Nurse practitioners (NPs) were created as a solution to the problem of physician scarcity and rising costs. Cheaper to train and employ than medical doctors, NPs can provide the kind of care that was once the sole domain of physicians. Moreover, in 27 states and the District of Columbia, NPs have the right to do so independently. While nursing is one of the oldest health care professions, autonomous NP practice is a fairly radical policy shift. But our looming healthcare crises allowed nursing to successfully make the case—to state legislatures, insurers, and organizations—that NPs could “stand-in” for physician care as one part of a common-sense, practical solution to these policy problems. 

In More than Medicine: Nurse Practitioners and the Problems They Solve for Patients, Health Care Organizations, and the State (Cornell University Press, 2020), I investigate the shape of that solution by chronicling the everyday work of a group of NPs as they cared for 400 African-American older adults living with poor health and limited means. They did this work within a community-based, comprehensive care organization that I called the Grove. The NPs had the support of an interdisciplinary team, including physicians and social workers, but they were the formal leaders of the team. For two and a half years, I spent time with these providers in order to understand how they worked together, as well as where the drew the line between their spheres of expertise.  Contrary to the predominant argument of interchangeability, what I found most salient about NP practice was less its similarity to physician practice, than its difference from it. These differences mattered deeply to patients, as well as to the organization that employed them.  

For patients, the NPs opened the exam room to a broad set of social and economic problems that are usually filtered out of the medical encounter. These NPs attended to problems as diverse as transportation, medication delivery, food insecurity, and access to specialist care. In response to this openness, patients and their families began to turn to the clinic as the place to get a diversity of needs met. While the Grove’s comprehensive mission facilitated these solutions, it was notable that it was the NPs, and not the physicians, who worked to make them happen. While the physicians carried out a narrow view of medical work, these NPs carried out an expansive notion of what I call clinic work. 

This existential openness did not just serve the interests of patients, but also the needs of the Grove. As an organization, the Grove struggled under the weight of its comprehensive-care mission. In a patient population with high levels of chronic illness and poverty, the line between medical problems, social problems, and administrative problems was neither apparent nor well defined. The NPs’ professional openness became an invitation for anyone—including administrators, other clinicians, and support staff—to bring problems that they could not solve to the clinic. Clinic work became a gendered form of organizational care work where the Grove’s NPs were obligated to be responsive to the collective needs of the organization as an integral and non-negotiable part of what it meant to care for patients. To the extent that comprehensive care happened at all, it was due to the work of these NPs. While this gendered obligation was a strain for some NPs, for their patients and the Grove, it was a lifeline.  In solving these problems alongside their patient’s medical problems, these NPs were not just adding nursing work to medical work, but were embodying a different understanding of what the medical encounter could be. Hired to perform medical work, they were just as often performing care work for patients and their employer. 

These NPs, however, solved problems not only for patients and their employer but also for the state. The defunding of anti-poverty programs, social welfare organizations, and public education are linked in complicated ways to the expansive set of problems that NPs are obligated to address.  At the Grove, as in most of the nation, NPs are more likely than physicians to be the provider for racial and ethnic minorities, the uninsured, those living in poverty, and those with disabilities. In this context, it is impossible to understand the utility of the NP without considering what the state has decided not to do in other realms. In describing the process through which all problems at the Grove were funneled to the better-resourced clinic instead of the social worker’s office, I demonstrate how the problems that appeared in the NP’s exam room were as much a product of state disinvestment as of the NPs economic utility. The federal government has largely withdrawn itself as a payor for social problems even as its financing of medical problems has soared. 
More than Medicine is not just an account of NPs at work.  It is the story of what happens when the state outsources its moral obligation to care for its citizens. In solving an expanded terrain of problems from inside the clinic, NPs are not only tasked with addressing a broader set of concerns for their patients, they have become a professional solution for managing “difficult patients” for health care organizations and “difficult people” for the state.

Written by LaTonya Trotter

The cover picture is designed by Nancy Folbre
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