Alliances of cooperation: Negotiating New Hampshire nurse practitioners' prescribing practice

Nursing History Review

Volumn 17, Issue , 2009, Pages 153-178

  Sampson, Deborah A ^a  

^a UNIVERSITY OF MICHIGAN   (United States)

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[No Author keywords available]

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EID: 53849108466     PISSN: 10628061     EISSN: None     Source Type: Journal    
DOI: 10.1891/1062-8061.17.153     Document Type: Review

References (97)

1. The New Hampshire 1973 legal designation "advanced registered nurse practitioners" included nurse practitioners, nurse midwives, and psychiatric clinical nurse specialists, adding nurse anesthetists in 1991. Perhaps because there have been few clinical nurse specialists in New Hampshire other than those in psychiatry, they have never been designated advanced practice nurses. For documents related to the 1973 designation, see Box 1-1, folders marked "Legislation 1970," "Charters," "Minutes 1970s," New Hampshire Nurse Practitioners Association (hereafter NHNPA) Papers, archived in the Tuck Library of the New Hampshire Historical Society, Concord, New Hampshire. See also Registered Nurses and Practical Nurses, RSA 326-B: 1-22, Laws of the State of New Hampshire (January 1, 1973), Concord, New Hampshire.
2. For documentation of prescribing practices see oral history transcripts of Donna White recorded December 28, 2004 (cited as White), lines 390-408, 445-62;
3. Jeanne Charest recorded May 15, 2005 (cited as Charest), lines 437-72;
4. Joyce Cappiello recorded August 2, 2005 (cited as Cappiello), lines 229-77;
5. Mary Bidgood-Wilson recorded May 27, 2005 (cited as Bidgood-Wilson), lines 535-45, 574-615;
6. Nancy Dirubbo recorded February 23, 2005 (cited as Dirubbo), lines 240-61;
7. Paula Weeman recorded January 24, 2005 (cited as Weeman), lines 294-381. Transcripts and tapes cited are archived in the Tuck Library of the New Hampshire Historical Society unless otherwise noted.
8. Oral histories from practicing nurse practitioners at this time document the nurse practitioners' prescribing practices and the physician complicity. See, for example, Weeman, Dirubbo, and Charest, also oral history transcript of John Argue, May 3, 2005 (cited as Argue), lines 493-513, 626-49;
9. Maynard Mires recorded April 6, 2005 (cited as Mires), lines 883-944; letter dated July 20, 1977 from Thomas Nadeau, MD, to Commission on Pharmacy, attached to Commission on Pharmacy meeting minutes, July 20, 1977. All Commission on Pharmacy minutes cited are found in the Office of Paul Boisseau, Board of Pharmacy, Concord, New Hampshire. Board of Medicine minutes, December 5, 1977, January 5, 1978. All Board of Medicine minutes cited are found in the conference room, Board of Medicine, Concord.
10. See Commission on Pharmacy minutes, January 17, 1973, December 18, 1974, November 19, 1975.
11. See Commission on Pharmacy minutes, June 10, 1972, all minutes of 1974 and 1975, July 20, 1977, December 13, 1978;
12. Board of Medicine minutes, February 16, 1971, February 19, 1972, December 3, 1973, January 4, 1979;
13. New Hampshire Medical Society News28, no. 4 (October 1977), 1. All New Hampshire Medical Society Newsletters cited are found in the Office of the New Hampshire Medical Society, Concord.
14. See a complete discussion of the Pharmacy Commission investigator s report incident in the Commission on Pharmacy minutes, July 22, 1977.
15. An interesting footnote is that the so-called nurse practitioner in question was not licensed in New Hampshire as a registered nurse or nurse practitioner, although she became licensed in both categories. Moreover, the prestigious university she claimed to have attended had no nurse practitioner program at that time. Yet her individual actions, sanctioned by the physician with whom she worked (who also happened to be her husband, a physician well known to the State Drug Investigation Unit), set in motion a lengthy struggle for all New Hampshire nurse practitioners to gain prescriptive authority. It was also at this time that the Board of Nursing was making considerable efforts to address the significant problem of unlicensed nurses working in physicians' offices. According to Board of Nursing minutes, this was a common problem well known to the Board of Medicine. It was not necessarily unusual for an office "nurse practitioner" not to be licensed. See Board of Medicine minutes, May 5, 1977;
16. "Doctor, Is Your Nurse Licensed?" New Hampshire Medical Society News 31, no. 1 (February 1979): 2;
17. Board of Nursing minutes, October 1, 1979, May 15, 1980;
18. Board of Nursing Newsletter 15, no. 1 (May 1980), 3. All Board of Nursing minutes and newsletters cited are found in the conference room, Board of Nursing office, Concord.
