For the Medical Record - Interview with Dominique Tobbell
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Mia Levenson: Welcome back to another episode of For the Medical Record, a podcast from Johns Hopkins University's Center for the Medical Humanities and Social Medicine. Today we have with us Dominique Tobbell, the Centennial Distinguished Professor of Nursing and director of the Eleanor Crowder Bjoring Center for Nursing Historical Inquiry at the University of Virginia.

Dominique recently came to the School of Nursing here at Johns Hopkins to talk about her book, "Doctor Nurse: Science, Politics, and the Transformation of American Nursing."

Richard Del Rio: Dominique, thank you so much for joining our podcast. I really enjoyed your talk. Uh, Would you mind going to a bit for our audience, um. how you came about engaging in this project. What problem did you identify that you felt needed a substantial book to be written about.[00:01:00]

Dominique Tobbell: Thank you Richard, and thanks Mia to both of you for inviting me. So this project, the book had its roots, uh, from when I was, when I was a graduate student at the University of Pennsylvania as it was there that I was introduced to the history of nursing and kind of began to develop an interest in it. But it was when I was a faculty member at the University of Minnesota and I was in charge of the University of Minnesota Academic Health Center oral history project. And it was during that project that the book took shape. Because as part of that oral history project where I had to in interview faculty, alumni, staff associated with the academic health center, I was di I was spending a lot of time in the university's archival records. And I also did a number of interviews with nurses who were trained, worked at and taught at the school of Nursing and worked in the university hospital. And it became clear to me that nursing was a critical lens through which to examine [00:02:00] major changes that have taken place in American healthcare. In the second half of the 20th century.

So I was seeing issues related to nursing status within the university and academic health center, but I was also seeing, um, nursing was a really effective lens to study some of the major challenges confronting the health professions more generally after World War ii.

Richard Del Rio: Is there a particular reason that you chose academic health centers as opposed to any other form of, um, hospital system?

Dominique Tobbell: So academic health centers were emerging as a new way of organizing uh, the academic health professions and health sciences after the war and by the 1970s had emerged as kind of a dominant institution within American healthcare. This was when a at a lot of universities that had, academic medical centers, so medical schools and teaching hospitals that instead the, the [00:03:00] different health science schools were being reorganized into academic health centers.

So like medical school, nursing schools, schools of public health, pharmacy school. They would all be organized under the institutional umbrella of an academic health center. And they were also in relationship to the university's teaching hospitals and clinics. And the academic health center was intended to kind of dismantle some of the disciplinary silos that had emerged among the health professions that kept like pharmacy and medicine and, and nursing all kind of distinct from each other. And it was also at least conceptualized as a way to kind of dissolved some of those disciplinary hierarchies as well that existed between medicine, nursing, pharmacy, public health um, that that was what it was in, they were intended in practice. But um of those kind of tensions within the health, among the health science professions did, weren't kind of eliminated by the [00:04:00] academic health centers, but it became really a, a dominant organizational form, especially at like research intensive universities that had the health professions on their campuses.

Mia Levenson: So the title "Doctor Nurse", is such a great title. In part because like you are talking about nurses with PhDs, so so doctor nurses, but it also, you know, calls to mind the way that, the history of nursing is not necessarily privileged under the broader umbrella of the history of medicine. And so I'm curious, like how does this title frame the issues that you're raising in your book?

Dominique Tobbell: Yeah. Thank you for that. Yeah, it is, um, I mean, the title is a little bit of a play on words because as you say, like what I'm talking about are doctorally prepared nurses and mostly PhD prepared. But toward the end of the book, I'm also talking about nurses who have completed the doctor of nursing practice, which was a relatively, which was a new degree [00:05:00] in the early 21st century. And so , here are nurses who are ostensibly entitled to be called doctors. So that's partly the title.

It also reflects the considerable opposition from national organizations representing physicians, particularly the American Medical Association and the American Academy of Family Practice, whose concerns have since the 1960s onwards really centered on titling and scope of practice, especially as nurses have with higher levels of education, have have taken on expanded roles like, like the nurse practitioner and other advanced practice nursing roles.

So this kind of the kind of debates over what you get to call yourself based on which health profession you're a part of and what your educational preparation is really reflects those kind of broad attentions within the health with, within the health professions and within the healthcare system. So, just as an [00:06:00] example, in 2011, the president, president of the American Academy of Family Physicians asserted that physicians were worried about losing control over the title of doctor. And that the use of the term would confuse patients if it was used by others other than physicians. And in fact several state, in several state legislatures, physician groups, push for legislation that would restrict who would be able to use the title, doctor.

