Where’s the Harm in Harm Reduction?

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Photo credit: Josephine Ensign/2016

Harm reduction, properly applied, is a good public health and individual health strategy. Its focus is on reducing or minimizing harms to the individual, their partners, families, and communities–harms stemming from a whole range of ‘risky’ behaviors. This focus includes providing care in a non-shaming, empowering way, including through the use of motivational interviewing. Harm reduction principles and practices are most well-known for people using drugs and/or alcohol. There is the successful public health practice such as needle exchange in terms of reducing HIV and other blood-borne infections in communities–the lack of which was highlighted recently by the HIV-surge in Indiana. (See the May 16, 2015 NYT article by Carl Hulse, “Surge in cases of HIV tests US policy on needle exchanges.”)  But harm reduction has been applied to other ‘risky’ behaviors, including tobacco adolescent sexual activity, and even for tattoos and body piercings.

I am all for harm reduction and have actively used this approach in my own work as a nurse practitioner for over twenty years. I am proud to live in Seattle-King County that is fairly enlightened in its public health approach utilizing at least some level of harm reduction.

But I have come to see the harm in harm reduction as applied to prostitution. What follows is the story of the evolution of my thinking about this topic, based on my work providing health care to homeless teens and young adults. It is an excerpt of my forthcoming medical memoir, Catching Homelessness: A Nurse’s Story of Falling Through the Safety Net (SWP, August 2016):

“A large number of our youth clinic patients worked in the sex industry as exotic dancers and prostitutes. Most came to clinic by themselves, some were brought in by their pimps, and a few young females came in with their male high school teachers who were fleeing other states on criminal sex charges. I was never sure which I found more despicable: the pimps or the teachers. The prostitutes were mostly young women, although there were also young men and transgender youth. We called it survival sex or just plain sex work, and erred on the side of nonintervention, harm reduction, trying to keep the young people as safe as possible until they could exit “the life.” This was a laudable goal and one I believed in. But in effect there were times we were supporting their lifestyle, enabling it, and becoming part of the problem. We mostly used the neutral term “sex worker” instead of “prostitute,” thinking it was more politically correct, more respectful of the young people involved.

I often asked myself: Is it possible for someone to be involved in commercial sex work and have healthy self-esteem? Is there such a thing as a happy, healthy hooker? Is the character Julia Roberts plays in Pretty Woman based on any sort of reality, or is she just part of a twisted fairy tale? 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 their statements have the off-key clang of the false bravado I know so well, having used it myself over the years. So many young prostitutes 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.”

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.”

Health Care Bucket Lists


Bucket list: a list of things you want to accomplish before you die. Derived from the saying, “kick the bucket,” a euphemism for dying–although no one seems to agree on the derivation of “kick the bucket.”

I recently ran across my own bucket list that I wrote when I was twelve years old. I wrote it as part of a seventh grade creative writing assignment. My mother kept all of my childhood writing and presented the packet to me before she died–something for which I am eternally grateful. My short stories about toothbrushes coming to life give me glimpses of my younger self that cannot be accessed through any other medium. Here is my bucket list at age twelve:

  1. Own a pair of sandhill cranes
  2. Have a zoo where all the animals can run free
  3. Have a greenhouse as big as a football field
  4. Learn to ride a unicycle
  5. Go to Australia
  6. Keep an otter
  7. Build my own house over-looking a lake
  8. Write a children’s book

I believe that I wanted to be a writer, a naturalist, or a veterinarian–most definitely not a nurse. My favorite books were (not surprisingly by my bucket list), Aldo Leopold’s A Sand County Almanac and Gavin Maxwell’s Ring of Bright Water.

What would my bucket list, my hopes for the future of health care be like? Since I am no longer young and idealistic, my health care bucket list comes out sounding way too jaded and cynical. So I turned to question to my younger and hopefully still idealistic senior nursing students. “What are your hopes for health care?” was my specific in-class reflective writing question to them a week or so ago. I asked them to write out a list of their top ten hopes.

Out of the 140 or so students, the vast majority listed some version of “universal access to quality and affordable health care.” Another frequently listed item was “provision of culturally humble health care,” as well as “eliminate racism in healthcare.” Many included ‘an emphasis on community-based primary health care,” and “more funding for public health.” Improved patient safety efforts, especially through good interprofessional health care team communication and safe nurse-to-patient ratios in hospitals, was a top-listed item. Closely related to that was “improve working conditions to reduce nurse burnout.” Improved access to better mental health services (including the astutely stated question “why are mental health units so ugly?”) and reducing stigma for mental illness and substance use issues, were also frequently mentioned. “Improving end-of-life and beginning-of-life care” as a way to improve quality of life as well as better use of our health care dollars was another top choice.

