Dr. Nurse: knowledge, politics, and the making of the academic nurse, October 25, 2018

- [Donna Hirst] So this is our October lecture. We're having Dominique Tobbell speak. She's the Assistant Professor in the History of Medicine program at the University of Minnesota and Director of the History of Medicine program there. Her research specialties include history of 20th century U.S. medicine, nursing, pharmaceuticals, health care policy, business history, and oral history. Her scholarship explains the political, economic, and social relationships that develop among academic institutions, governments, and the health care industry in the decades after World War II and assesses the implications of those relationships with the current health care system. She received her Bachelor of Science in Biochemistry from the University of Manchester, and her MA and PhD in the History of Sociology of Science from the University of Pennsylvania. Her first book Pills, Power, and Policy: The Struggle for Drug Reform in Cold War America and Its Consequences describes how the American drug industry and key sectors of the medical profession came to be allies against federal reform and details the political strategies used by that pharmaceutical medical alliance to influence public opinion and shape legislative reform and regulatory environment for prescription drugs. So she's got a background in what we're facing today. Her second book, Health Informatics at Minnesota: The First Fifty Years details the history of health informatics at the University of Minnesota. Whoa. - [Audience Member] I appeared to get mixed up, sorry about that. - [Donna Hirst] So Dr. Tobbell is currently working on a book, Dr. Nurse, Knowledge, Politics, and the Making of the Academic Nurse which examines the development of nursing doctoral education in the United States in the context of nursing workforce concerns and regional planning efforts after World War II and that's what she's going to be speaking about today! Her other work has focused on the role of academic and government researchers, biotechnology companies and disease-based organizations in the development of drugs to treat rare diseases. Dr. Tobbell has won lots of awards, has written lots of articles, but I think we wanted to hear what she has to say now. - [Dr. Dominique Tobbell] Okay, thank you Donna and thank you everyone for being here, this is quite the crowd! So just out of curiosity, who among you has some kind of relationship with nursing, is on the nursing faculty, is nursing student? Okay, great, okay so hopefully this will be particularly interesting for all of you and also something useful and interesting for the rest of you too. So, I'll get us started. So beginning in the 1950s, a small but growing number of nurse researchers and educators were engaged in an effort to establish nursing as an academic discipline and key to this academic project was the need for nursing to develop its own body of knowledge, nursing science, to guide nursing research and practice. And as part of this, nurse educators were working to establish new PhD programs in nursing which for the first time promised to train nurses within nursing schools to conduct research, underpinned by nursing theories in order to produce new knowledge that would be relevant to nursing practice and would lead to the development of nursing science. Now the push during the 1960s and '70s to establish nursing as an academic discipline held particular significance as the primary site of nursing education shifted from hospital to colleges and universities and nursing schools were working to secure their status on university campuses. Now by contributing to the production of nursing knowledge, nurse scientists would not only help advance patient care, they would also become members of the community of scholars. This was a phrase used at the time. In this way, nursing faculty would no longer be just teachers but would become full-fledged members of the academy and should, the deans of leading nursing schools argued, be accorded full institutional status and intellectual status as their university peers. Now while nurse educators and researchers argued that the establishment of nursing PhD programs was essential to nursing's academic project, they also joined health planners in arguing that the nursing PhD was critical to expanding the nursing workforce in the midst of ongoing nursing shortages and shortages of other health care professionals as well. They argued that by producing more doctorally-prepared nurses, schools of nursing could improve the quality of and expand the scale of master's, baccalaureate, and associate-degree level education. So beginning in the early 1970s, nurse educators framed their arguments for the nursing PhD in terms not only of a new type of disciplinary knowledge but also in the context of urgent nursing workforce concerns and get engaged in regional efforts to increase the development of nursing PhD programs. So that's kind of an overview of what I'm going to talk about today. My presentation, though, is going to be broken into three parts. First we'll examine the context for nursing's academic project, why there was even a need for nursing science as nurse researchers argued. Then we'll look at how these nurse researchers sought to construct the boundaries of this new kind of science and then we'll finish with a case study of a program, of a nursing school attempting to establish a PhD program in the '70s and early '80s. And I just want to add before I get into the details about it, I want to say that nursing wasn't the only discipline or practice profession that was trying to increase its academic standing and emphasize the scientific underpinnings of its discipline at this time. In fact, there were many practice professions who were engaged in similar work, particularly engineering, clinical psychology, pharmacy, and social work. They were all embroiled in similar scientific and political debates. I'm not going to talk about that in the context of my talk, but we can certainly talk about the differences and the similarities in the Q&A. So first, the need for nursing science. So nurses were confronted with new clinical realities after World War II. Improvements in public health and the introduction of antibiotics had contributed to the decline in infectious diseases and with chronic diseases like cancer and cardiovascular disease replacing infectious diseases as the leading causes of morbidity and mortality in the U.S. Major surgical innovations introduced in the 1950s such as open heart, vascular, and large scale abdominal surgeries had exposed patients to new types of post-surgical complications such as shock and respiratory failure, and the arrival of new medical technologies like kidney dialysis and electronic fetal monitors and the availability of increasingly powerful pharmaceuticals with oftentimes equally powerful side effects also contributed to the increasingly complexity of patient care in the decades after World War II. So in this context, nurses increasingly realized that they lacked the knowledge to provide safe and effective care to patients, especially because nurses were increasingly called upon to make rapid and complex clinical decisions. These conditions prompted nurses to use the knowledge they gained from experience to developing far more frameworks and theories to first describe and then to generate knowledge concerning their work and patients. Now early critical care nurses were pioneers in this type of knowledge development. In the 1950s they began to theorize that spacial location and the ability to observe their patients was critical to their survival, and identify the different kinds of knowledge and skills they needed to critically evaluate