And in the a in 2010, like the year, the year before that, the American Medical Association actually launched a massive truth in advertising campaign that was designed to ensure healthcare providers clearly and honestly state their level of training, education, and titling. And the AMAs, kind of opposition and this, this ad advertisement was really kind of precipitated by the growing influence of adv, advanced practice nurses, particularly with the doctor of nursing practice. And in fact, I just, um, saw that in, in the q and a to my talk, I had mentioned a couple of years ago in [00:07:00] California that nurse practitioners had filed suit against, they had filed suit against the California Attorney General and the ca, California Medical Association, as well as the boards, the state Boards of nursing and medicine, because they had been fined for using the title, their, the title of doctoring, kind of them, um, professional websites and such forth. And I, I, it literally just came across the, the why yesterday that the judge, um, determined the case and actually find, found against the nurse practitioners and kind of affirmed that in California only physicians can use the title of Doctor among Health Professions. So this, you know, this, it's about title, but it's about so much more.

I mean, one of the things that I talk about in one of the, in the early chapters is how opposed many physicians working in academic health centers were to the new type types of education that nurses were getting. So the, the changes in [00:08:00] the education for registered nurses move into the undergraduate level and physicians, particularly surgeons in some of these universities really just did not think that nursing schools were training the right kind of nurse, at least kind of nurse that they were used to, which was kind of subordinate to the physician and would, would do what the physician told them. And the, and in which physicians had a, a still quite a role in, in their education and training. So there's, yeah, real kind of tensions that, kind of move throughout the period that I'm looking at and that continue, as I say, into the present.

Richard Del Rio: I think it really is interesting because I think it's safe to say that that nurses are kind of the cornerstone. I mean the, the, the kind of main force of our healthcare system.

And I seem to recall your last talk, you mentioning that amongst polling or surveys, that they were the most trusted of [00:09:00] the health professions, based on patient experience. So I think it's interesting given like the wide range of nurses that this tension is taking place. And this book is really interesting because you're kind of detailing, the progress of nursing education, the, roadblocks nurses face in trying to raise their status as biomedical scientists. So to help our listeners kind of grasp the breadth of this book, can you tell us a story or an anecdote, that you feel really showcases these tensions within the profession, within the time period that you're writing in?

Dominique Tobbell: Yeah, I mean, my focus is really on the 1950s through the 1980s, although in my conclusion, the book's conclusion, I do bring it up to more or less the present moment, or at least up until, uh, 2020 ish. and so you know, what I'm talking about in the book is that I'm analyzing what I call nurse's academic project.

So this is this, the effort by [00:10:00] American nurses to establish nursing as an academic discipline. Nurses as valued researchers. And I argue that the work to establish nursing as an academic discipline included kind of three components. The first was raising the educational level of nurses, particularly to the baccalaureate level and beyond. two was creating and demarcating the boundaries of a distinct science of nursing. establishing nursing PhD programs to prepare new generations of nurse scientists.

And for the nurse educators and, researchers who were the kind of leading this academic project, they really saw this academic project as essential for nurses to be able to care for the patients whose health and illness needs were changing in the context of like the many kind of medical innovations after World War ii. And the growing, particularly the growing influence of chronic illness among the American population in general, but also [00:11:00] like with aging being a significant factor. Um, and yeah, I mean, nursing confronted a lot of barriers in, in their work, in their efforts to do this. And I think like of the ways, so I think the, the kind of story that I wanna tell is thinking about how once nurses, were embarking on this academic project, they were doing it, as I say, to like, focus on how to, to better care for patients. So nursing science to develop new, new understandings of illness and, and how nurses could better care for patients. What was the most effective way to care for patients.

But it was also to establish their status within universities and within academic health centers. As they were new arrivals on university campuses after World War ii. But even as the baccalaureate degree became, or nursing leaders argued that the baccalaureate degree should become the kind of entry level degree for registered [00:12:00] nurses. There was still a number, I mean, the majority of the nursing workforce in the 1950s and the 1960s were trained in the hospital-based diploma model and also new, degree programs have been introduced in the 1950s because of con ongoing concerns about a nursing shortage. And so you also had nurses being trained in two year associate degree programs. Whether a nurse trained in the diploma program, which was three years, a baccalaureate degree program, which was four years, or an associate degree program, which was two years, they all sat for the same licensing exam and all had the title of registered nurse. and there were also new categories of nurses who were trained in one year licensed practical nursing programs.