Here are some additional student ‘hopes for health care’ that make my heart sing and that give me more than a bucketful of hope for the future of health care:

  • To see the person, not the illness.
  • To create a nursing image that represents our smarts and not just our compassion (and nurses aren’t asked, “why didn’t you become a doctor?”)
  • To have more nursing involvement in policy change. Use my knowledge of the challenges faced by my patients to inform policy advocacy.
  • To ensure that ‘the least among us’ receives the best care possible, and “that I am courageous and prepared enough to advocate for the least among us.”
  • That we realize our patients have backstories that need to be recognized in order to provide the best care for them.
  • Full scope-of-practice for nurses uniformly across the country.
  • I hope I still have hopes for the health care system.

I am a Nurse, Just a Nurse

11164759_1057759667571978_8700043668876075012_nFor many years, whenever anyone said to me, “Oh! You’re a nurse,” I would correct them and say, “No, I’m a nurse practitioner.” Why? As if identifying myself as a nurse was somehow beneath me? As if being a nurse practitioner meant I wasn’t really a nurse, or I was more than a nurse because I could diagnose and treat medical problems, something nurses can’t do? As if I was too intelligent to be ‘just’ a nurse?

I was not born to be a nurse; I was not called to be a nurse. I didn’t need multiple-choice tests and multiple sessions of career counseling at pivotal junctures in my life to tell me these facts. What with the Myers-Briggs Type Indicator, the Strong Interest Inventory, the Eureka Skills Inventory, and the Holland Personality test results, my career counselor proclaimed, “You don’t have the personality, the interests or skills test results to match nursing.” It seems I was meant to be a writer. Oops. Too late. When she told me this I had already been a nurse/nurse practitioner for over thirty years. Of course, it was my job as a nurse practitioner and nurse educator (and most definitely not as as an unpaid writer) that allowed me to take these expensive tests in the first place.

But oh the places nursing has taken me! If I had it all to do over again, if I didn’t have to worry about being a single mom earlier in my career trying to earn a decent income, if I could choose any of the health professions to ‘become,’ I would choose to be a nurse. I would choose to be the ambivalent, skeptical, social-justice minded, community/public health-focused nurse that I am. Last summer I reflected on where community health nursing has taken me, and I made this short digital storytelling video: “My Story of Community Health Nursing.”  Even though this was my first video, and I see that it is clunky in places, I revisit/re-watch it on occasion to remind myself of who I am, and of why I love to do the work I do–including teaching nursing students and encouraging them to consider becoming a community/public health nurse.

The photo included in this post is a ‘retouched’ photo of a University of Washington School of Nursing promotional placard reading “I am a #huskynurse.” It’s not that I’m opposed to proclaiming myself an over-sized, plump nurse. But I am opposed to being a (branded) nurse. I am an–unqualified– nurse. I am a nurse. I am a community/public health nurse.

Happy National Nurses Week and Happy 195th birthday to Florence Nightingale!


“Just a Nurse” is used with a nod to the work of Suzanne Gordon, a journalist who writes about/is a longtime advocate for nursing.

Cross-over Clinic: Church and State

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Cross-Over Clinic/The Richmond Street Center May 1986/Josephine Ensign

Health and Homelessness in Richmond, Virginia in the 1980s: The clinic I worked for at the Richmond Street CenterCross-Over Clinic*—was started by physician Cullen Rivers and his Presbyterian church friend, the Reverend Judson “Buddy” Childress. Buddy had been a life insurance salesman before going to seminary.  His ministry was to business and professional people, as he said: “linking the talents and resources of suburban Richmond to the needs of the inner city poor.” For two years before the Street Center clinic opened, Cullen and Buddy had run a Saturday health clinic out of a downtown Richmond storefront apostolic church.

Balding, with long sideburns as bookends around a serious, intelligent-looking face, Cullen was prone to wearing cardigans. He was practical and caring in a genuine way, one of those people with a quiet personal faith you wouldn’t mind having yourself, even if you were agnostic. Some people have a loud, yelling at you through a megaphone, obnoxious sort of faith. He wasn’t like that, and it was one of the things that attracted me to Cross-Over Clinic. That, and the fact that he and Buddy were trying to provide free basic health care for poor people. Cullen was my main medical back-up, available to me by phone for questions; he exuded an unflappable, competent demeanor, as well as respect for me as a nurse. Buddy convinced the local Sisters of Bon Secours to pay my salary. I was the first employee of Cross-Over Clinic and began my work at the Street Center in May 1986 (photo is of me on the first day of clinic).

Over the nearly four years that I worked at Cross-Over Clinic, I grew as a health care provider and as a person. I was the sole health care provider M-F at the clinic for the first three years, before a Health Care for the Homeless grant (with the Daily Planet as lead agency) allowed Cross-Over Clinic to hire Dan Januzzi as a full-time physician. Cullen and other volunteer physicians and dentists came in on Saturdays to provide care for the more complicated patients.

