Five Questions with Dominique A. Tobbell, author of Dr. Nurse: Science, Politics, and the Transformation of American Nursing
Nurses represent the largest segment of the US health care workforce and spend significantly more time with patients than any other member of the health care team. Starting in the 1950s, academic nurses sought to construct a science of nursing—distinct from that of the related biomedical or behavioral sciences—that would provide the basis for nursing practice. Dr. Nurse: Science, Politics, and the Transformation of American Nursing, a new book by Dominique A. Tobbell, reveals how academic nurses transformed their field, and how federal and state health and higher education policies shaped education within health professions after World War II. We spoke with Dominique about her research and its relevance to contemporary issues in American health care.
What was American nursing education like in the twentieth century prior to World War II?
Prior to World War II, the majority of American nurses were taught in hospital training schools (or diploma programs). These training programs were three years in length and typically included six months of classroom work in the biomedical sciences and nursing. The focus, however, was procedure-oriented clinical training that emphasized learning by repetition. Students spent thirty to forty-eight hours a week on hospital service, practicing techniques and procedures repeatedly so that they became rote. Graduates earned a diploma and were entitled to sit for the state licensing exam, which would certify them as registered nurses. A product of this system was that until the 1940s, when hospitals began hiring more graduate nurses, the majority of hospital nursing labor was provided by student nurses. While students gained technical competence in hospital training programs, they were not educated to understand, think through, and respond to the specific clinical needs of individual patients. The limits of this approach to nursing education became increasingly clear after World War II, as new innovations in health care contributed to the increasing complexity of patient care.
Why did academic nurses feel they needed to establish nursing as a scientific discipline?
There were two major reasons that led nurses to advocate for the creation of nursing science in the decades after World War II. The first was empirical and motivated by broad-scale changes in patient care. Chronic diseases like cancer and cardiovascular disease had replaced infectious diseases as the leading cause of morbidity and mortality. The introduction of complex surgical procedures such as open-heart surgery exposed patients to new types of post-surgical complications. So too, the availability of new pharmaceuticals and medical technologies like kidney dialysis and electronic fetal monitors contributed to the complexity of patient care. As a result, nurses increasingly found themselves without the knowledge to provide appropriate care to patients with complex clinical needs. They also did not understand how patients made decisions about their health care. Nurses thus worked to develop a science of nursing with the goal of improving patient care by preparing nurses for the changing health and illness needs of the population.
The second rationale was political. Control over an organized body of knowledge was an essential component of professional development. And during these same decades, engineering, computing, clinical psychology, pharmacy, and social work were engaged in similar efforts to establish their professions’ disciplinary foundations. Nursing leaders saw the establishment of nursing as a scientific discipline as a political imperative, central to securing the profession’s legitimacy and establishing nurses as independent and expert practitioners. This was especially important once nursing education moved into universities.
Racial inequities in nursing persist today, as does a dearth of nursing research on the experiences of patients of color. How does your research help to explain these inequities?
During the formative years of nursing’s knowledge project, only those able to attain a bachelor of science in nursing, then a master’s degree, and eventually a doctorate, were invited to contribute to the science of nursing. The long history of segregation and racial discrimination in nursing, health care, and higher education (as well as gender discrimination in nursing) meant that the project of constructing nursing science was advanced primarily by white female nurses. This had consequences for the types of theories developed and research pursued by nurse scientists. For example, as the first generation of nurse scientists sought to improve patient care, they prioritized research they hoped would be legible within the biomedical research economy. In the process, they dismissed calls from nurses of color and public health nurses to conduct community-based research into the effects of poverty or racism on health.
During the 1970s and 1980s, nurses of color called for greater diversity in nursing, arguing that nurse scientists of color bring invaluable perspectives to the research process, including questions relevant to the health care needs of patients and communities of color. But by the 1990s, racial inequities in the field persisted because of ongoing systemic racism in nursing. The dearth of research focused on patients of color was also a product of the way in which nurses had constructed their science, which was underpinned by theories that centered on concepts of health, holism, and the environment. This had led to both a class and a race bias in nursing research in which the influence of racism, socioeconomic, or cultural factors on the health outcomes of individuals and communities of color had been ignored.