patients' conditions and make nursing care decisions and this, the work of the first early critical nurses led to the development of the ICU. It was very much a nursing innovation, but as Rozella Schlotfeldt, who at the time was Dean of Case Western Reserve University School of Nursing, as she noted in 1960, the complexity of clinical nursing and the concomitant demands placed on nurses meant it was, quote, unrealistic for nursing to continue to rely upon invention and intuition for its best practices. Instead there was now, quote, an urgent need for systematic observation of effective nursing action with a view towards conceptualization of its rationale. Now Schlotfeldt was joined in her call for the development of a systemized nursing science by several nurse researchers and scholars who saw the development of nursing science essential to the continued development of nursing and its establishment as a professional discipline. So as UCLA's Dorothy Johnson explained in 1959, the question of an existence of a body of substantive knowledge, what can be called the science of nursing is a question of considerable significance for nurses' continued development as a recognized professional discipline. Certainly no profession can long exist without making explicit its theoretical basis for practice so this knowledge can be communicated, tested, and expanded. For Yale University's Florence Wald, by developing its own theories, quote nursing would become an independent discipline in its own right. Now the need for nursing to establish itself as an academic discipline was particularly pressing by the 1960s. Through the mid-20th century, the majority of American nurses were trained in hospital training schools or diploma programs in which training and practice was rule-based, activity-oriented, and relied heavily on the repetition of procedures rather than on scientific or social theory based decision-making. It was a lot of you do it, there's one best way of doing it, if you repeat it enough, you'll understand how to do it, you don't want to think about how to adapt it into different situations. That was at least the model that the diploma model was based on, the diploma program was based on. It was also premised on regimentalized patient care and the concept of quote, nursing as merely ancillary to medicine. Beginning in the 1950s, though, nurse educators introduced a new model of undergraduate education. Located on university and college campuses that replaced this regimented procedure-based training of hospital diploma programs. Now although the first baccalaureate nursing program was introduced in 1909 and many university-based nursing schools offered baccalaureate programs prior to the 1950s, these early programs typically prepared RNs, those who had been trained in the diploma schools for careers in advanced practice, education, or administration. But beginning in the 1950s, nurse educators reformulated baccalaureate programs to become entry-level general nursing programs and these new BSN programs were premised on liberal education and integrated the physical, behavioral, and social sciences. So by emphasizing the nursing model of care and rejecting the medical model, these new BSN programs prepared professional nurses for careers as independent expert practitioners, so they were supposed to be very much separate from medicine. Now as the nature of nursing work expanded and patient care assumed greater complexity after World War II, which nurse educators argued necessitated these curriculum reforms, much of that so-called traditional bed and body work of nursing was transferred to less-trained technical nurses or bedside nurses, practical nurses and nursing assistants. And in fact in 1951 Mildred Montag introduced the concept of a new kind of specialized nursing worker, the technical nurse whose training would be more than that for a practical nurse, the LPN would have one year of training, but less than that for the diploma or baccalaureate-prepared nurse. Technical nurses were to assume the responsibility for the hands-on body work of nursing. They would be trained in two-year associate degree programs based at the new community colleges, receiving both general education and nursing education and clinical instruction. Now the first associate degree programs were introduced in 1952 and by 1960 there were more than 100 such programs in the U.S. and associate degree programs in nursing just took off. An important point to make here is that the diploma, the associate degree, and the BSN nurses all sat for the same licensing exams as they do today and on completion, earned the title of RN. So even though they were intended, they were trained somewhat differently, they were intended to assume these different roles, they all sat the same licensing exams and oftentimes you couldn't, you know, usually you couldn't tell them apart once on the nursing floor. But in this new educational hierarchy, the baccalaureate-prepared nurse assumed the status of the professional nurse and the responsibilities of the expert and independent clinical practitioner, while the associate degree-prepared nurse assumed the responsibilities of the technical nurse. Now professional nurses typically after completing advanced graduate education would go on to serve as clinical supervisors, educators, or administrators and indeed innovations in graduate nursing education also took place in these decades. By the 1960s, increasingly complex specialized patient care had created new roles for nurses who had undergone advanced clinical training at the master's degree level in various clinical specialties, so this is the clinical nurse specialist such as in psychiatric nursing, pediatric nursing, and geriatric nursing. These were some of the first clinical, advanced clinical specialty areas. And then the nurse practitioner movement of the '60s and '70s which emerged in the context of shortages of primary care physicians also expanded the demand for clinical master's programs. So as nursing education relocated from hospital schools to colleges and universities, nurse educators were anxious to secure nursing's place within the academy and assert their status as equal among their university peers. And for Schlotfeldt who I mentioned earlier, she was writing in 1965 nursing faculties had yet to achieve two major accomplishments, which would signal nursing's arrival as an academic discipline. First is that each nursing school must make its contribution toward developing and testing theoretical constructs which represent nursing knowledge. The second is that all faculties in nursing schools must exemplify the characteristics of, of, sorry, exemplify the characteristics appropriately expected of professionals and scholars who hold university appointments. And as part of this nursing faculties should be engaged in developing and refining nursing knowledge, of preparing practitioners for the future, and finding answers to significant questions concerning practice. In other words, Schlotfeldt was making the point that nursing faculties should fulfill the post-war university's tri-part mission of research, education, and service. Prior to this, the emphasis had really been on teaching and service, not on research. But to be sure, nurses had engaged in research for decades. However, prior to the 1960s the majority of nursing research had been focused on educational and occupational studies aimed at improving preparation of nursing and the recruitment and retention of sufficient numbers of nurses to meet the nursing workforce needs. This emphasis was in-part explained on the educational preparation of nurses. The first doctoral programs in nursing were launched at Teachers College, Columbia University in 1933, and that was an educational doctoral