A special Thanksgiving episode of Friends of Flo as we welcome Dr. Dominique Tobbell to the pod. We dive into nursing history, technological advances, and the evolution of nursing education.
Friends of Flo is: Dr. Rebecca Porter PHD, RN - Dr. Tess Judge-Ellis DNP, ARNP, FAANP - Dr. Andrew Whitters DNP, ARNP
A special Thanksgiving episode of Friends of Flo as we welcome Dr. Dominique Tobbell to the pod. We dive into nursing history, technological advances, and the evolution of nursing education.
Friends of Flo is: Dr. Rebecca Porter PHD, RN - Dr. Tess Judge-Ellis DNP, ARNP, FAANP - Dr. Andrew Whitters DNP, ARNP
This episode of Friends of flow is brought to you by an CLECs mastery. If you're a nursing student and you're about to take your inflects you need to go to the App Store right now and download inflects M.D.
Speaker 2:Good morning everybody and welcome back to friends flow. I'm Rebecca Porter and I'm Andy Wetters.
Speaker 3:And we're very glad to have her visit her with us today. DR. Professor Dominic Carrabelle from the University of Minnesota. Dr. Bell is a professor and director of the history of medicine program. And we're delighted to have her speaking here. University this week. So Dr. Bell Dominique we're glad to have you here. Thank you for having me.
Speaker 4:Yes of course of course continue to tell us a little bit about yourself and the role you have at the University of Minnesota.
Speaker 5:Sure. So I have my Ph.D. in history and sociology of science and I joined the University of Minnesota 10 years ago now and I teach undergraduate and graduate students in the history of medicine and we also have some med students who do some research electives with this but basically I teach a lot of pretty health science students including nursing students which is which is super fun cool.
Speaker 6:How did you make that leap from your undergraduate degree and biochemistry. All of a sudden here you are in history. So what happened.
Speaker 7:That's quite a leap.
Speaker 8:Yeah it's quite a leap and certainly for those of us who work in the history of science and medicine there is that there are a lot of us who started off in science and then moved into the history of science a history of medicine and I always loved science. Various times I thought I might want to go into medicine and decided that that wasn't what I wanted to do but I thought I wanted to be a bench scientist and often as part of my undergraduate degree in the UK I spent a year working at a drug company doing bench research and I was quite capable at it but I really found it quite dull. I thought if I could just for it to be an API I didn't have to run the experiments but could do the thinking that would that would be okay. And so what I was working in the lab and watching my experiments run I was looking at various Ph.D. programs and I thought I might do science journalism but realized they didn't really know anything about the sociopolitical context of science. And so a my looking for various doctoral programs I happened upon the history of science and medicine and thought This is great. This is I could still get to read about science and medicine but I really get to learn about what the social cultural political context is and so it seemed like a great fit cause that's how I made the transition.
Speaker 9:Yeah.
Speaker 10:Q Tell us a little bit about your your thoughts on the nursing history both perhaps hearing United States and even globally.
Speaker 2:But can I interject for just a moment because I don't think nursing history is taught anymore and in progress. Undergraduate Programs and I don't think its being taught to you having a history in your GNP program. No.
Speaker 4:No I have much history at all in fact I mean I think I think a lot. I think a lot of the classroom didactics that we received both and throughout my my nursing education has been more of an incidental sort of sort of teaching like oh hey by the way this is where a Left shift comes from like in a CBC. Its more of a scientific example but I suppose that the history of how many females are to have gone into nursing over the years particularly in American history of nursing. It was all the sort of supplemental information that was there wasn't like a book that we read on it or a chapter we read it was just like really our teacher would just sort of talk about it just self mentally.
Speaker 3:So in my Ph.D. program we had a whole year long course in the history of nursing. Yeah and I got bitten by that bug and my area of interest was ethics of course as you know. But to look at the history of how a topic is taught is is really interesting too. And so when you reach fracturing undergraduate students in particular Dominique what kind of questions are coming up are Wordsley interest that people have.
Speaker 5:So I mean the causes that I have a couple of cool courses that I teach in and one is called medicines and allergy in modern America and it looks at how health care became increasingly technological since the turn of the 20th century. And we look at specific genes but we also look at how the introduction of even technologies like the standardized patient chart transformed the ways in which medicine health care was practiced. We look at. So in that cause we don't just assume that it's the physicians who are using the technology we look at what technologies nurses were allowed. In many cases to use. And so we talk about the introduction of clinical thermometer. And initially it was used it was physicians who had taken temperature and they realized well actually this is taking too much time. You know our labor is worth too much for us to be doing this so we delegated they delate gated it to the nurse. Now obviously it's delegated even further even further. But looking at the ways in which the introduction of different kinds of technology transformed the way that healthcare was being delivered who was delivering the care how diseases have been understood how diseases have been treated. So that's I think that I mean that's very appealing to students who think they're going to go into medicine and dentistry nursing and all our courses aren't required for anyone but they are part of it. They are part of a major that feeds into the Health Sciences health science professions that's nice. And then to have another class. I teach women health and history which is very much focused on the roles different roles that women have played in healthcare as providers. So midwives nurses physicians the struggle that women had and in the field of medicine and his research subjects and his healthcare activists particularly around the women's health movement in the 1970s and also looking at the ways in which different diseases have been gendered and so hysteria being really the canonical example and Weich hysteria disappeared as a diagnosis these kinds of things. And that that attracts a good number of nursing students and it's just I mean I think the students tell me it changes how they think about health care both for those who are going into want to go into health care and then just as potential patients who are you know future patients consumers correctly.
