Nursing History Review, Volume 10, 2002: Official Publication of the American Association for the History of Nursing

NURSING HISTORY REVIEW

JOAN E. LYNAUGH, Editor DIANE HAMILTON, Book Review Editor PATRICIA O'BRIEN D'ANTONIO, Associate Editor ELIZABETH WEISS, Assistant Editor

Editorial Review Board Ellen D. Baer Florida

Diane Hamilton Michigan

Susan Baird Pennsylvania

Wanda C. Hiestand New York

Nettie Birnbach Florida

Mary Anne Lewis California

Eleanor Crowder Bjoring California

John Parascandola Maryland

Barbara Brodie Virginia

Susan Reverby Massachusetts

Olga Maranjian Church Connecticut

Naomi Rogers Connecticut

Donna Diers Connecticut

Nancy Tomes New York

Marilyn Flood California

NURSING HISTORY REVIEW OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR THE HISTORY OF NURSING

ISSN 1062-8061

2002 . Volume 10

CONTENTS 1

EDITORIAL JOAN E. LYNAUGH

A RT IC LES 3

To Work in the Garden of God: The Swedish Nursing Association and the Concept of the Calling, 1909-1933 ASA ANDERSSON

21

The Wind of Change is Blowing SUSAN MCGANN

33

The Beginning of Nursing in Brazil: Brazilian Sanitarians and American Nurses IEDA DE ALENCAR BARREIRA

49

"The Problem" of Student Nurses of Japanese Ancestry During World War II SUSAN MCKAY

69

Caring for Life: Nursing During the Holocaust BARBARA L. BRUSH

83

Smaller and Cheaper: The Chicago Hourly Nursing Service, 1926-1957 JEAN C. WHELAN

Springer Publishing Company • New York

ii 109

Contents Trained Nurses in Family Magazines, 1880-1928 BRIGID LUSK

127

Nurses: The Early Twentieth Century Tuberculosis Preventorium's "Connecting Link" CYNTHIA A. CONNOLLY

159

The Roots of Collaborative Practice: Nurse Practitioner Pioneers' Stories JULIE FAIRMAN

HlSTORIOGRAPHIC ESSAY 175

The Fork in the Road: Nursing History Versus the History of Nursing? SIOBAN NELSON

BOOK REVIEWS 189

Review Essay: Telling the Stories of World War II Military Nurses They Called Them Angels: American Military Nurses of World War II by Kathi Jackson All This Hell: U.S. Nurses Imprisoned by the Japanese by Evelyn M. Monahan and Rosemary Neidel-Greenlee REVIEWER: MARY T. SARNECKY

192

Mending Bodies, Saving Souls: A History of Hospitals by Guenter B. Risse REVIEWER: BARBRA MANN WALL

194

Learning, Faith and Caring: History of the Georgetown University School of Nursing, 1903-2000 by Alma S. Woolley REVIEWER: M. LOUISE FITZPATRICK

196

Devices and Desires: Gender, Technology and American Nursing by Margarete Sandelowski REVIEWER: ARLENE w. KEELING

198

Hearts of Wisdom: American Women Caring for Kin, 1850-1940 by Emily K. Abel REVIEWER: CYNTHIA A. CONNOLLY

Contents 200

iii

No One Was Turned Away: The Role of Public Hospitals in New York City Since 1900 by Sandra Opdyke REVIEWER: JEAN C. WHELAN

202

Nurses in Nazi Germany: Moral Choice in History by Bronwyn Rebekah McFarland-Icke REVIEWER: EVELYN R. BENSON

204

Letters From Belsen 1945: An Australian Nurse's Experiences With the Survivors of War by Muriel Knox Doherty, edited by Judith Cornell and R. Lynnette Russell REVIEWER: ELLEN BEN-SEFER

205

An American Health Dilemma: A Medical History of African Americans and the Problem of Race—Beginnings to 1900 by W. Michael Byrd and Linda A. Clayton REVIEWER: CARLA SCHISSEL

207

Enduring Issues in American Nursing edited by Ellen D. Baer, Patricia D'Antonio, Sylvia Rinker, and Joan E. Lynaugh REVIEWER: NETTIE BIRNBACH

209

Challenging Professions: Historical and Contemporary Perspectives on Women's Professional Work edited by Elizabeth Smyth, Sandra Acker, Paula Bourne, and Alison Prentice REVIEWER: CYNTHIA TOMAN

211

NEW D I S S E R T A T I O N S

217

Subject Index

Cover Photo: The Swedish nurse Elisabeth Lind at the ICN-conference in Montreal, 1929. Lind is the nurse in the dark suit. The other uniformed nurse is from Finland.

Nursing History Review is published annually for the American Association for the History of Nursing, Inc., by Springer Publishing Company, Inc., New York. Business office: All business correspondence, including subscriptions, renewals, advertising, and address changes, should be sent to Springer Publishing Company, 536 Broadway, New York, NY 10012-3955. Editorial offices: Submit six copies of the manuscript for publication. Submissions and editorial correspondence should be directed to Patricia D'Antonio, Editor, Nursing History Review, University of Pennsylvania, 420 Guardian Drive, Room 307, Philadelphia, PA 19104-6096. See Guidelines for Contributors on the inside back cover for further details. Members of the American Association for the History of Nursing, Inc. (AAHN) receive Nursing History Review on payment of annual membership dues. Applications and other correspondence relating to AAHN membership should be directed to: Janet L. Fickeissen, Executive Secretary, American Association for the History of Nursing, Inc., P.O. Box 175, Lonoka Harbor, NJ 08734-0175. Subscription rates: Volume 10, 2002. For institutions: $78/1 year, $133/2 years. For individuals: $38/1 year, $66/2 years. Outside the United States—for institutions: $90/1 year, $153/2 years; for individuals: $45/1 year, $77/2 years. Air ship available: $12/year. Payment must be made in U.S. dollars through a U.S. bank. Make checks payable to Springer Publishing Company. Indexes/abstracts of articles for this journal appear in: CINAHL® print index & database, Current Contents/Social & Behavioral Sciences, Social Sciences Citation Index, Research Alert, RNdex, Index Medicus/MEDLINE, Historical Abstracts, America: History and Life. Permission: All rights are reserved. No part of this volume may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying (with the exception listed below), recording, or by any information storage and retrieval system, without permission in writing from the publisher. Permission is granted by the copyright owner for libraries and others registered with the Copyright Clearance Center (CCC) to photocopy any article herein for $5.00 per copy of the article. Payments should be sent directly to Copyright Clearance Center, 27 Congress Street, Salem, MA 01970, U.S.A. This permission holds for copying done for personal or internal reference use only; it does not extend to other kinds of copying, such as copying for general distribution, advertising or promotional purposes, creating new collective works, or for resale. Requests for these permissions or further information should be addressed to Springer Publishing Company, Inc. Postmaster: Send address changes to Springer Publishing Company, Inc., 536 Broadway, New York, NY 10012-3955. Copyright © 2002 by Springer Publishing Company, New York, for the American Association for the History of Nursing, Inc. Printed in the United States of America on acid-free paper. ISSN 1062-8061

ISBN 0-8261-1477-6

American Association for the History of Nursing, Inc. Eleanor Herrmann President

Patricia Chammings Director

Sylvia Rinker First Vice President

Julie Fairman Nominations

Karen Buhler-Wilkerson Second Vice President

Karen Egenes Director

Mary Tarbox Secretary

Barbara Gaines Director

Brigid Lusk Treasurer

Wanda C. Hiestand Archivist

Lois Monteiro Director

Janet L. Fickeissen Executive Secretary

E. Diane Greenhill Director

NO PLACE LIKE HOME A History of Nursing and Home Care in the United States

KAREN BUHLER-WILKERSON Winner of the American Association for the History of Nursing 2001 Lavinia Dock Award "No Place Like Home provides historians of medicine, nursing, and social policy, as well as current policy makers, with a broadranging and thoughtful history of home care. No one knows this field more deeply than Buhler-Wilkerson. Her scholarship is impeccable—the sheer amount of research and thinking in this book is impressive." —Susan M. Reverby, Wellesley College $45.00 hardcover

THE JOHNS HOPKINS UNIVERSITY PRESS 1-800-537-5487 • www.jhupbooks.com

SAY LITTLE, DO MUCH

NURSING, NUNS, AND HOSPITALS IN THE NINETEENTH CENTURY Sioban Nelson Nearly a half century before Florence Nightingale became a legendary figure for her pioneering work in the nursing trade, nursing nuns made significant but little-known accomplishments in the field. In fact, in the nineteenth century, more than thirty-five percent of American hospitals were created and run by women with religious vocations. In Say Little, Do Much, Sioban Nelson casts light upon the work of the nineteenth century women's religious communities. HEALTH, ILLNESS, AND CAREGIVING 240 PAGES • 8 B/W ILLUS. • CLOTH $55.00 AVAILABLE WHEREVER BOOKS ARE SOLD

OR CALL 1.800.445.9880 WWW.UPENN.EDU/PENNPRESS

EDITORIAL

The first volume of Nursing History Review was dated 1993; now, to my astonishment, we are readying Volume 10 for the publisher. The American Association for the History of Nursing was scarcely ten years old when, in 1991, it took the decision to sponsor a research journal. The intent was to help all those interested in the history of health care keep in touch with new and ongoing research, gain access to related historiography, and analyze the historical perspective on contemporary health concerns. We hoped to inaugurate a new era of historical research and writing. Now, those intentions and hopes have been realized. The subject and its scholars are flourishing here and in many parts of the world. In this issue, as an example, we are very pleased to publish three excellent new studies from colleagues in Sweden, the United Kingdom and Brazil. And, in the historiographic essay for this year, we are challenged by Australia's Sioban Nelson to pursue an important conversation about the meaning and direction of the history of nursing. Which reminds me of another intention I haven't yet mentioned. As we study and interpret the history of nursing and health care we realize fully the opportunity to shape the past. One of the great joys of working as an editor is to encourage that "shaping" work. We have published ninety-nine original articles in these ten volumes. This is a good beginning. Now, after ten years, I am delighted to step down as editor and turn the Review over to my distinguished colleague Patricia D'Antonio. Many thanks to all of you for the wonderful opportunity to read and learn from your work. JOAN E. LYNAUGH Center for the Study of the History of Nursing University of Pennsylvania

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To Work in the Garden of God The Swedish Nursing Association and the Concept of the Calling, 1909-1933 ASA ANDERSSON Department of Historical Studies/History of Ideas Umea University

In May 1909, one of Sweden's leading nurses, Sally Peterson, wrote an article about nurses' uniforms in the Svensk sjukskotersketidning or Swedish Nurses Magazine (SNM). What is the meaning of the uniform, she asked? Her own answer was that the uniform did not appear for practical or hygienic reasons. The dress of the nurses was inspired by the nuns, and at all times uniforms were expressions of different ranks, of outward dignity and inner spirit. She pointed out that simplicity in dress always was significant for those who turned their minds away from the vanity of this world and sought to deepen their inner man. This, Peterson argued, ought to be the case with nurses; modesty, not influences from fashion, should characterize a nurse. Peterson further addressed a warning to the reader not to mix the uniform with modern clothes. What would it look like if a military officer wore partly uniform, partly civilian clothes? The uniform's purpose was to protect the nurse's morality and to give her a unique position. Only if the nurse wore her simple uniform, neither distorted nor touched by vanity and allurements from fashion, will people realize the serious and devoted feeling she has for her calling.1 Peterson's article summarised features from most current thinking affecting the development of nursing in Sweden. She associated the uniform with "ranks" and the nurse's "unique position," that is, with hierarchies. When she wrote about the uniform as a "protection" and equated the nurses with "military officers," she dealt with notions of gender and morality. Last-but not of less importance—she connected the uniform with the idea of a "calling" and the concept of the "inner man," both of which are religious concepts and, in the Swedish context, closely related to the Lutheran doctrines. The concept of the calling is in itself an ethical concept. The vocational aspect of the Swedish nursing profession was, above all, connected to notions of ethics and Nursing History Review 10 (2002): 3-19. A publication of the American Association for the History of Nursing. Copyright © 2002 Springer Publishing Company.

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of morality. From an international perspective, the Swedish emphasis on ethical thinking was not unique. As historian Anne Marie Rafferty has pointed out, the nursing profession was an essentially moral metier.2 This accords with studies of professions showing how common a professional strategy it is to make a strong point of ethics, often expressed as altruism.3 What then is special about nurses, and what is special about the Swedish nurses? I would like to argue that the ethical and vocational aspects of the profession were comparatively predominant among nurses, and that the ideas permeating vocation differed among countries depending on their various societal and cultural contexts. In the case of Swedish nurses, for instance, knowledge of Lutheran ideas of labor, hierarchies, and gender is important for an accurate analysis of their concept of the calling. Questions I address in this article are: What kind of calling is it that the leading nurses were preoccupied with, and what did the ethical outlines express? In what way were the ideas about the calling gendered? And why is the uniform so interesting? I will begin with a brief history of the concept of the calling, especially its Lutheran connections. Second, I will give an account of the development of the nursing profession in Sweden. Third, I will discuss some of the ideas about the concept of a calling found among the leading nurses of the Svensk sjukskoterskeforening, or Swedish Nurses Association (SNA), at the beginning of the twentieth century. I will conclude with an analysis of the hierarchy and gender implications associated with the military metaphor.

The Concept of the Calling and the Lutheran Doctrines The concept of the calling is historically linked to religious ideas and closely connected to the spiritual life of man. Most cultures had, and still have, special persons who have been called to mediate between this world and the spiritual. The shaman is an example of this. In Christianity and Islam, Jesus and Muhammad are regarded as "called" to proclaim the word and will of God to the people. These features of elevation, of being the chosen, are important aspects of the concept of the calling, and they were, among other ingredients, also central for Swedish nurses at the turn of the 19th century. With the Protestant reformer Martin Luther, the concept of the calling widened to comprise an ethic of labor and also a gender-specific calling for women grounded on notions of procreation. The Lutheran ethic of labor has close

To Work in the Garden of God

5

connections to the ethic of charity, which holds that it is a human duty to help and serve your fellow being. According to Luther, this is best done through our daily work. While we work and thereby serve our fellow beings, we also strive for a continuation of God's creation on earth.4 In this way of thinking, man is made the co-worker of God. Hence both the work and the one who performs the work are elevated. Luther's writings on man's calling on earth reveals a strictly hierarchic world view in which everyone has his or her predetermined place.5 Thus the calling is not only a task but also a social and biological position. The woman has a specific calling as a wife and a mother. As a wife, it is important that the woman subordinate herself to the husband. The father of the family should, Luther states, love his wife and cherish her, as she is the weaker vessel. The man is described as the head of the woman, just as Christ is the head of the church.6 Consequently, the Lutheran concept of calling incorporates notions of work, of charity, and of social and biological hierarchies—all of which are related to God's will.

Educational Institutions in Sweden in the Nineteenth Century When female health care professions developed during the nineteenth century, Lutheran teachings still had a strong influence in Sweden.7 This was especially the case among conservative Christian philanthropic groups from which the ideologically dominating educational institutions emanated. The first school for female health care workers in Sweden was the Ersta Institution of deaconesses, which was founded in Stockholm in 1851. The calling of the deaconesses was, above all, a Christian and spiritual calling with a missionary purpose.8 To be accepted at the Ersta Institution, one had to have a true love for the word of God and also a profound knowledge of the important sayings of the Bible. These elements were key aspects of religion within the Lutheran-stamped revivalist movement. The training was short and stressed biblical knowledge and the moulding of the personality of the deaconess. The deaconess ought to be hardworking, forebearing, and self-sacrificing towards her fellow beings. Further, she was expected to live in simplicity without any personal demands, and to show obedience and humility towards her superiors and to God.9 Some of the features of the Ersta Institution were slightly controversial. One thing that aroused concern was the deaconesses' likeness to Roman Catholic nuns. It was not just their nunlike dress that gave rise to negative attention, but also the

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ritual of consecration that concluded the training of the deaconess. The reason for this guarded attitude may be understood in the light of the religious history of Sweden. Catholicism was, in principle, forbidden until the 1860s, and distrust of Catholics was widespread within the Protestant church as well as among ordinary people.10 In spite of this slightly critical attitude toward the deaconesses, they were still accepted and even appreciated for their important philanthropic contributions in society. As nurses, however, they never really became a success. When the Swedish Nurses Association was founded in 1910, one still found many ideas and notions about the nursing profession clearly related to the deaconesses' vocation. An important source of this approach was the influence of the leading school for nurses of that time, the Sophia Home. Queen Sophia founded this school in Stockholm in the 1880s. The queen was close to the revivalist movement but was also influenced by journeys to England, where she was in contact with Nightingale-inspired nursing in English hospitals.11 The ideas and ways of organization permeating the Sophia Home were not far from the deeply religious ideas and organization characterising the Ersta Institution of deaconesses. For instance, the nurses at the Home were conformed in a "Motherhouse," closely resembling the sisterhood in the deaconess institution. To be accepted as a student at the Sophia Home, one had to be a Protestant with a serious inclination and an aptitude for nursing founded on a true belief in, and fear of, God.12 Another important demand, however, that differed somewhat from requirements for the deaconesses, was the expectation that the applicant to the Sophia Home have adequate educational grounding before entering the school.'3 Florence Nightingale's ideas on training, discipline, and supervision also differentiated the Sophia Home from Ersta. Hence, in contrast to the Ersta Institution of deaconesses, the Sophia Home increased the theoretical elements in the nurses' education. The school graduated well-qualified nurses, and because it came into being with the help of the Queen, it was assigned a certain status. We must recall, however, that at the turn of the century most education of nurses was handled by small hospitals in the provinces; for them, the most important goal was to quickly provide the growing health sector with female health care workers. Periods of training were short and the theoretical elements were almost nonexistent, or at least very limited. In more "distinguished" schools like the Sophia Home, the organizational system of the Mother-house was declining and there still was no control or supervision of the profession from the Swedish government. These were some of the important elements that led to the founding of the Swedish Nurses Association in 1910. Of course, nurses in other Western countries also influenced the leading nurses in Sweden. In particular, associating through the International Council of Nurses was of great importance.14

To Work in the Garden of God

7

Nurses, Education, and a Vocational Work Ethic In the circumstances of the heterogeneous educational situation and of worry about the descending status of nursing, the founders of the Swedish Nurses Association wanted to improve education. One immediate measure was to not admit nurses to the association who lacked at least 18 months of nurses' training. The consequence of this measure was exclusion of the majority of the Swedish nursing corps. The exclusion was confirmed by the stipulation that every new member should be recommended by two members of the association. As a result, the SNA was a very elite organization. 1 ^ Excluding nurses on the basis of limited education did not differ from the methods used by nurses in other countries. What actually is different in Sweden is that this hierarchic maneuver neither caused openly expressed conflict nor originated a split in the nursing corps. It appears that the leading nurses in the SNA really made efforts to avoid any kind of conflict, both with superior-status groups, such as doctors and administrators, and with groups of lower status. In the case of North American and British nurses, it appears that a stratification occurred in the early stage of their professional development and that open conflicts were rather common.1(> In Sweden, one attempt was made to organize the excluded nurses, but this arrangement never became a success and it never constituted any threat to the dominance of the SNA.1 Along with its concern for educational status, the Swedish Nurses Association attached great importance to ethical issues. The prescribed ethic emphasized personal virtue and a sense of duty. 18 Implicit in ethical outlines were notions associated with the Christian ethic of charity and the Lutheran ethic of labor. For instance, the association explicitly rejected the idea that it should take an interest in topics such as wages. According to the SNA, the work itself was to be seen as a reward, a possibility to work in the garden of God.19 But the reward would not occur unless the nurse approached her task with the correct attitude. Estrid Rodhe, editor of SNM, wrote that the work would be hard if not approached with a will to serve others, a will to self-sacrifice, and a capacity for selfdenial. It would be hard because it could not give the deep satisfaction that only the work of love can give. The satisfaction was explained to be an "inner salary" that one earned when working for the well-being of others. Rodhe asserted that one must forget oneself and serve with a spirit of self-sacrifice or one would end up with a feeling of poverty, as if following a low trade instead of a high calling.20 Sally Peterson, the nurse quoted in the beginning of this article, also dealt with Lutheran ideas on man's dubious ability to see to the good of others. When writing about the need to deepen the "inner man," she was actually touching upon this idea of the meaning of, and ethics of, work.

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These brief reflections on work are close to Lutheran teachings. In this doctrine of faith, the will and the capacity to renounce are emphasized. Moreover, while the primary goal of Christian charity should not be to satisfy the benefactor,21 according to Luther there is a problem with human nature: egotism is always near at hand, and man has a tendency to see first to his own good. The Lutheran solution to this problem contains interdependent notions of man's relation to labor and to God. Labor is seen as being a support for the good impulses in man. This idea is imbued, for instance, in the expression the "inner man." Luther's phrase, the "inner" and the "outward" man, means, in rough outline, the good, believing side of man and the bad, sinful side of man. The reluctant outward man is seated in man's flesh and needs to be subjugated—preferably through daily work. When the "outward man" must work he suffers, and so is driven closer to God. The "inner," believing man, on the other hand, wants to serve God with no claims for compensation. Consequently the "inner," believing man supports the working man, and the work itself will be easy to perform because the believing man has a natural inclination to serve his fellow being.22 Another part of the solution to man's problematic nature is to regard him as dependent on "agape"—the love that comes from God.23 The love of the Lord prepares the ground for man's capacity to goodness, provided that he has received God's love through the grace of faith. Estrid Rodhe, who herself was a firm believer, shares Luther's idea that the love of the Lord is the best guarantee of man's capacity for charity. It is quite clear that, in Rodhe's opinion, the most persistent nurse is a true Christian believer. Christ is the one who has made love perfect; he is the source of the right kind of love. It is obvious that at the same time Rodhe was aware of her own era in terms of ongoing secularization in Swedish society. She admitted that a nurse who is not a strong believer can be a good caretaker if she possesses the ability for self-sacrifice and unselfishness, and the capacity to renounce. But she stuck to her opinion that, even though many things were freed from Christian influences, they still were reflections of, and unconsciously dependent on, Christianity.24 The question then is, what are we to make of Rodhe? Are Estrid Rodhe's opinions on work representative? It is impossible, of course, to be precise about the extent of the Christian influence on the nursing corps. From articles in the SNM and manuscripts from the courses arranged by the SNA, one might draw the conclusion that ideas of altruism and of Christian ideology were common. Sometimes these ideas were explicitly combined with Christian faith, sometimes not. Anyway, I am inclined to agree with Rodhe-the influences of Christianity, presumably the Lutheran doctrines of faith, were all-pervading. We find evidence in articles in the SNM and discussions in the SNA. From a historical perspective, it is

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obvious that Christian notions often are implicit in the representations of altruistically shaped work ethics. The altruistic feature also finds expression in the multitude of symbols that embraced the nursing profession. One of these was the uniform.

Uniform and Legitimization The uniform was a marker for the ethic characterizing the nursing profession. In Sweden, as late as the 1920s and 1930s, it was not only a dress for the workplace but was always worn, even for several weeks during the summer holiday. The uniform was not quite homogenous, but the basic features were the same. On state occasions the well-educated nurse wore a dark-colored suit with a high-necked, stiff collar. A coat and hat belonged to that outfit. During work the nurse dressed in a blue and white cotton suit of the same model, with the high-necked stiff collar, as at ceremonials and feasts. The style of the hat or the coat could vary depending on what educational institution the nurse belonged to; consequently, from the look of her uniform it was possible to decide from which school the nurse came. During the three initial decades of the last century the uniform was often discussed, but in a somewhat cautious way. It was fairly common for the same person to express arguments both for and against change. Arguments in favor of change stressed the fact that the uniform was not all that well adapted to the tasks of a modern nurse, and that it could be viewed as interfering with the nurse's personal freedom. In arguments against change, the need to venerate and respect the uniform was strongly emphasized.2'' From this point of view, freedom was seen as a problem and venerating the uniform equated it with high status. Both the question of freedom and the status aspect are evident in Peterson's article. One of the meanings Sally Peterson ascribes to the uniform is that, as it reveals which educational institution the nurse is from, it legitimizes both the nurse and the institution. The uniform is also said to be a protection for the nurse. People see the nurse as having a certain position, and the uniform functions as a guarantee for her allowable errands. Peterson's argument can be understood in at least two directions. First, the uniform signals virtue and honor, and is a means for protection of the nurse. Second, the uniform functions as a way to control the nurse; because you can identify her, it is feasible to exercise control. What is in need of control? It is close at hand to interpret this in terms of control of sexuality—a matter I will return to. But apart from this, a generally ascetic ideal is expressed in pronouncements concerning the uniform. What is the function of this ideal? An inkling of the answer

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to this can be found in Peterson's formulation: "If the nurse carries her simple and undistorted uniform untouched by vanity and allurements from fashion, you will realize the serious and devoted feeling she has for her calling."26 The uniform is seen as a token of the devotion the nurse has for her task. Thus one may draw the conclusion that the simplicity of the uniform symbolizes the trustworthiness of the nurse. The uniform is a mark of the nurse's morality. This idea—that simplicity and a capacity to renounce are an expression of morality—was, and still is, widespread. Within a Christian context it has, for instance, been expressed in the monastic system as a means to strengthen the power of the spirit and to promote the will of God, but also as a way for man to reach blessedness. Since the Protestant doctrine of faith rests on the axiom that man's salvation is dependent on the grace of God and that man is justified by faith only, the idea's ascetic expressions take other forms—for example, encouraging submission to the sufferings that God lays upon man, and promoting the idea of selfmastery as a quality seen as a necessity for man to carry out his calling on earth. Nurses seem to have borrowed ascetic elements from both the Roman Catholic and the Protestant tradition to imbue their profession with an air of moral trustworthiness—and thus status. Another important aspect of the uniform is its implication for relations with groups in similar occupations. The style of the nurses' working clothes was a way to draw a line against other occupational groups, and it served as a way to exclude others. In Sweden, the line was mainly drawn between nurses from different schools and against nurses' aides and nannies. This can be interpreted as part of the process of professionalization, in terms of social closure. The tactic is used to convey for the profession an air of exclusiveness, with an intention to establish monopoly on the labor market.27 A somewhat peculiar element in the Swedish nurses' preoccupation with the need to be strict in dressing was their awareness of how nurses from other countries handled the uniform. From time to time, a more or less open critique was directed toward the nursing corps of other countries. For instance, in 1910 a nurse reported in the Swedish Nurses Magazine on a memorial ceremony on behalf of Florence Nightingale's death. She wrote that, despite the sanctity and solemnity during the ceremony, she could not help noting the lack of conformity and the manifoldness in the British nurses' uniforms. There are, she wrote in a disapproving way, uniforms in all kinds of colors and styles.28 In an another article, also observing British nurses, the writer noted an advertisement for a big festivity for nurses in London at which they were going to dress up as queens, saints, etc., and walk in procession to plead for state registration. Disregarding the fact that the Swedish

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Nurses Association did not sympathize with the effort to obtain state registration, the writing nurse wondered if this pretentious entertainment really was worthy of a nursing corps: "Does not this shallow and pretentious festivity stand out against the nature of our work?" She closed by commenting that signs of shallowness and vanity seem unnatural and insensitive when visible in a nurse.29 This expectant attitude is seen not only in discussions, but also in actual action. In a photograph from the International Council of Nurses conference in Montreal in 1929, Elisabet Lind, member of the board of the SNA, and another Nordic nurse are surrounded by nurses from other countries. Lind and her Finnish colleague are the only nurses dressed in uniforms—all the others are wearing evening dresses. One may regard the strict use of uniforms and the discussions of "the others" as means to create an identity within the corps, of both professional and national character, but these uses of the uniform can also be interpreted as expressions of a religious pietistic heritage.30

Hierarchy and Lutheran Ideas Within the hospital organization, the nurse was viewed as superior to the attendants and subordinate to the doctors. In reality, the nurse was involved in many different ranking orders, including those existing between nurses from different institutions of education and different hospitals, as well as hierarchies built on differences in class background. In Sweden, nurses from the provinces usually came from the lower parts of the social ladder.31 As professionals, however, they were put in the middle between doctors and attendants. The subordinate position in relation to doctors seems to have been obvious, while the superior position relative to the subordinate female hospital staff seems to have been more problematic. According to the nurses, there was one important difference between themselves and the subordinate hospital staff, which was that the attendants did not have a calling. The subordinate staff was said to be mainly interested in wages, vacations, and reduction in working hours, while this was, of course, not the case with the nurses.32 An underlying idea here is evidently connected to Christian ways of thought on social hierarchies. When opinions on equality were presented, the notion that "we are all equal in front of God" prevailed. When hierarchies were debated, however, nurses tended to rely on St. Paul, preferably in his first Corinthian letter, in which he says that God has put us in a social position and given each and every one of us a task, and that we all should live in accordance with that.

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Hierarchical features in the Lutheran ethic of labor are also present in this context. In an article in the Swedish Nurses Magazine, the chairman of the board of the Swedish Nurses Association, Bertha Wellin, expressed her opinion on this issue using openly Lutheran modes of expression. Wellin argued that some people are suited to be nurses, while others will do well for the sick from a more subordinate position. And, she said, it is best if each of us is placed in a position that is suitable and from which we can be of use. The important thing is not what kind of work we perform, but how it is performed. The simplest work can be done so that it commands respect. Consciousness of the fact that you have done your duties faithfully and have made, perhaps, a small but useful contribution in life brings pleasure in one's work and satisfaction in one's mission in life.33 Wellin's comments were in accord with the Lutheran ethic of labor, which says that a person of morality is one who performs every task with accuracy and diligence—it does not matter if the person is only a simple maid. The pleasure in work is presented as the primary reward in man's life.34 Taking notions from the military sphere is another way to sustain hierarchies. From time to time nurses used military metaphors when discussing their hierarchical relation to the attendants. The nurses, for instance, compared themselves with officers, while the attendants were named as noncommissioned officers.35 The military metaphor is, moreover, associated not only with ideas on hierarchies, but also with ideas on gender.

Gender and the Use of Military Metaphors Now let us look more closely at the military metaphor and its connections to the issue of gender. I have already mentioned the identification with the military sphere seen with the uniform. Military associations were also very common in the obituaries in the Swedish Nurses Magazine, which often cited an accumulation of the qualities the ideal nurse possessed. Sometimes the qualities were associated implicitly with femininity, and sometimes implicitly with masculinity. In the enumeration of all the good qualities in a nurse, the most common adjectives associated with the "feminine" were: compassionate, sympathetic, joyful, warmhearted, sweet, delicate, and loveable.36 All of these concepts are, of course, possible to associate with the Lutheran idea of the specific calling of woman as mother and wife. In my opinion, however, Lutheran ideas on gender are in the background here and not at all as present as they were with the deaconesses. I would even suggest that,

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in the case of the nurses, concepts associated with masculinity were just as prominent as concepts associated with femininity. These masculine concepts were preferably presented in the shape of military metaphors, using words such as sense of duty, faithfulness, self-restraint, and spirit of self-sacrifice. In obituaries from 1909 and 1918 (during 1918 Sweden was severely ravaged by the Spanish flu), nurses were described as self-sacrificing and inexhaustible. It was said about one of them that she faced the most dangerous battle as a good soldier and that she was killed at her post as a hero.37 How are this example and others with similar content to be understood? Why is it that the military became a comparative group or model for the nurses? There are several possible explanations. One has to do with nursing's intimate historical connection with medical care during wartime in the nineteenth century.38 The rise of the Red Cross and its contribution to the education of nurses is one example. Of course, the influence of stories about Florence Nightingale is very important. The image of her successful actions in the Crimean War includes a woman's war against filth and languid, inefficient commanding officers as well as notions of tender carethe saving angel.39 The nurse as a war hero finds an obvious icon in Nightingale; the military ideal is thus embedded in the history of this occupation. But in my opinion the military metaphor contains more than this. For one thing, it implies a more complex connection with gender than you might expect concerning nurses. The military ideal calls into question the idea of the nurse as synonymous with a totally subordinate and obedient woman in the traditional sense. It is plausible, I think, to imagine that the modern hospital organization in the beginning of the twentieth century demanded a firm hand and resolute action from the nurses in their intermediate position. Probably demands within a changing society, and a changing hospital world, interacted with changing feminine ideals. At the time, however, there were no obvious role models for the nurses to adopt. Firmness and decisiveness were still considered to be male characteristics. The nurses' use of masculine ideals, expressed in military metaphors, to add the needed characteristics to the profession in growth may therefore not be so odd. But are there other genderrelated aspects in this matter? Let us yet again return to Sally Peterson as she makes connections both to nuns who have renounced all vanity, and, of course sexuality, a topic not mentioned by Peterson at all, and to soldiers who always wear uniforms. Behind these connections may be found ideas on sexuality as problematic and, with a different professional ideal, "made male." The expression "made male"—or, "make male"—represents an idea, or myth, of the possibility for women to transcend the borders of gender. In Western culture, it has its roots in Christianity. 40 This idea is found in documents from early ascetic

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Christianity and in records from closely related doctrines of faith, as, for instance, Gnosticism. The most famous example of making woman male is from the Gnostic-inspired apocryphal Gospel of Thomas, in which the possibility for woman to enter the kingdom of heaven is associated with a transformation of her into a man.41 In stories on female Christian martyrs, the same notion is present. For instance, the female martyr Perpetua before her execution has visions of herself made male in the final, spiritual battle. She, as a result of this, comes closer to the kingdom of heaven. The victory is described as the "undressing" of a female identity.42 What functions did these ideas have within the Christian culture? I suggest that there are two. First, the notion of making woman male probably made it possible to imbue the notion of woman with an idea of transcendence. It might be seen as an expression of the ambiguity before the persistent identification of women with biology and reproduction. Second, making woman male has not just been a notion, but from time to time through history has been made concrete in masculine styles of dressing. This outward transformation has probably made it possible for women to enter the public sphere, but at the price of denial of their sexuality and reproductive capacity. What had been seen as woman's assets in the private sphere, her sexuality and reproductive capacity, in the public sphere were considered a problem.43 Even the concept of a "public woman" has been problematic, as it has been associated with being a prostitute.44 This was the case at the turn of the century. The nurses' use of military metaphors, of ascetic ideals, and of an almost masculine style of dressing might therefore be analyzed as one way to handle the problematic conception of being a public woman. This phenomenon did not become less problematic in light of the fact that nurses got very close to men's bodies in the hospital wards.45 Hence the different male-making strategies I have pointed to can be interpreted as a sort of defensive tactic, but can also be viewed as a professional offensive strategy. One may analyze this phenomenon in terms of gender, using historian Joan Scott's analytic tool to understand history. According to this approach, gender is a fundamental element constituting social relations based on perceived differences between the sexes. Gender is, further, a way to denote relationships of power. In this "gender-shaping" process, concepts associated with the masculine are seen as superior to concepts associated with the feminine. 46 The nurses' readiness to adopt masculine metaphors may, in this light, be analyzed as part of a strategy of professionalization—as a way to arrange the professional ideal in accordance with the male norm, and in a sense gain authority through powerful, masculine metaphors and ideals. These two theses are not opposed to one another in any way. On the contrary, they are quite consistent.

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The Political Turning Point As noted earlier, avoidance of conflict was a distinguishing feature of the politics of the SNA. Beginning in the 1930s, however, growing tensions concerning differences in salaries between nurses from big city hospitals and nurses from small countryside hospitals eventually did cause conflict. The rejection of discussions about wages was finally called into question and a threatening split of the nurses within the SNA was at hand. But the split never took place because, in the end, most of the leading nurses shifted opinion. Furthermore, the already more or less abandoned Motherhouse organizations approved of the SNA's taking over responsibility for nurses' terms of employment. At the SNA annual meeting in 1933, the charismatic and politically conservative chairman of the board, Bertha Wellin, seemed to be the only one among the leading nurses in favor of the "old" model. When she realized that the old ideals no longer were desirable, Wellin left the meeting in a rather restrained and dramatic way. She blessed those present, picked up a hymnal, laid down the chairman's gavel, and walked out of the room.4^ To sum up, the leading nurses in Sweden showed an interesting mixture of old Christian notions and awareness of the demands of a modern profession. I argue that one cannot dismiss the importance the nurses placed on the vocational aspects of their profession, expressed in different symbols; they were not just meaningless remnants of the past. On the contrary, in the case of the Swedish nurses, it rather seems as if their proclamation of the calling was used as a tool in the process of professionalization. The strategy was quite successful. The SNA received comparatively good support from Swedish government authorities. 48 For instance, in the end, the authorities supported the Swedish Nurses Association, rather than the Swedish Medical Association, when it came to questions about length of training and conditions of employment. In 1920, the government set a nursing education requirement at a minimum of 2 years. A special post was created for a nursing inspectress, with the goal of controlling the standards of the educational institutions. 49 In 1929, doctors lost a lot of influence over the nurses' terms of employment. From then on, a doctor could no longer discharge "his own" nurse. so Consequently, by 1929 the SNA had reached most of the professional goals that it had established in 1910. It appears that the strategy of avoiding politics and proclaiming the calling was of help rather than hindrance in the professionalization of the Swedish nurses, at least to a point. As time went by, the decisions made at the 1933 annual meeting meant an end to openly expressed, traditional vocational ideals. During the 1930s the Swedish Nurses Association began to lose the characteristics of an elite organization, and started to take an interest in questions about

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wages and work conditions. But along with concern for the nurses' economic and social conditions the SNA still, for many years, continued to plead for an altruistically shaped work ethic. Thenceforward the hierarchies inside the nursing corps gradually were toned down. The differentiated status of the educational institutions eventually became of no importance when it came to training, work conditions, and wages. This process did not relate only to changes in the strategy of professionalization of the SNA. Rather, these changes can be seen as part of the rise of the Swedish welfare state model, and general change in ideas of democracy and equality in society.

ASA ANDERSSON Department of Historical Studies/History of Ideas Umea University 5-901 87 Umet Sweden

Notes 1. Svensk sjukskotersketidning, 72-75. 2. Anne Marie Rafferty, The Politics of Nursing Knowledge (London and New York: 1996), 1. The emphasis on morale in the nursing profession is discussed in several works on nursing history, such as Susan M. Reverby, Ordered to Care: The Dilemma of American Nursing, 1850-1945 (Cambridge: 1987). 3. See, for instance, Randall Collins, "Market Closure and Conflict Theory of the Professions," in Professions in Theory and History: Rethinking the Study of the Professions, eds. Michael Burrage and Rolf Torstendahl (London, Newbury Park, New Delhi: 1990), 36. 4. Carl-Henrik Grenholm, Arhetets mening: En analys av sex teorier om arbetets syfte och varde (The Meaning of Labor: An Analysis of Six Theories on the Meaning and Value of Labor}. (Uppsala: 1988), 153-54. 5. Gustaf Wingren, Luthers lara om kallelsen (The Christian's Calling: Luther on Vocation). (Skelleftea: 1993), 18. 6. Martin Luther, Doktor Marten Luthers Lilla katekes [1529] (Small Catechism). (Stockholm: 1876), 99. 7. Inger Hammar, Emancipation och religion: Den svenska kvinnororeIsenspionjdrer i debatt om kvinnans kallelse ca 1860—1900 (Emancipation and Religion: The Pioneers of the Swedish Women's Rights Movement Debating Issues on the Calling of Women, 1860—1900). (Stockholm: 1999). 8. Gunnel Elmund, Den kvinnliga diakonien i Sverige, 1849—1861 (Deaconess Activities in Sweden, 1849-1861). (Lund: 1973), 28, 98. 9. Belysning och forklaring af "Stadgar for Diakonissorna vid Diakonissanstalten i Stockholm" (Regulations for Deaconesses). (Stockholm: probably 1870s).

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10. Katolska kyrkan i Sverige, 1783-1983: En historisk dterblick (The Catholic Church in Sweden, 1783-1983: A Historical Inquiry), eds. Alf Aberg, Barbro Lindqvist, and Lars Cavallin (Uppsala: 1983), 26; Yvonne Maria Werner, "Svenskhet och katolicism-ett komplicerat forhallande," i Signum. Katolsk orientering om kyrka, kultur och samhdlle ("The Swedish and the Catholic Belief-A Story of Complications," in Signum. Catholic Orientation on Church, Culture, and Society), 22 (1996): 251, 253. 11. John Nilsson, Drottningar och andra: En bok om Sophiahemmet (Queens and Others: A Book on the Sophia Home). (Uppsala: 1939), 142. 12. "Villkor for antagandet af clever och utbildandet af sjukskoterskor," i Redogorelse for Sophiahemmets verksamhet till och med, 1890 (The Sophia Home Annual Report, 1890). (Stockholm: 1891). 13. Eva Bohm, Okdnd, godkdnd, legitimerad: Svensk sjukskbterskeforenings fdrsta 50 dr (Unknown, Accepted, Registered: The First Fifty Years of the Swedish Nurses Association). (Stockholm: 1972), 31.

\4.IbuL, 43. 15. Ibid., 47; Agneta Emanuelsson, Pionjdrer i vitt: Professionella och fackliga strategier bland svenska sjukskoterskor och bitrdden, 1851—1939 (Pioneers in White: Professional and Trade Union Strategies Among Swedish Nurses and Nurses' Aides, 1851—1939). (Stockholm: 1991), 76. 16. Sandra Beth Lewenson, Taking Charge: Nursing, Suffrage, and Feminism in America, 1873-1920 (New York: 1996), 48; Reverby, Ordered to Care, 131-36: Rafferty, Politics, 42-59. 17. Emanuelsson, Pioneers in White, 79-81. 18. The prescribed ethic was formulated in, for example, Estrid Rodhe, Ur sjukvdrdens etik (On Nursing Ethics). (Stockholm: 1912), and Clara Wahlstrom, Anteckningar ur froken Clara Wahlstroms foreldsningar i etik. 22 november-17 december 1917 vid fortsdttningskursen (Notes on Ms. Clara Wahlstrom's lectures on ethics, 22 november-17 December 1917, at the SNA course (Stockholm: 1918).

19. SST(\926): 5. 20. SSr(1911): 92. 21. Martin Luther, Kyrkopostilla:Forklaringarna overdedrliga Son-ochhbgtidsdagarnas evangelier. Sommaravdelningen [1520s] (Collection of Sermons] (Skelleftea: 1987), 128. 22. Martin Luther, Om en kristen mdnniskas frihet [1520] (On the Freedom of a Christian) (Uppsala: 1917), 81. 23. The Greek concept agape is a fundamental motive in Christianity. Agape is an expression of a love characterized by a giving spirit rather than a demanding one. It marks God's way to man, and it awakens man's love for God and also man's benevolent love for his fellow being. Luther's contribution to further elaboration and development of the concept of agape is of considerable importance. Anders Nygren, Den kristna kdrlekstanken genom tiderna: Eros och Agape (The Notion of Christian Chanty Through History: Eros and Agape). (Stockholm: 1938-1947). 24. Rodhe, Nursing Ethics, 6. 25. Fbreldsningsmanuskript och diskussionsprotokoll 15/10, fortsattningskurs 1932, F6b vol. 3, SSF:s arkiv, TAM (manuscript from a talk and protocol from a discussion on the uniform at one of the continuation courses arranged by the SNA. Swedish Nurses Association archives at TAM, Stockholm).

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26. 557(1909): 75. 27. Christina Florin, Kampen om katedern: Feminiserings och professionaliseringsprocessen inom den svenska folkskolans lararkar, 1860—1906 (Who Should Sit in the Teacher's Chair? The Processes of Feminization and Professionalization Among Swedish Elemantary School Teachers, 1860-1906) (Umea: 1987): 76-77; Rolf Torstendahl, "Professionell och facklig strategi," i Fackliga organisationsstrategier ("Professional and Union Strategies," in Union Organizational Strategies), red. Anders Johansson (Solna: 1997), 40; Anne Witz, Profession and Patriarchy (London and New York: 1992), 40-42. 28. 557(1910): 180. 29. 557(1911): 56-57. 30. The Finnish nurse is probably the chairman of the board of one of the nurses' organizations in Finland, Emma Astrom. It is no coincidence that she, with Lind, is dressed in uniform in the Montreal picture. There appear to be many similarities regarding the uses of uniforms in the Nordic countries. 31. Emanuelsson, Pioneers in White, 41, 44. 32. SST (1910): 186-87, and "Personalfragan, den underordnade personalen," foredrag vid Fortsattningskurs, 1922, SSF:s arkiv, TAM (manuscript from a talk given at an SNA continuation course in 1922: "The subordinate hospital staff." SNA archives, TAM, Stockholm). 33. 557(1910): 80-81. 34. Martin Luther, Den stora katekesen [1529] (Large Catechism) (Stockholm: 1931), 68, 115. 35. Diskussionsprotokoll 28/2, fortsattningskurs 1922, SSF:s arkiv, TAM (record, SNA continuation course, 1922. SNA archives, TAM, Stockholm). 36. 557(1909): 106, 121, and (1918): 268.

37. 557(1909): 121, and (1918): 268. 38. Olof Cronenberg, Roda Korset (The Red Cross). (Umea: 1985), 14, 134-154; Reverby, Ordered to Care, 43-57. 39. Mary Poovey, Uneven Developments: The Ideological Work of Gender in MidVictorian England (Chicago: 1988), especially 167-70. Mary Poovey is discussing the gender aspect in terms of a militaristic side of a basically domestic ideal. This is also discussed in Reverby, Ordered to Care, 43. 40. Anna-Lydia Svalastog, Det var ikke meningen . . . Om konstruksjon av kj0nn ved abortingrep, et feministteoretiskt bidrag ("I Didn't Know . . . ": Induced Abortion and the Process of Gender Construction: A Theoretical Contribution] (Uppsala: 1998), 68. 41. Elisabeth Castelli, " 'I Will Make Mary Male': Pieties of the Body and Gender Transformation of Christian Women in Late Antiquity," in Body Guards: The Cultural Politics of Gender Ambiguity, eds. Julia Epstein and Kristina Straub (New York and London: 1991), 30; Kari Vogt, " 'Becoming Male': A Gnostic and Early Christian Metaphor," in The Image of God: Gender Models in Judeo-Christian Tradition, ed. Kari Elisabeth B0rresen (Oslo: 1995), 170. It is noteworthy that the notion of transcending gender borders is current in many religions. 42. Castelli, " 'I Will Make Mary Male,' " 42. 43. Svalastog, "I Didn't Know," 6%. 44. Hammar, Emancipation and Religion, 11. 45. This is pointed out, for example, in Poovey, Ideological Work of Gender, 177.

