As many of you know, Dr. Lane has entered the Family Nurse Practitioner program at Indiana Wesleyan. Since beginning graduate school, this has been on her heart, but there were so many other pressing desires that she kept pushing this to the back burner. More recently, as she has explored the functional medicine certification, she seems more and more than adding this training would help her better address the needs of her clientele. The midwife has always been the community care-taker and nurses have served everyone in the population, but oddly enough, once one gains advanced training as a nurse-midwife, it seems we are no longer competent to serve children or the male client.
Throughout the 20th century, nurse-midwifery remained an anomaly in the U.S. health-care system. ~Lucille A. Joel (2013, p 4)
When one choses the career path of becoming a midwife, particularly one practicing outside the hospital, there comes a sort of isolation, and sometimes this even presents as hostile persecution. We face this daily from questions with whether we are legal or frequent misunderstanding of our scope of practice. Just this past week, a physician reported Dr. Lane to the attorney general because he argued that when our staff call her a doctor it confuses our clients into believing she is a medical physician. We regularly hear from our clients that their friends and family encourage them to see “a real doctor.”
When the homebirth community advocates for the direct entry bill, they often share this grassroots movement as a “homebirth rights,” or “homebirth regulation,” or even “legalizing homebirth” effort which only confuses consumers and healthcare providers, when in fact, it isn’t the birth setting being regulated but rather, the credentials behind the birth attendant. However, all homebirth midwives and their clients are then perceived as a single group and then upon transfer or when seeking collaboration nurse-midwives have to navigate the anger and misunderstanding of their medical colleagues. Even nurse-midwives have been known to treat homebirth nurse-midwives as a second-class midwife with which they prefer not to associate.
Midwives were attending half of all the births in the United States as late as 1910, but just a hundred years later our society has moved birth into the hands of physicians, in the walls of the hospital, and forgotten about the art of midwifery. Our outcomes in maternal and neonatal health aren’t good either, but because our midwifery ancestors – unregulated and, by most accounts, unprofessional – were easy scapegoats for which we could blame these poor outcomes, the entire profession of midwifery is now thought of as “medieval.” Ironically, Cuba has better outcomes than the United States and countries like Great Britain and many other European countries, where trained midwives attend a significant percentage of births, including home births, lead the world in best perinatal outcomes.
As Dr. Lane has applied to programs for her post-graduate nurse practitioner certificate, she has routinely faced ignorance by the nursing administration in her experience and education as a certified nurse-midwife. There have been a few who quickly recognize our expertise in women’s health and even our role as primary care providers, but even nursing administration at Indiana Wesleyan felt it was appropriate for her to complete the entire program, including repeating the women’s health portion! Twelve e-mails later and we are still negotiating which portions, if any, will be credited by her prior graduate and doctoral training as a primary care provider for women.
As a graduate of the premiere midwifery program in the United States, the Frontier Nursing University, Mary Breckinridge has shaped Dr. Lane’s career. She saw nurse-midwives as independent practitioners and was an advocate of homebirth, but she specifically felt midwives should be well trained and academically prepared, similar to the public health nurse in Britain. Mary was not an advocate of direct entry midwifery and in spite of her efforts, nurse-midwifery has really struggled to bloom because of the unprofessional image of the lay midwife.
As frustrating as this all seems, it’s helpful to remember that Dr. Lane’s midwifery class was only the fortieth at the first school for nurse-midwifery in the United States. Her doctoral program was only the ninth class. As a member of the Homebirth Section with the American College of Nurse-Midwives, Dr. Lane assisted in the writing of the first homebirth standards of care. We are in the earliest of days for professional midwifery and pioneering this movement means facing a plethora of challenges, particularly when that movement is creating change that challenges others.
Nurse Anesthetists faced a similar trial in that it was first a nurse that managed the anesthesia of patients for surgeons because it was the surgeon that collected the fee for this service. Marianne Bankert authored a landmark book titled, Watchful Care: A History of America’s Nurse Anesthetists, in 1989 and explains how economics changed anesthesia practice. Once it became financially profitable, physicians claimed the field of practice they previously rejected by denying access, ignoring and denigrating the achievements of their nursing colleagues (Joel, 2013, p 6).
Nurse Anesthetists have also found themselves separated from the larger nursing profession, even the entire group being rejected by the American Nurses Association. This group of nurses is represented by the largest number of male nurses, which has not eased the advance of this nursing specialty. They too, have embraced the doctoral level of education, and so threaten the hierarchy of medicine when they’ve earned the “doctor-nurse” or “nurse-doctor” title.
The history of the nursing profession is fairly consistent in not supporting those who wish to advance the profession. Our clinical nurse specialists also lacked support by the American Nurses Association even though their aim was to improve quality of care rather than diagnose, treat and prescribe. It was simply inconceivable that any nurses could become a specialist. Our profession however, initially did lack a scientific underpinning and nurses were utilized as experts in healthcare procedures or tasks.
