THERESE HIDALGO, C.F.N.P.
PROUD TO BE A NURSE
Belen, New Mexico
Therese Hidalgo will tell you quickly and with pride that she is a New Mexican and a nurse practitioner. Twice a graduate of the University of New Mexico, trained at St. Vincent Hospital in Santa Fe, and now living in the railroad and farming community of Belen, she works at the town's ambulatory care center, which once was its hospital. Hidalgo has been a leader in the successful campaign to expand the scope of practice for nurse practitioners and an enthusiastic proponent of their role in delivering care in rural New Mexico.
Dressed in slacks and a vest, her desk stacked with patient charts, her office walls decorated with children's drawings, Hidalgo is at home in her clinic. When she began practice in Belen in 1991, she was the area's first nurse practitioner and, in her words, she had to “break some ground.” Doctors who had known her as a nurse had to adjust to her new role, and patients—many of whom had never heard of a nurse practitioner—had to try her out to form their own opinions. She does believe that doctors and nurses bring different perspectives to patient care, variability she salutes.
I'M A NURSE PRACTITIONER. I'VE had to break some ground, do some educating, and change some attitudes in both doctors and patients. I trained at New Mexico's premier educational institution—the University of New Mexico—but my practice is in a small town that never had seen a nurse practitioner before. Still and all, I see myself first and foremost as a nurse. I do some of the things that doctors do, but I am and always will be a nurse. I got a letter recently addressed to T. Hidalgo, M.D. The physician I work with saw the letter and said, “Look at that, Therese. Gosh, doesn't that make you feel good?” I said, “Absolutely not.” I want people to know that I don't feel I'm bringing something less than a doctor to my profession. I'm happy being a nurse who does some of what physicians do.
A person from Mars could probably tell by dropping in on our practice that doctors and nurses represent two different perspectives and ways to treat a patient. But it's subtle, and it also depends on the individual providing the care. I've seen some physicians who take almost a nursing-type approach to their patients. I remember telling one physician, “Gee, that was just so ‘nursey,’ the way you intervened with that patient. I'm really impressed.” I'd like to shed some of the old stereotypes and visions about our professions.
I began life as a New Mexican, but then detoured to Arizona for my early years before returning to New Mexico. I was born in Las Vegas, New Mexico, in 1955, and grew up in Phoenix. I went to Catholic schools in Arizona through high school, and then moved back to New Mexico to go to college at the University of New Mexico in Albuquerque. I've been here in New Mexico ever since.
My mom worked as a nurse's aide in Phoenix and raised eight children on that income, which was difficult. She was a single parent; my father died when I was in third grade. Later my mother remarried, and we have three half-sisters, so there were eleven children in my family.
My high school in Arizona was mostly white and middle-class. There were very few Hispanics, and I definitely encountered barriers because of my ethnic origin. My original last name was Lopez. When my step-father adopted me I became Bloyed, but I was clearly Hispanic in appearance. In Arizona, the Hispanic population is treated differently than in New Mexico. I think there's more discrimination in Arizona—and prejudice. Most of the Hispanics had Spanish last names and accents that stereotyped them. I was a good student without an accent, and I didn't
My mom always wanted to be a nurse, so I thought that by becoming a nurse I could fulfill her dream and mine, too. At first, actually, I thought about going to medical school, but I remember deciding as a sophomore in high school that I wanted to have a family and that combining family and medical school wouldn't work. In those days, in my culture, family came first. So that helped me make the decision about nursing. I had my mom's and my family's support in that decision. I knew when I went to UNM that I wanted to go into nursing, and I graduated with my bachelor's degree in nursing in 1979.
Eventually my mom did start nursing school, but at about sixty-five years of age she switched out of nursing school and went back to college. In 1999 she finally got a bachelor's degree in bilingual education and counseling. There are several other nurses in our family. My brother became a licensed practical nurse and then went on to become a registered nurse. He and I used to have long discussions about L.P.N.s and R.N.s, and I kept urging him to go back for his R.N. When he did, I was very proud of him. I also have a sister who graduated from Arizona State University in nursing and is working on an Indian reservation in Tuba City, Arizona.