Speaker 11:Can you just for the pleasantries of of our listeners. Can you talk about some of those examples of the diagnosis of hysteria.
Speaker 2:For example I'm not trying to put you on the spot here but like but that's a history because I mean so I am familiar with a little bit about that.
Speaker 12:It's great to have a historical sort of expert here with us to maybe describe that particular diagnosis and how it was I think the verbiage used it was gender wise.
Speaker 10:Correct. And so but now it's of course just not a appropriate term both both clinically or politically. It's a term it's just it's inappropriate. So could you just maybe speak to that particular diagnosis.
Speaker 13:I think this is kind of interesting especially in this day and age so well it was history it was one of several diagnoses particularly in the late 19th century that chlorosis was another one actually anorexia which had a slightly different meaning in the late 19th century. But these diagnoses that were typically given to women young women and for hysteria. Some historians have talked about it as the wastebasket diagnoses like oh look at the various symptoms symptoms of them across the board. I mean lethargy of frustration yeah body aches but also agitation you know maybe someone who was a radical would be diagnosed with hysteria and it was these were diagnoses that were historians have looked at the ways in which these diagnoses were given a time when women were really starting to mobilize and be activists is beginning to suffer the political social context.
Speaker 10:OK Sarah go and my feminism this is this is what I thought would be interesting. I mean how it relates to you know the movements of today. I think that to add to this in the 1920s and perhaps even the 1980s you had this strong culture of subjugation of women. Right. And so.
Speaker 14:So that that was pervasive in the Met and to a large extent still.
Speaker 7:Indeed it is.
Speaker 3:And so you have to have a diagnosis of hysteria just to describe talk about being labelled right to describe someone's frustration and then to just oh I better watch my soap box Herberger very much the propensity for medicine to reduce everybody and particularly women yeah to something it turn get out of my office right about.
Speaker 7:And that's still something I think that goes on today. I mean back to your story are saying oh yeah Haitians but forget what. Let's go back to this. I mean please continue your thoughts on this.
Speaker 5:Well I think this was a period in which physicians were for not just hysteria but chlorosis as well which no longer exists. It was a form of anemia. Well it's contested what it actually what it what it actually was. But the physicians were trying to be moral managers of their patients and particularly young women and so taking know having justification for taking patients out of the family home and saying let's put them in this clinical space where we will supervise them we will control what they eat. We will control what they experience and this is how they will get better with hysteria. It was I mean there was all these different symptoms it could have been different treatment suggested. And I haven't exercised that my students do in my costs and the we have a wonderful history of medicine library at the University of Minnesota the Wallenstein has his history of medicine. And seen live for the history of medicine and biology. And I work with the curators there who bring primary source documents into the classroom. And so we the curators they identify articles that will be in written textbooks things that will be written by physicians in the late 19th century and they are describing chlorosis describe in hysteria neurasthenia was another diagnoses and that was not typically given to men. It was a melancholy depression these things. And so the students read all these different treatises on these diseases I identify what the symptoms were what the suggested treatments were and they realize there's a lot of overlap and that basically physicians are throwing all kinds of different treatments at these conditions and they don't really know nothing's really sticking. And so it really reveals to the students that this is a really contested diagnoses or they are they are all contested diagnoses and it's really just like physicians trying to like how to make sense of these confusing symptoms and to go back to that political social context this is a period when suffragist movement women stopped going to school. Some are even going to university in colleges and so this is a period in which the role social role of women is changing. And so there's that kind of pushback of like how come we I mean this is about sounds a bit heavy handed but I think that when women's roles in society is changing that going into the work force there then social reformers who then push back and say hey there's something wrong with women. And medicine is one realm in which those arguments can gain traction. And this is a period when physicians are trying to assert their claim their own authority because there's a lot that physicians don't know in this period right.
Speaker 3:And I think society then and continues today is that medicine has claimed its moral authority and attention to its scientific authority. And when that final final common pathway over 30 which often is a physician challenge it opens up a whole political social context. And so when you get into it going back to the 60s and 70s or early post-war period the evolution of our nursing education and the different pathways that were very complicated and continue to be so that we were for me and Sharon decision and in the 70s when I started my career there was a lot of pushback particularly from physicians who were wondering why I was thinking of not just doing and so I think it was a reflection of that early push back.
