Julie Fairman, Making Room in the Clinic: Nurse Practitioners and the Evolution
of Modern Health Care (New Brunswick, NJ, Rutgers University Press, 2008)
A revolution was taking place in US healthcare during the 1960s and 70s. A shortage
of physicians, particularly in deprived and rural areas, coinciding, with a dramatic and
rapid advance in the development of nursing skills and knowledge, led to a seismic
shift in professional boundaries. The result was the emergence of the ‘nurse
practitioner’: a completely new type of nurse. The role developed slowly at first, as a
necessary response to patient need, and then gained momentum as governments and
policy-makers came to recognise its value and cost-effectiveness. Complex as it was,
the real nature of the nurse-practitioner movement has, until recently, been difficult to
define and trace. Its development has been shadowed in uncertainty and controversy,
and it is for this reason that Julie Fairman’s lucid and detailed history is such a
welcome contribution to historical scholarship.
Meticulously researched (using both archive sources and oral history interviews) and
convincingly argued, Fairman’s book is admirable in its willingness to tackle some of
the more complex and difficult aspects of the history of the nurse practitioner. The
author demonstrates how important the initial grass-roots development of the
movement was, showing how individual nurse-physician partnerships experimented
with the shifting boundaries between a medical profession which was becoming
increasingly hard-pressed in some of its less popular and lucrative areas of practice,
and a nursing profession which was, for the first time, asserting its rapidly-growing
knowledge and clinical prowess. Fairman also draws our attention to some of the
most impressive academic partnerships of the mid century, notably those of Dorothy
Smith and George Harrell at the University of Florida, and Joan Lynaugh and Barbara
Bates, at the University of Rochester.
When she moves to a consideration of how the nascent nurse-practitioner movement
began to cohere as a nation-wide health care reform, Fairman leads us adeptly through
the confusing turf-wars of mid-twentieth-century healthcare. She avoids
generalisations, demonstrating instead how some physicians supported and nurtured
the developing movement, whilst others were, at times, destructive in their opposition.
The book analyses the nature of the difficult and sometimes dangerous ‘borderlands’
between medicine and nursing demonstrating its author’s consummate skill as a
historian capable of uncovering the finest detail without losing sight of the larger
picture.
One of the most important sections of the book is that which offers an interpretation
of the relationship between physicians’ assistants and nurse practitioners which is
based firmly in an analysis of mid-to-late-twentieth-century gender-relations.
Physicians assistants, who were mostly male and nurse-practitioners, who were
mostly female, found it difficult to negotiate their roles within the ‘borderland’
territories between nursing and medicine. Fairman offers the reader clarity by
demonstrating how different the motivations of the two groups were: physician’s
assistants aiming to practise a ‘lesser’ form of medicine, whilst nurse- practitioners
saw themselves asserting the breadth of nursing practice, moving comfortably into
areas of natural overlap between their own profession and that of medicine.
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Finally, the book offers an important analysis of the political context of the nursepractitioner movement, tracing the ways in which federal governments dealt (more or
less successfully) with the complexities of mid-to-late-century shifts in healthcare
boundaries, and analysing the sometimes-disappointing responses of professional
organisations to the emergence of the new nursing roles. Fairman draws our
attention, in particular, to how difficult it was for the American Nurses’ Organisation
to free itself from its prevailing preconceptions about the boundaries of nursing work
in order that it could support the newly-emerging practitioners. The reader is left in
no doubt that it was not the leaders of the profession but a thriving grass-roots
movement that drove forward the reforms of the mid-century.
I would commend Julie Fairman’s carefully-researched and eminently readable book
not only to nurse-historians, but also to anyone interested in the development of postwar healthcare in the USA, or in political, economic and social change during the later
decades of the twentieth century. Above all, this readable text offers us insights into
the ways in which nurses were able to break free of pre-existing constraints in order to
demonstrate that they were not (and, in fact, never had been) merely operatives who
carried out ‘medical orders’. Their skills- and knowledge-base, their underlying
education and their capacity for astute clinical judgement, made them the
independent, autonomous practitioners at the apex of a rapidly developing healthcare
world.
Christine E. Hallett
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