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46. Joan Scott, Gender and the Politics of History (New York: 1999), 42. 47. Bohm, First Fifty Years, 181. 48. A comparative study has shown that they were successful from an international perspective, in terms of a quick accommodation and support from the Swedish government. Agneta Emanuelsson, "Den svenska distriktskoterskan: Kvinna eller fackman?" in Kvinnohistoriens nya utmaningar: Fran sexualitet till varldshistoria ("The Swedish District Nurse: Woman or Professional?" in New Challenges in Women's History). (Tampere: 1994). 49. Bohm, First Fifty Years, 102. It is noteworthy that the requirement of 2 years to a degree was a compromise from the side of the SNA, with the aim of avoiding conflict with the government. Within the realm of the Nordic Council of Nurses, they argued for an education of at least 3 years. This was already a reality at, for instance, the Sophia Home. Nete Balslev Wingender, Fern svaner iflok: Sykeplejerskers Samarbejde i Norden, 1920—1995 (Five Swans in a Flock: Nordic Council of Nurses, 1920-1995} (Aarhus: 1995), 13. 50. Bohm, First Fifty Years, 111.

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The Wind of Change is Blowing SUSAN McGANN Royal College of Nursing of the United Kingdom

In 1945 Anna Schwarzenberg, executive secretary of the International Council of Nurses, visited the various countries of Europe to assess the problems of the nursing profession following the war. Of her visit to England, she wrote, "Nursing has made great strides during the years of the war. A younger, more alert group is coming to the fore. . . . If the older nurses could realize that the times are so changed that they require the farsighted, vigorous outlook toward the future that only younger people can have, and if they, the older generation, could generously step aside and enjoy a well-earned retreat, nursing could go forward unhampered and in the right direction." 1

In the aftermath of the Second World War, great social changes swept through British society. Schwarzenberg was expressing the hope of many nurses in Britain at that time that the long tradition of animosity between the two main professional nursing organizations in Britain, the National Council of Nurses and the Royal College of Nursing, could be put behind them and that one unified organization could emerge to represent British nurses nationally and internationally. However, the process of change was notoriously slow in British nursing and, before unification could be realized, the last round in "the battle of the nurses" had to be played out. The "battle of the nurses" was the campaign for state registration, which in Britain lasted from 1888 to 1919. The campaign was led by Mrs. Bedford Fenwick, who was passionate about the rights of nurses and dedicated her life to achieving and defending their professional independence. Mrs. Fenwick had a profound effect on the development of professional nursing organizations in Britain, not just because she lived to the age of 90 and founded half a dozen organizations, but because she was a colorful, charismatic leader who could inspire great loyalty in her followers while alienating most rational people. Over the years, Mrs. Fenwick's opinions hardened into dogma and she became an autocratic leader. Her most Nursing History Review 10 (2002): 21-32. A publication of the American Association for the History of Nursing. Copyright © 2002 Springer Publishing Company.

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powerful weapon was the British Journal of Nursing, which she took over and edited from 1902 until her death in 1947.2

National Council of Nurses The origins of the National Council of Nurses (NCN) lie in the founding of the International Council of Nurses (ICN) in 1899 by Mrs. Fenwick and her fellow champions of nurses' rights. The ICN was to be a federation of national nurses' associations, and the constitution stated that only one association of nurses from each country could join. At first, such national associations did not exist, and it was part of Mrs. Fenwick's plan that the ICN would encourage nurses all over the world to develop professional organizations. Before British nurses could affiliate with the ICN, they needed a national association. Mrs. Fenwick's great friend and ally was Isla Stewart, Matron of St. Bartholomew's Hospital, London. They shared a vision of nursing as an independent profession for women, and emulated American nurses' professional organizations known as alumnae associations, through which the graduate nurses of a training school formed an association. In 1899 Miss Stewart formed an association for the nurses who had trained at St. Bartholomew's Hospital, called the League of St. Bartholomew's Hospital Trained Nurses; this was the first nurses' league in Britain. Over the next 25 years, many other hospital training schools formed nurses' leagues, and these played an important role in the early development of professional awareness and organization among British nurses. The leagues became the backbone of Mrs. Fenwick's various organizations, particularly the National Council of Trained Nurses of Great Britain and Ireland, which she founded as a federation in 1904 to enable British nurses to affiliate with the ICN.

College of Nursing When the First World War started in 1914, the British Red Cross Society appointed Sarah Swift, a former matron of Guy's Hospital, London, to be their Matron-in-Chief. Miss Swift was regarded as an elder statesman of the nursing profession, and during her long career had made many contacts and friends in influential places. She had not been directly involved in the state registration

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campaign but had done much to improve the standard of nurse education at Guy's and, like many of her contemporaries, believed that trained nurses should have a professional register. They did not share Mrs. Fenwick's conviction that it had to be a statutory register, and did not approve of her uncompromising style and aggressive tactics.3 By 1915, Miss Swift's experience with the Red Cross had convinced her that nurses themselves must take the initiative before the war ended. As Matron-inChief, she was responsible for the deployment of the thousands of nurses and untrained women who volunteered to nurse the wounded. The lack of any recognized standard among the nurse training schools meant that being a "trained" nurse could mean anything, and untrained women who had volunteered to nurse, known as VADs (members of Voluntary Aid Detachments), were regarded by the War Office and the public as the same as trained nurses. Miss Swift decided that nurses needed a College of Nursing that would establish a uniform standard of education, examination, and certification for nurses. Her proposal gained widespread support and she was able to draw on the support of many influential people, most noticeably Sir Arthur Stanley, Chairman of the British Red Cross Society and Treasurer of St. Thomas's Hospital, and Sir Cooper Perry, the Medical Superintendent of Guy's Hospital. The College of Nursing was established in April 1916 and these two gentlemen, who were pillars of the medical and social establishment in London, became the Chairman and Honorary Secretary of the College, serving for many years. Despite the fact that the war had dispersed nurses all over Europe, they applied for membership in the College in the thousands. Before the war, some of the strongest opposition to state registration had come from the matrons of the large training schools, but now they were prepared to give their support to the College of Nursing and took their place on the council alongside representatives of the army and navy nursing services, poor law nursing, district nursing, and private nursing. The success of the College also depended on its ability to attract support from the campaign for state registration. Despite Mrs. Fenwick's total opposition, a sufficient number of key persons within the campaign party were convinced that the College offered an opportunity to unite the profession and crossed over, bringing with them much support from the state registration lobby. Genuine efforts were made to negotiate with Mrs. Fenwick, but she could not accept the involvement of non-nurses on the council of the College, such as members of the medical profession and hospital governors. She believed that nurses' professional organizations should be governed by nurses, and described the College as a scheme for the government of nurses by their employers. As a result, the National Council of Nurses, of which she was president, was totally opposed to the College.4

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In the aftermath of the war the British government passed the Nurses' Registration Acts, setting up three statutory bodies known as General Nursing Councils, which became responsible for the registration of nurses in England and Wales, Scotland, and Ireland. Mrs. Fenwick was appointed the first Registrar of the General Nursing Council for England and Wales, in recognition of her leading role in the campaign, but her uncompromising behavior forced the resignation of the chairman and the rest of the Council. When the first elections were held in 1922 she was not elected, and the College of Nursing's candidates formed a majority on the General Nursing Council. While Mrs. Fenwick became increasingly cut off from the mainstream of nursing politics, the College of Nursing was going from strength to strength. In the 10 years since its founding, its membership had grown to 25,000 and it had 35 branches, scholarships, postgraduate education, and a library of nursing, as well as sick insurance, convalescent homes, and a pension plan. The College consolidated its position by acquiring a prestigious headquarters building in London, which was a gift from Lady Cowdray to the nursing profession, and in 1928 it was granted a royal charter in recognition of its educational, professional and welfare work for nurses. However, Mrs. Fenwick remained president of the International Council of Nurses and of the National Council of Nurses of Great Britain, and as long as she was president the NCN remained antagonistic to the College of Nursing. She was extremely angry to discover that the College had approached the ICN to see if they could affiliate directly without going through the NCN.5 The ICN was keen for the College to be represented, because it was the largest organization of nurses in Britain, but the constitution of the ICN restricted each country to one member organization and the only way for the members of the College to be represented at the ICN was by affiliation with the National Council of Nurses of Great Britain. So, in 1925 the College affiliated with the NCN. The College was never happy within the NCN; the seats on the Grand Council were not allocated on a proportional representational basis, and although the membership of the College greatly exceeded the combined membership of all the other affiliated associations, by as much as 20,000, the College was restricted to eight representatives and was thus easily outvoted. A second problem was the hospital leagues, which by 1939 numbered 34 of the 51 affiliated organizations. Originally, in 1900, Isla Stewart and Mrs. Fenwick had intended the leagues to be professional associations, but by the 1930s their main function had become social. The supporters of the College argued that the leagues were not democratic, did not represent the professional opinion of nurses, and should not be in a position to outvote professional organizations like the College on the Grand Council of the NCN. To some extent the NCN had become the voice of those nurses who were outside the College, and there were quite a few groups outside the College. The

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constitution of the College stated that only general trained female nurses could be members, which excluded all male nurses and all specialist trained nurses, such as fever nurses, sick children's nurses, and nurses for the mentally ill and the mentally handicapped. The logic behind this position was embedded in the politics of 1916 when the College was founded. The need at that time was to adopt a minimum standard of 3 years of general training as the definition of a trained nurse and therefore the minimum qualification for membership in the College. When state registration was introduced in 1919, however, the British government did not accept this definition of a trained nurse; it established a General Register for nurses with 3 years of general training, and five separate registers for male nurses, fever nurses, sick children's nurses, and nurses for the mentally ill and the mentally handicapped, all of whom, with the exception of male nurses, had a 2-year training. This meant that there were many registered nurses who did not qualify for membership in the College of Nursing, and these nurses formed smaller professional associations, such as the Fever Nurses' Association, the Society of Mental Nurses, and the Association of Sick Children's Hospital Nurses. These came together with the leagues in the Grand Council of the NCN. During the Second World War, the NCN ceased to function and the Royal College of Nursing, as the largest organization, took on the international side of its work. It is fair to say that the College had a good war. Its membership grew from 29,000 in 1938 to 38,000 in 1945, and its prestige grew as increasingly it was consulted for nursing opinion. During the decade 1939—1948 the nursing profession in Britain received unprecedented government attention, first due to the importance of the distribution and recruitment of nurses during the war, and then as part of the preparation for the introduction of the National Health Service. Several committees and working parties were set up to report on different aspects of nursing and the College was increasingly recognized as the most representative organization. When the National Health Service was introduced in 1948, the government set up a permanent negotiating framework for the different groups within the service; on the nurses and midwives council the College was awarded a majority of the seats on the staff side, which provided public recognition of its position as the largest membership organization within the profession.6

Post-Second World War The NCN reemerged at the end of 1945 with a new constitution, drawn up without consulting the affiliated associations. The College of Nursing, now entitled to use

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the prefix Royal, was not happy with the new constitution, which it considered inequitable and obsolete and which suggested that the NCN was the representative organization of British nurses at both national and international levels. The general feeling of College members was that the whole professional situation should have been reviewed before the National Council of Nurses was revived. Some of the branches of the College felt very strongly that the College, with its large representative membership, its educational and professional policy, its national and international contacts, and its established public position, should become the national body.7 The same two areas of the new constitution as under the old concerned the membership of the College; these were representation—the allocation of seats on the Grand Council-—and finance—the fees payable by the affiliated associations. In the past, the NCN had not been self-supporting but was maintained by the benevolence of its founder, Mrs. Bedford Fenwick. It was estimated that it needed an annual income of approximately £5,000, while current income was approximately £1,600 derived from a per capita fee of 8 shillings. The NCN agreed to send a questionnaire to its member associations seeking their opinion on these points. In replying to the questionnaire, the College proposed that the NCN arrange for an independent study to be made of the nursing organizations in the country, similar to those recently carried out for the American Nurses' Association and for the Florence Nightingale International Foundation, to determine what should be "the proper functions of the organisations and how far they fulfil that function and also to make suggestions as to what would be the most suitable channel through which British nurses might be represented in the International Council of Nurses without duplication of representation and over-complicated administration."8 However, when the Grand Council of the NCN met in May 1948 to consider the replies to the questionnaire, the College's proposal for an independent survey was rejected. It was agreed to set up a Constitution Subcommittee to consider the constitution and how it might be revised. The following year, 1949, the NCN adopted a revised plan for the number of delegates allowed to each member association and the fees payable. This new plan did little to address the concerns of the College. The majority, 43, of the 53 associations affiliated with the NCN had a membership of less than 500; they were allowed from one to four delegates per association, and there was a sliding scale of rates per delegate—the more delegates to which the association was entitled, the higher the fee per delegate. Of the remaining ten associations, nine had a membership of between 1,000 and 2,000 members, and then there was the College, which had a membership of more than 40,000. The smallest association, with less than one hundred members, was entitled to one delegate and paid a fee of £15.0.0; the largest organization, the

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College, was entitled to twelve delegates and paid £50.0.0 per delegate. Although the College had to pay a per capita fee based on its total membership, it had only twelve delegates on the Grand Council and could still be outvoted by the other 168 delegates. The College argued that this created an anomalous position whereby an organization of national influence representing nurses' interest at the highest level and representative of 46,000 was outvoted by the representatives of associations and leagues, none of which had an individual membership of more than 2,000 and the majority not more than 500, and which were not policy making and had no actual influence on the government of the nursing profession.9 The NCN defended its plan by pointing out that, if the delegates were allocated on a proportional representational basis, the College would have a clear majority of delegates and this would reduce the NCN to a shadow of the College, thus making it redundant. The College had to decide whether to continue affiliation despite disagreement on the constitution, or to withdraw before the revised constitution came into effect on 1 September 1949. In July 1949, at the annual meeting of the Branches of the College, the members were in the mood for withdrawal from the NCN, "not with the wish to take the place of the NCN, but ready to associate with one whose constitution did not interfere with the place and work of the College."10 When the resolution "that the Royal College of Nursing discontinue its affiliation" was put to the vote, it was carried by a vote of 76 branches in favor, 17 against, and 15 abstentions.11 The Chairman of the College Council, Mrs. Woodman, wrote in a personal letter to the President of the NCN, Miss Armstrong, in September 1949: "I have felt it my duty in representing nurses to strive for harmonious relationship and unity within the profession, but after several years of real effort I find the position which exists between representatives of the Royal College of Nursing and the National Council of Nurses is such that it is almost impossible to act with good and balanced judgement as an Honorary Officer of both organisations. Many individual remarks are made which are not intended to create better feeling or understanding, and particularly recent articles which have been published and posted around show a complete lack of appreciation of the real difficulties and have an undercurrent of vindictiveness quite unworthy of the profession. . . ."ll

She was referring to the recent editorial in the British Journal of Nursing which stated that many would "rejoice at the proposed action of the Royal College of Nursing" and accused the College of "hankering after autocracy."13 Although Mrs. Fenwick had died, the new editor continued her practice of interpreting the actions of the College in the worst possible light. The Council of the College was more conciliatory in its approach and decided that, in view of the negotiations then in progress between the two organizations,

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no action concerning the withdrawal of the College from membership should be taken until the work of the NCN's Constitution Subcommittee had been concluded. The position of the College was that it regarded the structure and management of the NCN as obsolete and inequitable, and it was concerned that British nursing opinion was not adequately represented at an international level. Instances had occurred when British delegates had been omitted from the arrangements or when the basis of their representation had been criticized.14 On the other hand, the NCN believed that the College wanted to usurp its position.15 The negotiations continued over the next 5 years with little progress. Eventually, in 1955, the NCN agreed that an impartial and objective study should be made of the structure, functions, and aims of all the professional nursing organizations in Great Britain and Northern Ireland "with a view to determining the best and most economic method of co-ordinating these bodies into a single national body."16

Wind of Change Although Mrs. Fenwick had died in 1947 and the older generation of nursing leaders had left the scene by 1950, the weight of tradition seemed to make change almost impossible and the independent survey, which had first been proposed by the College in 1946, was never carried out. The distrust between the two organizations came to a head over the ICN Congress in Rome in 1957. The College delegates who attended the Congress were very unhappy with the way the NCN delegates had voted on professional policy issues. In a letter to the NCN the College wrote: "Council is anxious to give every possible support to the Board of Directors in its efforts to reconstruct the National Council in such a way that unity within the nursing profession may be achieved and that, in the future, the opinion and policy of the nursing profession of Great Britain and Northern Ireland may be presented with strength and authority at an international level."17

The timing of these developments was probably not unconnected to the arrival of Florence Udell and Mabel Lawson into positions in which they were able to influence the relationship between the two organizations. They were both involved in the work of the ICN and had travelled extensively as nursing advisers. Miss Lawson, who was elected President of the National Council of Nurses in 1957, had qualified as a doctor in 1916 and had worked as a general practitioner before training as a nurse at St. Thomas's Hospital in the 1920s. She had been Deputy Chief Nursing Officer at the Ministry of Health for 16 years, and after the war was

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seconded to Germany to help reestablish the German nursing service. Florence Udell was a public health nurse who had joined the staff of the College of Nursing in 1931; in 1944 she was appointed Chief Nurse in the Health Division of the European Regional Office of UNRRA, the United Nations Relief and Rehabilitation Administration, and later she served as Chief Nursing Officer at the Colonial Office and then Nursing Adviser at the Ministry of Overseas Development. Miss Udell was chair of the College working party set up in 1958 to consider whether the College should open its membership to all registered nurses, male and female, general and specialist. The recommendations of this group to extend the membership were accepted by the members of the College and the necessary alterations to the charter were given royal approval in I960. This meant that the constitution of the Royal College of Nursing was now in line with the requirements of the ICN; previously, the noneligibility of certain categories of nurses had been contrary to ICN rules for its affiliated associations. At the same time, the negotiations about the future of the NCN's constitution entered a new phase; the Constitution Subcommittee was dissolved and replaced by a "Standing Committee to consider the Constitution." At the new committee's inaugural meeting in October 1958, Miss Lawson, who was the chairperson, said the committee should disregard the existing structure of the professional organizations and consider the subject from a completely new and unbiased approach.18 On the College side, Miss Udell was appointed to the small working group set up to negotiate with the NCN. At the first joint meeting, held in March 1959, the NCN put forward a plan for the separation of the professional and educational functions of the College; the College would become responsible solely for the postbasic training of the nurse, while a newly constituted professional body would continue the remaining functions of the College and the NCN. This new professional body would be called the National Association of Nurses.19 The representatives of the College could not accept this plan; they did not agree that it would be in the interests of the profession to make fundamental changes to the College as at present constituted. They believed that the College held a position of respect and authority built up over long years of hard work and impressive progress and that this was reflected in its royal charter, which gave it a privileged status and special dignity. If the constitution or the title of the College were altered they would have to surrender the royal charter, and there was no guarantee that the new body would be granted a new charter. They also believed that having the educational and professional activities carried out by one organization was very successful. By 1960 the discussions had reached a point at which everyone was in favor of one unified professional body, and a small group with four representatives of the

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NCN Constitution Standing Committee and four of the College was set up to negotiate. The negotiations over the constitution and title of the unified body continued for another three years. The proposed amalgamation was between one body constituted under a royal charter and another body that was unincorporated, with no legal entity of its own. To create an entirely new body would involve the dissolution of the two existing bodies and the surrender of the royal charter, which the Privy Council, responsible for the protocol surrounding royal charters, was unlikely to accept.20 It was finally agreed that the royal charter of the College would form the basis of the new unified organization; from 1 January 1963 the Royal College of Nursing undertook the work of the National Council of Nurses, and set up an international department. The title of the new organization proved to be one of the most difficult areas of the negotiations. The NCN's negotiators considered that the name should be different from that of any existing organization, but the Privy Council advised that they should keep "Royal College of Nursing" in the title and make additions to that. Formal amalgamation took place in May 1963 with the grant of a supplemental charter. The new organization that would represent British nurses at both national and international levels took the title Royal College of Nursing and National Council of Nurses of the United Kingdom, The rather unwieldy title was to be reduced for everyday purposes to the symbol Ren, with upper case R, lower case en, which it was hoped would be regarded as a sign of the true integration of the two organizations. Mabel Lawson was elected the first president of the new unified body in 1963; she was succeeded by Florence Udell, who held the office from 1964 to 1966. Ten years later, in 1973, the title of the unified organization was changed to the Royal College of Nursing of the United Kingdom. This story about the power struggle for the position of representing British nurses at an international level illustrates how the events surrounding the campaign for state registration exerted an influence 40 years after the Nurses' Registration Acts were passed. I have called it the final round in the battle of the nurses, as it seems to me that this was unfinished business left over from the registration campaign. The negotiations between the NCN and the College should have taken place in the 1920s, when the latter had become the largest representative organization of nurses in Britain and was seeking a way to affiliate with the ICN. However, due to the personality of Mrs. Fenwick and her ability to command passionate loyalty from her supporters, negotiations were impossible. From these events it would seem that international recognition was important to the College. In the interwar years international activities were growing, particularly in the world of health, and several of the founding members and office holders of the College were involved in the League of Red Cross Societies and the League of Nations Health Organization.21 It would have been incompatible with their

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international standing if the organization that they had founded and in which they were involved had not been represented at the ICN. After the Second World War, when the membership of the College voted to secede from the ICN, the College policymakers were still not prepared to hand over the international role to what they considered to be inadequate representatives. There was a chilling echo in the final negotiations in 1957-1963, when the representatives of the Royal College of Nursing showed the same passionate loyalty to their organization that Mrs. Fenwick and her supporters had displayed in the years before the Second World War, and refused to compromise on the structure, purpose, or title of the College. SUSAN McGANN Archivist Royal College of Nursing of the United Kingdom, Archives 42 South Oswald Road Edinburgh, EH9 2HH Scotland, UK

Notes 1. Editorial, International Nursing Bulletin 11, no. 3 (July 1946). 2. Susan McGann, "Mrs Bedford Fenwick: A Restless Genius," in The Battle of the Nurses (London: Scutari Press, 1992), 35-57. 3. McGann, "Sarah Swift, A Supreme Organiser," Battle of the Nurses, 160-89. 4. Ethel G. Fenwick, "Government By Consent," British Journal of Nursing 56, no.1465 (29 April 1916): 385-86 (hereafter cited as BJN), and Beatrice Cutler, "The National Council of Trained Nurses and Registration," BJN 57, no.1496 (2 December 1916): 455-456. 5. Papers of the National Council of Nurses, NCN1A, 1923, and Records of the Royal College of Nursing, RCN5/1/N/32, both at Royal College of Nursing Archives (hereafter cited as RCN Archives). 6. RCN13/B/1. RCN Archives. 7. RCN5/1/N/20/8. RCN Archives. 8. RCN5/1/N/20/8, RCN Archives. 9. RCN5/1/N/20/8, March 1949. RCN Archives. 10. "Branch Representatives Meet in Cardiff," Nursing Times45 (9 July 1949): 554. 11. RCN5/1/N/20/8. RCN Archives. 12. RCN5/1/N/20/8, RCN Archives. 13. Editorial, "The Royal College of Nursing and the National Council of Nurses," BJN 97, no.2173 (August 1949): 75.

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14. RCN5/1/N/20/8, February 1951. RCN Archives. 15. Miss Armstrong, President NCN, to Miss Goodall, Secretary of Royal College of Nursing, 6 November 1948, RCN5/1/N/20/8. RCN Archives; "National Council of Nurses of Great Britain and Northern Ireland," BJN, no. 2168 (March 1949): 24-25. 16. NCN22/6, March-September 1955. RCN Archives. 17. NCN22/6, January 1958. RCN Archives. 18. NCN22/6, October 1958. RCN Archives. 19. NCN22/6, March 1959. RCN Archives. 20. NCN22/6, 1960. RCN Archives. 21. Arthur Stanley, Sarah Swift, Alicia Lloyd Still, Ellen Musson, and Cooper Perry.

The Beginning of Nursing in Brazil Brazilian Sanitarians and American Nurses

IEDA DE ALENCAR BARREIRA Anna Nery School of Nursing

This paper describes the circumstances under which modern nursing was introduced in early twentieth-century Brazil, in the city of Rio de Janeiro, then the country's capital. This change was supported by Brazilian public health and American nursing, within the 1920s' sanitary reform. These directives meant a disruption of the former health policy. The paper also analyzes the basis on which modern nursing education and practice began in Brazil, within the recently created National Department of Public Health (DNSP). This happened under political and ideological American influence and emphasized the role then assigned to the public health nurse. Finally, the formation and reproduction of this new agent in a nursing school is discussed.

Introduction Beginning early in this century, popular literature describing unhealthy living conditions in Brazil proliferated. The need for a public health movement became apparent as nationalist intellectuals took note and the conscience of sanitarians (public health advocates) was raised. They formed the Brazilian League ProSanitation. This association refuted several colonialist theses: the unfeasibility of a tropical civilization, the concept of tropical diseases (meaning climatic), and the country's backwardness due to the ethnic composition of the population and its miscegenation. They also criticized the urbanist approach to Brazilian public health, noting that nothing had been done regarding rural endemic diseases. The League proposed the creation of a ministry, or at least a national department, of public health or sanitation.1

Nursing History Review 10 (2002): 33-47. A publication of the American Association for the History of Nursing. Copyright © 2002 Springer Publishing Company.

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The ineffectiveness of the public health services became evident during the Spanish influenza epidemic, which arrived in Rio de Janeiro in September 1918. The influenza affected two-thirds of the population and killed 13,000 people in less than 2 months. The result was a political imperative for sanitary reform.2 The presidential succession (1919—22) was polarized between two northeastern candidates: Rui Barbosa and Epitacio Pessoa. The government's candidate, Epitacio Pessoa, won by supporting sanitation issues, an important part of the governmental platform. A favorable economic situation provided the opportunity for a great program of public works bound to important internal and external political commitments. Brazil began to negotiate credit with the United States, a country in competition with Great Britain for the position of international financial center. The president-elect created the National Department of Public Health (DNSP) and sent the Congress a message that granted the main requests of the sanitary movement.3 Carlos Chagas, who was quite famous in the international scientific sphere due to the discovery of the Chagas Disease (1908), succeeded Oswaldo Cruz as director of the Oswaldo Cruz Institute (1918—34). He was appointed general director of the DNSP (1920—34), led a sanitary reform, and initiated the cooperative program with the Rockefeller Foundation. As a result, more U.S. capital came into the country.4 The DNSP brought to public service young sanitarians who, now with influence on governmental decisions, ascended in politics and gave consistency to public health strategy, presenting it in the form of a combined technical and humanitarian discourse. Because they combined both ideological and scientific reputations, their proposals were less vulnerable to political pressures.5 The executive action taken by the federal health authorities in the states of the federation started with rural sanitation activities.6 The Brazilian political system at that time was based on the liberal principles predicated by the positivistic doctrine of noninterference of the federal government in the states' affairs—principles that therefore supported states' autonomy. Since the political power originated from rural oligarchies, there were no conditions for the establishment of a wide range of national health policies under the coordination of the State. Therefore, the DNSP confined its activities mainly to the country's capital area.7 The plan was to have specialized programs for each "disease" to be attacked and centralized command actions in the respective boards of inspectors.8 At the same time, new programs were created to address tuberculosis, Hansen's disease, venereal diseases, and child hygiene, favoring the participation of specialists. Penalties and coercion characterizing the sanitary police were incompatible with the democratic principles adopted after World War I, and were replaced with

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publicity and sanitary education.9 DNSP sanitarians followed the U.S. public health movement, receiving specialized training at the Johns Hopkins University (Baltimore, U.S.A.) and becoming acquainted with the role and responsibilities of the public health nurse. The idea of implementing public health nursing in Brazil arose in a modest way at the Bureau of Tuberculosis Prophylaxis through organization of a service of health visitors who would be trained in the tuberculosis dispensaries. Among the defenders of health visitors was J.P. Fontenelle. Based on his experience as a hygiene inspector visiting downtown tenement houses and during the Spanish influenza epidemic, he determined that this was not an appropriate service for medical doctors.10 Carlos Chagas asked the Rockefeller Foundation to organize a Service of Nursing at the National Department of Public Health (DNSP). Subsequently, a Mission for Technical Cooperation and Development of Nursing in Brazil was created, sponsored by the Rockefeller Foundation, in order to promote the innovations at the DNSP. Participating in the mission were 31 nurses, of whom 26 were from the United States and 5 from Europe.'' This was considered necessary to accomplish the Carlos Chagas Reform. The Mission remained in operation for a decade (1921-31).

The Parsons Mission and the Project A nurse from the United States, Ethel Parsons, was sent to Brazil by the Rockefeller Foundation to study the situation. She found out that there were no nursing schools in the country that met the minimum standards adopted in the "AngloSaxon countries" regarding the candidates' school level, course length, emphasis on theoretical contents, and restriction on working hours in the wards. Nurses were not trained to meet such standards and were in charge of untrained men and women. The doctors were found to be interested and conscientious, but the hospitals, although well-built, were always overcrowded. At the DNSP, the American nurse verified that the doctors who worked at the Bureaux of Tuberculosis, Child Hygiene, and Venereal Diseases had hired 44 young women who, after attending 12 lectures, started to work as health visitors. Parsons reported that the Brazilian doctors themselves recognized the limitations of this system, and she thought they wanted Brazilian nursing to reach the standards practiced by other great countries in the world. Indeed, since the number of persons attending the clinics had increased 50 percent in the 4 months after the visiting service had begun,

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doctors not only insisted that the service continue, but also planned to double the number of health visitors. Mrs. Parsons felt she had to train these health visitors, without interrupting her job, before any disaster caused by their ignorance destroyed people's trust in public health nursing. 12 In 1922, as the leader of the Rockefeller Foundation's nurse mission and as General Superintendent of the DNSP Nurse Service, Mrs. Parsons brought seven public health nurses from the United States to train and supervise the health visitors of the Bureaux of Tuberculosis, Child Hygiene, and Venereal Diseases. Although Ethel Parsons recognized from the very beginning the need to adapt the U.S. conception of public health nursing to local conditions, she believed there were a few fundamental principles that were indispensable to every organization offering sick people capable nursing care.13 Such principles were based on the Nightingale system and the hospital and public health nursing practice developed in the United States.14 From the 1870s into the first decade of the twentieth century, the growth in nursing schools paralleled the dramatic expansion in modern hospitals in the United States. U.S. nursing schools were created to give support to the large hospitals that were being built, serving as a practice field for the students, who were good and cheap workers.15 In 1918, there were already more than one thousand U.S. nursing schools giving support to hospital services.16 Ethel Parsons claimed the role of the public health nurse—a central figure in the world's struggle for sanitation—as an invention by her country. To support her point of view, she relied on the declarations made by Dr. William Welch, director of the Johns Hopkins University School of Hygiene and Public Health, who placed public health nursing among the great initiatives of the United States in the twentieth century. The public health nurse played a prominent role during the postwar period, when the sanitary police approach was no longer valued. The intention was now to obtain people's cooperation for the sanitary project. Citing the American Public Health Association, the sanitarian J.P. Fontenelle stated that by teaching individuals the principles of a healthy life and bringing them little by little into contact with the community's medical resources, the public health nurse proved to be the most useful agent at our disposal. Thus, the modern public hygiene program in a given community can have its exact measure by extension of the development already reached by public health nursing.17

The first adaptation of the U.S. system to Brazil's situation was the establishment of a Service of Nursing at the National Department of Public Health. The DNSP's administrative structure included all nursing activities and was equal to the

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medical board of inspectors. Mrs. Parsons remarked that such inclusion at the federal level was unique in the world's history of nursing. 18 Maintaining discipline and control over the health visitors, training lasted 6 months and consisted of theoretical and practical education about nursing procedures and home cleanliness. Practical education was conducted in clinics or districts under the supervision of the American nurses, and theoretical education was given by doctors in the afternoon. 19 Ethel Parsons made it clear that this was an emergency course and, therefore, that health visitors were not allowed to take responsible positions and should always work under the supervision of a nurse. Health visitors should be replaced by graduate nurses as soon as possible; however, they should be given the opportunity to take the nursing course.20 Based on her own expectations, Mrs. Parsons's evaluation of the emergency course was not favorable, even though the students had "acquired some knowledge as well as a better perception of the value and dignity of their work." The reasons for her negative evaluation were the insufficient basic education of some students, the inadequate time for their instruction, and the limited opportunities for practical learning at the hospital and dispensaries. Furthermore, according to Mrs. Parsons, "many of the theoretical courses, though excellent, were too classic for the students' understanding." She proposed that the next course be developed together with the introductory intensive course offered at the Nursing School of the Sao Francisco de Assis Hospital during the first 4 out of the 10 months that the course would last. From the following year forward, health visitors' courses were no longer offered, and this was considered a victory: "The directors of Health Department Services noticed that the current arrangements were satisfactory only as an emergency measure and that it would be better to wait for fully trained nurses. . . ." 2I Parsons recalled that such a decision constituted "considerable progress if compared to the situation in 1922, when the demand was for a great number of slightly trained health visitors that were needed all at once."22 The inclusion of health visitors—and nurses, afterwards—in the field of public health did not occur peacefully. J.P. Fontenelle himself reported that "the idea of having young women as public employees for paying home visits was considered an American fashion and a scandal." The sanitarian defended the need for the new category, comparing the sanitary organization at the time to the "national guard" introduced by Emperor Pedro II, which was composed only of officials [doctors] without capable soldiers [nurses]. He also compared health visitors to the former "mata-mosquitos brigades" (employees of the Sanitary and Hygiene Department who killed mosquito larvae and destroyed their breeding places) created by Oswaldo Cruz. According to him, women were better suited for home visits, so that

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public health could profit from the physical and moral advantages of the female sex. The sanitarian concluded: "The public health nurse is the better propagandist, the most listened-to teacher, the most pleasant instructor, who can thus multiply the work done by the sanitary doctors."23 The daily work of a public health nurse was to visit families in which there was sickness, physical disability, or a need for advice to prevent them. The public health nurse would take care of those sick who were lying in bed, observe the sanitary conditions of the house, and find out physical deficiencies and incipient diseases. Further, the nurse's role would involve teaching family members or even neighbors how to carry out the doctor's determinations and protection measures, explaining the importance of the environment's hygiene and principles of good nourishment, and "using the ability of a consummate nurse [and] sending doctors to sick people and sick people to doctors."24 This idealistic view of the role of the public health nurse and health visitor did not fit those families' precarious life conditions. The nurse or visitor tried "to teach" these people how to be healthy (as Fontenelle himself had already had the opportunity to verify in person). Even so, families were reluctant to receive the visits, at first. Later, public health nurses began to perform the educative work at the dispensaries, too. The new roles performed by the Service of Nursing expanded the scope of their practice and helped increase the population attending clinics. To implement a unified visiting service, the city was divided into zones, each having a nursing service branch; zones were divided into districts. Each zone had an American public health nurse and each district had a health visitor. Although all that could be done at first was to integrate the tuberculosis and child hygiene work, the goal was that each district should have a public health nurse who would be responsible for all of the nursing care and sanitary education the families needed.25

The New Nursing Education The curriculum of the DNSP's Nursing School was similar to the Standard Curriculum of American Nursing Schools, established in 1917.26 It proposed a three-year course, required completion of high school for admission, emphasized the theoretical program, and limited the work at the infirmary to 48 hours a week.27 This model, based on the subsequent Goldmark Report, was followed as closely as possible.28 The program required 28 months of classes with a 2-week vacation break per year. Admission required a diploma from normal school or approval in a

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selection exam. Further, pupils completed a mandatory 4-month experience period and maintained a 48-hour work week, with study and theoretical instruction hours excluded. Finally, housing and a small monthly payment were offered.29 Hospital-oriented nursing education took about four-fifths of the course, and public health nursing education was offered in the last quarter only. This predominance of hospital training in the development of nurses who were meant for public health service seemed natural to the pioneers because, in their opinion, the nurse would be "the health messenger" in the homes, the "real sanitary instructor, who treated and gave comfort to the patient with her own hands, due to the experience acquired at the hospital." 30 Aside from emphasis placed on individual or collective care, the major differences between nurses' hospital work and public health work were the need to improvise necessary material in the residences and also to solve difficult situations on their own.' 1 At first, the School of Nursing's dean and two assistants were responsible for education and supervision of the students' work, eventually encompassing a number of infirmaries and finally involving the whole hospital. By then, the School had six foreign teachers among its staff. Along with emphasizing students' practical training, this approach also demonstrated the advantages of setting a higher standard for nursing practice. 32 From the start, the informational folder for the new course, entitled "A enfermeira moderna: apello as mocas brasileiras" ("The modern nurse: a call for Brazilian young women"), indicated that the profession was meant for women only. This prospectus compared the nurse's life to the nun's life: "When all the nurse's work was done by Sisters of Charity, it was referred to as a life of sacrifice; now, however, it should be called life of dedication, for in no other labor . . . may a girl have . . . the opportunity to practice the sweetest of all arts, to find happiness, to reveal her own gifts and forget about herself. . . . " It also pointed out, however discreetly, that nursing could represent an "emancipation with honor" to women.33 As the candidates' statements in their registration forms reveal, the nursing course could mean the prospect of an honest life to a poor young woman; at that time, the nursing career represented almost the only opportunity for women's access to education after normal school.34 The search for a nursing career by upper-class girls was favored by the surplus of working women and the economic crisis: "Once the Brazilian woman enters the great life activity, having to earn part—or even all—of her living and sometimes that of other family members, the number of candidates for the nurse career will certainly increase. . . ."-^ Several candidates who answered the sanitary doctors' humanitarian and patriotic calls were middle-upper-class girls, many of whom were recruited directly

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by the doctors. Although lower-class candidates could be welcome, the same would not be true of Black candidates. From the class of 1926 on, the opposition newspapers started to denounce the issue of racial discrimination in candidates' selection. Ethel Parsons admitted that the School's policy, as was true of the Naval Academy, was to avoid the admission of Black students, so that it was possible to attract the best class of women for the new profession. She reported that the admission of a Black girl, in compliance with a DNSP request, gave rise to a series of student protests.36 As the School prepared prospective nurses for public health or hospital work, it also carried out a strong ideological indoctrination, in accordance with the spirit of the profession. From the point of view of the American nurses, obeying hierarchy and discipline were the strongest references in the student's evaluation. After admission, the high standards were maintained through constant examinations and strict conformation to all decisions. In Mrs. Parsons's opinion, this approach was appreciated by desirable students and served as a means of early elimination of the unsatisfied ones, before time and money were wasted on them.37

The Implementation of the New Profession As nurses graduated, they were soon integrated into the sanitary project, improving and expanding the work already in progress. The total substitution for health visitors by graduate nurses was worth mentioning by President Washington Luiz, in his address to the National Congress. On the other hand, Brazilian nurses who had been granted a scholarship in the United States replaced the American colleagues in the command of district nurse zones upon their return to Brazil. The concern about employers' acceptance of the new professional was dismissed; rather, the first annual report registered their apparent approval. "From all over Brazil there were requests for trained nurses to occupy positions of responsibility. .. ,"38 A constant effort was made to promote the importance of the work done by the nurse, in order to obtain favorable public opinion about the profession. All kinds of publicity was used to the fullest extent, to educate Brazilians about the value of the highest standard of public health nursing.39 From 1926 on, one can tell that a new mentality about the nursing career in Brazil was being created. The increasing respect for, and trust in, the nursing service and the career's future in the minds of Brazilian people was one of the most important, and particularly gratifying, achievements of the whole health program, not only because it revealed the attitudes of the doctors, employees, and patients,

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but also because it led to a considerable increase in the number of educated and cultured young women who applied for the School of Nursing, especially at the end of the year.40 The high priority given by the Parsons Mission to the implementation of the School of Nursing can be seen in the 1925 report. The financial resources for the project were cut due to the country's economic crisis, and a dilemma was created: either reduce the activities of the Service of Nursing, or jeopardize the School's development. The choice was the School's preservation, even if public health activities were drastically reduced; it was agreed that the School's development was the most important part of the program and should not suffer from the lack of funds. Consequently, 12 of the 47 health visitors were dismissed, visits to those suffering from tuberculosis were limited to the "open cases," and activities related to prenatal care and to children older than 2 years of age were suspended. Despite protests from the doctors, the restrictions continued until the following class could graduate. With the admission of new health visitors to the School of Nursing, their number was reduced to twenty-six. Visits were restrained even more due to a smallpox epidemic, which required more nurses and health visitors to be at the isolation hospital.41 Before the School's destiny was passed over to the Brazilian nurses' hands, the practice of nursing became regulated in Brazil.42 Although the possibility of incorporation of the School into the University had been studied, that did not occur.43 It was stated in the introduction to the decree of 1931 that, although nursing schools "in more developed countries" have been granted "privileges of superior schools," such a move would not satisfy "conveniences of sanitary character" at that time. The same legal document acknowledged the Anna Nery School of Nursing as the official school, a standard of excellence against which nursing schools yet to be would be measured. The clear intent was to guarantee a high standard for the development of nursing professionals in Brazil. During the ten years of the Parsons Mission (2 September 1921 to 3 September 1931), there were no other nursing schools in Brazil. Soon after the American nurses left their command of the Anna Nery School, people tried to minimize its position as a standard official school for the establishment of nursing at military and religious hospitals.44

Final Considerations The implementation of modern nursing in Brazil was one of the greatest achievements of the Carlos Chagas Reform. Chagas would even declare in public that the

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creation of a nursing school in Brazil is a remarkable event in its history, and no less important than the elimination of yellow fever by Oswaldo Cruz.45 Nevertheless, the most immediate objective of this endeavor was to supplement the work accomplished by the sanitary doctors and represent the sanitary authority within society. Contrary to the expectations of most DNSP doctors, whose only aim was to solve an immediate problem in their daily practice, the outcome of the Parsons Mission was to create a solid base for the introduction of a new professional category in the field of health in Brazil. The Parsons Mission transferred to Brazil the Nightingale system of nursing, which after 1873 had experienced a half-century adaptation process in the United States. Thus, the Mission imposed of techniques and social values unfamiliar to the Brazilian culture. Interestingly, the reasons and circumstances surrounding the development of professional nursing in Brazil differed from those in other countries. In Brazil, the emergence of a new professional category was "the result of a governmental measure and not a product of social consensus, since the Brazilian society of the time," with the exception of the DNSP group, "didn't have a clear notion of what was the use or the meaning of a nursing school."46 Ethel Parsons's challenge was to convince the DNSP physicians that it was not only possible but also essential that the high American nursing standards be adopted in Brazil. Further, it is important to recognize the powers at play at the time. The General Superintendent of DNSP's Service of Nursing was under the orders of the General Director, Dr. Carlos Chagas, and the Rockefeller Foundation's International Sanitary Council. Also, the positions of School Dean and Director of the Hospital's Service of Nursing were both occupied by the same American nurse, Ms. Clara Louise Kieninger, who therefore was subordinated to both the Hospital Director and the General Superintendent. Such arrangements enabled the leader of the Rockefeller Foundation's nurse mission to have extraordinary powers during ten years (1921—31), and made it possible to accomplish a project for which there was, at least initially, little support. Ms. Kieninger was replaced by Ms. Lorraine Dennhardt in 1925, and then by Ms. Bertha Lucille Pullen in 1928.47 The DNSP Director's decisive support for the implementation of the modern nursing project in Brazil and the reputation earned by the Mission's nurses were announced publicly. During the inauguration of the new director of Sao Francisco de Assis Hospital, Dr. Carlos Chagas emphasized in his speech that his support was based on the interest he had demonstrated in the nursing nchool, since the hospital's main purpose was to serve as a training laboratory for the nurses, and that the school should be offered all facilities.48

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Home visiting, considered an inappropriate task for a doctor, required a great deal of personal dedication. Not only was there opposition (of a moral, political, or philosophical nature) from certain sectors of society, but also resistance from the families receiving the sanitary visitors. The presence of the public health nurse in poor families' homes, even if they were offering effective assistance, had a strong ideological connotation. Such work can be characterized as "women's work," due to the conditions under which visits were made and the scarcity of financial or personal rewards. The work was based on moral rewards.49 The Anna Nery School, created with minimal influence of the Catholic Church, was probably seen as a threat to the religious orders' power and prestige. In fact, as the influence of the American nurses on the future of the Brazilian nursing lessened, the Sisters of Charity were recognized as nurses in 1932; the first school to graduate religious nurses in Brazil was created in 1933. Evangelical sects also managed to protect their interests. Two schools were created by the Evangelical Church, both located in the state of Goias. These religious schools were linked to hospitals, unlike the Parsons Mission approach. It seems, thus, that the high standard of nursing education adopted by the Anna Nery School, based on patterns that were considered scientific, did not correspond to the Brazilian mentality of the time.30 The Parsons Mission work plan included the creation of a nursing school and a school-hospital based on Nightingalean principles and a public health nurse service based on American principles. Therefore, the implementation of modern nursing in Brazil represented "a symbolical struggle for producing and imposing a legitimate point of view about the world."51 Further, the inclusion of a new feminine professional category-one that had not existed before in Brazil—evolved out of decisions of the Brazilian legally constituted authorities and was contrary to the social expectations of the DNSP doctors. The constitutional process led to a new social identity, that is, a new feminine professional category. It was consolidated by a new social practice, and articulated into the sanitary policy of the period. The struggle for building a nurse identity implied the use of what Pierre Bourdieu termed "symbolic violence." This began with applying criteria for candidate selection and recruitment that avoided body or behavioral stigmas that could discredit the new profession before the dominant elite. During their training, there was a drastic habitus transformation of the candidates to the career. Unceasing dedication to the service and strict obedience to orders and decisions was mandated if one wanted to remain in the course or in the job. The program's transition from the DNSP doctors' initial expectations to the innovative plan of the American nurses resulted in what may appear to be

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contradictory evaluations. On one hand, the nurses wanted to highlight their accomplishments (clientele and productivity increases, cost decreases). On the other hand, they emphasized the need for having higher training standards, increasing the course's duration, and institutionalizing the nursing organs under central command. The strengths and weaknesses of the program were reflected in its successes and setbacks. At the same time, a better perception of the new role and appreciation for its potential were developing inside the DNSP. Efforts to make the new profession more visible focused on creating a positive mental image—a social persona—for the nursing student and the nurse. For example, during a health crisis (e.g., an epidemic) when nurses were left unpaid (due to budget problems), nurses were willing to sacrifice themselves to demonstrate the "nursing spirit" and the high moral and spiritual character for which the profession wished to be known. The successful implementation of modern nursing in Rio de Janeiro, and the conviction of its enduring character, resulted from a shift in the statement of a belief in an appropriate role for Brazilian nursing to the effective accomplishment of this role. Throughout the years, nursing developed into a professional role in health care that has come to be considered normal, evident, and natural. IEDA DE ALENCAR BARREIRA, PHD Full Professor at the Department of Fundamentals of Nursing Anna Nery School of Nursing Federal University of Rio de Janeiro Founder of the Research Center on the History of Brazilian Nursing (Nuphebras) Rua General Glicerio, 827 apt. 503—Laranjeiras—22245-120 Rio de Janeiro, Brazil

Acknowledgments This work was supported by the National Council for Scientific and Technological Development/Brazil (CNPq) and by the Vice-Presidency for Graduate Programs and Research of the Federal University of Rio de Janeiro (SR-2/UFRJ), and corresponds to part of the report forwarded to CNPq regarding the joint project, "The beginning of nursing in Brazil: Brazilian sanitarians and American nurses. "

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Notes 1. Nilson do Rosario Costa. Lutas urbanas e controle sanitaria: origens das politicas de saude no Brasil (Petropolis: Vozes/Rio de Janeiro: Abrasco, 1985), 93. 2. Ibid., 86, 93. 3. J.L. Benchimol (Coord.), Manguinhos do sonho a vida: a ciencia na Belle epoque (Rio de Janeiro: Fundacao Oswaldo Cruz/Casa de Oswaldo Cruz, 1990), 56. 4. Costa, Lutas urbanas e controle sanitaria, 101, 118. 5. Ibid., 99. 6. Bichat de Almeida Rodrigues, Fundamentos de Administrate Sanitaria (Rio de Janeiro: Freitas Bastos/USAID, 1967), 143. 7. Soraya M.V. Cortes, "Os services estaduais de saude antes de 1940," Boletim da Saude, Escola de Saude Piiblica, Secretaria da Saude e do Meio Ambiente, Porto Alegre, 11, no. 2 (December 1984): 33, 36. 8. J.P. Fontenelle A enfermagem de saude publica: sua criafdo e desenvolvimento no Rio de Janeiro (Rio de Janeiro: Canton and Reile Graf., 1941), 6. 9. Rodrigues, Fundamentos, 114. 10. Fontenelle, Enfermagem de saude publica, 5. 11. Edith de Magalhaes Fraenkel. "Historico do service de Enfermagem do Departamento Nacional de Saude Publica," Annaes de Enfermagem 4, no. 5 (October 1934): 4-6. 12. Ethel Parsons, " 1922," in Annual Report of the Service of Nursing (1922-1926). (National Department of Health of Brazil), 1-3 (copy). Federal University of Rio de Janeiro/ Anna Nery School of Nursing Documentary Center, Rio de Janeiro, doc. no. 06, box 02. 13. Ethel Parsons, "A enfermagem moderna no Brasil," in Archivos de Hygiene: Exposicoes e Relatorios (Rio de Janeiro: DNSP, 1927), 202. 14. leda de Alencar Barreira, A enfermeira ananeri no pais do futuro (Rio de Janeiro: UFRJ, 1997), 49. 15. Glete Alcantara, A enfermagem moderna como categoriaprofissional: obstaculos a sua expansao na sociedade brasileira. Conference presented at the University of Sao Paulo School of Nursing as part of the requirements for admission as Full Professor. (Ribeirao Preto: University of Sao Paulo School of Nursing, 1966), 22. 16. Waleska Paixao, Pdginas de historia da enfermagem, 3rd ed. (Rio de Janeiro: Bruno Buccini, 1963), 55. 17. "Public Health American Association," cited in Fontenelle, Enfermagem de saude publica, 35-36. 18. Parsons, "Enfermagem moderna," 202. 19. Ethel Parsons, "1925," in Annual Report of the Service of Nursing (1922-1926) (National Department of Health of Brazil), 4-5 (copy). Federal University of Rio de Janeiro/ Anna Nery School of Nursing Documentary Center, Rio de Janeiro, doc. no. 06, box 02. 20. Ibid., 5. 21. Ethel Parsons, "1923," \nAnnual Report of the Service of Nursing (1922—1926) (National Department of Health of Brazil), 13 (copy). Federal University of Rio de Janeiro/ Anna Nery School of Nursing Documentary Center, Rio de Janeiro, doc. no. 06, box 02.