Nurse-run clinics were rather frowned upon in Virginia (and still are), and less than six months into beginning my work, the Virginia Health Regulatory Board opened an investigation of my ‘too independent’ practice. I’ve written about this experience in a previous blog post, “Not Just Culture” (11-19-11). And, as I’ve written before [see my recent “No Place Like Home(less)” in Pulse: Voices from the Heart of Medicine], even though I was never charged with anything, the stress of the 18-month long investigation into my practice contributed to the loss of my faith, job, family, and home: I spiraled into homelessness.

It didn’t help that when Buddy became the clinic director during my final months there, he admonished me not to refer women for abortions and to council patients with HIV to repent of their sins. When I refused, he put me on a mandatory leave-of-absence to be spent in ‘prayer and reflection to ask for a humble and teachable spirit.’ He also admonished me to return to church and to my husband from whom I was separated. The Cross-Over Clinic lost the Health Care for the Homeless grant funding due to issues of–shall we say–lack of appropriate separation of church and state. The Cross-Over Board also decided to focus its mission on the ‘working poor’ rather than on the homeless population. I did not part from Cross-Over Clinic on the best of terms.

Several years ago I decided to revisit Cross-Over Clinic to see what they’re up to and perhaps to try and heal old wounds. I was scheduled for an interview and site visit with Dan Januzzi, still the Medical Director of the clinic. Dan and I hadn’t parted well, but he was friendly and welcoming on the phone when I talked with him to schedule a visit. He is committed to what he calls poverty medicine, charity care medical practice focused on indigent patients.

I drove down Belvidere Street, past the corner where the Street Center had been, and across the James River. In amongst rundown Pentecostal churches, greasy car repair shops, and towing companies, sits Cross-Over Clinic. The building looks like it might have been a used-car dealership. Printed signs greet you when you enter: “We are sorry if you have to wait to see us. Thank you for your patience,” and, “Cross Over does not receive direct government funding. Our services are possible through funding by the community.”

The waiting room was small and cramped, with fifteen or so patients already seated. I checked in at the front desk and was told to have a seat. At first I was irritated, then amused, sitting there in the waiting room of a clinic where I had once worked–in a clinic that had changed my life so profoundly. A woman seated next to me started cussing loudly at no one in particular about the long wait times. After an hour of waiting I decided I had experienced enough; I left and have not returned.

From public records, I discovered that Cross-Over Clinic has an annual budget of $2.5 million, and receives an additional $2 million of in-kind donations: doctors, nurses, dentists and pharmacists volunteer for Saturday clinics—they call these “mission trips that you don’t have to leave the country for.” A local private hospital does $800,000 of clinic lab work per year free of charge and the hospital uses it as a tax write-off. VCU/MCV Medical Center (one of my alma maters) sends nursing, pharmacy, and medical students to assist with clinic. Cross-Over sees about the same number of patients per year as the Daily Planet clinic, although they include outreach screenings in churches by lay volunteers in their patient numbers.

Virginia has the second highest number of free clinics in the country. North Carolina has the most, and Georgia is close to Virginia’s number. Most free clinics, like Cross-Over, are faith-based, and since George W. Bush’s Faith-Based Initiative, are legally able to discriminate in provision of services and in hiring (and firing) practices. George W. extended his father’s campaign to blur the separation of church and state.

I find it ironic that the principle of the separation of church and state had its founding in the U.S. in 1786 less than a mile from the Richmond Street Center, at the Virginia General Assembly, when they voted in favor of Thomas Jefferson’s Virginia Statute for Religious Freedom. This statute was the forerunner of our country’s first amendment protections in religious freedom. Part of Jefferson’s statute stipulated that no person could be compelled to attend any church or to support it with taxation.

President Obama promised to reverse the erosion of basic civil rights (and the erosion of separation of church and state) from the Faith-Based Initiative, but so far, he has not done so. U.S. Congressman Bobby Scott from the 3rd District in Virginia, which includes Richmond, is trying to address this issue. He is the first African-American congressman from Virginia since Reconstruction, and he has an excellent ‘Faith-Based Initiative’ information page along with an explanation of how it allows discrimination based on race, gender (and, I would add–sexual orientation), as well as on religion.

While I don’t agree with how I was treated as an employee of Cross-Over Clinic, and neither do I agree with their principles of ‘poverty medicine,’ I know that many Richmonders view Cross-Over clinic as an essential part of their health care safety net. Which is probably true given the fact that Virginia has an extremely ‘hol(e)y’ health care safety net [see previous post: “Got Medicaid (Expansion) Virginia?” from 6-20-14).

* The clinic was called/spelled ‘Cross-Over Clinic’ when I worked for them. Since then, they have variously called themselves ‘Cross Over Clinic’ and ‘CrossOver Clinic.’

Radical Hat-Burning Nurses Unite!

IMG_1082Radical nurses are back, or perhaps they never left and are just becoming more visible, more organized. The photo here is of my nurse’s cap-wearing trained seal mascot given to me by a friend in nursing school–who promptly dropped out of school because she was too radical for them.