Speaker 5:Yes. I mean that's a really important point and I think throughout certainly throughout the 20th century late late 19th century when nurses the first training schools and nursing were introduced in the late 19th century and there since then there's been a lot of that that nurses say that nurses need in order to be effective at the kind of care that they give and sometimes that challenges physicians that has challenged physicians territory and physicians pushing back about and having ideas about the kind of nurse that they want. And so there has been this this tension within history about what what is the role of the nurse. How do you how do you train educate the nurse. What kind of skills and what kind of scientific foundation does the nurse need in order to be an effective nurse and you know even in the early 20th century nursing leaders were arguing that nurses needed to have more science education and so would incorporate more science into the nursing curriculum because they and historians have shown that that physicians was saying actually we need nurses that will think because their patients are becoming complex and we are always there to interact in a particular moment but the nurses so we need the nurse to understand what's happening with the patient. The nurse can't diagnose but we want her to respond. But I mean really through the mid 20th century the there was a lot of assumption really that the nurse was really just kind of I mean had Maaden of physicians and I think nurses have never never claimed that role but I heard was one that was assigned to us. And I think a lot of us in education particularly some moroseness in education. Most nurses prior to the 1950s were trained in hospital based diploma programs. And that model of education was really was very much based on the medical model. It was nice being I mean getting lots of clinical education. They were working at the same time as being in exchange for the education they receive. So they were being taught procedure. And it was very routinized the patient has this diagnoses these are the procedures you do. You just you just do.
Speaker 2:You don't think it's kind different a prince and a princess ship which is how medicine. Absolutely.
Speaker 3:Such an apprenticeship and change. But Andrew we were talking before the podcast started and you were talking about what nurses in the graduate program that you're teaching are watching and acquiring more in the sciences right.
Speaker 9:I think from my viewpoint in my in my career so far which has been arguably shorter I mean I've been practicing now for for ten years. But I'm seeing this pattern where students are wanting the DNP doctors and nursing practice or wanting more science based information evidence based practice. There's certainly more in the clinical vein which is sort of goes against I think some of the the the current classes that are offered and traditional schools of nursing more pathophysiology more biostatistics more chemistry base based classes so so we as providers then when we go into the community can sort of better understand that the diagnoses that that are out there that we are that we are using to treat our patients. I think that there is there was a previous educational model of well if your patient has a symptoms it's likely this and then less than what does kind of match it up like while you're in practice and so I think that's that has encouraged nurses then to sort of think outside the box when it comes to their advanced education.
Speaker 3:This is it is. You're saying from looking back at how your apprenticeship model into more academic scholarship. Yeah education for nurses.
Speaker 10:So we left off in the 1950s. I mean can you can you walk us through this evolution from like the 60s 70s until today what what you're seeing. And then we can talk about the future then to you of what nursing education looks like.
Speaker 5:Well after World War 2 there was a lot of change within health care and patient care was becoming increasingly complex you had new pharmaceuticals antibiotics the first drugs to treat high blood pressure new vaccines. But a lot of these pharmaceuticals had really complex side effects too. And then you have new medical technologies like kidney dialysis the electronic fetal monitor which nurses were had a lot of responsibility for at least monitor setting up and then monitoring those those technologies new kinds of surgical procedures open heart surgery get the first transplants in the late 50s 60s and so patient care is becoming increasingly complex in patients struggling with chronic conditions cardiovascular disease cancer. And so nurses realized they were having to make a lot of complex clinical decisions and nurse leaders would say well you know honestly need to have a different kind of education. And so in the 50s nice educators reformulated baccalaureate education in nursing. And this introduced what you know is now the B.S. and the baccalaureate of Science in Nursing. There were previously Baccalaureate programs in Nessim but they went generalist. They were really more foot training in those given advance education to those who already had it Ahren through the diploma program. But the BSN from the 1950s onwards was really moving away from that medical model of the diploma program in emphasizing a nurse a model of care provided nurses with the science not just the biomedical sciences but the Behavioral and Social Sciences. There was a lot of emphasis on the behavioral and social sciences and ground in nursing students in a liberal education on university campuses and this was really really kind of move away from that medical model to say we are independent expert practitioners. And so with the emergence of the BSN and also in this time period because there's a lot of concerns about nursing shortages the community colleges emerged after World War II and the associate degree nursing was introduced in 1952 as and there was Mildred Montag was the nurse educator who introduced the associate degree in nursing a two year program. Again obviously based in community colleges. And the idea was that the associate degree nurse would be the technical nurse who would do a lot of the bedside body work of nursing and the BSN preparedness would be the quote professional nurse who would do do the other parts of nursing. And in 1965 the American Nurses Association said OK we want to do away with the diploma model we want to eliminate the diploma programs and we want to mandate that all nurses have to get have to be trained in a collegiate program so we either associate degree or baccalaureate degree.
