were now wallowing in white guilt: white guilt which is itself a white self-indulgent privilege. How many of us white Seattleite audience members are willing to push past white guilt to do anything constructive to confront racism in our country, in our city, in our neighborhood, in our own homes? And what are we as health care educators doing to ‘teach meaningfully to’ the effects of personally-mediated and institutionalized racism?

“…as Americans we are so heavily invested in shame, avoidance, and denial that most of us have never experienced authentic, face-to-face dialogue about race at all.” (“To Whom It May Concern” by Jess Row in The Racial Imaginary: Writers on Race in the Life of the Mind edited by Claudia Rankine, Beth Loffreda, and Maxine King Cap, Fence Books 2015, p. 63.) In this same essay, Row states she once saw a book on classroom management for college teachers with the title When Race Breaks Out. “As if it’s like strep throat, as if it has to be medicated, managed, healed.” (p62.)

We need to allow ourselves–and our students–to be uncomfortable, to confront uncomfortable truths in order to learn any lessons that are worth learning.