2023/01/01 by Dominique A. Tobbell · 1 voice
Nursing · Arts and Humanities · Social Sciences · #Nursing Education, Practice, and Leadership #Historical Studies on Reproduction, Gender, Health, and Societal Changes #Historical Education Studies Worldwide
paper · doi:10.5325/nursinghistory.31.0009
openalex publication_date 2023/01/01 · openalex created_date 2025/10/10 · openalex updated_date 2025/12/20
In the decades after World War II, American nurses were engaged in a knowledge project to develop a science of nursing. They did so to formalize the foundations of and legitimize nursing’s professional work, and to prepare nurses to better care for the changing health and illness needs of the population. Indeed, this knowledge project took place amidst broadscale 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 postsurgical complications. So too, the availability of new pharmaceuticals and medical technologies like kidney dialysis contributed to the increasing complexity of patient care.1 As a result of these transformations, nurses increasingly found themselves without the knowledge to provide appropriate care to patients with increasingly complex clinical needs.2 They also did not understand how patients made decisions about their health care, or why patients behaved in particular ways.3Beginning in the 1950s, a small but growing number of academic nurses sought to build a science of nursing with the goal of improving patient care. They did so by drawing upon the biomedical, social, and behavioral sciences, and by developing new theories and addressing research questions that were unique to nursing. In the process, academic nurses engaged in critical boundary and legitimation work: the process of selecting the requisite credentials of researchers, the types of research questions to be asked, and the methods and theoretical perspectives to be used for the purpose of drawing epistemic boundaries between nursing science and the existing biomedical and behavioral sciences.4 They also transformed nursing practice into a valuable site of clinical research and demonstrated the ways in which application of this new knowledge was integral to improving patient outcomes and health care delivery.To be sure, as historian Susan Reverby has described, academic nurses held and mobilized differing meanings of science during the first half of the twentieth century, and this continued to be the case in the decades after World War II.5 The multiple and changing meanings that academic nurses held of nursing science were both political and epistemological. On the one hand, academic nurses understood the development of nursing science as a political process to justify nursing’s positioning within universities and academic health centers, while on the other hand, they conceptualized nursing science as a process of knowledge development and application to practice. As I attend to the shifting definitions and meanings of nursing science that my historical actors mobilized, however, I rely on a definition of nursing science that reflects the overall process of research, knowledge production, and application of knowledge into practice and policy.This paper examines the history of nursing science, explaining the ways in which its development was shaped by gender and race, and by the knowledge politics of post-World War II biomedicine. In doing so, I make two arguments. First, the work of drawing boundaries in the construction and maintenance of disciplines is about making rules about what and whose knowledge counts, and thus who is allowed to contribute new knowledge to the discipline. During these formative years of nursing’s knowledge project, only those able to advance through the educational hierarchy to attain the formal educational credential of first a BSN, then a master’s degree, and eventually a doctorate, were invited to contribute to the science of nursing. Since the introduction of trained nursing in the late nineteenth century, health care and nursing education—as well as higher education in general—were segregated in the Jim Crow South, and heavily circumscribed by racial discrimination in the North. Black, Indigenous, and other women of color, as well as men—regardless of race—faced significant barriers accessing undergraduate and graduate nursing education. These barriers meant that nursing’s knowledge project was advanced primarily by white female nurses6—a fact that had consequences for the types of theories developed and research pursued. As this first generation of nurse scientists engaged in research to improve patient care, they prioritized research they hoped would be legible within the postwar 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 and health outcomes. They also dismissed calls from feminist nurses to reject the patriarchal frameworks of biomedicine.My second argument relates to the broader changes taking place in the health sciences during the decades after World War II. Of particular importance: the efforts to establish a science of nursing occurred alongside academic physicians’ efforts to establish a science of clinical medicine. The physicians’ knowledge project influenced both the development of nursing science and the ways in which that science would be evaluated within the biomedical research economy. Since the late nineteenth century, knowledge generated by researchers in the laboratory-based biomedical sciences underpinned medical practice.7 When the National Institutes of Health (NIH) became the primary patron of biomedical research after World War II, it pursued its mission primarily through the funding of basic research in fields like genetics, biochemistry, molecular biology, and immunology.8 Physicians relied on the “integrity and expertise” of biomedical researchers to “produce reliable, untainted knowledge about the effects of medical treatment” in the lab. They then could apply that knowledge in their own clinical practices.9 However, beginning in the 1950s, physicians sought “to make clinical care more scientific by developing a new clinical science, additional to the science of biomedicine.”10 This new clinical science centered on producing scientific evidence of therapeutic interventions—of what worked and what didn’t work—and using that evidence (rather than subjective clinical judgment) to direct clinical decision-making.11 The randomized controlled trial emerged as the gold standard research method for establishing the effectiveness of an intervention.12 Rooted in statistical analysis, the trial reflected medicine’s trust in numbers. In other words, reliance “on quantification to produce objective knowledge and reduce uncertainty.”13 But while academic physicians constructed an empirical and statistically derived clinical science, academic nurses instead constructed a science that was not only empirical (utilizing both quantitative and qualitative research methods) but also theoretical. This paper examines the reasons academic nurses took this approach, the critiques they encountered, particularly from activist and feminist nurses, and what the implications were for the status and standing of nursing science within the postwar research economy.Beginning in the late 1950s, the Public Health Services’ Division of Nursing began providing federal training grants to nurses to pursue doctoral-level training in the research methods, data analysis, conceptualization, and theory