Speaker 13:But as we well know that didn't that didn't pan out. We still have diploma programs and the debate over entry into practice has been contentious ever.
Speaker 3:Junior doctors and nurses that have graduated where they are and with a diploma or associate degree rather they are saying well what's wrong with what I already know. What's so good about what you do. And there's a mandate by 2020 to have. I don't know about Minnesota where the current Stotish and eyewash by 2020 85 percent of nurses have to have a minimum show of a backyard or a career in nursing. And the resistance to that is still it boggles my mind. I don't I don't understand that.
Speaker 11:I think I think you're right. I like the word you prescribe. It is contentious. I mean it has been has been very contentious between I think your bedside nurses and your nursing leaders that there is there seems to be an educational difference within those two roles alone.
Speaker 4:I've found that in my practice and observations at a four year educated nurse is always encouraged to go on and take a leadership role especially in a hospital based setting whereas to your nurses are sort of said well words can keep at bedside and so and is that appropriate. And does that does. Are we shooting ourselves in the foot so to speak by you if you're going.
Speaker 3:She's probably going to be a politically incorrect thing to question but here I go What why would you not go back to an apprenticeship through your hospital based or community based through your diploma program and then have that instead of a tree. I don't understand how you can learn enough in two years to safely practice.
Speaker 5:Well and this was actually something that the diploma trained nurses and educators that diploma program said actually the diploma now is a coming out way a much better level higher level clinically. And so you know if it it for the same license in exams.
Speaker 7:So everyone is just crazy.
Speaker 5:And so in the actual clinic the actual wards the diplomacies new mold clinically then the B is prepared.
Speaker 3:But we had to in defense of having a bachelor of nursing from 100 years ago we had the same number of clinical hours as such a comment because you have to have X number of clinical hours to sit the exam. But it seems to me that it's still a contentious issue and ensure it is intense.
Speaker 4:So what is what does the future of this issue I mean. I mean where do we go ten years from now.
Speaker 5:So you know my I actually feel that that the debates over entry into practice have in many ways been bypassed and now you know the emphasis being on advanced practice and as in education and the debates over whether the DMP is going to be the standard for education for advanced practice nurses and that maybe has a little bit of a safer safer ground for nursing because even though you have a lot of advance obviously a great number of advanced practice nurses who are Mazda's educated and can quite rightly say what's wrong with our education. I think the move is to have the DMP eventually be the standard for advanced practice education. And I think that for most Mazda's educated nurses I mean when those in those programs with a DMP when he was first introduced the Master's students were doing the equivalent number of credits as a doctoral student. And so in a way you can make that claim like actually this is better for nurses you're already doing that level of work that qualifies you for doctoral degree in terms of credit. So you're not we're not taking away from the education that you've received which is saying the education you receive should have been rewarded and recognized as at the doctoral level and of course the DNP does provide other kinds of education training beyond what the Mazda's does. But I think that has that. I mean when the DNP was first introduced it was still contentious. There was a lot of pushback from Nessim late as you know really really really significant nursing schools were saying we don't want the DMP but that tide has turned. And I wonder if that's just being safe terrain then then that debate over entry into entry level practice. I mean I do think again that obviously there's a push to have baccalaureate education be the standard of entry for nurses but if the if the debates over the diploma model or anything to go by that that it's going to be a long time before the associate degree moves out and we have to recognize that the multiple pathways educational pathways into nursing.
Speaker 6:It's really important for the Korean mobility and equitable access to and as I say that the BSN is for you school is is very exciting daunting and expensive and short comparing a model is an average Rakshasas for older people and particularly for non-traditional people adults in particular who are thinking about another career a transition is hard to give up or pressures for your cause.
Speaker 5:So I think you know moving forward Gnassingbé just have to appreciate that there is a there's a value and there's an important in terms of increasing diversity within the nursing profession and make it accessible to many types of people and that so having the associate degree as an entry point has been really important and will probably continue to be in terms of the cost of education.
Speaker 12:Right. Indeed. We'll take a quick break and we'll be back here with Dr. dominate Nobel.
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Speaker 9:This is Eini from Friends of Flo and I have my colleague Rebecca Porter. Hey and we're also we have our guest with us today Dr. Dominique tobo. Thank you again for being here. We had just finished talking a little bit about equitable access into the nursing career in the field of nursing. We've talked about different pathways that is educationally regarding the nursing career two years versus four year DMP being sort of the standardized approach I guess to the most advanced level of practice. Just want to see if you could talk to the workforce issues do you see that the teacher programs have contributed or help help cure that issue so to speak within the workforce being having a need for more nurses throughout the years.
