Conclusion

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.

The Misrecognition of Social Problems

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.

New Boundaries, New Relationships

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.