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22. Parsons, Ethel, "1924," in Annual Report of the Service of Nursing (1922—1926) (National Department of Health of Brazil), 21 (copy). Federal University of Rio de Janeiro/ Anna Nery School of Nursing Documentary Center, Rio de Janeiro, doc. no. 06, box 02. 23- Fontenelle, Enfermagem de saude publica, 8, 21, 34. 24. Ibid., 9-10. 25. Parsons, "Enfermagem moderna," 210-11. 26. Amalia Correa de Carvalho, Orientafdo e ensino de estudantes de Enfermagem no campo clinico (Ph.D. thesis) (Sao Paulo: University of Sao Paulo School of Nursing, 1972), chart no. 1 on 29-30. 27. Ibid., 21-22. 28. Parsons, "1923," 8. 29. Carvalho, Orientafao e ensino, 27, and chart no. 1 on 29-30. 30. Fraenkel, "Historico do service de Enfermagem," (October 1934), 4-6. 31. Edith de Magalhaes Fraenkel, "Historico do service de Enfermagem do Departamento Nacional de Saude Piiblica," Annaes de Enfermagem 4, no. 4 (April 1934): 14-17. 32. Parsons, "1925," 5-6. 33. Brasil, Ministerio da Saude, Justica e Negocios Exteriores, Departamento Nacional de Saude Piiblica, A enfermeira moderna: appelo as mofas brasileiras (Rio de Janeiro: Oficinas Graficas da Inspetoria de Demografia Sanitaria, Educacao, e Propaganda, 1922), 6. 34. leda de Alencar Barreira and Jussara Sauthier, As enfermeiras norte-americanas e o ensino da Enfermagem na capital do Brasil (1921—1931) (Rio de Janeiro: Anna Nery, 1999), 88-89. 35- Fontenelle, Enfermagem de saude publica, 17. 36. Ethel Parsons, "1926," in Annual Report of the Service of Nursing (1922-1926) (National Department of Health of Brazil), 2-3 (copy). Federal University of Rio de Janeiro/ Anna Nery School of Nursing Documentary Center, Rio de Janeiro, doc. no. 06, box 02. 37. Parsons, "1923," 14. 38. Parsons, "1922," 7. 39. Parsons, "1923," 15. 40. Ethel Parsons, "Addendum," in Annual Report of the Service of Nursing (1922— 1926) (National Department of Health of Brazil), 5 (copy). Federal University of Rio de Janeiro/ Anna Nery School of Nursing Documentary Center, Rio de Janeiro, doc. no. 06, box 02. 41. Parsons, "1925," "Addendum" on 4, and 24-25, 28-29. 42. Decree no. 20109, dated 15 June 1931. 43. Anayde Correa de.Carvalho, Associafdo Brasileira de Enfermagem, 1926-1976: documentario (Brasilia: ABEn, 1976), 15. 44. Suely de Souza Baptista,. "Trajetoria das escolas de enfermagem na sociedade brasileira," Escola Anna Nery Revista de Enfermagem 1, no. 2 (Rio de Janeiro: Anna Nery, 1997): 84-105. 45. Parsons, "1924," 21. 46. Alcantara, Enfermagem moderna como categoria profissional, 21-22.

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47. Carvalho, Associafao Brasileira de Enfermagem, 1926—1976, 14-15, 21. 48 .Parsons, "1924," 21. 49. Barreira, Enfermeira ananeri, 52. 50. Baptista, "Trajetoria das escolas de enfermagem," 84-105. 51. Pierre Bourdieu, O poder simbolico, trans, by Fernando Tomaz. Cole^ao memoria e sociedade (Rio de Janeiro: Bertrand Brasil, 1989), 140.

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"The Problem" of Student Nurses of Japanese Ancestry During World War II SUSAN McKAY University of Wyoming

Consider the problem of the American girl of Japanese ancestry, evacuated from the West Coast to a relocation center after war came [with Japan], and denied the right to enroll in a school of nursing, or not permitted to return to complete the course which was at schools that claimed they accepted relocated Japanese American students.'

When this 1943 American Journal of Nursing (AJN) editorial was written, 20 schools of nursing claimed to accept relocated Japanese American students. However, of 371 young Japanese American women wanting to enroll in nursing school that year, only 84 were admitted. The irony of the AJN position was that, although it agreed that Nisei (second-generation Japanese American) nursing students should be allowed to continue their educations, the editorial did not acknowledge the denial of these students' rights as citizens or recommend that nursing professionals and organizations advocate on their behalf.2 In this paper I examine the life trajectories of four Nisei student nurses who were forced to leave their nursing schools in California, evacuate with their families to assembly centers at either Pomona or Santa Anita in California, and then relocate to Heart Mountain, Wyoming, a permanent internment camp. The stories of these four women, third-and fourth-year nursing students at the time of their evacuation, are part of a larger study of 24 young women who lived at Heart Mountain, Wyoming.3 Their experiences provide insights about how Nisei nursing students were affected by internment. These women, because of their persistence and courage, found ways to continue their nursing educations. Many Nisei women students did not continue their educations because of daunting challenges in locating new school placements, surmounting family objections, and finding financial assistance. Others were fearful of independent lives away from their families. For women who overcame these barriers, a positive

Nursing History Review 10 (2002): 49-67. A publication of the American Association for the History of Nursing. Copyright © 2002 Springer Publishing Company.

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consequence of evacuation and relocation was having new and unexpected life experiences that deviated from traditional gender roles for Japanese Americans. Historian Valerie Matsumoto notes that changes fostered in young Nisei women's lives included opportunities for travel, work, and education.4 Further, their developing sense of independence and growing awareness of their abilities as workers fostered self-confidence.

Evacuation and Internment of Japanese Americans Military necessity was the official reason given for evacuation and relocation, but that necessity was never proven. The actual historical causes that drove relocation decisions were race prejudice, war hysteria, and failure of political leadership.5 The decision to remove Nikkei (ethnic Japanese) from the West Coast became official when President Franklin Roosevelt signed Executive Order 9066 on 14 February 1942.6 Altogether, 113,000 Nikkei resided in the Pacific states. Only three other states (Colorado, New York, and Utah) had as many as a thousand ethnic Japanese.7 Two-thirds of those evacuated were U.S. citizens, English was their primary language, and they attended U.S. schools. By 1940, the oldest of the Nisei were young adults with children of their own.8 Edna Gerken, Supervisor of Health Education for the U.S. Indian Service in Denver, Colorado, reported in the American Journal of Public Health, "As a wartime necessity the War Department has evacuated some 100,000 persons from the West Coast which was designated a military zone."9 Gerken characterized this exodus as follows: "[They] abandoned their homes and business enterprises and went to temporary assembly centers to await the preparation of permanent relocation projects."10 Gerken's depiction conceals the truth, that Nikkei were forced by the U.S. government to abandon these homes and businesses and take only what they could carry. Many never recovered what they had lost. Families were evacuated together to one of 16 assembly centers, suffering great emotional and physical stress in the process. Most evacuees who eventually relocated to Wyoming's Heart Mountain internment camp initially evacuated to an assembly center at either Santa Anita or Pomona. Santa Anita was the site of a racetrack, and families were assigned to horse stalls or barrack apartments for living quarters. At both Pomona and Santa Anita, internees used central latrines and mess-hall eating facilities. Barbed wire surrounded the assembly centers and, as at the permanent relocation camps, military guards patrolled and kept watch from

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guard towers. The centers, intended to be temporary accommodations until the Army-barrack construction relocation camps could be built, were crowded, unhealthy, unsanitary, and demoralizing, far outlived their intended use, and posed strong threats of public health disaster." Perhaps the one advantage of the assembly centers was that some were located near family homes, and friends could bring food and gifts of kindness. By late summer and fall of 1942, Nikkei were moved to one of 10 permanent camps that the U.S. government euphemistically called "relocation camps." These were located in desolate and remote areas from inland California to as far away as Oklahoma. A 1943 AJN article referred to the internment camps as "pioneer communities," reflecting War Relocation Authority (WRA) rhetoric,12'13 and asserted that "these are not concentration camps, the residents are not prisoners of war. Their movements are restricted, it is true, but it is now possible for evacuees to apply for permission to leave the project to live and work in areas approved by the Army."14 The article claimed that the WRA's aim was "to establish the evacuated people in productive American life," and ignored any mention of the massive injustice that had occurred. 1 ^ The entire editorial assumed a tone of largesse as evacuees' living and working conditions were described: "Life in a relocation center is almost completely communal. Evacuees live in small barrack apartments, but they share community mess halls, showers, lavatories, and laundries. Stores and other enterprises are consumer cooperatives. Government is by councils elected according to democratic principles"16 Not mentioned was that relocation camps were standard Army structures, inadequate and ill-equipped for family life, built without consideration of culture, class, and gender in the organization and construction ot the camps, let alone of basic human rights. Further, as expressed in the article, the AJNs view that these were not concentration camps defied the obvious: enemy status had been the reason cited by the U.S. government for Nikkei incarceration. Internees were classified as to whether or not they were "loyal" to the United States. Those judged to be loyal became eligible to leave the camps to relocate elsewhere than on the West Coast. Young people between the ages of 17 and 35 were most likely to take advantage of the opportunity to resettle in the Midwest and the East.r College students were the first to be approved for release, with 4,300 students eventually going to inland colleges.18 Some left almost immediately in the fall of 1942, even as the camps were still filling. 19 Although no travel allowance was provided when relocation began, eventually the WRA gave a travel allowance of $25.20

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The Heart Mountain Nisei Nursing Students Among the evacuees were four young women, all student nurses, who went first to either Santa Anita or Pomona and then were relocated to Heart Mountain in 1942: Fumiye Morita Furuya, Mary H. Takagi, Mary Hidaki Kawakami, and Alice Okomoto Uriu. All grew up in California, came from Issei (first-generation) families with fathers who worked in agriculture or horticulture, and were born between 1918 and 1921. Each worked in the Heart Mountain Hospital prior to resettlement outside of camp. The Heart Mountain internment camp was situated in the north central part of Wyoming near Yellowstone National Park. At its peak in the fall of 1942, Heart Mountain's population exceeded 11,000 people. Restricted to living behind barbed wire fences in a desolate setting, these young women wanted to move their lives forward. Fumiye Morita Furuya recalled, "We were all ambitious. We were young, and by hook or crook we finished [nurses'] training, and it has been positive for most of us." 21 1 will briefly sketch each of these four women's lives up to the time of the bombing of Pearl Harbor by the Japanese military. Each had completed two years of prenursing collegiate course work and was enrolled in a three-year nursing education program in California. FUMIYE MORITA FURUYA Fumiye was born in 1921 in Milpitas, California. Fumiye's parents were teenagers when they immigrated to the United States, met, and married. The oldest of five brothers and sisters, Fumiye assumed considerable responsibility for the care of her siblings. When she was in grammar school, her family moved to Gilroy, California, where her father managed an orchard. Her longtime dream of becoming an aviatrix was out of the question in 1939, her high-school graduation year. Nursing was also an interest, so Fumiye enrolled at San Jose State for her first two years of preprofessional courses. In August 1941, she began a 3-year program in nursing education at the University of California in San Francisco (UCSF). She was among approximately eight Nisei students in her class, and her roommate was Japanese American. Fumiye remembered nursing school as an adventure because "in those days Japanese women, especially my mother, wouldn't let me out of sight."22 MARY H. TAKAGI Mary, hereafter called Mary T., grew up in the desert of the Imperial Valley, California. One of five children, she was born in 1920. Her family was part of a larger community of about 500 Nikkei families who engaged in small-crop farming. After high-school graduation, she worked as a domestic for a French

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family. By 1938, Mary had earned enough money to begin 2 years of prenursing courses at Pasadena Junior College. She lived with her family in Baldwin Hills, commuted to school in a Model A Ford, and worked to pay her expenses. In 1940, Mary T. began her nursing studies at Huntington Memorial Hospital in Pasadena. ALICE OKAMOTO URIU Alice was born in 1921 and lived in the small town of Elmira, California, where her father worked in a fruit orchard. The second of four children, Alice and her family moved to Mountain View when she was 4, and she grew up there. Her father was a nurseryman who raised chrysanthemums. Her mother, a former school teacher in Japan, worked on the family's 5-acre farm. Because her father wanted his children Americanized, Alice joined the Girl Scouts, which sparked her interest in nursing. She attended San Jose State for 2 years after high-school graduation in 1939, and began her nursing education at Santa Clara County Hospital in San Jose in 1941. MARY HIDAKI Hereafter called Mary H., she was born in 1918, the oldest of four children. Her family lived near San Jose in the rural town of Coyote, where her father farmed on leased land. Growing up, she had limited contact with other Nikkei families. After high-school graduation, Mary H. enrolled at San Jose State for a 2-year prenursing course. Upon its completion, she entered the nursing program at Santa Clara County Hospital, now called Valley Medical, where she lived in the nurses' residence. Pearl Harbor and Evacuation. When Pearl Harbor was bombed, the four young women were in the midst of assigned clinical rotations. Their immediate responses varied, but all felt unsettling effects from the news, either immediately or within a few months. Although they left school at different times, all were required to evacuate with their families to an assembly center and, subsequently, to Heart Mountain. Mary H. was halfway through her second year of nursing when the U.S. entered the war. The morning Pearl Harbor was bombed, she had gone to Sunday breakfast without listening to the radio. We were living in the nursing home, and I went to breakfast. This woman [RN] said, "Would you please move?" I really didn't know why. After that, I found out what happened. She didn't want me to sit there with her. I think it might have been a week or two later that the director told us we had to leave. She told us because of the directive that came through that we had to leave.23

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Fumiye had been in school 6 to 7 months when she left school because of Pearl Harbor's bombing, which occurred on her birthday. She remembered thinking that "the island of Japan was pretty stupid for attacking a big country like the United States."24 Being forced to leave UCSF resulted in lifelong feelings of bitterness about her nursing school. Back in her family home, Fumiye remained within a 5-mile limit of her home, as was required of all Nikkei. After completing one and one-half years of school, Mary T. left in March 1943 to evacuate with her family. "I thought that I had really studied and worked to get myself established. So it was rather sad to think it was going to abruptly end. It was such a traumatic time. Everyone was in turmoil."25 She was in the middle of a clinical affiliation in communicable disease at Orange County Hospital. Before returning home, she went to Huntington Hospital to explain why she suddenly had to leave school. She was treated kindly by the school's director: I'll never forget her. She said [that] during World War I she was just a child. Her folks were German citizens. Her father made them [children] stand out in the snow to sell war bonds so she was much more sympathetic and realized what was happening in our lives. I really appreciated her telling me this. I think she was the only person I really went to see and told her why I was leaving.26

Alice Okamoto Uriu began her nursing studies in September 1941 and left school on 26 May 1942, later than the other three women. She had been living in the nursing residence with other student nurses. I remember being called, packing, and just leaving. My roommate was also a Japanese American, and there was another Japanese American. We didn't have time to say goodbye to anybody. I was ashamed and hurt that the government would do this to citizens. Yet, if my parents who were immigrants had to go, we would have gone too. We wouldn't have let them go by themselves.27

In April 1942, Fumiye's family was evacuated to Santa Anita Assembly Center, the largest of the 16 assembly centers. Alice's family of six was also at Santa Anita, and they lived in a horse stall for 3 months. Alice initially worked weaving camouflage nets. The two students' professional education soon led to jobs at the Center's hospital. Fumiye worked with Nikkei evacuee nurses and was supervised by them. She called the work "a lot of fun" and spent most of her time at the hospital. "When you work at a hospital, you have a clique. You spend all your days off, everything, in the hospital helping out when and where needed."28 She bathed patients, gave enemas, and did routine bedside care.

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Mary H. and her family were evacuated to Pomona Assembly Center, traveling from their home by overnight train. Before boarding the train, family members were examined by doctors. Her brother had tuberculosis, so was required to stay behind and was sent to a sanitarium. 29 Mary H. was struck by what she saw upon arrival: All these Japanese were lined up. I guess they were anxious to see if they had any friends coming in as we came through. We all had gunny sacks to fill with straw for our mattress, and I think I was allergic to that hay because I coughed all the time I was there. As soon as I left on the train [to Heart Mountain], my cough was gone.30

Maiy H. worked under a Nikkei nurse in the assembly center hospital, which she characterized as fairly primitive. Mary T. also went to the Pomona Assembly Center, traveling there in early May to help prepare the Center's hospital. She recalled that the hospital "was not a special building but it was at the fairgrounds, and soon I did help with one delivery."

Health Care During Evacuation and Relocation Although each camp was equipped with a hospital, clinics, and public health care, historical accounts of internment give minimal information about hospital and public health care in the camps. There were notable variations between camps in terms of organization, delivery, and quality of health services and health personnel.31 Inadequate medical facilities and supplies, scarcity of trained personnel, insufficient procedures for handling health and medical problems, and problems with the public health infrastructure—such as securing clean water and uncontaminated food—existed within the camps. Evacuee student nurses were part of the medical team at assembly centers and relocation camps. Louis Fiset32 described an evacuee staff in March 1943 at Heart Mountain Hospital that consisted of two RNs, two graduate nurses, six student nurses, six Nikkei doctors, and 83 resident nurses' aides, clinic aides, and dental aides. A nursing student was part of the medical team to greet the first arrivals at Heart Mountain on 12 August 1942.33 At both assembly centers and relocation camps, continued problems maintaining adequate nurse staffing were initially eased by student nurses. The Heart Mountain Hospital opened on 12 August 1942. The hospital, located in a converted recreation hall, was bleakly supplied with sheetless army cots

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covered only with pillows and blankets. Water was unfit for use, some equipment came from physicians' personal kits, sterilization of instruments was by the heat of Sterno cans, and baths were given from fire buckets. There were no towels, washcloths, or soap.34 Evacuee medical and nursing staffs from Pomona Assembly Center were among an advance group who prepared for arrivals at Heart Mountain from the Pomona and Santa Anita assembly centers. In August 1943, Mary H. and Dr. Hanaoka, a physician from Los Angeles who practiced at Pomona Assembly Center, were among the first arrivals and were assigned to set up the temporary Heart Mountain hospital. Dr. Hanaoka was, I think, the top doctor there [Pomona]. When we first went to Heart Mountain, they took a few from each department in the hospital. I went with Dr. Hanaoka as the first contingent at the hospital. I think there were two of us students. And my brother went, too, because he was in transportation. I remember that we had our hospital in the barracks, the army barracks. It was quite primitive. We had latrines outside, and we had to get our food from the mess hall. I don't know how we nursed the patients there. We couldn't have had too many sick ones. The patients were not that ill, the ones we got, so we really didn't do that much nursing there.35 Evacuees traveled by train from California. Mary T. also arrived early in the relocation of evacuees to Heart Mountain. Her train traveled from California to the corner of Texas, then up to Colorado Springs and on to Wyoming. She recalled a rainstorm and hail in Colorado. At Heart Mountain, she and Mary H. became good friends. Mary T. recalled: There were quite a lot of students, but kind of green. We hadn't really gone out and worked. It was entirely new to us. Everyone was so busy, got to get through this ordeal. I don't remember anyone really instructing us. I gave a lot of medicine. Some of the patients were cancer patients so it was mostly pain meds. We didn't have much of a treatment unless they had surgery, so it was more or less routine.36

Mary T. sometimes worked nights when the Heart Mountain ambulance (actually a truck) would come to her barrack to pick her up. The Nikkei doctors told the nurses what to do. The students tried to help oversee the aides, to make sure that they were doing the right thing and that patient care was done, but the aides, like the students, were pretty much on their own.37 Mary T. concluded that people at Heart Mountain were well cared for, as much as possible. "I didn't think that it was any poorer than anyplace else at that time because during wartime, you just do the best you can. Even on the outside . . . you just did the best you could."38

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Mary H. worked on a ward with general patients. She and the other students earned $12 a month ($l44/year) for her work. Although contentious relationships between Nikkei health care workers and Caucasians have been documented, Mary wasn't aware of these problems at the Heart Mountain Hospital.39 She had, however, experienced racist comments after Pearl Harbor from nurses at the California hospital where she was a student. They told her she shouldn't be working at the hospital. About living at Heart Mountain, she recalled: It didn't bother me that much that I was there. I guess it was later that it struck me. Except for the food, my mother took care of the washing and things around the barrack. I didn't have anything to do because we had that one room so I could do everything I wanted to on my own. There were so many crafts I could take. There were a lot of people who knew how to teach . . . and I enjoyed crafts. I was running all over the place to go to those crafts that I never did before, and so I really enjoyed that.40

Fumiye felt safer inside camp because of the animosity outside. She didn't remember seeing Caucasians at the hospital, and there was plenty of help. As at the assembly center hospital, her time at the Heart Mountain Hospital was positive. It was a happy time again in the hospital clique. It became the center of our lives. We just went home to sleep. We ate at the hospital, showered at the hospital. So I don't know much about camp life. You learn from the RNs, you learn from senior student nurses. You had to be in charge in the evenings and nights. We were left explicit orders, and we didn't do anymore than we knew how. It was just taking temperatures and knowing when to call the doctor.41

Alice responded differently. Because women and children had no reason to go out of camp like some of the young men did [to work], she felt confined. She thought she was numb throughout internment. "I just took it, worked and slept, and that was it. No anger. No happiness."42 She retained few memories, either good or bad, of Heart Mountain. Alice assumed everyone was happy to be working. She remembered that the food at the Heart Mountain Hospital was much better than at the mess halls. She spent time in the operating room as a surgical nurse and also in medical ward eight. Although she saw several Caucasian nurses, she never talked with them except for Mrs. Harvey, who was in charge of the operating room. However, she was used to working with Caucasians, so associating with them wasn't unusual. Alice's time was spent working or sleeping, not within the larger Heart Mountain community participating in its activities. She remembered an ambulance driver coming to pick her up one evening, probably because of a surgical emergency when she was working in the operating room. Later, in the medical

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ward, with a division for men and one for women, she was in charge. Nurse aides did patient care, whereas Alice gave medications and treatments, made rounds with the Nikkei doctors, supervised nurse aides, and followed doctors' orders. Resuming nursing education at the request of Milton Eisenhower, WRA director, the National Japanese American Student Relocation Council (NJASRC) was organized in May 1942 by the Philadelphia-based American Friends Service Committee (AFSC)43 and cooperated with the WRA to facilitate nursing student admissions. Under the original leadership of Quaker leader Clarence E. Pickett, the NJASRC was headed by eminent West and East Coast educators and churchmen who intended to pry open academic doors to Nisei students44 and establish scholarship funds. The Council worked closely with Katharine Faville of the National Nursing Council for War Service and Joy Stuart of the WRA, but placement was difficult until November 1943.45 One reason was that many nursing schools in the Midwest and the eastern United States resisted admitting Nisei students. In 1942, the National Nursing Council, the National League of Nursing Education, and the NJASRC approached a number of nursing schools to find out whether they would accept these students. Schools gave multiple reasons for refusing admission, including: not having clearance by federal departments; concern for difficulties that might arise when students of Japanese ancestry worked with the public; crowded facilities due to an abundance of local applicants; and preference for admitting refugee students instead of students of Japanese ancestry.46 Also, local and state resistance and racial distrust frequently interfered with Nisei student admissions. Notably, willing schools were not free to admit students until they obtained clearance from the War and Navy Departments, and those restrictions prevented many schools from accepting Nisei students.47 By late 1942 and early 1943, Nisei nursing students started to leave the camps to continue their educations. WRA files indicate that students who would have graduated in a few weeks or months had they not been evacuated could, through special arrangements made by the state board of nurse examiners and the school of nursing concerned, graduate from their own schools by affiliation with the project hospitals.48 All four Nisei students eventually completed their nursing studies, three during World War II and one afterwards. Although Mary T. made inquiries early in internment about continuing her education, she waited until after the war. At Pomona she wrote to several dozen schools and applied to schools of nursing at Methodist hospitals. Many told her it was not a good time to take Japanese students. Ultimately, she was accepted at several, including at Marquette University in Milwaukee. The school was willing to give a year's credit for her nursing course work (which totaled one and a half years), something many schools would

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not do. However, Mary T. decided to defer her schooling, and left Heart Mountain for Chicago in May 1943. With her sister, she worked as an aide at a children's convalescent hospital. She remembered cute and innocent children. "One kid said 'Bang, bang, bang, bang—there goes another Jap'—he didn't know who I was or anything."49 When she left Chicago, Mary T. went to the University of Michigan at Ann Arbor, where she worked for three or four months before traveling to Colorado to marry. When she returned to California after the war, she completed her nursing education at Hollywood Presbyterian Hospital, taking a year and a half plus 45 days to finish. She graduated in 1949. In the days of strict behavioral rules for nursing students, she was the first student at Hollywood Presbyterian to be married, have a child, and commute from home. After graduation she worked parttime for several years at the city health department, raised four children, and later worked part-time in a hospital. She and her husband now live in San Luis Obispo, California. The remaining three students sought ways to continue their schooling during the war years. The process was a complicated one, especially during 1942 and most of 1943 when requirements were strict. Documents of the NJASRC listed application requirements, including clearance through the FBI and/or Army Intelligence, permission from the Army, Navy, FBI, U.S. Office of Education, and WRA to relocate, and evidence that public attitudes in the new community would not create difficulty. The last requirement referred to the potential for racist behavior toward Nisei, although racist attitudes toward people of Japanese ancestry were largely confined to the West Coast. Few people in the Midwest and East had personal experiences with Nikkei, so people there were usually curious, not racist. Students also submitted a statement that they could leave the Relocation Center on 10 days' notice, evidence of acceptance by a college or university in the form of an official letter or telegram, and verification of sufficient financial resources to pay travel costs, college fees, and living expenses for a year.50 With the help of the NJASRC, Fumiye searched for a nursing school, but her plans were interrupted because of her mother's illness. On the back of a mimeographed communication from the JANSRC that gave instructions to students wishing to continue their education, Fumiye had handwritten a note, presumably a draft, saying, "I received your most kind letter to help me in being relocated in a nursing school, and I want to thank you for all your sincere helpfulness. I was planning to go to school as soon as possible but due to an emergency operation on my mother, I will not be able to leave for a while. May I write to you when I am able? Thank you again. Most sincerely, Fumi Morita."51 On 21 December 1942, the NJASRC/ West Coast Committee answered, "We have received your letter in which you tell us that you'll not be able to leave the project at present in order to

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attend nursing school. We are sorry to hear of your mother's operation and do hope that she is recovering her strength. We are keeping your records in our active file and hope to hear from you in the near future that you are ready to leave for a nursing school. We shall then attempt to find an opening for you."52 On 6 February 1943, Fumiye received another NJASRC/West Coast communication announcing that the West-Coast NJASRC office was moving to join the Philadelphia office. The letter also announced that 487 students had been placed at 122 colleges in 25 states. Another 438 student placements were in process. Throughout most of 1943, Fumiye searched for a nursing program that would accept her. She wrote to the big schools: Boston Mass, Yale, and Bellevue. She received letters of rejection in response to all her applications.53 From the Philadelphia General Hospital, she received this reply from Loretta Johnson, Director of the Nursing School, written 4 February 1943: "My dear Miss Morita, We have not considered admitting American Citizens of Japanese ancestry at this time since our quota for admission to our school is filled. The Pennsylvania Hospital at Eight and Spruce Streets, Philadelphia, is admitting those of Japanese ancestry, and I would suggest that you write to Miss Helen McClelland, Director of Nursing." On 6 February 1943, Bessie A. R. Parker, Director of the Cornell University-New York Hospital School of Nursing, wrote to Fumiye, "I am sorry but we feel that at this time it may be better not to admit Japanese students to our school. We have had them in the past and hope we may again, but we fear that right now it may expose them to unhappy situations in their contacts with so many kinds of people." Pennsylvania Hospital's Director of Nursing, Helen McClelland, wrote on 16 February, "I have received your letter in regard to entering this school of nursing. We have already agreed to take five students recommended by the National Student Relocation Council, and we feel we will be unable to consider your application at this time." Another letter, written 19 February 1943, came from Anna D. Wolf, Director of the Johns Hopkins Hospital School of Nursing. "In reply to your letter of February 11th, may I say that because of a recent ruling by our Board of Trustees, we will not be able to admit students of Japanese ancestry. We trust you will be able to place your application elsewhere and that you will be happy in your work." Yet again, Fumiye's application was turned down—this time by the Massachusetts General Hospital. The rejection, communicated via the NJASRC, explained, The Massachusetts General Hospital, unfortunately, does not feel free to accept students of Japanese ancestry at this time although many of the staff there have been very anxious to accept them. We have recently had called to our attention by Miss Joy Stuart, whom you probably know as the nursing consultant of the WRA Health

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Division, the name of the Flower Fifth Avenue Hospital in New York City which is evidently anxious to take about five student nurses into its training program.

By April 1943, Fumiye had left Heart Mountain to work as a schoolgirl (helping in the house with cooking and cleaning) for an Evanston, Illinois, family. She stayed with them for six months and continued her search for nursing schools. Syracuse University's School of Nursing dean, Edith H. Smith, wrote on 14 June that a class would probably be admitted in January or February of 1944, and Fumiye should write if interested in applying. The NJASRC continued its search for an opening for Fumiye, making inquiries to the Cambridge Hospital School of Nursing in Boston, the Flower and Fifth Avenue Hospital in New York City, Bellevue Hospital in New York City, and the University of Maryland School of Nursing—which was unaccredited. Lack of accreditation had important consequences for applicants because students were ineligible to enroll in the United States Cadet Nurse Corps, which paid school expenses in exchange for service upon graduation. On 30 November, Fumiye received a letter from the NJASRC indicating that her search was finally complete. "We are thrilled to hear that you have been officially accepted at Bellevue." The letter ended, "We will look forward to a letter from you when you reach the big city. Meanwhile, although we are a week ahead of time, may we send you many happy returns of the day on your 22nd birthday."54 The date was almost exactly 2 years after Pearl Harbor. Because of its fine reputation, she viewed her acceptance at Bellevue as an honor. Her father was happy she was continuing her nursing education, but her mother thought she should get married. Fumiye resumed her nursing education almost from scratch. "They wanted only Bellevue methods. You know, it is different from school to school as to how you make a bed, which was so important at the time. All the principles and practices of nursing had to be learned all over again." Her training was reduced by 3 months; completing her education took 2 years and 9 months. She joined the U.S. Cadet Nurse Corps, which paid for her education and gave her spending money. If the war had not ended, she would have worked in the military after graduation. Two other Nisei students were in Fumiye's class. Her pediatric instructor was Nikkei. She found that people were very nice, and she did not experience racist behavior. She never returned to the University of California, and was determined never to go back. "I said, I'm a Bellevue graduate at NYU. I have my degree from NYU, and I think I was better off."^ For Fumiye, the positive side of internment was going to New York, completing her education at an excellent school, meeting her future husband, and

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raising two children. Her nursing career throughout her life has been rich and varied: she worked in an emergency department as nurse in charge for 9 years, as a nurse at a World's Fair, at the American Museum of Natural History, and in a neighborhood Catholic hospital. She retired from nursing in 1982 and, now a widow, continues living in New York. Mary H. applied to schools in Colorado and several others close to Heart Mountain, but did not receive responses from the latter. She left Heart Mountain after 6 months and traveled to Philadelphia to begin school. It was very scary because I had never been out. The furthest I had been was to San Francisco. I got off in Philadelphia and afterwards I found out there are two stations in Philadelphia, but I got off at the first one. As I was getting off the train, the director of the Pennsylvania Hospital where I was going came directly at me and asked me if I was Mary. Fortunately, there were hardly any other Japanese getting off the train so she probably knew who I might be. She took me back to the hospital and I often wondered afterward, "How was I going to get to the hospital if I was by myself?" She took me on the busses and we had to transfer to get to the hospital."56

At Pennsylvania Hospital, prior to her arrival, the students gathered to see how they felt about having a Japanese American coming there, and were agreeable to her enrollment. Once at Pennsylvania Hospital, Mary H. repeated her second year and remained in school for 2 years. She worked at the hospital for a year after graduation, and when she returned to Los Angeles 3 years later, she had left behind good friends. After obtaining a California certificate to practice, Mary H. worked in a hospital until she married. She quit work during the period when her three children were born, but returned to nursing in 1954 to work in a doctor's office. Now she is widowed and retired and lives in San Jose, California. As they did for many students, including Fumiye and Mary H., Quakers helped find schools that would accept Nisei. Quakers' kindness extended far beyond the confines of internment camps and provided support for Nisei students who lived far away from their families. At Pennsylvania Hospital, Nisei nursing students were invited to the home of a Quaker man who volunteered at the hospital. Mary H. recalled that "he was such a friendly man, and he had us come to his house during our vacation time and spend the time with them. That is why I felt so good about being in Pennsylvania, or Philadelphia anyway, because they were so nice to us."57 She experienced no racial animosity at Pennsylvania Hospital, only curiosity, because people hadn't seen many Japanese Americans and had many questions to ask. Alice left Heart Mountain in June of 1943 and went to Kahler Hospitals School of Nursing, in affiliation with Mayo Hospital in Rochester, Minnesota. She

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applied to two or three nursing schools. At Rochester, she was the first Japanese American student accepted at the school. Her family thought it a good idea that she was continuing her education. Her two younger sisters also left camp to continue their schooling. By leaving, she felt freedom again, which was wonderful. Alice had little money, but had few needs. A good friend in Mountain View, California, sent her $ 10 a month. Even so, she did not have enough money for a one-cent post card to write home to request money from her parents. At Minnesota, she felt no discrimination. As had been Mary H.'s experience, few people had previously seen Japanese Americans. She was, nevertheless, startled when one of her patients asked her if she was Finnish. Alice believes she may be one of the only students to have been capped twice. "1 had been capped in San Jose, at Santa Clara County. Until they could get my records from Santa Clara County, I had to be on probation. So after six months, I was capped again. Towards the end of my training they gave me the full nine months that I had worked in Santa Clara County Hospital. That is why I was able to finish in December of 1945 instead of 1946. But it took a long time for them to decide how many months to give credit for."58 After she graduated, Alice worked at Kahler Hospitals in the radiology and dental sections and was head nurse in both these departments. She decided to go into anesthesia, and returned to San Francisco to gain additional operating room experience at Stanford University Hospital. After a year, she entered a one-year anesthesia program at University Hospitals in Cleveland, Ohio. Upon its completion, she returned to San Francisco to work as a nurse anesthetist for almost a year at St. Francis Hospital before she married. Next, she was a nurse anesthetist at Mercy Hospital in Sacramento for 4 years until her husband completed his PhD degree. She quit to start a family of four children. While they were growing, she occasionally worked part-time. Her children are grown, and she and her husband live in Davis, California, where he is a retired professor of horticulture.

"The Problem" of Students Revisited Fueled by racial injustice and the negation of civil rights and precipitated by the bombing of Pearl Harbor, relocation and internment of Nikkei markedly changed life trajectories. Some Japanese Americans especially young people, used adversity to their own benefit, whereas others never fully recovered from their collective and individual trauma. Although many nursing students did not complete their education because of the formidable barriers, family objections, and fearing to

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venture out of prescribed gender roles, these four Nisei women were determined to pursue their chosen careers. Despite hardships and emotional trauma, they coped with relocation and internment by working as student nurses in assembly centers and at the Heart Mountain hospital while actively pursuing ways to continue their educations. Americanized, intelligent, and ambitious, they completed nursing school and became nursing professionals. When they left the Heart Mountain internment camp, these young women were exposed to new geographic spaces, new people, and a radically altered political climate. They found relatively little racism toward Japanese Americans in the areas where they studied and lived—mostly acceptance, curiosity, and kindness. In the process of completing their educations, they gained new skills and self-confidence as well as a strong sense of professionalism. For these four Nisei women, the problem of being Japanese American student nurses inverted to become a time of new opportunities. SUSAN McKAY, PHD Professor of Nursing, Women's, and International Studies University of Wyoming P.O. Box 4297 Laramie, Wyoming 82071

Acknowledgment Support for this research: Wyoming Council for the Humanities, Rockefeller Foundation, University ofWyoming Office of Research, University of Wyoming Alumni Association, University ofWyoming School of Nursing

Notes 1. "The Problem of Student Nurses of Japanese Ancestry," American Journal of Nursing (1943): 895 (hereafter cited as AJN).

2. Ibid., 895. 3. Susan McKay, The Courage Our Stories Tell: Women, War, and the Japanese American Internment at Heart Mountain, Wyoming (unpublished manuscript); Susan McKay, "Maternal Health Care at a Japanese American Relocation Camp, 1942-1944: A Historical Study," Birth, 24, no. 3 (September 1997): 188-93. 4. According to historian Valerie Matsumoto, women were one-third of the first 4,000 Nisei students to leave internment camps. A postwar study of 21,000 relocated

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students showed 40% to be women. Many chose nursing education; by July 1944, more than 300 Nisei women were enrolled in more than 100 nursing programs in 24 states. Valerie Matsumoto, "Japanese American Women During World War II," Frontiers 8, no. I (1948): 10. 65,000 students were admitted to schools of nursing for the year 1 July 1943 to 1 July 1944, mostly U.S. cadet nurses. "It Happened in 1944," AJN45, no. 1 (January 1945): 45. 5. Roger Daniels, Prisoners Without Trial: Japanese Americans in World War II (New York City: Hill and Wang, 1993), 3. 6. Ibid., 46. 7. Ibid., 16. 8. Ibid., 20. 9. Edna Gerken, "Health Education in a War Relocation Project, " American Journal of Public Health 33 (April 1943): 367. 10. Ibid., 357. 11. Louis Fiset, "Public Health in World War II Assembly Centers," Bulletin of the History of Medicine 73, no. 4 (Winter 1999): 576 (hereafter cited as Bull. Hist Med.) 12. "War Relocation Projects: Nurses Pioneer in Historic Wartime Operation," AJN43, no. 1 (January 1943): 61-63.<notes>13. The War Relocation Authority was the civilian agency responsible for administration of the relocation camps. Assembly centers were administered by the U.S. Army. 14. "War Relocation Projects," 62. 15. Ibid., 61-62. 16. Ibid. 17. Ibid., 82. 18. Ibid., 72-73. 19. Daniels, Prisoners Without Trials, 72. 20. Ibid., 77. 21. Fumiye Morita Furuya, telephone interview by author, New York City, 9 January 1998. 22. Ibid. 23. Mary Hidaki, taped interview by author, San Jose, Cak, 11 December 1997. 24. Furuya, interview 9 January 1998. 25. Mary H. Takagi, taped interview by author, San Luis Obispo, Cal., 10 December 1997. 26. Ibid. 27. Alice Okamoto Uriu, taped interview by author, Davis, Cal., 12 December 1997. 28. Furuya, interview 9 January 1998. 29. Gwenn Jensen observed that tuberculosis (TB) was arguably the single largest public health threat for internees, exacerbated by the crowding at centers. Further, the Japanese culture stigmatized TB, so that people hesitated to seek treatment for fear of social ostracism. Excluding infant mortality (deaths under 1 year of age), TB was the third leading cause of death. Gwenn Jensen, "System Failure, Health Care Deficiencies in the World War II Japanese American Detention Centers," Bull. Hist. Med. 73, no. 4 (Winter 1999): 61921. Elizabeth Vickers stated that, at the Poston hospital, about two-thirds of the slightly more than 100 daily hospital patients had TB. She noted the social stigma of TB among

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Nikkei and their efforts to prevent discovery as long as possible. Elizabeth Vickers, "Nursing in a Relocation Center: Pioneeering With WRA at Poston, Arizona," AJN45, no. 1 (January 1945): 5-26 30. Hidaki, interview 11 December 1997. 31. Roger Daniels, "Professional Health Care and the Japanese American Incarceration: An Introduction to the Symposium," Bull. Hist. Med. 73, no. 4 (Winter 1999): 56164; Louis Fiset, "Health Care at the Central Utah (Topaz) Relocation Center," Journal of the West38, no. 2 (April 1999): 34-44 (hereafter cited as/OW); Louis Fiset, "Public Health in World War II Assembly Centers," 565-84); Louis Fiset, "The Heart Mountain Strike of June 24, 1943," in Remembering Heart Mountain: Essays on Japanese American Internment in Wyoming, ed. Mike MacKey (Powell, Wyoming: Western History Publications, 1998), 101-18; Gwenn Jensen, "System Failure," 602-28; Susan McKay, "Maternal Health Care," 188-93; Susan Smith, "Women Health Workers and the Color Line in the Japanese American "Relocation Centers" of World War II," Bull Hist Med 73, no. 4 (Winter 1999): 585-601. 32. Fiset, "Heart Mountain Strike," 109. 33. WRA files, Heart Mountain Relocation Center, Community Management Division, Health Section. Final Report, Section b. 34. Fiset, "Heart Mountain Strike," 115. 35. Mary Hidaki, interview 11 December 1997. 36. Ibid. 37. Nurse aides and other nursing personnel at Heart Mountain were issued "suggestions" for their practice on the wards by Chief Nurse Anna Van Kirk, who arrived at Heart Mountain in March 1943. Included in the "Ethics" section, which delineated conduct toward patients, were the following: "Never discuss patients and their diseases with your family, relatives, or friends; Don't call any patients by their first names or nick names, no matter how well you may know them; Don't diagnose patient's condition; Don't let patients read their thermometer; Don't tell patients what their temperature is; Don't argue with a patient; Stand for all doctors and supervisors and rise when visitors approach to ask information; Don't argue with doctors and supervisors. Arguing consumes valuable time. Please remember your doctors and supervisors speak from experience." I am indebted to Velma Kessel for letting me photocopy her handbook. 38. Takagi, interview 10 December 1997. 39. Fiset, "Heart Mountain Strike," 115; Jensen, "System Failure," 623-26. 40. Hidaki, interview 11 December 1997. 41. Furuya, interview 9 January 1998. 42. Uriu, interview 12 December 1997. 43. Michi Weglyn, Years of Infamy: The Untold Story of America's Concentration Camps (New York: Morrow Quill, 1976), 106. 44. Ibid. 45. I am grateful to historian Allan Austin for his electronic correspondence on 9 May 2000, providing the names of Katharine Faville and Joy Stuart, which he obtained from NJASRC papers, box 14, at the Hoover Institute in California. 46. "The Problem of Student Nurses," 896.

