Guest Editorial: History Matters

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Washington is abuzz with history. Almost every commentator uses history to explain the foundations of critical issues and remind us how our modern problems and their solutions are shaped by historical perspectives. Thomas Freidman asks us to look back first to the Great Depression and later to the recession of the early 1970s to understand our current economic predicament and to develop useful strategies to overcome our own financial downturn. Our President, Barack Obama, has turned to economic historians Ben Bernanke and Christine Romer to chair, respectively, the Federal Reserve and the Council of Economic Advisors. He himself looks to the past when thinking about the future. “History reminds us,” he said in a recent speech, “that, at every moment…of upheaval and transformation, this nation has responded with bold action and big ideas.”¹

History infuses health reform debates, helping us explore tensions and inconsistencies. Perhaps, as Atul Gawande suggests, we should not be overly concerned that, in place of sweeping reforms of our healthcare system, we have only incentives for small experiments. Drawing on the research of historian Ron V. Scott, he goes on to explain how one small pilot program using local extension agents laid the foundation for the sweeping changes that transformed early 20th century agriculture from an industry that was choking the United States economy to one that was feeding the world.² History similarly informs those in health policy. As historian Robert Aronowitz has argued, we keep repeating but never following the same advice about mammography screenings because the early 20th century claims of successful prevention and early detection profoundly addressed deeply held fears rather than any available evidence.³

Yet nurses committed to the advancement of the discipline seem, to our mind, reluctant to use history as a valid source of data or as a reliable foundation upon which to build knowledge. We are educated to be professional practitioners, often prioritizing science and statistics over the humanities. Most nurses can tell the story of Florence Nightingale, but, as Diane Hamilton has pointed out, the entire swath of time from the late 19th century to the late 20th century seems an intellectual and scientific wasteland.⁴ We have little sense of our roots in the development of hospitals, our roles in constructing community-based care, our success in battling some of the deadliest diseases of the 20th century, and our place in making the academy a somewhat more hospitable place for women.

History provides a critically important perspective if we are to understand and address contemporary health system problems. As one of the Academy's Living Legends, Joan Lynaugh, constantly reiterates: “What happens in the present is not an accident. It has a past.” Issues of quality and safety, for example, are not new: they led directly to the formation of training schools in hospitals throughout the country in the late 19th century as physicians needed what we have called in other work “educated allies” to maintain asepsis in surgical suites and on hospital wards. Our predecessors have constantly struggled with issues of shortages of professional personnel: their experiences call attention to issues beyond numbers and to the politics and prerogatives of power embedded in the question of who defines the notion of adequacy and adequate staffing.

History also provides a way to look forward. Certainly, the search for a defined body of knowledge has been the definitive intellectual quest of our generation of researchers. But a strong body of historical work shows how the lack of specific nursing knowledge did not hinder the construction of innovative and life-saving clinical interventions by midcentury pioneering critical care and coronary care nurses. These nurses, in fact, thrived in the open space between the knowledge domains of nursing and medicine. Their histories suggest that discipline-specific knowledge may indeed be necessary but it is not, in and of itself, sufficient.

Most importantly, history creates an imaginative space that refracts and reflects practice. History, like real life and day-to-day nursing practice, is contingent and often uncertain. Historians have a tolerance, and perhaps even a preference, for contingency, ambiguity, and uncertainty. We prefer to “complicate” that which seems self-evident and to concentrate on the sometimes contentious space where ideas about people, events, or issues collide with the reality of personalities, politics, gendered assumptions, and the class or racially structured hierarchies of day-to-day practice. Our quantitative colleagues need to control such variances to isolate that which they hypothesize is critical to change. Historians, by contrast, hold steadfast to the belief that all variables are intrinsically interconnected. Rather than wonder which variable is likely to produce the largest magnitude of change, we wonder how variables interact within time and place to effect change. We thrive in the uncertainties and subjectivities of politics, power struggles, and practice. Our unique methodological tool is time and, as John Gaddis reminds us, we use the distance of time to lift us above the familiar to experience vicariously what we cannot experience directly: a broader explanatory view, given the data at hand, of how the past informs the present and gives direction to the future.⁵

History's power is in this broader view. It also lies in its practitioners' ability to critically, meaningfully, and forthrightly assess meaning and significance. History is about data: it is about reliable and valid facts in a logical chronology. But it is about more than the data alone. Rigorous histories create a “nest” in which these facts and dates have meaning. They subsume methods into a prose-like explanatory narrative that carries the reader along with it. These histories can sometimes make us uncomfortable because, to paraphrase Robert Kohler, they judge historical ideas not only for their truth value but also for their usefulness in the political process of building a discipline.⁶ But they are essential as the hallmark characteristic of a professional practice. They give us the ability to stand back from the immediate situations of life to consider and evaluate them.

Our discipline needs this historical perspective. We stand at the precipice of enormous upheaval that creates an opportunity to move forward nursing's professional and intellectual agenda. Our success will depend on our ability to give voice to an historical perspective that places nurses and nursing at the center of long-standing debates about health services delivery, knowledge formation, patient safety, technology, and education for practice. We need to take our cue from our president and use our understanding of past successes and failures, strategic choices, and political compromises to respond now with our own bold actions and big ideas.

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References 

1. Obama B. Address to Congress. February 24, 2009.
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2. Gawande A. Testing, testing: the complex battle to cut health-care costs. The New Yorker. December 14, 2009;34–41
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3. Aronowitz R. Addicted to mammograms. The New York Times, November 19, 2009. Available at: http://www.nytimes.com/2009/11/20/opinion/20aronowitz.html?_r=1.
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4. Hamilton D. Constructing the mind of nursing. Nur Hist Rev. 1994;2:3–28
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5. Gaddis J. The landscape of history: how historians map the past. Oxford, UK: Oxford University Press; 2004;5
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6. Kohler R. From medical chemistry to biochemistry: the making of a medical discipline. Cambridge, UK: Cambridge University Press; 1982;6
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