19. For the purposes of this article, the terms nurse and nursing are used to denote all licensed registered nurses and their practice. Nurse practitioners are one branch of nursing. They are educated to work in capacities that include concepts of nursing care and also provide some components of medical care traditionally performed by physicians, such as diagnosing and treating disease, prescribing medications, and even performing surgery and invasive procedures. While all nurse practitioners are nurses first, not all nurses are nurse practitioners. Therefore, the concepts and contexts of nursing history are applicable, for the most part, to nurse practitioner history. The converse, however, may not be entirely true.
20. Julie Fairman, "Delegated by Default or Negotiated by Need? Physicians, Nurse Practitioners, and the Process of Critical Thinking," Medical Humanities Review 13, no. 1 (1999), 38-58. State regulation is often shared with federal legislation, but states, even in the same geographic region such as New England, can vary widely in their ideology about regulation of citizens.
21. Interview with Maynard Mires, Georgetown, Delaware, April 6, 2005 (cited as Mires 2005), lines 173-82;
22. Ronald L. Akers, "The Professional Association and the Regulation of Practice," Law & Society Review 2, no. 3 (1968), 463-482.
23. It is not unusual for professional organizations to form coalitions to combat other competing professional groups, particularly when negotiating mutually amenable legislation. Conversely, professions may introduce or support legislation that is actually detrimental to the public interest. The Commission on Pharmacy introduced legislation in 1975 to prevent outpatient clinics and physicians' offices from dispensing more than a 24-hour supply of medications, including contraceptives from family planning clinics. Patients would be forced to take a prescription to a pharmacy instead. Limiting access to often free or low-cost contraceptives would most certainly be detrimental to patients. Fortunately for many women of New Hampshire, this Commission on Pharmacy initiative failed. Commission on Pharmacy minutes, April 2, 1975, book marked "NH Commission of Pharmacy Minutes January 1975-December 1978."
24. Bobbie Schwaninger Hughes, "Role Evolution vs. Legislation," Nurse Practitioner 8, no. 3(1983), 9, 12.
25. Letter dated July 28, 1977 from Marguerite Hastings, Executive Director of New Hampshire Board of Nursing, to Gloria Klein, President NHNPA, folder "Legislation 1970s."
26. Letter dated November 29, 1977 from Betty H. Mitchell and Donna White to "Dear Fellow Practitioners" sent to all New Hampshire nurse practitioners; letter dated January 24, 1978 from Debbie Clark, RN PNP, Recording Secretary NHNPA, to "Dear Practitioner," folder "Legislation 1970s."
27. For excellent in-depth discussions of nursing and the contested terrain of medical boundaries, see Julie Fairman, "Playing Doctor? Nurse Practitioners, Physicians and the Dilemma of Shared Practice," Journal of the Massachusetts School of Law 4, no. 4 (1999);
28. Arlene Keeling, Nursing and the Privilege of Prescription, 1893-2000 (Columbus: Ohio State University Press, 2007), 27-35.
29. See Obituaries, Berkshire Eagle (Pittsfield, Massachusetts), July 7, 1998, Marguerite Hastings, http://oa.newsbank.com.oa-search/we/Archives (accessed December 13, 2005).
30. Hastings was also New Hampshire representative to the National Council of State Boards of Nursing and consulted to the Caribbean Nurses Association. After her retirement from nursing, she was New Hampshire director of the New Hampshire Association of Retired Persons, an active member of the Boston University Alumni Association, and volunteered every winter to help elderly people prepare their federal income taxes. Carolyn Andrews recorded May 16, 2005 (cited as Andrews), lines 480-599.
31. The admiration Hastings engendered is consistently repeated in oral histories collected for this research. For information on Hastings's power, stature, and relationships see, for example, transcripts of Charest, lines 832-937;
32. Andrews, lines 240-309,971-1020;
33. Christine Kuhlman recorded November 19, 2004 (cited as Kuhlman), lines 314-32, 882-88;
34. Stanley Plodzik recorded March 4, 2005 (cited as Plodzik), lines 465-529. Also personal communication June 6, 2005 with Doris Nuttelman, former executive director of the New Hampshire Board of Nursing; transcript may be obtained from the author.
