A few days ago, I was having coffee with a colleague who had been a significant nurse leader in Canada in the 1980s and 1990s. It struck me later how closely our conversation mirrored the highly political and professionally confounding story of Dominque Tobbell’s excellent Dr. Nurse. My colleague recalled the massive barriers nurses faced trying to establish graduate programmes in universities across the country. She recalled the condescension and occasional outright sneering nurses faced when getting their graduate programmes approved, the infuriating catch-22 of needing graduate faculty to teach graduate programmes when no graduate faculty existed without said programmes. She also recalled the outright hostility from colleagues in practice, who keenly felt the threat of more highly qualified nurse graduates, along with their frustration that the emerging research agenda of the university schools offered little upon which to build the scientific basis of nursing practice.
Tobbell seeks to historicize and open out this series of conundrums to trace the policy drivers and the professional implications for nurses – from the GI Bill that expanded the US university student body after the Second World War, through to a plethora of federal and state funding initiatives that nurses exploited to build master’s programmes, expand the base of the nurse academy with PhD-prepared nurses, and subsequently support the development of an advanced-practice doctoral degree, the doctor of nursing practice or DNP. Focusing on a series of public universities, Tobbell communicates the breadth of the American story, as well as locating that story within state higher education and health policy initiatives.
One of the great strengths of the work is that Tobbell avoids the kind of ‘nursing exceptionalism’ that often befalls those who write on nursing. Yes, this is a nursing story, but parallel stories of engineering, physical therapy, pharmacy, social work and so forth run close. In many ways it is the history of a profession establishing itself in the academy in the second half of the twentieth century. A further theme is that nursing’s large-scale shift into the academy took place in the context of the growth of medical research and in the emergence of structures that supported it, such as the academic health science centre.
Tobbell takes a deep dive into the curricular concerns and obsessions of leading nurse educators to build nursing as a distinct discipline, and how graduate training became synonymous with ‘advancing’ the discipline and practice. The development of nursing theory, the ever-with-us theory–practice gap, and the disconnect between the academic training of most faculty, who were primarily educators, and the research agenda of the time, are all expertly woven into the analysis. Two trends in health science research in particular were fortuitous for nursing’s research agenda: the evidence-base movement and the quality movement. These strategically important initiatives fostered the development of research teams outside the unreachable lab-based biomedical research juggernaut that dominated the era. Nursing’s struggle to get a foothold in the new academic health science centres is also a universal story as the payment models for medicine do not map onto nursing.
It was fascinating to read Tobbell’s take on the gendered critique of medicine that at times drove nursing academics to disdain from teaching any clinically relevant content to nursing students. Likewise, it was appalling to see the resistance to nursing’s progress from hospital schools to university programmes by both the American Medical Association (AMA), who were deeply suspicious of the move, and the National League for Nursing (NLN), for whom the loss of accreditation revenue was paramount.
At times Tobbell seems to elide biomedical science with medicine. But medicine is far from a singularity and subdisciplines in medicine, such as primary health care and palliative care, have also long felt marginalized by the dominance of lab-based research and RCTs. In fact, colleagues in these disciplines, and in the other health sciences, would likely describe themselves, as opposed to nurses, as the Cinderellas of the academy.
Nursing’s view of itself as downtrodden underwrites many of the interview quotes, and of course is widespread within the discipline itself. Tobbell could have taken a more sceptical and less sympathetic approach at times – there is great power in being the underdog, after all. I felt, too, that Tobbell accepted the progressivist narrative of the nurse educators as self-evident. Was graduate education really the only way to advance practice? She was also overly respectful of the nursing-theory era in my view – which, it has to be acknowledged, veered into the whacky at times.
Dr. Nurse is a very US story. And it helps the reader to understand the distinctiveness of the American nursing academy. The size, budget and prestige of US academic nursing is without parallel. The multiple elements over the decades that went into making it so are elaborated, contextualized and discussed. So, too, what is missing from the picture is also examined. If the American nursing profession lacks diversity and representation as a whole, the situation is intensified in the academy. Not only have members of the nursing academy been overwhelmingly and disproportionately white, but also historically the content of nursing research has largely ignored issues of the health disparities that impact so many in the United States and, ironically, are often amenable to nurse-led interventions.
In sum, Dr. Nurse is an excellent work – well researched, detailed and comprehensive. It reminds us that the edifice of academic nursing in the United States was the product of a particular moment of expansion in the post-secondary sector. The book gives due credit to the political acumen of nurses who garnered support for policies that created the multiple initiatives at state and federal levels that underpinned the wholesale development of this major academic enterprise. Along the way these women battled the medical profession, unwelcoming colleagues in the academy and deep divisions within the profession to keep moving forward. Their commitment and their hubris make it a compelling story, and Tobbell makes it a compelling read.