program so those who went through the program got an EdD and the emphasis was on preparing nurse educators rather than researchers. And in 1934, NYU School of Nursing established the first nursing PhD program. And although the program emphasized the teaching of theory development, it was still largely modeled on an educational degree. Graduates were just given, were awarded the PhD even though most of their classes had actually been in nursing education. So before 1960, most doctoral nurses were graduates of either Teachers College or NYU but by the mid-1950s the leadership of the U.S. Public Health Service Division of Nursing, which was a major federal funder of nursing education and research recognized that in order to promote a different type of research, nurses needed a new type of research training. In 1962, the Division of Nursing established the Nurse Scientist Graduate Training Program which funded nurses pursuing research-based graduate degrees in university by medical, behavioral, and social science departments. For Schlotfeldt, nurses with PhDs in the basic disciplines were needed so that nursing can quote, begin to inquire systematically and with proper rigor into the questions that are nursing questions. So between 1962 and 1975, 10 universities in the U.S. established Nurse Scientist PhD programs with the support of the Division of Nursing, and this lists them here and the disciplines in which what the cognate science was. And the premise of the Nurse Scientist Graduate Training Program that the nurse scientist would then bring knowledge generated in these scientific disciplines into nursing so a lot, you can see there is a lot in anthropology, sociology, psychology, but also physiology and anatomy. Those were the main main areas. However Dorothy Johnson observed that despite the valuable scientific contributions that these nurse scientists made, constrained by the conceptual frameworks and research parameters of their scientific disciplines, the research being done by nurse scientists found it was often had little to do with nursing practice, it was more squarely situated within those scientific disciplines in which they got their training. And reports that tracked the careers of nurse scientists found that in many instances, nurse scientists who pursued doctorates in non-nursing fields never returned to nursing and they stayed in their scientific field. So nurse educators and researchers began calling for the establishment of nursing doctoral programs modeled on the research-based PhD. As the University of Illinois' Helen Grace argued, quote, doctoral programs in nursing in contrast to doctoral programs for nurses, serve to focus research upon areas as yet unresearched and of essential importance to the creation of new theories and validation of nursing practice. Now nurse educators were also motivated in their efforts to establish nursing PhD programs by ongoing nursing shortages. Beginning in the early 1960s, health policy makers joined nursing educators in calling for the increased production of doctorally-prepared nurses, and in fact the increased production of all kinds of nurses at all educational levels. In 1963, the Surgeon General's consultant group on nursing warned that by 1970, the country would need 850,000 professional nurses including 100,000 with graduate preparation. In particular, doctorally-prepared nurses were needed to serve as deans of collegiate programs, faculty of graduate programs, researchers, and nursing serving directors of large hospital or health agency systems. But through the 1960s, there are only six doctoral programs in nursing and this here, this lists the six doctoral programs and you'll see the EdD and the PhD, you'll also see the DNS, the Doctor of Nursing Science. I just want to say a word about that, so the DNS was described as a professional doctorate. It was supposed to be clinically-oriented as opposed to research-oriented like the PhD. So in name, the DNS and the nursing PhD were intended as different types of degree programs with different objectives and end-products. The primary emphasis of the PhD was nursing research and scholarship, while the emphasis of the DNS was advanced clinical practice with the integration of research to improve nursing care. So we might think of it, we could think of it as a predecessor to the DNP but actually it's quite different and even though they were intended as different degrees, essentially in practice the boundary's very very much blurred. And in fact some nursing schools such as those at Boston University and University of California, San Francisco that are both listed here, they established DNS programs after university administrators opposed their plans to established a PhD. So as a professional doctorate, the DNS didn't fall under the graduate school. It remained under the authority of the nursing school. So nursing schools could confer, they could confer the degree and they didn't have to get permission from the graduate school to establish those programs. So with such proposals to establish DNS programs face significantly fewer obstacles than did establish in PhD programs. So in some schools like at BU and later at Penn, this faculty said we'll go for a DNS, prove that we can be researchers and then we'll put forward a proposal for the PhD. Sometimes it worked, sometimes it didn't. But that's the difference in nomenclature. So the efforts of nurse educators to recruit more women and men into nursing at both the undergraduate and graduate level were both helped and hindered by the women's movement of the 1960s and '70s. So together with the civil rights movement, the women's movement helped create new educational opportunities and employment opportunities for women, that by the 1970s meant that there were far more, far greater numbers of women entering higher education. So as nursing schools were trying to tackle the nursing shortage, this in theory provided nurse educators with an expanded pool of students to recruit from in their efforts to stem the nursing shortage. However in practice, nursing schools instead encountered increased competition for the students from professions and disciplines that had previously been closed to women, and at the same time many within the women's movement actually criticized the nursing profession for promulgating negative female stereotypes. As Wayne State University's Virginia Cleland reported in 1972, when attending meetings on women's rights, I've heard nursing used time and again as the illustration of discrimination. The assumption always is that if a nurse is intelligent, educated, and capable she is a nurse instead of a doctor only because of sex discrimination. As such, Cleland continued, nursing is going to have an increasingly difficult time trying to recruit intelligent young women. Indeed, nursing's recruitment efforts were explicitly undermined by feminists who called on women to reject careers in nursing in favor of careers in medicine. So in this context, the efforts of nurse educators and researchers to establish nursing as an academic discipline as evidenced by the creation of nursing PhD programs was one way to overturn these negative stereotypes of nursing. So beginning in the 1960s, several nursing schools initiated plans to establish nursing PhD programs, and so they did so in response to state and regional shortages of doctorally-prepared nurses as well as the academic imperatives of nursing. So in 1966 for example, the College of Nursing at the University of Illinois Chicago initiated plans for a doctoral program in nursing to quote, meet the dire needs of the state for nurses prepared for university teaching for faculty and for research for improvement of nursing care. At that time, there were no doctoral programs in