35. See, for example, adjudication discussions in minutes of each meeting of Board of Nursing and the Commission on Pharmacy through 1986. Nurses routinely had licenses suspended or revoked for actions including mishandling medications, IRS fraud, or substance abuse. Pharmacists routinely had licenses suspended for similar actions, but often had the majority of the suspension period "stayed" or forgiven. The Board of Medicine, however, rarely suspended or revoked licenses even after Drug Investigation Unit investigations (see Board of Medicine minutes, January 5, 1978).
36. One physician who was found guilty of Medicare and Medicaid fraud had no action (Board of Medicine minutes, December 11, 1978).
37. One who was found guilty of breaking prescription narcotic laws was allowed to "retire with dignity," as were others (Board of Medicine minutes, August 15, 1972, July 7, 1977).
38. Another physician, while spending the night at a patient's hospital bedside, injected himself with massive amounts of Demerol, a potent morphinelike narcotic, while the patient died. Although the physician was subsequently found to exhibit bizarre and unstable behavior and to have a dtug and alcohol abuse problem, the Board of Medicine left his license intact for many months (Board of Medicine minutes, July 6, 1978, October 5, 1978, December 11, 1978).
39. These examples are a few of many during the years of study. Mires indicated that there were many "problem" physicians but due to the threat of being sued for an adjudicatory decision, the Board of Medicine was reluctant to take action against physicians (Mires, lines 121-55).
40. Physicians did, however, have licenses revoked if their relicensing fee checks were returned to the Board of Medicine for insufficient funds (Board of Medicine minutes August 7, 1980).
41. Minutes of Special Joint Meeting, Board of Registration in Medicine, Board of Registration in Nursing, Thursday, March 8, 1973, Board of Medicine minutes files, 2.
42. Minutes, March 8, 1973, 3.
43. Hastings died suddenly in 1985, several years after she retired from the Board of Nursing. Although she remained active in the New Hampshire Nursing Association, she spent her time as an H&R Block consultant helping elderly people prepare their federal income tax reports and renovating the house she bought at her retirement (the first she had ever owned). Hastings never married (see Andrews, lines 808-50).
44. Mires was a close personal friend of New Hampshire Attorney General David Souter, who had a hand in backing several rulings supporting nurse practitioners' dispensing in defiance of the Commission on Pharmacy (Mires 2005, lines 18-81, 98-101, 202-25, 380-430, 668-86, 728-840, 1036-40, 1224-29).
45. Letter dated January 9, 1978 from Marguerite Hastings, Executive Director, New Hampshire Board of Nursing, to Deborah F. Clark, RN, PNP, Secretary NHNPA, folder "Legislation 1970s";
46. letter dated July 5, 1979 from Andrew R. Grainger, New Hampshire Assistant Attorney General, to Maynard Mires, MD, MPH, Executive Secretary, State Board of Registration in Medicine and Miss Marguerite Hastings, Director, Board of Nursing Education and Registration, folder "Joint Regulation Board of Medicine 1979";
47. letter dated September 13, 1982 from Assistant Attorney General James Townsend to Paul G. Boisseau, Secretary, Commission on Pharmacy, in reply to Subject; "Who Can Dispense," folder "Legislation 1980s."
48. See also Registered Nurses and Practical Nurses, RSA 326-B: 4, Powers and Duties of the Board Laws of the State of New Hampshire (January 1, 1974), Concord, New Hampshire, and Commission on Pharmacy minutes, September 19, 1979.
49. See Board of Nursing minutes, January 14, 1974.
50. For comments by Mires and others on the impending closure of the last hospital-based nursing schools, see New Hampshire Medical Society News 32, no. 2 (March 1980), 4.
