1

                               SUNN1 LEVINE

                          Dr. Fitzhugh Mullan,
                               Interviewer



 Mullan:   We are in Jacobi Hospital in the Bronx, New York, with
 Sunni Levine.     We are in the pediatric outreach office, a place
 in and around which Ms. Levine has worked for a number of years.
      What we want to do is start back at the beginning, and why
 don't you tell me a bit about how you got into nursing, I
 presume, first or into health care in general.


 Levine:   Mom pushed me into it.    Mom said, "You like children,
 you like biology.    Nursing would be a good way to go."   I really
 didn't have aspirations to be a nurse as a child.     There was no
 Florence Nightingale or Clara Barton kind of story.     I started
 going to school right over here, at the nurses' residence.


 Mullan:   Where did you live? Where did you grow up?


 Levine:   I grew up in the Bronx, was born and raised in the
 Bronx, right around here, Pelham Parkway, and actually just left
 a year and a half ago.


 Mullan:   When were you born, could I ask?


 Levine:   1946.   The Bronx was not a prairie then.


,Mullan:   What was it like?
                                                                            2

Levine:       Small.    There were some private houses coming up, some
apartment houses, pre-war buildings.           This area was mostly Jewish
and Italian.         Park Chester was Irish.   There were some minorities
around but minimal.        It was a nice, safe, old-fashioned kind of
neighborhood with a sense of tolerance where you could leave your
doors open and not worry about anything.          School went up to the
eighth grade, and then you went to high school.           There were lots
for children to play in, you know, tires strung up as swings,
life the way it should be, in my perspective, anyway.
       I went to all the local schools, and the local nursing
school was Bronx Community, right here on the grounds of Jacobi.


Nullan:       You went out of high school?


Levine:       Yes.   I was in the degree program.    Actually, the first
year I went at night, and I worked here at Jacobi Hospital in the
laboratory part time, first filing, then spinning blood and
working with the autoanalyzers.        It was the period in lab
medicine when technicians were going from the traditional Bunsen
burner tests to these fancy machines.


Mullan:       What years are we talking?


Levine:       We're talking now 1967. No.      No, no.   I graduated in
'64.   '65.     1965.   The experience of being in a hospital was
exciting.       I got up to go around to the wards and deliver lab
test results--in those days they had a double slip of paper with
a piece of carbon in it, and the electrolytes, BUN and all other
results were written there.        You'd rip the slip and file half,
                                                                      3

and then go around to the floors to give out the other half.        And
just going to the services.     It really turned me on.   I was
initially going to go for labs.    Mom wanted the nursing part, it
was unusual for Jewish girls to go into nursing in those days.
So I did it.    I really think that she thought I might marry a
doctor.    [Laughter] It didn't work out that way.
       So two years, Bronx Community, and then my job in Basement
South, which was then a communicable disease unit.     I started on
the tail end of an era--1 guess polio had just finished.      But
pertussis and meningitis remained--we isolated everything in
those days.


Mullan:    [Unclear] diarrhea as I recall.


Levine:   Yes, respiratory infections and diarrheas.      And I was
down there as a staff nurse under the direction of Miss Kolter.
I don't know if you remember her, an older woman, previously an
Army nurse.    After a couple of years I took on the role of
assistant head nurse.    In 1974 the position of head nurse opened
up in the intensive care unit on the eighth floor.     Although I
had never worked in the ICU, Ms. Michaels, who was the supervisor
at that point, felt that I had leadership skills, and they needed
somebody to lead.    So I made my way up to the eighth floor for
about three and a half years.    Just about the time I was burning
out.   As far as I'm concerned, any normal person can't hack it
for more than a few years.


Mullan:   t'It'lbeing ICU.
                                                                         4

Levine: The ICU.     Yes.   It was too much, too much death, too much
of the minute they got a little bit better, they were out the
door.     And I realized I was missing the continuity, really
getting to see kids get better.      The nurses were very stuck on
not having moms in there, you know, that elitist mentality, and
it wasn't my cup of tea, it really wasn't.      If the kid wanted to
have his bear, I thought the kid should have his bear, and if Mom
wanted to be there, I thought Mom should be there.      And the
nurses really had a hard time with that.      It was too much to
fight after a while.
     It was during that time that I was exposed to the nurse
practitioners who were working for Dr. Ruth Stein in what was
then the pediatric home care program.


Mullan:    Which year are we in?


Levine:    This was between 1974 and '77.


Mullan:    So these must have been the earliest generation of nurse
practitioners.


Levine:    You got it.   Yes.   Ruth ran the program here.


Mullan:    And had she trained them?


Levine:    Yes.   She had a training program here.   In fact, Pat
Donovan was in the first program--1 was in a later program.        The
initial program was a two-year work study program.      I think it
was really the best.     They got their didactic and clinical here,
                                                                          5

and they got paid while they were doing the training, two full
years of it.       It was more like an internship.   The second program
Ruth ran was a one-year program, where you had to take a year of

educational leave.       The first four months were didactic followed
by eight months of clinical here in the institution.          I believe

certificate programs are much better than--today's master's
programs.    Masters students don't get enough of what they really

need.


Mullan:     What's the distinction there?


Levine:     If you go to a master's program,    he amount of clinical

hours you have comes nowhere near the eight months of clinical
hours that I had.       You just don't have the experience.    Todays

new grad is thrown into a managed care world and expected to be a
revenue producer.       How is somebody coming out of a master's

program who's had limited experience in the provider role
supposed to start seeing eight patients in a three-hour period of
time?     It's a little stressful.


Mullan:     What you're saying is that the current trend towards
master's programs, which are stronger on the classroom and less
on the experiential, is not as efficient or as effective as the
more clinical exposure that you had in both the longer program
and a more intensive clinical program?


Levine:     Yes.    Another difference is establishing clinical
placements.        The certificate programs provided continuity with
respect to classroom and clinical teachings.         The needs of the
                                                                        6

students were built in as not to put extra demands on preceptors.
Approximately    80   percent of the practicum remained with the
institution.


     Todays masters students have to search for clinical
placements.     Practicing nurse practitioners must maintain
productivity.     Providing a quality preceptorial experience is
difficult under the pressure of productivity.      The nurses
practitioners at this institution have drastically reduced the
amount of clinical placements previously provided.


Mullan:   Tell me what you thought of seeing nurse practitioners,
the transition in your thinking between what a nurse had been and
what a nurse might be?


Levine:   Nursing is limited.     There were certain things that were
just taboo.     In those days, you couldn't put an NG tube in.
There was only certain information you could share with the
family, and then you had to get the physician to do the rest.


Mullan:   Were nurses doing IVs in those days?


Levine:   Sneaking.     The beginnings of sneaking to do it.    A lot
of the stuff just doesn't make sense.      You know, anybody can
learn a skill, but they had these rules.      The thing that I liked
about nurse practitioners, not even so much the skills, was the
intensity of the relationship that they had with the family.
They really knew the families, they felt comfortable with them,
they could be there supportively, and they were going to be with
                                                                        7

them again once the kids got out of the hospital.        So there was
always somebody there for a family to rely on.        It was real nice,
it reminded me of old-time family docs, you know, the type I had
when I was growing up, they knew every aspect, and you didn't
have to tell the story again.      They knew you.    They knew where
you were coming from.      The family knew them, and it made for
clinical care in a nice supportive relationship.        I've always

felt that you need to know what's in somebody's head to treat the
whole body.      And how do you get into somebody's head but have a
longstanding relationship with them?       The nurse practitioners
made home visits, so they got to see how the family was
functioning in their environment.      The whole thing just excited
me.   So I said, ''Okay.    Time to go on.''   And I applied for one of
the newer, later programs and got into it.