Speaker 5:Sure. I mean if we go back to when the associate degree programs in nursing were introduced after World War II one of the main motivation for that was that there was serious concern. I mean big concerns about shortages of all kinds of health care providers but including nurses and so the two year programs were a strategy for getting more recruiting more knows more people into nursing and getting them through more quickly being effectively trained and so the two yet they associate degree Ness's have been vital I think to helping to tackle some of those shortages. But I think studying the history of nursing and as an education you see that a consistent constraint on the production of the nursing workforce has been the shortage of nursing faculty and the increase the expectations that nursing faculty will be higher more highly educated as nurses were expected to be more highly educated. So first with the associate degree in BSN and then with master's level clinical education then there would be needed faculty who could teach at that level and so there was the call for more doctors prepared nurses. And so I think one of the real challenges in dealing with the cyclical nursing shortages is that even as there are applicants numbers of Aklan applicants being turned away from nursing school unqualified applicants nursing programs can't expand because they can't they don't have the faculty to a faculty to teach the expanded program. So I think the associate degree program has certainly helped with shortages. But then there's also been that kind of top down push. There aren't enough faculty to train them and then with the retired lots of nursing faculty reaching retirement age I think we've got even more concern about renewed shortages of doctoral faculty.
Speaker 6:Yes that's sort of our shortage mantra. The issue of peer HGH crescendoing nursing a growing orga Thatcher a particular scholarly or particular area of your scholarship and your talk last night here was so informative.
Speaker 3:Werner there were no issues. Is it I wonder if nurses are not thinking about a Ph.D. in nursing but there's this huge push for the DNP and I think almost at the expense of the appearance program. What are your thoughts Robert. No we don't have another hour to talk about history of computer program but what about Pichi accessibility and preparation and wider acceptance in the Academy of Nursing ph.
Speaker 5:So the first doctoral programs in nursing were introduced first in 1920 at Teachers College Columbia University and then the 1930s at NYU and those even though the teachers college program wasn't educ a doctorate in education and the NYU program was a Ph.D. but both were very much heavily emphasize emphasize the educational model of doctoral education and went so heavily research base. They weren't even the Ph.D.. NYU wasn't as thoroughly grounded in the research model of doctoral education so often beginning in the 50s and 60s and Nesson educators as well as health plan those who say we need more doctors prepared nurses and nurse leaders and nurse researches and educators were saying well we need to introduce the Nessim Ph.D. because with the move of undergraduate nurse and education onto colleges Ng and university campuses nursing faculty wanted to secure their status within the university and be respected and regarded among their university peers. And obviously the expectation at the university level certainly in the non professional schools is that faculty have a doctorate and even in the professional schools the M.D the JD the DD s and so nurses argued we need to establish the nursing Ph.D. both in terms of making sure that we have we are recognized as academics on campuses but also that we are doing research that specifically geared towards nursing problems. So the most doctrinally preparedness is prior to the 1950s had the edge doctoral education in education degrees and really doing research focused on clinical nursing problems. The scientists graduate training program that was established by the Public Health Services Division of nursing in 62 paid for nurses to go get Ph.D. in the biomedical behavioral and social sciences and the expectation was that they would then bring that knowledge back into nursing and apply it to nursing problems but often happened. Base those nurses who then got Ph.D. and the basic basic sciences and they stayed in those fields and they didn't didn't come back to Nisson and so no. A lot of NASA researchers and educators were saying we need a nursing Ph.D. so that we can be sure that we have nurses address and research questions of clinical relevance specifically to Nesson and that we can build a body of knowledge nursing science with which to guide practice and also future research. And so there was a real intellectual imperative and particularly as I mentioned earlier the increasing complexity of nursing and patient care at this time we need the scientists to do that research to generate the knowledge in order for nurses to improve patient care. So it was it was more multifaceted. So I think the Ph.D. has been incredibly important for building and expanding nurses knowledge base and for creating innovations in nursing in nursing practice. So it had a Ph.D. nurses have been critical for that for that regard. And I think also for securing nursing status on university campuses so that they could go to committee meetings and be I mean I'm sure there was still prejudice isn't discrimination against the nurses but they could say hey I'm a doctorate. Just like you. I can participate in this conversation. I'm contributing to the university's tripod. Polityki mission of research education and service. So I should be accorded that status.
Speaker 3:There's so much we take for granted and you know when you do appear you're going through your pitch to you and get on with it. But it's so important to have the historical context to understand where we've come now where we're going. One of the stars came to my mind where we were where you were talking or Birkner supporters that technological revolution that happened after World War Two and were happening now. How does that picture your education compared at that time to now or do you do a comparative analysis.
Speaker 13:I think it's a little it's a little closer to I think draw a comparison. I think what I would say is when I think about the the the role that technology has played and innovations in healthcare have played in the history of healthcare is to think about now what do those innovations translate to. I mean we assume in America and I think in other parts of the world the assumption is that every new innovation means that it's better you know that new in new technology better yet new is better hey. And as we know the U.S. healthcare system is the most expensive in the world and it's one of the things that Americans pride their selves on is that we have the most advanced high tech medicine. And there is a correlation between the high tech the high cost and the assumption that if the technology is there you should use it.