nursing being offered by any university in the Midwest region and two years later those plans assumed new import when the board, Illinois Board of Higher Education's Commission on Nursing recommended that at least one Illinois university offer a doctorate designed for nurses to provide the faculty needed for master's programs and for research. So the University of Illinois at Chicago College of Nursing established its nursing PhD program several years later in 1974. But even as state and regional workforce needs provided nursing schools with important justification and indeed state and federal support to develop nursing PhD programs, nursing schools struggled to convince university administrators of the value, legitimacy, and academic rigor of the proposed programs. In 1960, for example, UCLA School of Nursing submitted a proposal to establish a nursing PhD program to the University of California's Committee on Education Policy. The committee, however, denied their request on the grounds that its faculty had, quote, extremely limited research background to supervise and train research scientists in nursing and that the field of nursing had not yet achieved the scientific sophistication to warrant offering a doctoral degree. The committee's rejection reflected the barriers confronted by nursing schools seeking to establish nursing PhD programs from the '60s through the early '80s. Before convincing university administrators that a nursing PhD program was legitimate, nursing faculty first had to define nursing science as a distinct body of knowledge and establish themselves as scientific researchers. So, I mean the opposition that UCLA faced, that is kind of an example of why some schools like BU and UCSF opted for the DNS because they could bypass some of those barriers so that, just put that in some context. So how did nurses create a science of nursing and what should constitute that science? What research was necessary and what research methods should nurses use in order to produce a body of scientific knowledge you need to nurse in? What theories, if any, should underpin nursing's research agenda and how should nurses go about developing those theories? These were key questions that occupied nurse researchers during the 1960s and '70s. As they worked to address these questions and established nursing science in these decades, nurse researchers engaged in critical boundary work to one, determine the degree to which nursing science would draw upon the theories, knowledge, claims, and research methods of the biomedical and behavioral sciences and two, to identify what was unique to nursing and thus what nursing would do differently from the established disciplines in order to clearly distinguish nursing science from the existing sciences. So some scholars such as Johnson and Cleland saw that boundary work as drawing upon the theories and knowledge derived from the basic and behavioral sciences to develop nursing theories based on definitions of nursing practice, and remember a lot of these researchers had gotten PhDs through the nurse scientist graduate training program in other sciences, in physiology, in anthropology, and sociology. So folks like Johnson and Cleland thought that nurse researchers would then use these nursing theories and this, quote, borrowed knowledge to address research questions of specific relevance to nursing, phenomenon that researchers in these other fields had no interest in pursuing. But other scholars like Florence Wald at Yale University challenged the concept of borrowing theories from the basic and behavioral sciences and applying them to nursing. Instead Wald, in collaboration with sociologist Robert Leonard advocated for an empirical approach to building nursing knowledge directly from systematic study of nursing experience. Only by developing so-called practice theory, they argued, would nurse researchers be able to identify and inform the ways in which nurses effected improvement in patients' health. A focus on developing practice theory would also enable nurse researchers to distinguish nursing science from the biomedical and behavioral sciences. In these purely academic disciplines, researchers could and indeed would encourage to produce knowledge for the sake of knowledge. In contrast, practice disciplines like nursing had a responsibility to produce knowledge that could be used in practice. But what would distinguish nursing theory and nursing knowledge from theory and knowledge of other practice disciplines like medicine? As the University of Iowa's Ada Jacox explained in 1974, it is difficult to define boundaries in these basic essentially academic areas concerned with the production of knowledge, and here she referred to psychology, physiology, anthropology, and sociology. Difficulties are compounded when trying to specify clearly what part of the empirical world can be claimed by disciplines in which the major concern is use of knowledge. So another key aspect of nursing's boundary work in this period, then, was to identify the core concepts of nursing that distinguished it from other health professions and demarcated that unique area of empirical focus for nurse researchers and theorists. By the late 1970s there was a lot of conversations in journals, conferences, there was a lot of, a ton of back and forth and a lot of theory generation that was done in this period. But by the late 1970s, four things had emerged from the efforts of theorists to conceptualize nursing that became critical to distinguishing nursing's empirical focus, and for those of you who are nursing students or graduate students in nursing, I mean, I think these four things still resonate. Person, environment, health, and nursing. These are the four concepts that theorists identified by the '70s. So nursing's focus is the whole person, not simply the locust of disease or disability. Persons are viewed as biopsychosocial beings constantly interacting with and being influenced by their social and physical environments. As such, the environment is a source of or an influence on the health or illness of a person. Nursing's focus is health. It's not, it's maintenance, restoration, and promotion. Nursing's focus is not disease or disability. Nursing actions enable and support patients' agents in the pursuit of their health goals. In this way, nursing had moved from doing for patients to working with patients, helping people to care for themselves and involving them in their care and decisions about their health. That last part is a direct quote from a theorist, and but this was all language that theorists were using at the time to distinguish nursing. So by emphasizing a health perspective rather than a disease perspective by considering the patient holistically and by prioritizing the agency of the patient in shaping his or her health, nursing stood apart from the reductionist model of medicine that emphasized disease, diagnosis, and cure and this was particularly salient and very political in the '70s at the time when the women's health movement and aversion in patient consumer movement were criticizing the medical profession for being reductionistic, for being dehumanizing, and for being paternalistic. So nursing was really setting itself up, and not only identifying what nursing did differently but saying this is explicitly different from medicine and that's a good thing. So by the end of the 1970s then, nurse researchers and theorists had made progress in demarcating the boundaries of nursing science. Despite this progress, however, the boundary work of creating a nursing science was still incomplete. Researchers and theorists varied in how they operationalized the four essential concepts. Some theories were too vaguely articulated or inadequately developed to clearly signify