There is the Radical Nurse on Facebook (aka Rebekah Dubrosky, RN) who says of herself, “Radical nurse goes to graduate school with hopes of starting a nursing revolution!” Her profile photo is of the formidable radical nurse and mother of public health nursing, Lillian Wald. Ms. Dubrosky is a doctoral student in the College of Nursing at the University of Wisconsin/Milwaukee. She just published a very good article “Iris Young’s Five Faces of Oppression Applied to Nursing” (Nursing Forum vol 48(3):205-210, July/Sept 2013).

There is the newly-formed Rebellious Nursing! group, which had its first national conference this past fall in Philadelphia. They state: “We believe that Nursing is an inherently political profession and that all nurses are rebellious.” I’m not sure I agree with their tag line, but I do love their logo of a white nurse’s cap going up in flames. An extension of the bra-burning second wave feminists and the corset-burning first-wave feminists. The third-wave feminists seem to have nothing left to burn so they’re putting the push-up bras and corsets back on. (Just kidding. Don’t burn me all you wonderful third-wave feminists–including my former nursing student who introduced me to Rebellious Nursing!).

Going back to the second-wave feminists, there was Casandra: Radical Feminist Nurses Network from the 1980’s. Some of their old newsletters are on Peggy Chinn’s blog, NurseManifest. Peggy Chinn, RN, PhD, is Professor Emerita, University of Connecticut, but she will never truly retire.

There were also Radical Nurse Groups (RNGs) active in the 1980’s within the UK. A nurse blogger who goes by the pseudonym Grumbling Appendix (gotta love British humor) and who works in an NHS hospital (hence the need for a pseudonym), is now archiving material for the RNG’s. In the recent post in the New Left forum, Grumbling Appendix makes the observation that some things have not changed much. I love the Radical Nurses Archive: So….Just How Radical Are You? It includes a funny-sad multiple-choice test from 1982 (when I graduated from wretched nursing school wearing a wretched nurse’s cap), although I need a Brit to help interpret the final scoring scheme.

For an amazing blast from the past that is also sobering in terms of how little things have changed, take a look at the 20 minute film The Politics of Caring from 1977 (produced, directed, and edited by Joan Finck and Timothy Sawyer in collaboration with Karen Wolf, RN.) It is posted on Peggy Chinn’s NurseManifest blog. The only difference between then and now that I see is that the nurses then were still wearing white nurse’s caps (non-flaming) and white dress uniforms (and oh my! those disgusting thick white opaque pantyhose that kept the oh my! pubic hairs from dropping off onto the operating room floor!) There’s something about ‘radical’ and the use of exclamation points….

In the film they begin by saying that while nurses are the largest component of the healthcare workforce they have the least say in health policy. Familiar? They discuss the disconnect between what is taught in nursing school about providing quality of care, and the reality of what is possible within the practice environment. (I hear this from my students all the time). They also question whether nursing can even be called a profession when the majority of nurses don’t have control over their work environments. And they discuss the tensions within nursing with the then newly-emerging role of advance practice nurses/nurse practitioners, pointing out (somewhat rightly so) that these ‘new nurses’ were mainly working within the medical model of care.

As a community health nurse I was fascinated to hear the nurses in the film talk about “the mecca of community nursing” as a place where nurses could practice ‘real nursing’ focusing on health prevention and promotion within the nursing model of care. Community health is what attracted me to nursing in the first place and it continues to be what I love most about my work. But we need hospital nurses and there are nurses who love working in hospitals and don’t want to have to ‘trade up’ to community health, or to become a nurse practitioner or a nursing professor in order to have greater control over their working conditions. Besides unions and Radical Nursing! groups, what is there for them?

Back to the Future of Nursing

wierdflightattendantsBack to the Future of Nursing: A Look Ahead Based on a Landmark IOM Report, part of the Rosenthal Lecture Series, was held today at the National Academy of Sciences in Washington, DC. The panel discussion focused on progress made in the past three years since the release of IOM report The Future of Nursing: Leading Change, Advancing Health (FON). The webcast recording of the event will be posted soon. Check out their infographic poster which is quite nicely done.

Some of the highlights that I picked up on during this panel discussion included efforts to increase diversity in nursing as well as career mobility, and national efforts to increase scope-of-practice for nurse practitioners. Currently there are 17 states that allow nurse practitioners to be fully independent and two additional states that allow nurse practitioners to be ‘almost’ fully independent (Maryland and Utah). In the past three years seven states have removed major barriers to practice, and Nevada recently gave nurse practitioners full practice authority. Opposition by state medical organizations blocked passage of similar bills in Connecticut, Kentucky, New York, and most recently in California. But the momentum is growing in favor of independent practice for nurse practitioners across the country. The Federal Trade Commission is challenging limits to nursing scope-of-practice in many of the recalcitrant states (including, I hope, my home state of Virginia).

