On Not Being Heard

I pounced on the invitation I received early this year to provide testimony to the Virginia Senate Subcommittee on Health Licensing. I, along with others, spoke in support of a bill that would move responsibility for licensure and regulation of NPs from the joint boards of medicine and nursing to the sole authority of the board of nursing. The bill would also remove requirements for physician supervision of NPs. In my effort to invite more edge in my life and to be of maximal service, I recognized this as an opportunity to speak in a public forum on a topic that is very meaningful to me—after all, I am in a private practice in Virginia and must comply with Virginia’s antiquated nurse practice act, which was last updated in 1973.

The Virginia Council of NPs made a valiant effort to get this bill introduced and to get it as far as this hearing. The behavior of some people attending the hearing indicates that we still have a lot of work to do.

My role was to provide the national NP context. My charge was to describe how states need to modernize their practice acts to accommodate 21st century practice; how Virginia needs to comply with the APRN consensus document, as states must align with new national standards; how the chronicity epidemic is impacting the primary care workforce; how 4 decades of research on NPs demonstrate high quality and safety, blah blah blah….

The Hearing

Over 30 Virginia NPs packed the front of the room. The last row was all physicians in white coats. NP colleagues explained current NP practice and the ramifications of physician supervision. Members of the subcommittee asked questions such as “Why would we give nurses a license to practice medicine?” and “Are NPs practicing medicine?” It became apparent that the legislators were not listening to the answers.

The physicians’ organizations testified after the NPs. Several national and state physician organizations denounced the bill, calling it “unsafe” and claiming that “it is important to maintain the tethered relationship physicians have with NPs.”  Some of the groups testified that the educational preparation of NPs was less than that of MDs and was of inferior quality. These speakers maintained that NPs must be regulated by MDs from a public safety perspective.

What shocked me most of all wasn’t these claims by physician organizations but the behavior of the legislators. One by one the legislators got up and left the hearing room during the testimony, appearing as if they had to answer cell phone calls or address other business. When it was time to take a vote, only 2 senators remained in the room. Without a quorum, the bill just faded away.

Maybe the legislators had to attend to other pressing legislative matters. Maybe they did want to support the bill but felt they could not support it with the heavy physician presence. Perhaps they did not have the courage, energy, knowledge, or respect for the NPs in the room to state their opposition to the bill. I was taken aback by both the limited knowledge base of these legislators and their indirect, unorthodox approach for killing a bill.

If you were in the room, you would have heard us. You also would have heard us not being heard.

I realize that I spend far too much time with like-minded NPs—all of my students and most of my colleagues are NPs. I have been in a cocoon, protected from direct interaction with the uninformed and with those who are invested in repressing NPs. The testimony I provided would have had the same  outcome if it had been presented to a brick wall. I am not frequently in a world in which I am not heard. It was hard to miss the lack of national NP organizations in the room supporting the bill and collaborating with the Virginia Council of NPs. The physician organizations were far more sophisticated in their opposition to the bill. There are over half a dozen national associations of NPs, and it was astonishing that not one was there to defend the bill and assist a state towards modernizing its NP practice act.

By far, the best part of the experience for me was being witness to a room filled with NPs who came to  support the profession. Men and women took time off work and came prepared to say and do whatever was asked of them. Seeing the NP leaders who had shepherded the bill to this point, carefully scripted the testimony, and arranged to fill the room with NPs has left me with a deep sense of optimism.

When Women Speak

Women’s voices have been heard in many arenas in this country; they have shaped drunk driving laws, reproductive rights, and employment discrimination. Could APNs be on the verge of influencing health care? In the hearing room there was a very deep conflict, and it was palpable as the male legislators disconnected from our concerns. It ended in the “pull of the familiar”—the traditional pull of medicine was granted the higher value.

For centuries, women have been excluded from many professions, and once admitted, they have been expected to practice within established structures. What APNs are doing is entirely different. We are not asking to acculturate into medicine, but rather to create new standards and new roles that are largely  dominated by women. What we are doing across states, in our attempt to emancipate ourselves from the medical profession, is to stake out an entirely new domain: to practice advanced practice nursing.

While we can’t divide the world along gender lines, the relational framework used by NPs is not universal in health care. Women are much more attentive to values of caring, connection, and context than are men. The relational approach that all APNs (men as well as women) embody brings a distinctive perspective to our professional roles and patient encounters.

It is important not to oversimplify or overclaim the role of APNs. We have multiple sources of identity. From the beginning, NPs were grounded in primary care.  As we have evolved to roles in every sector of health care, our identity has changed. What happened in that hearing room was quite threatening to the MDs present and perhaps to the few legislators who listened, because we were publicly asking to be free of subordination. We were requesting that health systems release themselves of physician dominance and become transformed in the process.

It’s Not Over

All of the NPs present at the hearing are emboldened to see this measure pass in the next session. The hearing was a call for us to resist and to speak up more, because what we are promoting goes against the grain of what is socially accepted: the physician as captain of the ship. There are many ways to resist oppression, and being heard is just the beginning. We hope to be listened to, understood, and integrated into the mainstream.

 Dr. Eileen T. O’Grady is in private practice as a certified nurse practitioner and wellness coach. She teaches health policy and wellness coaching at Pace University. Dr. O’Grady is the policy editor for NP Communications, LLC, and an editorial board member for The American Journal for Nurse Practitioners. She can be reached through www.eileenogrady.net.