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47. /£/W.<notes>48. Ibid., 63. 49. Takagi, interview 10 December 1997. 50. Furuya provided the author with copies of original rejection letters and WRA information sheets on student relocation. 51. Ibid. 52. Ibid. 53. Ibid. 54. The majority of nursing students recruited from 1 July 1943 to 1 July 1944 signed up to be U.S. cadet nurses, as cited in "It Happened in 1944," 45. 55. Furuya, interview 9 January 1998. 56. Hidaki, interview 11 December 1997. 57. Ibid. 58. Uriu, interview 12 December 1997.

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Caring for Life: Nursing During the Holocaust BARBARA L. BRUSH Boston College School of Nursing

This paper examines the experiences of Jewish nurses incarcerated in ghettos and concentration camps during the Holocaust. It explores their understanding and interpretation of nursing care during this period and how altered standards of care affected nurses and their patients, both victims of the brutal and inhumane circumstances imposed by their Nazi captors. Focusing on an extreme example of the shifting meaning of nursing care, the paper raises broader questions about the preservation of human dignity and human rights under circumstances that are antithetical to nurse training and practice principles. Oral and written testimonies of Jewish nurses were collected and analyzed within the broader context of Holocaust historiography. Most of the oral testimonies used in this paper were housed in the Fortunoff Video Archive for Holocaust Testimony at Yale University and were recorded between 1984 and 1994, a period that coincides with the development of many commemorative programs for Holocaust survivors. 1 Thus, nurses' testimonies were prepared as part of a larger commitment to preserve Holocaust history, and not specifically to highlight nursing and health care conditions and experiences. Of course, one of the concerns in relying on memories recorded four to five decades after an event is ascertaining the reliability and validity of the shared information. Critics of oral history argue that the fallibility of human memory raises serious concerns about internal and external consistency, especially when one is recollecting the distant past. As Moss put it, "Recollections are clearly another step removed from reality into abstraction.... As evidence they must be considered less reliable than other primary evidence such as written documents."2 Further, because many of the oral testimonies of Holocaust survivors are one-time interviews, there is also an inability to develop conversation that allows for questions and revisions; one must therefore extrapolate meaning from the individual's story without an opportunity for clarification.

Nursing History Review 10 (2002): 69-81. A publication of the American Association for the History of Nursing. Copyright © 2002 Springer Publishing Company.

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As Greenspan notes, however, when specifically examining the recountings of Holocaust survivors, "Through words that come from mouths rather than books, there is at least the possibility of pointing more tangibly to what cannot be told. . . . We hear silence as an abrupt halt, a gasp for breath, the agonized deliberation around the choice of a single word."3 Thus, he argues, "bearing witness" or "giving testimony" is more than simply recalling specific incidents and experiences; it also conveys what it is to be a survivor.4 In listening to the oral testimonies of surviving nurses, one recognizes that the survivors' voices are as varied as the survivors themselves. Situating their stories within the context of testimonies written immediately after the Holocaust, photographs, diaries, and other primary documents helps to give shape to their lives as well as conformity to their words.

Remembered Helplessness In 1942, 53-year-old Gertrude Groag, her mother, her husband, her son Willi, and his wife Madia were transported from Olmuetz, Moravia, to the Theresienstadt concentration camp.5 Upon arrival, Groag registered to work as a nurse in return for the promise that "nurses enjoyed privileges and would be deferred from transport to other camps."6 Although her basic nurse training was limited to a 4week course at the Jewish Hospital in Moravia's capital city of Ostrau, Groag was assigned to Schleuse Hospital LI24, where she, one other nurse, and one physician cared for 150 patients without running water, food, or supplies. Most of the patients were elderly and three to four died each day, usually from complications of enteritis. Despite providing care under extremely poor, if not impossible, conditions, Groag initially took comfort in her belief that she was saving the lives of Hitler's potential victims. Later, to her horror, she discovered that most of her surviving patients were gassed to death upon recovery. "Everything we did lost its real value," she noted in 1965. "I felt like a marionette that moved, but it was all pretense, all hypocritical. The doctor who tried to promote the patient's well-being did not know whether he would be deported in a few days. When he saved a woman from pneumonia, she was deported two days later. What was the purpose of it all? It was an incomprehensible swindle, a fraud, and we all fell into it."7

In a poem entitled "The Sluice," Groag captured her feeling of helplessness and the bond it created between herself and her patients:

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My helpless brother at my side Old, sick, a stranger I never sought your company I never cared for your destiny How close I feel to you, my brother Helpless as 1 am myself.^ The feeling of helplessness in saving people for imminent death was echoed by Resi Weglein in "As a Nurse in the Concentration Camp Theresienstadt: Memories of a Jewess from Ulm." Written immediately after her 3-year incarceration (1942— 1945) in Theresienstadt, Weglein's memoirs were intended as a public record for Holocaust survivors and their families and a means of exorcism of her own experiences in the camp.'1 Weglein was deported from southern Germany to Theresienstadt on 22 August 1942. As she and thousands of fellow prisoners disembarked from the transport train, the sick were immediately taken by waiting trucks to the "Schleuse," while the more physically able were forced to march two hours from the station to the camp barracks.1() Exhausted after marching in the "glowing heat carrying their hand luggage," prisoners entered filthy and crowded barracks with no beds, no toilets, no food, and no light." It was at this moment, Weglein noted, "I started my duty" (p. 28). "During those days," she confessed, "I doubted God's justice and was really in despair.... The work with the sick opened my way back. I understood that I had to experience all the misery and sickness myself to be able to be what I thought a 'nurse' should be" (p.30).

Divided Discourse Weglein's misery and sickness contrasted sharply with the experiences of 22-yearold Irene W. Trained as a nurse in the Jewish Hospital in Cologne, Germany, and transported to Theresienstadt in 1943, Irene W. worked temporarily in a barracks for people suffering from life-threatening infections, washing and reusing bandages between patients, before transferring to the camp hospital surgical ward. There, she worked with nurses from Czechoslovakia who "looked like American nurses with white uniforms and lipstick." 1 Irene Ws description of a modern hospital and well-groomed Czechoslovakian nurses was substantiated in an anonymous letter written to the International Council of Nurses after the war: "Our [Czechoslovakia!!] nurses, pupils of our training schools, who volunteered for [work in Theresienstadt] have overcome all the difficulties by their enthusiasm and

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Barbara Brush superhuman effort. At the side of the doctors, they have fought bravely filth, disease, and typhus."13

Czechoslovakian nurses worked as volunteer hospital staff beside nurse and physician prisoners, their crisp white uniforms and makeup in sharp contrast to the ragged garb of other providers who shared their patients' "filth and disease." Although Irene W. did not share the good fortune of her Czech colleagues, she did receive extra food in the community kitchen and an additional bread ration for night duty. She and the other nurses also slept in a special area with bunk beds apart from other inmates and the patients and had access to Lysol with which they disinfected their rooms. More specifically, she recalled almost 50 years later, "Because I was in the hospital, I could take better care of myself. . . . I could take a shower every day."14 After a year in Theresienstadt, Irene W. and 1,000 other women and children were transported to Bergen-Belsen. She and four other nurses banded together to provide mutual physical and emotional support under the horrible conditions of camp existence. Covered with lice, in freezing weather, with no water for hygienic or drinking purposes, she volunteered to clean barracks to keep busy. Work, she noted, gave her purpose and helped her to survive, especially when it was rewarded with a few potato skins for extra sustenance. Eva K., who also worked as a nurse in the hospital operating room in Theresienstadt between July 1942 and October 1944, recalled that "you helped people get well so that they could go into transport."15 Although demoralized by the hopeless situation under which she and other nurses labored, she, like Irene W., found that "being active helped even if it was senseless." Eva K. denied receiving special privileges for her work but reported that she was not "terribly unhappy" during her 2-year incarceration at Theresienstadt. Perhaps, as for Irene W., the contrast between Theresienstadt and her later experience in Auschwitz made Theresienstadt seem tolerable in hindsight. Or perhaps, like nurse Golly D., she viewed Theresienstadt as "the lesser of many evils."16

The Lesser of Many Evils A converted military base located in the Czechoslovakian town of Terezin, Theresienstadt housed more than 60,000 people in a place originally designed for 7,000.17 Inmates, mostly Jews from Austria, Holland, Denmark, Germany, and Slovakia, were held there temporarily until they could be transported to death

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camps for extermination.18 The overcrowded conditions, limited food and water, lack of protection from environmental elements, body lice infestation, and dearth of medical supplies and care providers often equated with death by starvation, dysentery, frostbite, tuberculosis, pneumonia, and other forms of infectious or communicable disease. Of the total inmate population during the camp's existence, estimated to be around 140,000, more than 33,000 died in the camp and 88,000 were sent to death camps. Only 19,000 survived the war.19 Despite the camp's miserable conditions, however, Theresienstadt served as a "model camp," where Germans promoted the fiction that deported Jews were simply being "resettled" in the east. In the camp's ghetto area, Jews were even allowed some semblance of self-government along with cultural and artistic activity.20 Thus, when rumor spread in 1943 that doctors and nurses could remain in Theresienstadt and be spared transport to other camps, Weglein noted, "so many women applied for nursing that there was now enough people for the work."21 The eagerness with which individuals signed on to caregiving roles suggests that many conceived of worse fates upon transport outside of Theresienstadt, just as they had upon leaving the ghettos. Mary E., for instance, recalled that, although no one knew for sure what occurred after deportation, there was an indication of what was happening.22 When she and her family and friends were sent to various camps from the Lodz ghetto in 1941, for example, they bade farewell with the common expression, "We'll meet on the shelf." In other words, they suggested a future reunion as bars of soap made from human fat.23 Historian Walter Laqueur argues that many inhabitants of the ghetto did know about the "Final Solution" from witnesses to events in the Soviet Union and death camps like Chelmno, only 40 miles from the Lodz ghetto. Because post offices in Poland continued to function, warnings arrived from all over the country to family and friends in the ghettos.24 Most people, however, simply did not believe what they heard or read.^

A Landscape of Terror By 1942, there were 15 major concentration camps and six extermination camps in the Fuhrer state. The extermination camps—Chelmno, Auschwitz, Treblinka, Sobibor, Belzec, and Majdanek—were located in occupied Poland. Auschwitz consisted of three camps: Auschwitz I, for political prisoners; Auschwitz II, or Birkenau; and Auschwitz III, or Buna, for slave laborers. Birkenau, the official "killing center" for the camp complex, had four gas chambers capable of extermi-

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nating 6,000 people per day. They were constructed in special combination units that promoted immediacy and efficiency; each had an underground dressing room, the gas chamber itself, and its own crematorium in which to dispose of the bodies.26 Individuals sent to these camps were either gassed upon arrival or were worked to death in local factories or quarries, their bodies destroyed in crematoria situated on site. While other camps did not have crematoria, deaths by disease, starvation, or shooting were commonplace. Cruel medical experiments were routinely conducted by Nazi physicians on unwilling prisoners.27 Nurses often assisted physicians in their work.28 Each major camp served as the center of a system of smaller camps throughout Germany, Austria, and occupied Poland. For example, there were an estimated 240 auxiliary camps under the control of the Dachau camp administration alone, each created to serve a particular labor need.29 Among all the camps, the systematic murder of Jews, which began in 1941, resulted in the death of over 6 million men, women, and children.30

Risk and Resistance Polish pharmacist Siegfried H. was one of 400 Jewish men transported to Gross Rosen in September 1941.31 There, high in the Sudeten mountain region in Germany, he and the others were forced to do hard labor in the rock quarries until only 17 men remained alive 4 months later. In January 1942, he was transported to Auschwitz as part of the Final Solution.32 When the Germans discovered his pharmaceutical background, he was sent to "nurse" in the camp infirmary along with one physician. The Krankenbau, or Ka-Be, as the infirmary was called, consisted of eight huts and two clinics, one for medical patients and one for surgical patients.33 Three to four people shared each hospital bed, and most were morbidly ill from tuberculosis or pneumonia. Direct care was limited to the application of cold compresses for fever reduction and the administration of basic kindness. Inmates quickly realized that few people who entered the infirmary emerged alive.34 A few months into his assignment, however, an SS (Schultzstaffel) guard unexpectedly supplied the hospital with twelve tablets of sulpha, only recently discovered to be effective treatment against some forms of bacterial infection.35 Given the limited supply, the hospital physician was forced to decide which patients would benefit most from the treatment. In a bold move, Siegfried H. asked the guard for more pills; to his surprise, he was given 24 more tablets. Though only

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a small amount, the additional antibiotics offered hope of survival for a chosen few. Siegfried H. and his physician colleague also successfully organized a makeshift surgical department, with instruments made by fellow prisoners and smuggled into the hospital. They built their own X-ray machine and experimented, he believed for the first time in the world, with shock treatment for mentally disturbed girls. Whether shock therapy was part of Nazi medical experimentation or an effort by sympathetic caregivers to help psychiatric patients is unclear from Siegfried H's testimony. Because he lived in the notorious "Block 10," known as a center for experimental projects on female prisoners, however, Siegfried H. was probably privy to, perhaps part of, the experimental impulse of Nazi physicians.36 He noted that, when physician Josef Mengele chose individuals for experimentation, he [Siegfried] often erased the numbers of two or three of the prisoners selected. In doing things like that, he believed, the camp hospital and its workers became a key form of organized resistance against the Nazis. Author Inga Clendinnen equated overt resistance in Nazi labor camps with suicide.37 For many, however, resistance, with all its associated risks, proved morale-transforming. Physician Olga Lengyel noted, for example, that her participation in an underground resistance movement in Auschwitz helped her to focus on survival rather than despair: "In the beginning, I did not know much of the enterprise in which I was participating. But I knew I was doing something useful. That was enough to give me strength. I was no longer prey to crises of depression. . . . That, too, was a way to resist."38 Resistance also defined the survival experience of Richard O. One of three men trained in a 3-month nursing program in the Krakow, Poland, ghetto in 1940, Richard O. was deported to the Plaszow labor camp after helping a friend escape from the ghetto in 1943. At Plaszow, he was assigned to work in the camp hospital until the camp's liquidation in January 1944.39 As in other camps, most of his patients suffered from pneumonia or bronchitis, frozen feet, or malnutrition. Because contact between male and female inmates was permitted, abortions were also performed routinely. When women brought pregnancies to term, their newborn infants were drowned, poisoned, or smothered shortly after birth by nurse and physician caregivers. The infants' deaths ensured that the mothers would live. "The mother knew about it but nothing could be done," Richard O. recalled later. "Pregnancies were not allowed. . . . Dogs were allowed to attack pregnant women.'"10 Infanticide, justified as life-saving for women, also became a key form of resistance in a system that routinely killed both mother and child at delivery."

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However, as many nurses reported, there were numerous risks in attaching oneself to the cause of saving others. As children were being transported to Auschwitz after the liquidation of the Plaszow labor camp, for example, Richard O. hid the 10-year-old daughter of a physician colleague in the hospital morgue to save her from certain death. Upon learning of his action, the girl's father asked that she be returned for transport, as discovery would have meant death for all of them.42 Later, however, Richard O. successfully cared for a friend shot through the neck by the Camp Commandant and left for dead. Richard O. put his friend on a stretcher, instructed him to feign death, and cared for him in hiding. His friend ultimately survived, and lived his remaining years in Israel.43

Benefits and Survival Even as risks were regularly associated with nursing care in camp infirmaries, the benefits of being a nurse were equally tangible. Work as a nurse often brought additional food, shelter, and access to materials that aided survival. While paltry, these amenities, nonetheless, were often the difference between life and death. Daniel C. recalled that, as a nurse in Auschwitz for 18 months, he labored inside, under a roof, when most inmates were exposed to extreme weather conditions wearing only thin cotton pajamas and wooden shoes.44 Typically working 17-hour work shifts, many inmates froze to death during the winter or died from a combination of starvation and illness within months of arrival at the camps.45 Food rations usually amounted to nothing more than a slab of bread made from flour and sawdust accompanied by a hot, foul-smelling liquid for breakfast, a watery soup made from turnips, potato peelings, cabbage, and pieces of wood at midday, and a slab of bread with margarine or putrid meat for dinner. Usually, inmates waited hours in line for their food rations, often to be turned away with nothing.46 Although Daniel C. and the other nurses received the same meager food rations as other inmates, the lack of hard labor stretched their limited caloric intake farther and, along with shelter from the elements, enabled their survival.47 Regina G. also attributed much of her survival to working inside as a nurse in the Gypsy camp hospital at Birkenau.48 She and other nurses were able to steal extra food rations that helped prevent severe malnutrition. Mary E. reported that the camp infirmary at Ravensbriick was the only heated place in the entire camp. There, she could sit, be warm, and get extra soup. She felt ashamed each time she passed other starving prisoners to receive her extra soup ration. She walked with her eyes cast down to avoid their stares, she confessed in 1984, "but I went."49

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The Shame of Survival Nurses who described self-preservation in the form of extra food rations, indoor conditions, or salvation from transport often expressed shame or remorse in the aftermath of the experience. In 1989, for example, Daniel C. confessed to lying about having pharmaceutical training in order to secure a nursing position in Auschwitz, knowing that by doing so he may have replaced someone else.50 Often, survivor guilt was expressed as the struggle between professional selflessness and self-preservation. As Mary E. noted, "Much of the survival effort centered on yourself. . . . The sufferings, the wounds, the lice were eating you alive from top to toe."51 Nurses who "passed" as non-Jews to avoid incarceration and death also described their survival with mixed emotion. Helene R. was 10 years old when Hitler came to power in 1933." Raised in a large Orthodox Jewish family in Warsaw, Poland, she entered nurse training at the age of 16 after the Warsaw ghetto was established. When a typhus epidemic ravaged the ghetto and sick patients overwhelmed its limited resources, the Germans deported doctors, nurses, and patients to Auschwitz so that "they would have a better chance to recuperate."53 Because typhus in ghettos was essentially a death sentence for victims and their families, many people believed the falsehood.54 Soon thereafter, however, a rumor spread that individuals sent to Auschwitz were being "burned," and that the ghetto, facing liquidation, would similarly be cleared of its population.^ Helene R. and her sister escaped, traveling by train throughout Germany until they were captured and returned to Poland to work as laborers for the German war machine. Hiding her Judaism, Helene R. identified herself as a Polish national and was assigned to the Mosebach-Baden Hospital to nurse Polish, Russian, Italian, and French prisoners. For almost three years, she worked beside Nazi physicians and nurses, leading a "double life." As she put it, "In the day I was a Pole and at night I was Jewish, dreaming of my mother."56

Conclusion Regardless of their gender, prior nurse training, nationality, or camp location, nurses consistently linked the work of caring with self-preservation, not only because of the material benefits of food and shelter, but because it provided a physical and mental diversion from the reality of camp existence. As Weglein noted, "Work helped nurses forget their own misery, or at least cope with it

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differently."57 In other words, nurses maintained their busy work to redirect their focus from what they saw every day—the inhumane destruction of life. One survivor of Birkenau described this as a process of "pulling down the shade" to the realities of camp existence.58 Unfortunately, when the "shade" was up, many nurses discovered the helplessness and hopelessness of their situations in the pain and suffering of their patients, their families, their friends, and themselves. Whether the shade was generally up or down during the actual period of incarceration is difficult to determine in testimonies given years after their traumatic experiences. For other nurses, caring helped them preserve their own humanity through the moral treatment of others. Thus, the act of caring itself, rather than just the tangible gains of being a nurse, correlated with survival. Indeed, several nurses noted that being needed or loved by their patients gave them purpose and strengthened their ability to stay alive.59 Whether nurses attributed their roles as nurses as helping with their own or, in some isolated instances, their patients' survival, however, there are consistent threads throughout their testimonies. Caring work was taxing and difficult and, usually, hopeless. Nonetheless, caring was also hopeful and distracting and helped individuals find greater strength than they would have had if they had been taking care of themselves alone. Indeed, caring for others meant caring for life, both from an individual standpoint and from the broader perspective of trying to save people from annihilation. BARBARA L. BRUSH, RNC, PHD, FAAN Associate Professor Boston College School of Nursing 140 Commonwealth Avenue, 420 Gushing Hall Chestnut Hill, MA 02467

Acknowledgments The author wishes to acknowledge the support of a Boston College Research Expense Grant and a Sigma Theta Tau Chapter XI grant for this study. Notes 1. Actually, several programs began in the late 1970s after NBC aired "Holocaust' on television, watched by an estimated 120 million people over four evenings in April 1978.

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See Edward T. Linenthal, Preserving Memory: The Struggle to Create America's Holocaust Museum (New York: Viking, 1995). 2. William Moss, "Oral History: An Appreciation," in Oral History: An Interdisciplinary Anthology, 2nd ed., eds. David K. Dunaway and Willa K. Baum, (Walnut Creek, Cal.: Altamira Press, 1996), 110. 3. Henry Greenspan, On Listening to Holocaust Survivors: Recounting and Life History (Westport, Conn.: Praeger, 1998), 27. 4. Ibid., 15. 5. Theresienstadt is known as Terezin. 6. Translated interview of Gertrude Groag by Gershon Ben David, 21 September 1965 and 3 October 1965. In Mothers, Sisters, Resisters: Oral Histories of Women Who Survived the Holocaust, ed. Brana Gurewitsch, (Tuscaloosa: University of Alabama Press, 1998), 242-56. 7. Ibid. 8. Ibid. 9. Resi Weglein, Als Krankenschwester im KZ Theresienstadt (As a Nurse in the Concentration Camp Theresienstadt (Stuttgart: Silberburg-Verlag, 1988). 10. Weglein described the "Schleuse" as a place where everyone was checked in upon arrival at the camp. 11. Eve Nussbaum Soumerai and Carol D. Schulz describe the long, arduous treks from the train stations and ghettos to the camps, noting, "Regardless of how exhausted, hungry, injured, thirsty, or ill, all newly arrived inmates were treated with brutality."Daily Life During the Holocaust (Westport, Conn.: Greenwood Press, 1998), 173. 12. T-2268, Irene W. Interview 5/30/91 by Jan Darsa, Zelda Kaplan, and Harriet Wacks, Fortunoti Video Archive for Holocaust Testimonies, Yale University Library (hereafter called HVAHT Yale Library). 13. Undated and anonymous letter to the International Council of Nurses Office, The Czechoslovakian Nurses and Health Staff During the War and Occupation, two pages. International Nurse Refugee Files, Center for the Study of the History of Nursing, University of Pennsylvania, Philadelphia, Pa., MC 112, Box 12. 14. Ibid. 15. T-0681, Eva K. Interview 3/21/84 by Gabriele Schiff and Emanuel Landau, FVAHT Yale Library. 16. These words were used by Golly D., T-2475, when describing her incarceration in Theresienstadt in May 1943. Interview 10/22/92 by Margaret Agnee, FVAHT Yale Library. 17. Ruth Bondy, "Women in Theresienstadt and Birkenau," in Women in the Holocaust, eds. Dalia Ofer and Lenore J. Weitzman (New Haven: Yale University Press, 1998), 310-26. 18. See Michael Berenbaum, The World Must Know: The History of the Holocaust as Told in the United States Holocaust Memorial Museum (Boston: Little, Brown, 1993). 19. Berenbaum, The World Must Know, 87. 20. For further discussion of the concentration camps between 1939 and 1943, see Mary Fulbrook. The Divided Nation: A History of Germany 1918-1990 (New York: Oxford University Press, 1992), 106-119. 21. Weglein, As a Nurse, 38.

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22. The Nazis were known to use the hair and body fat of their victims as a profitmaking enterprise. See Berenbaum, The World Must Know. 23. T-0260, Mary E. Interview 3/21/84 by Dana Kline, FVAHT Yale Library. 24. Walter Laqueur, The Terrible Secret: Suppression of the Truth about Hitler's "Final Solution" (Boston: Little, Brown, 1980), 130. 25. The disbelief many displayed when given news of Nazi treatment of the Jews is echoed in the testimony of Ernest Gelb, documented by Soumerai and Schulz in Daily Life During the Holocaust, 210-17. 26. Berenbaum, The World Must Know. 27• See Robert Jay Lifton, The Nazi Doctors: Medical Killing and Psychology of Genocide (New York: Basic Books, 1986). 28. The professional and moral choices made by German nurses are poignantly described by Hilde Steppe, "Nursing Under Totalitarian Regimes: The Case of National Socialism," in Nursing History and the Politics of Welfare, eds. Anne Marie Rafferty, Jane Robinson, and Ruth Elkan (London: Routledge, 1997), 10-27, and Bronwyn Rebekah McFarland-Icke, Nurses in Nazi Germany (Princeton, NJ: Princeton University Press, 1999). 29. Among the companies that regularly used slave labor was BMW, the auto manufacturer. See Robert H. Abzug, Inside the Vicious Heart: Americans and the Liberation of Nazi Concentration Camps (London: Oxford University Press, 1985). 30. Richard Overy, The Penguin Historical Atlas of the Third Reich (London: Penguin Books, 1996), provides a comprehensive geographical overview of the rise and fall of the Nazi state. 31. T-0411, Siegfried H. Interview 10/11/95 by Melissa Pleasant, FVAHT Yale Library. 32. The dictate for a "Final Solution to the Jewish Question" was handed down by Adolf Hitler to Heinrich Himmler in the summer of 1941. Mass killings of Jewish prisoners by gassing and cremation were widely operationalized. See Lucy S. Dawidowicz, The War Against the Jews, 1933-1945 (New York: Bantam Books, 1975). 33. Soumerai and Schulz, Daily Life During the Holocaust. 34. Primo Levi, Survival in Auschwitz: The Nazi Assault on Humanity (New York: Collier-MacMillan, 1971). 35. Lifton, in The Nazi Doctors, noted that the SS initially began as Hitler's elite personal guard unit and attracted many individuals from the aristocracy and professional classes, including physicians. As such, it was independent of the ruling bureaucracy and had its own courts, press, and military, the Waffen-SS. According to Soumerai and Schulz, however, at Auschwitz the guards were German SS troopers held incapable of battlefield assignments. Daily Life During the Holocaust, 179. 36. Lifton describes the experiments in Block 10 in detail in The Nazi Doctors, 269-302. 37. Inga Clendinnen, Reading the Holocaust (Cambridge: Cambridge University Press, 1999). 38. Olga Lengyel, Five Chimneys: The Story of Auschwitz, trans. Clifford Coch and Paul Weiss (Boston: Northeastern University, 1995). 39. T-2935, Richard O. Interview 4/18/94 by Joni-Sue Blinderman, FVAHT Yale Library.

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40. Ibid. Leni Yahil also describes how specially trained dogs were used to attack people in Buchenwald, particularly Gypsies who refused sterilization. "After their hands were tied behind their backs, the dogs tore them to pieces." The Holocaust: The Fate of European Jewry, 1932-1945 (New York: Oxford University Press, 1990), 536. 41. Women discovered to be pregnant or to have given birth were killed by the Secret Service (SS). See Lifton, The Nazi Doctors, 224-25. 42. T-2935, Richard O., 4/18/94. 43. Ibid. 44. T-1143, Daniel C. Interview 1/11/84 by Sharon Reichlyn, FVAHT Yale Library. 45. Soumerai and Schulz, Daily Life During the Holocaust, 190. 46. Eugene Aroneau, Inside the Concentration Camps: Eyewitness Accounts of Life in Hitler's Death Camps, transl. Thomas Whissen (Westport, Conn.: Praeger, 1996). 47. T-1143, Daniel C., 1/11/84. 48. T-1286, Regina G. Interview 11/13/89 by David Mascari, FVAHT Yale Library. 49. T-0260, Mary E., 3/21/84. 50. T-1143, Daniel C, 1/11/84. 51. T-0260, Mary E., 3/21/84. 52. T-0015, Helene R. Interviewer not identified, FVAHT Yale Library. 53. Ibid. 54. The penalty for the typhoid victim and his/her family was a 2-week isolation period, during which the house was locked and guarded and no one was allowed to bring food. This often condemned the family to starvation. In addition, all of the home's residents and those of neighboring houses were taken to bath houses, where conditions were "so inhumane that many healthy people fell ill and many older sicker people died." Soumerai and Schulz, Daily Life During the Holocaust, 100. 55. Ibid. 56. Ibid. Helene R. attributed her inability to "speak Jewish" to saving her life. Although her parents spoke Yiddish in the home during her childhood, she did not master the language because she went to a Polish school. 57. Weglein, A Is Krankenschwester, 85. This is the rough translation provided by Tatjana Meschede, University of Massachusetts. 58. Greenspan, On Listening to Holocaust Survivors, 16. 59. Weglein described her work on a ward with 72 older women who "loved me a lot" in Als Krankenschwester, 85. In addition, Adele "Deli" S. received training as a nurse at the age of I 7 . Born in Vienna, Austria, to a well-known Jewish businessman and a Christian mother, she studied nursing in a hospital for ailing Viennese Jews in 1938. There, a dying woman begged her to care for her daughter, Nita, upon her death. In 1941, Deli and Nita were taken in one of the first transports to Theresienstadt, and they stayed together from 1941 to 1945. Deli cared for Nita throughout their incarceration. Caring for Nita, she testified 47 years later, gave her a reason to live and hope for survival. T-1145, Adele "Deli" S. Interview 12/12/88 by Ellen Nusgart and Frania Block, FVAHT Yale Library.

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Smaller and Cheaper: The Chicago Hourly Nursing Service, 1926-1957 JKAN C. WHF.I.AN Center for Outcomes and Policy Research

In the summer of 1926, along with their regular home deliveries of milk and cream, Chicago milk dealers included folders announcing the grand opening of an Hourly Nursing Service.' Established by the First District of the Illinois State Nurses Association, the Chicago Hourly Nursing Service was designed to deliver affordable, short-term private nursing care to paying patients in their own homes. Hourly nursing schemes, which gained popularity in the late 1920s and 1930s, aimed to solve two early twentieth-century health care problems: serious underemployment of private-duty nurses, and high out-of-pocket patient expense for professional nursing care. Notwithstanding significant publicity, substantial financial investment, and the assistance of the milkmen, the initial years of operation for the Hourly Service proved disappointing. Stymied by Depression-era conditions, hourly nursing failed to make an impact on either nurse employment or patient expenditures. Despite its poor showing, the Chicago Hourly Nursing Service remained in business. By mid-century, the Service had an established record of furnishing patients with an alternative to dominant methods of nursing care delivery and providing nurses with additional choices regarding their workplace setting. On 31 December 1957, after 31 years of operation, the First District cited persistent financial deficits that it was no longer willing to assume, and terminated the Hourly Nursing Service. The precise reasons for discontinuing the Service are obscure. Implicit in the decision was acceptance of contemporary ideas regarding the proper role and place for professional nurses in the delivery of health care. Recognizing that acute-care institutions monopolized the market for nurse services, the professional association rejected a program that concentrated on home-based services. Hourly nursing services delivered care to patients at their own request and in convenient home settings. This model of independent nursing practice was incompatible with

Nursing History Review 10 (2002): 83-108. A publication of the American Association for the History of Nursing. Copyright © 2002 Springer Publishing Company.

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patterns established by the mid-1950s, in which nurses worked predominantly as employees providing patient care in large health care organizations and institutions. This paper will describe conditions in the professional nurse job market that led to the institution of hourly nursing services in general, and specifically to the establishment of the Chicago Hourly Nursing Service.2 Records, reports, minutes of meetings, and statistical data of the Chicago Service from its inception in 1926 to its 1957 termination will be reviewed and analyzed. Emphasis will be placed on events leading up to the final decision to end the Service, and will highlight how changes in demand for nurses occurring during the post-World War II era shaped the manner in which nursing care was delivered. For a small group of Chicago nurses, the closure of the Service meant a lost opportunity to maintain a significant amount of autonomy in their working lives. Analyzing the circumstances that led to that decision can help to increase understanding of nurses' work as it developed in late twentieth-century America.

Solving Employment Woes Hourly nursing programs supplied private home-based nursing care for short periods on a temporary basis to paying patients. The genesis of hourly nursing services can be traced to the peculiar occupational problems faced by professional graduate nurses in the first decades of the twentieth century. Turn-of-the-century hospitals in the United States solved their need for a trained group of nurse workers to deliver increasingly complex patient care by opening schools of nursing. These schools offered young women a modicum of training in return for their labor for the duration of their studies.3 Once students completed training programs, hospitals had little interest in them. Graduate nurses, considered too expensive or troublesome for hospitals to employ, typically sought work as private-duty nurses hired and paid for by individual patients.4 The private-duty job market was a rugged job market. Graduate nurses faced uncertain employment, insufficient income, and abysmal working conditions.5 Contributing to troubles encountered by nurses pursuing work were certain inflexible customs of private-duty nursing that served to exacerbate an already dismal situation. The conventions of early twentieth-century private-duty practice dictated that nurses work 12-24 hours, 7 days a week, in hospitals or patient homes, caring for one patient for the duration of an illness.6 The custom of remaining with one patient for extended periods of time created difficulties for nurses who received

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no relief during a case, and was often impractical from the patient's perspective. Not all patients needed the constant attention of a registered nurse throughout an illness. When a patient required only very specific nursing measures that could be given in a few hours, hiring a nurse for an entire shift of work seemed excessive. For home-based patients, living quarters did not always allow sufficient space for a nurse who was expected to remain in attendance throughout the night. In many cases, the expense of hiring nurses for an entire day over a period of weeks was simply prohibitive.7 By the 1920s, estimates of private-duty nurse fees ranged from $4-7 for 12-24 hour duty.8 The cost of a lengthy illness put professional nurses' services out of reach for most of the population. Estimates vary about what proportion of people actually received private-duty services, but it was generally understood that only wealthy or upper-middle-class patients could afford private nursing. 9 Poor patients relied on visiting nurse services when illness struck, but individuals between the two economic extremes, when confronted with a nursing care dilemma, were often forced to forego nursing care.10 For nurses, the pool from which patients could be drawn was limited, restricting the aggregate number of cases available. Leaders in the health care field realized that middle-class patients were as entitled to receive professional nurse services as the wealthy and the poor, and that those services did not necessarily require 24-hour nurse availability. They urged nurses to find ways to increase the numbers of patients receiving nursing care, thus addressing nurse employment problems while reducing the price of nursing care." Hourly nursing was one mechanism that promised to deliver affordable care while increasing work opportunities for nurses. For both patients and nurses, the benefits were evident. Hourly nursing schemes allowed one nurse to deliver care to multiple patients, each for a few hours. Delivering care to several patients over the course of the day offered nurses a varied, less boring work experience. More patients could receive professional nursing care in their homes without the expense and inconvenience of full-time private-duty services. Diversification of private-duty services offered nurses the potential to enlarge the pool of patients to those less affluent. Patients could be nursed at a price they could afford, and nurses were promised a degree of economic security. 12 The public, one author noted in writing on the subject of hourly nursing, "would buy much more nursing if it could get it in smaller and cheaper parcels."13 In the first decades of the twentieth century, enterprising nurses could and did set up independent nursing practices. Early professional journals reported anecdotal stories of successful nurses who hung out their own shingles.14 These articles, clearly biased in favor of successful hourly nursing ventures, presented a valid argument that hourly nursing met a legitimate need of patients while at the same

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time supplying an income for nurses.'5 But independent practice, often called "freelance nursing," aroused the suspicions of nursing leaders on two counts.16 First, the average graduate nurse was deemed to be inherently in need of supervision and guidance in daily work activities.17 Second, a potential threat existed that unlicensed nurses might enter the hourly nursing field if it were not regulated through reputable groups.18 By the mid-1920s, delivering hourly nursing care through established organizations, rather than by hiring individual nurses, was preferred. Organizations with employed staff capable of answering patient requests for services at any time seemed to offer the most economic, efficient way in which to meet patient needs for intermittent nursing care, while at the same time furthering the aims of professional leaders for whom legitimating and controlling nursing practice was a major priority.19 Two types of agencies were suggested as ideal for supplying hourly nursing: private-duty registries, and Visiting Nurse Associations (VNAs). VNAs already specialized in providing hourly services to the poor. By expanding their services to paying patients, VNAs reaped financial rewards, lessening their dependence on contributions for survival. Their organized nursing staffs and experience in delivering intermittent bedside care promised success in hourly nursing ventures. Several VNAs throughout the country operated some form of hourly nursing program by the late 1920s.20 Despite a seemingly perfect arrangement, visiting nurse organizations failed to deliver effective paid hourly services. Historian Karen Buhler-Wilkerson, in her analysis of public health nursing, concluded that VNAs experienced difficulty in connecting their mission to serve the less fortunate with those who could pay.21 Visiting nurses placed less priority on meeting the needs of paying patients and created inflexible arrangements that did not fit private patient requirements and expectations. Contemporary reports indicated that hourly nursing accounted for only 1-3% of visiting nurse services.22 Private-duty nurse registries were the second type of agency through which hourly services could be provided. Nurse registries existed as placement bureaus for nurse services. Patients or physicians requiring private nursing services found in registries a convenient way to contact available nurses. Private-duty registries were generally classified into three main types: hospital-based or alumnae association registries, which placed nurses within specific institutions; commercial, profitmaking agencies, which worked as employment bureaus answering requests for a variety of nursing services; and professional nurse registries. Professional nurse registries were sponsored by either state or district nurse associations and adhered to professional association guidelines. They offered the patient a higher-caliber nurse than might be provided by a commercial agency, while, unlike hospital-based registries, covering an area greater than one specific hospital.23

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Leaders of the professional nurse registry movement envisioned a role for professional registries as a nurse distribution system capable of meeting a wide variety of community nursing needs.24 Hourly nursing fit neatly into plans to expand private-duty services via professional registries. Registries offered a structure through which hourly nurses could be screened and organized, which assured a level of control over nurses' work that the professional organizations believed necessary to solidify nursing's status with the public. Hourly nursing seemed likely to create new opportunities for work in a field beleaguered with severe underemployment. Accounts in professional journals in the mid-1920s indicated that several professional registries nationwide had established hourly nursing programs.25 One endeavor that promised a high degree of success was the Hourly Nursing Service operated by the Official Registry of the First District, Illinois State Nurses Association.

The Chicago Scene The First District of the Illinois State Nurses Association, containing the counties of Lake, DuPage, and Cook and including the city of Chicago, operated one of the largest, best-known professional nurse registries.26 Opened in 1913, the Official Registiy achieved a great deal in a short time. By 1925, the registry had 1,364 enrolled nurses and recorded its busiest year for patient calls received.27 Despite these accomplishments, concerns over the cost of private nursing and an unstable job market led to the development of a new type of registry service, an Hourly Nursing Service for the city of Chicago, in 1926.28 Cooperating with the First District in this endeavor was the Central Council for Nursing Education, a group composed of business and professional leaders and members of hospital auxiliaries.29 This group promised significant financial support for the first year of operation. A Joint Committee on Hourly Nursing, composed of representatives from the First District and the Central Council, was organized to oversee the Service's initial years of operation. The Official Registry administered the Service. An extensive publicity campaign, which included newspaper articles, radio talks, and speakers to community groups, was inaugurated to familiarize potential patients and physicians with the availability of the Service, which opened for business on 1 July 1926.30 Designed primarily for patients newly released from hospitals who might benefit from short periods of nursing care, as well as for patients living in small quarters or hotels where the long-term presence of a nurse would prove burden-

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some, the Hourly Nursing Service charged patients $2 for the first hour of nursing care and $1 for each hour thereafter.31 Hourly nursing was designed to be patientfriendly, and allowed patients an unusual array of choices about timing and number of nursing visits. Patients had the option of determining frequency and length of nurses' visits up to a 4-hour limit. Nurses made designated appointments with patients based on patient request and convenience. This accommodation, considered essential to attract middle-class patients, was a major differentiating characteristic between hourly nursing and regular paid visiting nurse services.32 It was anticipated that the new program would fail to make a profit in its first year of business, but hope was high that a deficit could be avoided. Operating costs for the first year included director and staff nurse salaries and expenses for publicity.33 Hiring staff nurses to deliver private nursing services differed from traditional practices of private-duty nursing. Private-duty nurses worked as independent contractors, relying on patient-generated fees for income. The registry served as a liaison between nurses and patients, not as an employer of nurses. Promoters of hourly nursing supported use of salaried nurses, rather than independent private-duty nurses, as a way to provide a stable workforce available to meet sudden requests for care. Unlike private-duty nurses, who were believed to be distracted by the need to acquire cases, the salaried hourly staff nurse was assured of a guaranteed income and leisure time. She would be relaxed and rested, able to devote full energies and attention when working. Hiring staff nurses was a costly proposition, and the expense would present future problems. Having a salaried staff did not eliminate the need to engage part-time nurses who worked on a feefor-service basis and supplemented the regular staff as necessary.35 The first years of operation for the Hourly Nursing Service were disappointing. Slow growth resulted in repeated deficits that continued to be covered by the First District and the Central Council. In an effort to reduce operating expenses, the number of staff nurses was decreased to one in 1929.36 Despite poor financial returns, the Joint Committee was convinced of the need for hourly nursing, believing that if the Service were better known to the public, success would follow. Commitment to the project by the Joint Committee and the First District remained high. The American Nurses Association's executive director, Janet Geister, echoed the Joint Committee's enthusiasm. Geister had been a strong advocate of new initiatives for delivering private nursing services to meet changing patient needs. She supported hourly nursing approaches, particularly those operated by professional registries. In 1930, Geister sent the Chicago project a lengthy letter outlining features she believed necessary for a well-run operation, pointing out that the

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Chicago program had many elements already in place.37 But limited growth of the Service meant that more would be needed than either Geister's endorsement or the Committee's resolution to make hourly nursing a success.