At the end of today’s lecture there was an excellent televised address by Rissa Lavizzo-Mourey, MD, who is the director of the Robert Wood Johnson Foundation (sponsor the FON report and follow-up efforts). Among other things she spoke of the need to change the “caste system in hospitals” that treats nurses as second-class citizens. That seems to be a daunting task.

I have read the entire IOM FON report several times and think it is an excellent document. (Previous blog post Undoing Nurses as Functional Doers Nov 24, 2010). Of course, being a primary care nurse practitioner myself with previous run-ins with state health regulatory boards over scope-of-practice issues (see To Forgive, Divine blog post), I have been cheering the efforts in this area spurred on by the IOM Future of Nursing report. And being a nurse educator who loves teaching (and who abhors most approaches to nursing education–another nursing care plan anyone?), I applaud the IOM/FON report section on changes needed within nursing education.

So what has changed for me in the past three years since the IOM FON report? Many faculty members invoke the FON report from time-to-time when making various points about needed changes in the curriculum. Not many of our current students have even heard of the report (shame! I need to assign parts of it as required reading). I’ve seen a large uptick in the support for interprofessional educational experiences for students and faculty. And I’ve seen an increased emphasis on adding leadership content as well as political advocacy skill-building activities for students within our various programs (although there’s still a shameful paucity of resources and nursing role models in these areas). The other thing that bugs me in the area of politics and policy education for nurses is the emphasis on self-advocacy for nursing practice. While that’s important, nurses can and should be using their advocacy skills and energies for less self-serving health policy changes.

Nurses Go Where Doctors Don’t

Mary Breckinridge Statue
Mary Breckinridge Statue (Photo credit: jimmywayne)

One of the most e-mailed NYTarticles/blog posts over the past twenty-four hours was Tina Rosenberg’s Opinionator/Fixes post “The Family Doctor, Minus the M.D.” (10-24-12). In her online article, Ms. Rosenberg focuses on the expanding role of nurse practitioners in providing cost-effective, accessible, comprehensive, and quality primary health care—especially in rural and underserved urban areas of the U.S. where physicians typically do not want to work. There is already a severe shortage of primary care physicians in the U.S., a shortage slated to grow with the ‘perfect storm’ of the aging/chronic disease-challenged population combined with Obamacare’s expanded coverage of previously uninsured patients.

Ms. Rosenberg, who is a journalist and contributing writer for the NYT Magazine (and not a nurse), points out that nurses “take a different approach to patient care than doctors(…)”—and that nurses’ more holistic approach to patient care is particularly useful in the management of chronic disease, especially in patients with complex socio-economic barriers to care. She included organized physician resistance to nurse practitioner-run clinics, citing a recent position statement by the American Academy of Family Physicians in which they oppose independent practice by nurse practitioners. Ms. Rosenberg points out that in sixteen states plus Washington, D.C, nurse practitioners have complete independence. (Of course, what she left out is the fact that nurse practitioners have to maintain their RN license; as RNs they are independent practitioners within commonly accepted nursing functions.)

It is a well-researched and well-written article. Perhaps equally interesting are the reader comments—all 295 of them. Unlike local newspapers, the NYT carefully moderates all reader comments. They screen them before allowing posting of only the “thoughtful, civil and articulate” ones. Most of the comments to this article were on-topic. There were the usual vitriolic negative comments by some physicians about care by nurse practitioners being “second rate care,” and how nurse practitioners were dangerous unless “under the direction of a fully trained and clinically seasoned M.D. or D.O.” There were the physician assistants weighing in with “what about me?!” and saying that since they were trained under the medical model they provided superior health care compared with nurse practitioners. There were patient testimonials (for and against) care they received by nurse practitioners. There was an off-topic comment about how all nurses are into narcotic diversion and are addicted (Nurse Jackie, you brought on this misconception). And there were more than a few comments about how professional “turf wars are only hurting the patients and the nation.” I agree with that sentiment. I also am glad to see a healthy debate about the need for more primary care providers in the U.S., as well as about the important role that nurses can (and do) play in our health care system.

Becoming a Nurse: The Book

Creative Nonfiction’s anthology is currently in press and due to be released March 12, 2013. The book’s full title is I Wasn’t Strong Like This When I Started Out: True Stories of Becoming a Nurse (Lee Gutkind, editor/In Fact Books).

Here is the official book blurb:

“This collection of true narratives reflects the dynamism and diversity of nurses, who provide the first vital line of patient care. Here, nurses remember their first ‘sticks,’ first births, and first deaths, and reflect on what gets them though long, demanding shifts, and keeps them in the profession. The stories reveal many voices from nurses at different stages of their careers: One nurse-in-training longs to be trusted with more ‘important’ procedures, while another questions her ability to care for nursing home residents. An efficient young emergency room nurse finds his life and career irrevocably changed by a car accident. A nurse practitioner wonders whether she has violated professional boundaries in her care for a homeless man with AIDS, and a home care case manager is the sole attendee at a funeral for one of her patients. What connects these stories is the passion and strength of the writers, who struggle against burnout and bureaucracy to serve their patients with skill, empathy, and strength.”