I started my nursing career on the floors at St. Vincent Hospital in Santa Fe. Obstetrics was my first love, and gradually I moved toward maternal-child areas, doing several years in labor and delivery followed by a year as the hospital staff educational coordinator. Altogether, I practiced in Santa Fe about seven years.
In 1977 while I was still at UNM, I married Miguel Hidalgo, a fourth-generation New Mexican from Belen. Miguel graduated from the University of New Mexico in architecture and has worked for both the state and in private practice over the years. Currently he is the director of capital projects for the state's Commission on Higher Education. We had the first of our three sons in 1980, while I was working in Santa Fe. Nursing has been very good to me in terms of raising a family because it allows a lot of leeway in choosing shifts. People think working the graveyard and evening shifts can be a real downer on family life but, actually,
When I was pregnant with my third son, my husband and I decided to make the move here to Belen, New Mexico, where my husband was born and raised. It's very different from Santa Fe, but it was good for our family goals, including raising the boys in the country. We have a ranch where we all help with breeding Santa Gertrudis cattle. We enter the cattle in state fairs, show them, and travel with them—it's a lot of fun.
In August of 1986, I began to work at the local hospital here in Belen. At first I was fearful about the new job, because I had become very specialized in maternal-child care early on in my career. I had no experience working in a small rural hospital, where an R.N. is responsible for an emergency room. I also had to handle geriatrics and take care of male patients again after primarily caring for women in recent years.
So the transition made me a little bit nervous—but it was probably the best thing that could have happened to me. I was challenged by the diversity of the job and became much broader. Even so, I was quickly driven toward labor and delivery again, and became head of the clinical department for maternal-child areas, including labor and delivery, postpartum, and pediatrics. I became a supervisor as well as a clinician.
Our hospital was one of several satellite rural hospitals owned and operated by Presbyterian Health Services, and it was closely affiliated with the main Presbyterian Hospital in Albuquerque, thirty-five miles to the north. It was a thirty-four-bed hospital with full obstetrical services, including surgery and C-sections. We had a general surgeon here, an obgyn, two internists, a pediatrician, and some family practice doctors. We saw some acute care patients, but most emergencies were transported to Albuquerque.
Like many other rural hospitals around the country, however, it was in financial trouble. We served a large Medicaid population at the hospital, and there were reimbursement problems and ongoing financial losses. Finally, Presbyterian decided that, without support from the community, they would be forced to close the hospital. This was tough for the town and tough for me personally.
There was a lot of community discussion and some division, even
The year 1990 was also a year of change for me personally. Since the mid-1980s, as the obstetric nurse director in Belen, I had served on a lot of committees, both in the local hospital and in the larger organization in Albuquerque, which took a lot of time and commitment. By 1989, I wanted to do something for me, so I decided to go back to school for my master's degree in nursing. Even back in the 1970s, when I was getting my R.N. degree, I knew that I eventually wanted to be a nurse practitioner, but the UNM Medical School closed down its nurse practitioner program in 1980. So I had to tuck that dream away for a while, but I never let it die.
When I started looking around in 1989, I learned that the University of New Mexico was thinking of starting up a nurse practitioner program again. Even though they hadn't found grant funding yet, I started telling people I met that I was going to be part of UNM's new nurse practitioner program. I think the school felt sorry for me; in any case I was one of the first seven people chosen for the pilot program. I entered in fall 1989 and finished in 1991.
I had a lot of the same instructors in the UNM graduate program that I'd had as an undergraduate, but there was room for growth, and our group was able to make suggestions that were used to improve the program. There were still no role models in our preceptorships, though. I knew a nurse practitioner in Santa Fe, Barbara Salas Stehling, and asked her to come and talk at some of our educational programs, but I never worked directly with her. She was probably the only role model I had. The physicians I worked with in preceptorships didn't know much about nurse practitioners either, because they hadn't really worked with them.