Help From the Rosenwald Fund By 1930, the hourly nursing venture needed an infusion of capital to survive. The Julius Rosenwald Foundation came to its rescue with an $11,500 one-year grant. Included in the grant was provision for a demonstration project conducted by the Service to determine if better publicity would result in greater success, or if hourly nursing was not the type of nursing service wanted by patients. The grant provided monies for promotional activities and half of the operating deficit.38 A Board of Directors was appointed and charged with responsibility for the direction of the project. An executive director and one additional staff nurse were employed, bringing the total number of salaried staff to three. As in previous years, part-time nurses, now titled "Associate Nurses," were utilized. Associate nurses paid a 10% commission to the Service on fees collected from patients.39 The Rosenwald Project began on 1 January 1931.'10 The initial 6 months of the study were encouraging. Across-the-board increases were noted in new cases received, patients under care, visits made, and fees earned.41 This success was fleeting. Over the second 12 months of the project, calls for services declined. To offset losses, a new fee arrangement was offered to patients under which they could be charged a lower rate if they accepted non-appointment visits. 42 Few patients took advantage of this saving. The Rosenwald Fund granted a second appropriation of $10,000 in January 1932.43 The number of cases admitted in the first 6 months of 1932 nearly equaled those for the first 6 months of 1931. During the second year, however, lower fees for nonappointment services and fewer visits per patient reduced collections.44 The disappointing outcome of the experiment in the first half of 1932 resulted in a decision to conclude the study in July 1932. The study generated a significant amount of data on financial returns, patients served, promotional techniques, and types of cases visited.45 The most significant finding was that hourly nursing, created to serve patients of moderate income, was instead used by those considered to be in the upper middle class. More than 60% of the patients served were classified as being either comfortably well-off or wealthy.46 It was hypothesized that those in prosperous financial circumstances,

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who would have normally used regular private nursing services, may have been exercising financial prudence by using less expensive nursing during the economically unstable period of the early 1930s. Most requests for nurse services were from patients with acute problems. Acute cases were of shorter duration and required fewer visits per nurse, which reduced total earned income. More than half of acute cases were dismissed after one or two visits. Chronically ill patients, particularly those over 65 years of age, constituted a significant number and received more visits than those with acute problems. The chronically ill represented a potentially more profitable source of earnings for hourly services. Sixty percent of requests for nursing services were for morning visits, which met patient needs but resulted in inefficient use of nurses' time and were a major contributing factor to deficits. Once nurses completed their morning cases, little work remained. Salaried nurses employed on an 8-hour basis generated revenue for only a portion of the day. The Service was unable to devise a workable solution to this problem. The nonappointment service, which spread visits out throughout the day, was not widely used. Associate nurses might have been used to make initial patient contact, transferring subsequent visits to staff nurses who could then arrange their schedules more efficiently. But two principles of nurse assignment— arranging visits at patient convenience and providing care by the same nurse throughout the case—were strictly adhered to throughout the project and prevented consideration of alternative methods of nurse assignment. Conclusions of the study indicated a need for hourly nursing services, particularly in the care of the chronically ill, but that there was less demand for such services than expected. The market for hourly nursing, lower than anticipated, was considered insufficient to solve professional nurse underemployment. Problems in maintaining sufficient staff to deliver personalized service to patients limited the ability to make the Service self-supporting. The timing of the project during the Great Depression was unfortunate. The unusual economic conditions probably were detrimental to the success of any new business venture, and limited Service use. Michael Davis, Director of Medical Services of the Julius Rosenwald Fund, reviewed the study's findings.47 Davis agreed that a real demand for hourly services existed, but challenged offering it through a private-duty registry. He believed that the financial outlays required to support a staff large enough for efficient functioning were impossible to generate from patient fees alone. An hourly nursing service operated by a private-duty registry would continue to require large subsidies. Davis maintained that hourly nursing administered via a private agency violated public health nursing principles. Historically, a variety of public health nursing agencies

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specializing in specific disease entities or conditions had competed with one another, creating confusion and duplication of efforts.48 Replacing specialty agencies with generalized public health services and providing for all community health needs through one agency had been a goal of public health leaders. Davis believed these goals had been achieved by the 1930s. Dividing home nursing services economically between private and charitable organizations was, in his opinion, a step backwards. Davis recommended that hourly nursing services be developed as an integral part of a general public health or district nursing organization. Davis's ideas reflected both contemporary practice and a consensus among health policy leaders.49 Nonetheless, providing hourly nursing services through organized public health agencies remained controversial. Most contemporary writings on hourly nursing agreed that, while a need existed, a tremendous demand did not. This view should not have been surprising, given contemporary trends in which sick care was largely centered in hospitals.50 Using large public health or visiting nurse organizations to deliver a service for which demand was modest, while seemingly efficient economically, might also have represented overkill. Smaller localized nursing services might be able to meet the need equally well. It was probably useless to encourage visiting nurse organizations to support hourly services. A national study carried out by the Joint Committee on the Distribution of Nursing Services, a committee of the three largest professional nursing organizations, found that the vast majority of hourly nursing services were operated by visiting nurse associations and that these services were not flourishing financially.31 The Joint Committee recommended joint ventures with private-duty registries as promising greater success. These arguments were persuasive, and eventually moved Davis to agree with this suggestion. In 1939, citing the half-hearted attempts by VNAs to institute hourly nursing services, he advocated joint VNA/private-duty registry approaches to hourly nursing. 52

Success and Failure As the Rosenwald Fund grant expired, the First District, maintaining a belief in the future viability of hourly nursing, decided to continue carrying on the Service as an activity of the Registry.S3 The First District once more resumed responsibility for operating the Hourly Service, reactivating the Joint Committee on Hourly Nursing responsible for overseeing the Service prior to the Rosenwald study. The Hourly Nursing Service continued to operate with a salaried supervisor, one staff

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nurse, and a corps of associate nurses who paid a 10% commission to the Official Registry on patient fees collected.54 In the immediate years after the First District resumed operation of the Hourly Nursing Service, few dramatic changes occurred. Between 1934 and 1939, the number of patient cases remained relatively stable, approximating 3,000 yearly visits and 300 new patients admitted per year.55 A 1936 decision eliminating the commission paid by associate nurses, charging them instead a $20 registry fee, limited the earnings of the Hourly Service.56 This action lowered the total amount paid by hourly nurses for registering with the Service, and was based on reaffirmation by the First District's Board of Directors of its decision to continue the deficitridden program. The First District was convinced that the Hourly Nursing Service was essential for patients and represented an altruistic work of the professional association, funds from which should be contributed by all members and not unfairly charged only to those nurses working as hourly nurses. The Service continued to run average yearly deficits of $700, which the First District absorbed.57 Staffing adjustments were made as conditions demanded. By 1935, only one staff nurse was employed; 19 associate nurses worked on commission. In 1939, a decision was made to operate the Service with associate nurses only.58 The associate nurses met regularly to discuss problems and compile reports, and assumed implied responsibility for the general direction of the Service.59 The 1940s witnessed considerable growth for the Hourly Service. The number of patient visits made by nurses more than quadrupled between 1940 and 1950 (see Table 1). Patient fees were raised periodically, with no negative effect on the number of visits. By 1950, hourly nurses charged patients $3 for the first hour of service and $1 for each additional hour.60 Commissions paid by associate nurses, resumed in 1939, were lower because of fees received exceeded the cost of maintaining the Service. By 1946, hourly nurses paid a mere 4% commission. Although the Service continued to run deficits, the amounts were quite small. The 1950 deficit was recorded as $ 180.61 In the 17 years since the Rosenwald study had determined that hourly nursing programs could not be self-supporting, the Chicago Hourly Nursing Service came very close to proving that conclusion incorrect. Although the Service was nominally under the management of the Official Registry, renamed the Nurses Professional Registry (NPR) in 1942, most requests for changes in fees or modifications in service came from the hourly nurses themselves. In 1948, a committee of hourly nurses revised regulations and formalized objectives for the Service.62 A 1949 suggestion of the hourly group that an industrial hourly service for area business be inaugurated was accepted.63 Hourly nurses were active in devising advertising and promotional activities. Emerging

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Table 1 Yearly Visits, Hourly Nursing, 1940-1957 Year calls

Visits

Unfilled

1940-'

3,265 N/A 5,190 5,958 9,429 13,774 N/A 15,107 13,563 13,092 14,168 16,421 17,605 20,211 19,770L 16,454' 15,987s 16,123

N/A N/A N/A N/A N/A N/A N/A 232 144 140 114 116 90 124 N/A 9 4<109« 93

1941

1942h 1943h 1944b 1945b 1946

1947C 1948t 1949C 1950C 1951 C 1952'

1953C 1954d 1955d 1956d 1957d

Sources: ''"First District. Annual Report,"1940. INAP, Box 7. h Summary of Activities of First District," 1942, 1943, 1944, 1945. INAP, Box 313. L Nancy Allen to Robert Cunningham, 16 May 1957, 4. CNRC, Box 1. d "Monthly Reports Hourly Nursing Service." CNRC, Box 1. Notes:c Estimate based on 10 months actual data. Estimate calculated by adding the average monthly visits to actual data to equal 12 months. f Estimate based on 8 months actual data. Estimate calculated by adding the average monthly visits to actual data to equal 12 months. g Estimate based on 7 months actual data. Estimate calculated by adding the average monthly visits to actual data to equal 12 months.

from this picture is an image of professional nurses not only running an independent, viable service, but being a proactive group interested in improving and advancing work they considered valuable. The freedom enjoyed by hourly nurses in directing their own service, at odds with the philosophy proposed 25 years earlier in which nurses were believed to be in need of supervision and guidance as they delivered care, resulted in effective functioning. Subtle changes in the First District's approach to the hourly service, beginning in the early 1950s, can be discerned in minute reports and decisions made regarding the Service. In February 1951, during NPR budget discussions, the hourly nurses recommended that the First District continue to absorb the Hourly Nursing Service deficit, as had been the custom from previous years.64 This recommendation was accepted, but hourly nurses were asked to consider and suggest ways by which the Hourly Nursing Service budget could be balanced in the future. 65 The

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record is silent on what, if any, suggestions the hourly nurses made in response to this request. No changes were noted in either fees charged or rate of commissions. Budget deficits remained fairly even during this period, averaging approximately $220 per year between 1950 and 1952.66 The deficit was discussed again in March 1953, when hourly nurses were expressly directed to make a recommendation regarding their plans for meeting the budget deficit.67 Why did Hourly Nursing Service budget deficits, at their lowest recorded point in the history of the Service, raise concern? Analysis of indices of the Service's effectiveness reveals little explanation. The number of patient visits made during these years shows minor variations. In 1953, 20,211 patient visits were reported, the Service's highest number. After that year, the number of visits decreased, leveling off at 16,123 in 1957, the last year of operation (seeTable 1). For the years 1954 to 1957, decreases in other categories of operation are noted, but none of a significant nature (see Table 2). A remarkably low rate of unfilled calls, averaging eight per month in the last 3 years of operation, indicated an efficient, effective operation meeting patient requests for care68 (see Table 1). In comparison, other fields of private duty were experiencing very high rates of unfilled calls, averaging 32% nationwide.69 In 1957, professional registries in Illinois reported 55% of calls received as unfilled.70 Despite a seemingly efficient operation, problems loomed for the Service. The budget issue became a crisis in 1954. Citing increased costs in providing services, the First District's Board of Directors raised hourly fees to $4 per hour for the first hour and $ 1 for each additional half hour in November 1954.71 The biggest growth in costs during this period resulted from an increase in the total amount of salary charges budgeted for the Hourly Service. Between 1950 and 1952, personnel charges for administering the Hourly Nursing Service averaged $600 per year. In 1955, a salary charge of $3,420 was lodged against the Hourly Service.72 Explanation of why the increase occurred cannot be located. Although other problematic issues were discussed at meetings, including the need for more qualified supervision of hourly nurses, no other changes in personnel took place at the time; business remained stable.73 Actual personnel costs are also unclear. It is possible that estimates of salary costs prior to 1954 were too low, and that the higher charges reflected a more accurate assessment of actual costs. This seems unlikely, given other circumstances existing within the NPR. During the year in which salary charges rose precipitously for the Hourly Service, the Practical Nurse Registry (PNR), also administered by the NPR, had actual salary costs of $3,080.74 The PNR, a 24-hour service, enrolled 42 practical nurses as compared to 23 associate hourly nurses in the Hourly Service; the Hourly Service was charged $360 more for providing service for fewer hours and with 19 fewer nurses.75 Subsequent to the

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Table 2 Hourly Nursing Service, Monthly Averages, Visits Made, Patients Visited, Hours Worked, 1954-1957 Year

Visits Patients

Total # Worked

New

Hours

1954

1,648 1,402

242 208 196 189

56 45 58 46

1,465

1955 1956 1957

1,332 1,344

1,297 1,219 1,134

Source: "Monthly Reports Hourly Nursing Service." CNRC, Box 1.

budget increase for personnel, Hourly Nursing Service salary costs were $3,350 and $3,420 for the years 1956 and 1957, respectively. By increasing salary expenses of the Hourly Service, operating deficits rose dramatically, from $273 in 1952 to $1,924 in 1956. '" The large deficits resulted in a call to review the entire operation of the Hourly Nursing Service. Was the First District searching for a reason to discontinue the Hourly Service? In February 1957, the First District, Board of Directors asked the Committee on Hourly Nursing of the Health Division, Welfare Council of Metropolitan Chicago, to assist in finding a solution to the growing deficits of the Hourly Service. The Welfare Council, a group concerned with developing comprehensive approaches to nursing and medical care needs facing Metropolitan Chicago, agreed to study the Hourly Nursing Service. Nancy Allen, executive secretary of the First District, in communicating with the Welfare Council, reiterated her conviction that a need for an hourly service existed, but pointed out that in addition to problems caused by growing deficits, the First District's varied responsibilities limited attention it could give to the Hourly Nursing Service.78 Clearly, the First District had lost its commitment to hourly nursing. On 7 August 1957, the Welfare Council responded with its report, the main thrust of which was a comparison of the Hourly Nursing Service to the hourly pay service offered by the VNA of Chicago. The report noted that in 1956 the VNA had made 206,501 visits, compared to 15,946 visits made by the Hourly Nursing Service for the same year. Duplications of services offered by the two agencies were noted, including geographical areas served, type of service, and operating expenses. Unlike the VNA, the Hourly Service was limited to only those who could pay. VNA fees charged to paying patients were lower than those of the Hourly Service. The Council credited the VNA with possessing a supervision, screening, and in-service training system superior to that of the Hourly Service. Citing the growing interest of official public health services and VNAs in meeting the needs of home-based

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patients, and their active, well-established staffs, the Welfare Council questioned seriously whether the Hourly Service needed to exist, and recommended that the VNA could better serve patients.79 The First District's Board of Directors lost no time in considering the report from the Welfare Council, voting on 20 August 1957 to discontinue the Hourly Nursing Service, effective 31 December 1957.80 A special committee was appointed to implement the decision and release a report outlining the reasons for closure. This committee acknowledged the unlikelihood that the VNA would assume responsibility for the Hourly Service.81 Nonetheless, for the First District to continue sponsoring a program based on patient request rather than need, especially given the contemporary nursing shortage, was considered unprofessional. The perceived lack of guidance given to hourly nurses, a growing concern recorded in minutes and reports after 1953, was highlighted. In the words of the committee, "Sponsoring a service with no administrative or supervisory leadership was not sound practice."82 Finally, the high commissions paid to the hourly nurses were criticized. Was it possible that hourly nurses were simply making too much money: It is impossible to do a complete analysis of hourly nurse earnings. Records do exist for 7 months of 1955, indicating associate nurses' number of visits, hours worked, and fees collected (see Table 3). These data are useful for providing a general idea of the income received by hourly nurses. Of 24 nurses enrolled in the Hourly Service, 20 worked 6 months or more. Of those 20, the highest earning nurse Nurse A made $3,951 in 7 months. Nurse A averaged thirty-four hours of work per week. By continuing at her average rate of fees collected throughout the year, the potential to earn $6,773 per year existed. Working as an independent contractor, Nurse A received no benefits, sick time, or vacation, and had extra business expenses of commission fees, professional dues, and travel costs. Nurse A's earnings compare quite favorably with those of other nurses. The average weekly earnings of general-duty nurses in nongovernmental hospitals in Chicago in 1957 were $72 for a 40-hour week.83 Yearly earnings averaged $3,744. In 7 months, the highest-paid hourly nurse made slightly more than the average Chicago hospital staff nurse made in a year. Not all hourly nurses made such a lucrative salary. Six nurses, however, earned over $2,500 dollars for a half year's work (see Table 3). No hourly nurse worked a full 40-hour week. Hourly nurses themselves noted that several retired nurses were dependent on their income for a livelihood.84 Ending the Service would create a financial hardship for them. Considering the generally low salaries that nurses earned in acute-care institutions, replication of their earnings outside the Service was unlikely.

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Table 3 Hourly Nurses Work Record, 1955

Nurse

Visits

Hours

Fees

Com.

Mos. wk

A

1,027

B C D E F G H I J K L M N O P

888 719 704 746 782 655 491 528 452 427 448 348 292 255 218 239 151 148 104 59 81 70 66

961.5 885.5 874.5

3951.00 3541.50 2930.00 2807.00 2589.50 2546.00 2239.00 1967.00 1881.00 1639.00 1620.00 1512.00 1363.50 1073.00 1000.00 760.00 734.00 625.00 606.00 424.00 402.00 319.00 256.00 199.00

158.04 141.68 117.20 112.28 103.58 101.84 89.98 78.68 75.24 65.56 64.80 60.46 53.56 42.93 40.00 30.40 33.36 25.00 24.24 16.96 16.08 12.76 10.24 7.96

7 7

Q R S T U V W X

633 456.5 784 452.5 491 408 338.25 385.50 312 400.5 248.5 237 159.5 157.75 163.5 154.5 107 142 87 56.5 30

7 7 7

6 7 6 6 6 6 6 7 7 7 5 7 6 7 5 7 5 4 7

Source: "Monthly Reports Hourly Nursing Service," 1955. CNRC, Box 1.

The committee charged with implementing the Service's closure disagreed strongly that hourly nurses might suffer financially from the closure. It predicted that hourly nurses would experience little difficulty in finding employment, because many hospitals were willing to hire nurses on part-time schedules. "Because of the tremendous need for nurses in varied phases of nursing, these nurses could readily find positions."8'' The committee was blunt in dismissing hourly nurses' concerns regarding future work. "Employment for the hourly nurse thus does not pose a problem." 86 The swiftness of the decision to close the Hourly Service stunned the nurses. As no hourly nurse had been involved in the process, this was not surprising. The hourly nurses requested a conference with the First District's Board of Directors to discuss the situation and "plead their case." At a September meeting, the nurses objected to the conclusion of the Welfare Council that the Hourly Service duplicated services provided by the VNA, citing such differences as the appointment nature of the Hourly Service, the speed with which patients were seen, and

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the provision of specific treatments, including early-morning insulin injections not provided by the VNA. The nurses believed that hourly nursing was essential when families were not able to administer certain treatments to home-based patients. They claimed that a trend toward earlier discharge of hospitalized patients made their practice indispensable: "The early discharge of patients from hospitals make some of our calls necessary. Care of the aged, arthritics, chronic cases such as old strokes, or multiple sclerosis relieve the shortage of hospital beds."87 The nurses asked the Board to reconsider the method by which salary charges were calculated. They argued it was unlikely that the small Hourly Service could incur such high personnel costs. They made several recommendations designed to increase financial returns from the Hourly Service, including higher patient fees and commission rates for hourly nurses. The nurses proposed that their commission rates be raised from 4 to 7%. To save the Service, the hourly nurses were willing to accept more guidance and leadership from those in authority. They suggested that a chief registrar might help with the proper functioning of the Hourly Service. The nurses concluded with the statement that the care they delivered was neither menial nor a luxury. "We feel that bedside nursing in the Florence Nightingale tradition is a skillful necessity, and to the nurse a rewarding service."88 The First District turned a deaf ear to the pleas of the hourly nurses. The decision to close was irrevocable. On 31 December 1957, the nurses of the Chicago Hourly Nursing Service cared for their last patients.89

Conclusion At first glance, the decision to close the Hourly Nursing Service and the activities surrounding that event appear to have been an effort on the part of the First District to rid itself of an anachronistic and insignificant operation that garnered little support except from its staff and presumably the patients it served. Use of an artificial deficit to rationalize termination was charged by those most affected: the hourly nurses. By examining the history of the Chicago Hourly Nursing Service within the context of contemporary changes in health care, further insight can be gained. During the 1930s, changing patterns of illness care reduced patients' need for hourly nursing services and helped to eliminate persistent nurse underemployment—the two original purposes for which hourly nursing programs had been conceived. A tremendous increase in patients seeking hospital care and able to afford it as a result of obtaining hospital insurance shifted the predominant site of

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illness care from homes to acute-care institutions.90 As hospitals admitted a largerpaying-patient population, they abandoned the practice of rejecting graduate nurses as employees and began hiring them in large numbers. 91 Shortages of nurses, not nursing jobs, became the norm. 92 For both patients and nurses, hospitals became the center of sick-care activities and work. Home-based nursing practice went into eclipse. The years between the end of the Rosenwald project and the mid-1950s witnessed steady, healthy growth of the Hourly Service, which continued to attract patients prepared to pay out-of-pocket expenses for nursing care. This accomplishment, in an era of rapid hospital expansion and transfer of patient responsibility for health care costs to third parties, indicated a small but present market for homebased services. The accommodations and conveniences extended to hourly patients most likely contributed to its popularity, but other factors such as patients' conditions and family situations that may have necessitated home nursing visits influenced patient determination to receive and pay for nursing care. Professional nursing failed to capitalize on this private market for nurse services. Uncertain job security experienced by professional nurses in the early decades of the twentieth century, a critical element in establishing hourly services, had been reversed by the 1950s. The huge workforce required to deliver increasingly sophisticated postwar hospital care created an insatiable demand for nurses.93 Professional nurses made a giant leap in achieving job stability. However, they remained locked in unsatisfactory work conditions. Joan Lynaugh and Barbara Brush have documented the serious employment problems of poor compensation, bad working conditions, and few benefits that prevailed after World War II.94The Chicago hourly nurses enjoyed working conditions superior to what most nurses encountered. Able to choose their own assignments, they received excellent compensation, and freedom not typically found by nurses of that era. This troubled the First District Board of Directors, who highlighted the lack of nursing and medical supervision for the hourly nurses and high fees commanded by them as partial reasons for closing the Service. The independent practice of nursing so at variance with the rest of the contemporary nursing world may have been just too radical for a professional organization to continue to support. The Chicago Hourly Nursing Service demands attention for being one of the most famous, organized, and long-running hourly programs. Ultimately, it was never able to have the impact on patient care envisioned for it by its promoters. Factors extraneous to hourly nursing threatened survival throughout the life of the Service. Economic distress, changing patterns of illness care, lukewarm support from the organization charged with its administration, and a market considered by those in authority to be insignificant sentenced it to death. Despite its failure,

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however, small successes can be glimpsed in the story of the Chicago Hourly Nursing Service. Hourly nursing compensated nurses with an income more lucrative than that offered by the average institution, under conditions that the hourly nurses found satisfying and rewarding. The Hourly Service gave patients choices about the type of nursing care they wanted and gave nurses an innovative means in which to deliver autonomous care. The availability of an alternative means of receiving and delivering professional nursing care made the Hourly Nursing Service a popular choice for those who supported it. The contemporary labor market for professional nurses remains in a state of continual flux. The early 1990s saw new patterns of patient care created by managed care and the need to decrease overall costs of health care. Much of the nursing care formerly given in institutions was transferred to home settings. As patients relocated, the workplace setting for nurses was centered less in hospitals and returned to a site familiar to previous generations of nurses, the home. By the end of the decade, reports indicated that heightened demand for nurses to staff acute-care institutions had emerged. Analysts predict that future nursing shortages will be larger than those experienced in the past.95 In response, nurses will most likely be drawn back to hospital employment. As nurses go through the mechanics of practicing in a changing job market, strategies used in the past to secure work and provide care are worthy of our critical consideration and can be helpful in making new transitions. The 31 years of service provided by the Chicago hourly nurses present us with a cautionary tale. It illustrates the profession's failure to sustain creativity in devising ways to deliver nursing care. More important, it highlights an example of the potential that can be realized from nurses' efforts to plan, support, and nurture innovative programs. JEAN C. WHELAN, PnD, RN Postdoctoral Fellow Center for Outcomes and Policy Research University of Pennsylvania 420 Guardian Drive Philadelphia, PA 19104-6096

Acknowledgments The researchfor this article was supported by grants received from the National Institute for Nursing Research (Grant No. NR07270-02), American Nurses Foundation

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(Eleanor LambertsonRN Scholar Grant), Sigma Theta Tau International, and Sigma Theta Tau, Xi Chapter. A version of this paper was presented at the Sixteenth Annual Conference of the American Associationfor the History of Nursing, Boston, Massachusetts, 2 October 1999. I wish to thank Julie Fairman, Joan Lynaugh, Karen BuhlerWilkerson, and Patricia D'Antonio for their thoughtful comments and guidance provided on earlier drafts of this paper.

Notes 1. "Annual Report Club and Registry Committee 1926," First District Bulletin 24 (February 1927): 10—11. Illinois Nurses Association papers, Springfield, 111., Box 3, folder 10 (hereafter cited as INAP). 2. The most extensive analysis of hourly nursing schemes is Karen Buhler-Wilkerson, False Dawn: The Rise and Decline of Public Health Nursing, 1900-1930 (New York: Garland Publishing Co., 1989), 215-219. Susan Reverby, in her examination of privateduty nursing, highlighted the political implications of the debate between visiting and private-duty nurses over who should deliver hourly nursing services, the resolution of which proved elusive. See Susan Reverby, "'Something Besides Waiting': The Politics of PrivateDuty Nursing Reform in the Depression," in Nursing History: New Perspectives, New Possibilities, ed. Ellen Lagermann (New York: Teachers College Press, 1983), 143— 146. 3. For the use of students as workers, see Joan Lynaugh, "Riding the Yo-Yo: The Worth and Work of Nursing in the Twentieth Century," Transactions and Studies of the College of Physicians, Ser.5, 11(3), 201-217; Susan Reverby, Ordered To Care: The Dilemma of American Nursing, 1850—1940 (Cambridge: Cambridge University Press, 1987). For the phenomenal growth and acceptance of hospitals by the public, see Charles Rosenberg, The Care Of Strangers (New York: Basic Books, 1987). 4. See Lynaugh, "Riding the Yo-Yo," 205. 5. For private-duty nursing, see Susan Reverby, "The Search for the Hospital Yardstick: Nursing and the Rationalization of Hospital Work," in Health Care In America, eds. Susan Reverby and David Rosner (Philadelphia: Temple University Press, 1979), 206255; idem, "'Something Besides Waiting'"; Jean Whelan, "Too Many, Too Few: The Supply, Demand, and Distribution of Private-Duty Nurses, 1910-1965" (Ph.D. diss., University of Pennsylvania, 2000). 6. Numerous articles appear in early twentieth-century journals discussing the difficulties long hours presented for private-duty nurses. Early examples include Anonymous, "Problems in Private Duty," American journal of Nursing (hereafter cited as AJN) 6 (June 1906): 597-99; Helen Claxton, "A Plea for the Profession of Private Nursing," AJN 9 (October 1909): 32-34. The best contemporary discussion of problems in the privateduty market is Janet Geister, "Hearsay and Facts in Private Duty," AJN 26 (July 1926): 515-28. 7. For contemporary discussion of the changing needs of patients for private nursing services, see Geister, "Hearsay and Facts"; Elise Van Ness, "Hourly Nursing Fulfills a Long

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Felt Need in the Home," The Modern Hospital 29 (December 1929): 124, 126, 128. Reverby also provides a succinct analysis of the difficulties in the private-duty nurse labor market in Reverby, '"Something Besides Waiting.'" 8. Geister, "Hearsay and Facts," 519; Josephine Goldmark, Nursing and Nursing Education in the United States (New York: The Macmillan Co., 1923; repr., New York: Garland Publishing Co., 1984), 169. 9. In a 1928-31 study conducted by the Committee on the Costs of Medical Care, of all patients with illnesses who received nursing care, only 2% received care from a privateduty graduate nurse. When categorized by type of illness, the percentages vary; e.g., for surgical hospital cases, 24% had private nurses. For non-surgical cases, rates for private services were approximately 2%. See Selwyn D. Collins, "Frequency and Volume of Nursing Service in Relation to All Illnesses Among 9,000 Families," Milbank Memorial Fund Quarterly 21 (January 1943): 33-34. 10. The Goldmark Report provided an extensive contemporary discussion of public health and visiting nurse services. See Goldmark, Nursing and Nursing Education, 39-160. The most complete analysis of public health and visiting nurse services is Buhler-Wilkerson, False Dawn. 11. For contemporary discussion of this problem, see Julia Stimson, "What Shall Be Done For and With The Middle Class Patient," in Transactions of the American Hospital Association, 28th Annual Convention 1926, 259-262; Nathan Van Etten, "The Nurse Question," AJN 27 (July 1927): 515-22. Discussions of employment difficulties in the private-duty field appeared in the popular press as well. See, for example, Martha Bensley Bruere, "The Impossible Profession," Century Magazine N.S. 90 (September 1926): 58492. 12. The Committee on the Grading of Nursing Schools, which examined the economics of the nursing profession, recommended hourly nursing programs as an excellent way to increase employment among nurses. See May Ayres Burgess, ed., Nurses, Patients, and Pocketbooks (New York: Committee on the Grading of Nursing Schools, 1928; repr., New York: Garland Publishing Co., 1984), 510-13. 13. Bruere, "Impossible Profession," 592. 14. See, for example, Elena Weaver, "Hourly Nursing," AJN 7 (November 1906): 105-106; Alma Wrigley, "Another Point of View for the Tired Nurse," Nurses Journal of the Pacific Coast 3 (September 1907): 406-408. 15. See especially Alma Wrigley, "The Hourly Nurse and Her Place, "AJN 16 (June 1916): 874—81. Wrigley reported on 108 nurses providing hourly services, many of whom supplemented their income with other activities, such as massage or relief work for privateduty registries. 16. For the dangers of freelance practice, see Burgess, Nurses, Patients, and Pocketbooks, 472-81. The term "freelance nurse" was also applied in later years to unlicensed nurse workers. See, for example, Harlan Hoyt Horner, Nursing Education and Practice in New York State With Remedial Measures (Albany: University of the State of New York, 1934), 7; Ellen Creamer, "Practical Nurses—Their Preparation and Sphere," Hospitals 13 (August 1939): 64. 17. Supervised practice offered uniform policies and procedures considered key to safe nursing practice. Supervisors, drawn from the higher echelon of nurses, were believed

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to have a more global vision of community needs for nursing services than did the individual nurse. See Geister, "Hearsay and Facts," 524; Stimson, "What Shall Be Done," 261. 18. Van Ness, "Hourly Nursing," 128. 19. For discussions regarding individual versus organized service, see Geister, "Hearsay and Facts"; Stimson, "What Shall Be Done," 261; Van Ness, "Hourly Nursing," 128. Geister, a strong advocate of centralized private-duty registries, provides the clearest explication of the benefits of an organized service. 20. See, for example, "Hourly Appointment Service," Public Health Nurse (hereafter cited as PHN) 22 (April 1930): 199-200; Mary E. Edgecomb, "How We Found the Cost of Our Hourly Appointment Service," PHN 23 (March 1931): 121-22; Harriet Lech, "The Hartford Hourly Nursing Service," PHN 20 (May 1928): 238-40; Mrs. Stanley Merrill, "Hourly Nursing on a Pay Basis as Conducted By a Visiting Nurse Association," AJN24 (June 1924): 726. 21. Buhler-Wilkerson, False Dawn, 218-19. 22. Louise M Tattershall, "Hourly Nursing in Public Health Nursing Association," PHN 19 (August 1927): 400. 23. For a contemporary description of the growth and purposes of professional registries, see "Official Registries and Professional Progress, "/I/TV 2 6 (February 1926): 9195. Whelan provides a full description of the origins of and different types of nurse registries in Whelan, "Too Many, Too Few," 18-24. 24. For a thorough contemporary discussion of the evolution of professional nurse registries, see Ella Best, "Nursing Service—How to Balance Supply and Demand?" Modern Hospital 39 (August 1932): 97-102. For nursing leaders' ideas regarding future nurse registries, see Geister, "Hearsay and Facts," 523-24; Julia Mellichampe, "The Development and Value of a Nurses Registry," AJN 19 (October 1916): 24-28. 25. An American Nurses Association (ANA) study found 50 registries nationwide offering hourly nursing services. See Van Ness, "Hourly Nursing," 126. 26. Mary Dinwiddie, A History of the Illinois State Nurses Association, 1901—1935 (Chicago: Illinois State Nurses Association, 1937), 94-97- See also Whelan, "Too Many, Too Few," for an analysis of the Chicago registry's operation between 1913 and 1965. 27. "Annual Report, First District," 1925. INAP, Box 3, folder 10. 28. See Dinwiddie, Illinois State Nurses Association, 98-99; Evelyn Wood, "How One City Solved a Nursing Problem," Pacific Coast Journal of Nursing 22 (October 1926): 586. The First District's registry had supplied some hourly services in homes when requested, but no effort had ever been made to promote this service. 29. The Central Council on Nursing Education, formed shortly after World War I ended, included as members directors of many Chicago-area schools of nursing, civic leaders, members of hospitals' women's auxiliaries, and related nursing organizations. The main purpose of the organization was to raise standards of nursing education. For the origins of the Central Council on Nursing Education, see Brigid Lusk, "Professionalizing Strategies and Attributes of Chicago Hospital Nurses During the Great Depression" (Ph.D. diss., University of Illinois at Chicago, 1995), 209-10. 30. See "Annual Report Club and Registry Committee, 1926," First District Bulletin 24 (February 1927): 10-1 1. INAP, Box 3, folder 10. See also Miriam Ames, "Hourly Nursing Service," AJN 33 (February 1933): 1 13.

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31. See "What Is Hourly Nursing," ISNA Bulletin 23 (September 1926), 4. INAP, Box 3, folder 8. 32. Lillian Guerlin, Differentiation Between Hourly Nursing and Visiting Nurse, undated, probably 1930. Chicago Nurses Registry Collection, Midwest Nursing History Center, College of Nursing, University of Illinois, Chicago, Box 1 (hereafter cited as CNRC). 33. The First District underwrote three positions and the Central Council one position. The Service also received a small amount of money from the Bordon Company. See "Hourly Nursing Service," 1937. CNRC, Box 1. 34. See Bruere, "Impossible Profession," 587-90; Van Ness, "Hourly Nursing," 126. The image of the exhausted private-duty nurse constantly worried over where the next case would come from is a persistent one in writings on private duty in the first three decades of the twentieth century. 35. See "Hourly Nursing Service," 1937. CNRC, Box 1. Part-time nurses retained the patient fees in lieu of salary. They paid the registry the regular membership fee charged to private-duty nurses, which in 1930 was $15- Most of the part-time nurses were reported to be married and uninterested in full-time work. See "Report of the Registry Committee," 7 June 1930,2. INAP, Box 4. 36. "Hourly Nursing Service," 1937. CNRC, Box 1. 37. Janet Geister to Joint Committee Hourly Nursing, 10 January 1933. CNRC, Box 1. Reverby recorded Geister's efforts to encourage the ANA to support ways to diversify private-duty nursing, including hourly nursing programs. She concluded that Geister was ultimately unsuccessful in the attempt. See Reverby, " 'Something Besides Waiting,' " 140— 48. 38. See "Annual Report of First District," Illinois State Nurses Association, 15-18 October 1930, 29th Annual Meeting. INAP, Box 4, folder 13. 39. "Hourly Nurse Service," 1937. CNRC, Box 1. 40. The project was the subject of extensive reports in professional journals. See "Final Report of the Hourly Service in Chicago," PHN 25 (February 1933): 88-91; Miriam Ames, "Hourly Nursing—A Civic Enterprise," AJN 32 (January 1932): 55-62; idem, "Organized Hourly Nursing in Chicago, PHN 24 (January 1932): 17-21; idem, "Hourly Nursing Service," AJN 33 (February 1933): 113-18; idem, "Hourly Nursing Service," AJN 33 (March 1933):215-22; Michael Davis, "The Meaning of the Hourly Nursing Experiment in Chicago," AJN 33 (February 1933): 111-12. 41. Miriam Ames, "Hourly Nursing Service," AJN 33 (February 1933): 115. 42. "Hourly Nursing," ISNA Bulletin 29 (March 1932), 8. INAP, Box 5, folder 16. 43. The full amount of the money was not used. The early conclusion of the grant led to spending of about half of the grant. See "Hourly Nursing Service," 1937. CNRC, Box 1; Annual Report, 1932, Joint Committee on Hourly Nursing, January to 1 October 1932; Hourly Nursing Service, 1 October 1932 to 31 December 1932. CNRC, Box 1. 44. Annual Report, 1932, Joint Committee on Hourly Nursing, January to 1 October 1932. CNCR, Box 1; Hourly Nursing Service, 1 October 1932 to 13 December 1932. CNRC, Box 1. 45. This discussion of the results of the study was compiled from journal articles and official reports of the project, as previously cited.

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46. Estimates of income were based on nurses' subjective observations of patients' living quarters and lifestyles. Measures used were home furnishings, number of rooms in the house, family size, number of servants, car, employees, and occupation. Ames, "Hourly Nursing Service," AJN 33 (March 1933):215-22. 47. See Davis, "Hourly Nursing Experiment in Chicago," 113. 48. Buhler-Wilkerson, False Dawn, 111-15. 49. Delivering nursing services through organized medical or public health groups had been a recommendation of the influential 1932 Committee on the Costs of Medical Care, on which Michael Davis had served and which had been funded in part by the Julius Rosenwald Foundation. See Committee on the Costs of Medical Care, Medical Care for the American People (Chicago: University of Chicago Press, 1932; repr., Washington, DC: Department of HEW, 1970). 50. For the increased use of hospitals for illness care, see Rosemary Stevens, In Sickness and In Wealth (New York: Basic Books, 1989), 172. Stevens records that occupancy rates for general hospitals rose from 64% to 70% between 1935 and 1940. 51. "Hourly Appointment Nursing Service," PHN25 (November 1933): 615-17. The Joint Committee on the Distribution of Nursing Service was a committee of the American Nurses Association, National League For Nursing Education, and National Organization for Public Health Nursing. In 1932, the ANA assumed sole responsibility for this committee. See Lyndia Flanagan, One Strong Voice (Kansas City: American Nurses Association, 1976), 86-87. Reverby discusses the ineffectiveness of the Committee. The Committee did not include any private-duty nurse members. See Reverby, " 'Something Besides Waiting,' " 144. 52. Michael M. Davis, "Nursing Service Measured By Social Needs," AJN 39 Qanuary 1939): 35-40. 53. The Rosenwald Fund contributed $ 1,200 to help defray the first year's expenses. The total amount received by the Hourly Service from the Rosenwald Fund was $16,900. "Hourly Nursing Service," 1937. CNRC, Box 1; "Annual Report, 1932, Joint Committee on Hourly Nursing, January to 1 October 1932; Hourly Nursing Service, 1 October 1932 to 13 December 1932." CNRC, Box 1. 54. Ibid. 55. "Brief Comparative Registry Report of a Three-Months Period Including May, June, and July, 1933 and 1934," ISNA Bulletin 31 (September 1934):6. ISNA, Box 6, folder 21; "Annual Report, First District," 1936. INAP, Box 6, folder 21. 56. See "Hourly Nursing Service," 1937. CNRC, Box 1. 57. Ibid. 58. Ibid. 59. "Annual Report, First District," 1939. CNRC, Box 1. 60. Special charges applied to care given to a second patient in a home or for specific treatment such as hypodermic injections. See "Hourly Nursing Service," pamphlet, 1 July 1947. CNRC, Box 1. Attempts by the hourly nurses to increase the charge for the second hour of service to $ 1 for each additional half hour were denied by the Committee on Nurses Professional Registry in 1950. Fees remained at 1947 rates until 1954. See "Minutes, Nurses Professional Registry Committee," 7 June 1950. CNRC, Box 2. 61. "Income Statement, Hourly Nursing," 1950. CNRC, Box 1.

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62. See "Minutes, Committee on Nurses Professional Registry," 29 November 1948. CNRC, Box 2. 63. See "Minutes, Committee on Nurses Professional Registry," 2 March 1949. CNRC, Box 2. An industrial service was instituted but was unable to attract significant business. Statistics on calls received for the industrial service are only available for the years 1955-1957, when the service averaged eight to ten calls per month. See "Monthly Reports Hourly Nursing Service," 1955-1957. CNRC, Box 1. 64. The deficit for 1951 was $161.16. See "Minutes, Committee on Nurses Professional Registry, NPR, 6 February 1951." CNRC, Box 2. 65. See "Minutes, Special Meeting of the Committee on Nurses Professional Registry, NPR, 10 December 1951." CNRC, Box 2. The Committee relayed recommendations from the Hourly Nurses to the First District's board of directors. Beginning in the 1950s, this committee took on a more active role in decisions regarding the Hourly Nursing Service, particularly over budget matters. 66. "Income Statement, Hourly Nursing," 1950, 1951, 1952, 1955, 1956. CNRC, Box 1. 67. See "Minutes, Committee on Nurses Professional Registry, NPR, 3 March 1953." CNRC, Box 2. 68. See "Monthly Reports Hourly Nursing Service, 1955-1957." CNRC, Box 1. This represents less than 1% of total visits made. 69. Set Facts About Nursing, 1959 (New York: American Nurses Association, 1959), 115. The percentage was calculated by averaging the percent of unfilled and canceled calls for the years 1954-1957. 70. Ibid., 117. 71. See "Announcement to Staff," 1954. CNRC, Box 1. 72. For budget data, see "Budgets, Nurses Professional Registry," 1950, 1953, 1955. CNRC, Box 1. Salary costs actually increased in 1954. The exact amount budgeted for personnel costs that year is unattainable. The Hourly Nursing Service budget was separate from the NPR budget. How expenses incurred by the NPR for managing the Hourly Service were apportioned is unclear. See "Budgets, Nurses Professional Registry, Hourly Nursing Service," 1950-1957. CNRC, Box 1. 73. See "Report of Special Committee on the Hourly Nursing Service," 19 April 1955. CNRC, Box 1. The result of this report seems to have been the creation of a Committee on Hourly Nursing Service within the Public Health Section of the First District. Few meetings followed. Topics discussed included uniform, bag contents, medical counsel, and inservice education. See "Report, Public Health Nurses Section, Committee on Hourly Nursing Section," 3 Junel957. CNRC, Box 1. Policies regarding written verification of physician orders were clarified at this time. See "Memo, To Hourly Nurses, From Adelaide Fritz, President, First District," 21 June 1955. CNRC, Box 1. 74. See "Budget, Nurses Professional Registry, 1955," 24 January 1957. CNRC, Box 1. 75. For data on Practical Nurse Registry, see "Monthly Reports, Practical Nurse Registry," 1955. CNCR, Box 2. In 1955, the NPR received $2,463.09 in commission fees from hourly nurses. The PNR registry fees totaled $657.50 for the same year. See "Nurses Professional Registry," 1955. CNRC, Box 1.

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76. "Income Statement, Hourly Nursing," 1950, 1951, 1952, 1955, 1956. CNRC, Box 1; Adelaide Fritz to Alexander Ropchan, 7 June 1956. CNRC, Box 1. 77. Robert Cunningham to Nancy Allen, 13 February 1957. CNRC, Box 1. 78. Nancy Allen to Robert Cunningham, 16 May 1957. CNRC, Box 1. 79. See "Report of Hourly Service to the Executive Committee of the Health Division," 31 July 1957. CNRC, Box 1. 80. Nancy Allen to Alexander Ropchan, 20 August 1957. CNRC, Box 1. The Committee on the Nurses Professional Registry, a committee charged with overseeing the NPR, had already voted to discontinue the service on 1 July 1957. See "Minutes, Special Meeting, Committee on Nurses Professional Registry," 1 July 1957." CNRC, Box 2. 81. There seemed to be agreement among all parties involved that the VNA was unlikely to take over the Hourly Nursing Service. In the late 1980s, as a result of changes in the home care market, the Chicago VNA demonstrated greater interest in serving paying patients. For a description of the VNA's shift to profit-generating services, see Kathleen Kilbane and Beth Blacksin, "The Demise of Free Care: The Visiting Nurse Association of Chicago," Nursing Clinics of North America, 23 (1988): 435-42. 82. "Report of the Special Committee on the Hourly Nursing Service," September 19, 1957. CNRC, Box 1. 83. See Facts About Nursing, 127. Chicago and San Francisco-Oakland recorded the highest average weekly earning for general-duty nurses nationwide. 84. See Hourly Nurses Division of the Public Health Nurses Section,"Report to the Board of Directors," 24 October 1957. CNRC, Box 1. 85. "Report of the Special Committee on the Hourly Nursing Service," 19 September 1957. CNRC, Box 1. 86. Ibid. 87. See Hourly Nurses Division of the Public Health Nurses Section, "Report to the Board of Directors," 24 October 1957. CNRC, Box 1. 88. Ibid. 89. As part of the closure procedure, the First District did agree to refer persons requesting hourly services from the registry directly to nurses enrolled in the Service at the time of discontinuance. See Agnes Hohf to Gertrude Coyne, 1 5 November 1957. CNRC, Box 1. Alexander Ropchan, Executive Secretary of the Health Division of the Welfare Council, suggested that a list of hourly nurses be forwarded to the Chicago Medical Society and area hospitals for referral. See Alexander Ropchan to Nancy Allen, 11 October 1957. CNRC, Box 1. I was unable to locate data on how the group of hourly nurses fared after the Service's closure. 90. In 1935 there were approximately 75,000 subscribers in insurance plans; by 1939 there were 2,900,000 subscribers. See Facts About Nursing (New York: American Nurses Association, 1939), 26. 91. Hiring of graduate nurses by hospitals was the result of a combination of factors, one of which was higher occupancy rates. The most extensive analysis of the transformation of nurses from private practitioners to employed staff is Marilyn E. Flood, " The Troubling Expedient: General Staff Nursing in United States Hospitals in the 1930s, A Means to Institutional, Educational, and Personnel Ends." (Ph.D. diss., University of California, Berkeley, 1981}. In 1930, 77,000 nurses worked in institutions. Data are unavailable on

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the capacities in which these nurses worked. See Facts about Nursing, 1939, 13. In 1941, an estimated 109,000 RNs worked as general-staff nurses. See Facts About Nursing, 1941 (New York: American Nurses Association, 1941), 34. 92. Complaints of shortages of nurses began appearing in professional journals in the late 1930s. See "Nursing at Recent Hospital Conventions," AJN 36 (November 1936): 1156-62; Stella Goostray, "Supply, Demand, and Standards," AJN41 (July 1941): 745. The nursing shortage continued well into the war years and beyond. For an analysis of the nurse-hospital relationship in the last 50 years of the twentieth century, see Joan E. Lynaugh and Barbara L. Brush, American Nursing (Cambridge: Blackwell Publishers, 1996). 93. For discussion of factors fueling the nursing shortage and attempts to alleviate it, see Lynaugh and Brush, American Nursing, 1-25. 94. Ibid., 7-8. 95. For the current nursing shortage, see, for example, Geraldine Bednash, "The Decreasing Supply of Registered Nurses: Inevitable Future or Call to Action," Journal of the American Medical Association 283 (14 June 2000): 2985-87; Peter Buerhaus, Douglas Staiger, and David Auerbach, "Implications of an Aging Registered Nurse Workforce," Journal of the American Medical Association 283 (14 June 2000): 2948-54. For recent news reports and commentary on the nurse shortage, see, for example, "Nursing Shortage Projected," New York Times, 13 December 2000; Stacey Burling, "Major Nurse Shortage Feared in Years Ahead," Philadelphia Inquirer, 10 October 2000; Bill Cruice and Teri Evans, "Nursing Crisis Taking an Unhealthy Toll," Philadelphia Inquirer, 17 March 2001; Ovetta Wiggins and Larry Lewis, "Lawmakers Taking Steps to Address Nurse Shortage," Philadelphia Inquirer, 14 March 2001.

Trained Nurses in Family Magazines, 1880-1928 BRIGID LUSK Northern Illinois University

Priscilla Sargent, fictional heroine of The Romance of the Trained Nurse, published in 1893, had a "plain, strong face" and was "homely both in looks and ways." She decided she was not clever enough to be a teacher, or a writer, or a painter. "Yes," she thought, "I was made for a nurse. I am sorry for sick people and know I could take care of them" 1 (Figure 1). Trained nursing was a new occupation for women when Katie Upson Clark's story of Priscilla's romance was published in Godey'sMagazine. The days of "Sairy Gamps," of male and female convalescents nursing other patients, of well-meaning yet untrained religious sisters, were coming to a close. Following improvements in medical science and with implementation of progressive-era welfare initiatives, trained nursing responded to a societal need. This paper traces the representation of nursing in family magazines from 1880 to 1928. The first nursing schools in the United States had opened in 1873, and in 1928 the landmark first report of the Committee on the Grading of Nursing Schools,2 describing the current status of the profession, was published. During this period, hospitals changed from being primarily charitable institutions to being essential providers of modern medical care, and, similarly, patients gradually changed from being recipients of charity to being paying consumers. The purpose of this study is to assess the lay perception of nursing, as presented in popular family magazines, during this formative period in nursing's history. Since communication media may both reflect and shape the public's conceptualization of a cultural entity, the media's portrayal of trained nursing during this period may have influenced nursing's status.3 Certainly, as journalism historian Carolyn Kitch asserts, media imagery provides a lens through which we may examine social, economic, and cultural aspects of American history.4 Furthermore, although Roland Marchand, an advertising historian, cautions that advertisements do not accurately reflect social reality, he maintains that they can provide

Nursing History Review 10 (2002): 109-125. A publication of the American Association for the History of Nursing. Copyright © 2002 Springer Publishing Company.

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Figure 1. Katie U. Clark, "The Romance of a Trained Nurse," Godey's Magazine (March 1893): 270, 278.

a basis for reasonable deductions concerning attitudes and values of the period. 5 Kalisch and Kalisch analyzed the portrayal of nurses in novels during the nineteenth century,6 but no studies have been identified that describe a broader assessment of nurses in communication media during this early, formative period. Further, this paper describes the presentation of actual nurses, as well as fictional images of nurses, adding depth to current understanding of nurses' roles at that time. Moreover, the nursing references have been interpreted with regard to national and nursing social and cultural events of the period assessed. All issues of Godey's Lady's Book and Magazine, Frank Leslie's Illustrated Newspaper, The Saturday Evening Post, and The Ladies'Home Journal horn 1880 to 1928 were reviewed for this study. Only the latter two journals, from the same publishing house, were published continuously throughout the period under study. Godey 's ceased publication in 1898 and Leslie s ceased in 1921. Frank Leslie's

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Illustrated Newspaper and The Saturday Evening Post were published weekly, while the ladies' magazines came out every month. Godey's Lady's Book and Magazine, also published as Godey's Magazine and Godey's Lady's Book, first appeared in 1830 and had a circulation of more than 150,000 by the eve of the Civil War. Following Godey's sale of his magazine in 1877, the circulation gradually declined. Frank Leslie's Illustrated Newspaper, founded in 1855 by an English-born engraver, Frank Leslie, was a highly successful pictorial magazine during the late nineteenth century. The Saturday Evening Post had few readers until 1897, when, following a major infusion of money and talent, it greatly increased its circulation. Likewise, when Edward Bok became editor of The Ladies' Home Journal in 1889, the Journal's circulation expanded. By 1905, both the Saturday Evening Post and The Ladies Home Journal had circulations of more than one million readers.' While two of the magazines reviewed were primarily for women, with Bok targeting The Ladies' Home Journal specifically at women from the middle and working classes, women were the main consumers of most magazines of the period.8 Review of these magazines for all content related to trained nursing revealed more than 460 items. These included descriptions of nurses' work, articles about individual nurses, health advice columns written by nurses, advertisements featuring nurses, and fiction related to nursing. The findings have been grouped into three periods, which were somewhat arbitrarily designated The Progressive Period, from 1880 to 1909; The Decade of War, from 1910 to 1919; and The Years of Prosperity, from 1920 to 1928.