Lee Gutkind, dubbed by Vanity Fair as the godfather of creative nonfiction, is currently Distinguished Writer-in-Residence at Arizona State University’s Consortium for Science, Policy and Outcomes—where, among other things, he is “(…) helping scientists, engineers, nurses, lawyers, philosophers, etc share what they know with a general audience.” (Creative Nonfiction blog post 7-7-08).

In Fact Books is the new book imprint of the Creative Nonfiction Foundation. They have published two books this year: An Immense New Power to Heal: The Promise of Personalized Medicine(Lee Gutkind and Pagan Kennedy), and At the End of Life: True Stories About How We Die(Lee Gutkind, editor). Gutkind has a special interest in the narrative of medicine, beginning with his 1990 book Many Sleepless Nights: The World of Organ Transplantation (U. Pittsburg Press). In the introduction to the anthology he edited, Becoming a Doctor: From Student to Specialist, Doctor-writers Share Their Experiences (Norton/2010), Gutkind marvels at how there are so many writers who are doctors and doctors who are writers.

I look forward to reading Gutkind’s introduction to the “Becoming a Nurse” anthology, specifically how he addresses the paucity of nurses who are writers/writers who are nurses. Gutkind was reportedly surprised that they did not receive a flood of submissions for their “Becoming a Nurse” anthology, and wondered why there weren’t more nurses who write about their work.

I can think of many reasons why there are not more nurses who write (see my blog post “Nurses and Writing: Writers and Nurses” 3-31-11). Besides the fact that nursing is a servile, mainly female, “functional doer” profession that doesn’t require a basic four-year liberal arts education, nurses who want to write about their work are bullied out of it by their bosses. Quite frequently I hear from nurses who are writers (or who want to become published writers) that they have been threatened with termination by their employers if they continue to write about their nursing work—even when they are appropriately changing details in order to protect patient privacy. Because of the differences in professional power dynamics and the rigid hierarchy within the health care system, doctors who are writers do not have this barrier to writing—or at least not to the same extent.

But what that means is that Gutkind’s anthology on “becoming a nurse” is all the more important a contribution to the growing field of narrative medicine/nursing/health care. The book serves as a platform for a total of 21 nurses from around the world to tell their stories about what it means to become a nurse.

Transparency here: my essay “Next of Kin” is included in the anthology. My essay is the “a nurse practitioner wonders whether she has violated professional boundaries in her care for a homeless man with AIDS” in the book blurb. Thanks to a grant from 4Culture, I was able to complete the site visit/research for my essay (and book from which this essay is taken) last fall, in time to submit it to Creative Nonfiction.

At 320 pages and retailing at $15.95, the book I Wasn’t Strong Like This When I Started Out: True Stories of Becoming a Nurse ( is available for pre-order from your favorite bookstore—like mine here in Seattle: Elliott Bay Book Company. And if you live in (or want to travel to) the Seattle area, stay tuned for information on several group readings/presentations by some of the authors from the anthology—at Elliott Bay Book Company and at the University of Washington Health Sciences Library. Both events are still in the planning stage and will most likely be in mid-March.

Not Just Culture

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The following is an essay I recently wrote about the health professions regulatory system in the US. It is written in the format for Narrative Matter’s “narrative policy” essay, and as such is longer than my typical blog posts. Please share widely, with proper attribution, of course…. I want to thank Morris M. Kleiner for reviewing drafts of the essay for accuracy.

One evening this past April, I was sitting on the floor of O’Hare airport, near a packed gate, waiting to board my flight back home to Seattle. Headphones on, working on my laptop, I clicked on the Seattle Times news site. “Nurses’ Death Follows Tragedy,” was the title of the lead story, with the byline summary, “The suicide of Kimberly Hiatt, a nurse who accidentally gave an infant a fatal overdose last year at Seattle Children’s hospital, has closed an investigation but opened wounds for her friends and family members.” (Carol Ostrom, The Seattle Times, 21 April 2011)

I read the brief article, and then stared at the ubiquitous overhead TV screens in the waiting area, wondering why her death wasn’t included in the endless loop of news. Kim’s story seemed weighty—national in scope. Kim was 50 when she died from hanging herself. She had miscalculated a medication dosage for a medically fragile infant, and immediately reported her mistake. This was the first serious medical error Kim had made in her 25-year career. An official medical report stated it was unclear that the medication error contributed to the infant’s death. But the hospital fired Kim. And the Washington State Nursing Quality Assurance Commission—the sate nurse licensing unit—fined her $3,000 and placed such severe restrictions on her nursing license that she could no longer find employment as a nurse.

In the weeks following news of Kim’s death, I was left wondering how this could have happened—not the medical error—but the cascade of negative consequences for Kim. I thought I knew how health systems worked; I had a doctorate in health policy. And I was convinced that Washington State had a progressive health professions regulatory system—that things like this couldn’t happen here—or now.