Mullan:   That was here?


Levine:   That was here in 1976, '77.


Mullan:   Associate degree was acceptable as an entry level at
that point?


Levine:   Yes.     They probably would have taken, I think, diploma
grads, because they knew your clinical work here.       They knew your

experience.      They had the advantage of seeing the kind of nurse.
They advertised all over.      Anybody could have applied for the
position, but the thing that was good was they knew who they had

grown here as nurses, and it didn't always work to your
advantage.    I didn't get in the first go-round, but the second
                                                                        8

go-round I did.     I always felt that a nurse practitioner was
something a registered nurse worked towards.       You took a nurse in
pediatrics and then took him or her onto newer levels.        You know,
they have this new entry into practice--do you know that?


Mullan:     Yes.


Levine:     Somebody with either a bachelor's or a master's can go
into a program.     If it's a bachelor's, you just take what you
need as far as nursing to get the bachelor's of nursing, and then
they pop you right into the master's program in like a two-year
period.


Mullan:     This is somebody with no background in nursing?


Levine:     No background in nursing, and not necessarily in health
care at all, they make you a nurse practitioner.


Mullan:     In three years?


Levine:     That's if you need the bachelor's.    If you already have
a bachelor's or you have a master's, you can go into something
else.     You can go into a master's program and do it in a year and
a half or two years, get your F W license while you're in there.
They throw you into a couple of clinical settings as a nurse.
That's not to say that some of the nurse practitioners that I've
met that come out of these programs aren't good NPs.       They don't
understand the in-patient part of nursing.       We actually hired
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somebody who does the HIV program with Pat.      She's excellent, her
name is Marina Lugovoy.


Levine:     I can't think of the mom's first name.   Her mother works
with Henry Barnett in the Children's Aid Society.


Mullan:     Henry Barnett is still active?


Levine:     Yes.   And so Marina came to us having graduated from one
of these family nurse practitioner programs.      Prior to that she
was a forest ranger.     She really had nothing to do with health
care.     And she's very good.   A couple of years after she was
here, the nurses on the in-patient unit were saying, "She's not
that friendly,#'you know what it was?      She had never really been
on an in-patient service, and she was terrified up there and
really uncomfortable and just didn't know the workings of it.       So
I think there's something to be said even in being able to
provide for a child if you can anticipate, the experience, for
the parent of what a hospitalization is going to be like.


Mullan:    You entered the program here?


Levine:    I entered the program here.



Mullan:    What was it like?


Levine:    Scary, but we were learning all these physical
assessment skills and differential diagnosis and history-taking.
All the pediatricians that I knew, Andy Mezey and his cohorts,
                                                                         10

were, you know, our teachers and our consultants, and it was
wonderful because they really understood the transition.         You
know, they could help ease us into it.        But it was very scary
because suddenly you don't turn around to the doctor anymore.
You are the front line.        I wanted to be able to do more, now
suddenly responsibility was on me, and it was really frightening
in the beginning.       Well, I'm talking about eight or nine years.
It takes a long time to really transcend that gap.         But it was
fabulous.     It was probably the best thing I ever did.      I really
feel that I have impacted and made differences in people's lives.
Of course they make the big difference.


Mullan:     And this was a pediatric program strictly?


Levine:     Yes.   Strictly peds.


Mullan:     And it was two years?


Levine:     One year.     I was in the one year.   I was in the second
go-round.     One year.


Mullan:     And you got a certificate at the end?


Levine:     Certificate at the end.


Mullan:     And what happened then?    What did you do?


Levine:     There was a position in the pediatric home care program,
fortunately, which is chronic illness and home visiting, and I
                                                                    11

was accepted into it, working with, to me, the dinosaurs of nurse
practitioning.     I was really being challenged and learned a lot.
I had my own caseload of patients.


Mullan:   You were doing home visits as opposed to seeing the kids
in the office?


Levine:   Yes.    Both.   We would see them in the office, this
actual office.     You would do your initial intake either on the
floor, I mean on the wards, or in the office, try to connect
right away and follow up with home visits and do as much of
whatever it was you were doing, whether it was health education
or examinations or follow-ups, as much as you could in the home.
In those days it was real safe.     We weren't dealing with
crackheads.


Mullan:   And what sort of conditions, what sort of diseases?


Levine:   Everything from diabetes to sickle cell to congenital
hypothyroid to--oh, God.


Mullan:   You were actually managing medication decisions?


Levine:   There was a child by the name of Brenda Castro, who's no
longer with us.     I think everybody who ever worked at Jacobi knew

this kid and her family, and she had some sort of autoimmune
process going on that knocked out all of her hormones and her
glands.   Aida LiBasci was taking care of her, balanced
everything, all her meds, all her lytes.     It was just incredible.
                                                                      12

But you learned that once you got into caring for the kid and
really knowing every aspect of her, it could be done by a nurse
practitioner.       I mean, she really got to know the ins and the
outs.     When the kid would come into the emergency room, the house
staff would panic because they didn't know what to do first, and
Aida would go along and just, you know, help them get her
stabilized.       Whatever it was that needed to be done.


Mullan:    And you worked in the home care program for several
years?


Levine:    Up until about, I guess, about seven years ago.


Mullan:    Ten years that would make it, from the late seventies to
the late eighties?


Levine:    Yes.    I became the supervisor of the home care program
when the supervisor left, and my patient panel got smaller.      When
the supervisor for the clinic left, and there weren't enough
nurse practitioners in the clinic to warrant hiring another
supervisor, I took over the responsibility for the NPs and the
clinic also.


Mullan:    This now is on the hospital-based side, ambulatory?


Levine:    Ambulatory.


Mullan:    So you were supervising them as well as continuing to do

home visits?
                                                                       13

Levine:     Right.   My administrative responsibilities grew when we
got a new director--actually, we got a new director of nursing
who was wonderful.      She was just becoming familiar with what a
nurse practitioner was, did her homework and saw that this was
the wave of the future, and helped me to apply for the state for
rate appeal money to educate our own nurses, for funds to send
them to Columbia.     Actually, the first rate appeal was for
Cornell.     Cornell had a neonatal nurse practitioner program, an
eight-month training program.      Andy Mezey had already started
bringing nurse practitioners into the in-patient service.       Andy
had this telescope that saw what was coming down the road and
knew that the training program was going to have a reduced house
staff.     He started by bringing in the nurse practitioners in the
newborn nursery.     That was the first inpatient NP that we had.
Eventually we increased to three of them.     With the changes in
graduate medical education, primary care and managed care, we
knew that we were going to lose house staff, and we thought that
they could be replaced by bringing nurse practitioners.


Mullan:    What year are we now?


Levine:    Early nineties.   The NPs thaw we brought into the
newborn nursery were excellent also, and we started gearing up to
bring them into the--NICU (neonatal intensive care unit).