direction for nursing research or practice and many theorists had yet to empirically validated. In fact, two major critiques of nursing theory in this period were that they were neither useful nor relevant to research or to practice. Most notably nurse theorists confronted resistance from their colleagues in practice who criticized them for being disconnected from practice concerns and failure to relate theory to clinical practice. It just, like, there was just a lot of consternation about what the value of theory might be. And I want to make the point here, though, that the tensions between academics and clinicians were certainly not unique to nursing. The tensions between academic physicians and clinicians, those in practice, so called town-gown politics, they have a very long history. And academic engineers who had been engaged in an effort to establish the academic standard of engineering and to shore up its scientific base, the academic engineers were routinely criticized in these same decades that nurse theorists were being criticized. They were being criticized for failing to adequately prepare students for careers in engineering practice. So again I just want to make the point that the struggles that nursing's encountered in this period, some of them were shared by other practice disciplines going through other similar transitions. So the efforts of nurse theorists and researchers to demarcate the boundaries of nursing science were also constrained by a lack of resources. Throughout the '60s and '70s there was, as Madeleine Leininger reported, limited awareness about the value of nursing research and limited monies available for nursing research through state, federal, and private sources. Nurse researchers engaged in qualitative research, so those who had taken more a sociology or an anthropology approach found it particularly difficult to secure research support as federal funding agencies prioritized quantitative research and this may still be true today to a lesser extent, lesser or greater extent. And the financial situation was even worse for theorists who throughout the '60s and '70s struggled to justify the need for nursing theory even to their nursing colleagues let alone funding agencies. So for example, leading nurse theorist Imogene King in 1980 reflected that for the past 10 years any type of group of individual with something going for theory development and testing, the obstacles begin to arise. In particular, King had struggled to get funds to describe, explain, and predict events in nurse-patient interactions because of the rejection by peers who sit on the committees that give money. King noted I have had to use my own money and time for the past 10 years when $50,000 in grant money could have done it in three to five to move my own theoretical formulations forward. And I just want to make the point here that the national institute, the National Center for Nursing Research, the predecessor of the NIH's National Institute for Nursing Research wasn't established 'til 1986 so there wasn't a central funding federal funding source for nurse researchers to apply to at this time. The portrait and reward structure within nursing schools which were also shaped by generational politics also impacted the development of nursing science in this period. By the 1960s, the political economy of American universities, especially in the health sciences was one that prioritized research and the acquisition of federal research funding over teaching and service. And then the transition from the service-based to the university-based education reflected in the shift from hospitals to university campuses, however nursing schools were slow to adopt an academic culture that supported and rewarded research, often encountering resistance from their older faculty, socialized, quote, past normative expectations of faculty only being involved in teaching. So Leininger, who had served as dean at the University of Washington and the University of Utah noted in 1977, quote, highly conservative and traditionally-oriented faculty who have been limitedly prepared in research and who are often tenured through time rather than by academic criteria often pose serious problems in schools and thwart research climate and direction. And these faculty were also socialized to a reward structure that used teaching effectiveness for faculty evaluations and salary merits and only very limitedly on research and research productivity. As such, nursing deans and their research-oriented faculty often had to do, quote considerable work to change the dominant teaching emphasis and give proportional emphasis to research. And this was work that was essential to securing nursing status as an academic discipline and ensuring nursing was respected as having a legitimate place on university campuses. So the incompleteness of nurse's boundary work is reflected in the difficulties encountered by nursing school's attempting to establish doctoral programs in this period and this very final part of my talk we'll just take a very very brief look at the efforts of the University of Minnesota School of Nursing to establish a nursing PhD program. And through this case study, we'll see now nurse educators particularly at state-supported schools mobilized nursing workforce arguments to secure the establishment of nursing PhD programs even as they struggled to resolve the incomplete boundary work of the nurse theorists. So throughout the '70s and early '80s the University of Minnesota School of Nursing confronted considerable opposition from the general university faculty who questioned whether nursing had the theoretical underpinnings and a distinct body of knowledge to justify the PhD and whether the nursing faculty had the research capabilities to conduct scholarly research. This should resonate with UCLA's problems that it had a decade or so earlier. When the nursing school submitted its proposal for the nursing PhD in 1981, the university committee that reviewed the proposal was divided on the question of whether nursing is defined in this program as a scholarly discipline which is evolved to the point where the offering of a PhD program is academically justified. For the committee, nursing was a major health care profession which is presently dependent on a significant part of its instruction, practice, and research studies on the physical, behavioral, and social sciences. Now some of the nursing faculty saw the committee's opposition to the program as purely sexist, yet several faculty believed the committee simply did not regard nursing as an appropriate area of research. As Mariah Snyder recalled, they didn't face much opposition from the schools of medicine, dentistry, or public health but instead from the basic sciences because of their strong emphasis on research and how advanced they were. I think they found it very difficult to find an emerging profession and the need for a doctorate. Marilyn Sime read the committee is worrying that the nursing doctoral program would be overlapping this discipline and this discipline and this discipline. There seemed to be some concern for the strict boundaries between disciplines. In other words, the policy and review committee that had evaluated the PhD proposal wanted to protect the boundaries of the existing scientific disciplines and was uncomfortable because the nursing doctorate would transgress those boundaries and create new boundaries around the science of nursing. Now as the School of Nursing struggled through the '70s to justify the need for the PhD program among its university peers, state health planners were looking to the School of Nursing to fulfill the state's needs for graduate level nurses. At this time the University of Minnesota School of Nursing was the only