As early as the 1940s, however, nurses began moving beyond their expertise in specific procedures to providing consultation as experts across specialities. As soon as the 1960s, the nursing role expanded as technology demanded nurses who were competent to care for patients with complex health needs. In 1965, the American Nurses Association developed a position statement declaring that nurses specialists should have a minimum of a graduate degree, which led to federal grants from the Department of Health, Education, and Welfare for nursing education at the graduate and doctoral levels.
While the nurse specialist was thought to have a role in clinical practice as the educator, consultant, researcher or administrator, today we find the nurse practitioner and clinical nurse specialist role combining into a single profession. However, all four advance practice nursing roles are still defined, and regulated in the state of Indiana, as the: certified nurse-midwife (CNM), certified registered nurse anesthetists (CRNAs), clinical nurse specialist (CNSs), and the certified nurse practitioner (CNPs). The advanced practice registered nurse (APRN) is further defined as a registered nurse who has completed a graduate degree or postgraduate program that has prepared him or her to practice in one of these four roles.
The Nurse Practitioner
Interestingly, the physician assistant (PA) role was introduced into the healthcare infrastructure because Dr. Eugene A Stead, who had desires for introducing graduate level training for nurses at Duke, was rejected in 1957. The story is told that he was somewhat disheartened by the women in nursing leadership so he turned to military corpsmen to actualize this new role, which he named the physician assistant, and insisted they be exclusively male (Joel, 2013, p 11).
Admittedly, while many argue that the nursing profession missed a tremendous opportunity, his efforts are a representation of what he felt the physician needed. Nurses have a growing specialty of their own. They have their own unique science, and their profession is defined by its own knowledge base. The role of the advanced practice nurse is autonomous, separate and distinct from medicine. Stead’s efforts were viewed as gender-role stereotyping and at a time when advanced practice nurses were collaborating in fruitful relationships with physicians, the nurse practitioner role was viewed by many as more ideal (Joel, 2013, p 11).
The challenges were then the implication that advance practice nurses required supervision and control by physician colleagues and of course, prescription authority. When the good of the patient is at the forefront of each clinician’s mind, roles are clear, as each offer their best and coordinate care to the extent of their own expertise. Prescribing has always been within the realm of nursing, as nurses have always utilized a variety of techniques and substances that enhance the therapy of their patients entirely independently, yet with the growing role of the advance practice nurse, prescription authority has created some of the fiercest turf battles.
The nurse practitioner role is also a new one. It emerged in the 1960s, but even into the late 1970s, the American Nursing Association didn’t embrace the role. In fact, they felt the nurse practitioner distracted from nursing and felt the movement was “an issue.” The nursing profession lacked leadership that had also obtained advanced training, and even in Indiana, it was only in very recent years that our own board of nursing invited an advanced practice nurse to join its rank. That lack of leadership for advance practice nurses within our professional organization is thought to contribute to our slow growth as practitioners. By 1987, the federal government had spent $100 million to promote education for nurse practitioners and by 1980s, the masters degree was the standard for advanced nursing practice.
Despite clear statutes in many states for all advanced degree nursing professions, credentialing by insurance companies lags, providing additional barriers to care. Nurse practitioners though, have gained a higher degree of autonomy in practice and associated prestige with the mandate for continued advancement in the Institute of Medicine’s report, but still, they too continue to battle for autonomy and consumer recognition in practice, especially in states with many physicians. Satisfied consumers continue to support the advancement of APRNs.
The Doctorate Nurse
There is a lot of discussion about the doctoral level nurse, as my recent attorney general report can testify. Even many nurses oppose this educational pathway, but I suspect this is largely an opinion of ignorance to its origination. As educational programs for nurses have advanced, their requirements have increased without adjusting the credential awarded. The number of credits are comparative, if not exceeding other doctoral prepared clinical role such as the pharmacist, physiotherapist, occupational therapist, dentist, chiropractor, pharmacist or physician. Outcomes as well, by advanced practice nurses, have demonstrated in random controlled trials to be on par with physicians, if not better. The current movement towards the doctoral degree isn’t necessarily increasing the requirements for practice, but rather, finally assigning the appropriate credential with our level of education.
Dr. Lane has blogged a number of times about doctoral preparation for clinical practice as an advanced practice nurses. Those can be read here: The Doctorate Mindset, A History Lesson: The Doctor, Doctorate as the Entry Level to Practice, and What exactly is the Doctor of Nursing Practice degree. The future of nursing was outlined in the Institute of Medicine’s 2010 report and will require active participation of all the renegades, rebels, and trailblazers nursing has to offer.
Dr. Lane will continue to approach her practice and education based on the needs of her clients and achieving best outcomes. The struggles are real and will continue. This is only the beginning. Her motivation has always come from her concern for the individual experiences of her clients, her concern for community, and her concern for humanity. Progress is slow, sometimes unsteady – but always committed.