Mullan:    Before we do this, let me ask about the decade between
the late seventies to late eighties and your experiences in
there.    How did the role perceptions, acceptance of the nurse
practitioner evolve during that time, as you saw it?
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Levine:     You have to remember that this was a really special
place.    This is a hospital that ran training programs for nurse
practitioners, that had the earliest nurse practitioners running
them, okay?     So we had some of that, W h o do they think they are?
They think they're doctors practicing medicine.     They don't have
a license."    There was some of that but not much--and, you know
what?     It was within nursing, not within medicine, because we had
the support from the pediatricians.     They trained us.   They were
not threatened by what we were doing, we worked well with them,
but nursing had a problem with us.     When I first came out of the
program, although I worked for the city, there was no supervisor
for me in nursing, and we were kind of out there by ourselves.
        Looking at it now from their perspective, they didn't know
how to supervise us.    What were they supposed to tell us to do?
They weren't even sure if what we were doing was legit.     So those
were very exciting years because our senior people, Doris Lovejoy
and--1 don't know if you remember Rachel Kolb--Doris had been in
Vista, so, you know, Doris was a real change agent and very
politically involved and was going to make sure that we were
allowed to do what we were supposed to be doing, this was what we
trained for, and the medical board wasn't going to get in our
way, and nursing wasn't going to get in our way.     So us babes
were really exposed to a group of politically savvy senior NPs
that really helped transcend those early years, which were
difficult.    And I think because I was exposed to them, I didn't
know any other way but you band together, you group together, and
you teach the world what it's all about.     And that's what we did
here.
                                                                         15

     So, yeah, there was a little bit of that, ItI'm not doing

your blood pressure.     1'11 do the doctor's.   You're a nurse; you
can do a blood pressure.@l    But very quickly, I guess, as I
started getting into the administrative part of it, weld been
around enough at that point that we were able to just make the
changes as necessary.


Mullan:   So acceptance grew?



Levine:   Yes.


Mullan:   What about with younger nurses coming along?     Did the
role model appeal?     Did you see more interest?


Levine:   Yes, I guess there was some, because some folks started
going outside to programs.    There were no more programs here.      A
lot of people would say, ''If you ever bring it back, let me know.
I want to be a nurse practitioner.lt    But, I guess more so, people
just were able to be in their roles and work together accepting
one another.     I was not the kind of person that thought that just

because I'm a nurse practitioner I'm better than.      To me, a good

staff nurse is a good staff nurse, and you respect that.      Your
role is just different than mine.    And most of us were like that.
These were our roots.    This is where we came from.   We were just
doing something differently, but we respected the people we
worked with, and we depended on them.     So many of the people that
are still here, like Pat and myself and the folks that were in
the late sixties and early seventies, we've never had a problem
with that in nursing.
                                                                    16

Mullan:     What about the development of the clinical nurse
specialist, which I gather took place over that same period, in
this case, nurses who are developing advanced but highly targeted
specialty practices?      Were they trained here, and how did you
relate to them?


Levine:     They were master's-trained.   There was no training going
on here.     In the early days, particularly the clinical
specialist, which was a clinician here, was a nurse who had gone
back for her master's, who did the education of the staff nurses.
That's how it ran in the earlier days.      Later on, when they
changed from clinician to clinical nurse specialist, most of the
folks that we had here wanted to function the way they were in
the privates, where you had the enterostomy nurse or the diabetic
nurse.     This hospital didn't hire folks like that.   It was a
loss.


Mullan:    How about in the CCU?    Were there CCU nurses or   --

Levine:    Yes.



Mullan:    At the clinical nurse/specialist/master's-prepared
level?


Levine:    No.    They were CCU nurses that took critical care
courses given at Jacobi--


Mullan:    So OJT as opposed to master's training?
                                                                        17

Levine:     Yes.


Mullan:     So within nursing, I gather, during the late seventies,
late eighties, there was a growing acceptance, at least here, of
your role.        The clinical nurse specialist wasn't too much of an

issue one way or the other.


Levine:     No.     They did their thing, and we were really very
separate.


Mullan:     And were there a lot of nurse practitioners functioning
throughout Jacobi, throughout the Bronx?        I'm not clear how much
is your experience, how much is generalized.


Levine:     Right.    Well, when I got to really know what was going
on around the Bronx is in 1987, when New York State passed a

certification process where if you wanted to work in the state of
New York you had to register as a nurse practitioner.       And they

had criteria.        It's somewhat changed since then, but we applied,

you know, with proof that we graduated from the program here, and
we were licensed.        I carry two; one's actually a certification,
one's a license.        I have my RN license.


Mullan:     Both from the state?


Levine:     Both from the state.    When the law went into effect,

what it said was that in order to practice in the state of New
York, you had to be in a collaborative practice agreement with a
physician and work from protocols.        The way the law was really
                                                                         18

set up was for people who were out in private practice, and I
don't think there were many out in private practice.         Most of us
were working in hospitals or clinics.         So the networking started.

W h a t does it mean?"     "What do we do?"    "How do you set it up?"

Who's running the collaborative practice?"        And of course, I was
going to wait for the Health in Hospitals Corporation to give us
some direct input.       It was clear that they didn't have a clue to

what was going on.
        So I got the law, and I read the law, and we developed
collaborative practice agreements in every area where there were

nurse practitioners, in the medical clinic with the medical
director, in the pediatric clinic with the pediatric medical
director.     Those were the first two.   At this point I realized I
had some political s a w y because I could read a law and do what I
needed without direction.      And the protocols, of course, became
an issue, because nobody wants to spend time--doctors didn't
like, then, the idea of following protocols.        They certainly
didn't want to write protocols for somebody else to follow.          The

state actually came up with some books that were acceptable,
national protocols.      One of them is the Harvard Community Health
Plan.    Those were acceptable.    To be honest, you know, in an
inpatient setting, those things don't do much, but the state
wouldn't accept those little spiral books that the docs use,
because there weren't protocols on them, so they tell us what we
should use, we tell them that's what we're using, and nobody
checked, and everybody gets good care.        But, you know, this is a

bureaucracy.
        But it was the networking at that time that I really got to
talk with folks to find out, actually in the Greater New York
                                                                       19

area, what was going on.      And at that point--that was 1987--NCB,
North Central Bronx and Monte [Montefiore] had a substantial
amount of nurse practitioners.      We've lost numbers over the
years.     But Comprehensive, the Russo Building over on Morris Park
Avenue, had a nice cadre of nurse practitioners.      I don't know
how many are there anymore.      We've kind of lost ties with the
place.     There weren't a lot in hospitals, at least in Peds.     I
can't speak to the adult services, but I think we had the
greatest amount, at least in a hospital, certainly a city
hospital, and it started growing.     As Andy dictated what the need
was and we realized what the need was in Peds the need would be
in medicine also, we started advertising for inpatient--NPs.


Mullan:    That's a very important story.    I want to get that.
That comes after '89, is that right?     There would be a few other
things in that period.      As you began to network more and get a
sense, tell me a little bit about what 1'11 call the culture of
master's-prepared versus non-master's-prepared, and how has that
played out for you?


Levine:    Okay.   At that point, the certificate programs were
almost nonexistent.


Mullan:    By the late eighties they had given way to the master's
program?