And these were, these nurses were intended to kind of do more of the traditional bed and body work of nursing that the higher educated nurses were delegating to LPNs. While nursing [00:13:00] leaders wanted to really wanted to cement the baccalaureate degree as the entry level degree, they faced a lot of barriers in doing so.

And part of that was because of like the state politics involved. So I mentioned about kind of academic health centers being such a dominant institution in the decades after World War ii, and partly because state legislators were looking to academic health centers in their states to, to, particularly if they were, based at land grant universities or state funded institutions, they were looking at academic health centers to train the right number of the right type of health healthcare professionals and um, state policy makers were really concerned about the, the ongoing nursing shortage and were looking to their state universities to say, are you training enough of the right kind of nurses?

And even as universities might have wanted to, to focus on the BSN, the baccalaureate of science in nursing degree, a lot of registered nurses as well as licensed practical nurses who had trained [00:14:00] in, hadn't gotten their BSN were looking for ways to upgrade their education. And they were facing a lot of barriers to do so. And so for example, in Minnesota, state legislators were under pressure from nurses in the state to facilitate this so-called educational mobility to help them get the baccalaureate degree that they needed to upgrade their education. And these legislators in turn were putting pressure on the University of Minnesota, which was the state's land grant institution, and, and asking the university to resolve these issues.

For example, they wanted the university to create accelerated RN to BSN programs, they ought to consider award in college credit for their prior diploma education or associate degree training, as well as the clinical experience that they'd had. The other way that they wanted to facilitate this educational mobility was to enable nurses to complete challenge exams and so test out of classes [00:15:00] that covered knowledge they already had competency in. And so state legislators wrote to the University of Minnesota. Asking for the university to resolve the difficulties nurses had faced in their efforts to obtain advanced education. this one particular legislature, he was chair of the Minnesota House's Higher Education Committee, as well as Vice Chair of the Appropriations Committee. So he was pretty powerful, within the state legislature. And he, said to the university Vice President to quote, direct your immediate attention to the problem of educational mobility, and if in fact the solution to these problems can be found that I want to say in the most forceful manner, I know how, let's have the art and so forth come in soon.

And so a year later, he then calls on the university and particularly the Dean of Nursing, to report on the progress that they had made in facilitating nurses who had diploma degrees or associate degrees to upgrade their education. And the reason the issue of educational mobility was [00:16:00] so politically charged was also about kind of the role of nursing organizations in, in this too. So a retired faculty member who I'd interviewed, as part of the oral history project, Mariah Snyder had recalled that because two year programs were typically located in rural parts of the state. Legislators weren't gonna do away with them. They weren't gonna do away with the schools in their cities because that cultivated a lot of community support for the legislators and the Minnesota Nurses Association also opposed restriction access by closing diploma or associate degree programs because the largest membership of the Minnesota Nurses Association was graduates of two and three year programs. as much as nursing leaders wanted to kind of force the closure of diploma programs and push as many students as possible into baccalaureate programs, they faced a tremendous amount of opposition doing so and really looked to the, the nursing schools, [00:17:00] particularly those at academic health centers, and particularly those funded by the state to really kind of resolve this issue and make it possible for nurses who had been trained in associate degree licensed practical nursing or diploma programs to, to, to really, um, have the opportunity to upgrade their education. And so now we're in a situation, we still have multiple educational pathways into nursing. And consistently , nursing leaders as well as healthcare leaders have pushed to increase the proportion of nurses who are trained at the baccalaureate level. And there have been talk of like closing or kind of minimizing the associate degree. There's a few diploma programs I think that still exist, although those, those have last largely gone away. But the reality is, that these, the associate degree and licensed and practical nursing, um programs provide an important access to nursing education, particularly [00:18:00] for students from underserved communities or for historically marginalized communities. And so it continues to be a really important way to fulfill the nursing workforce needs. And these nurses, even though , you know, they're trained at the in associate degree programs or LPN programs, they have consistently provided exce excellent care and providing essential care. And so there's also the kind of issue that when nursing leaders and healthcare health policy makers call for the elimination of these programs or the minimization of the associate degree or the importance of having more BSN educated nurses. It can serve to like, kind of denigrate the, the excellent care that nurses trained at the asso, educated at the associate degree or the LPN level, give. And so it really kind of brings up a lot of issues and tensions that while it was particularly prominent in the sixties and seventies, continues to still be a factor today.