The Progressive Period: 1880-1909 This was a period of change for some women, as they experienced a more public role following the societal upheaval of the Civil War and during suffragette agitation. The "New Woman" differed from her mid-Victorian predecessor who espoused the cult of "true womanhood," described by historian Barbara Welter as a state of "piety, purity, submissiveness, and domesticity."9 Although Bok's editorials in The Ladies 'Home Journal promoted women's domestic role, he readily featured articles describing employment opportunities for women, including nursing, reflecting the actual needs of his readers for paid employment. Prior to the 1890s, there were few references to nurses, trained or untrained, but several hospital scenes were depicted. Hospital construction and visitation exemplified this era of social responsibility towards the sick poor. Historian Charles

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Figure 2. "Resuscitating Cradle at the Gray Nunnery, Montreal," Frank Leslie's Illustrated Newspaper (26 April 1884): cover page.

Rosenberg has described the evolution of trained nursing as a natural outgrowth of the work of religious nursing sisters and Protestant lady hospital volunteers.10 Several engravings portrayed society women giving flowers or tobacco to the patients. In one illustration, these women were identified as Ladies of the Flower and Fruit Mission.11 Occasionally nuns were shown as nurses, particularly if the scenes were gruesome or newsworthy in some other way. The Gray Nuns of Montreal were shown nursing during a smallpox epidemic in 1884, while members of the same order appeared on the cover of Frank Leslie's Illustrated Newspaper as they attempted to revive a frozen infant 12 (Figure 2). Paid attendants were not visible in hospital scenes, but were shown working in orphanages or homes for the destitute. Usually these untrained nurses were portrayed as serious young women, clean and demure, but there was one instance of a "Sairy Gamp" type of nurse (Figure 3). The accompanying article described a recently exposed charitable institution in which several children had died, partly due to "the want of sufficient and experienced nurses."13 Frank Leslie's Illustrated Newspaper devoted much space to the condition of President Garfield as he lay dying following his assassination in 1881, but no nurses were evident. In a two-page engraving, many men and one woman are shown turning the president in bed, but the woman was later identified as a physician.14

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Figure 3. "Baby Farming in New York," Frank Leslie's Illustrated Newspaper (17 June 1883): 261.

The portrayal of trained nursing as a positive influence on health was, however, beginning to appear. In a detailed 1890 article describing the Hospital for Ruptured and Crippled Children in New York, the reader learned, "At the head of each hall in the hospital is a Bellevue trained nurse, with a force of ordinary nurses or caretakers at her command."15 Two years before, Leslie's newspaper reported that Clara Barton had sent 18 experienced yellow-fever nurses to Jacksonville, Florida, during an outbreak of the disease.16 Trained nurses were also evident in the care of young children during the end of the 1880s, and gave nursing advice to wives and mothers through columns and letters to the editor.' One Journal article, with no author identified, gave instructions for young mothers to follow after "the ruling spirit of the sickroom, . . . a Sairy Gamp or that modern improvement, a trained nurse," had left. 18 A physician writing in The Ladies' Home Journal in 1889 publicized the changing face of medical care. He wrote: "The . . . scientific methods of combating disease have made a steady demand for better nursing and more intelligent nurses. . . . Women are rapidly superseding men as nurses, even for surgical cases."19 In 1884 The Saturday Evening Post asserted, "For trained nurses, the demand is enormous and ever increasing; but not everyone can follow this profession. It is reserved only for the brave and strong, the sympathetic and intelligent."20 Godey's Magazine, in an 1892 article about New York hospitals, wrote, "Another great

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advantage which the hospital possesses over the private residence is in the prevalence of intelligent and trained nursing, especially in those institutions where women are employed."21 Thus trained nursing was portrayed positively and supportively by these magazines, with nursing regarded as beneficial for the sick and a suitable occupation for respectable women. As the 1890s continued, and the United States engaged in the SpanishAmerican War, news and human-interest stories involving trained nurses became more evident. An article on trained nursing, which appeared in Godey's in 1896 as part of a series on successful women, stated, "The trained nurse is now recognized as member of an important profession." It continued, "A number of college graduates have become nurses and the average of intelligence is higher than in most professions."22 The positive impact trained nurses had had among the poor was also noted. The following year, Godey's reported on "The Colored Woman of Today" in an article that featured several prominent African American women, including a nurse who had graduated from Chicago's Provident Hospital.23 Several pages in an 1898 Ladies'HomeJournalissue were devoted to the career of trained nursing— written by a trained nurse and including two pages of photographs.24 News of Dr. Anita Newcomb McGee's government appointment, charging her to hire nurses for the Spanish-American War, included McGee's requirement that the nurses must be graduates of reputable training schools.25 In another story, The Saturday Evening Post reported that four trained nurses, society women who were graduates of the Johns Hopkins Hospital in Baltimore, had volunteered at the Naval Hospital where "the staff of nurses, all male hitherto, has been taxed to the utmost." One of these nurses was the daughter of the Secretary of the Navy.26 As the new century opened, trained nurses continued to be portrayed in the magazines as refined and educated women. In 1900, a full-page article in The Saturday Evening Post concerned women in business. Discussing nurses, it stated that "a vast number have made their influence felt throughout our country, although here, as in England, they are frequently employed in the families of their social inferiors and subjected to cruel tests of their patience and high courage."27 Various letters to the editor in The Ladies Home Journal were from trained nurses. To one, written in 1906 and concerning meals, the Journal responded that the trained nurse should certainly eat with the family, not the servants, because her "education and daily life"28 were more like that of the family. The Journal instituted a health-advice column written by a trained nurse, which appeared in most issues during 1903 and 1904.29 In 1904, the Journal noted, "Nursing as a profession has taken a foremost place in our present scheme of society."30 Several short stories published in the magazines during this period featured nurses, some with a nurse as the central character. These stories usually revolved

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around the eligible hero who, after several plot twists, eventually married the heroine. Fictional heroines from the early 1880s were either well-bred volunteer nurses or upper-class patients, rather than paid nurses. A few years later, as trained nurses appeared in these short stories, the nurse heroines were either wealthy but plain, as in this paper's opening story of Priscilla,31 or formerly wealthy and beautiful. Yet nursing was not considered a suitable occupation for the upper classes. In a 1900 story, a rich heiress changed her name when she started nursing, to avoid embarrassing her family,32 while a fictional nurse in 1898 entered nursing when the family became impoverished. She really wanted to become a doctor, but could not afford the education. This story made reference to the nurse's fees, that "bank-breaker of a nurse."33 The 1900s saw the start of many advertisements recruiting student nurses and some advertisements using images of nurses. The Chautauqua programs for correspondence nursing courses advertised heavily from 1902 in The Saturday Evening Post and in The Ladies' Home Journal. These advertisements featured images of women smartly dressed as nurses, while the text described the benefits of nursing as a womanly occupation that was also well-paying and that offered some independence. Product advertisements showed nurses endorsing infant-, diet-, and cleanliness-related products. Titles of textual advertisements purporting to be regular articles often included the words "A trained nurse" and then described how a trained nurse recommended a brand of tea or cereal for people suffering such health problems as "stomach trouble, nervous prostration, or brain fag."34 Some images of nurses in the advertisements were used just to add authenticity to a sickroom scene, but in others the nurse was placed as a professional authority, with text such as "A nurse knows. . . ." or "Endorsed by nurses."33 These magazines thus portrayed nursing with some professional attributes, suitable for women from a middle-class social station. Professional knowledge and some level of autonomy were demonstrated through the nurses' advice columns, through discussions about the superiority of trained nurses in hospitals, through nurses' billing for their services, and through advertisements showing nurses endorsing products. The call for intelligent women as nurses, and their giving advice on aspects of home nursing, such as nursing people with contagious diseases, illustrated that some degree of scientific education was required of these trained nurses. Their altruism was noted in pictures showing nurses caring for contagious patients and, in public health, caring for impoverished families in their homes. Nursing leaders during this period sought to guide and protect their professional status. They formed professional organizations and followed the lead of other countries in pursuit of licensure, an attempt to limit the legal use of the term "nurse." Yet the number of nurses, both hospital-school trained and trained by

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correspondence courses such as those regularly advertising in the family magazines examined in this study, was increasing exponentially. In 1910, there were more than 82,000 nurses, compared with about 560 in 1880.36

The Decade of War: 1910-1919 The following decade opened with news of Florence Nightingale's death and continued with multiple references to nurses and nursing. In the earliest years of the decade, medical advances and national disasters showcased nurses' work. Nurses were shown with children in open-air tuberculosis sanatoriums, with earthquake victims, in public health work with recent immigrants and tenement dwellers, and on board ships that gave health-giving day cruises to poor patients. In 1910, The Ladies' Home Journal featured a warning article on the dangers of fireworks. The accompanying full-page drawing showed children maimed by fireworks, with a nurse who was placed there because she "typifies modern scientific medical care."37 Articles also appeared that indicated that something was amiss with nursing. The Ladies' Home Journal warned in a 1910 editorial that trained nurses lasted only 15 years, and after that they were too exhausted to continue.38 In 1913, the Journal wrote of a need for better-educated student nurses who expressed "finer feelings."39 Another article that year was written by a registered nurse. She described the harsh discipline and hard work, but she still encouraged young women to enter nurses' training. 40 With the advent of war in Europe in 1914, images of nurses, both "over there" and at home, proliferated. Several reporters visited hospitals in France and Germany and wrote about their experiences for the home audience. One volunteered her services as a nursing assistant, while another, noted nurse-author Mary Roberts Rinehart, actually took a nursing position 41 (Figure 4). Other reporters wrote of the plight of the civilian population. These articles showcased the women nurses and the combatants' need for their services. The Saturday Evening Post stressed that only trained nurses, not volunteers, were fit for service in a military hospital.42 In 1917, with the U.S. involved in the war, Rinehart authored a Saturday Evening Post article about the nation's need for trained nurses. She wrote, "If his pulse fails, to stimulate him, to watch for the wicked seeping hemorrhage that may make its presence known too late; to guard him in his delirium . . . such mothering as only the trained observer can give."43 In her article "Miss Greenhorn Goes A-

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Figure 4. Illustration from Mary Roberts Rinehart, "For King and Country," Saturday Evening Post (24 April 1915): 14.

Nursing," reporter Elizabeth Fraser stressed that trained nurses, not volunteers, were really needed.44 The government echoed this view. In a 1918 Ladies' Home Journal advertisement, the government called all women to war service, but said that if they wanted to nurse they had to enroll in nurses' training.45 The following year, the Journal published an article describing nursing education and encouraging young women to apply.46 The patriotism of nurses was the theme for several covers of The Saturday Evening Post. In the cover from 21 September 1918, Norman Rockwell painted a child dressed as a nurse giving a first-aid box to an elderly gentleman—possibly Marshal Ferdinand Foch, Supreme Allied Commander (Figure 5). Articles described the uniforms of the nurses at the front, and The Ladies' Home Journal featured a full-page portrait of a war-weary nurse, called "the best-dressed woman in the world."47 Former president William Howard Taft twice appealed on behalf of the Red Cross for more trained nurses and urged college-educated women to enter the profession. 48 The Journal wrote a feature story on the Red Cross

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Figure 5- Norman Rockwell, Saturday Evening Post (21 September 1918): cover page.

Training Camp for prospective nurses at Vassar College, open to women college graduates. 49 Nurses were regularly featured in the short stories of the period that appeared in The Ladies Home Journal and the Saturday Evening Post. In 1911, two stories featured nurses in significant supporting roles, and their efficiency and calm demeanor were described as features of trained nurses.50 In a 1912 story, a wealthy young woman pretended to be a nurse, her pretense made easier because she had "a complexion of such health and cleanliness and dewiness as blooms only on trained nurses."31 Mary Roberts Rinehart authored four stories with nurse heroines, in which the nurses were college-educated young women leading independent lives. Nurses in the war and nurses in private duty were featured, while the cost of hiring a private-duty nurse was alluded to—a man almost died upon discovering that his two trained nurses cost him $8 a day.32 There was an increase in the presence of nurses in advertisements during this decade compared with earlier years. One reason was the appearance of war-related advertisements near the end of the decade; nurses, as a female military presence, were often included. Another reason was the use of nurses in all images used in the extensive advertising of three companies. The San-Tox line of toiletries featured a rather stern nurse's face as its trademark, calling her symbolic of "purity, quality, and safety," a view that paralleled the assessment of fictional trained nurses

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Figure 6. Saturday Evening Post (13 February 1915): 2. Courtesy of Warner Lambert Consumer Group, Pfizer, Inc.

described above. In 1918, the San-Tox nurse was replaced by a softer, smiling image; the nurse became approachable rather than authoritative. "Listerine" and "Lysol" products featured directive-appearing nurses in several advertisements (Figure 6). The extensive presence of nurses in advertisements for other products is of interest, given the general nature of these magazines. Some of these advertisements reflected the role of private-duty nurses and their use of products associated with nursing in the home. Others, such as advertisements for toothpaste or a set of encyclopedias, appear to indicate that nurses were regarded as trustworthy, knowledgeable women, and as suitable spokespersons for a wide range of products. Advertisements for the correspondence nurse training schools continued to appear frequently, but some had developed an air of defensiveness not seen in the earlier years. A Chautauqua school advertisement in 1916 asserted that correspon-

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dence courses were not intended to supplant hospital-based training, but offered an alternative for women unable to attend a hospital training school. In 1918, the government's request for 30,000 army nurses was cited by another Chautauqua school advertisement, with the implication that correspondence-school graduates could replace these hospital-trained nurses on the home front. 53 Just two hospitalbased training programs advertised, both in 1911: one in The Saturday Evening Post, and one in The Ladies' Home Journal. It is curious that the influenza pandemic of 1918-19, which, like the war, endangered nurses' lives, was not touched upon in the magazines assessed. This phenomenon invites the question of why nurses were extensively covered in their war work and not when working during an equally dangerous event at home. In the war coverage, particularly after the United States entered the war in 1917, nursing was a highly patriotic occupation in which female nurses had a significant presence near the front lines. Nurses thus apparently were shown because they were necessary to the overall war effort and were in an exciting position for women. Women certainly heeded the patriotic call during this period, entering nursing in record numbers and thereby setting the stage for unemployment in the years ahead. In 1920, there were almost 150,000 trained nurses. For the first time, trained nurses outnumbered physicians as, following reforms in medical education, the number of physicians declined.54

Years of Prosperity: 1920-1928 The 1920s, years of national prosperity, featured real nurses less frequently, but nurses remained popular images in advertisements and appeared as heroines of short stories. Three articles about nursing appeared in The Ladies'Home Journal'in 1920 and 1921.55 The first, written by a nursing organization executive, assured potential applicants that the drudgery associated with nurses' training was long past. The others, again written by nurses, encouraged young women to enter training, although one author thought her own training had been made pointlessly unpleasant by dictatorial training school policies. Several prominent physicians wrote about the urgent need for nurses in rural areas and the need for nurses to be trained as midwives.56 Two health columns written by a nurse appeared in The Ladies 'Home Journal'in 1920, but the series was not continued.57 There were fewer mentions of nurses in the magazines' short stories during these years, but the plot format of impoverished high-society women entering nursing and marrying either a wealthy patient or a brilliant doctor continued. One

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Figure 7. Saturday Evening Post (26 February 1927): 124. Courtesy of Texaco, Inc.

story, from 1925, illustrated how the portrayal of nurses had changed since the war years, as the nursing school's director deliberated on whether to accept a socially superior but extremely young applicant. "But I don't get many of this sort now . . . not since the war," she mused.58 A 1928 fictitious working-class student nurse expressed her dissatisfaction with nursing when she moaned, "I wish I'd gone to work in a store. I wish I were a telephone operator. I wish I had a job as a typist."59 One story was different from the rest in highlighting a visiting nurse, with no romantic interests, making her calls on the sick poor. 60 Nearly 50 advertisements with nurses appeared during this period, predominantly in The Saturday Evening Post. These advertisements included several images portraying nurses in supportive roles, with a physician as the central character (Figure 7). Years earlier, nurses had more often been presented alone or, during the war years, with men in uniform. In these 1920s advertisements, some nurses

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appeared to be medical props, standing by an actively engaged doctor or exhorting the reader to follow the doctor's advice. Interestingly, Listerine's dictatorial nurse had left the scene. Nurses who appeared more independent were portrayed in the Metropolitan Life Insurance Company advertisements of the early 1920s, as the benefits of Metropolitan's nurses were described. The last advertisement for the Chautauqua School of Nursing appeared in 1920, although small advertisements for other correspondence nursing schools continued until 1924. The visibility of nursing within the magazines studied declined during these years as the nation entered a period of postwar prosperity. More and more hospitals, however, wanted the economic benefits of their own training schools, and hundreds more opened.61 The nursing articles in The Ladies' Home Journal appearing in 1920 and 1921 continued to encourage women to become nurses, but some of the short stories and advertisements during this period portrayed a drop in the autonomy of nursing. The discontinuance of correspondence-school advertisements during this period might have been linked to the effectiveness of licensing requirements, which excluded graduates of such schools. In conclusion, nursing was interesting to the lay public. The graphic illustrations of Frank Leslie's Illustrated Newspaper, the short stories, and the stories from the war front demonstrated that people were, then as now, interested in the human condition and that nurses were central to these interesting events. Throughout the time period studied, nursing was considered a necessary force in modern medical care. However, while the excitement of the new role and the dearth of other opportunities for women in the 1880s, followed by the glamour of nursing during the First World War, placed nursing on a social pedestal, these factors did not extend through the 1920s. The positive war coverage of nurses' work did not result in an enhanced presence of nurses following the war. By the end of the period of this study, trained nurses were not giving health advice; they were not plain, but genteel; and their work was not presented as a distinct new medical benefit. Nonetheless, their continued presence in advertisements intimated that the public associated them with cleanliness and wholesomeness, and that their image could boost trade. In these lay magazines, nurses were shown as working women performing a necessary service. BRIGID LUSK Northern Illinois University 736 Randall Street Downers Grove Illinois, 60515

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Acknowledgment Alpha Lambda Chapter, Sigma Theta Tau International, generously provided financial support for this study.

Notes 1. Katie U. Clark, "The Romance of a Trained Nurse," Godey's Magazine 126, no. 753 (March 1893): 270, 278 (hereafter cited as GM}. 2. May A. Burgess, Nurses, Patients, and Pocketbooks (1928; reprint, New York: Garland, 1984). 3. Philip A. Kalisch and Beatrice]. Kalisch, The Changing Image of the Nurse (Menlo Park, Cal.: Addison Wesley, 1987). 4. Carolyn Kitch, "The American Woman Series: Gender and Class in The Ladies Home Journal, 1897" Journalism and Mass Communication Quarterly 75, no. 2 (Summer 1998): 243-62. 5. Roland Marchand, Advertising the American Dream: Making Way for Modernity, 1920-1940 (Berkeley: University of California Press, 1985), xix. 6. Philip A. Kalisch and Beatrice J. Kalisch, "The Image of Nurses in Novels," American Journal of Nursing 82, no. 8 (August 1982): 1220-24. 7. Kitch, "Gender and Class," 246. 8. Jennifer Scanlon, Inarticulate Longings: The Ladies'Home Journal, Gender, and the Promises of Consumer Culture (New York: Routledge, 1995). 9. Barbara Welter, Dimity Convictions: The American Woman in the Nineteenth Century (Athens: Ohio University Press, 1976), 21. 10. Charles E. Rosenberg, The Care of Strangers (New York: Basic Books, 1987), 212-36. 1 1. "A Hospital Tent," Frank Leslie's Illustrated Newspaper (2 October 1880): 6970 (hereafter cited as FLIN). 12. "The Good Gray Nuns of Montreal," FLIN (3 October 1885): 105-106; "Resuscitating Cradle at the Gray Nunnery, Montreal," FLIN(26 April 1884): cover page, 151. 13. "Baby Farming in New York," FLIN (\7 June 1882): 261, 263. 14. "The President Recovering," FLIN (30 July 1881): 359-61. 15. "The Hospital for Crippled Children," FLIN (22 November 1890): 283. 16. "The Progress of the Plague, FLIN (22 September 1888): cover page, 87. 17. Annie R. Ramsey, "Nursing in Fevers," Ladies Home Journal (November 1889): 15 (hereafter cited as LHJ); Annie R. Ramsey, "Nursing in Fevers," LHJ (January 1890); "How to Cure a Cold by a Trained Nurse," LHJ (February 1891): 9; Elizabeth R. Scovil, "Words for Young Mothers by a Trained Nurse." LHJ (April 1890). 18. Christine T. Herrick, "Bathing the Baby," LHJ (May 1887): 5. 19. Frank Fisher, "The Trained Nurse," LHJ (April 1889): 4. 20. "Femininities," Saturday Evening Post (8 March 1884): 13 (hereafter cited as SEP).

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21. Thomas B. Preston, "Our Hospitals," GM (November 1892): 508. 22. Alice Severance, "Talks by Successful Women," GM (December 1896): 622-25. 23. Fannie B. Williams, "The Colored Woman ofToday," GMQuly 1897): 28-32. 24. Elizabeth R. Scovil, "The Life of a Trained Nurse," LHJ (May 1898). 25. "Close Range Studies of Contemporaries," SEP (11 June 1898): 11. 26. "Close Range Studies of Contemporaries," SEP (16 July 1898): 43. 27. Mrs. Burton Harrison, "Society Women in Business," SEP (15 December 1900): 8. 28. "Should a Trained Nurse Eat With the Family?" LHJ (April 1906). 29. Maud Banfield, "The Journals Trained Nurse," LHJ (January 1903; February 1903; March 1903; April 1903; May 1903; June 1903; July 1903; September 1903; October 1903; November 1903; February 1904; March 1904; December 1904). 30. "The Trained Nurse," LHJ (April 1904). 31. Clark, Romance, 269-338. 32. Julia Magruder, "A Voice in the Choir," LHJ (July 1900): 9-11. 33. Katharine Bates, "The Romance of an Old Bachelor," SEP (3 December 1898): 353-55. 34. "The Doctor's Wife Agrees With Him About Food." FUN (28 June 1906). 35. "Mennen's," SEP (2 July 1902): 16; "Hand-I-Hold," LHJ (June 1906): 12. 36. Burgess, Nurses, Patients, and Pocketbooks, 40. 37. "Just As We Prepare for a War," LHJ (April 1910). 38. "The Girls in White," LHJ (January 1910). 39. "The Decrease in Good Nurses," LHJ (October 1913). 40. Natalie W. Nixdorf, "The Training of a Professional Nurse," LHJ (September 1913). 41. Elizabeth Frazer, "With the French Wounded," SEP (5 May 1917): 20, 30, 34, 37; Elizabeth Frazer, "Ward Eighty-Three," SEP (13 January 1917): 14-15, 45-46, 48; Mary Roberts Rinehart, "For King and Country," SEP (24 April 1915): 14-16, 65. 42. Cora Harris, "A Communique," SEP (25 January 1915): 15. 43. Mary Roberts Rinehart, "A Cup of Water to the Thirsty," SEP (26 October 1918): 42, 45. 44. Elizabeth Frazer, "Miss Greenhorn Goes A-Nursing," SEP (9 June 1917): 1819, 58-59. 62. 45. "Women of America," LHJ (September 1918). 46. Irene VanDyck, "How Can I Really Learn a Profession?" LHJ (August 1919): 39-40, 42. 47. "The Best Dressed Woman in the World," LHJ (May 1918). 48. "The American National Red Cross," LHJ (September 1917); 5; "The American National Red Cross," LHJ (October 1917): 33. 49. William Howard Taft, "Wanted: 30,000 Nurses," LHJ (May 1918): 22. 50. Margarita S. Gerry, "The Other Man's Baby," LHJ (May 1911): 12-14, 66-67; Josephine D. Bacon, "The House of Their Rest," LHJ (Feb. 1911). 51. Richard H. Davis, "The Red Cross Girl," SEP (2 March 1912): 3-6, 44-46. 52. Maximilian Foster, "The Dollar Bill," SEP (16 June 1917): 15-17, 89. 53. "Nurses Needed," Advertisement, SEP (31 August 1918): 54.

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54. Burgess, Nurses, Patients, and Pocketbooks, 40, 41; Abraham Flexner, Medical Education in the United States and Canada (New York: Carnegie Foundation for the Advancement of Teaching, 1910). 55. Ella P. Crandall, "Do I Want My Daughter to Be a Nurse?" LHJ Qune 1920): 99-100; Corinne Lowe, "Does the Nursing Profession Need Nursing?" LHJ (October 1920): 29, 158, 160; Ida F. Butler, "How to Nurse the Nursing Profession," LHJ (April 1921): 12, 146. 56. Rupert Blue, "The Lookout on the Mountain," LHJ (April 1920): 45, 98-99; Josephine Baker, "Why Do Our Mothers and Babies Die?" LHJ (April 1922): 32-

33. 57. Mary E. Bayley, "The Care of Children's Feet," LHJ Qune 1920); Mary E. Bayley, "Fractures—Before the Doctor Arrives," LHJ (July 1920). 58. Mary Roberts Rinehart, "The Surgeon Explodes a Bomb," SEP (7 February 1925): 3. 59. Sidney Hershel Small, "Matched Sable," SEP (29 September 1928): 16-17, 95, 101, 103, 106. 60. Elsie Singmaster, "The Messenger," SEP (2 June 1923): 12, 164-66. 61. Burgess, Nurses, Patients, and Pocketbooks, 35.

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Nurses: The Early Twentieth Century Tuberculosis Preventoriums "Connecting Link" CYNTHIA A. CONNOLLY School of Public Health Columbia University

Introduction Speaking to her colleagues at the nineteenth annual National Tuberculosis Association (NTA) meeting in 1923, Colorado public health nurse Ida Spaeth stressed the nurse's importance to a newly founded institution, the tuberculosis preventorium, for indigent children presumed "pretubercular": The service the public health nurse can render the preventorium and the tuberculous child is invaluable. She is the connecting link between the home and the institution; between the child and his physician; between the public and the tuberculous child in need of preventorium care. Whether she works out from the institution or in the community as the public health nurse, her responsibility and opportunity toward the tuberculous child and the preventorium are alike. . . .'

The preventorium strove to prevent children infected with the tubercule bacillus from developing active tuberculosis (TB), and there is ample evidence to support Spaeth's claim that nurses were integral to the institutions. In New York City, for example, nurses practicing in dispensaries, schools, and community-based settings such as the Henry Street Settlement identified pretubercular children and referred them to the Charity Organization Society's association of TB clinics, the primary referral base for that city's biggest preventorium, located at Lakewood (later Farmingdale), New Jersey.2 Nurses staffing the preventorium oversaw children's daily health needs, managed its programs, and worked alongside teachers, a matron, and other employees.3 Still other nurses from New York City's Department of Health conducted mandatory home visits throughout a child's preventorium stay. Nurses in all the aforementioned capacities instructed parents on the importance of cleanliness and Nursing History Review 10 (2002): 127-157. A publication of the American Association for the History of Nursing. Copyright © 2002 Springer Publishing Company.

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hygiene. When feasible, nurses facilitated sanatorium admission for the tubercular parent. Nurses visited the home for years after children left the preventorium; if their assessment revealed deteriorating home conditions or former patients' weight loss, they usually recommended readmission to the preventorium.4 In this paper I examine the role of nurses in the preventorium movement. To understand nurses' thoughts and actions related to these institutions, it is necessary first to describe the preventorium and outline the relevant medical, social, and cultural frameworks in which it evolved. Second, I trace nurses' efforts with regard to the preventorium movement within the context of early twentieth-century public health nurses' antituberculosis work. Finally, I argue that nurses' efforts made the institutions possible, and describe the ways in which preventoria relied on nurses at every juncture.

Changing Ideologies of TB Causation The youngsters sent to preventoria often remained there for months or years and generally came from poor, often immigrant, families in which at least one parent suffered from tuberculosis. The first preventorium opened in 1909 at Lakewood, New Jersey, and the nation's last, San Diego's Rest Haven, closed in 1951. During the preventorium's heyday, from the 1920s through the early 1930s, at least 26 institutions in 15 states cared for children labeled at-risk for TB. California, home of at least eight preventoria, dominated the landscape of the preventorium movement, while the rest of the institutions were scattered throughout the United States, with concentrations in rural areas surrounding the large urban centers of the Midwest and Northeast.5 The preventorium idea originated during frustrating times in the early twentieth-century antituberculosis movement. As the nation's most visible infectious disease, TB was a national preoccupation during most of the late nineteenth and early twentieth centuries. Although many people died from the disease, many more experienced long periods of tuberculosis-related debilitation. Minimizing TB's toll on society became the focus of numerous public and private endeavors.6 Throughout the first three quarters of the nineteenth century, tuberculosis, like most diseases, was postulated to be hereditary and noncontagious. The concept of disease as a discrete entity did not exist in its contemporary form. Physicians as well as the lay public believed that constitutional endowments, hereditarily transmitted, promoted or resisted illness.7 Notions of TB were radically changed in the 1880s by new frameworks through which disease and illness came to be

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understood.8 While Robert Koch's 1882 isolation of the tubercule bacillus facilitated the emergence of the germ theory, many scientists did not immediately discard sanitarian and hereditarian philosophies. Instead, as Nancy Tomes has argued, these older ideas were accommodated, and in many instances incorporated, in newer infectious-disease explanatory models.9 Thus, most health care providers continued to interpret racial, ethnic, and socioeconomic variations in TB's incidence as evidence that certain groups needed moral, not just material, uplift. The first years of the twentieth century, the period of time during which the germ theory's acceptance evolved, were tumultuous ones for the United States. As the pace of industrialization accelerated, many North Americans moved to urban areas seeking greater opportunities. In addition, waves of immigrants, many of them indigent, poured into U.S. cities. People crowded into tenements, were often unable to speak English, and frequently engaged in cultural practices foreign to earlier arrivals and the native-born. Poverty, inadequate sanitation, crime, and infectious diseases, especially tuberculosis, became rampant in the poorer districts. 10 Widespread fears of contamination from immigrants and the poor spurred health care professionals to practice what Alan Kraut has labeled as "medicalized nativism."11 Indeed, most nurses, physicians, and others active in the fight to eradicate TB considered race, ethnicity, and social class critical variables in their estimation of patients' TB risk. They cited research published in prestigious professional journals to justify their positions. 12 Moreover, although the germ theory enriched scientists' and society's understanding of TB and spurred the creation of newly formed antituberculosis organizations, it added no effective tools to the curative arsenal. Treatment in the early twentieth century, whether in the home or the sanatorium, remained much the same as in the nineteenth century. Adjusting patients' environment, nutrition, and exercise-to-rest ratio remained therapeutic mainstays, along with providing health advice and encouraging the modification of deleterious behaviors.13 As a result, the era bookended by Koch's findings and the widespread availability of an antibiotic cure in the 1940s was a time not just of enormous hope, but also of frustration for antituberculosis activists in the United States. Furthermore, the intricate interplay between bacteria, host, and environment proved difficult to unravel. Epidemiological investigations revealed that host factors such as individual behaviors, heredity, and environment all played a role in disease progression, though researchers often disagreed with one another on the extent of their influence.14 Fears of contagion did lead to legislative approaches to control of TB's spread. These laws, mandating registration and segregation of the tubercular, were enacted in many cities during the early twentieth century. Many of these regulations

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generated controversy and fear among the poor. 15 Reformers seeking to arrest TB's spread sought less contentious solutions, and found one in the idea of two prominent New Yorkers.

Progressivism, Child-Saving, and the Evolution of the Preventorium Concept Nathan Straus, member of the wealthy New York retailing family, was a wellknown benefactor and activist. Alfred F. Hess was a respected pediatrician. These men became the chief protagonists in the development of the first preventorium. Together, they galvanized support among the rest of New York's social and medical elite. Their outlook, that the tuberculosis movement needed to be less treatmentoriented and more prevention-focused, reflected a growing philosophy among public health leaders.16 While poverty-related conditions such as an inadequate living environment, excessive crowding, overwork, and insufficient nutrition clearly enhanced one's risk for developing TB, these social problems were, by themselves, too nonspecific to categorize as predisposing criteria unique to TB. Clemens von Pirquet's 1908 discovery that a byproduct of tubercule bacilli culture, known as tuberculin, could be used to identify those individuals who were infected with TB before they developed actual symptoms, further energized public health experts.17 Before tuberculin, physicians classified children into two groups with regard to TB, the sick and the well. After 1908, a third disease category was created, comprising those infected with the organism but without active disease. Referred to as "pretubercular," these children became the target population for the preventorium. New York City's activist public health officer, Herman Biggs, estimated that approximately 40,000 such children resided in the city's tenement districts.18 The tuberculin test's discovery illuminated individuals' infection status, but it raised new questions as well. For example, almost all people over the age of 14 reacted positively to tuberculin, indicating widespread exposure to TB.19 Only some infected youngsters actually developed TB symptoms, however. Many concluded that these data implied the influence of an intervening variable, perhaps resistance to infection. Low resistance, termed "physiological poverty" by New York physician Sigard Adolphus Knopf, condemned a child to a life of indigence and ill health.20 Seizing upon the tuberculin test's objectivity, Hess, Straus, and their colleagues sought to use it as an efficient tool to identify the pretubercular child. Once

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recognized, children at risk could be admitted to the preventorium and have their health preserved or restored. Preventorium supporters believed this outcome would be achieved not just by removing the child from the source of the infection, but also by recreating within the institution the social conditions and moral climate of the wealthier classes. With the preventorium's founding, both men hoped to combine the best elements of a home, school, and sanitorium into one pediatric institution. 21 Its founders designed the preventorium to articulate with the New York City Charity Organization Society (COS) and its programs by emphasizing the importance of choosing COS trustees to serve as preventorium medical board directors. For the first several years of the preventorium's operation, at least four individuals served jointly: physicians Herman M. Biggs, Abraham Jacobi, and James Alexander Miller, and social worker Lawrence Veiller. 22 Because of this close affiliation, the preventorium was influenced by many of the same principles that guided the COS. Many COSs in the United States conflated the medical and social problems faced by their clientele. This resulted in interventions that reflected a desire to improve patients' morality and reshape what they saw as inappropriate behaviors and patterns of thought, in addition to providing health care services and material assistance. 25 The campaign to institutionalize pretubercular children was strengthened by the national reform-oriented ethos of the time known as Progressivism, and a media barrage in the professional literature as well as the lay press helped popularize the movement. Subsequent institutions patterned their therapeutics and daily operations after the New Jersey preventorium but, unlike that institution, many newer facilities restricted admission by sex, ethnicity, race, or religion. Some operated as private, voluntary institutions similar to Farmingdale, while others were founded with private capital but grew to be managed by public agencies such as health departments or school districts. Still others functioned in association with public or private sanatoria.^ The numbers of preventoria grew after World War I, partly due to the fact that the massive preparedness efforts revealed that more than 80,000 young recruits were unfit to serve in the military because of active or suspected TB.2S Most institutions drew patients from within a several-hour train or automobile ride. Several new preventoria opened in the early 1930s, but by that decades end, falling numbers of new cases of TB and its champions' inability to quantify the institution's efficacy eroded its mission. In addition, a growing number of 1930s child welfare interventions, such as those implemented by the 1935 Social Security Act, prioritized family preservation, making the preventorium out of step with the times. The advent of antibiotics represented the single most damaging factor to the

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preventorium's existence, however. The discovery of streptomycin in 1943 followed by isoniazid in 1952 reframed TB as a disease treatable with outpatient therapy. The incidence of TB in the United States declined rapidly, and the era of the preventorium was over. The preventorium never became a fixture in every community in the way its loyalists had hoped. Preventoria remained few in number, and were usually located adjacent to cities with large numbers of TB sufferers or regions with many TB migrants. However, the institutions received a great deal of attention in the lay and professional TB literature as well as from local, state, and national antituberculosis organizations. One reason for the preventorium concept's popularity may have been its emphasis on children in a time-period rich with child-saving rhetoric. Moreover, in an era in which no TB vaccine or cure existed but many people were exposed to the tuburcule bacillus, interventions with potential to prevent morbidity and mortality appeared to many people to offer the best hope of eradicating the epidemic. That they were expensive to operate and required a relatively sophisticated public health infrastructure for maintenance probably limited their number, but not the idea's popularity. Throughout the duration of the preventorium movement, the presence of trained nurses emphasized founders' vision of the preventorium as a health care facility. To date, however, there has been little research into nurses' duties with regard to individual preventoria, and no one has described what role, if any, nurses played within the broader effort to institutionalize pretubercular children. Many of the nurses who interfaced with the preventorium, its child clientele, and their families, carried out one of public health nursing's most visible and prominent campaigns, tuberculosis eradication.26 In the next section of this paper, I explore preventorium nursing in the context of public health nursing as well as antituberculosis public health efforts.

Nurses and the Antituberculosis Movement PUBLIC HEALTH NURSING IN THE UNITED STATES While fewer in number than their colleagues in private-duty and hospital work, public health nurses exerted a profound impact on early twentieth-century health care.27 Despite the emergence of a professionally driven health care delivery infrastructure over the course of the early twentieth century and a growing number of institutions devoted to the sick, many ill people could afford no services whatsoever. Poverty and crowding overwhelmed city governments' outdated

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mechanisms for monitoring water quality and eliminating sewage and other waste. Infectious diseases spread rapidly among those crowded into tenement slums. Public health officials recognized that these illnesses could easily spread to the general population because the indigent sick often prepared food, cleaned houses, or sewed clothes worn by those who could afford to purchase such services.28 Reform-oriented men and women struggled to respond to the social and public health problems caused by the rapid pace of immigration, industrialization, and urbanization. Drawing upon the British concept of district nursing, they formed charitable organizations such as visiting nurse societies. By sending trained nurses out into the community to care for, educate, and monitor the sick poor, they hoped to ameliorate disease and improve living conditions.29 Some Progressive activists even moved into residences, known as settlement houses, in the most destitute neighborhoods with the goal of studying, and hopefully remediating, the social conditions surrounding poverty, crime, and disease.30 Nurse Lillian Wald developed the philosophical framework for public health nursing in the United States. In 1893, she and a colleague merged the concepts underlying district nursing and settlement houses by creating the nurse-managed Henry Street Settlement. Wald believed that bringing subsidized nursing care to the poor in their homes, as with the care that the middle and upper classes could afford for themselves, both heightened the chances for its success and made treatment more humane. 31 Public health nurses' work differed from that of their peers in several substantive respects. Though they worked long hours in dangerous neighborhoods, unlike their colleagues in private-duty or institutional settings, nurses in public health negotiated more autonomy and less physician control for themselves. Furthermore, since the class relationship between patient and nurse was usually reversed from that of private-duty nursing and the care was subsidized by a third party, public health nurses held more authority than did other nurses.32 Public health nurses often worked 6-61/! days a week. They usually visited between 8 and 12 patients over the course of an 8-10-hour day. These nurses maintained responsibility for the nursing care of both pediatric and adult patients suffering from a variety of acute and chronic illnesses. Some patients were so sick that the nurse visited them once in the morning and again in the evening before she went home. Because many patients were immigrants, their cultural background and ethnic origins often differed from that of the nurse.33 Public health nursing quickly evolved to become the province of a certain type of nurse, the graduate of a premier nursing school or a woman with the means to seek postgraduate training at one of the programs designed to supplement the narrow hospital nurse training with subject material related to economics, sociol-

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ogy, psychology, and public health.34 In addition to having a broader knowledge base, nursing leaders believed that public health nurses needed more sophisticated skills than those of their colleagues in hospitals and private duty, along with better critical thinking and more initiative. They also had to be highly flexible, and well versed in the social service and health care resources available within their communities. Since patient education constituted an important part of their role, they also needed to be articulate.3> Wald and her fellow public nurses successfully created an expanded nursing role that fit the needs of early twentieth-century American society. They made health care more accessible and less threatening to the poor by providing it within the social and economic context of New York's vulnerable populations. Since eradicating a "house disease" such as TB required the trust and cooperation of the poor in their homes, public health nurses' success made them indispensable to early twentieth-century public health efforts.36 The deftness with which public health nurses worked in the interstices of traditional health care assured them a unique niche within the antituberculosis movement.37 The shift in emphasis from treatment to prevention in the antituberculosis crusade mandated an intensive campaign based in homes, schools, and community settings, one that focused on people before they developed TB symptoms. Though nurses continued to care for ill and dying tubercular patients at home as well as in sanatoria, clinics, and dispensaries, those who specialized in TB prevention represented the vanguard of public health nursing by 1910.38 Public health nurses recognized that their work differed from that of the general nurse. Both because they faced issues that other nurses did not and in an effort to establish themselves as an elite corps within nursing, public health nurses founded their own organization in 1912, the National Organization for Public Health Nurses (NOPHN).39 THE BEGINNINGS OF TUBERCULOSIS NURSING Tuberculosis public health nursing evolved out of experiments in both Baltimore and New York City. In 1903, amid growing concerns about New York's TB problem, the city's Charity Organization Society and the health department made provision for a nurse to visit TB patients in their homes. Public health officials quickly deemed the nurses' efforts a success, and 13 more nurses were hired over the next 2 years.40 Although Baltimore's Johns Hopkins Hospital had developed a program a few years before New York did, it did not initially involve nurses. Beginning in 1899, the hospital's physician-in-chief William Osier assigned female medical students to monitor TB dispensary patients at home. Osier believed that the work required supervising patients' household cleanliness as well as personal hygiene, and saw

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these functions as women's roles. In 1904, Mary Adelaide Nutting, American nursing pioneer and Superintendent of Nurses and Principal of the Nurse Training School at Hopkins, convinced Osier that nurses could do the work more effectively/" Soon after, Baltimore's Instructive Visiting Nurses Association (IVNA) added nurses devoted exclusively to tuberculosis public health nursing.42 Many TB nurses had themselves battled TB. While a few had contracted the disease while caring for tuberculous patients, many were recruited into sanatorium nursing schools from among the healthier female patients. Since TB's stigma, even for those considered cured, was potent, nurse training often represented the best option for many women who needed to work. Like public health nurses everywhere throughout the United States, tuberculosis nurses visited patients in their homes. In many instances, they combined dispensary work with patient visits. For example, in both Baltimore and New York, nurses made home visits for part of the day and staffed the dispensary with the time left.43 While tuberculosis nurses needed to possess all of the characteristics of other public health nurses, they especially needed a persuasive demeanor so that patients could be induced to follow directions. Tuberculosis public health nurses filled the bulk of their time with patient education because unless they were near death, patients could usually care for themselves. Nurses kept careful records of their work, monitored patients' progress or deterioration with each visit, and searched for new TB cases in the community as they made their rounds.^ They instructed patients about every aspect of daily living, including matters related to personal hygiene and habits, food preparation and diet, childrearing, and the importance of home ventilation and cleanliness. Nurses also developed written teaching points and distributed them in pamphlet form in immigrants' native languages.45 Much of the information nurses taught patients could, if followed assiduously, protect the health of the tuberculous and those with whom they lived. For example, tuberculous parents who collected their sputum in a cup and discarded it appropriately reduced the chances that children in the household would come in contact with infectious materials. But differences in social class, culture, and ethnicity between nurses and their patients often made it difficult for them to understand one another. In 1915, for example, tuberculosis public health nurse Sarah Stevens shared with her colleagues the way in which cultural differences sometimes made TB care more difficult and confusing for all involved. She described her frustration with a Jewish woman who refused to let her child be sent away for "fresh air" after his father had died of TB because the mother believed that Judaism dictated that children must pray daily in a synagogue for a deceased parent. 46 Stevens recounted another instance in which an Italian immigrant woman who had lost her husband and oldest child to TB brought her two remaining

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children to a dispensary. When the nurse began to prepare one child's arm for the von Pirquet tuberculin test, the mother screamed, swept up both children, and ran from the clinic. Stevens later learned that the mother told neighbors that nursing personnel wanted to burn a hole in the child's arm.47 Though some nurses acknowledged the importance of learning about different cultures and customs alien to them, most did so only to be better able to sway patients from their beliefs and practices, not to incorporate them together in a way that met the demands for public health safety but also preserved patients' cultural practices.48 Stevens, for example, did caution nurses to respect patients' "racial and religious preferences," noting: "The mere fact that a certain dish does not appeal to our American palate is not proof positive that it is unfit to eat.. ..It is not unlikely that some of our own table delicacies seem quite as impossible to our friends from across the water." She asserted that such "unlimited forbearance toward the ignorant and superstitious" paid off because the nurse gained the trust of the family more quickly, which made it easier to persuade them to make changes the nurse suggested.49 Delores Gladys Spicer informed her colleagues that "the cultural level of many a tenement house mother is not far removed from that of her primitive ancestors," reminding nurses that tact will encourage a prospective mother to try " 'American ways' because she wants her child to be a real American, and because she trusts the nurse and wants to do all she can to please her."50 Physicians and philanthropists who funded public health initiatives usually came from the upper classes and viewed public health nurses as a conduit between themselves and the indigent people they perceived to be in need of moral uplift, education, and other direct assistance. By design, therefore, nurses in the antituberculosis movement laced their interventions with educative functions reflecting White, middle-class cultural practices.51 As a result, some of the information that nurses dispensed to sick TB sufferers had less to do with minimizing contagion but was instead more oriented toward inculcating bourgeois behaviors into patients' personal habits and daily activities. For example, Sara Shaw, the supervising nurse at New York's Bellevue TB program, emphasized the importance of a plain (nonethnic) diet and wrote condescendingly of patients' tendencies toward "delicatessen knickknacks." She also stressed to her patients the importance of properly served meals, cleaning house, arranging furniture, behaving patriotically, and using childrearing techniques aimed at making "enthusiastic little [American] homemakers" of the girls and "strong, manly men" with "fine ethical codes... champions of a clean city".52 Furthermore, nurses did not always recognize the economic barriers that prevented full compliance for many tuberculosis sufferers. For example, in 1904 Jane Delano, superintendent at Bellevue Hospital's nurse training school, pub-