Levine:    Yes.    Cornel1 had the neonatal nurse practitioner
certificate program, one of the last certificate programs.
                                                                       20

Mullan:    The master's program is certainly all over the country,
supplanted--so today there are very few certificate programs.


Levine:    Yes.


Mullan:    What I'm asking about is, how did that manifest itself
in terms of your role, and did it become more burdensome to only
have a certificate within--


Levine:    Well, I'm probably not a good example.   Having been born
here, having grown here, I was judged on what I did, not what
paper was hanging on my wall.      I'm going to be honest.    Again,
the physicians never asked.     It was nursing who always asked.
Now I was entering this dinosaur era as being one of the
oldest--you know, it's weird--and really knowing a lot just in
terms of the law and the protocols, you know, I was now becoming
the maven here.     It wasn't an issue for me.   Had I gone
elsewhere, probably it would have been.      I got my bachelor's in
1989.     I realized that my administrative position required
credentials to back it up.    As   matter of fact, I just got my
master's this May, at Columbia.


Mullan:    Great.


Levine:    It was a completion program.   They accepted my
certification. They gave me fifteen credits for that, and I did
the completion.


Mullan:    So it's a master's in nursing?
                                                                      21

Levine:     Science, master's of science.


Mullan:     And where did you do your bachelorls?


Levine:     Mercy College.   I picked the fastest thing.   They had
three sessions a year.       It was in behavioral sciences and
community health.     I needed to get the papers.    I was in and out.


Mullan:     So I asked about how credentialism and how it related to
you when you saw it develop.


Levine:     I saw what was happening, and whether I believed it was
the right way or not, nursing as a profession decided--well,
they'd been battling it for years, really, you know, associate
degree, bachelor's.     They've been fighting for years, and they'll
never clear it up, that to be a professional nurse, you know, the
only way to do it, especially as a nurse practitioner, was to
have the masters' degree.      Now, this was the decision they had
made.     I could argue the point that they're opening up schools
and nobody's checking the quality of the education or the quality
of the preceptorships, and what were we really doing?      Just
because you've got the letters after your name doesn't mean that
you're the best we have to offer.


Mullan:    But that's what was going on?


Levine:    Yes, that's where it's at now.
                                                                         22

Mullan:     You mentioned the issue of a more explicit but also
 arguably a more limiting law, i.e.,      the protocol, the physician
 collaborative practice, etc.      How was that greeted by the nursing
community, and has that evolved on in New York State?


Levine:     It was limiting in the sense that we would have to work
from protocols, and the law also limited prescriptive privileges,
I'm only allowed to write prescriptions for patients within the
collaborative practice.       If you asked me for a prescription for
yourself or your son for Amoxicillin, I'd be breaking the law to
do that, unless your son has Jacobi chart number.        My own feeling
was, @@Bigdeal.       I don't want to be writing prescriptions for
folks that I'm not treating anyway."        So I don't have an issue

with it.    And the reality of the protocols is that the state has
limited resources and can't check on their use.        That's the
reality.    They don't know what's going on.      They just don't have
the funding to check to see what people are doing.        I think
institution by institution, we have to monitor what we are doing

through a QA process and chart reviews.        We should be responsible
for that.    We really shouldn't be leaving it to the state.        We do
that here (QA)   .
     That's the law.       So it gave us the ability to write
prescriptions.       So that was good.   We don't have to get co-
signature anymore.      And legislatively, they continue to work for
direct reimbursement.      There are groups.   There's the Coalition
of Nurse Practitioners, NAPNAP, which is the National Association
of Pediatric Nurse Associates and Practitioners.       They work on
the legislative policy.      So they're always working for us to make

sure that we're in the arenas where we need to be.
                                                                        23

        Although it may have seemed initially a little limiting
having a law, we needed to have some structure.     I mean, you just
couldn't have people graduating from any old school, going out
there, and not have some kind of consistency in what people were
doing across the state.     So from that perspective, I understand

it.     Everybody should be at the same level, at least on paper,
and there should be a standard.     And that's what they're aiming
for.


Mullan:     How about, again, the eighties, the specialist versus
generalist, primary care versus non-primary care thinking?        Did
you see yourself as a primary care practitioner?


Levine:     Yes.


Mullan:     And realizing you--you [unclear] pediatrics always,
right?     I mean, you always were a pediatric--


Levine:     Right.


Mullan:     How did you see that, and particularly in this
generalist/specialist work?


Levine:     I really always felt that we're the primary providers,
we should be working in consultation with all the specialists.
They should be advising us on what to do.     They should not be

seeing the patient in isolation.    We've had some issues around
here.     Diabetes was the big one, because they were growing and
moving and changing, and they really felt that they provided
                                                                     24

primary care, but I think their sphere was a little bit limited
 in comparison to ours.   And I saw myself as a generalist.   Even
though my area of expertise was chronic illness, my focus was the
child in the broad sense and the family.
     I have to tell you that I also think that, to be honest with
you, there are some specialists that I've worked with in this
hospital that are wonderful primary caregivers. Dr. Maria
Santorinean, who's a hematologist--


Mullan:   She's still here?


Levine:   She's still here.   If a patient with a hem0 problem is
followed by her, that would be enough, because she's making sure
that the immunizations are up to date.    She's involved socially,
psycho-socially.    So it depends on the person.


Mullan:   Sure.   But you're speaking now not only in terms of your
experience, but as you have seen the nurse practitioner move
into--


Levine:   They consider themselves primary providers.


Mullan:   Certainly in surveys and other kinds of querying that
have been done in the nurse practitioner community measuring has
suggested that the identity of the nurse practitioner in general
is largely as a primary caregiver or a generalist, whereas the
physician assistance has tended, as that movement has grown, to
be in larger numbers specialty-focused. Any sense of why within
nursing the generalist mission has remained paramount?
                                                                     25

Levine:     Because I think we see ourselves as holistic and really
believe that if you're going to treat and care for and educate,
that's how you do it.     And we learn that as nurses.   So you just
carry it over into nurse practitioner.     But the difference with
PAS, physician assistants, their training is very different.

They get a six week rotation in each area, medicine, surgery, OB,
peds, etc.     They don't specialize in either pediatrics or
medicine.     So although they do believe they come out, some of

them, with a primary focus, they don't have the intensity in that
one area.


Mullan:     Would it be fair to argue that the clinical nurse
specialist is something of the analog of the specialist in the
medical model?


Levine: Absolutely.


Mullan:     Well, let's move into the late eighties, early nineties,
when some major changes started to take place here at Jacobi.
Tell, both for me and the record, updating a little bit, what
kind of institution Jacobi is and has been and then what changes
it went through at that point.


Levine:   Well, we were, I guess, in the beginning, a 700-bed
level one trauma, 911 receiving, city, public hospital, and a
training institution in affiliation with the Albert Einstein
College of Medicine.


Mullan:   With large numbers of house staff.
                                                                     26

Levine:   Huge.   Huge.


Mullan:   House-staff-run, as I recall.


Levine:   It's a house-staff-run hospital, actually.     For me, the
change took place when they split and they became a combined
program with Montefiore.


Mullan:   Saying what?     You mean split?


Levine:   Well, Jacobi Pediatrics used to be here.


