Nursing and the Power of Change

In “The Transformation of American Nursing” (Issues, Spring 2023), Dominique A. Tobbell presents a fascinating, complicated, and multidetermined case for the post-World War II development of PhD programs in nursing. Built around the faith that there was a “nursing science”—akin to but foundationally different from the dominance of “biomedical science”—the white women (and they were almost exclusively white women) used financial support from the federal government’s health scientists’ programs to first earn PhDs in related disciplines such as sociology, education, and psychology and then to translate borrowed concepts into the ideological stance and the practice of nursing.

Some initiatives were spectacular successes: the changes that coalesced around nurse Hildegard Peplau’s intellectual translation of Henry Stack Sullivan’s interpersonal theory of human relationships forever changed nursing practice into one that focused intensely of what we now call (and teach and research as) patient-centered care. Others were as spectacular failures: the edict from nursing’s national accreditation association that all schools had to teach nursing content and practice specifically organized around one of the models Tobbell describes was a mercifully short-lived disaster after it became apparent that classroom content had no relation to clinical experiences.

Such unevenness, of course, is hardly unique to any knowledge-building enterprise. My question is why, after more than 80 years of this enterprise, are people outside the narrow confines of my discipline still puzzled when they learn of my PhD and hear the term “nursing science.” I honestly do not blame them. And I think this points to yet another source of tension that the history of PhD education in nursing elucidates: Should knowledge-building in nursing or in any another discipline be a “top down” or “bottom up” experience?

In nursing, we have evidence of the power of change driven by collaborations among clinicians at the point of intersections with patients in need of care. The nurse practitioner movement, for example, came about in the same political, social, and technological contexts and among the added pressures of shortages among primary care practitioners. In response, collaborative, entrepreneurial efforts of physicians and nurses seeking expanded opportunities came together in individual dyads across the country to experiment with shared responsibilities for medical thinking, medical diagnosis, and prescribed treatments. Similarly, in coronary care units, dedicated to ensuring the survival of “hearts too young to die,” the new technology of electrocardiology brought physicians and nurses together to learn how to read rhythm strips. Both groups quickly learned, again together, that it was not necessary to have to wait for a physician to intervene in life-threatening emergencies as nurses could interpret arrythmias and respond immediately with life-saving protocols. Our current health care system now organizes itself around these two innovations.

The PhD in nursing, by contrast, came about as a solution to a problem that only a relatively small group of nursing educators identified. It would be a new form of knowledge generation, albeit one distanced from the bedside and imbricated with the knowledge-generating tools most valued by the biomedical establishment. It was, I would suggest, an essentially political and prestige process. And really interesting questions remain to be asked. Did the status position of nursing in clinical care and knowledge development necessitate a surrendering to the stronger and more privileged epistemological position of medicine for its own validity? Will nursing’s claims that it “asks different questions” survive the collapsing of boundaries between acute and chronic care needs of patients? And, to me most important, does the inherently interdisciplinary knowledge that we know nurses need to practice fail to translate into a knowledge agenda when it exists within an academy and a culture that knows only firm disciplinary boundaries?

Patricia D’Antonio