Speaker 2:And that's I think we need to change that. Absolutely. And I'm sure that the outcome will always be better. And we know that they're not.
Speaker 16:And I think that I mean the shift towards high tech medicine and highly specialized care has has pushed done a disservice to the importance of preventative health care primary care which is low cost and low cost in the long run too because if you're doing preventative health care fewer patients are going to need that high tech medicine. So I think it's always important to question just because we have it. Does it mean to say we have to use it. Who gets access to that new high technology. So is it about equitable access or is it depend what insurance system insurance you have and if you're on Medicaid are you going to get access to high tech medicine. And so what does that mean for equitable healthcare access. I mean I think those are really important questions. And also I mean not all the introduction of new technologies doesn't effects different communities of patients differently. So with the introduction of genetic screening a lot of those screening for genetic diseases prenatally the assumption is Well that's a good thing we can understand. You know if we can identify problems befall early and hopefully intervene and whatever that intervention may be. But for when Jannette genetic screening was introduced for sickle cell anemia in the 60s and 70s my screening and the assumption was well this will be a good thing we can help prevent the decrease the incidence of sickle cell anemia. But for the African-American community it wasn't a clear benefit because this was just seen could be read as another example of the American government and white Americans suppressing that community. And not really factoring in what that history of racial oppression and particularly by the medical community what that meant. And so it's not it's not always going to be a clear benefit. So I think it's important to us what those costs and benefits are. And I and again also who's who gets access who is the provider is and has responsibility for the technologies. So nurses you know as nurses that it's actually the nurses who bear a lot of the responsibility for making sure those new technologies work how they get maintained that they're monitored. And and I think kind of thinking about what new technology means for the different levels of providers who are responsible.
Speaker 4:I think it's I think a clinical example at least in today's healthcare. I see this a lot with labs that are being ordered nurses will be the first to question. Why is it that we really need this this this is expensive. This
Speaker 9:doesn't really fit the diagnoses and so they're the ones who are usually trying to encourage a conversation about the patient's needs.
Speaker 14:But do you think that this harkens truly important and the relevance of advanced education. Of course we're talking about caracter pitching or so this is this is a really important role for nurses to consider early in their career about research and policy development efforts and equitable distribution and access of healthcare and social policies developing. And it's really relevant for Diing Pinner says as well to be in the clinical realm. I'm looking at this and having the knowledge and expertise to questioner's very similar technology and that's critical because the hope of the whole premises of the nursing Ph.D. all of nursing.
Speaker 5:As I said earlier we like to distinguish itself from the medical model that nurse is OSK they have a different theoretical underpinnings they have a different focus than physicians and so as a side effect generation of scientists said you know we we all different kinds of research questions and so the Ph.D. today are asking different questions than M.D. Ph.D.. From other crankcase deals and so these these are critical questions that nurses are uniquely positioned to address particularly if they have that training in science.
Speaker 3:From a historical perspective it would be a really wonderful project to look at your new Sugarfoot of research questions. Nurses have been asking Ph.D. programs for the last several decades and how her short changed her work has that impact on patient care.
Speaker 12:I'm interested in the holistic nursing care model. The fact that that seems to be the underpinnings that seems to be the underpinnings of of of DNP practice here in the States. Can you speak at all to that and how it's been developed.
Speaker 9:You know we had been talking about how nurses think a little bit differently we advocate a little bit differently. Can you can you speak to that just a little bit with the idea of the holistic care model and then maybe where that starts to rear its head in history.
Speaker 13:Absolutely. So your friends have flow so. So Florence Nightingale really happy Kate is right. Look at the patient holistically and in the context of his or her environment. And so I have to acknowledge that if we're going back to Nesson history that we can certainly see the arguments about considering the patient holistically back to Florence Nightingale but I actually the emergence of the nursing Ph.D. or the second generation of nursing Ph.D. So the 60s and 70s and this need to build a science of nursing. The research is now researchers who were working in the 60s and 70s were really trying to construct the boundaries of what is known in science. And there was the nesting theory movement emerged when theorists nest theorists were trying to really identify what is unique to Nessie and nest in science. And so there was a lot of there was a lot of conversation and publications and conferences around this issue. But by the end of the 1970s most theorists had identified the focal concepts of nursing that distinguished and defined nose in science and that was the person the whole person the holistic patient the environment the noce in action so that nurse actions were geared towards helping the patient do for themselves.