Mullan:   So it was an Einstein-affiliate program but was separate
from the Montefior program.


Levine:   Yes.


Mullan:   So at some point they combined them?


Levine:   At some point they combined them.


Mullan:   When was that?


Levine:   I'm not sure on the dates.    The day we became two
campuses, we lost the Jacobi family, which is too bad.     That was
the end of it, as far as I'm concerned.      It was just too massive,
and house staff weren't here all the time, the house staff was
split between two sisters.     It was difficult for the patient to
access them, for us to access them.     Continuity was gone.
                                                                        27

        It was happening for a reason.    There was a plan here.    You
know, I wasn't privy to it, but I remember in my younger years,
talk of Dr. Cherkasky, Dr. Martin Cherkosky wanted to build an
empire at Montefior.       And I was young, and I didn't pay much
attention to the talk in those days.       But even during my time as
a nurse practitioner, we started losing census and numbers of
particular types of patients, certainly the patients with the
tracheotomies, we weren't getting that many referrals.        That's
because ENT had moved their offices.       They were either at
Einstein or at Monte, but people were leaving this place.


Mullan:     So the intensity level in this place became less?


Levine:     Yes.   If you sat back and opened your eyes, you, you
could see what was happening.       How long are you going to run a
pediatric service without neurosurgery or ENT being right here?
So I'd seen it happening, pick, pick, pick, little, by little, by
little.
        When I left the ICU, there generalists who were running the
ICUs.     They didn't have intensivists then.   After I left,
intensivists came in.       If you didn't have that intensivist, you
couldn't run a unit.       So we lost the intensivists.   We lost the
unit here.


Mullan:    Were the number of beds falling at Jacobi [unclear]?


Levine:    A little bit.
                                                                    28

Mullan:   And this was going on in medicine and other services as
well?


Levine:   Yes, but it hit Peds first.


Mullan:   So what happened then in terms of house staff?


Levine:   They started to reduce numbers.    Well, there was the
other part.   They weren't meeting their match, and there were a

couple of years there where the quality of the house staff was
not the historical great Jacobi house staff.    And I think they

made a decision one year--1 don't remember the year--that rather
than try to fill, that they would level off, that they weren't
just going to take anything.   It was just getting too difficult.
So we had a few years there where there were diminished numbers,
and then for whatever the reason was, the allure for Jacobi Peds
and the quality started increasing again.


Mullan:   I'm going to turn the tape over.


[Begin Tape 1, Side 21


Mullan:   This is Sunni Levine, tape one, side two, continued.


Levine:   From the nursing perspective, you know, just sit back
and talk to the nurses about, "What's the house staff like?"       As
the years went on, they didn't trust anymore.    You felt it was a
house-staff-run place, but it started getting scary because the
quality had dropped, and has never come back up.
                                                                      29

Mullan:    It was a separate program still from Montefior?     It was
a separate [unclear]?


Levine:    No,    it was a combined program.


Mullan:    So the diminished quality is part of the overall--



Levine:    Yes.


Mullan:    What happened in terms of phasing out?    I gather the
pediatric house staff program has been phased out.


 evine:   N o , not completely.   We lost the house staff completely,
Lalmost completely, in the newborn nursery.      We only have one
resident who we're losing at the end of this month.      The NICU, we
lost all of the residents--about four years ago, the entire house
staff.    That's why we did a "grow your own" neonatal nurse
practitioner.      We got the State support and sent our nurses off
to Cornell.       So we had PAS and neonatal nurse practitioners
running the NICU.      This year we're probably going to lose the
fellows--this year has been a real disaster year.      I don't know
what's going to happen.      But the census has dropped dramatically.
Had it not, we probably would--we had to drop it at times by
ourselves because we just didn't have the manpower to provide

care.


Mullan:   Why has the census dropped?
                                                                      30

Levine:    I don't know.   I don't know if it's the managed care.
It's unclear.


Mullan:    What is the patient population?


Levine:    Mostly Medicaid.    Some will argue that since Medicaid is
being taken all over the place, why should a woman come deliver
here and be in a six-bedded room, when she could have privacy at
our Lady of Mercy, Einstein?     So I don't know that anybody's
really studied it to know.


Mullan:    How many beds does this hospital have now?   You said it
had 700.


Levine:    Well, it had 700.   I think we're about down to 600, but
the truth is we're going to 300.     We have a new medical director,
a new CEO, and the plan for this hospital was to make it a 300-
bed community hospital.    A year from now, it's not going to be
anything like what I've known it as.     At first it was the medical
realm that was affecting us.     It was the funding, losing the
funding, the consolidation of services, the move towards primary
care, and the decrease of specialties.     That was initially what
was affecting us.
     In there was managed care drawing out--you know, the
contracts happening much more quickly all around us.     The city's
very slow at getting anything.     So we were losing our census.

They were actually going to the welfare centers, these HMOs and
managed care programs, and enrolling folks.     A patient would come
into clinic and the financial counselor--bet you never heard of
                                                                        31

one of those in a hospital--would say, tvWe'resorry.      We can't
see you here because your managed care organization won't pay."




Mullan:   As the nature of the hospital has changed and as the
nature of the house staff for related or unrelated reasons has
changed, the role of the nurse practitioner on the inpatient side
has become more prominent.    Tell me about that.


Levine:   We thought we would be able to run the inpatient

pediatric service with NPs and PAS and going for a model where
they would run it and the house staff, the limited house staff,
would come in and just have a different experience of working in
a multi-disciplinary setting with the NPs and attendings, and
have their rotation here.    It didn't pan out.


Mullan:   Why not?


Levine:   We were unable to attract enough nurse practitioners to
man the floor, basically.    You know, I think by the time you
become a nurse practitioner, you're well into your career.        The
last thing you want to do is start going back to rotations, which
I guess we really didn't think of initially.      The role of a
             intern is not what NPs have in mind.


Mullan:   The labor intensity of it, rotating call schedule,
crisis orientation was not appealing at all.
                                                                       32

Levine:    It wasn't appealing at all.     So we lost folks faster
than we could bring them on.    We never had the numbers that we
needed.    For some reason, [unclear]. We couldn't pull it off
here in pediatrics.    And there were conflicts between the house
staff and the nurse practitioners.       Interestingly, once the nurse
practitioners got their feet on the ground and they really felt
like they knew what they were doing, they only wanted to work
with the attending.    They really didn't want to be advised by the
house staff, what if a house officer was telling them to do
something that was inappropriate?    It's a different generation
now.    Even with the house staff, it's very, !'me, me."   The
commitment is not there.    I think the Bell Commission and the 405
regs impacted immensely on the way house staff provides
continuity.


Mullan:   For the record, though, the 405 regs were the ones that
limited house staff working hours?


Levine:   Yes.


Mullan:   And the Bell Commission?


Levine:   It was Burt Bell working with Axlerod.     That was the
Bell Commission--Committee, we're not supposed to say
commission--Committee that set up the 405 regs.      It was probably
good for the lifestyle of the house staff, but it destroyed the
care.


