An ethnographic study of the work of nurse practitioners at an outpatient care facility shows how these medical professionals must endlessly multitask to fill gaps in the US social safety net. In the context of the COVID-19 pandemic, a new focus on the essential work of nurses and the lack of resources with which they often contend is especially timely.
More Than Medicine: Nurse Practitioners and the Problems They Solve for Patients, Health Care Organizations, and the State
by LaTonya J. Trotter
Cornell University Press, 2020
A woman stands alone on a street corner in Harlem, her hospital scrubs just visible under her unzipped puffy winter jacket. The long shadows of early April stretch along the empty sidewalk and brick buildings behind her. The streets are eerily quiet for this time of the morning. Her brown eyes appear tired but determined as she looks over the blue face mask, straight into the camera’s lens. So, she is not alone after all. Someone has stopped to help her out and take a photo of her cardboard sign, with its message written in a precise but hasty script: “Please don’t call me a hero. I am being martyred against my will. Defense Production Act Now!”
During the early days of the coronavirus pandemic, this emergency room nurse, Jillian Primiano, became a meme. Fed up with the helpless gestures of performative gratitude and virtue signaling perceived in their neighbors' nightly applause for medical professionals while frontline health care workers and their patients were getting sick and dying of COVID-19, Primiano and other New York City nurses took to the streets and social media to protest that their lives were being sacrificed to the political interests of the White House.
In an interview with Slate, Primiano explained the motivation behind her meme-worthy sign. She made it at 7 a.m. before going to the protest to stand in solidarity with other nurses who didn’t have adequate personal protective equipment (PPE), because “[i]f it’s happening to one nurse, it is happening to all of us.” She bristled at the “wartime rhetoric” of calling nurses heroes because it implied that “the deaths of health care workers and the illnesses of health care workers were inevitable, and unavoidable, when really we’re being sacrificed by the refusal of the federal government to up its manufacturing of PPE.”
In spite of their protests, nurses and other frontline care workers were dragged from behind the hospital curtain of obscurity to be made the heroic faces of the pandemic. Some turned to social media with tweets or Instagram posts from inside emergency rooms and COVID-19 isolation wards, using their new national spotlight to amplify their warnings on the dangers of the virus. Others were memorialized by newspapers such as the Guardian, which published tributes to every health care worker felled by the coronavirus and kept a running tally of the deaths. Nurse practitioners (NPs) were invited onto nightly newscasts and talk shows to share their stories from the front line. The nursing profession had never enjoyed such celebrity before.
The publication of LaTonya J. Trotter’s More Than Medicine, an ethnographic account of the expert care work performed by nurses in hidden-away spaces of quiet desperation—nursing homes and rehabilitation centers—couldn’t be better timed. Released earlier in 2020, More Than Medicine details and makes visible the clinical labor of nurse practitioners, a category of medical professionals unique to the US system of profit-driven healthcare.
Trotter’s account in many ways follows a well-trodden path cut by classic studies in medical sociology—examinations of how surgeons undergo professionalization, or ethnographic observations of students in elite medical schools, such as Howard Becker and colleagues’ Boys in White: Student Culture in Medical School (1961) or Paul Starr’s The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry (1982). But it is in Trotter’s choice of whom to study, rather than in her chosen methods, that her work departs from traditional medical sociology. She forges a new way to understand just how broken America’s health care system is, by closely observing the labor of nurse practitioners.
Early in Trotter’s book, we begin to glimpse how bad things were for patients, for health care workers, and for families caring for loved ones even before the pandemic. Most of the study was conducted at an outpatient nursing care facility she calls Forest Grove Elder Services, or The Grove. The nurse practitioner–managed center served close to 250 patients (whom it called “members”) per year. About 96 percent of them were Black, elderly, suffering from compounding comorbidities, and insured by Medicare. In the context of the pandemic, The Grove’s members are in the highest risk category for the deadly effects of the coronavirus. As I was reading, I wondered how they’ve coped in the pandemic.
Trotter opens the book by recounting how a nurse practitioner she calls Michelle expertly organized the administration of eye drops for Ms. Payne, an 86-year-old Grove member with dementia and cataracts. Eye drops might seem like a pretty trivial matter, but in the context of value-based care—where every clinical action, no matter how small, has a price tag—each molehill becomes a mountain to be scaled. Ms. Payne lived alone, and because she was incapable of doing it herself, someone from The Grove would need to administer the drops twice a day over the weekend. But this is where the mountain comes in: if a health care worker is sent to Ms. Payne’s home to drop the medicine into each eye, that becomes a billable action, and there are limits on how much can be billed. Through a series of emails and phone calls over an entire Friday afternoon, Michelle modified the regime so that fewer home visits were needed, and she enlisted the help of a neighbor, ensuring that Ms. Payne received the care she needed.