Richard Del Rio: I'd like to just take a step back. I would like to know more about [00:19:00] this legislative urgency that you mentioned from your Minnesota example. What was the problem or what was, the issue? What was the source of the buy-in that that, created this lawmaker's urgency regarding the nurse's education problem?

Dominique Tobbell: Yeah, so there were a couple of factors at play. I mean, first and foremost was that states throughout the US were facing nursing shortages. That this was also a time of physician shortages, dentist shortages. But nursing, the shortage of nurses was particularly pronounced. This was also a time when legisl state legislators were really interested and committed to increasing access to higher education and, particularly increasing access to higher education for communities, for people from communities who've been historically underrepresented in higher education.

So this was during the, you know, the [00:20:00] 1960s, civil rights movement, which in part, focused on diversifying universities and colleges. And that increased with subsequent legislation in the federal legislation in the 1970s as well. So providing grants to students from underrepresented communities to be able to afford to go to college. this was, a moment when both state and, and, and federal legislatures were, committed to diversifying higher education as well as this Kind of significant concern for the, the shortage of nurses. And so because there was of a multifaceted buy-in on the part of legislators that the kind of, the issue of educational mo mobility in nursing was able to garner quite a bit of, of attention. And I mean, the community co community colleges had, significantly expanded as a result of the GI bill after World War II and community colleges were seen as a really important access point [00:21:00] to students from low income, rural, historically marginalized populations like, uh, for, for students of color, they were a really important way, to get access to higher education, in part because community colleges were located in communities throughout the state. There was supposed to be more geographically accessible than say, four year colleges, which were often located in one or two major cities in a state.

And, so there was really a significant amount of state and federal investment in this kind of education system that, that, that kind of was premised on the idea that there were two year and four year colleges and that students should be able to move ideally through through those levels within the higher education system. And it's funny because at a time that nursing leaders were calling for the closure of diploma programs. Raising questions or kind [00:22:00] of speculating that maybe the associate degree should designate someone as a practical nurse while the baccalaureate degree would be the designated entry for the registered nurse. Others were other educators and educational policy makers and, and leaders were actually saying, how can we actually make it easier? For students to move in and out of higher education. And that nursing was with its multiple educational pathways was actually a good model for how it could be done.

And, and that this was a way, like rather than just have. Only the four year degree be the only entry point into higher education. To have a system where, you know, someone could go, go to college for two years, step off, go work for a few years, then step back on and come back into the education system. This was actually seen as really appealing and beneficial, especially in terms of like meeting that kind of need to diversify higher education. So it was interesting that nursing [00:23:00] was like trying to do away with that and do like I mean, I think a lot of what nursing leaders were trying to do was have always been but particularly in these decades after World War ii, to, to be able to seen as having parity to an equity with physicians and other members of the healthcare team and so was often looking to like, well, how is medicine doing it? Maybe, you know, that's maybe how we should do it, but in reality, those multiple pathways into nursing were really important and have continued to be and continue to be really important.

Mia Levenson: So you've talked a little bit about how these issues regarding the status of nurses persisted today. I think that California example where nurse practitioners were sort of ruled against using the title of Doctor is really illustrative of sort of how, how the argument of your book is really like playing out today.

I'm curious, like, are you noticing changes in the way [00:24:00] that these issues around status arise. What are sort of the ramifications of a ruling like that in California?

Dominique Tobbell: Yeah, I, I think that there continues to be, issues of parity and status within the healthcare professions and in many ways, nursing has done a tremendous job, like it's done a tremendous job in, its like professionalization effort in the sense that like a great number of nurses are educated, educated at the baccalaureate degree level or higher. And that, as Richard mentioned a while ago, I mean, consistently nurses are ranked the number one, the most trusted profession, like period, not just even within the healthcare team. And, you know, nurses are providing, they're, they're the, they're the, the members of the healthcare team that spend the most time with patients, particularly hospitalized patients. And so that's been really significant. [00:25:00] But nursing still faces challenges both within and, kind of external to it. So there are definitely like this, this kind of professionalization agenda, the academic project that n that nursing leaders were engaged in, um, did impact and potentially like further marginalized nurses who didn't have access to like higher education in nursing, particularly at the, at the graduate level. And the, there's often been a tension between kind of nursing's professional aspirations and its, its kind of commitments and obligations are to its workforce and some of the really like consistent workplace issues that nursing have faced.