Mullan:   Really?
                                                                     33

Levine:   Oh, yeah.   Yeah.   The commitment is not there anymore.
But the world is much different.     What seems to be lost is the
quality of the relationship once held by nursing and house staff.
The NPs on the in-patient unit have had difficulty in developing
routine collaboration with the house staff.      The house staff are
in training, the NPs are working shifts.      This led to   There were
controversies of who's in charge, and who's doing what, and, ''Why
should they be allowed to leave at 3:OO    if I have to stay here
and finish my work until I'm done"
     The NPs were pretty picky about the quality of the sign-outs
that the house staff was giving and reported that some
information wasn't shared with them.    The only thing I can think
of is the quality relationship NPs and physicians have had in
ambulatory care is based on a relationship with attending
physicians.    If the in-patient NPs had worked solely with
attendings, maybe it would have worked out better than working
with house staff.


Mullan:   What has happened to the service?


Levine:   We're going to downsize the amount of NPs that work
there now.    We have four teams upstairs from the old Bronx
Municipal Hospital Center, which is now Jacobi Medical Center,
there's the BMH and C teams, each one with a team leader who's an
attending, NPs and PAS and the house staff.
     We're at the point now where the amount of providers that we
have for the census is too great.    The average daily census--
maybe sixteen or twenty, aa a goad day thirty, on the best day
                                                                       34

forty in respiratory season.    The house staff can manage it, and
we're probably just going to need one NP or PA per team.


Mullan:    And they'll provide enough house staff to do that?


Levine:    There'll be enough house staff.   We have the house
staff.    Their involvement and the numbers went up again.     As long
as we can provide some kind of an experience, as opposed to what
Monte's doing, and as this is a more ambulatory-based experience,
we have the ambulatory care pavilion over at Van Etten a really
hotsy-totsy OPD experience.    We'll have something for a while to
draw house staff, but my gut feeling is that Monte's like Pacman;
it's eating up the Bronx.    They are even inside of Jacobi.     The
Monte dental clinic is inside this very building.      Employees
discuss the similarity of the sign age color.    Our affiliation
with Einstein is likely to end and our new affiliate will be
Montefiore.


Mullan:   So in terms of the interplay between nurse
practitioners, PAS, and house staff, it didn't go so well, and I
understand the sign-out and the different understanding of what
each is about.


Levine:   Yes.


Mullan:   What about an issue that's raised many times in many
different ways about comparability of not [unclear], but it's
said in some circles to replace a house officer you have to have
three nurse practitioners.    Now, that assumes the house officer
                                                                      35

is working around the clock and is not taking elective months or
research months or a variety of other things and that a house
officer is like a second or third year, you know, fairly well
fired-up house officer.    1'11 always believe that if you really
take the total specter of house officers ranging from the wet-
behind-the-ears intern, who is very slow and very efficient,
requires a lot of supervision, to the third- or fourth-year very
competent person and then you factor in the teaching time and the
elective months and the research months and so forth, that the
replacement requirements are not as hefty as some would say.
What do you think about all that?


Levine:   Remember the spectrum of NPs that you get is also
variable.     If we could hand select the NPs, in a year or two we
could, we would have excellent clinical practitioners.    If we
could retain the experienced NP and find a group willing to work
the off hours, we might stand a chance.


Mullan:     I guess it would stand to reason that even with, say, a
third-year resident and a seasoned nurse practitioner, the third-
year resident is going to have more required hours on duty.


Levine:   Right.


Mullan:     So he or she is going to be cheaper in that sense.   To
replace him or her, you're going to have to have more than one
nurse practitioner because they are working a forty-hour week,
whereas the resident's working something approaching an eighty-
hour week.
                                                                     36

Levine:     I think they thought it was going to be cost-effective.

Maybe in a hospital in another community where you're dealing
with fewer social problems, fewer economic problems, in one of
those "white picket fence" kind of communities, maybe it would
work.     You get a kid in who's sexually abused here, and the nurse
practitioner wants to stay, and you go into overtime, it's not
cost-effective.     The house staff is going to stay without
overtime costs.     Now, that's not to say that there are some of us
who would stay and would not put in for the overtime, but as in
medicine, there are nurses who may not have the type of
commitment I have.     I never watch the clock.   And some people can
tell me I'm a fool, okay?     I never watched the contract.     I just
wasn't like that.     And many of the people I grew up with were not
like that.    And if I had to stay because something was going on,
I just stayed, and I signed in and signed out my regular time.
The world is not like that anymore.      There are a lot of folks who
feel like if they're going to stay for their patients, they want
to be compensated.


Mullan:    It's expensive.


Levine:    It's expensive.


Mullan:    So let's go back to your story in particular.      The last
number of years, the late eighties to the present, you have been
involved in overseeing and coordinating this inpatient activity?


Levine:    Yes.   Well, everything.   If there was a nurse
practitioner or a PA involved in it in pediatrics, I was
                                                                       37

overseeing it, and basically we worked to educate neonatal and
pediatric.     I was associate director for the NPs throughout the
hospital.     We also sent off about fifteen adult nurses to become
adult nurse practitioners.      We were supposed to do the same thing
in medicine that we were doing in peds.        It just never happened,

and I don't know why.      The money was here for the pediatric
people to take NP positions.      I don't know what happened in

medicine.     Somebody forgot to send something out in the mail, but

we graduated a whole lot of adult nurse practitioners and didn't
have positions for them.      It was really sad.   We coordinated that
effort.


Mullan:     So what did they do then, went and got jobs elsewhere?


Levine:     No, because they have a commitment to the city.


Mullan:     So did they come back and work as nurses?


Levine:     Well, they were here working as nurses.     It was three
years that they gave back as an NP and a year and a half if we
couldn't get them a job.     Most of those people are still here,
and, actually, they're finding positions for them and creating
positions now.


Mullan:     As nurse practitioners?


Levine:     Yes.   In this new service line.   Our graduate neonatal
nurse practitioners came back and are now running the unit.
We've had some turnover.     The pediatric people came back.
                                                                     38

They're all still here.     The ones that we sent out are all in an
inpatient unit right now.      Some of them will be going down to the
clinic, the outpatient department, and a few of them will stay
upstairs, doing inpatient.


Mullan:    But your job is largely to oversee these developments?


Levine:    It was.


Mullan:    Now it's changing?


Levine:    It changed a year ago when we went service line.


Mullan:    Which means what?


Levine:    Which means that instead of having traditional
Department of Medicine, traditional Department of Nursing, and
Social Work, the hospital was rearranged by service.     So medicine
has nurse practitioners in it.     The medical nurse practitioners
went to the medical service line.     Each service line is
spearheaded by an administrator.     It's not a doctor or a nurse.
They're hospital administrators. There's Children's Health
Service.    There's Behavioral Services, which is Psych, Medicine,
Surgery.


Mullan:    What about the Pathology, Radiology?


Levine:    That falls under some other service line.
                                                                     39

Mullan:     So it's an effort to break down the traditional cross-

cutting chunks, docs, nurses, administrators, whatever?


Levine:     Exactly.   So Ruth Stein basically is in charge of the
physicians.


Mullan:   Within the pediatric?


Levine:   Within the pediatric service line.    And our service line
is comprised of OPD, Peds, Emergency, the inpatient service, we
have an AIDS day care center.      They separated women and
children's.     So there's the Women's Health service line.   So I
get the children and my counterpart gets the mothers.      So I have
the NICU and the newborn nursery.     That's our service line.   The
good part of that is we've really been able to facilitate getting
admissions from the ER.     We are really working very well
together.     So it works really well for the patient.   The problem
is, of course, the other lines, obviously, variations.