institution in Minnesota and in the Upper Midwest providing graduate-level instruction to nurses. In 1970 for example, the Minnesota's Comprehensive Health Plan Advisory Council's Subcommittee on Nursing, basically let's health planners, made its first priority the preparation of increasing numbers of graduate-level educated nursing faculty so that they could then go and teach an expanded undergraduate and graduate programs elsewhere in the state and region. At this time there were persistent shortages of primary care physicians, particularly in rural areas of the country. And state planners looking to quote, expand the primary care capacity in the state, made training in the educational programs directed towards such care, so including educational programs preparing nurse practitioners, they made them a high priority. So the subcommittee subsequently urged the state legislature to appropriate to the School of Nursing the biannual request of $1.8 million so that the school could expand both the graduate level and undergraduate degree programs and expand the number of faculty they had to support that expansion. By 1978, the recommendations of state health planners were even more urgent that October the Advisory Committee on Nursing Education for the Minnesota Higher Education Coordinating Commission had recommended that in order to alleviate the critical shortage of nurses with graduate preparation in nursing, nursing education at the graduate level must be doubled within the next few years so the expansion of existing programs and the opening of new ones. The Advisory Committee asserted that 500 additional nurses prepared at the master's level were currently needed both for faculty positions, upon which the expansion of baccalaureate programs depended, and for advanced practice and clinical leadership positions in hospitals and health care agencies. The committee warned that currently the state's only two master's programs at the University of Minnesota were unable to accommodate all qualified applicants. During 1976 and 1977, the university had graduated just 115 nurses from its two master's degree programs. At this rate, the committee noted, these programs cannot meet the needs of the state. The state's problem was even more severe when it came to the matter of doctorally-prepared nurses. The committee put it a conservative estimate that 150 doctorally-prepared nurses were needed in the state but as of 1978, there was at best 25 doctorally-prepared nurses. And finally a doctoral program in Minnesota was needed, the committee urged, to increase the likelihood of graduates staying in the state. So even if there were some other PhD programs in the broader region and on the East Coast and West Coast but planners said, well if you get your PhD in Philadelphia you're probably going to stay in Philadelphia. You're not going to come back to Minnesota, so there was also this argument we needed them in their home state. To this end, the University of Minnesota School of Nursing argued that establishment of the nursing PhD was critical to securing the state's nursing workforce. For example, in 1980 the American Nurses Association Council and State Boards were planning to implement a new policy that required all faculty teaching in basic nursing programs to hold at least a master's degree. As of 1978, there were 440 faculty members in basic nursing programs in Minnesota without master's degrees so they were still going to be needed that those would have to go get training in master's programs. So in order for Minnesota schools of nursing to be in accordance with the Council of State Boards position and to meet accreditation standards the state's existing graduate programs, i.e. those at the University of Minnesota would need to expand substantially and new programs would need to be created. For the more, the faculty's proposal noted, there would be a significant increase in the number of nurse doctorates to serve as faculty to ensure the quality of these expanding and newly established programs. So in making these arguments, the nursing faculty also sited the findings of a 1976 survey of nursing doctoral programs in the U.S. that documented the importance of the Midwest region for contributing to the nation's future supply of doctorally-prepared nurses. There's a lot on this, but basically you can see that a lot of the PhD programs and it also lists DNS programs, it's combined the two. A lot of them are on the East Coast. There are a good chunk in the Midwest region, but then there's barely any out West and so the Midwest was really a center of production for doctorally-prepared nurses. So in the end, the nursing school's proposal for a PhD was approved and the school admitted its first doctoral students in the fall of 1983. However, the difficulties the University of Minnesota nursing faculty encountered as they sought to convince the university administration of the strong conceptual underpinnings of the nursing PhD reflects the limits of nursing's boundary work by the early 1980s. It also highlights the importance of nursing workforce arguments to shoring up the academic arguments of nurse educators in state-supported nursing schools. And you can see Iowa is listed on there, maybe one of you on the nursing faculty can confirm this but at least in the material I saw they were planning to open the PhD program in 1980 so I'm not sure if it opened at that time or it took a little bit longer, but-- - [Audience Member] '86. - [Dr. Dominique Tobbell] 86, okay so it was more delayed, okay. So just to conclude, from the 1960s through the early 1980s nurse researchers, theorists, and educators reviewed the establishment of nursing science, underpinned by nursing theory as critical to nursing's academic project. But as the efforts to establish nursing as an academic discipline and secure its status within the university were undermined by generational and interprofessional politics, limited resources, and the gendered and hierarchical politics of universities. Now as nursing confronts ongoing shortages of doctorally-prepared nursing faculty, anyone who's in nursing now will know there's been concerns about the shortages of nursing faculty since the turn of the 21st century. I mean it's been a perennial problem and of course there, the cycles of concerns about nursing shortages are, I think, we're in a moment of concern as well. Nurse scientists and educators are reassessing how best to prepare the next generation of PhD-prepared nurses to perform innovative research that will advance nursing science and the practice of nursing. As part of this, academic nurses are still engaged in demarcating and defending the boundaries of nursing science. For example, as academic nurses are reasserting the importance of nursing's core disciplinary knowledge they are also debating whether and how to incorporate knowledge and skills derived from emerging sciences like the OMICS, big data, and biomedical and health informatics, internursing science. Furthermore, a recent analysis showed that while nursing theory is infrequently used to frame nursing research, theoretically-oriented nursing research is dominated by theories from psychology and sociology, so this kind of turns on its head the claims that nurse theorists were trying to make, we need a nursing theory and nursing theory is obviously still heavily taught in nursing schools but when you actually then look at what research has been done, a lot more of that theory is coming from the related disciplines of, in this case, psychology and sociology. So this is raising questions about the degree of nursing theory and nursing science content in PhD education. So the efforts by academic nurses to realign doctoral education to best prepare a new generation of nurse