They understand and act on the complex social webs that their patients inhabit.
Through such thick descriptions of the care work that NPs provide for Grove members, Trotter argues that while the professional category of nurse practitioner was created to give patients routine care, NPs now have to stretch their expertise to its limits in order to bridge the gaps for those most marginalized by medicine—the poor, disabled, and isolated—so that they don’t fall through those cracks. NPs are fixers, tasked with solving the insurmountable problems created by profit-driven health care and a technocratic system of government that would rather shed the detritus of the most vulnerable in our society, patients living in economic and social precarity, than provide effective care and dignity. And the responsibility for solving these problems always seems to depend on the unpaid and invisible labor of women.
Well into the nineteenth century, women were barred from the health professions, including nursing. Male physicians and nurses, looking to police professional boundaries and protect their own jobs, argued that women were primed by “nature” to care, and therefore it was immoral for them to be paid for doing such work. It was only after the likes of Florence Nightingale and Mary Seacole did the hard work of “heroic” battlefield nursing that women nurses were able to fight for professional legitimization and enter medicine, albeit at its lowest rungs. Women-led nursing has fought for legitimacy ever since.
Care work is work. But as with most fields that rely on stratified and feminized labor, nursing in American health care is hierarchical, underpaid, undervalued, and overworked. Many of the nurse practitioners that Trotter followed went to great lengths to distinguish their work from that of the consultant physicians working at The Grove. They believe that they alone are able to understand and to act on the complex social webs that their patients inhabit—the social and economic conditions that shape their health. Whereas physicians simply parachute in to make a diagnosis, NPs are poised to solve the problems of the whole patient. Their “skills of relationship and of seeing the whole person put NPs in a position to be expert providers to those for whom economic and social precarity were daily realities,” Trotter writes.
They do this by being astute web weavers, working with the social, technical, and bureaucratic threads that are connected to the patient. Through their web weaving, NPs cocoon the patient in a customized safety net made tirelessly by means of phone calls, emails, and walks down the corridor to talk face-to-face with a dentist or radiologist to make sure that Grove members receive the care they need. But the social support resources NPs work with have been decimated over recent decades by the federal government.
Compare the expert and professional care work that Trotter’s nurse practitioners perform for their patients with the sycophantic ineptitude of White House adviser Jared Kushner and the rest of the Trump administration. In the early days of the pandemic, Kushner reportedly devised a plan to divert or deny the delivery of PPE and test kits to Democrat-led states in an election year. In September, Dawn Wooten, a nurse fired from a detention facility for undocumented migrants in Georgia, bravely went public with allegations that the Department of Homeland Security had purposely withheld life-saving gear and treatment from staff and detainees alike. The administration’s actions have been responsible for the deaths of thousands of Americans, putting political profit over the lives of elderly Black patients denied ventilators or the frontline health care workers dying for lack of protection from the virus. It will take more than medicine to heal the wounds inflicted by the malicious indifference of the death cult leaders who sit in the White House and the Senate, and their enablers in the federal health agencies.
In contrast to the shambolic political response to the pandemic, Trotter’s book provides an unexpected but sorely needed spotlight on the hidden labor of nurses. Through her focus on the care that nurse practitioners deliver for the members at The Grove, Trotter illuminates the ingenuity and grinding hard work it takes to improve the quality of life and preserve the dignity of so many people considered dispensable by American political leaders. Trotter’s work demonstrates the Sisyphean task required of nursing professionals: to provide patients and the whole of society with more than just medicine. They must try to fix an entire system that has turned against the very people they are trying to keep alive; to give them a semblance of dignity and comfort, and perhaps even some joy in their last days.
Our health care system makes both patients and health care workers poorer and sicker. During her fifteen minutes of fame, the meme-worthy nurse Jillian Primiano sharpened her point to American voters in an interview with Teen Vogue, urging support for universal access to Medicare, the federal health insurance program: “Don’t tell me ‘thank you’ and then, you know, support a system where the rich get richer and the poor die.” It is up to the rest of us to do the care work for one another at the polls in November 2020.