So throughout the mid, mid 20th century onwards, nurses have consistently called for better pay, better work conditions, safer work conditions, and particularly safer patient to nurse ratios. [00:26:00] This has been a consistent theme, throughout the history of US nursing. I mean at least, at least since the 1930s and, you know, they continued not to be able to resolve, those kind of workplace issues, which of course involves a negotiation with like hospital leaders and physician leaders and such forth. But the fact that we still have nurses who are calling out like kind of real safety concerns, particularly around safe patient nursing ratios. That's like, that's that, that has persisted despite all the kind of reforms and changes that have taken place within healthcare and, and within nursing.

Mia Levenson: I guess the, the thing I'm, I'm really curious about is like, are, like I, I, I know asking a historian about the, the present and even the future is, is touchy, but I, I am really curious about like, do you see potential ramifications for a ruling like that in California? Do you, like, what do you think about, about the status of nurses going forward?

Dominique Tobbell: You know, this issue of, [00:27:00] titling is just the, the ruling in all in California. Is it? I'm like, it's frustrating to see play out because nurses and particularly nurse practitioners who it most directly impacts and other advanced practice nurses like certified nurse midwives, nurse anesthetists and clinical nurse specialists. They're all providing essential care in the healthcare system and particularly even with, I'm gonna go back like historically because hey, that's where I'm more comfortable, but it, it matters. But like even the introduction of the nurse practitioner role in the mid 1960s was, I mean partly it was because nurses were practicing in advanced roles, in particularly in rural areas where they might have been the only or main clinician in proximity to patients. But it was also the nurse practitioner role was also billed as a potential solution to the shortage of primary care physicians. So nurse [00:28:00] practitioners have established themselves over the last 60 years. That they can provide high quality, cost-effective care, that they can help reduce, structural and social determinants of health in because they're practicing in a nursing model of care. And yet. We still have seen, like concerns raised about, well, is it, can nurse practitioners be trusted to deliver safe care? If you, if a nurse practitioner refers to themselves as a doctor with, according to their doctorate, are they gonna confuse patients since, are they, is this raising an issue of trust for patients?

I mean, I actually think, I mean, I dunno the, the nurses who filed the lawsuit in California, but of the nurses that I've spoke to, it's not so much that they're trying, they're not trying to confuse or mislead any patients. They will also always, like, identify themselves as a nurse practitioner that like, [00:29:00] like their, their credential is a doctorate. But they, it's always that nurse practitioners and other advanced practitioner nurses are identifying themselves by, that they are nurse practitioners or advanced practice nurses. and so it, it just seems really, um, unnecessary and kind of dismissive of the high quality education that nurse practitioners have and the high quality and critical care that nurse practitioners provide. And I, and it's just frustrating to see this continue to be an issue because it is a, I mean, I, I, I think the issue of titling, and scope of practice extends beyond like advanced practice nurses and physicians. Like, there is, but there are so many other healthcare professionals now who train at the doctoral level. So physical therapists, audiologists, you know, the, the list is, is, is kind of [00:30:00] numerous and I'm not sure if the kind of titling becomes as contentious as it does with nurses and to kind of jealously guard kind of like titles just seems like it seems harmful and just dismisses the expertise that nurse practitioners and other advanced practice nurses have.

And I just wanna add like a caveat here, like as I understand it from conversations with nurses and nurse practitioners and with physicians as well, there's a difference between like what individual physicians feel and like will say and what. Like their national organizations, might be kind of communicating and representing. And I think that the, you know, it used to be the case like in the 1960s that majority of physicians were members of the American Medical Association. Now that is not the case, and that hasn't been the case for a long time. So I think. Some of this, some of these kind of politics and tensions are playing out at the national organization [00:31:00] level and, and thankfully are not, often not playing out at the, at the level of individual, kind of clinical collaborations.

Richard Del Rio: Dominique, you are the director of the Bjoring Center for Nursing Historical Inquiry at the University of Virginia, which is a internationally recognized archive and research center. So we assume you have a great vantage point. For trends within the field of nursing history, what questions are scholars in this field pursuing now? What is the direction the field is taking and, what do you expect to be working on next?