researchers, are thus shaped by nursing's earlier boundary work at the same time that they are potentially redefining what those boundaries might be. So thank you. And I'm happy to take questions if anyone has any, or comments, yeah. - [Female 1] How early was the Seattle, you know, were the programs started in Seattle? I had a cousin who's lived-- - [Dr. Dominique Tobbell] Yeah, okay yeah so I think that the University of Washington program, did I, I think it might have been on there earlier. It was in the early '70s because Leininger, Madeleine Leininger was there at the time when the program was established so I think it was in that-- - [Audience Member] Or earlier, I think. - [Dr. Dominique Tobbell] Well, let me see if it's on that first, on that slide. - [Female 1] Is it well-regarded? - [Dr. Dominique Tobbell] Yes, yeah and they had a nurse scientist graduate program so the nurse scientist program where they paired with a cognate discipline and gave, awarded nurses PhD in those cognate disciplines. It was definitely in the early '70s, but as I said, they had a nurse scientist training program as well before that, but yeah it was very well regarded and actually yeah Madeleine Leininger was dean at the time that it was established and she was a prominent nurse theorist. Yeah, Katie. - [Katie] So I'm very curious about the boundary work that PhD nurses might have to do in the field 'cause they're trying to do research. So to do research and possible, say alongside physician scientists or other scientists, and whether they had to fix conflict in that realm. - [Dr. Dominique Tobbell] That's a great question and you know, I haven't, I don't have any insights into that answer. I mean, I think it's a really important question and I think what is, I think what kind of comes through in the research that I've done is that a lot, there was a lot of, you know, articles written, there was a lot of conferences held debating what distinguished nursing from other fields and that that was important in making those arguments to university administrators but when it came to doing research in practice, that that didn't really, they didn't really matter as much. It was really a kind of an institutional need to establish those disciplines because, I mean, a lot of nurses were, nurses who had PhDs in sociology or psychology or physiology, they were doing legitimate research and I don't think anyone was questioning, any other researcher was necessarily questioning the kind of research that they were doing so and I think that there was, I think that's a good question that I need to look at but my sense is that a lot of this was really more the administrators were concerned and the basic scientists were concerned about protecting but maybe in practice it wasn't so contentious, I don't know. - [Female 2] Except, so I was just thinking if anybody can answer this too. There are a lot of nurses who got their, some type of PhD at certain colleges. A lot of nurses who got their PhD in other disciplines when they were adopted into research who didn't necessarily identify themselves as a nurse. They identified with the profession that they got their PhD from so that they could avoid those kinds of conflicts of I'm inferior to you or you're superior to me, or I belong here or I don't belong here. So I identified as a psychologist. I can easily do this research and nobody's going to question me. - [Dr. Dominique Tobbell] That's really great, thank you. And I think that, I mean, what strikes me is that you have a lot of physician researchers who don't have doctoral, I mean they have an MD. They don't, there's no requirement that a physician in order to be taken seriously as a researcher has to go get a PhD. That onus is placed on nurses and, I mean, I think, yeah, I mean that's really problematic, that's highly problematic and even the fact that nurses felt like they had to develop theories to justify the research that they were doing and the knowledge production that they were doing, that's also really problematic because medicine doesn't have any grand theories that stick, determining what it's doing, medicine is derived from borrowed knowledge. And so it's been held to different standards so I think there's a lot of, it's, I mean it's highly problematic and contentious so I think questions like this is really important and then having that perspective that yeah, okay, don't identify as a nurse, you identify as the scientist first and that's what's, that avoids those professional conflicts. So thank you, yeah. - [Female 3] So compared to other practice disciplines at this time when we're trying to start PhD programs, was nursing on a similar trajectory or because it's a historically female profession was it behind? - [Dr. Dominique Tobbell] So a lot of these, so there's a lot of practice professions who are doing this around the same time and a number of those practice professions are heavily female too, like social work being the obvious one. Engineering, I, you know I haven't done primary source research in the other practice disciplines but what I've been reading in their professional journals, what they've been writing at this time. So engineering, it seemed that, though yes there was tension with engineering practitioners saying you're not, academic engineers aren't doing what we need you to do, but I haven't seen any discussion that they had any barriers to establishing PhD programs. In clinical psychology, which was more heavily gendered male, no, clinical psychology went through, and the other piece that kind of factor in here is like, is it a research-based doctorate or is it a professional doctorate, like the DNS as they were arguing at the time. But actually I even want to sidestep the DNS in nursing because that was really, I think they were trying to have that be a research degree but they were calling it something else so they could get it established. There was also, nurses were also trying to establish the doctorate of nursing which would be a postbac, a clinical doctorate equivalent to the MD and DDS. So nursing had debates about whether they would have a postbac clinical doctorate. Psychology, clinical psychology, they were debating whether they should have a clinical doctorate, would end up being the PsyD, or the PhD and so initially they were arguing no, we want to be the PhD because we want to have that academically legitimacy. They wanted the status that came with the PhD but actually in practice what they really were doing was a clinical doctorate and so eventually they actually switched to the PsyD, and I mean you can get the PhD and the PsyD. So I haven't studied it in depth. I've only kind of looked at what was being written in their professional journals at that time. It seems that they were having similar internal debates. I can't tell you externally what kind of conflicts they were having. So I do think, I very much think that there's an element of gender, absolutely is an element of gender here. There are gender politics involved and I think particularly in the history of medicine, that medicine has historically been very kind of protective of its boundaries and its claims to practice, and you don't, and I think that, you know, obviously nursing has been like a kind of one of the professions that has kind of had conflict with that but it's not always been contentious. On the ground it's been far more amicable. But pharmacy, you know, was established in the clinical doctorate at the Pharm.D at this time and they had tensions within schools of pharmacy between PhD-prepared faculty who were in schools of pharmacy so they might have been pharmacologists. They weren't necessarily trained as pharmacists. So even within schools of pharmacy there were tensions between clinicians and the kind of