Mullan:   And they've got to communicate across.


Levine:   For me it's [unclear].


Mullan:   Surgical--


Levine:   Surgical.    But fortunately the person that's doing
Women, she also happens to be a pediatric nurse practitioner.
She was in my program, and we have a good relationship. So we
                                                                       40

can work really very well together.     The two service lines work
well.


Mullan:   That job is changing too, service-line job that you've
had?


Levine:   That's what I just took a year ago.      So rather than just

being in charge of the nurse practitioners, I'm now responsible
for all the NPs, the PAS, and all of nursing in the service line.
So it kind of quadrupled for me, the responsibilities.       I had
never done operational nursing before.


Mullan:   Operational nursing?


Levine:   Well, being in charge of R.S.   and LPNs and nurses'
aides.    I've dealt with NPs since I graduated.


Mullan:   HOW'S it going?




Levine:   It was challenging, to say the least.


Mullan:   What about the NP versus PA functioning
outpatient/inpatient primary care in general?      What do you see?



Levine:   There's only one PA here who works in primary care, and
she works in adult medicine.     She used to be a pharmacist.    She

works in OPD, medical clinic.    To be honest, they do seem to want
to specialize.    Even though we see our PAS on the inpatient
                                                                    41

services as primary care providers, they don't like to go to

clinic.   You know, they're supposed to follow their patients.
They really don't like that.   They want to be inside.     It's
almost like people who work inside the ICU, they just didn't want

to go outside to work.    They're really not interested.   They see

themselves as primary care providers, but they don't want to do
the primary care in the clinics.     They want to be where the

action is, I guess.    There are probably some PAS who are probably
excellent primary care providers.     I think that anybody that's

got a background and wants to do it can learn how to do it.       It's
a mind-set.


Mullan:   Has the interrelation between the PAS and NPs been okay?



Levine:   Yes.   They work pretty well together.


Mullan:   Let me go to a few big-picture questions.    One of the
significant policy controversies, particularly in Washington--and
I suspect in state capitals around the country, but certainly in
Washington--over the last few years has been the question of the
independent nursing or the degree of independence, with the nurse
practitioner being in the lead.     How do you see that developing,

and where do you see that going?     Is nursing ultimately going to
be a separate, stand-alone profession as some nursing pundits

would suggest?


Levine:   You mean the NP part of it?
                                                                       42

Mullan:     The NP part of it being the kind of leading edge, but
the way I've seen it anyway, with apologies for pushing my ideas,
 is that the nursing leadership that has long bridled at being
under the thumb of doctors has seen the NP as the lead dog, if
you will, or the lead agent for pulling nursing more out on an
independent par with medicine and no longer being as responsible
to medicine, or subservient to medicine, as they've been in the
past.     And at least on the political levels, those debates are
hotly engaged.     How do you see that developing here?


Levine:     When I went into nursing, I saw my role as somebody who
worked along with the physician for the patient, not at all
subservient.     I was never treated that way, and if I did I would
deal with it just like a woman anyplace.     I really believed that
we had independent roles, but we worked together.      And I know
that my experience is very different than a lot of other folks
have had.     Nursing, I know, has fought to come out from
under--you know, they see themselves as working under the
physician.     I think it's an individual problem.   I think they've
made it a professional problem.    I think people lose perspective.
I think we have to see ourselves as, yes, we're an independent
agent, but we're a collaborative group working towards patient
care--we have our own jobs.    We have to work together.     I think
that nursing should dictate what the nursing profession is about,
the same way physicians would not want another profession telling
them how to do things.    I think, for the nursing part of it, that
we should be independent, but I think we can't lose perspective
that we're all in the same arena--not the business--the health

profession.
                                                                      43

      I resent the profession of nursing seeing the NPs as a
leader to pull us out of this because I don't see the problem the
same way they do.     I think if you're an independent practitioner,
you develop the respect from the people that you work with, that
if we were all doing the right thing, the glory would come
automatically.    I really think that they get too stuck in
politics sometimes.    They have been fighting for years and years
and years what the entry level should be.    This has been going on
since the day I became a nurse, and there are still associate
degree programs and baccalaureate programs and master's programs.
Let's work on the quality of what we are putting out there and
not worry what the letters are--because they really are not
concentrating on the quality--and, you know, get down to the meat
of this stuff and make sure you have a good registered nurse out
there.    To be honest with you, I think they've blown it.    I think
they've worked so hard at offending the medical profession and
pissing them off, you know--and I don't mean us.    I mean those
folks at the AMA, you know, the big boys' club.    That's why a l l
this patient care associate stuff is happening.
     I think that some people have gotten to the point where they
don't want to bother anymore and saying, "We can find somebody
who can do it cheaper and will listen to us.t1 And that's what's
happening.   You know, they're bringing all these non-licensed
folks now to do the job, and they're saying, "Well, you know, you
can teach the skill to anybody."


Mullan:   Is that happening here in New York?   Because I know
that's the   big deal in California.
                                                                      44

Levine:    Yeah, it's happening.   And 1'11 tell you what's
upsetting.    My son had to have a minor surgical procedure at
Einstein, and there was a woman in a lab coat who took his vital
signs.    That was the first time we were there.    And the second
time I was there, the secretary told her, "Well, you know, the
doctor wants you to draw up the lidocaine," and she was getting
me to sign the consent, and something just wasn't right.      And I
said to her, "Are you a registered nurse?"     And she said, "NO,
I'm a medical assistant.@'    And I was worried, I really was,
because I don't know what their level of training is, and I don't
know who oversees them.     Why is she drawing up the lidocaine?     Is
she injecting it?     You know, so, for me, on a very personal
level, it brought up a whole lot of issues, and I think we need
to be careful.   But I think it's working to the detriment of
nursing, I really do.


Mullan:   Let me ask, if I might, on a more personal level.
You've had a fascinating career that's bridged major changes in
health care and major changes in the provision of care, major
changes in nursing.     How has that all embellished, enriched, or
impeded your personal life?


Levine:   My personal life?


Mullan:   How has your career related to your personal life?     Has
it been enhancing or troubling?    This is a question I often ask
physicians.
                                                                        45

Levine:     I think the whole experience has made me a better
person.     I have two children.   I have two boys.    They're 13 and
16 now.     In August, they'll all go up a year.      I've been
separated for ten years, so I basically have raised them solo.          I
think it's given them an experience that they would not have
otherwise had.     It has made them more sensitive.


Mullan:     Because of what they know of your work?


Levine:     Yes, because I've had them here, and I talk.     Some of my
patients have my home number.      I've had people call me at home.
You know, I've always believed that it takes two seconds on the
phone for somebody to call me, whatever it is, and people never
abuse it.    And I can relieve a little anxiety, a little direction
to somebody rather than having them have to deal with the system.
In the chronic illness program, there are people who called
pretty regularly, and I was nurturing the way I was with my own
kids, and my kids got to know some of them, at least my oldest,
it gave him an appreciation for what he has, because he saw folks
in tough situations--in particular, this kid I took care of, he's
in his early twenties now, Ralphie Diaz, who has Werdnig Hoffmans
disease.    It's a debilitative, degenerative neuromuscular
disease.    And Ralphie managed to get through high school at home
and even with this, with a trach, he became computer proficient,
is working for the T i m e s , collecting the stats for their
bestseller list.    I would tell Ian about this all the time, and
they met other kids with handicaps and they saw the challenge.
     They also see where I've gone so they know that it doesn't
matter how old you are, you can accomplish at any point in life.
                                                                         46

You don't give up.      My oldest son was 16 when I got my master's,
he came to the graduation.        In school, he was writing a
composition on "The person I most admire."          He told me he was
writing it about my brother, but he wound up writing it about me.

