Nurses Step to the Front
In hamlets and high-tech hospitals, nurses are taking on bigger roles
When white-haired Harry Curry shuffles into the Minnie Hamilton Health Care Center in rural Grantsville, W.Va., he says he'll see only "his doctor." That's his name for Teresa Ritchie, the nurse practitioner who looks after the 71-year-old at this tiny complex tucked in the Appalachian hills. And it's not really a misnomer. The veteran nurse takes on everything from minor surgery to emergency room crises. Ritchie has admitting privileges at area hospitals, still unusual for a nurse, and can prescribe medication with just a doctor's checkoff. Her autonomy surprises her as much as anyone. "When I started out, nurses were not told we could think for ourselves," says the West Virginia native, who delivers care with a dollop of down-home gossip and finds ways to give her predominantly low-income patients free medicine. "We just did what a doctor planned out for us."
But those times are long gone. Many of the country's more than 2 million nurses are taking on jobs that were once the purview of physicians, like administering chemotherapy and running their own primary-care practices. They are carving new niches in fields such as genetics and computerized patient records, where nurses were once hard to find, and bringing philosophies oriented toward health promotion and problem prevention to geriatric care and case management. "When we are allowed to think outside the box, there is a lot we can do," says Jane Barlow, a University of North Carolina nurse who is developing a disability screening and intervention system for children in her home state. "In every situation, there is more that nurses can do if they feel empowered."
The seeds of nurses' liberation from doctors' white coattails were sown in the 1960s. That's when a nationwide shortage of primary-care physicians, especially in rural and inner-city areas, pushed many nurses into advanced roles. "Nurses were doing things that most people thought just physicians were doing, like seeing patients and recommending medication," says Lynne Vigesaa, who in 1972 became the first nurse practitioner in the state of Washington and later helped write the state's regulations defining and governing that role. Through the 1980s, the idea of nurses' doing more than just assisting doctors gained acceptance as patients began seeking out nurses--who seemed to have more time for them--and resistance from physicians' organizations eased. States began formalizing nurses' expanded roles. "It's pretty amazing, when you think about it," says Vigesaa, who now manages a dermatology clinic outside Seattle.
Filling a void. The advent of managed care also opened doors. The law defining health maintenance organizations was passed in 1973. But the idea--prepaid plans that enroll members and arrange their care from a designated network of doctors--brought on serious complications. The plans often tightly control how, when, and why doctors offer medical services. The reimbursements doctors get from the plans are prearranged but haven't all risen in step with the ballooning cost of healthcare. That problem now extends beyond HMO s to all insurance plans, doctors complain, which means they must see ever increasing numbers of patients to remain profitable. Those busy schedules have created voids in patient care--and nurses are filling them. "When patients call doctors for advice these days, many times nurses are the ones at the other end of the line," says Patricia Rowell, a senior policy fellow for the American Nurses Association.
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