Nurses with doctorates, professional autonomy and the social construction of skill

A recent article in the Sunday New York Times reported on the growth of health professionals earning doctorate degrees and how this has generated “a quiet battle over not only the title ‘doctor,’ but also the money, power and prestige that often comes with it.” The article reports that, as would be expected, physicians are none too happy with this development. Laws already exist in Arizona and Delaware that limit the right of nurses to use the title of ‘doctor’. And a bill proposed in the New York State Senate would bar nurses outright from using the title, whether or not they hold a doctorate.

According to the article, “Nursing leaders say that their push to have more nurses earn doctorates has nothing to do with their fight of several decades in state legislatures to give nurses more autonomy, money and prescriptive power.” This is a rather strange position for nurses to take, and the article does not present any further reporting indicating that that “nursing leaders” do in fact hold this position. The only nursing leader interviewed is Dr. Kathleen Potempa, dean of the University of Michigan School of Nursing and the president of the American Association of Colleges of Nursing, who said the doctor of nursing practice degree is an attempt to “continuously improve our curriculum” in a context of ever-expanding knowledge.

But surely issues of autonomy and prescriptive power are central to good nursing practice and inextricably bound up with the issue of nursing skill. It is a staple of the sociology of professions that autonomy is a core element of what defines a profession, with physicians being the canonical example. Physicians and their associations (like lawyers and other professionals), continuously seek to expand their autonomy vis-à-vis the state, hospital boards and administrators by arguing that, as professionals, they are capable of self-regulation within their occupational body. It is argued that such autonomy is critical to their ability to do their job effectively.

So why wouldn’t the same logic apply to nurses? It should, and nursing associations should embrace it. (Of course, there may be problems with the arguments of physicians for professional autonomy, but that is another issue.) But there is another underlying issue here that has even less to do with medical effectiveness and efficiency: gender and the social construction of skill.

The article reports that physicians are concerned that patients may be confused over use of the word “doctor.” But this touching concern may be masking a more serious concern, which is a threat to the “autonomy, money and prescriptive power” of physicians! In other words, the issue provides a classical instance of a jurisdictional dispute that has little or nothing to do with concern for patients’ well-being.

We tend to think of the existing division of labor in healthcare, like much else in our society, as natural. But it is the product of a particular set of historical struggles. And there is nothing natural about the unfortunate fact that the profession of physician is predominantly composed of men while nursing is predominantly female. While it is true that physicians have more training than nurses, it is highly questionable whether this difference in education fully accounts for the massive gap in pay between the two groups.

On the one end, the pay of physicians is artificially inflated above market rates by their professional power to restrict entry into the field. Indian and Cuban doctors have the same skills and would work for substantially less. On the other end, nurses are engaged in emotional labor of caring for patients that can be terribly stressful, performing tasks that are undervalued because nursing is seen as a female occupation and caring a female attribute (rather than a skill). And because of their status as semi-professionals, nurses are less able to resist work intensification than physicians are.

Nurses, indeed, are under severe pressure for work intensification, with patients as well as nurses losing out due to chronic hospital understaffing. One way for nurses to resist work intensification and claim some dignity is through unionization. Another is through increased education and professionalization.

If, by earning doctorates, nurses are increasingly able to capably perform more and more of the work of physicians, then the latter should be worried indeed. But I suspect that confused patients are a minor source of their concern.

In any case, the struggles over professional autonomy and the social construction of skill will continue, and it is far from clear whether the continuing professional dominance of physicians is better for patients or for healthcare efficiency.