Speaker 5:So it wasn't about doing for the patient it was working with the patient. So really this emphasis on patient agents patient agency which was really important in this in the 70s as counterpoint to reductionist paternalistic medicine and also the emphasis foreignness is health it's not disease is not disability it's not the locus of disability or disease it's it's health. So seeing the patient on a health continuum. And so those with a four person holistic person interactions with the firemen the health being the emphasis of nursing and that nursing actions are geared towards empowering the patient to be an agent in his or her care. Those were the four essential elements that were by the end of the 1970s. There has been signs this is that this is this is what defines Nissin and I think that even though research scientists have maybe operationalize those concepts in different ways. I think that still retained continues to be that cool element. And politically it was very important because the 1960s and 70s. Impatient consumer movement the women's health movement and health feminist was saying medicine is reductionistic it's paternalistic it's it's basically saying everything that's wrong with a woman is a medical problem as opposed to being just natual.
Speaker 13:And so nursing could say good genuinely say we are very different from that we are about empowering patients were about thinking about the patient within their bio psycho social environment. This holistic approach. So I think that has been incredibly important for us in quite well said.
Speaker 7:I have nothing to add and I think that's the only thing I can think of.
Speaker 3:Aerators. It goes from that phrase earlier today about medicine being a moral manager of the kicker women for men as well. And helping people find their own moral agency. And it's very much a movement today as nurses help people work and give life care go planning and keeping their life the focus of what's happening to their bodies sharing a health care continuum.
Speaker 12:I'm curious to go back to the history of technology and health care and nursing. Can you give us take us back to the 1920s here just for a moment. And can you give us an example of what was a cutting edge technology of that time when. Because that's a time that the I think I know as Sternes of practice being questionable at the time like there is there was a draw into different practices of alternative medicine that time I'm just kind of curious as to what your thoughts are on what was considered cutting edge that maybe patients or some some people in society didn't either have access to due to costs or to of course privilege.
Speaker 9:But what if you could speak to that a little bit.
Speaker 16:Well that's a great question and I think that a couple of the technologies that come to mind and they were actually introduced a little bit earlier but I think they were important in the 1920s so the introduction of the X-ray X-ray was introduced in the late 19th century and the hospitals were first acquiring x ray machines like 1910 but they weren't really using them until the 1920s so they had them because it represented the cutting edge of medicine. But actually physicians where it was expensive to use they at that point you didn't have radiologists who specialized in and in in the X-ray machines. So the physicians and hospital administrators had to figure out who's going to be in charge of the X-ray machine who's going to run it. And so the infrastructure wasn't there to support widespread use of the X-ray machine. By the 1920s what they were called ontologies at the time but what we now consider radiologists had started began to emerge as a specialty and hospitals had created special rooms for the X-ray machine. They create a on the patient chart that that kind of standardize the use of x ray. So that was by the 1920s the EKG machine was also introduced in this early 20th century period and that had a more rapid uptake in part because the x ray had set the foundation for how a new medical innovation could be incorporated into the hospital infrastructure and so that was I guess another example and whether it was being used diagnostically or not that depended on the different hospitals in the course. These were. I mean we're talking about hospitals in urban areas like New York Philadelphia maybe onse and San Francisco on the West Coast but in smaller hospitals in smaller communities where they couldn't afford to necessarily have these technologies. And I think if we go fast forward to the late 1920s the introduction of the iron lung for the treatment of certain cancers the very expensive technology that couldn't that wasn't accessible ostensibly had the potential to not be accessible to everyone. But then the March of Dimes Foundation was established to raise funds to ensure that I and lungs would be distributed across the country so that every community had access to iron lungs. And so it wasn't that every hospital had an iron lung but that in the various areas there would be enough iron lungs to support the treatment in those in those communities and actually go back to your earlier question about oh my point out about the costs and benefits of the iron lung the lung was only useful in cases of I think it was bulbar polio. So that impacted the intercostal muscles. That was the only form of polio which the iron lung could help and physicians knew this but they were so helpless in the face of polio that even kids with other kinds of polio were still put in the iron lung. Even though there was no way that technology could help them because physicians wanted to do something. And so again that kind of raises the question Will how when should this technology be used.
Speaker 5:And should it be used by everyone with that diagnosis that the diagnosis the kind of polio diagnosis Madad. But it also brings up this wasn't going to be available to everyone unless this philanthropic foundation stepped in and raised a ton of money in order to help distribute and increase equitable access to the technology. This is an X I think a kind of an exceptional example in the history of medical technology.
Speaker 12:Well I think about today's examples of technology particularly in the procedural areas where Specialty medicine like robotics. Not everyone has a robotic platform to do surgery. But the benefits of robotic surgery I mean if it's research depend on where you're getting the information you know it's less pain. You know a shorter length of stay which all contributes to the bottom dollar of a hospital's function. I'm curious. Other examples you can think of today where there might be technologies that are available that might we may have difficulty accessing and and perhaps the technology as we had discussed earlier that the technology is just too expensive and not necessarily worthwhile to put our health care system through the burden of having it there as an option.