Dominique Tobbell: Yeah, thanks for this question. It's good to think about like where the field is going and it's, it's going, it's, it's really exciting. I think, you know, one of the things that I had kind of noted, that I'm pretty frank about in, in [00:32:00] my book, and that as I mentioned at the talk that, you know, the nurses that I'm writing about are overwhelmingly white women nurses. Because during the, the, the period, the years that I look at, american nursing was overwhelmingly white and female, and particularly at, you know, once you got to the kind of higher education levels because of, of segregation in the US but also ongoing, ongoing effects of systemic racism within nursing and higher education.

So a lot of excellent history of nursing has been, has focused, on , kind of what white nurses have done. And now there, I mean there has always been other, historians who have looked at the experiences of nurses of color. But, now that has become, I feel like that's a really important direction that, the history of nursing is moving in where it's beco, where like there's some really exciting scholarship that really is centering on the [00:33:00] experiences of black nurses and particularly indigenous nurses working throughout the world. and, and that's been really important. And, and thinking specifically about within the US healthcare system, not just, it's not just, these aren't just histories of like oppression and disadvantage, but really emphasizing the agency advocacy and activism of nurses of color, and not only on behalf of themselves, but also on behalf of their patients and communities. So that's a really exciting, kind of growth, that that is happening right now.

I think another important, area is focusing not just on the history of those who have, had access to professional nursing who you know, get, are called registered nurses or, in, in other way designated professional nurses in other, in other countries, but actually taking seriously the experiences and histories of those who, who provide important nursing care [00:34:00] as nursing aides, nurse assistance, oftentimes as orderlies, particularly when thinking about like for folks who were, excluded from higher education in nursing, particularly men, through like the 1970s and as well as, women of color. Oftentimes they were, disproportionately like funneled into these, assistant or age positions or orderly positions, and yet they've been doing really important work. Within the healthcare system.

And so I think there is, sometimes it's hard to get access to like those histories and and I think this is where oral history is so important, but there's, there has, there is like, some scholarship happening in this space and I think that's really important. The other thing I will say, I mean, I'm an Americanist so I am like I really, you know, obviously focus on the history of healthcare in the us. but we must and, and we, there's a whole like vibrant global history of nursing too. And again, like [00:35:00] historically, the historiography has focused on North American and European nursing. But there is like an exciting and growing scholarship that analyzes the host social histories of nursing and healing in Africa, Asia. Australia and South America, and again, like this scholarship too is kind of highlighting the agency of men and women nurses who introduced oftentimes were, you know, are tasked with, introduced in biomedical discourses and practices in the context of colonialism and post-colonialism. And so again, this is another really exciting area of, of research that's, that's already been underway, but I just see that's where the, the, the kind of field is going.

My own new project, examines the work of nurses and nurse practitioners in the US to improve access to healthcare services among underserved communities. I'm looking particularly through the, the establishment of [00:36:00] community-based nurse-led clinics, which really began in the 1960s and have intensified, in really it's, it's been an important, aspect of healthcare and particularly, the case, the case study I'm looking at right now is looking at, nurse-led clinics in rural areas.

And so I'm, I'm pulling together a series of case studies about urban and rural community-based nurse-led clinics. And I'm asking a series of questions like I'm analyzing how the nursing model of care shaped the kinds of services that nurses provided in these clinics. I'm assessing the impact of the clinics on the communities they served. I mean, they're intended to provide care to underserved communities. How effective were they doing that? And I'm particularly interested in the role that the communities themselves played within these clinics. and that's been really, really exciting to see. Like the community, it's like an example, some examples of community health activism as well. And then I'm also kind of analyzing [00:37:00] how evolving health policies and political debates over healthcare, financing, reimbursement, scope of practice legislation, issues over titling, how those kind of policies and politics have constrained nurses' ability to practice independently, and that this has influenced the sustainability and impact of community-based clinics. So that's my new project, which I'm super excited about.

Mia Levenson: Yeah, and we'll absolutely link to more resources in the, in the show notes for anyone who you know, wants to read up more on the history of nursing. Dominique, thank you so much for being here. This was such a wonderful conversation and such a rich discussion about your book. Thank you so much.

Richard Del Rio: Thanks for coming.