So I feel like I gave them more than just the mothering part of
it.   I've been very committed to work, and sometimes it's very
hard to balance.      Often I've said--"I1m on the phone now." "This
is really important.        This is job-related."   And in the last year
my work hours have been outrageous, this last year.         They know
they're number one, but I'm sure sometimes they question it.            The
exposure it's given them and it's given me the realities of life,
I think, really has just been the best thing I could have
provided.


Mullan:     And is your mom still alive?


Levine:     My mom's still alive.


Mullan:     Is she proud of what the decision she made?


Levine:     Yeah.   Yeah.   My father died in 1990, and I'm sorry, you
know, that he couldn't have seen, because he was an administrator
over at Einstein.      He worked his way up, just worked his way up
by himself.     He was just an eighth-grade graduate.      I mean, for
him to see his daughter in an administrative role I just know it
                                             is the word in
would, you know, he just would have---nkvellll

Jewish.     It would have made him proud.
                                                                            47

Mullan:     Did your work [unclear] on your marriage?       Was that an
issue in the marriage?


Levine:     Yeah.     Probably.    Not because of the work, probably its
importance to me.        He's a club date    musician, a singer with a
band.     Really did not go on educationally, just got out of rehab.
He just now at age forty-nine realized that he's had a drinking
problem all these years.          I realized there was a problem earlier.
For a long time, we were in therapy.          I guess I was a caretaker
in the beginning.        I was going to fix everything.    I really think
it was other things other than just the nursing, although I know
that he would make remarks from time to time, you know, about
professionals.        I know it distressed him.    But he had his own
issues.    So I don't know that it was just my profession.        Thank
God, though.        I mean, it was this profession that got me through,
really.


Mullan:    To go back to the profession, your thoughts on the
future,    where do you see primary care going?        Where do you see
nurse practitioning going?


Levine:    I think we're going to go back around again to the way
things kind of used to be with more focus on the generalist
primary care, because I think we're being forced to do that.            I
think we're going to have a complete cycle. I think they're going
to diminish the subspecialists and then they're going to have to

put them back out again.          I don't see how this whole managed
care/HMO stuff is going to make it, because of who's getting rich
off of it.    I think it's going just going to be a matter of time
                                                                     48

until there's enough horrors out there, you know, patient
horrors, then we're going to have to re-equilibrate again.
     But I think primary care is important.     I think there's a
role for NPs out there.     I think the government thinks it's out
in the boondocks.     That's really where they were hoping we would
all go, and the doctors didn't want to go out there, to the areas
that are under-served.     I think if we don't price ourselves out
of the market and don't overdo it, we have a chance.      I think
we're starting to get too many schools pumping out too many NPs,
and there are too many folks needing to be primary care
providers, as per the government--1 think we'll have to find some
other track to go in.     But nursing is very creative.


Mullan:   You're saying the market is getting saturated with
primary care providers?


Levine:   Yes.    But you know, it's these markets, like the East
Coast and the West Coast.     I think there's a great need in
between, but I don't think anybody's going to go there.


Mullan:   But even the urban inner city market?    Even in the Bronx
where new nurse practitioners are having trouble finding jobs?


Levine:   I think they're having trouble finding jobs because of
the downsizing.    We always worked in clinics, and they're just
expecting to do more with less.    That's what I see right now.


Mullan:   Are nurses being laid off in general in the Bronx?
                                                                         49

Levine:     I just went through two weeks of laying off 100 nurses.


Mullan:     In the pediatric--


Levine:     It affected us here.   We didn't give any lines up but
civil service has a bumping process.      So there's about
thirty-five nurses in pediatrics that were affected by it.         The
least senior.      My service had done a lot of hiring in the last
year.     I just had the ship ready to move out of the port.
Everything was clgo,tt
                     and their last day is Friday.        It's a sin.


Nullan:     It's what?


Levine:     The [unclear].   It's the best part.    You know, the dead
wood that's probably been here longer than me--


Mullan:     Is staying.


Levine:    Yeah.   So I don't know.   Especially with this place, you
know.     I don't know what's going to happen.     I don't know.   I'm
not privy to the politics, but I went to a community board
meeting last Thursday and somebody said publicly about Montefior
taking us on.
Mullan:    Any other aspects of either your career or observations
you'd like to mention?


Levine:    Because we live in very difficult times, and I am pained
by what I don't see in nursing and medicine anymore, the care
giving.    It really distresses me.   I am pained by NPs going into
                                                                       50

a profession because they make good money, and, trust me, there
are people who have gone into this profession because it's better
bucks than some of the other stuff around.       I mean, that really
hurts me, because to me it was this real caregiving profession
that I went into.     It just changed over time.
        So it's difficult.    Every day is difficult, but every now
and then there's a patient who comes back to thank you.       Elvira
Mahmatovic, who was congenital hypothyroidism, who had just come
over from Yugoslavia, the mom didn't speak a word of English.
The child lost a lot--mom wasn't giving her child her medication
because she thought we were trying to poison her.       She can speak
English now, and she tells me what those early days were like,
and comes in and says, "Thank you.       You made the difference.    If
it wasn't for you--tt Phil Candelario's [phonetic] mom, the worst
two-year-old asthmatic on the face of the earth, who was
intubated in the unit a million times, who is functioning now and
doing really well, they had a difficult psycho-social situation,
and she'll come back and she'll say, "Sunni, if I didn't have you
then, I don't know what I would have done."       She had what it
took.     She just needed the directions.    And those things make up
for every bit of pain, every horror that you have, because for
somebody to think that you're that important, or really to have
made that much of a difference to somebody, nothing, nothing on
the face of the earth can equal that.       And we still get that
around here.    You know, we've helped.     And to me, that's what
it's all about.


Mullan:    That's great.     Where did the name Sunni come from?
                                                                      51

Levine:     When I was in nursing school, I was Ellen, and there was
a Helen.     There was a Helen Sternberg, and I was Silverberg at
the time.     We both had long straight brown hair, because, you
know, it was the sixties, long hair was in.        And they kept mixing
us up.     Like I said, there weren't a lot of Jewish gals in
nursing.     They kept calling me Helen.   They kept calling her
Ellen.     So we said, *'Let's take nicknames.It   So being the fairly
creative person that I was, I loved the Johnny Mathis song,
tlSunny.t*And then there was that sixties hit song ttSunny.ggI
never had a nickname.     So I took Sunni, but I spelled it S-U-N-N

and over the llItfI made a big sun.     She took ftHolly.ftAnd it
just stuck.


Mullan:    Great story.   I think it's a good place to stop.    Thank
you.


Levine:    You're welcome.


[End of interview]