The week after Kim’s death hit the news, the topic of my health policy class was quality of care. I planned to talk about just culture: having open, fair, and just organizational cultures supportive of patient safety. There is strong evidence indicating that just cultures are more effective at ensuring patient safety than are traditional punitive health care work climates. Kim was an alumnus of the nursing school where I taught. Most of my nursing students were graduating in a month and would obtain their Washington State nursing license. Our class discussion was no longer at the theoretical level.

But I had a more personal connection with the news of Kim’s death: I was seeking closure to an investigation of my own nursing license by a health regulatory board. I was seeking both emotional and literal closure. For the past year, I had been writing a book about my work as a nurse practitioner providing health care to homeless people in the 1980s. Back then, my life and my career had been derailed by a collision with a state licensing system.

Early in my career as a nurse practitioner, I had my nursing license investigated by the Virginia Health Regulatory Boards of Medicine and Nursing. At the time, I was the sole provider at a clinic for Richmond’s homeless population. I was working within written protocols with a supervising physician available for telephone consultation. This was in compliance with the practice regulations in Virginia. In my second year of working at the clinic, I had an unannounced visit by an investigator for the Health Regulatory Board. I remember the day—and him—vividly.

I noticed an older man walk into the waiting room of the clinic. His shoes were what I noticed first: beige puffy comfort shoes with Velcro straps. He pulled out a business card and handed it to me.

“ I’m doing an investigation of a complaint made to the Boards of Medicine and Nursing about your practice.”

I was stunned. My mind raced through worst-case scenarios: had I killed a patient?

“What complaint? And where did it come from?” I asked.

“I can’t tell you that information. It was requested to remain anonymous. I’m just gathering information for my supervisors.”

He asked to see my patient files and medication dispensary. He stayed for several hours, interrupting clinic.

The health regulatory board investigation of my nursing license sent destructive tentacles—like mold hyphae—throughout my life. The process of the investigation remained unclear to me. I was told they were investigating my scope of practice, including prescribing of medications. Fear was the first thing I felt: fear verging on terror. The most immediate threat was the potential loss of my nursing license. This would have devastating effects on my family since my salary supported all of us. My husband was still in seminary, and I was paying for childcare for our then five-month-old son so I could work and my husband could finish school. An additional threat was the loss of my professional reputation: people assume there are valid reasons for an investigation.

For several months after the investigator’s initial visit, I couldn’t sleep well. I lost so much weight that I had to stop nursing my baby before he was six months old, and that made me feel even more guilt as a working mother. My husband and I got in spats. Due to the ongoing investigation, I was forced to work at the clinic in reduced capacity. The Health Regulatory Board kept threatening to close the clinic, and they finally did for several weeks in the eighth month of the investigation.

The Board of Directors for the clinic where I worked responded to the investigation by increasing their efforts to hire a full-time physician. No physicians were clamoring to do this work. The clinic Executive Director enlisted the help of a volunteer lawyer who talked with lawyers at the Virginia Office of the Attorney General, who advised the Health Regulatory Board. No one seemed to know what nurse practitioners could and couldn’t do. I was told it was a contested area of state law, and that they had never had a nurse practitioner as the only health care provider for a clinic. Even at the time, I knew I was a pawn in the grand political game of professional turf battles.

I was treated as if I were guilty until proven innocent. Investigators and lawyers told me not to talk to anyone about the situation or it could make the outcome worse—effectively issuing a gag order and isolating me from seeking help. More recently, I’ve asked myself why I didn’t get my own lawyer back then. No one advised me to and I couldn’t afford one. There were large gaps of time of not hearing anything about the investigation, but I was always aware that it was unresolved, like a large noose dangling above my head that could come down around my neck at any time.

The stress of the investigation contributed to the dissolution of my marriage, loss of my job, and my own spiral into homelessness. I seriously contemplated suicide on several occasions during the investigation. It was such a painful chapter of my life that I had not been able to look at it before—or talk about it.

Twenty-five years later, as I was writing a book about my work with people experiencing homelessness, I wanted to include the investigation of my license. I realized I had no documentation on it. When I read the news of Kim’s death in April of this year, I was awaiting a reply from the Virginia Board of Nursing to my written request for a copy of my case file. I had expected some resistance, but was confident I would eventually see copies of the investigation. I asked for redacted records: I was not interested in knowing who had ratted on me.

Jay Douglas, the Executive Director of the Virginia Board of Nursing, refused my request. In a telephone conversation with me in late February, she stated that they were confidential records, “Board property, and besides, Virginia’s Freedom of Information Act doesn’t apply to people who are not state residents.” This made me angry: confidential records on me by a government agency that I wasn’t allowed to see? This wasn’t a matter of national security; I wasn’t a terrorist. And freedom of information—the right to a transparent and accountable government—only applies to certain citizens? I studied the relevant laws and wrote a polite rebuttal based on the Code of Virginia. While I waited for her reply, I began to do more research on health care workforce regulatory systems. Between my own experience and that of Kim Hiatt, I wanted a better understanding of how these systems worked.

