Nurse practitioners and the pursuit of social justice

“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” — Martin Luther King Jr.

If there’s one question every nurse practitioner is familiar with, regardless of geography, specialty, or number of years in practice, it’s the one that sounds something like this: So, are you a doctor or still a nurse?

I was two months out of my graduate nursing program when an elderly patient posed that question to me. She had come in expecting to see the physician for a routine, post-hospital follow-up visit that quickly became not so routine. Slightly overweight, she presented with the common triad of chronic conditions I was becoming adept at managing—diabetes, hypertension, high cholesterol. Added to that were depression, anxiety, COPD, GERD, and arthritic knee pain. Her scribbled list of medications spanned the alphabet: amlodipine, clonidine, Cymbalta, furosemide, gabapentin, hydrochlorothiazide, K-Lor, lisinopril, Lantus, pantaprazole, Senekot, sliding-scale insulin, Symbicort, and tramadol. After determining that the physician was unavailable, she settled, albeit reluctantly, into seeing me that day, her slightly raised brow indicating lack of confidence in my capability.

We began by reviewing the most obvious: her hospital discharge summary, the list of medications she was supposed to stop taking, those she was supposed to start taking, and, with regard to the latter, a quick but subtle quiz on why she was taking each one. Her answers revealed little to no knowledge of the purpose of the medications, correct dosages, and, least of all but most importantly, potential side effects.

We proceeded into what is known as the ROS, or review of systems, a quick query from head to toe about important systems and any symptoms that may be present. Given her conditions, I asked if she was monitoring her blood pressure at home (Yeah, sometimes it’s as high as 170, 180); if she was monitoring her blood sugar (Not really. I can’t figure out how to work all those buttons); and how often she was using her inhaler (What inhaler? I don’t have an inhaler). I also asked about pain and how much pain medication she had been taking (That stuff never works, so I just sit for most of the day to keep from hurting so bad).

From there we proceeded to her physical assessment, which underscored the majority of her story. Her blood pressure was indeed high, her knees were indeed crackling, and the wheezing in her lungs could be heard without even lifting the stethoscope. I went on to ask how many of the medications she actually had at home, only to discover that she was still waiting for the pharmacy to deliver nearly half of them. From there, the plot thickened even more.

Truth was she lived alone, depended on an untimely cab service to get to and from appointments, had children who, for one reason or another, could not help and had given up on trying to figure out whom else to call. Her funds were limited and, more often than not, she took only half the dose of insulin to “stretch” her supply until the next Social Security check came in. After purchasing food from the corner market (which was as far as she could reasonably walk without getting too tired) and paying the gas bill, she would buy her medicines, if she bought them at all.

Some say it isn’t the primary-care provider’s job to get involved with social issues, such as transportation, food, finances, and physical access to needed services and educational supports. That some individuals live in what we now know as food deserts—communities without access to nutritious, healthy foods—is a personal problem, they say, one beyond our control. Certainly, there are social workers who are better suited—and have the time—to address these issues, and there’s no argument that our payors will not reimburse us for helping individuals find transportation or locate family members to help. But to ignore the social determinants of health—defined by both the Centers for Disease Control and Prevention (CDC) and the Office of Minority Health as the range of personal, social, economic, and environmental factors that influence health status—is to contribute directly to the very health inequities that our care is supposed to eliminate.

The role of the primary-care nurse practitioner—who, yes, is still a nurse—is multifaceted, with good reason for being so. Certainly, he or she is credentialed to provide the same level of care that a physician would provide in the primary-care setting. We can describe, ad nauseum, to our patients and to the world the educational preparation that enables us to do so. We can attain doctorates, perform and publish research, and gain the skill sets needed to perform a number of advanced, highly technical clinical procedures. But, at the end of the day, what matters most is the actual delivery and fulfillment of the work for which our role was created in the first place—the equitable and efficient delivery of comprehensive health care with a focus on health education and disease prevention.

In truth, the foundational premise of our role dates as far back as the 1870s, a time of severe postwar food shortage, rampant spread of contagious disease, and a medical infrastructure inadequate to care for returning wounded soldiers across the rural South. Our role dates back to the early 19th century, a time marked by racial segregation and African-American families migrating to northern cities in search of better living conditions and employment opportunities—only to find themselves in overcrowded, often vermin-infested tenements where unsanitary water supply, high infant mortality, and poor childhood nutrition were the order of the day.

And our role now, in the most contemporary sense, will be defined and shaped by the uncertainties of health care policy reform amidst a struggling economy, a growing demographic of aging, medically underserved citizens and of whole immigrant communities lacking access to the most basic preventive care. In truth, medical care is what we deliver, but social justice and eradication of health inequities are, and always have been, our foundation.

In meeting with that patient that day, the focus was not on my credentials and the myriad differences between my physician colleague, whom I respect and admire, and me. My focus was on doing what I’ve always tried to do best: provide patient-centered, age-appropriate, culturally competent care.

For patients who ask, “But are you still a nurse?” the answer should be evident in the work we do: simplifying medication regimens by eliminating or combining medicines where feasible, thereby reducing costs and the risks associated with polypharmacy; securing home-care referrals for medication teaching, diabetes education and blood-pressure monitoring; collaborating with community pharmacists to find efficacious drugs, particularly those offering financial benefit for the medically underserved; and speaking out wherever and whenever we can for those most vulnerable in our society—the elderly and the young. The nurse and nurse practitioner as continual advocates of social justice, health equity, and comprehensive health care are roles that we should defend and be proud of.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.