51. See Board of Nursing minutes, February 21, 1974. Selma Deitch, MD, another formidable woman with a national reputation in pediatric health and a significant statewide power base, was director of the New Hampshire Division of Maternal and Child Health services at the New Hampshire Department of Public Health, and reported directly to Mires. Deitch believed strongly in the need for, and abilities of, nurse practitioner care within the public health system, even meeting with Hastings and the Board of Nursing to explore sponsoring a nurse practitioner training program in New Hampshire. Although this idea never reached fruition, Deitch was responsible for facilitating nurse practitioner training for several New Hampshire public health nurses and also for assuring that nurse practitioners held significant positions of power in New Hampshire pediatric programs, public health department administration, and public clinic patient care. It is probable that Mires, when faced with negotiating nurse practitioner practice boundaries on behalf of the Board of Medicine and physicians, was keenly aware that Hastings and Deitch, with whom he had close and often daily working relationships, supported nurses and patients rather than focusing on protecting physician boundaries. Susan McKeown relates how Deitch was responsible for the state supporting education of pediatric nurse practitioners, including Susan herself, to staff federally funded public pediatric clinics in Manchester in the 1970s. McKeown also discusses the remarkable dedication Deitch had to multidisciplinary care for all children in New Hampshire. Transcript of oral history Susan McKeown recorded March 22, 2005 (cited as McKeown), lines 85-626. Kathleen Hoerbinger, former state coordinator and case manager for home care of children with spina bifida, relates that Deitch was "a character. She was dauntless and wouldn't take 'no' for an answer" (personal communication with Hoerbinger, August 22, 2005). Both nurses had great respect and admiration for Deitch.
52. Letter dated January 9, 1978 from Marguerite Hastings, Executive Director, New Hampshire "Legislation 1970s";
53. see "Joint Regulation of Board of Registration in Medicine & Board of Nursing Education and Nurse Registration relative to definition of professional nursing" discussing the rule for dispensing, attached to letter dated July 5, 1979 from Andrew R. Grainger, New Hampshire Assistant Attorney General to Maynard Mires, MD, MPH, Executive Secretary, State Board of Registration in Medicine, and Miss Marguerite Hastings, Director, Board of Nursing Education and Registration, folder "Joint Regulation Board of Medicine 1979";
54. letter dated September 13, 1982 from Assistant Attorney General James Townsend to Paul G. Boisseau, Secretary, Commission on Pharmacy, in reply to Subject; "Who Can Dispense," folder "Legislation 1980s."
55. In an interesting coincidence, in June 1978, while Hastings and Mires were negotiating the process to allow nurse practitioners to dispense, the Commission on Pharmacy refused to relicense the State Public Health Department Laboratory (which held pharmaceuticals over which the Commission on Pharmacy had jurisdiction) and required Mires, who oversaw the lab, to close the lab, move the facility, and install expensive and extensive environmental, architectural, and procedural controls prior to reopening. At this same time Mires was also in difficult and contentious negotiations with the Commission on Pharmacy to allow paramedics and emergency medical technicians to administer medications in emergencies, and the Commission on Pharmacy and Board of Medicine (of which Mires was a member) were disputing Board of Medicine handling of physicians referred for Board adjudication by the Drug Investigation Unit and Commission on Pharmacy, Commission on Pharmacy minutes, April 19, May 10, June 21, July 26, November 8, 1978.
56. Letter dated November 17, 1977 from Attorney General David Souter to Commission on Pharmacy, attached to Commission on Pharmacy minutes, December 14, 1977;
57. Commission on Pharmacy minutes, September 19, 1979, August 13, 1980, May 26, 1982.
58. See Mires 2005, lines 675-91.
59. The Commission on Pharmacy also opposed dispensing, prescribing, or possessing medications by nurses in college health clinics, and by optometrists, chiropractors, paramedics, and emergency medical technicians. Commission on Pharmacy minutes, December 18, 1974, April 19, 1978, July 26, 1978, June 18, 1980, May 7, 1986.
60. See White, lines 909-31; letter dated November 12, 1977 from Betty H. Mitchell and Donna White to "Dear Fellow Practitioners," folder "Legislation 1970s."
61. Personal communication with George Roberts, February 8, 2005. See also transcript of oral history with George Roberts, January 22, 2005 (cited as Roberts), lines 105-50, 415-20, 681-88.
62. Letter dated January 24, 1978 from Debbie Clark, RN PNP, Recording Secretary, NHNPA, to "Dear Practitioner," folder "Legislation 1970s."