Health Care Workforce Regulation

All states in the US license health care professionals, as well as an increasing number of other occupations ranging from architects to wrestlers, and even frog farmers. These are labor market institutions, administrative agencies with executive, legislative and judicial powers, ostensibly under public mandate to protect public health and safety. According to economist Morris M. Kleiner in Licensing Occupations: Ensuring Quality or Restricting Competition? (Upjohn Institute Press, 2006), they are self-policing, self-regulating bodies, and have been identified as state-sanctioned monopolies. The most autonomous units of state health care licensing systems—medical boards—have been formed by powerful professional associations and their lobbying arms which make large campaign contributions to state legislators. Many state legislators who serve on health subcommittees, which make the health care workforce regulations, are themselves health care providers and members of the professional organizations “funding” state regulatory systems.

But do these state health regulatory systems really protect public health? While there may be the perception of protection from ‘charlatans, quacks, sexual predators and drug abusers,’ it is not supported by data. Kleiner points out that there are no data to support improvement in overall quality of health care by state health regulatory systems. There is some indication that higher-income people gain from stricter health professions licensing, but there is no measurable impact on overall quality of health care for the population as a whole. There is robust evidence that by effectively limiting supply, licensing of health professions increases overall health care costs, and creates longer wait times for health care services. This worsens health inequities in the US. In addition, licensing laws that standardize health care services effectively restrict innovation and improvements in the health care system. Health care workforce regulatory systems in all states are notoriously inefficient, with many taking over two years to investigate and resolve even the most serious of cases. There are wide inconsistencies between the different health professions licensing boards in how they discipline individual health care providers for similar infractions, as well as inconsistencies between states.

The Pew Health Professions Commission Taskforce on Health Care Workforce Regulation—a national, nonpartisan panel of experts—issued a series of reports in the late 1990s’. They called this a significant public health policy issue that flies under the radar. They stated there is a lack of oversight and accountability of the state regulatory systems, as well as a lack of effort to provide consumers access to information on health care providers’ practice histories. They called for national scope-of-practice standards, as well as consideration of changing from licensure to certification of health care providers, which is more likely to improve overall quality of care while not driving up health care costs. According to the reports, the next best alternative to a certification system would be to appoint more neutral parties as the decision makers on licensing boards, with members of the profession available to advise board members on technical issues.

None of the major Pew Commission recommended changes have been made. Instead, there have been incremental reforms, including improved websites, and uniform sanctioning guidelines, which sound good in theory, but have not proven to be effective in practice. According to Kleiner and the Pew Commission experts, powerful professional associations that helped create the licensing system in the first place, benefit from its continued existence. Higher income health professionals benefit from limiting supply by restricting competition, thus boosting their own salaries. Administrators at universities and technical schools support its continuance, since their institutions benefit financially from licensing requirements tied to entry and continuing education. And the current state licensing system continues because the risk-averse voting public has been repeatedly told it is an effective system protecting them from harm by sorting out the “bad apples” of incompetent, impaired, immoral health care providers.


Ms. Douglas informed me that without a court order she refused to provide a redacted copy of my individual case file. It took hiring a lawyer to convince her to provide a copy of the Case Decision Memorandum for the investigation of my nursing license. Dated February 13, 1989, the memo stated that if I continued consulting with my supervising physician as reported, no further action would be taken. It concluded, “There have been no further complaints or problems and the case is closed with no violation and no sanctions.” The memo confirmed that it had been a scope of practice issue, and that the Medical Board had wanted tighter reign on my nursing practice. What surprised me though was the date of the memo. While I had remembered the investigation as being a painfully long process, I hadn’t realized it took 16 months. My husband and I had separated a few days before the official closure of my case. And by that time I was disillusioned with nursing and with our health care system.

Ironically, the same week I received the one-page Case Decision Memorandum, I received 1,500 pages of redacted, detailed information on the case of Kimberly Hiatt from the Washington State Health Department. I requested Kim’s files in order to better understand the current decision-making process of the Nursing Commission in a state where I am responsible for teaching nursing students health policy. And in a state where I maintain nurse and nurse practitioner licenses. Reading through Kim’s records only deepened my distrust of the health professions regulatory system. The Washington State Nursing Commission refused the request by Kim’s lawyer for copies of their investigative reports in order to adequately advise his client.

I remind myself that Ms. Douglas and others in the health regulatory system are well-intentioned people who believe their work promotes public health and safety. But the system they work within is not part of a just culture. The current regulatory system is not working to protect public health and safety. It is not working for the majority of health care providers, who justifiably view it as capricious, punitive, and with little oversight or accountability. If we are to have a higher quality and more equitable health care system in our country, it is essential that we reform the byzantine health professions licensing system.