Despite the lack of a role model or mentor, I did come away from the
The role of the nurse practitioner was more limited when I was in school. Prior to changes in the Nurse Practice Act in 1991, nurse practitioners worked only under the supervision of physicians and protocols. But some nurse practitioners were working in very rural areas, with only phone consultation, so physicians weren't really doing direct supervision. And while nurse practitioners have always been able to prescribe, their prescription authority did not include narcotics or scheduled drugs. Revisions to the Nurse Practice Act in 1991 tried to address all the different levels of independence: supervisory, interdependent, and independent. Nurse practitioners still had to maintain a connection with a physician, however, and various affidavits were signed to determine the level of the relationship.
In 1993, the act was amended again and cleaned up to get rid of all the language about differences between independent, interdependent, and doing supervised work. The new language says that we are “independent in primary care, chronic and acute, and will consult as needed.” At the same time, we gained the opportunity to apply for a Drug Enforcement Administration [DEA] number to write prescriptions for controlled substances. These changes in the Nurse Practice were supported unanimously by the state legislature in Santa Fe. I tell you, I think the nurses took the state medical society by surprise here in New Mexico. There was a lot of lobbying done on the part of our state Nurse Association. Not all the responses to the changes in the act have been positive, however. The osteopathic society, for example, has some objections on principle and has formally complained that the state legislature didn't give enough opportunity for rebuttal, so the changes slipped past them. I believe the state Medical Society also has made some comments. Pharmacists are also trying to become primary health care providers, and they have raised a lot of flags. The lack of role models is changing now. I have served on the Advanced Practice Committee for the Board of Nursing,
As the role of nurse practitioners has evolved, the program at UNM has also been growing. There were seven in our class, the next year about twenty, and this year almost forty. The goal of the program has been to promote rural health care, and much of the funding is linked to that goal. The program accepts people from out of state, and all graduates are encouraged to work in underserved areas. In my class, most of the graduates stayed in New Mexico, or on the border of Colorado and New Mexico, and about half ended up in rural areas such as where I work now in Belen.
After I finished the graduate program, I came back to work in Belen at the clinic in the former hospital, this time as a nurse practitioner. Many of the doctors and some of the nurses were left over from the hospital staff. It was comfortable to know the physicians already, but at the same time I felt a lot of pressure, because they had known me only in my previous role as a nurse. I thought, “Gosh, I'm supposed to know a heck of a lot more now.” So I put expectations on myself that I thought they would have for me. Actually, the physicians here have been very nurturing.
I was the first nurse practitioner at the clinic in 1991, and, although we have a number more now, I had to teach the doctors how my role had evolved. It turned out that I was a very welcome addition to the clinic staff, however, because the physicians were trying to handle their scheduled appointments and taking turns doing urgent care. It was very difficult for them, and they weren't happy about it. So I felt needed when I came back. It was hard at first because I was a new graduate, and I did need extra time, but they were willing to make an investment in me for their future benefit. They needed help most with urgent care, so that's where I started, and it really freed them up. I worked Monday through Friday in urgent care for about two years.
Doing just urgent care was challenging and exciting, and I loved coming up with diagnoses and treatments, but I missed having any continuity or follow-up with patients. And although providing urgent care was an ideal setting for learning more, by talking to the doctors and reviewing the charts, I simply didn't have the time for that. I was seeing patients constantly from the minute I arrived until way past the time to leave, and it wasn't fulfilling for me.
I wanted to develop longterm relationships with patients. That's why
It worked, and over time I have developed my own patients, who are pretty much exclusively mine unless they go to urgent care or can't get an appointment. The selection process by which patients and I choose each other is interesting. I've learned to know my own level of skill and experience and to recognize when I'm not the best provider for a certain patient. I can think of some complicated cases, like the woman with chronic obstructive pulmonary disease, polycythemia, and depression—a lot of health problems. She was fed up with the traditional physician providers that she'd had in the past, and she desperately wanted me to handle her care. Some patients see me as a person they can talk to, who won't talk down to them. But I knew at the time that this case was very, very complicated, so I consulted frequently with a female internist here. When the internist retired and that link disappeared, I felt I needed to direct this patient to another level of care. The process of learning my limitations was just part of the growing process, the learning curve. But it was hard when I first started, because the physicians didn't know quite what a nurse practitioner was, and the public surely didn't. It was different when I did just urgent care, because those patients don't choose who sees them. When patients make an appointment, they're making a selection, so it's clearer.