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lished the hospital's 41-point educational protocol which all nurses followed when they visited TB patients in their homes. Delano made no mention, however, that certain of the recommendations were not feasible for the very poorest patients. Although many TB sufferers themselves agreed that it made sense for the tuberculous not to work or become overtired, and to have their own beds and bedrooms, those living in poverty had little control over these factors. Thus, patients' ability to adhere to many of the instructions dictated to them by nurses was hampered by the fact that, in many instances, compliance was economically untenable.53 Nurses often felt angry and frustrated when patients disregarded their directions, and often attributed noncompliance to a lack of intelligence, self-discipline, or callousness toward the health of others.54 For example, Winifred M. Allen and Elizabeth McConnell, nurses at New York City's tuberculosis clinic at Gouverneur Hospital, signaled their attitude toward the dispensary's patients, 94% of whom were immigrants, stratifying them by race and ethnicity into the following categories: "(A) fairly intelligent, (B) stupid, (C) inexpressibly stupid or defective."55 Such attitudes were not limited to nurses in the northeastern United States. California's Elsie M. Courrier, an Oakland tuberculosis nurse, presented a paper at the 1909 convention of the Nurses' Associated Alumnae in which she complained about the difficulty of inculcating better health practices into immigrants and the poor. Seemingly oblivious to the formidable cultural and economic obstacles that made such changes difficult, Courrier vented her frustrations: "What is to reach the army of ignorant, vicious, depraved, and often non-English-speaking people whom poverty, overcrowding, and our pernicious system of foreign immigration have placed among us? Can they be taught a sufficient knowledge of the subject to be anything but an ever-present menace in our midst?"56 In yet another instance, Rose MacGowan of Los Angeles alphabetized the nationalities of the patients with whom she interacted in her role as a school nurse. Based on her experiences, she described her interactions with children and their parents, attributing their behaviors and responses to her interventions to racial or ethnic characteristics. MacGowan's two-page summary of 16 different minority characteristics reflected prevailing early twentieth-century stereotypes. For example, MacGowan believed Mexicans to be shiftless and dirty and assumed that Jewish children shrewdly accepted her interventions primarily because they knew she could get them free services if they cooperated with her.^7 In addition to case-finding new TB patients, educating patients about healthrelated issues, and monitoring their progress, an important nursing role also consisted of policing indigent communities for compliance with public health measures. Patients who did not follow nurses' instructions could lose part or all of

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their charitable assistance. They could also recommend forcible removal of noncompliant patients, or their at-risk children, to sanatoria or other institutions. 58 Nurses' authority to withhold much-needed assistance, as well as attitudes such as those expressed by Stevens, Shaw, Delano, Allen, McConnell, MacGowan, and Courrier, caused at least some patients to perceive TB nurses' efforts as coercive and threatening. Tuberculosis nurses themselves generally viewed their work as rewarding and contributory to society, however. Most considered their role a pivotal one, possessed of what Lillian Wald termed "civic intelligence.'"'9 THE MATURATION OF TUBERCULOSIS NURSING While the efforts of nurses at prestigious hospitals such as Johns Hopkins as well as those in large cities such as New York, garnered the most attention, public health nurses throughout the nation joined the antituberculosis movement. National, state, and local nursing organizations convened committees and task forces to fight the TB epidemic. Articles, letters to the editor, and editorials on TB-related issues proliferated in nursing journals such as the American Journal of Nursing, Trained Nurse and Hospital Review, Public Health Nurse, and the Pacific Coast Journal of Nursing. Almost every issue of the aforementioned nursing journals between 1903 and the late 1920s emphasized some aspect of TB nursing work or highlighted issues and controversies related to its practice. In addition to their activities within the profession, many TB nurses played influential roles within the wider antituberculosis community. The media paid attention to their accomplishments and rewarded them for their activism as well as their ability to link health care's public sphere of dispensaries and sanatoria to private spheres such as patients' neighborhoods and homes.60 Many tuberculosis nurses participated in local, state, and national antituberculosis organizations as well. The National Tuberculosis Association (NTA) valued its nurse members' opinions. As a result, TB nurses as a group did not experience the invisibility faced by many private-duty and hospital-based nurses.61 The NTA highlighted nurses' contributions at its annual meetings, and especially emphasized their work at the widely publicized 1908 International Congress on Tuberculosis in Washington. The organization sought their opinions on major issues, organized a nursing section within its membership, and regularly included features by nurses and about tuberculosis nursing issues in publications such as the Journal of the Outdoor Life, Transactions of the National Tuberculosis Association, and the Bulletin of the National Tuberculosis Association. Several TB nurses became famous as a result of their activism and one, Ellen La Motte, emerged as an early leader and spokeswoman for tuberculosis nurses.62 La Motte's thoughts, and those of her colleague Mary Lent, published in articles

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and books over the next few years, emerged as TB nurses' manifesto.63 The influence of both women, particularly La Motte, was so substantial that many of their philosophies and ideas were propagated almost without revision in texts of both public health and tuberculosis nursing from 1915 until streptomycin came into use as a treatment for TB in the 1940s.64 La Motte and Lent had long championed nurses' role as patient educator. In 1908, both women, discouraged by the unwillingness or inability of many patients to comply with that which they had been taught, began to advocate for more patient incarceration. No longer did they see the nurse's primary role as a teacher; they now fervently deemed it her duty to enlighten the public about the virtues of institutionalization for the tuberculous, and to encourage sufferers to "submit to the state's demands" in all matters, including segregation and even institutionalization. 6 ^ Not everyone agreed with La Motte and Lent, however. Their colleague 100 miles to the north in Philadelphia, Mabel Jacques, thought their stance too harsh. She argued that La Motte and Lent could not expect appreciable changes in TB mortality based on their interventions in just a few years, especially given the fact that Baltimore had hired only a few nurses to serve a large population of indigent TB sufferers. While Jacques agreed that some patients did need to be institutionalized, she scolded La Motte and Lent for being too quick to break apart families and for what she saw as their insensitivity. 66 In addition to conflict surrounding the better place for treatment, home or institution, another issue divided tuberculosis nurses. Disagreement centered around whether the same nurse should provide preventive as well as curative care. Most health systems lacked a unified framework that allowed the nurses to provide both direct and preventive care. Care of the sick at home, considered therapeutic rather than preventive, fell increasingly under the purview of voluntary organizations such as visiting nurse societies, who called their staff "visiting nurses." By 1910, more and more health departments hired public health nurses and classified their efforts as purely preventive, partly to avoid strife with private physicians who saw these nurses as a threat to their economic livelihood.67 Lillian Wald opposed the idea of one nurse delivering bedside care while another provided education, but Ellen La Motte thought it made good sense.68 Like many of her physician colleagues, La Motte saw this trend toward greater specialization as positive. She and her supporters hoped that specialization might afford nurses greater recognition as well as opportunities for leadership, both within professional nursing and in the public health world.69 But nurses received mixed messages from physicians about their place in the antituberculosis movement. Allowed to be authoritative with patients, they were

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not permitted to forget their place in the professional hierarchy. For example, the Johns Hopkins physician who wrote the introduction to La Motte's book on TB nursing admitted as much when he emphasized that nurses must look to medical science for direction, a good nurse being one whose "attitude always conform [ed] to [that of] medicine."70 Physicians, while recognizing nurses' contribution to the antituberculosis movement, may also have attempted to moderate TB nurses' power to stifle competition and protect their own status. Even though he praised nurses' value to the antituberculosis movement, Dr. Theodore B. Sachs reminded them that "the physician designates the method of treatment and the nurse puts it into action."71 In order to preserve her role as the nurse "most equal to physicians," in the words of one physician, TB nurses maintained this status only by being "as wise as a serpent and as harmless as a dove," as another doctor admonished."72 Tuberculosis nurses received other confusing and frustrating messages as well. As nurse Mary Sewall Gardner, author of a prominent text on public health nursing, noted, society wanted TB nurses to be visible and "pile up brilliant results" but did not understand the structural impediments that made their work difficult, such as inadequate resources, too few numbers, physician resistance to their efforts, and, in many instances, weak authority to structure their own practices.73 Gardner wrote in reference to a report published in Public Health Nurse the month before by Linsley R. Williams, M.D., and Alice M. Hill of the National Tuberculosis Association, wherein the authors concluded that TB nurses were not doing all they should to address the disease, even when taking into account forces over which nurses had no control.74 Nurses even received conflicting signals from one another. For example, although one 1908 American Journal of Nursing editorial encouraged nurses to "make practical application of the plans established by the medical men and the lay public," it did not encourage them to lead or innovate.75 The outspoken La Motte, however, did not believe that nurses needed to subjugate themselves to doctors; in her 1915 treatise on TB nursing, she charged her colleagues with the task of subverting unqualified medical practitioners at every juncture. 76 Tuberculosis nurses themselves counted leadership, intelligence, their thorough knowledge base regarding the disease, relevant legislation, and the latest therapeutics among their most important attributes; however, they also encouraged one another to be cooperative, cheerful, tactful, and patient, and to adapt their roles to accommodate other professionals and community agencies.77 Margaret G. Weir, for example, aTB nurse from Massachusetts, encouraged nurses to keep their work health-oriented, and not to provide "material relief." Weir recognized, however, that, when "no such agencies exist in her community [and] if relief agencies are not doing their job," nurses were obligated to take on this responsibil-

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ity in addition to their other duties.78 Grace L. Anderson, Director of the East Harlem Nursing and Health Demonstration in New York City, asserted that the successful TB nurse was one who synthesized those health services already present in the community into her role formulation. 79 Thus, nurses needed to design their interventions not just based on what they saw as patients' most pressing nursing care needs, but also in such a way as to fill gaps left by others in the community. In spite of the controversies between TB nurses and others, and the many issues related to nurses' role, however, the numbers of TB nurses grew. In 1912, Lillian Wald estimated the number of TB public health nurses to be approximately 3,000. National Tuberculosis Association records indicated that, of these nearly 3,000 TB nurses in practice in 1912, most (2,809) nurses worked for charity organizations, churches, state and local health and education departments, dispensaries, the Metropolitan Life Insurance Company, hospitals, clinics, factories, and shops. Not counted in these numbers were private-duty nurses hired to care for ill tubercular patients in their homes.80

Nurses and the Preventorium NURSES' SUPPORT FOR THE PREVENTORIUM IDEA Nurses found the concept of institutionalizing pretubercular children attractive for several reasons. First, in the preantibiotic era the preventorium seemed to many nurses to offer the most potential for reducing TB morbidity and mortality. Second, many of the factors believed to cause pretuberculosis, such as poverty, poor hygiene, inadequate nutrition, and ignorance, were also implicated in other diseases that afflicted large numbers of children, such as infant diarrhea. As a result, those nurses who became interested in the preventorium movement often found that their antituberculosis work put them at the leading edge of not just one popular reform movement but two: child-saving and tuberculosis prevention. Third, the preventorium underscored a fundamental Nightingalean precept, that of health promotion, and did so definitively because of its focus on not-yet-ill children. The concepts underpinning the preventorium were not new to nurses. In fact, years before the advent of the first preventorium, some nurses suggested that circumstances sometimes warranted separating children from tubercular parents. In 1903, for example, nursing leader Lavinia Dock advocated removing not just ill tubercular children (and adults) from their homes, but also children "strongly predisposed to consumption." 81 Influenced by the growing eugenics movement,

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some public health nurses, like their physician colleagues, believed that a mixture of genetics and environment caused TB predisposition.82 Such assumptions not only gave nurses an imperative to assert control over minute aspects of patients' lives, but cloaked their biases, as well as those of the physicians and philanthropists with whom they worked, with a veneer of objectivity. Many antituberculosis activists did not even believe that their actions breached the family unit. La Motte, for example, asserted that TB, not the actions of the nurse who removed the ill parent or at-risk child, disrupted the home.83 According to her thinking, nonremoval of the child constituted abuse and the state's abrogation of its responsibilities, to the child as well as to society. She argued that, since the law prevented parents from abusing or neglecting their children, authorities must intervene to protect children from parents with tuberculosis. Otherwise, La Motte noted: "A father may not beat his child or brutally misuse it, [but] he is quite within his rights in giving it whatever disease he pleases."84 Jacques took a more muted stance on the issue of removing children from tuberculous parents, perhaps a reflection of her ambivalence. In Jacques's prizewinning educational leaflet from the 1908 International Congress on TB, she wrote that, with proper hygienic practices and family education, children of tubercular parents were at low risk for contracting the disease.85 In another article published the same year in the Trained Nurse and Hospital Review, however, she seemed to support segregating such children and parents from one another.86 Public health nurses were on the front lines in the search for pretubercular children. In fact, they could make the difference between a successful preventorium and an unsuccessful one. For example, in her aforementioned presentation at the 1923 NTA meeting, Ida Spaeth described the use patterns of that city's two preventoria, arguing that their difference in occupancy rates demonstrated the need for more public health nurses. She noted that the preventorium affiliated with public health nurses and a referring clinic enjoyed a long waiting list, while the second preventorium with neither of these features always posted patient vacancies.87 As the preventorium movement gathered momentum just after World War I, nurses proclaimed their support for the idea.88 Elizabeth Stringer, supervising nurse for the Metropolitan Life Insurance Company, summarized the beliefs of many nurses when she wrote: "Where the father or mother of a family has been tuberculous, the children should be watched for symptoms. Even before they develop, if the child does not seem to have the necessary resistance, it should be sent to one of the many institutions provided for such cases."89 In 1925, the NTA asked its nursing subcommittee for a recommendation on the preventorium's value to the antituberculosis campaign. Oklahoma nurse Mary

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Van Zile, the chair of the subgroup, reported to the NTA that her membership supported the preventorium idea with conviction. In its recommendation the nursing subgroup urged the NTA to strengthen the affiliations between children's hospitals and preventoria, both to reduce the institutions' chronic financial straits and to standardize nursing and medical care.90 There is no evidence that the NTA acted on any of these recommendations, although during the 1930s, as fewer children sought preventorium care, individual institutions did respond to nurses' suggestions to broaden admissions policies and seek out different types of children.91 PRF.VKNTORIUM NURSING Though preventoria everywhere in the United States depended on nurses to locate prospective patients, manage the institutions, care for their pediatric clientele, and monitor children's status postdischarge, in at least one state, California, nurses created them. ): Sidney Maguire, the first public health nurse in Los Angeles and later the secretary of the city's TB association, founded California's first preventorium in 1917. M Maguire, struck by the number of pretubercular children she encountered and the paucity of public and private resources for their care, took action. With very few resources and only one helper, she gathered 20 of the sickliest children she could find and kept them for an entire summer at Long Beach, California, where they lived outdoors in tents and ate nutritious food. As a result of her efforts, this health camp grew into a year-round preventorium in the San Gabriel Mountains, wherein public health nurses oversaw the typical preventorium routine of fresh air, exercise, good food, sunshine, play, and hygienic education.9'1 In 1921 Maguire, proud of her efforts and anxious to promote the preventorium concept, addressed her colleagues at the annual convention of the California State Nurses Association and touted her preventorium's contribution to the child welfare and antituberculosis campaigns. 91 While they were not listed among the founders of the first preventorium in New Jersey, prominent nurses such as Lillian Wald maintained an active interest in the institution's affairs and supported its efforts. Wald's Henry Street Settlement referred prospective admittees for admission, and Wald herself attended the dedication of a new preventorium building in 1912.% Alfred F. Hess, the physician who oversaw the New Jersey preventorium, recognized nurses' critical importance to the institution's success from its inception. In a letter written in August of 1909 to Marcus Marks, a wealthy New York philanthropist and president of the preventorium, Hess expressed his concern for an unnamed nurse whom he deemed "not quite suitable." He went on to note the need to replace her "if she cannot get the affection of the children."9

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In his first formal summary of preventorium activities to the institution's board of trustees, delivered in November 1909, Hess noted trained nurse Ella Wheelwright's responsibility for children's care and physical welfare "from the day she fetches them from the railroad station until she returns them to their families 2—3 months later."98 Anne Thompson, listed as a former "nurse" for the Grover Cleveland family, is also acknowledged, but her role is elusive. Hess did not mention whether or not Thompson had formal nurse training, and her duties appear to have been subordinate to those of Wheelwright. She may have served as matron. Subsequent to Wheelwright, J. Palmer Quimby, a trained as well as registered nurse, became the preventorium's supervisor." Both Wheelwright and Quimby lived at Farmingdale, as did many of their counterparts at similar institutions. Since the preventorium strove to be a health care facility, nurses needed to be available 24 hours a day in the event that a child became ill or suffered an accident. Hess charged the preventorium nurse with monitoring children's welfare, observing for illness, educating about hygiene, and supervising all aspects of life at the institution.100 Most preventoria strove to have a nurse available at all times, although it is not clear how many institutions actually achieved this goal. At San Diego's Rest Haven Preventorium, for example, it was not until 10 years after its opening, in 1931, that children had 24-hour access to a graduate nurse. This meant that, while children received the requisite nursing care during the day, at night no health care providers were on site should their services be needed.101 Since overseeing the daily operations of the institution consumed nurses' days, they must have been exhausted when a sick child kept them on duty into the night. At Farmingdale, the nurse's time was almost as regimented as that of her patients, with little time to catch up on rest. Upon the arrival of each patient, she performed an initial health assessment and weighed the child. New admissions spent their first few weeks isolated from the other children in an effort to minimize widespread outbreaks of infectious disease. During this time, nurses got to know the patient and made general estimations of his or her health and symptomatology, the results of which she reported to Hess.102 Although isolating children may have prevented communicable disease outbreaks within the preventorium population, such a practice must also have been psychologically traumatic for the child just wrenched from the familiar surroundings of home and family. The preventorium's therapeutics deviated little from day to day. The central nursing role included the creation and maintenance of an environment superior to that of the child's home. To this end, the nurse managed the institution, making sure that food and supplies got ordered, laundry was washed, and the physical plant

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remained in working order. She addressed issues related to the preventorium's operations as they arose and determined which crises needed to be forwarded to the Board of Directors.103 The nurse also needed to address children's emotional needs and development. If they acted out, she dealt with the problem. She comforted them when they were homesick or upset. Like her physician colleagues, however, Quimby minimized the family disruption and potential for emotional turmoil resulting from family separation. She stressed children's improving health and believed the patients to be happy at the preventorium. 104 Quimby was also a link between parents and children. She responded to inquiries from parents worried about their children. Finally, she designed and implemented educational programs on TBrelated issues for both parents and children. In addition to the Farmingdale nurse's role as chief operating officer, educator, disciplinarian, counselor, and substitute mother, she also needed to attend carefully to children's health, monitoring their nutritional intake, weight, temperature, and other barometers of physical well-being. Since the nurse oversaw every aspect of the children's strict schedule, it became her timetable as well. As a result, her days were full, as this 1912 Farmingdale schedule of children's daily activities reveals: 7 AM 8 AM 9 AM 9:30 AM 10:45 AM 10:45 AM—12 noon 12:30 PM 1:30-2:30 2:30-3:30 3:30-4:30 4:30-5:30 5:30 PM 6:30 PM 7:30 PM

PM PM PM PM

Rising bell Breakfast: cereal, milk or cocoa, stewed fruit, bread and butter Clear tables and make beds School Luncheon of crackers and milk Recess and play in the fields or in the laurel grove Dinner: Meat, fish, or eggs; potatoes, green vegetables, pudding, milk, and bread Rest in bed (no talking) Play School Play Supper: One egg, stewed fruit, bread and butter, cocoa made with milk Sleep (winter) Sleep (summer) IOS

Quimby worked at the New Jersey preventorium for more than 20 years. The National Tuberculosis Association's Directory of Sanatoria, Hospitals, Day Camps, and Preventoria for the Treatment of Tuberculosis in the United States lists her as the nursing superintendent in its 1916 through 1938 editions.106 She evidenced her

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strong commitment to the preventorium's mission in a 1917 article published in the journal Modern Hospital, wherein she described the institution, offering many of the same justifications for its existence as did Hess. Quimby also unwittingly pointed out a fundamental flaw in preventorium supporters' thinking when she noted that, even when a tuberculous mother was willing to go to a sanatorium rather than have her child sent to a preventorium, she could not be spared if there were other children in the home. In such instances, Quimby argued, the preventorium protected the "delicate" child while preventing the disruption of the entire family. 107 However, since Quimby presumably knew the germ theory's basic precepts, the rationale behind leaving an infectious mother at home to care for children not yet labeled "pretubercular" or "delicate" is difficult to understand, since this practice potentially doomed siblings to the same fate as that of their sickly brother or sister. Rules governing parental visitation varied from preventorium to preventorium, but the practice was generally discouraged or at least limited in order to minimize contact with the tubercular parent. Quimby did not mention it in her descriptions of the preventorium's practices. Perhaps she was ambivalent about parental/child contact, or maybe she did not consider it noteworthy because it was not a medical or nursing intervention. 108 Hess, in a description of his effort to broaden the preventorium to provide care for at-risk infants, noted that he believed the institutions should be at least "far enough away from the city [Hess suggested 2 hours] for the items of expenditure of time and money to act as a deterrent to frequent visits on the part of mothers."109 Before a child's discharge, either a preventorium nurse or a public health nurse visited the home to make sure it met specified requirements, which included recovery or death of the afflicted parent or at least a cleaner, more hygienic, better ventilated environment. Nurses followed former patients indefinitely. As one Farmingdale report emphasized: "No child is returned from the Preventorium until the nurse reports home conditions safe. The children are followed up [by nurses] for years. . . .Our purpose is to permanently save every child that comes to us." 110

Conclusion: The Decline of Preventorium Nursing Through their publications, we know that Quimby and Maguire ardently believed in the preventorium cause.111 But what of other preventorium nurses? We know little of their thoughts. In fact, the nursing perspective on preventoria is framed

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largely by the public health nurses who referred patients to the institutions and followed them once they were discharged back into their communities, and not by those nurses employed by the preventoria. Even basic demographic information is missing about most preventorium nurses. What, for example, were their ages? Marital status? Tuberculosis status? Where did they train? Furthermore, we don't know how they came to be working in such a role. Did they feel their work conferred greater status than that experienced by other nurses, or was it the only job they could get? We also know little about preventorium nurses' professional activities. Were they leaders in the nursing profession? Maguire, for example, served as executive secretary of the Los Angeles TB Association in f 921, but was she similarly active in the California State Nurses' Association? 112 While nurses who belonged to the NTA supported the preventorium idea, was there broad support for the preventorium movement within the National Organization for Public Health Nursing? How many nurses practiced in preventoria throughout North America? What was the nurse's work environment really like? No conclusive answers to these questions exist. Moreover, since preventoria themselves varied widely, so did the roles of the nurses who worked there. Quimby and Maguire seem to have had at least as much power and autonomy as public health nurses. This was not true for all preventorium nurses, however, since those at Rest Haven appear to have had no more authority than did their peers in a hospital or private-duty setting. Ida Spaeth summarized the public health nurse's role succinctly when she referred to her as the "connecting link" among all aspects of the campaign to institutionalize pretubercular children." 1 The nurses who worked within the preventorium performed a similar function, though in a more circumscribed environment. They linked the community within the preventorium to the outside world of parents, schools, physicians, public health nurses, and other resources. While nurses' contributions to preventoria made them invaluable assets to the movement, there was a downside to serving as the glue that held the system together. In most communities, tuberculosis prevention and treatment were linked together through a complex web of public and private initiatives. It was the nurse's job to fit people and resources together appropriately, as both Margaret G. Weir and Grace L. Anderson noted. 11 ' 4 As a result, however, public health nurses often found themselves caught between different parties with competing agendas. Part of nurses' success depended on their ability to buffer tensions between groups and make a particular community's programs articulate with one another in a meaningful fashion. Although some nurses, such as Lillian Wald, Mabel Jacques, Ellen La Motte, and Sidney Maguire, for example, did press their own

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antituberculosis agendas, other nurses may have been inhibited from doing so. While nurses were usually well positioned to make determinations regarding community needs, forging their own initiatives may have subverted their ability to mesh together what was already in place. Using Spaeth's words to examine the potential negative outcomes inherent in her "connecting link" metaphor, it is difficult to be in a position both to create a chain's links and to weave them together. In other words, it is not easy to be ubiquitous as well as unique. Though preventorium and TB public health nurses both focused their energies on the same disease, their roles did differ. At least some preventorium nurses lived at the institutions, which perhaps rendered their work more similar to that of nurses who worked in sanatoria or hospitals than of those in the public health arena who visited patients at home.115 Preventorium nurses also appear to have remained employed by their institutions, unlike many other public health nurses, whose affiliation shifted from voluntary agencies such as TB associations to city and state health departments between 1900 and 1920.!16 In at least one respect, preventorium nurses and TB public health nurses' roles bore a striking similarity. Both appeared to accept their Americanization mission with vigor, believing, like their employers, that children could be used as "little missionaries that can be sent back into the home."117 The paucity of surviving evidence makes it difficult to make sweeping comparisons between preventorium nurses' work and that of their peers in private duty or other institutions, but a few similarities and differences stand out. Since a certain fluidity of roles existed between the nurse and the institution's social worker or teacher, preventorium nursing may have been more interesting than privateduty nursing work. Just as with other nursing specialties, however, the boundaries between physicians and nurses remained impermeable in most instances. Moreover, some preventorium nurses may have felt their professional actions and judgment constrained, not just by their relationship to physicians but also by the institution's board of directors, an experience shared by many public health nurses.118 Finally, both preventorium and TB public health nurses shared the almost universal feature of early twentieth-century nursing practice in that they struggled with too few resources to fully achieve their own ambitious goals as well as those set for them by others. In the late 1920s, the economic, social, and medical trends that had made the need for TB and other public health nurses seem so compelling a few years earlier began to erode, the result of a growing trend toward fee-for-service hospital care, the falling incidence of infectious diseases in the United States, and reduced immigration. 119 By the end of the 1940s, preventorium nursing had virtually disappeared as the institutions closed or became converted for other uses. Although

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nurses remained heavily invested in children's health, after World War II they did so in a very different environment, one increasingly bureaucratized, hospital-based, and technologically driven. CYNTHIA A. CONNOLLY, PHD, RN Postdoctoral Fellow Center for the History & Ethics of Public Health Columbia University New York, NY 10027 Notes 1. Ida Spaeth, "The Public Health Nurse, The Tuberculosis Problem, and the Child in the Sanatorium," Transactions of the National Tuberculosis Association 19 (1923): 438-39. 2. "Organization Report of the Tuberculosis Preventorium." Nathan Straus papers, Box 8, New York Public Library, New York City (hereafter cited as NYPL). 3. First Medical Report of the Preventorium, July-November 1909. Straus papers, Box 8, NYPL. Annual Report of the Tuberculosis Clinic for Bellevue Hospital, New York, for the Year 1909; Alfred F. Hess, "The Tuberculosis Preventorium," Survey (August 1913): 666-68. Nurses in other regions performed functions similar to those of their New York counterparts. For example, one Pennsylvania public health nurse detailed her efforts with a tuberculous mother to protect her children from infection. This article described in depth the nurse's assessment of the home and family situation, the way in which she coordinated social welfare services for the family, and her efforts to work through family resistance to get a child to the preventorium. See Anonymous, "The State Nurse Goes 'AVisiting,'" Listening Post (January 1923): 18-22. For a Pennsylvania nurse's description of a preventorium case, see a letter from Elizabeth M. Dennie in Listening Post (May 1924): 2122. 4. Annual Report for the year 1912, The Tuberculosis Preventorium for Children. Straus papers, Box 8, NYPL. These same functions were carried out by nurses in other cities with preventoria. For examples, see John B. Hawes of Boston's Prendergast preventorium, 336-42, and Henry Farnum Stoll, "The School Child and Tuberculosis: A Plea for Preventoria," 122-31, in Transactions of the National Tuberculosis Association 6 (1910). 5. National Tuberculosis Association, A Directory of Sanatoria, Hospitals, Day Camps, and Preventoria for the Treatment of Tuberculosis in the United States (New York: National Tuberculosis Association, 1926). 6. Mark Caldwell, The Last Crusade: The War on Consumption, 1862—1954 (New York: Atheneum, 1988), 9; Sheila M. Rothman, Living in the Shadow of Death: Tuberculosis and the Social Experience of Illness in American History (Baltimore: Johns Hopkins University Press, 1990), 179-84. 7. Rene and Jean Dubos, The White Plague: Tuberculosis, Man, and Society (New Brunswick: Rutgers University Press, 1952), 3-11.

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8. Charles E. Rosenberg, "The Bitter Fruit: Heredity, Disease, and Social Thought in Nineteenth Century America," in From Consumption to Tuberculosis: A Documentary History, ed. Barbara G. Rosenkrantz (New York: Garland, 1994), 154-94. 9. Nancy J. Tomes, "American Attitudes Toward the Germ Theory of Disease: Phyllis Allen Richmond Revisited," Journal of the History of Medicine and Allied Sciences 52 Qanuary 1997): 17-50. 10. Rothman, Living in the Shadow, 179-84. 11. Alan M. Kraut, Silent Travelers: Germs, Genes, and the "Immigrant Menace" (Baltimore: Johns Hopkins University Press, 1994), 2-4, 31-78. 12. For examples, see Sigard Adolphus Knopf, "What Shall We Do with the Consumptive Poor?" Proceedings of the National Conference of Charities and Corrections at the 29th Annual Session. (Boston: Lea and Febiger, 1902): 219-31, and Arnold C. Klebs, Tuberculosis: A Treatise by American Authors on Its Etiology, Pathology, Semeiology, Diagnosis, Prevention, and Treatment (New York: Appleton and Company, 1909), 120-30. 13. Barbara Bates, Bargaining for Life: A Social History of Tuberculosis, 1876-1938 (Philadelphia: University of Pennsylvania Press, 1992), 25-41. 14. Klebs, Tuberculosis, 120-130. 15. Hermann M. Biggs, "The Administrative Control of Tuberculosis," Medical News 84 (20 February 1908): 338-45. 16. Preventing TB in New York City. Ninth Report of the Committee on the Prevention ofTB of the Charity Organization Society of New York, 1911, 1912, 1913 (New York: MB. Brown). 17. Clemens von Pirquet, "Frequency of Tuberculosis in Childhood," Journal of the American Medical Association (February 1909): 675-79 (hereafter cited us JAMA). 18. Biggs is quoted in Linsley L. Williams, "Tuberculosis in Children," Journal of the Outdoor Life 9 (August 1907): 241-44. 19. von Pirquet, "Frequency of Tuberculosis," 675—79. 20. Sigard Adolphus Knopf, "Overcoming the Predisposition to Tuberculosis and the Danger From Infection During Childhood," in Sixth International Congress on Tuberculosis, vol. II (Philadelphia: William F. Fell, 1908), 635-47. 21. Hess, "Tuberculosis Preventorium," 666-68. 22. "Tentative Scheme for the Operation of the Proposed Preventatorium [the word was later shortened to preventorium] for Children." Straus papers, Box 8, NYPL. 23. For more on the New York COS, see Emily K. Abel, "Medicine and Morality: The Health Care Program of the New York Charity Organization Society," Social Service Review 71 (December 1997): 634-49. For more on the COS movement in the United States in general, see Michael B. Katz, In the Shadow of the Poorhouse: A Social History of Welfare in the United States (New York: Basic Books, 1986), 66-80. 24. National Tuberculosis Association, Directory, 1911, 1916, 1923, 1926, 1928, 1931, 1934, 1938, 1942, and 1948. 25. Merritte W. Ireland, "Physical Defects Discovered in Selective Draft Men During the World Tffzz? JAMA 79 (November 1922): 1579-81. 26. Karen Buhler-Wilkerson, "Left Carrying the Bag: Experiments in Visiting Nursing, 1877-1909," Nursing Research (January/February 1987): 42-47 . 27. Susan Reverby, Ordered to Care: The Dilemma of American Nursing, 1850-1945

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(New York: Cambridge University Press, 1987), 109-110; Barbara Melosh, "The Physician's Hand": Work, Culture, and Conflict in American Nursing (Philadelphia: Temple University Press, 1982), 113-59. 28. John Duffy, "Social Impact of Disease in the Late Nineteenth Century," in Sickness and Health in America, Judith W. Leavitt and Ronald L. Numbers, eds. (Madison: University of Wisconsin Press, 1985), 414-22; Kraut, Silent Travelers, 180. 29. District nursing, an innovation created in the second half of the nineteeth cenrury, involved sending trained nurses to care for the indigent sick in their homes. See Karen Buhler-Wilkerson, False Dawn: The Rise and Decline of Public Health Nursing, 1900-1930 (New York: Garland, 1989), 1-45. 30. For a description of America's first settlement house, located in Chicago, see Jane Addams, Twenty Years at Hull House (New York: Macmillan, 1910), 90-110. 31. Wald, born in 1867 and raised in an upper-middle-class German-Jewish home in Rochester, New York, epitomized Carroll Smith Rosenberg's Progressive Era "new woman." Carroll Smith Rosenberg, Disorderly Conduct: Visions of Gender in Victorian America (New York: Knopf, 1985), 176. A chronicle of Wald's life and work can be found in her autobiography, The House on Henry Street (New York: Henry Holt, 1915), and in biographies such as Doris Groshen Daniels, Always a Sister: The Feminism of Lillian Wald, (New York: Feminist Press at City University of New York, 1989). 32. Bates, Bargaining for Life, 237-43. 33. Karen Buhler-Wilkerson, "False Dawn: The Rise and Decline of Public Health Nursing in America, 1900—1930," in Nursing History: New Perspectives, New Possibilities, Ellen Lagemann, ed. (New York: Teacher's College Press, 1983), 89-106. For several firsthand accounts of public health nurses' daily activities, see Caroline Bartlett Crane, "The Visiting Nurse in a Small City," Charities and the Commons 16 (April 1907): 25-28 (hereafter cited as CQ, and Lillian Wald, "In the Day's Work of a Settlement Nurse," ibid., 34-44. 34. Perhaps the most famous postgraduate course for public health nursing was the program developed by Adelaide Nutting at Teacher's College, Columbia University. For a description, see M. Adelaide Nutting, "Education for Nurses for the Home and Community," Modern Hospital6 (March 1916): 196-200. For a discussion ofwhy nursing leaders believed TB public health nurses needed additional education beyond that acquired in their training programs, see F. Elizabeth Crowell's "Report of the Special Committee on TB Nursing," presented at the Fourteenth Annual Convention of Nurses' Associated Alumnae of the United States, American Journal of Nursing 11 (August 1911): 973 (hereafter cited as AJN). 35. Elizabeth Stringer, "What Every Public Health Nurse Should Know," AJN 14 (August 1914): 976-79. 36. Karen Buhler-Wilkerson, "Bringing Care to the People: Lillian Wald's Legacy to Public Health Nursing," American Journal of Public Health 83 (December 1993): 177886 (hereafter cited as AJPH). Johns Hopkins Hospital physician William Osier made one of the earliest calls for the home treatment of tuberculosis, arguing that the disease lurked in the home and was thus a "house disease." Osier also believed that home treatment was more cost effective than institutionalization. See Osier's "Home Treatment of Consumption," paper read in 1 899 at the Medical and Chirurgical Faculty of Maryland. Archives of the Medical and Chirurgical Faculty, Baltimore, Md.

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37. Hermann M. Biggs, "What Has Been Learned About Tuberculosis Since the International Congress of 1908, and What Modifications, If Any, Should This Have on the Constructive Program?" Journal of the Outdoor Life 13 (February 1916): 45-48 (hereafter cited as/OZ). 38. Jessica Robbins, "Class Struggles in the Tubercular World: Nurses, Patients, and Physicians, 1903-1915," Bulletin of the History ofMedicine 71 (Fall 1997): 412-34; Annie M. Brainard, The Evolution of Public Health Nursing (Philadelphia: W.B. Saunders, 1922; reprinted in New York: Garland Press, 1985); Mary Sewall Gardner, Public Health Nursing (New York: Macmillan, 1932), 269-70. 39. Melosh, "The Physician's Hand,"113-59. 40. Committee on the Prevention of TB of the Charity Organization Society, TB Needs and the City Budget. Community Service Society Archives, Box 109, Rare Book and Manuscript Library, Columbia University, New York. By 1910, New York City was divided into districts, each with a centrally located clinic. Each district was subdivided into sections with a nurse assigned to each section. The nurse visited homes for half the day and practiced in the clinic the rest of the time. Nurses' clinic duties included obtaining patient histories, weights, and temperatures, keeping records, and educating sufferers and their families about TB. For more on TB nursing in New York City, see Elizabeth Gregg, "The Tuberculosis Nurse Under Municipal Control," Public Health Nurse Quarterly 5 (October 1913): 15-25, and General Description and Annual Report of the Tuberculosis Clinic, Bellevue Hospital, 1909 (New York: Martin B. Brown Press, 1909), 8-15. 41. M. Adelaide Nutting, "The Tuberculosis Exposition, Baltimore," AJN4 (April 1904):497-99; M.A. Nutting, "The Visiting Nurse for Tuberculosis," CC16 (April 1906): 51-55; Robbins, "Class Struggles," 412-34; Bates, Bargaining for Life, 234-35. 42. Reiba Thelin, "Visiting Nurses and the Prevention of Tuberculosis," AJN 5 (August 1905): 743-56. Reiba Thelin, a 1902 graduate of the Johns Hopkins Training School for Nurses, was the first TB nurse in Baltimore. Thirty-two years old when she completed her training, she had no experience in public health nursing when she took the position. She worked in the role for only one year and then, desirous of more public health experience, left Baltimore to work at Wald's Henry Street Settlement. For an overview of Thelin's career, see Brainard, Evolution, 278, and Robbins, "Class Struggles," 417. For more on antituberculosis nursing efforts in Baltimore, see Johns Hopkins Nurses Alumni Magazine, vols. 2 (1903) to 14 (1915). See also Ruth Brester Sherman, "The Discussion on Tuberculosis," AJN 2 (October 1901): 24-27; R Thelin, "Report of Results of Nursing Dispensary Tubercular Patients," Johns Hopkins Hospital Bulletin (May 1904): 171; J.S. Ames, "The Work of District Nurses Among Tuberculous Patients in Baltimore," AJN 4 (June 1904): 671-73; Ellen N. La Motte, "Tuberculosis Work of the Instructive Visiting Nurse Association of Baltimore," AJN 5 (1905): 141-48; and Jane B. Newman, "The Public Health Nurses of the Baltimore City Health Department," Public Health Nurse 16 (July 1924): 339-41 (hereafter cited as PHN). 43. Gregg, "Tuberculosis Nurse," 15-25; Anonymous, "Visiting Nurses in Connection with the Phipps Dispensary, Baltimore," AJN 8 (1908): 541-42. 44. F.E. Crowell, "Standards of Nursing in Communities With TB Dispensaries," PHN 7 (April 1915): 14-21; Elsie Thayer Patterson, "The Visiting Nurse," JOL 4 (December 1907): 412-14.

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45. Sara E. Shaw, "Social Activities of Bellevue Tuberculosis Clinic," JOL 9 (October 1912): 230-33; Winifred M. Allen and Elizabeth McConnell, "The Teachableness of the Consumptive Patient," AJN 15 (October 1914): 25-30; Ames, "Work of District Nurses," 671-73. 46. Sarah B. Stevens, "The Tuberculosis Nurse and Some of Her Problems," PHN 7 (April 1915): 35-41. 47. Ibid. 48. Ibid., 35-41; Crowell, "Standards of Nursing," 14-21. 49. Stevens, "Tuberculosis Nurse," 35-41. 50. Delores Gladys Spicer, "The Foreign Mother and Her Child," Trained Nurse and Hospital Review 92 (March 1934): 257-61 (hereafter cited as TNHR). 51. Karen Buhler-Wilkerson, "Public Health Nursing: In Sickness or In Health?" AJPH75 (October 1985): 1155-60. 52. Shaw, "Bellevue Tuberculosis Clinic," 230-33. 53. Jane Delano, "Outline of TB Work in Connection With the Outpatient Department of Bellevue Hospital," AJN 4 (March 1904): 440-42. 54. Mabelle S. Welch, "Control of Tuberculosis Through Family Health Supervision," PHN 20 (August 1928): 413-15. 55. They characterized 18.1% as fairly intelligent, 69.5% stupid, and 12.4% intensely stupid or defective. Allen and McConnell originally defined three categories: (A) intelligent, (B) fairly intelligent, and (C) stupid, but acknowledged that they felt that their revised groupings better fit the characteristics of their patient population. Allen and McConnell, "Teachableness," 25-30. 56. Elsie M. Courrier "Some Aspects of the TB Problem," AJN 9 (1909): 924-31. 57. Rose C. MacGowan, "The Attitude of the Various Nationalities Toward the Work of the School Doctor and Nurse," Pacific Coast Journal of Nursing 21 (August 1922): 490-92 (hereafter cited as PCJN). 58. Gregg, "Tuberculosis Nurse,"15-25. 59. Wald defined civic intelligence as the ability to plan and carry out comprehensive public health programs for a given community. Lillian D. Wald, "The Visiting Nurse and Tuberculosis Control" JOL 9 (December 1912): 306. 60. For example, the Philadelphia Inquirer newspaper trumpeted the life and career of Philadelphia TB nurse Mabel Jacques on 18 February 1909. 61. Reverby, Ordered to Care, 128-29. 62. La Motte was born in Louisville, Ky. She graduated from the Johns Hopkins Hospital Training School for Nurses in 1902, and soon joined the Instructive Visiting Nurse Association (IVNA). Vern L. Bullough, Olga Maranjian Church, and Alice P. Stein, "Ellen La Motte," Dictionary of American Nursing Biography (New York: Garland, 1988), 204-205; Obituary, "Ellen La Motte," TNHR 81 (September 1928): 312. 63. Mary Lent, a 1905 graduate of the Johns Hopkins Training School for Nurses, was employed as head nurse at Hopkins until 1898, when she went to work at the Baltimore IVNA. She became the IVNA superintendent in 1903 and held the post until 1916. Vern L. Bullough, Olga Maranjian Church, and Alice P. Stein, "Mary Lent," Dictionary of American Nursing Biography (New York: Garland, 1988), 211-12; Brainard, Evolution, 238.

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64. Ellen La Motte, The Tuberculosis Nurse: Her Functions and Qualifications (New York: Knickerbocker Press, 1915), and Grace M. Longhurst, Tuberculosis Nursing (Philadelphia: F.A. Davis, 1945). 65. Ellen N. La Motte, "The Unteachable Consumptive," Transactions of the Sixth International Congress on Tuberculosis, vol. Ill, sec. V (Philadelphia: Wm. F. Fell, 1908), 256-63; Mary E. Lent, "The True Functions of the Tuberculosis Nurse," ibid., 576-85; Mary E. Lent and Ellen N. La Motte, "The Present Status of Tuberculosis Work Among the Poor," Maryland Medical Journal 52 (April 1909): 147-63. 66. Mabel Jacques, "Saving the Home,"/OZ 6 (November 1909): 265-69. For an overview of Jacques' professional life and activities, see Bates, Bargaining for Life, 244-45; LaMotte, Tuberculosis Nurse, 87-104. 67. Buhler-Wilkerson, False Dawn, 1-45, 85-129. 68. Lillian Wald, "Visiting Nurse," 306-307, 310; La Motte, Tuberculosis Nurse. 69. For the best overview of the early twentieth-century trend toward specialization in medical care,see Rosemary Stevens, American Medicine and the Public Interest: A History of Specialization (New Haven: Yale University Press, 1971; updated edition, Berkeley: University of California Press, 1998), 132-48 (page references are to reprint edition). 70. Louis Hammond, The Tuberculosis Nurse, xi. 71. Theodore B. Sachs, "The Tuberculosis Nurse," AJN (May 1908): 597-98. 72. Benjamin Lee, "The Value of a Nurse in a Tuberculosis Dispensary," Transactions of the Sixth International Congress on Tuberculosis, vol. 3 (Philadelphia: William F. Fell, 1908), 554-55. Lee made this comment with regard to the nurse's role toward patients, but the subtext of the article shows that he believed nurses should structure their interactions with physicians in the same way. 73. Mary S. Gardner, Letter to the Editor, PHN2\ (February 1929): 66-67. 74. Linsley R. Williams and Alice M. Hill, "The Public Health Nurse and Tuberculosis," PHN21 (January 1929): 4-7. Gardner was not the only nurse incensed by Williams's and Hill's conclusions. An editorial written by Violet H. Hodgson, Assistant Director, National Organization for Public Health Nursing, accompanied the article by Williams and Hill. Hodgson identified multiple flaws in the way in which Williams and Hill designed the study, gathered data, and interpreted their findings with regard to capturing the nursing contribution. For example, Hodgson noted that physicians often limited private patients' access to TB nurses so that nurses could not be held accountable when those patients were not evaluated by them. Further, she wondered if the 18 sanatoria and 1,499 patients reviewed could be considered representative of the 600 sanatoria and 60,000 TB sufferers in the United States. Williams and Hill reported that only two of 1,499 TB patients had been located by nurses. Hodgson argued that nurses may in fact have identified potential patients, but because it was the physician who made the diagnosis it was he who was given sole credit. Finally, she expressed surprise that the authors had not looked at nursing efforts for those under the age of 15 years, since nurses directed much of their time and energy toward TB prevention in children and adolescents. Violet H. Hodgson, "Some Remarks About the Study Which Follows," PHN2\ (January 1929): 2-3. 75. Editorial, AJN 8 Qune 1908): 665. 76. LaMotte, Tuberculosis Nurse, 88.