63. See transcript of oral history, Cynthia Cote recorded February 11, 2005 (cited as Cote), lines 860-63.
64. Cote, also lines 1353-86.
65. Kuhlman, lines 118-25, 1037-51;
66. Interview with Donna Cassioly, March, 3, 2005, lines 403-24. All NHNPA meetings from January 1977 through September 1983, with the exception of a few dinner meetings at area restaurants, were held after hours or on Saturdays at the Concord Clinic in Concord, where Kuhlman and Cassidy worked with Kuhlman's husband, obstetrician Gerry Hamilton.
67. See NHNPA minutes, January 11, 1977-September 18, 1983. Letters sent to nurse practitioners through January 1980, when NHNPA had its own letterhead printed, were sent on Concord Clinic letterhead.
68. See Weeman, lines 934-41;
69. Cote, lines 617-716;
70. Charest, lines 1060-70, 1500-1580;
71. Dirubbo, lines 440-57, 815-29, 844-80;
72. letter dated January 24, 1978 from Debbie Clark, RN PNP, Recording Secretary, NHNPA, to "Dear Practitioner";
73. letter dated January 29, 1979 from Kathy Higgins Cahill, President, NHNPA, and Prescription Task Force members Chris Kuhlman, Gloria Klein, and Paula Weeman, to "Dear Nurse Practitioner," folder "Legislation 1970s";
74. NHNPA minutes May 1, 1979, folder "Minutes 1970-1980."
75. Kuhlman, lines 215-16.
76. See NHNPA minutes September 11, 1978, folder "Legislation 1970s."
77. NHNPA minutes June 5, 1979, folder "Minutes 1970-1980."
78. Reginald W., Rhein, Jr, "Nurses Colleagues or Competitors," Medical World News, 1979, 20-65, 69-71, 73.
79. Roberts 2005, lines 552-54.
80. Interview with Laurie Harding, White River Junction, Vermont, June 14, 2005 (cited as Harding), lines 683-716.
81. NHNPA minutes, January 12, 1980
82. NHNPA Papers, Box 1-1, folder "Legislation and Minutes 1980."
83. Mires 2005, lines 239-81.
84. Board of Medicine minutes, October 1979, New Hampshire Board of Medicine Minutes, July 6, 1978-December 16, 1979.
85. NHNPA minutes, June 12, 1981, folder "Legislation and Minutes 1981."
86. The June 2, 1981 NHNPA minutes discusses the second legislative attempt and failure. See May 1980 minutes, folder "Minutes 1980s"; minutes, January 1, February 2, September 16, 1983, folder "Minutes & Correspondence 1980-1983."
87. NHNPA minutes June 5, September 11, 1979, folder "Legislation & Minutes 1978 & 1979."
88. Cote, lines 1120-65.
89. Medical-nursing boundaries are further discussed in Fairman, "Delegated by Default or Negotiated by Need?";
90. Keeling, Nursing and the Privilege of Prescription.
91. Julie Fairman, "The Roots of Collaborative Practice: Nurse Practitioner Pioneers' Stories," Nursing History Review 10 (2002), 159-194.
92. Susan M. Reverby, "The Sorcerer's Apprentice," in Prognosis Negative: Crisis in the Health Care System, ed. David Kotelchuck (New York: Vintage Books, 1976), 170-183.
93. Other scholars disagree with Reverby's analysis in this early work. For example, in more recent scholarly work, Fairman, "Delegated by Default" (1999) has found that nursing academics' dismay at the idea of nurse practitioners was more an aspect of "insecurity" and a "prevailing fear ofa middle man between nursing and medicine taking away nurses' power," while physicians were supportive of and encouraged nurses crossing medical boundaries. See also O'Reilly, Health Care Practitioners: An Ontario Case Study on Policy Making. (Toronto: University of Toronto Press, 2000).
94. Weeman, lines 1165-74.
95. Cote, lines 1336-86.
96. Nursing history is, of course, more varied and nuanced. For a comprehensive discussion of nurses' work identity intermingled with personal, cultural, and community identity, see Patricia D'Antonio, "Revisiting and Rethinking the Rewriting of Nursing's History," Bulletin of the History of Medicine 73 (1999): 268-90, at 270.
97. Nancy Rudner Lugo, Eileen T. O'Grady, Donna R. Hodnicki, and Charlene M. Hanson, "Ranking State NP Regulation: Practice Environment and Consumer Healthcare Choice," American Journalfor Nurse Practitioners 11, no. 4 (2007), 8-9, 14-18, 23-24.