Then there were the patients who didn't like the idea of having a nurse instead of a doctor, so that was really hard. A lot of older people, especially, felt this way, although they expressed it in many different ways. Some said point blank: “I don't want to see a nurse,” while others would say, “Oh, I thought I was seeing my doctor.” The first year was probably the roughest, when I still found a lot of people who preferred to be seen by doctors. By the second year the numbers dramatically declined, and after that I hardly ever saw it.
People have a mental picture of a nurse and a physician; they've been socialized into those roles through television and their own past experiences in hospitals, so their whole frame of mind about a nurse is totally different. Once I gave a talk about nursing and the advanced practice role to some high school juniors on Career Day. I did an experiment, going
I've had coworkers say, “Therese, can't we call you something? Isn't there a title we can use instead of your name?” The doctor is called a doctor, and that makes people feel comfortable; people are not used to calling the doctor Rick. We joke around about that, but those comments reflect a real problem in how the public sees advanced practice nurses. I still go by my first name, like most nurse practitioners that I know. A title might make some people feel more secure, but, on the flip side, people feel more comfortable and less distant using first names.
I think physicians often have a different perspective on patients than do members of the nursing profession. When Ford brings out a new model truck, they put it on a revolving table for the cameras. Then they show you pictures from the side, from the front, and from the back, so you can get a feeling for the whole vehicle. Health care providers, in our different domains, also see patients from different perspectives. I can tell you from my early nursing experience, physicians brought more of a disease perspective, while nurses seem to provide the health perspective. Now, because of the changing health care market, we're all trying to work toward disease prevention and health promotion, so those lines are getting more blurred.
I do think primary care physicians are better than specialists and subspecialists at viewing the patient as a complete person, as more than just the disease, the organ, or the organ system. But nurses bring their own skills as educators and communicators to their relationships with patients. The emphasis on education is one of our strongest points. Nurses also definitely bring more of a casemanagement perspective. I'd like to see everybody really put their money where their mouth was. We all talk about disease prevention and health promotion, but no one is willing to pay for it.
On a personal level, I do a lot of counseling on weight management and diabetes education. This is an arena that's separate and different from the clinical care being provided by physicians. I see patients who, with regular consultations on weight management and nutrition, are able to stop their medicines, with obvious benefit to the patient and to the
The community context is also very important from our perspective. Nurses don't look only at the patient; we want to look at how that patient is affected by or affects the family context, and then at the family within the community. That is part of our perspective.
I'd like to see doctors and nurses take advantage of their different perspectives and look at patients as a team. Some tasks can be done by either, so let's consider cost effectiveness and let the nurse practitioner handle some areas, freeing up physicians for other things. With a health care team, we could improve access. When you sign up for a provider, you should be signing up for a team of providers that shares the responsibility for your care. That's how I'd like to see it evolve, but people need to think in new ways. You don't need a bazooka to shoot a rabbit; a BB gun will work just fine. You don't need that much velocity to get the rabbit, and you don't always need a doctor for primary health care services.
Although many more women doctors are entering the workforce, they are not necessarily more comfortable than men are with the nurse practitioner model. Actually, it has been the male physicians, in my experience, who are more comfortable with the two roles, and it's the male physicians who often show more of the “nursey” qualities at our clinic. I can tell you that many of the female physicians I've worked with have not brought those qualities to their role. In fact, a woman entering medicine and moving through medical education may actually suppress some of the feminine qualities she would normally bring to her role because of the competitiveness of medical school.
Politically, because New Mexico is a rural state, nurse practitioners are very well accepted, although I've been told that not all clinics are as accepting as ours is. One problem in a salaried setting is a certain amount of economic competition. At a meeting in Albuquerque, I heard a family practice physician sounding very resistant to the role of the nurse practitioner in her team, feeling that her income is threatened by the nurse practitioner. It's not the nurse practitioner per se that she's resistant to; it's the fact that physicians are seeing fewer patients because people are seeing the nurse practitioner when they could be seeing her, and her paycheck is based on that.