development necessary for building a science of nursing. These training grants led to a significant increase in the number of doctorally prepared nurses. Between 1955 and 1974, a total of 589 nurses received fellowships from the Division of Nursing. Three-hundred and thirty of these nurses completed doctoral degrees in a range of disciplines, including 121 in education; 89 in the behavioral sciences (which included psychology, sociology, and anthropology); and 21 in the biological sciences.14 The imbalance between those enrolled in the behavioral and biological sciences would later influence the nature of nursing’s subsequent boundary work. Nurses’ disciplinary choices for the doctorate also reflected similar patterns in other post-World War II sciences in which women flourished. As historian Margaret Rossiter documents, women tended to cluster in the life, behavioral, and social sciences—disciplines more open to women and, not coincidentally, accompanied by less prestige and less money.The overwhelming majority of this early generation of nurse scientists were white and female. Even after civil rights legislation in the 1960s dismantled the legal system of segregation and made racial discrimination in education and employment illegal, practices of racial exclusion in nursing and higher education continued.15 Of the 589 nurses who received fellowship support from the Division of Nursing between 1955 and 1974, only six were men, one of whom was Black.16 Twenty Black female nurses and eight Asian American female nurses also received fellowship support.17 This lack of diversity impacted the development of nursing science, shaping what were and were not considered important areas of research and theory development (a topic I’ll return to later).It was among this first generation of nurse scientists that the movement to establish a science of nursing underpinned by theory emerged. The pursuit of theory development, however, was not an inevitable path to securing nursing’s academic legitimacy. During these same decades, academic physicians were looking to the laboratory, the new methods of clinical epidemiology, and the rigors of statistical analysis—not theory—to build the scientific base of clinical medicine.18Academic nurses, however, regarded theory development as integral to the making of nursing science. They did so for at least two reasons. First, the majority of nurses who received research training and earned doctorates during the 1950s through the early 1970s did so in the social and behavioral sciences such as anthropology, sociology, and psychology, all of which had strong theoretical orientations.19 Nurse leader Ada Jacox had earned her PhD in sociology from Case Western Reserve University in 1969. As she explained, “We developed our notions of what science is in those disciplines and that’s what we brought back to nursing in writing and teaching about theory construction.”20 Second, as the sociologist Andrew Abbott explained in his seminal work on professionalization, “only a knowledge system governed by abstraction can redefine its problems and tasks, defend them from interlopers, and new In this the and of theory reflected the of nurses thus in theory development the to establishing nursing’s disciplinary and I not to into the of this theory development, to a number of nurses engaged in theory development during the 1950s, and the worked to the and of nursing’s in the health care They also worked to establish the theoretical frameworks by which nurses could better understand and influence the health of their patients and reduce barriers to health and The also nursing’s empirical and thus nursing science from the biomedical and behavioral the late they had that nursing’s empirical the the of disease or health as to disease and its the influence of the social and on an and what nurses for and with patients to and support patients as in the pursuit of their own health In this nursing from doing for patients to with to care for themselves and them in their care and decisions about their important these reflected the efforts of nursing a of medical the to disease and to as They were also that had at the of public health But by the the of and health had broader political They nursing’s knowledge system from the of that and which was increasing by a growing of health science, however, was not only to be from nursing theory but also by clinical During the 1960s and nurse scientists also transformed nursing the a site of valuable research and knowledge production, and demonstrated the ways in which application of this knowledge was integral to improving patient outcomes and health care Nurses’ clinical research on the of nursing on patient outcomes and on the ways in which the in which patients shaped their health and health nurse researchers ways to reduce and and to improve care, and the of illness and the clinical research that nurses during these decades were from as as to as as a of research of these were controlled and quantitative research But were on qualitative research methods including and In of these did nurse researchers nursing those researchers that did theory upon and theories to and their its on improving patient nursing’s clinical research with the movement in health care. 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They did so to to doing As they did so, they engaged in disciplinary boundary and legitimation work that was both and Indeed, the work of drawing disciplinary boundaries in the construction and maintenance of nursing science has a project in which the and of those who not the educational credential of the or PhD in nursing as an to the discipline. This has contributed to a within the of knowledge and knowledge from of nursing as a to the of nursing science. The the of in the of nursing science is the of this boundary history thus the and in the boundary and legitimation work that the of new nurses their disciplinary on the development of and unique nursing theories at a the broader research and biomedical statistically As academic biomedical and funding not only to understand the of and for nursing they also did not place on the nursing research by In this academic path to knowledge development contributed to the of nursing science and the of nurse scientists within the research and within academic health these nurses did to doing the women scientists in the decades after World War II, sought to scientific disciplines, nurses worked to build an new scientific discipline. they the of an knowledge system underpinned by nursing theory as to to science is of the The other important of this history is that in the process of to science, this early generation of nurse scientists nursing’s practice as a site of critical knowledge practice that has all regarded as by feminist be sure, the overwhelming majority of nurse scientists did not to feminist ways of they constructed a system of knowledge of that nursing’s as it was in and an on this early generation of nurse scientists to establish their scientific they nursing practice as an important site of research and demonstrated the ways in which application of this new knowledge was integral to improving patient outcomes and health care is upon from my and the of American Nursing University of The research was by fellowships from the for the of the of Nursing and the University of I to Susan and for their on of this work.