Speaker 5:I don't think I can. I don't think I can provide a good answer that I can't think. I mean the examples I'm most familiar with biological Pharmaceuticals which is maybe not the technology that you were thinking about but it's still technology nonetheless.
Speaker 12:I mean that's that's a treatment option that is indeed expensive that not everyone society might have equitable access to.
Speaker 3:Don't you think of the biopharma sort of course exactly. So cars. Yeah actually it's a great example and I know some of your work focuses on the history of biopharmaceuticals and an access to social and political repression shops that exist to increase storage costs and decrease accessibility.
Speaker 9:Well yeah and even even things like genetic counseling that's not every area or state or population has access.
Speaker 7:I think access to the appropriate technologies in today's day and age is I think the fastest and challenging.
Speaker 3:I think a fascinating question yet to be answered and historians in the future will be looking at this is what is impacting how was this technology whatever it is we just started to talk about whichever piece of technology. How is it being you start to think about electronic medical records you spoke earlier about how how the patient care record impacted their care that patients receive not. We look at the impact of the electronic medical record on things like privacy rights and data mining and and those ethical questions and the relationship with your patient. Has it changed because of your electorate.
Speaker 13:Yeah I would say that was all fantastic questions and yet to be answered yes. And actually I mean going back to what kind of high tech medicine isn't high technology isn't equitable and accessible to everyone and I think the area of fertility medicine is a really clear example of that sound because insurance companies don't reimburse for fertility care. And so it's very much it is very inaccessible to large segments of the community of the population and it's very much about if you have the financial means in order to get to go for IVF or other kinds of fertility treatment. And there's a lot of new prion preimplantation genetic diagnosis is one aspect of fertility medicine. There's been a lot of innovations in the fertility field and that is very inequitably distributed.
Speaker 3:Having a child becomes a privilege.
Speaker 9:Q Lastly speak to the HRN Tronc health care record. I mean what is your what is your opinion observation on that from a historical perspective.
Speaker 13:I think it's really important to situate it in the context of the change. Changing of the patient record even. I mean in the early 20th century the introduction of the standardized patient form and deciding. And I know with the electronic health record it's I mean a lot about it is what are the categories what are the classifications that are listed on the electronic records so as soon as you go from from the 19th century where physicians would handwrite whatever their diagnosis was to an increasingly circumscribed charge that says you have to put it in use in this particular language or else their record doesn't make yeah right. I mean for me I've actually done a little research on the history of health informatics and the history of the electronic health record and I know that one of the major barriers is into operability. So yes I mean one of the arguments for the electronic health record is that it will be into operable and the patient can go to any health clinic in different parts of the country and that provider will be able to access that patient. We know that that hasn't borne out the infrastructure there's been limits with the infrastructure. There's I mean it depends what software that you use which which provider of which electronic health record provider you use. So there are really real constraints so and I think you ask any any patient or any of us who've been to see a provider and now if the provider whether it be a nurse practitioner or a physician's assistant or or a physician they sit in in front of the computer and then interact in so that that shift in focus and that isn't unique to the electronic health record with the introduction of new technologies into the healthcare environment physicians and nurses attentions were directed from the patient to the monitors. So yeah the monitors are introduced you know post what to even the EKG and so that shifts that that provide a patient relationship. And so I think that raises real questions and then you Rebecca you brought up about the ethics the privacy concerns and yes electronic health records are such an important source for health information in informatic cysts. The data mining potential.
Speaker 12:So there is so much potential but that is hard at will cost and who's who's data and who you're blind to oh I like what you said about the having information be accessible across the country. And we're still using you know 1970s and 60s technology by using the fax machine. So I hear the word burn. I mean it's it's a misnomer. It's a misrepresentation of of what our system of medical information is because it's not paperless at all. In fact I would argue that in fact it probably generates more paper because there there is that need still and sometimes preference really that providers want something that's that they can fit in their hand as they read.
Speaker 13:And I will say that the other. I mean the other take on the electronic health record or another aspect of it that's important to consider is for the patient that they're not seen the entire electronic health record but they can access their healthcare and their results from their medical exam electronically. I mean if they have access if they have access to the Internet. And so I think there that is an increase in the information that patients have access to and it's another medium in which patients can then communicate with their providers through that.
Speaker 3:But that just a fair amount of sophistication particularly when you look at the aging population that the older people I don't want to generalize but not just to that medium and an understanding of others.
Speaker 11:Indeed Dr. turbo we really appreciate your time here. We try to end each of our segments with words of wisdom for our audience. Do you have anything anything to add. Any words of wisdom advice you might want to share with our audience.
Speaker 7:Study history. OK so as not to repeat some cases I'd imagine. Yes. OK. And this is Eini Wetters telling you to innovate agitate and educate.
Speaker 1:And this is Rebecca Porter telling you to keep her stick on our show. Thank you guys. Friends of our friends a flow was brought to you by CLECs mastery. Go to the App Store right now downloading clucks mastering.
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