To be sure, nursing’s research priorities reflected those of the major funding agencies. These were decades during which the National Institutes of Health’s research mandate was overwhelmingly disease-focused, emphasized individual responsibility for health, and privileged basic research in the biomedical sciences or clinical studies underpinned by quantitative research methods (preferably, the randomized controlled trial). Indeed, continuing through the early twenty-first century, community-based research and studies on the structural and social determinants of health occupied a marginal status within the research economy.
Many people—including those who work in health care—are still surprised to hear that nurses do research and that this work is underpinned by a distinct body of knowledge. And relative to other types of health science and biomedical study, nursing research is poorly funded. Why is nursing science undervalued within the research economy?
The reasons are complex. As relative newcomers to university campuses in the decades after World War II, and as a predominantly female profession, the ability of nursing schools to establish their status in the post-war university and research economy was indelibly shaped by gender. For example, at some universities and academic health centers, nursing deans and their faculty encountered gender discrimination from university administrators, academic physicians, and biomedical scientists who questioned the need for nurses to do research or for nursing schools to establish PhD programs.
The status of nurse scientists in the post-war research economy, however, has also been shaped by the way they chose to do science. While rejecting the medical model and seeking to distinguish nursing science from the biomedical sciences, academic nurses opted to construct nursing science as a theoretical and empirical discipline, one that drew heavily upon the theoretical frameworks and qualitative research methods of the social and behavioral sciences. They did so at the same time that academic physicians were establishing the empirical and statistically-derived discipline of clinical epidemiology and asserting the primacy of the randomized controlled trial for generating the most objective and reliable knowledge. In this context, academic nurses’ path to knowledge development—particularly their reliance on new, nursing-specific theories and on research methods other than the randomized controlled trial—contributed to the undervaluing of nursing science and the siloing of nurse scientists within the research economy and academic health centers.
A nationwide nursing shortage continues to impact a health care system strained by the COVID-19 pandemic. Your book raises several relevant considerations regarding labor, staffing, and pathways to a nursing career. What are a few?
The US has faced cyclical nursing shortages since the turn of the twentieth century and in each case, the response by nurse leaders, health care institutions, and policy-making organizations has been to focus on increasing the supply of student nurses, rather than address the workforce issues that drove nurses from the workforce, particularly discriminatory hiring practices, low wages, and poor working conditions. For example, after World War II, nursing leaders introduced the new associate degree in nursing, which offered a more affordable and accessible pathway into the profession. But almost as soon as the associate degree was introduced, nursing leaders were already working to establish the bachelor of science in nursing as the requisite credential. In response to demands from nurses and with the support of state legislatures, nursing leaders implemented career ladders and articulated educational pathways to support the educational mobility of nurses prepared at the associate degree level. Today, the associate degree remains a critical entry point into nursing, particularly for people from rural areas, disadvantaged backgrounds, or underrepresented populations. Continued support and resources for educational mobility within nursing remain essential for enhancing the recruitment and retention of underrepresented students into nursing.
But prioritizing strategies to increase the production of more nurses—while ignoring the working conditions that drive nurses to leave—has failed to solve nursing shortages in the past and it will similarly fail to solve the current shortage. For more than a century, hospitals have obscured and devalued the expert and essential care that nurses provide and as such, have failed to adequately respond to nurses’ demands for adequate staffing, higher wages, and improved working conditions. As the 15,000 Minnesota nurses who went on strike this September highlighted, it is essential that nurse leaders, health care institutions, and policy-making organizations finally address the working conditions for nurses throughout the country. Only by tackling both the production and retention of nurses, will they be able to address the nursing shortage.
Dominique A. Tobbell is the Centennial Distinguished Professor of Nursing and director of the Eleanor Crowder Bjoring Center for Nursing Historical Inquiry at the University of Virginia. She is coeditor of Global Health and Pharmacology and the author of several books, including Pills, Power, and Policy: The Struggle for Drug Reform in Cold War America and its Consequences.