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77. Delya Nardi, "The Special Training of the Tuberculosis Nurse," Transactions of the National Tuberculosis Association 22 (1926): 479-87; Margaret G. Weir, "Problems in Tuberculosis Work," PHN 12 (February 1920): 111-15. 78. Weir, "Problems," 111-115. 79. Grace L. Anderson, "Standards for Tuberculosis Work in a Generalized Nursing Program," JOL 24 Qune 1927): 340-45. 80. Wald, "Visiting Nurse," 306-307. 81. Lavinia Dock, "The World's War Against Consumption," AJN 3 (1903): 16061. 82. Editorial, "Consumption,"AJN5 (1905): 392. Arthur Hamilton, "Some Direct Relations Between the Science of Eugenics and the Nursing Profession," AJN 15 (1915): 475. 83. La Motte, Tuberculosis Nurse, 161. 84. Ellen La Motte, "The Neglected Tuberculous Child,"/OI 7 (March 1910): 6570. 85. Mabel Jacques, "Educational Leaflet for Mothers," Transactions of the Sixth International Congress on Tuberculosis, vol. I (Washington: National Tuberculosis Association, 1908), 307-309. 86. Mabel Jacques "Special Schools for Tuberculous Children," TNHR41 (October 1908): 234-36. 87. Spaeth, "Public Health Nurse," 438-39. 88. Anne Sutherland, "Tuberculosis Nursing by a Generalized Staff," Transactions of the National Tuberculosis Association 17 (1921): 536-55; Mary A. Meyers, "The Public Health Nurse in Tuberculosis Work, Especially As It Touches Children in the Clinic," Transactions of the National Tuberculosis Association, 19 (1923): 434-38; Spaeth, "Public Health Nurse," 438-39; Van Zile, 508-11; and Grace L. Anderson,"Standards for Tuberculosis Work in a Generalized Nursing Program," JOL 24 (June 1927): 340-45. Every one of these articles champions the idea, and all concur that nurses must play the central role in obtaining patients for, and managing the operations of, the preventorium. 89. Elizabeth Stringer, "What Every Public Health Nurse Should Know," AJN 14 (1914): 976-79. The Metropolitan Life Insurance Company operated a well-known visiting nurse service. For an overview, see Diane Hamilton, "The Cost of Caring: The Metropolitan Lire Insurance Company's Visiting Nurse Service, 1909-1953," Bulletin of the History of Medicine 63 (1989): 414—34. The Framingham tuberculosis project, an epidemiologic study of TB morbidity and mortality based in Framingham, Mass, (and heavily dependent on the services of Metropolitan Life) also grew out of the liaison between the insurance company and public health leaders. See Diane Hamilton, "Research and Reform: Community Nursing and the Framingham Tuberculosis Project, 1914-1923," Nursing Research 41 (January/February 1992): 8-13. For other articles in the nursing literature supporting the preventorium concept, see Alice C. Bagley, "The Public Health Nurse in Tuberculosis Care," PCJN27 (May 1931): 301-305, and Marcia A. Patrick, "Our Local Preventorium Camps," PCJN 16 Quly 1920): 434-38. 90. Van Zile, 508-1 1. 91. Rest Haven Preventorium Manuscript Collection #6, San Diego Historical Society, San Diego, Cal.

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92. Bagley, "Public Health Nurse," 301-3055. Bagley not only gave examples of nurses' founding California preventoria, she also suggested that, if the relationship between children and TB had been discovered earlier, child welfare and tuberculosis public health nursing might have developed as one specialty. 93. Ibid., 301. 94. Genevieve Parkhurst, "A Chance for the Borderline Child," Good Housekeeping 84 (May 1922): 143-46. 95. Maguire emphasized that she sought to select those children "who in the future will bring the greatest amount of good to the community." Presumably she believed the children she selected were those whose health she deemed salvageable. Maguire did not note whether factors such as race or ethnicity went into this determination. The hundred children cared for at the San Gabriel Canyon preventorium resided there an average of 2 months. After discharge, followup was conducted by Los Angeles city and county public health nurses. Sidney M. Maguire, "Tuberculosis in the Southern Section," PCJN 17 (October 1921): 589-93. 96. Editorial, New York Times, 25 April 1912. 97. Letter to Marcus Marks from Alfred Fabian Hess, dated 1 August 1909. Straus papers, Box 16, NYPL. 98. Organizational Report of the TB Preventorium; First Medical Report of the Preventorium, July to November 1909. Straus papers, Box 8, NYPL. A man by the name of Sherburn Wheelwright, perhaps Ella Wheelwright's husband, is listed in the above records as an employee who taught industrial training to the boys at the preventorium. 99. Registration of nurses was an attempt to restrict nursing practice to only those nurses who had undergone some form of training. For history and analysis of the registration movement in one state, New York, see Nancy Tomes, "The Silent Battle: Nurse Registration in New York State, 1903-1920" in Nursing History, ed. Lagemann, 107-32. 100. First Medical Report of the Preventorium, July to November 1909. Straus papers, Box 8, NYPL; Hess, "Tuberculosis Preventorium," 666-68; J. Palmer Quimby, "The Tuberculosis Preventorium for Children, Farmingdale, N.J.," Modern Hospital 8 (1917): 177-79. 101. Transcript of radio interview with Rest Haven Preventorium board members Mrs. Osborn and Ekern, April 1947. Manuscript Collection #6, Box 3, File 4, San Diego Historical Society, San Diego, Cal. 102. First Medical Report of the Preventorium, July to November 1909. Straus papers, Box 8, NYPL. 103. Records of the Rest Haven Preventorium for Children, San Diego Historical Society Research Archives, San Diego, Cal. 104. Quimby, "Tuberculosis Preventorium," 177-79. 105. Preventorium Annual Report for 1912, 5-6. Straus papers, Box 8, NYPL. 106. The National Tuberculosis Association's Directory listed Quimby as superintendant in its 1916, 1919, 1923, 1926, 1928, 1931, 1934, and 1938 editions. 107. Quimby, "Tuberculosis Preventorium," 177-79. 108. Ibid. 109. Alfred F. Hess, "The Significance of Tuberculosis in Infants and Young Children," JAMA 72 (January 1919): 83-88.

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110. Preventorium Annual Report for 1912, 6-7. Straus papers, Box 8, NYPL. 111. Quimby, "Tuberculosis Preventorium," 177-79; J. Palmer Quimby, Report of Nursing Activities in "The Tuberculosis Preventorium for Children," 15. New York Historical Society, 1928; Maguire, "Tuberculosis," 593. 112. Maguire, "Tuberculosis,"589. 113. Spaeth, "Public Health Nurse," 438-39. 114. Weir, "Problems," 111-15. 115. Unlike sanitorium nursing, however, no record can be found of training schools for nurses at preventona. For a discussion of sanitorium nursing and sanatorium nursing schools, see Bates, Bargaining for Life, 110-12, 197-213. 116. Buhler-Wilkerson, False Dawn, 87. 117. Patrick, 434-38; Spaeth, "Public Health Nurse," 438-39. 118. Buhler-Wilkerson, False Dawn, 48-49. 119. Ibid., 89-106.

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The Roots of Collaborative Practice: Nurse Practitioner Pioneers' Stories JULIE FAIRMAN School of Nursing University of Pennsylvania

Perhaps the problems of doctor and nurse are not so much professional, as simply human. We [physicians] must learn to share—to share rewards, both psychological and economic—and to share responsibility in a risk-fraught world where our training has taught us to depend only on ourselves. . . . And we must learn to communicate sufficiently with one another so that each may function effectively, and safely, and reasonably efficiently. 1

Collaboration, exemplified in this paper by the daily working relationship established between nurse practitioners (NPs) and physicians, and eloquently described above from a physician's perspective by Barbara Bates in 1973, is a much analyzed concept. It has been formalized, theorized, and legislated to the point at which its meaning and implications are no longer assumed and differ from purpose to purpose. 2 Nurse practitioners contend they want to practice collaboratively, sometimes incorporating principles of equality of decision making, power sharing, and open communication, for the sake of their patients and, perhaps less altruistically, to advance and ascertain their own place in the health care hierarchy. Physician colleagues, to whom many of NPs' collaborative efforts are directed, are in many cases also eager to engage in practice arrangements characterized as collaborative, but that might include a heavy dose of supervision. The June 2000 American Medical Association's (AMA) Citizens' Petition calling for nurse practitioners to collaborate with [sic under the direction of] physicians is an example of the supervisor)' component naturally embedded in collaboration by many physician professional groups, and of their fears of independent (and quite effective) NP practice. 5 Nursing History Review 10 (2002): 159-174. A publication of the American Association for the History of Nursing. Copyright © 2002 Springer Publishing Company.

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At times nurses and physicians seem to be holding parallel conversations, as the meaning of collaboration and expectations held by both groups may be quite diverse, compelled by complex historical antecedents, and with important implications for patient care.4 It is for these reasons that a backward glance to uncover the roots of early collaborative agreements between NPs and physicians may provide the foundation for a contemporary perspective mutually acceptable to NPs, doctors, and the patients they serve. In this paper, I discuss the roots of collaborative relationships between NPs and physicians from a historical perspective by analyzing the oral history data obtained from five nurse practitioners, "pioneers," who practiced in the early 1970s.5 I argue that, before collaborative care could be mutually constructed, negotiations between individual physicians and nurses had to occur concerning the boundaries of nursing and medical knowledge and practice.6 Availability of both practitioners, including the important concepts of timing and place (for this argument, both concrete space and access by telephone constitute space), was an important factor in establishing collaborative relationships, as was the ability of each party to engage in a highly personal and social relationship.7 In other words, collaboration did not rise up de novo from the practice setting. Collaboration was preceded by a process of negotiation between individual nurses and physicians that both tested and established boundaries, illuminated the importance of trust and respect, and provided a frame from which collaborative practice proceeded. These negotiations were embedded in changes in nursing and medical education and practice, gender, federal entitlement policies, and economics of the post-World War II society.8

Oral History Oral history is an intellectual process of connecting individual experiences with the broader canvas of social change and providing the foundation for different ways of generating historical questions.9 Oral history encapsulates daily life from which the framework for larger trends, social experiences, and social movements can be constructed. In many ways, oral history democratizes the study of the past by examining the experiences of people who have been hidden—those ordinary human actors who individually may not seem extraordinary, but taken as part of a larger societal experience provide a connection to a historical episode. Oral history also refers to the process of collecting oral narratives, including recording, transcription, editing, and making public the account.10

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Oral history data are used here to describe the everyday, personal realities that NPs experienced as they began and sustained their practice. Although this is admittedly a one-sided perspective, it is a valid and useful one nonetheless. The oral history process uncovers the lived experiences of nurses and allows us to understand their work at very local, specific levels, in the context of their individual practices as they negotiated their roles. In this way, the nurses are able to express their stories through familiar language, the language of practice. The language nurses use to convey their experiences also provides a way to understand and document nurses' culture and history; this method enables nurses to connect the past to the present and to make sense of their lives and the world around them.11 Nurses' words, while perpetuating traditional myths and stories, also give us new ways to think about how nurse practitioner practice was negotiated and delivered in the practice arena.12 In the oral history process, women in particular may feel comfortable documenting experiences outside of those considered acceptable in the usual forms of public discourse.13 This process is not merely the recording of experiences, but nurse practitioners' interpretation of their own experiences. Thus their narratives create a way for nurse practitioners to acknowledge the power inherent in their daily work and the strength of the knowledge underpinning their work. u

Negotiation and Collaboration The term negotiation has been chosen deliberately to describe the development of collaborative practice because it implies agency and participation of both parties— doctors and nurses—involved in the process of constructing work boundaries.15 Agency is a requirement for negotiation even when one party holds greater power, and it assumes the power and the ability to make choices of some kind.16 Also, it is the power in the everyday agency evoked by NPs and physicians in practice settings that, in turn, contributes to the tension between the realities of clinical practice and larger societal structures of power. The local level, the point of patient care, can be seen as the nexus where relationships of power are exercised and the interconnected ness of power and knowledge is made large. At this point, rules and policies are not definitive, but at their most flexible, and some degree of uncertainty exists.17 It is here that nurses and physicians practicing in the early 1970s both made choices to relinquish traditional tasks and the knowledge embedded in them or to take on new ones that redefined their immediate work boundaries at the point of patient care—it was a two-way process. In turn, these choices were, at times, at odds

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with the positions taken by national and state organizations, and were made within existing structural obstacles such as gender and class.18 The word collaboration is drawn from the Latin—to work—and is defined by the American Heritage Dictionary as "to work together, especially in a joint intellectual endeavor," such as patient care.19 Also implicit in this definition, the earlier description by Bates, and later conceptualizations such as those by researchers Judith Baggs and Madeline Schmitt, are several other components: the presence of a problem or conflict that could not be solved by a single party, and the ability of the collaborative parties to work together, communicate with each other, solve problems together, and make decisions.20 Essentially, collaborative practice incorporates interpersonal interactions based upon socialization and interpersonal factors.21 To understand the roots of contemporary collaborative practice, we must first think about how doctors and nurses navigated and negotiated their work in the changing health care environment 30 years ago, and what "working together" meant for them.

Contextual Background Nurse practitioners and physicians in the early 1970s were influenced by a rapidly changing social and economic milieu that created the framework for contemporary health care. In the 1960s, for example, Lyndon Johnson's Great Society entitlement programs such as Medicare and Medicaid expanded the number of people able to afford private physician care, but came during a critical period of shrinking numbers of primary-care physicians and a general policy of deinstitutionalization of the chronically and mentally ill.22 Although Model Cities programs, part of Great Society initiatives, supported community clinics in underserved areas, patients in poor urban and rural areas still suffered from a lack of access to basic health services because of a lack of health care providers. In 1965, the President's Commission on Heart Disease, Cancer, and Stroke issued its report and targeted both medical research funding and prevention programs in communities. Regional medical programs, an outgrowth of the report and the public movement supporting the right to health care, began to target these diseases in rural communities. Additionally, there was a general movement by the public to have more control over health care decisions and to be more informed about their health care. Many social movements, such as the women's movement, the civil rights movement, and the antiwar movement, and strong labor organizations asserting their right to strike created a sense of tension as conservative and liberal groups fought for their place

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in society. Economic inflation and recession both contributed to the instability and uncertainty felt by the nation. Nursing and medical education and practice were not immune to the societal changes occurring during the 1960s and 1970s. Nursing education slowly moved into colleges and universities, where critical thinking and individualized care became new models of practice. The College of Nursing at the University of Florida in Gainesville, headed by Dorothy Smith, exemplified the new spirit of theorybased practice and clinical expertise.23 Medical practice and education were becoming more specialized as fewer students entered the less lucrative primary-care arena and opted for higher-paying specialties with practices in affluent suburban communities. Report after report issued by the American Medical Association and the Association of American Medical Colleges, although applauding the high level of medical expertise and technology found in U.S. hospitals and medical schools, decried the shortage of physicians in poor rural and urban areas and the shortage of medical technicians (who were primarily nurses). The reports targeted similar solutions: using nurses to ease the load of primary-care physicians (instead of using nurses for clerical work) and gaining control over the training of technicians, foreshadowing the 1990s debate over registered care technicians. During the 1960s and 1970s, the federal government infused large amounts of money into the health care system through the support of nurse and physician education programs. Many innovative programs emerged from this spirit of federal largesse and milieu of change. Both the graduate certificate program to train NPs at the University of Colorado and the Physician Assistant Program at Duke University emerged in 1965. Moreover, many of these federal programs, such as Title 10, paid for the training and practice of NPs in rural and urban health clinics.24 All of these changes provided the opportunity for creative nurses and physicians to work together in relationships that were entrepreneurial and groundbreaking, and to engage in the kind of dialogue that supported new models of care.

Negotiating Practice: NP stories In the NP-MD dyad, negotiations centered on NPs' right to practice an essential part of traditional medicine: the process or skill set of clinical thinking. In this paper, the term encompasses the formalized skills and knowledge that physicians traditionally used to organize and collect particular patient data (e.g., perform a physical examination, elicit patient symptoms, and, depending on the symptoms, order diagnostic tests), create a diagnosis, formulate treatment options, prescribe

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treatment, and make decisions about prognosis.25 The negotiations leading to collaborative practice centered on clinical thinking because intellectual and practical discussions concerning patient care problems occurred at the point of care. Clinical thinking was most intense and the opportunity for dialogue and problem solving most likely at the bedside or in the exam room, between individual nurses, physicians, and patients. At the point of care, the negotiations were continuous, and involved informal and sometimes tacit social interactions framed by the personalities of the individual doctors and nurses and local community needs.26 Initially, close proximity of practitioners and receptivity of both NPs and doctors to listen and to engage in dialogue were key. One NP noted, "initially we had to always have a physician on site—for instance, when we were doing clinical work. And I didn't resent that. Actually, I needed the backup."27 However, as the negotiations progressed and trust was established on both sides, availability rather than close physical proximity was required. "I was seeing the patients [in rural western Pennsylvania] with the physicians on call for me in Pittsburgh," one nurse noted. "You and I both know they're not coming out here. So they were available to me on the phone. . . ."28 Establishment of trust, sometimes through trading knowledge, was essential for negotiations to progress to collaborative practice, as this nurse described: In the beginning he was real gentle in letting me do things. Don't even make a referral without him. Don't do this. Don't do that. But soon he [knew] you well enough. . . . It is a situation you have to go through with each physician, and I had a lot of them, and we probably taught them a lot of their basic people skills they [didn't] learn in their training.29

Although the status of the knowledge trade might have been perceived by the professions as unequal, the medical skill holding greater perceived status over the communicative skills, each NP and physician contributed to the relationship, and each learned from the other.30 Negotiations were supported and nourished by the mutual dependency of medical and nursing professionals as they struggled together to provide health care for their clients and meaningful work for themselves. In fact, and perhaps most germane to this argument, negotiations and the collaboration they led to were not mandated "from above" by the edicts of national organizations such as the American Medical Association (AMA) or the American Nurses' Association (ANA), or by educational institutions. In fact, neither the AMA nor the ANA initially supported the concept of the NP.31 Negotiation and collaboration happened in a seemingly disconnected way in many different places, and only later came together as a movement. "This all [NPs working with MDs] occurred because

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[the] physicians knew us and felt that we had good judgment—we had worked with them before... ."32 As this NP implied, the process was personal and individualistic, rather than institutional, and served the needs of the triad of both kinds of practitioners and patients. Although imbalances in power and skill status existed between the nurse and physician negotiators, and each party may have held different perspectives on how negotiations proceeded, incongruent power and perspective did not prevent the process from occurring because both physicians and nurses obtained what they needed or wanted.33 Among other things, physicians gained time to pursue other interests, and received help to enlarge their busy practices and the freedom to pursue more interesting cases by teaching nurses to perform various parts (e.g., physical examination, history taking, decision making based on the data collected) of the clinical thinking process. "Very quickly," one nurse explained, " I got to do all of the stuff he didn't want to do, which was the physicals, which was fine."34 She added, "He [the physician] taught us to do things that needed to be done when he couldn't get there, like suture lacerations. . . . We got good at it. ... Our insurance carrier came out and said "Don't do that," but he wanted us to do everything we could to help him... ."3l Another nurse added, "He [the physician] was in one clinic one day, and another clinic another day. He had a private practice too. But he was always available by phone and always responded immediately."36 Participating nurses, in turn, agreed to the instruction and eagerly took on skills traditionally performed by medical professionals. A nurse working in a rural clinic noted: So I was really with him [the physician] like two and a half days and really learned an awful lot from him. He was very patient and, like I said, he didn't have a problem with nurses learning to do this and he really taught. And I really learned to take care of a lot of the abnormal patients. Before I quit he was already teaching me how to do fertility things, which was pretty unheard of back then.3"

Nurses received the benefits of status linked to the new skills, and the ability to practice in new and more meaningful ways that corresponded with their experience and education: I didn't have to rely on what the physicians said. I had my parameters and I could treat a patient within them. I had my own decision making. I was a lot more independent, autonomous and it did a lot to help me realize that hey, I can do this. I'm not dumb. I can do this. And then as I learned more and more, I really was able to do the things for patients that I had always wanted to do for years and had to wait for a physician to agree. I could take care of the problems I saw. It relieved frustration. 38

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When NPs went outside the territory of collaboration or entered into new relationships, the importance of the local, personal character of their negotiations was sometimes quickly made apparent. "I almost never saw [another] physician. It [contact with physicians] was almost always on the phone. There was more antagonism. 'An NP? What is that, what did you do? Who did the exam? You did the exam? Well, was there a doctor there?'"39 Outside of the frame of individual practices, nurses and doctors renegotiated collaborative relationships one, by one, by one. One nurse astutely described this individualist approach: Any of my independent jobs, I went in with a physician who had never worked with an NP before and so I always started out very, very slowly, very cautiously. [I] would start out with, "These are the things I can do, but you tell me what you want me to do."And that generally started out pretty restrictive. Self-restrictive, because I wanted them to feel comfortable with my decision making and I wanted them to feel comfortable with how I did things and then slowly show them that I knew how to do some other things and that I would be glad to do it. You know, tell them that "This woman has a big mass on the right side, it's pretty tender, I think we need to get an ultrasound. Is that what you want me to do?" And then, pretty soon, it was just—"Oh, you didn't need to call, just go ahead and do that."'1"

Negotiation was a time-intensive, and sometimes painful, process. As this same nurse noted, "There were times when I would come home and say to my husband, 'Do I have holes in my head? Why am I doing this again?'" But the negotiation process led to a mutually beneficial practice, as the NP noted: Although I was in the community, I was not working with any physicians from the community because the physician that worked in the clinic was from another town. So, recognizing that we had patients that lived in this town, we felt the need to refer them, if they needed additional help, to a physician in the vicinity. So it was kind of hard getting those physicians to not grumble and growl, and to take you serious, recognize that you were doing something worthwhile and that you were not stupid. But then as we were there longer and longer, and that when we sent a patient to them, that patient did in fact have an accurate diagnosis, had been treated well, things sort of settled down. 4I

In turn, NPs also had to trust their physician colleagues not expect or force the NPs to go beyond mutually established boundaries. "I just trusted the physician I was working with that what he told me to do was ethical, proper, and legal. . . ,"42 Of course, in the absence of concrete rules, individual creativity and needs held sway. Although each individual's state practice laws, and later, federal regulations should have served as a guide, within the framework of individual negotiations

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between NPs and physicians there was room for contingency and flexibility, as the state regulations were sometimes vague. In Pennsylvania, for example, by 1977 both the State Board of Nursing and the State Board of Medical Education and Licensure regulations (in Pennsylvania NPs were and remain jointly promulgated) allowed that an NP, "once qualified, could perform acts of medical diagnosis or prescription of medical, therapeutic, or corrective measures in collaboration with and under the direction of a licensed physician. . . ."'3 However, collaboration was not defined, and throughout the 1970s the Medical Board continued to entertain and investigate complaints lodged by physicians about NPs practicing medicine. These complaints ranged from the general (e.g., NPs were collecting health history data) to the specific (e.g., NPs were performing physical assessment).44 Distrust, lack of information, or personality incompatibility obstructed the negotiation process. Collaborative practice could not be supported when the NP and physician were unable to construct clear, mutually agreeable boundaries. In such cases, nurses and physicians working together resembled toddlers at parallel play rather than professionals engaged in a more sophisticated intellectual and interactive relationship. In one example, a newly graduated NP hired by a group of physicians to work in a North Philadelphia pediatric clinic that had received funding from the Model Cities Program described the difficulty: They [the physicians] weren't familiar with it [the NP role]. They had gotten HEW funding to hire such a person. They had no clue, and I had almost no clue myself. I had a little more information than they did, but I was kind of looking for somebody to help me implement the thing, and they were like kinda filling a position because the government said, "Hire such a person and pay them X salary." So it wasn't really clear what I was to do. n

When the fledgling NPs found themselves in new situations in which they were uncertain and untrusting of their own abilities, the trust embodied by physician colleague support was an extremely important ingredient in the negotiation process. If they could not trust their physician colleagues to back them up when problems arose, collaborative practice was insupportable: 1 let them know in the beginning that this was my first job and what I would need is a lot of checking things out with them, them becoming familiar with what 1 knew, learning from them because this was my first job. [But that] fell on deaf ears. They didn't seem to quite understand that it wasn't OK just to go to lunch if I had a patient with a 104 temp who possibly had meningitis. I would have to go find them in the lunchroom. They'd forget to turn their pagers on. . . . I didn't know whether they thought I could do it or if they just weren't on top of things.46

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Without establishment of trust, and in the absence of substantial negotiations, the NPs felt isolated, with their unique contributions to the care of patients in the clinic or practice unacknowledged or invisible. Patient care may not have been compromised at its most basic level, but the potential for expanded services may have been limited. The nurse continued: I don't have any good memory of them [the physicians] being very informative. I don't know if it just wasn't a great fit, but they sort of left me on my own. They didn't want to seem to make it fit. To find more of a support group, I used to go up to St. Christopher's. There were NPs up there I could hang with.... I could work with those nurses and .. . discuss common concerns that we had in clinical practice, what we were doing, how we were sorting things out. It was useful.47

Seeking out other sources of validation and support helped NPs during their negotiations with physician colleagues. These sources ranged from the NP support group described by the previous nurse to support from a particular patient group. An NP working in the same practice since 1974 noted a familiar duality early on in her practice: I was not the first NP in the practice . . . so it was already geared for NPs. It was harder in the hospital. We used to go on nursery rounds to convince them [hospital residents and other physicians]. Now . . . the nurses are so happy we're there. They think kids get better care on weekends and every baby gets examined. Every mother can see we are doing this. They always feel issues get dealt with more comprehensively when the NPs are there. So it's a full 180 from not having any backup to completely having a fan club.48

Conclusion For early NPs, collaborative practice with a physician was a complex, individually negotiated process. It involved recognizing opportunities for negotiation, however limited, making overt and covert efforts to grasp more responsibility, and generally using artful and creative strategies to carve out significant and satisfying practice areas within NP-physician relationships.49 When NPs, along with their physician colleagues, constructed new kinds of working relationships to meet the needs of themselves and their patients, all parties benefited.50 In the past 10 years, collaboration has become a sort of "silver bullet" for many nurses, who see it as the "cure" for inequities in power and perhaps as a gateway for

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greater participation in health care decision making. On the other hand, NPs perceive a basic inequity when they are mandated to collaborate with physicians without collaborative reciprocity from physicians. Collaborative unidirectionality is exemplified by the language of current federal regulations and in the AMA's Citizens' Petition, defining and equating collaboration with physician supervision of NPs and diluting the ability of NPs to practice independently. Physicians' professional groups have developed a new interest in the collaborative process as an overarching principle, and in some cases as a "protective" concept. In Pennsylvania, for example, the Pennsylvania Medical Society recently urged its members to oppose new professional legislation and demand revisions to include "specific] requirements for written collaborative agreements regarding prescriptive authority," although nurses have independently prescribed medications for patients in the state since the mid-1960s.51 In this case, collaboration has changed in perspective from individual negotiations based on community needs to a specific protocol-driven legal requirement that in many instances is protective of medicine's traditional territory. Although explicit policies and procedures are important, a collaborative relationship, as the oral history interviews with NPs suggest, is based on the ability of individual practitioners to negotiate and construct work boundaries—and may be influenced more by the social environment and individual personality than by explicit directives to "collaborate." In effect, collaboration is easy to define in legislative terms—e.g., a physician may supervise a certain number of NPs under the auspices of jointly defined protocols—but less easy to apply at the point of patient care, where personalities, trust, and respect matter. At this juncture, it is perhaps informative to go back to the Venn diagram conceptualized by Barbara Bates in the 1970s as a metaphor for the interrelatedness of nursing and medical practice.52 The area of practice shared by nurses and physicians is fluid and constantly changing, in part due to the complex and equally fluid societal perceptions of health care, technology, gender, and economics. Granted, collaboration is more than the acknowledgment of shared skill sets. It is an intellectual as well as a functional endeavor that involves the negotiation of the skill set to devise solutions to patient problems. As practitioners know, collaboration is easy to legislate, but difficult to apply without the consent of doctor, nurse, and patient. All parties in the collaborative relationship must be compatible intellectually and philosophically to see through the mire of health care politics and to the patient problems that await solution. As these pioneer stories suggest, it is a very personal process that occurs on a foundation of trust and respect, and even the passage of time and legislation cannot remove the inherent intimacy of the concept.

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JULIE FAIRMAN, PHD, RN, FAAN Associate Professor Associated Scholar, Center for the Study of the History of Nursing

and Center for Health Outcomes and Policy Research School of Nursing University of Pennsylvania Philadelphia, PA 19004 Send correspondence to home address: 217 Glenn Road Ardmore, PA 19103

Acknowledgments This work was supported by Sigma Theta Tau, Xi chapter, and the Pew Charitable Trusts. The author wishes to thank M.J. Murphy, research assistant, for her help on this project, and Judith Gedney Baggs for her helpful comments. Thanks also to the NHR reviewers for their useful critiques.

Notes 1. Barbara Bates, "Nurses, Doctors, and Patients," Sybil Palmer Bellos Lecture, Yale University School of Nursing, New Haven, Conn., 11 April 1973. 2. For example, collaboration has been defined for reimbursement purposes by the United States Congress and the Health Care Finance Administration. In subsection (aa)(6) of the Social Security Act, collaboration is defined as a process in which the nurse practitioner works with a physician to deliver health care services within the scope of the practitioner's professional expertise, with medical direction and appropriate supervision as provided in jointly developed guidelines or other mechanism as defined by the law of the state in which the services are performed. (42 United States Congress, 1395x (aa)(6) as cited by Sandy Sherman and Sharon McRath, memo to National Medical Specialty Societies. "Endorsement of Citizens' Petition on Physician-Nurse Collaboration," 5 June 2000). From a different, more theoretical perspective, Judith Gedney Baggs and Madeline H. Schmitt, ("Collaboration Between Nurses and Physicians," Image 20 (1988): 145-49) describe collaboration as "interdependence, where nurses and physicians have complementary roles." The American Nurses' Association and American Medical Association negoti-

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ated a definition of "collaboration" in 1993 to be used as a broad-based dimension of nursephysician professional relationships. The ANA adopted the definition in 1994, but the AMA failed to adopt it (American Nurses' Association, "Collaboration and Independent Practice: Ongoing Issues for Nursing. Executive Summary," Nursing Trends and Issues3 [5] [1998]: 1-8). In this article I have relied on the conceptual rather than the legal or professional definitions. 3. Sherman and McRath, memo 5 June 2000. At press time, the Citizens' Petition appears to have lost its initial impetus with the public and federal agencies. 4. Lazar J. Greenfield, "Doctors and Nurses: A Troubled Partnership," Annals of Surgery 230 (3) (1999): 279-88. 5. The author acknowledges the limitations imposed by the one-way perspective of the analysis (this analysis is from the nurses' perspective alone), and the small number of subjects. These limitations are mediated somewhat by oral history methodology that places value on the individual respondent's language and memories rather than on the ability to generalize experiences to other groups. See the introduction, Elizabeth Tonkin, Narrating Our Pasts: The Social Construction of Oral History (New York: Cambridge University Press, 1992), 3-11. 6. Deidre Wicks, Nurses and Doctors at Work: Rethinking Professional Boundaries (Buckingham: Open University Press, 1998), 1-5. 7. Baggs and Schmitt, "Collaboration,"145-49. 8. In this paper, gender is defined as the exploration of biological and cultural knowledge about sexual differences, and how this knowledge has shaped and still shapes the social and political distribution of power in the world under study (Ludmilla Jordanova, "Gender and the Historiography of Science," British journal of the History of Science 26 [1993]: 469-83). 9. Alessandro Portclli, The Battle ofValle Giulio: Oral History and the Art of Dialogue (Madison: University of Wisconsin Press, 1997). 10. See Sherna Berger Gluckand Daphne Patai, eds., Women's Words; The Feminist Practice of Oral History (New York: Routledge, 1991), 4. 11. Robert Perks and Ahstair Thomson, eds., The Oral History Reader (London and New York: Routledge, 1998), Introduction for Part I, 1-8. 12. Gluck and Patai, Women's Words, 1-5. 13. Carolyn Heilbrun, Writing a Woman's Life (New York: W.W. Norton,1988), 29-31. 14. Wicks, "Nurses and Doctors at Work" 10-11. 15. It should be noted that patients were also part of a broader negotiation process, as were other nurses and physicians outside of the collaborative relationship. This paper is focused on the more narrow collaborative relationship between individual NPs and physicians as they established their practice boundaries. 16. Andrew Abbott, The System of Professions: An Essay on theDivision of Expert Labor (Chicago: Chicago University Press, 1988), 143-57. 17. Anselm Strauss, Negotiations, Varieties, Context: Processes, and Social Order (San Francisco: Jossey-Bass, 1979); Roland Svensson, "The Interplay Between Doctors and Nurse—A Negotiated Order Perspective," Sociology of Health and Illness 18(3) (1996): 379-98.

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18. For a discussion about the tensions between local practices and the policies of national organizations, see Julie A. Fairman, "Delegated by Default or Negotiated by Need: Physicians, Nurse Practitioners, and the Process of Clinical Thinking," Medical Humanities Review 13(1) (Spring 1999): 38-58; Julie A. Fairman and Patricia D'Antonio, "Virtual Power: Gendering the Nurse-Technology Relationship," Nursing Inquiry 6 (3) (1999):178— 86. See ibid, for a discussion of the influence of gender on the negotiations between NPs and physicians. In general, the NPs working during this time period (and those quoted in this paper) were White females and most of the physicians they worked with were White males. 19. The American Heritage Dictionary of the English Language, 3rd ed. ( Boston: Hough ton Mifflin, 1992), 371. 20. Baggs and Schmitt, "Collaboration," 145—49; Judith Gedney Baggs and Madeline H. Schmitt, "Nurses' and Resident Physicians' Perceptions of the Process of Collaboration in an MICU," Research in Nursing and Health 20 (1997): 71-80. 21. Many researchers draw their models from sociology and labor relations conflictresolution process models of the late 1970s. See, for example, K. Thomas, "Conflict and Conflict Management," in Handbook of Industrial and Organizational Psychology, M.D. Dunnette, ed. (Chicago: Rand McNally College Publishing Co., 1976), 889-935; R.R. Blake and J.S. Mouton, "The Fifth Achievement," Journal of Applied Behavioral Science 6 (1970): 413-26. For an earlier perspective, see Everett C. Hughes, Men and Their Work (London: Free Press of Glencoe, 1958). 22. For an overview of these changes, see Fairman, "Delegated by Default," 38-58. 23. The Collected Works of Dorothy M. Smith, 1948-1967 (Gainesville, Fla.: College of Nursing Section, University of Florida Alumni Association, 1968). 24. Denise H Geolot, "NP Education: Observations From a National Perspective," Nursing Outlook 35 (3) (1987): 132-35; Denise H Geolot, "Federal Funding of Nurse Practitioner Education: Past, Present, and Future," Nurse Practitioner Forum 1 (3) (1990): 159-62. 25- See Fairman, "Delegated by Default." There are many terms used in the literature to describe the process of clinical thinking. Clinical judgment (Alvan R. Feinstein, Clinical Judgment (Baltimore: Williams and Wilkins, 1967); H. Tristram Englehardt, Jr., Stuart F. Spicker, and Bernard Towers, Clinical Judgment: A Critical Appraisal (Boston: D. Reidel Publishing, 1977) and diagnostic reasoning are two examples. The terms actually connote very similar concepts. Feinstein's idea of clinical judgment, however, relies more heavily on symptom grouping and categorization (using mathematical principles) for the purpose of rationalizing treatment decisions and developing an accurate prognosis. I prefer to use clinical thinking as suggested by Barbara Bates in A Guide to Physical Examination and History Taking, 6th ed. (Philadelphia: J.B. Lippincott, 1995, 635-48). Bates's presentation combines rationalization with flexibility to accommodate patient individuality and social circumstances in treatment decisions. Clinical thinking and critical thinking are not synonymous terms. 26. Fairman, "Delegated by Default." 27. Corene Johnson, 20 September 1997- Oral history telephone interview by M.J. Murphy. 28. Bonita Roche, 18 September 1997. Oral history telephone interview by M.J. Murphy.

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29. Faye Davies, Oral history telephone interview by M.J. Murphy, 24 September 1997.

30. Londa Schiebinger talks about the power of knowledge trades in her book Has Feminism Changed Science? (Cambridge: Harvard University Press, 1999). 31. Natalie Holt, " 'Confusion's Masterpiece': The Development of the Physician Assistant Profession," Bulletin of the History of Medicine 72 (1998): 246-78. 32. Corene Johnson, 20 September 1997. 33. Many scholars acknowledge that negotiations can occur when parties do not share the same status or power. See Anselm Strauss, Shizuko Fagerhaugh, B. Suczek, and Carolyn Wiener, Social Organization of Medical Work (Chicago: University of Chicago Press, 1985); Eliot Friedson, Professionalism Reborn (Chicago: University of Chicago Press, 1994). For negotiations in particular settings in which power between negotiators is also uneven, see Rue Bucher and L. Schatzman, "Negotiating a Division of Labor Among Professionals in the State Mental Hospitals," Psychiatry 27 (1964): 266-77; Julie Fairman, "Watchful Vigilance: Nursing Care, Technology, and the Development of Intensive Care Units," Nursing Research 41 (January/February 1992): 56-60. 34. Faye Davies, 24 September 1997. 35. Ibid. 36. Bonita Roche, 18 September 1997.

37. Ibid. 38. Ibid. 39. Corene Jones, 20 September 1997. 40. Bonita Roche, 18 September 1997. 41. Ibid. 42. Faye Davies, 24 September 1997. 43. Pennsylvania Bulletin 7 (30) (23 July 1977): 2061, 2063. State regulations do not define collaboration. They do, however, define a collaborative agreement. This year, the state of Pennsylvania amended Title 49—Professional and Vocational Standards, State Board of Medicine and State Board of Nursing[49 Pa. Code CHS. 18 and 21, CRNP Prescriptive Authority—and included a procedural definition of a collaborative agreement between an NP and a physician based on the definition of collaborative agreement between a physician and a nurse midwife (49 Code § 18.1). 44. See, lor example, Pennsylvania State Board of Medical Education and Licensure, minutes of the Board meetings, 10/22/71, 1/6/72, 12/4/73, Department of Professional and Occupational Affairs, Harrisburg, Pa. 45. Diane Purcell, Oral history telephone interview by M.J. Murphy, 12 October 1997. 46. Ibid.

47. Ibid. 48. BMC, Oral history interview by M.J. Murphy, Philadelphia, Pa., 23 October 1997.

49. See Wicks, Doctors and Nurses, 1-5. The power in the ability to make choices is described by Ruth Schwartz Cowan, More Work for Mother: The Ironies of Household Technology From the Open Hearth to the Microwave (New York: Basic Books, 1983); Julie Fairman, "Alternate Visions: The Nurse-Technology Relationship in the Context of the History of Technology," Nursing History Review 6 (1998): 129-46.

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50. American Nurses' Association, "Collaboration and Independent Practice: Ongoing Issues for Nursing. Executive Summary," Nursing Trends and Issues 3 (5) (1998):l-8. 51. Pennsylvania Medical Society, " Physicians Urged to Comment on Nurse Prescribing Regs," Hot News 12 October 1999. 52. Barbara Bates, "Physician and Nurse Practitioner: Conflict and Reward," Annals of Internal Medicine 82 (5 May 1975): 702-706.

HISTORIOGRAPHY ESSAY

The Fork in the Road: Nursing History Versus the History of Nursing? SIOBAN NELSON School of Postgraduate Nursing The University of Melbourne

Professions tend to be strongly attached to their history, often a progressivist account of the growth of skill, influence, and importance of their particular field. On the other hand, historians are likely to be more interested in what historian John C. Burnham, in reference to medicine, has described as "the changing place of the special spirit ok being a professional." In what follows I shall reflect upon that "special spirit" in nursing. The state of nursing historical scholarship will be examined, and a critique offered of its uneasy fit between nursing scholarship on one side and historical scholarship on the other. 1 The question that underpins this essay is "Who is writing nursing history, and tor whom?" In contemporary market-speak, this paper looks at nursing history's "core business and our "customer base." It will be argued that both the business and the customers of nursing history have changed dramatically over the past century. This is not a call for relevance. History is always relevant. Rather, the call is for self-consciousness and confidence on the part of nursing historians, and the development of linkages with historical scholars. For nursing to become the subject of research that it needs to be, I will argue, we need to rethink the traditional "professional agenda" of nursing history—to reconsider its purpose and its audience. At the same time we need to be better historians, to make the connections between our work and broader historical scholarship, to adapt to and absorb historiographical shifts in thinking, and to meet the challenges they bring. Finally, and vitally, we need to keep talking to professional historians—stimulating them to rethink Nursing History Review 10 (2002): 175-188. A publication of the American Association for the History of Nursing. Copyright © 2002 Springer Publishing Company.

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nursing, challenging them when their silences reinforce the invisibility of so many women's lives.

Parti History of Medicine and Nursing History There are many diverse groups interested in the history of professions for as many diverse reasons. First, there are clinicians engaged in writing the history of their profession, association, or clinical area—the core of nursing historical research comes together under this banner. Then there are historians interested in the history of health, medicine, and the professions, as well as women's studies scholars, sociologists, and anthropologists who have longstanding interests in health and disease. Medical history was first written by members of the profession.2 Medical practitioners, enthusiastic about the scientific and intellectual tradition within which they worked, were fascinated by the pioneers of treatments, technologies, institutions, and professional societies. The audience for this history was other members of the profession. These histories have been variously condemned by scholars outside of the profession as archaic, antiquarian, self-congratulatory and even "iatrogenic."3 The nobility with which professions infused their practice did not impress social scientists. In fact, when viewed from the outside, professions were clearly powerful groups protecting their own interests. More than this, it was observed that professional history actually played a key role in this process of professional development. Finally, sociologists made the unpalatable observation that professional history arose out of the self-conscious drive for members of a new profession to distinguish themselves from the motley crew that preceded them.4 This observation about the function of professional history certainly holds true for the history of medicine, where early work in the field functioned to constitute medicine as a modern science and characterize the rest of the field as quacks. History of medicine as history of science excluded those without modern training. It portrayed modern medicine as authoritative, and emphasized the scientific expertise of physicians as their defining professional attribute. Nursing history had a similar function of separation. The histories written by early nursing leaders served this aim with history absolutely vital to the professionalisation of nursing. Nursing leaders frequently took up their pens and wrote the story of nursing from the dark and chaotic past to the glorious present.5

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These early histories heralded the arrival of the trained nurse, separating her from the common woman who also claimed the title "nurse."6 How else was it possible for nurses to develop their identity as progressive, respectable reformers of society? The nursing narrative, past and present, reflected the triumphant march of nursing from Saiery Gamp to the respectable, compassionate trained woman—complete with before-and-after pictures!7 This internalist narrative wrote into being the importance of nursing by trained women as a female remedy for a vast array of physical and social ills.8 It was a tonic for nurses and ammunition for the great battles they fought, and fight to this day, for respect and power.9

Part II Q. What do "outsiders" bring to professional history? A. Whoever discovered water, it certainly wasn't a fish.

But history of the professions—medicine and nursing among them—did not remain the province of practitioners. Over the years, social historians developed an interest in the rich topic of professional practice. Health, in particular, offered the opportunity to examine diverse aspects of society—disease, science, government policy, migration—as well as the big issues—class, gender, race, and culture. By the 1970s and 1980s, medical practitioners and academics writing medical history had moved into each other's territory, engendering a cross-fertilization of insights, preoccupations, and approaches.10 This trend of social history flowed over into nursing as well. Nursing history benefited from this broadening of concerns and, with the advent of women's history, nursing finally received the scholarly attention of a critical mass of historians with no connection with practice. Social historians, feminist historians, and nursing historians together began to look at nursing in a more complex way, and as a result the 1980s were an astonishing decade of revision and critique of the traditional nursing narrative—a watershed in nursing history. In fact, from the gentle corrections of Monica Baly11 to the iconoclasm of Barry Smith,12 the traditional nursing narrative almost collapsed under the weight of critique! But for once nursing was a topic of substance, exciting the imagination of the likes of U.S. feminist historians Martha Vicinus, Mary Poovey, Susan Reverby, Nancy Tomes, and Barbara Melosh, and British historians Anne Summers, Robert Dingwall, Anne Marie Rafferty and Charles Webster, and Celia Davies, among others.13

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These researchers, immune to the holy imperatives of nursing history, situated their nursing history within women's history, social history, and labor history. They took advantage of the enormous source material and extraordinary stories nursing can provide, and at the same time explained the social and gender context of nursing's story to nurses. 14 Patricia D'Antonio's review paper published last year in the Bulletin of the History of Medicine traces the shifts in nursing history subsequent to the glorious eighties.15 D'Antonio voices optimism about the impact of nursing history on the history of health care and hospitals. She argues that nursing history has moved onfinally and firmly. It is no longer possible to ignore nursing when writing medical history and, for nurses writing their own history, even the most triumphant and uncritical works have now incorporated some notion of gender and class in their analysis. There is much to support this view. Nursing historians have benefited from the scholarly interest in the field and nursing can now pride itself on a stable of historically trained nursing researchers, producing interesting and stimulating work.16 Meanwhile, as John Burnham points out, sociological thinking had moved beyond conceptualizations of the professions to reconsider the social role and function of the professions in general. The result was an assault on professional authority by writers such as David Rosner, Rosemary Stevens, and Matthew Ramsay.17 Worse was to come for the professions. By the late 1980s, "problematizations" of institutional hierarchies, inspired by Foucault, and his insights into the nexus between power and knowledge had cast the health professions in quite a different, and profoundly disturbing, light.18 These intellectual developments, in my view, have confronted nursing history with its biggest challenge to date. For what does nursing history start to look like if we accept the professions as all inherently self-serving? Moreover, if the new historiography calls for a non-subject-centered approach to research, emphasizing issues or themes that have not traditionally been the subject of historical analysis— such as ethics, technology, civics, religion, and so on—what does nursing history begin to look like minus its great women? D'Antonio's review provides us with one answer. Her paper brings to light a shift in historical preoccupations and a reorientation of historical perspectives in the history of women and work. The fruits of feminist revisions have moved beyond critique of the progressive narrative to an examination of the inadequacies of the conventional understanding of profession when applied to women's work. This view centers instead on the place of work in identity formation of women. This is a critical development. Citing work by historians such as Judy Giles (England) and Sharon Harley (the African American community),19 D'Antonio

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argues that work as nurses or midwives forms only part of women's complex set of socially embedded identities. She claims that patriarchal models of professional identity fail when applied to women whose lives can be rich and respected as community members, as family providers, and as valued community resources through their nursing and midwifery skills.20 This thinking abandons the conventional "ladder" of professional status and starts from a woman-centered perspective—focusing on the place of work in the woman's life and community. It offers a perspective long denied to nurses, who have heretofore failed to attain the professional stature assigned by more traditional, and fundamentally patriarchal, models of professions—something British sociologist Celia Davies has been pointing out for some time. 21 But if nursing history is now more pluralistic than ever before, with diverse scholars, within and outside of nursing, involved in writing history, who constitutes the audience for this work? Are nurses reading this new history? For this work about women, work, health, and nursing, is the audience women's history scholars and students or nurses? One suspects the former. Perhaps this is because this new history in fact constitutes a different discourse than what we conventionally call nursing history. One finds nursing embedded in the social world of women—not in a progressivist professional narrative. So what history do nurses read? It is this question that brings me to the particular issues facing nursing history.

Part III Nursing Particularities The history of nursing of old came largely from individuals of some standing in the profession. