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Advanced practice registered nurses (APRNs) provide care that includes tasks traditionally done by physicians. APRNs combine the holistic nursing care model with additional practitioner training. Research shows that APRN care is at least as effective as physician care, contrary to the claims of some physicians and their organizations. Hollywood depictions tend to suggest that APRNs are merely skilled assistants to physicians. Other portrayals show disdain; consider a joking suggestion on Disney’s Lab Rats in 2013 that one character was a nurse practitioner because he had flunked out of medical school. Other shows have suggested that ambitious nurses aim for medical school. Some news stories have given a sense of APRN practice, but APRNs are usually ignored as health experts. Other press accounts have wrongly suggested that APRNs can treat only minor problems. The news and advertising media often reinforce the idea that practitioner care is provided only by “doctors.”

This chapter evaluates how the presence of the nurse practitioner (NP) does not just signal changes in nursing work; it portends changes in medical work. Although real tensions exist between nurses and physicians, broadly speaking, they have worked collegially alongside one another for well over a century. This collegiality has endured despite significant changes in what both physicians and nurses do for patients. Its endurance, however, has been predicated on the one thing that has not changed: the power relations between the two. It is the difference in authority, and not just the difference in work, that undergirds the stability of the relationship between the two professions. The NP threatens to disrupt that stability. When registered nurses (RNs) become NPs, they are not just learning new skills; they are crossing lines of authority that they had previously learned to treat as constitutive of their profession. The chapter then looks at the voices and experiences of the NPs of Forest Grove Elder Services. Their narrated and actual practices negotiated physician authority in very different ways.

This chapter discusses the status and identity of the nurse practitioner (NP), which was not fully resolved until the mid-1980s. Nursing did eventually rally around NPs, so that today there is little question over which profession they belong to. The chapter then situates who the NPs of Forest Grove Elder Services understood themselves to be within nursing's larger political and existential fight for an identity apart from medicine. NPs may have been created to provide routine care, but in becoming the providers of the poor, disabled, or otherwise medically marginalized, they have been asked to meet a fairly high bar of expertise. Ultimately, the Grove and its NPs were on the front lines of an enduring fight to both expand nursing's reach and maintain its separateness from medicine. While nursing has not been above marshaling claims of interchangeability when it appeals to policy makers, its advocates have also understood that its professional independence depends upon nursing maintaining work and knowledge that exist apart from medicine.

Policymakers and healthcare leaders have highlighted the potential for nurse practitioners, physician assistants, and pharmacists to play a larger role in meeting healthcare needs. Each of these professions has a different history and role in healthcare delivery, but they share common issues regarding professional control and independence, and rising educational standards. The influence of these factors on the professions’ roles in different healthcare settings including integrated practices, hospitals, and community-based practice organizations are reviewed. The chapter assesses the potential need for changes in education, scope of practice regulations, and payment policies to optimize the employment of these professions in the enhancement and expansion of care. There also is a need for research and evaluation to determine the optimal placement of each of the professions, the efficacy of their educational programs and licensing standards, and approaches to ensure optimal collaboration and decision-making across the professions and organizations.

This chapter explores the ways in which the presence of the nurse practitioners (NPs) is both a cause and a consequence of the changing organization of medical work. While NPs are often thought of as filling in for physicians, at the Forest Grove Elder Services, there were new pressures on the physicians to fill in for the NPs. In the face of these pressures, the physicians marshaled the traditional prerogative of being a professional and engaged in acts of refusal. These physician refusals had the intended effect of protecting their status and expertise, but they had the unintended consequence of leaving even more of medicine's traditional realm of responsibility to nursing. Ultimately, the introduction of the NP into the medical encounter raises questions not only about what uniquely constitutes a physician's work but also about what it means to be a medical expert in modern health care.

This chapter examines how certain problems arrived on the nurse practitioners' (NPs) lists of things to do and how this arrival reflected both professional and organizational understandings of NP work. From meetings to email exchanges, the NPs were joined by a host of others in receiving member information. This information was not only about disease processes but also about family relationships, community context, and each member's experience of the Forest Grove Elder Services' system of coordination. Yet the NPs were singular in performing a professional openness to incorporating such diverse information into their clinical view of members. The NPs' openness allowed them to cultivate a layered knowledge of each member that was distinct from the understandings of other providers on the team. More importantly, they were uniquely positioned to wield that knowledge from inside the medical encounter. In a health care context, problems that could be relocated to the clinic were treated with more urgency and more resources than those located outside the clinic. The act of relocating a broad range of problems to the medical encounter was at the core of the NPs' performance of clinic work. Situated in the health care encounter, clinic work was not just added to traditional notions of medical work, it was a reconfiguration of what it meant to practice medicine when it was practiced by nurses.

This chapter investigates how the nurse practitioners' (NPs) performance of clinic work was at once a professional responsibility and an organizational one. Although the Forest Grove Elder Services' model pressed all its providers toward more diffuse definitions of work, the responsibility to resolve distinctly organizational problems was unique to the NPs. Despite an organizational logic of interchangeability, clinic work was not medical work, and the physicians were not NPs. The enacted distinctions between NP and physician work were not the result of an agreed-upon division of labor. Rather, they were a function of who had the power to say no to organizational concerns. At the same time, the NPs' obligations to dispatch organizational care work did not absolve them from attending to medical concerns. Instead, they were asked to carry out the mission of the organization as an integral part of what it meant to medically care for members. The NPs were not just doing different work from the physicians; they were doing so as very different kinds of organizational actors. The NPs' performance of organizational care work was crucial to how the Grove fulfilled its mission of comprehensive care; however, like other forms of care work, it was neither always visible nor recognized as requiring expertise.

This concluding chapter argues that, although created as a solution to physician scarcity, the nurse practitioner (NP) is just as often working on the front lines of the care crisis. The Forest Grove Elder Services ostensibly hired its NPs for their medical expertise, but in practice, it deployed them as much more than substitute physicians. In addition to the mandates of medical work, the Grove held its NPs uniquely responsible for care coordination. Ultimately, the NPs' performance of organizational care work had become the cornerstone of the Grove's goal of comprehensive care provision. Yet it was equally clear that the work and expertise required to meet this goal were largely unacknowledged. Indeed, NPs' work often goes unrecognized, but their performance of it has the potential to transform how patients experience the health care encounter. The chapter then suggests that NPs are often not doing the same work as physicians. In this account, the aim is not only to reveal the hidden work of yet another location of feminized labor but also to shine a light on the central importance of that work for patients.

This introductory chapter provides a background of Forest Grove Elder Services and its nurse practitioners (NPs). It advances the notion of clinic work to illustrate the ways in which the Grove's NPs brought care work into the medical encounter. The term “clinic work” reflects the reality that the NPs' work was different in both form and content from the medical work of their physician colleagues. It also underlines the ways in which the NPs' work invoked a different form of relationality—it was in deep relationship with the organization or clinic in which it was located. Forest Grove Elder Services is not an ordinary outpatient clinic. It is a federally backed policy experiment to evaluate whether a comprehensive care model could ameliorate the state's economic burdens for long-term care. In some ways, the Grove's experimental objective was to figure out how to deliver care work under the aegis of medical care. Thus, the Grove's NPs were not simply performing an expansive form of work on behalf of their patients; they were also providing an expansive form of organizational care work for their employer. The chapter then considers the utility of NPs under state retrenchment.

This chapter assesses the challenges faced by the Forest Grove Elder Services' social workers, providing a better understanding of the hurdles faced by the profession at large. State disinvestment in social problems grounds the devaluation of social work as a profession. However, this may be of little interest to anyone who is not a social worker. If the Grove's members were getting their needs met by others—whether it be nurse practitioners (NPs), chaplains, or occupational therapists (OTs)—it is not readily apparent how this devaluation might impact anything other than the professional aspirations of social workers. The chapter then argues that there are consequences for relocating problems from one terrain to another. The tools found in the clinic may not be the same as those located outside it. Moreover, not all social work concerns are necessarily taken up by those best positioned as advocates. At the Grove, social concerns were addressed both by those with recognized credentials and by those without them. When anyone is perceived as able to do social work, clients may lose an ally with the organizational power to advocate on their behalf. The chapter illustrates that the relocation of social problems has implications for people's understanding of what constitutes those problems and what they envision as the available arsenal of solutions.

This chapter, like the entire volume, is dedicated to the memory of Channi Kumar. I first met Channi in August 1984 in Oakland, California, at the biennial meeting of the Marcé Society, hosted by James Hamilton. I had already been impressed by Channi’s research but knew him only through his published work. In person, the man did not disappoint. He was elegant and kind, a man who treated everyone with respect. Over the years, my affection and admiration for Channi grew through many stimulating discussions and delightful social occasions. Even our last series of meetings focused on a new, exciting initiative of Channi’s: the ‘Transcultural Study,’ which he envisioned as a way to harmonize the detection, assessment, and treatment of perinatal mood disorders, across western Europe and even the United States, Asia, and Africa. Through experiences like these, Channi made my life richer, personally and professionally; and I greatly miss him as a mentor and a friend, and feel privileged, along with my colleague Lisa Segre, to contribute a small piece to honor this great psychiatrist and humanitarian. Michael W. O’Hara Perinatal depression is a significant mental health problem that afflicts women around the world at a time when they are highly vulnerable—pregnant or managing a new infant. In one form or another, perinatal depression has been recognized for thousands of years; however, only in the past 50 years has there been a sustained focus on the non-psychotic mental illnesses experienced by some during pregnancy and the postpartum period. The literature of the 1960s contains only a few papers with the words postpartum depression, postnatal depression, or perinatal depression. Not until the 1970s did these terms come into common use. Indeed, a search for at least one of these terms on the PsycNET database (from entries catalogued between 1884 and 9 September 2012) revealed the vast majority (2,743 or 75%) of 3,651 papers, books, and book chapters on perinatal depression were published after 2000. These findings show how work in the field of perinatal mental illness has expanded exponentially.