Dr. Nurse: Science, Politics, and the Transformation of American Nursing, Dominique A. Tobbell

It is a well-known fact that nurses constitute the largest proportion of the American health care workforce and that year after year, they are voted “the most trusted profession.” When patients talk about their experience in a hospital, they are most likely to remember the nurse who cared for them. But rarely do they think about what education went into this care. In her important book, Dr. Nurse: Science, Politics, and the Transformation of American Nursing, Dominique A. Tobbell meticulously details the processes by which nursing leaders fought to transform nurse education and research as part of nursing’s “academic project” after World War II (p. 1). And importantly, she lays out the ways that this project was, and remains, incomplete and limited due to the various racial, gendered, and interprofessional hierarchies at play.

Written in engaging and accessible prose, Tobbell sets out three main arguments for the book: that the nursing academic project exists in tension with nursing workforce needs; that this project has been shaped by the gendered politics of academia and interprofessional health care; and that this history is central to understanding current health workforce issues. Tobbell threads and expands on these arguments through five well-structured chapters (as well as an Introduction and Conclusion) that are organized both chronologically and thematically and supported by rigorous archival research from several key sites.

Chapter One recounts the longer history of the rationale and processes by which nursing education moved into the university sector post WWII. The increasing complexity of medical technology and patient care required much higher levels of nurse education than hospital-based training schools could provide. At the same time, buoyed by their role in the war effort, nurse leaders were of the belief that nurses themselves should be able to articulate what their practice looked like and be able to provide the scientific rationale for it. For this, a university-based education was required, but the push to establish university-based courses raised questions of equity and diversity. At the very moment of establishing its academic project then, Tobbell demonstrates the way that structures of racism and inequity were baked in to nursing science.

In Chapter Two, Tobbell highlights the foundational concerns that shaped the establishment of nursing as an academic discipline. Nursing’s academic project was also an epistemological one — what were the scholarly questions with which nurses should be concerned, and what were the ideas and theories with which they should engage? Tobbell calls this process nursing’s “boundary and legitimation work” (p. 55) and she clearly demonstrates that in the debates about how nurses would construct their own discipline, they engaged with “science as it was currently done” (p. 57) rather than developing a feminist critique of science. The first generation of nursing theorists made important strides in developing an approach to nursing science that prioritized wholistic approaches to health, but there were limits to this enterprise born of the lack of diversity in the profession and the types of questions that this generation of theorists chose to engage with.

These problems were exacerbated by the development of funding models that privileged the Academic Health Center (AHC). In Chapter Three, Tobbell explores the ways that NIH funding models and the gold standard randomized control trial (RCT) shaped the structures of the nursing research enterprise. Gender and power hierarchies were reproduced within and by AHCs, and the politics of interprofessional disciplines worked to limit the way that nurses were able to make a space for themselves. At the same time, the ability of nursing leadership to develop innovative research agendas was limited by what state health policy makers felt was appropriate. In Chapter Four, Tobbell clearly analyzes the role of state legislators and AHC administrators whose primary concern was the nursing workforce shortage. While nursing leaders knew that a baccalaureate-prepared nurse led to better patient outcomes and was necessary for the continued development of nursing science, state-level administrators were more concerned with delivering nurses to the bedside. Diploma and associate degree programs were more accessible to people from underserved communities, whose presence in nursing was so desperately needed. The move to baccalaureate education was essential but was also inherently exclusive. This problem of multiple pathways into nursing is one that has still not been solved and remains one of the greatest tensions within the health professional workforce debates.

If the move to university-based education created disparities in the pathways to education and the types of knowledge produced, it also created what was known as the education-service gap. In Chapter Five, Tobbell explores the way this gap was created and documents the attempts made to address it. Across the country, various nurse leaders and administrators tried to address the problem through the creation of the Clinical Nurse Specialist, or unified models of research and practice, but they were continually stymied by the employment and reimbursement models within both universities and AHCs. The most significant barrier was the gendered power hierarchies within AHCs and the persistence of the medical profession in seeing nurses as handmaidens to physicians. Nurse leaders reading this book will nod their heads in recognition.

Tobbell’s book is a clarion call to administrators of health systems and schools of nursing everywhere. Professional hierarchies based on race and gender continue to stifle the way that health education is delivered, valued, and compensated, and these hierarchies shape the direction of scientific knowledge itself. Policy makers would benefit from reading this book if they are serious about clearing barriers to health professional education in the best interest of patients. Historians of health care more broadly would benefit from understanding the extraordinary battles that nurses have had to fight to be taken seriously and to develop their profession, at the same time as they carry the greatest burden of direct patient care. We cannot understand the development of the health systems we have today without understanding the challenges and limitations of nursing’s academic project.