professional priorities of schools of pharmacy versus what the research scientists were doing. So I think there were definitely differences, but I think there's also a lot of overlap between those debates. - [Female 4] I'm not sure if I can say this correctly, but with the MD it is a practice degree. It's not research-based and so most faculty in medicine have to get another master's in some specialty. Some have the MD-PhD program as well. And yeah, and it's this, the same thing exactly. And so, and maybe it's because they're, in order to become MD or DDS they have to have the four years beyond the baccalaureate. And that may be the difference that they're seeing 'cause I've always been confused about that 'cause they really aren't trained as researchers. They are trained as clinicians, this is nurses trained as clinicians but we've had all this brouhaha about getting, defining our science. I don't know what medical science is, the science of medicine, I don't know what the science of dentistry is so if you try to define it. And I just think it's a fascinating arena. - [Dr. Dominique Tobbell] Yeah, no I, I mean I agree, and I think-- - [Male 1] I think it is that there's so many pieces of nursing where you have the practical nurse, you know the one-year, two-year-- - [Audience Member] Does not make it easier. - [Male 1] Where, where, where it wasn't established really what is a nurse, you know there's that. 'Cause a lot of it was hospital trained. - [Dr. Dominique Tobbell] Absolutely. I do think, I mean I think that the educational diversity has both helped and hindered nursing because on the one hand it provides career mobility, educational mobility for nurses who enter at the associate degree or the diploma or the LPN level and can progress upwards but I do think that has also given a useful flow to those who don't want to regard nursing, haven't wanted to regard nursing as an academic discipline to say, but you can go to a two-year program and you can teach with an associate degree or you can teach with a hospital diploma in certain programs so I think it's both helped and hindered, and that was Case Western Reserve University's School of, Frances Payne Bolton School of Nursing introduced, they introduced the PhD in 1973 and then they established the ND, the Doctorate of Nursing in 1979 as the post-baccalaureate trying to be equivalent to the MD and the DDS in part to say hey, we can raise the professional standing. We should be training our nurses in the same way and that, it tanked. It completely tanked and there are reasons, there are reasons that they didn't do a very, they didn't talk to anyone about what they were doing and whether anyone wanted it. There wasn't a career pathway for those nurses who got the ND because they then still had to go back and get a master's if they wanted to specialize. I mean, there was a lot of problems with it but I think their intent was to say let's get nurses up to, so that at least credentially they look the same as everyone else in the clinical encounter so that that should hopefully give them equal status and that didn't pan out, and there were other ND programs that were post, that weren't generalist, they were more akin to the DNP now but it just didn't take off. So I think that the variety of doctoral degrees, the variety of undergraduate degrees, the multiple pathways of entry into nursing have been really problematic for nursing being able to establish its academic credentials at the same time that it, it has absolutely been essential for getting nurses in and moving through so it does allow, it's more accessible than say other professions might be. And, I mean, one thing I had taken out of my talk that when the associate degree was introduced and the BSN was reformulated, the ANA, the American Nurses Association in 1965 said okay, this is it. To be a nurse, you have to be trained in a college university program, only the associate degree or baccalaureate degree will, and that's the only thing that will count. We're going to do away with the diploma program. Well clearly anyone who's a nurse or knows a nurse or knows nursing, that didn't succeed. There are still diploma programs to this day, not very many and I don't know, you know, like they still exist. - [Audience Member] Support teams. - [Dr. Dominique Tobbell] Yeah, and so that's really problematic so even though the ANA said we only want college-trained nurses to be RNs, you know, 60 years, 50 years later, we still don't have that so I think there's, and I think that's because the nurses who are obviously trained in the diploma programs didn't want that, I mean the material that I read in Minnesota, the diploma programs were saying in the '70s, in the context of these nursing workforce shortages, hey, if people want, still need us, we're still going to train nurses, you know, we're still going to do it. If you tell us you don't want us anymore, fine, we'll close our doors. But as soon, as long as we have students coming to us and there's a nursing shortage, we're going to keep doing what we're doing so I think there hasn't, you know, yeah, it's difficult. Yeah, good. - [Female 5] So in the struggle to define in a body of knowledge that is explicitly a nursing body of knowledge, was that body of knowledge ever gendered in any way, you know the idea being that female scholars can perhaps bring some kind of unique insight or unique perspective and as kind of a companion question, was there much discussion of the make up of nursing, the student body being predominantly female and was there an effort to include more men or was that, the predominantly female nature of the student body laudable in some way. - [Dr. Dominique Tobbell] Yeah, there's a, that's another great question and I, so I'll take it in two pieces. So first, yes there were at least lip service was paid, we want to get more men into nursing and certainly this, you know, we can't cut off half the population if we want to increase recruitment into nursing. I'm not really sure how heavily recruited male students were but they were certainly, there was lip service paid to having more men in the field and certainly the ND degree that Case Western had, they hoped that they would attract more male students than say a BSN would and this is, the numbers looked like there was maybe a slightly higher number of men in the ND program than was in the BSN program so I think there were certainly has been an intent and interest in it and then Luther Christman was a prominent dean, he was dean at Rush University, Rush University also had an ND degree and he was very vocal about, yes we need more men in the field and actually if we had men in the field nursing wouldn't be as low status as it was, I mean I don't know how any of his female colleagues took that article that he wrote, butI was alarmed when I read it. But certainly there was an effort to get, there was some effort to get more men into the field. I think the issue about whether the theories or the science was gendered, for me that's a little bit hard to tease out because nursing, I mean certainly Leininger whose theory of transcultural nursing, it was an emphasis on nursing care. It was very much, it was about what is it that nursing does and what do nurses do and it was very much emphasis on that kind of history of care and so I think there is obviously gender components to it but I don't know that anyone was claiming any kind of unique benefit from being a female profession that that gave unique expert claims, so I think yes we can read some gender into it but I don't think it was explicitly argued that this should be women only who's doing this. I think in this period there was the assertion that we should be open to men as well as women. - [Donna Hirst] Thank you very much.