Nurse practitioners have been in New Mexico a long time, and I don't think they're going to go away, despite competition among different types of health care providers. I think the system will retain a variety of
Here in our practice we provide both primary care and nonappointment urgent care. I see primary care as an ongoing relationship. You begin a relationship by doing a new patient history and physical, and both of you should identify needs to maintain or improve health care of that patient, with ongoing surveillance. Primary care includes health promotion, screening, and episodic care. It's more than just coming in for treatment of a sinus infection or for an annual Pap smear.
Some people here in Belen, including many older people, have a different point of view. Some people show up at a doctor's office and just want medicine. They've been accustomed to thinking that when you've got a cold, you just go in and get a shot. But they don't go in for screenings or for consistent follow-up for a particular problem like hypertension. There's still a large population here that is very episodic, and quick fixes are all they want out of the health care system.
Here at Presbyterian we see an economic cross-section of the community. Honestly speaking, the physicians I work with provide good primary care, meaning more than just episodic care and referrals to specialists. I've actually seen a change in the referral process over the last couple of years, both as a consumer and as a provider. As a consumer, I know when I need to see an ophthalmologist, and I don't want to go to a primary care provider first. I believe a lot of people share that view. But I've also seen physicians roll with the punches. I think at the beginning, when physicians were given the gatekeeper responsibility, they took it very seriously as a way to keep costs down. But in actual practice, the gates are now looser and physician referrals are multiplying because patients have demanded it.
Looking to the future, I don't see primary care being squeezed out by specialists. Consumers don't want to be seen as just a liver, a skeleton, or a heart. They want to be seen as a whole person. And I think that's what primary care and the health care team of physicians and non-physicians can provide. The hierarchical approach is old stuff. After we have educated consumers about the system, I think they may feel better cared for and not feel this need to reach for the specialist right away.
In the future I'd like to develop educational programs for diabetics and others, in an entrepreneurial sense. I'd like to be able to demonstrate the cost savings and get HMOs to recognize those programs and be willing
People know what a doctor does, but explaining the distinction between a nurse practitioner and a doctor isn't easy. It's so much easier to say, “I do what a doctor does.” But I don't like using a physician as a reference point. My family now basically understands what I do. My husband has been my biggest promoter among his extended family here—about how exciting my job is, and how elevated it is from what they see as a nurse. Some people still see a nurse is a nurse is a nurse. My mother-in-law, God bless her, I think she's just now figuring it out. Attitudes are hard to change. But the family has been very supportive, and they sacrificed a lot when I went to school. So I think they've had just as much commitment to this career as I have.
My boys are really ranch-oriented, and none has shown much interest in medicine or health care. They still have dreams of going into professional sports. My oldest is twenty and a student at UNM. My seventeen-year-old will study architecture or engineering if baseball doesn't work out. My youngest is working his way through high school. I thought that maybe I could get one of the boys to be a veterinarian, but it doesn't look promising. So, it will be interesting to see what they finally decide to do.
Twice recently, I visited Presbyterian Hospital in Albuquerque. The first time was to care for my nephew, who has muscular dystrophy. During my visit, I met hospital's peds intensivist, Dr. Rob Miller, and he told me how pleased he was to meet me finally since he'd been on the receiving end of so many hospital referrals of mine in the past. He really greeted me as a colleague. The other instance was when I traveled to Presbyterian to check on a newborn of one of my special prenatal patients. I walked into the nursery and introduced myself. All of the nurses looked up. “You're Therese Hidalgo?” one of them asked. “All your patients call you Doctor. All this time I thought you were a doctor.” I reassured them that I tell my patients over and over again that I'm a nurse practitioner. “I'm still a nurse,” I explained to them, “and proud of it.” One young nurse responded, “Well, you may be a nurse, but being a nurse practitioner is quite an accomplishment!”
