Nursing and the Privilege of Prescription, 1893–2000 (review)

Physicians are responsible for prescribing drugs and other treatments for patient problems, and this has long symbolized medicine’s most deeply imbedded cultural authority and power. This prescription responsibility is also the site where practice boundaries are most actively contested as other providers and even patients believe they can safely prescribe in certain situations. In her book, Nursing and the Privilege of Prescription, Arlene Keeling uses this concept to examine the shifting professional boundaries of clinical practice. The book is built around a series of case studies that illustrate nurses’ informal diagnostic and prescriptive activities from 1893 to 2000. Keeling uses the nurses of the Henry Street Settlement, the Frontier Nursing Service, the Bureau of Indian Affairs, critical care, and nurse anesthetists to demonstrate the “elusive and fine line” (p. xix) that demarcates clinical care and how this artificial boundary is contextualized by place, time, and economics.

The Frontier Nursing Service is the focus of at least two of the chapters and illustrates how physician shortages, the type of population needing health care, supportive physician colleagues, specialty education, and astute political maneuvering supported nurses’ prescriptive activities. Founded in 1925 by nurse Mary Breckenridge, a member of the Kentucky elite, the Frontier Nursing Service was a decentralized nurse-midwife program that provided care to Leslie County, Kentucky, patients in their homes. This was one of the most rugged and poorest areas in the nation and claimed only five physicians. To gain local medical society approval for the nurses’ expanded practice, Breckenridge enlisted supportive physicians to devise “medical routines” to guide them as they confronted problems ranging from minor injuries to the administration of ether. Traveling over poor rural roads by car or horseback, these nurses carried their tools and medicines in their car trunks and saddlebags; they routinely diagnosed, prescribed, and dispensed treatments to patients.

The boundaries of nurses’ work across all of the cases depended on the place, time of day, availability of physicians, financial conditions, personalities involved, and the political capabilities of nursing and medical societies to work together despite restrictive legal and social boundaries. And, in many of the cases, nurses’ diagnosing, dispensing, and prescribing occurred informally and were largely supported by physician colleagues who valued nurses’ ability and willingness to perform these activities in their absence. But not all providers were supportive. To cloak nurses’ diagnostic and prescriptive activities from uncooperative medical and nursing colleagues, mechanisms such as protocols and standing orders were developed. As Keeling points out, nurses essentially diagnosed patient conditions to know when and how to apply protocols.

Keeling examines places lightly covered in other sources, such as Indian reservations and Appalachia. Her sources are extensive and document less well-known actors such as grassroots practitioners, allowing the reader to see the general breadth of the instability of practice boundaries and the creativity individuals used to conceive innovative practice models. Her main argument—that the boundaries for prescriptive privilege are contextually dependent—supports an examination of contemporary health care beyond the rhetoric of both the nursing and medical professions to intraprofessional dissonance in nursing, medicine’s less than altruistic economic concerns over competition, and the collegiality between doctors and nurses that was required for service delivery in poor rural and urban areas.

The short conclusion (two-and-a-half pages) abruptly ends this overall successful, well-written, and important book. Prescriptive privilege is related to current health policy debates over access, cost, and quality of care, and a discussion of the intersection of these issues might have provided a more satisfying ending. Even so, the book provides a new historical understanding of contemporary health issues and should be a significant resource for policy strategists at all levels.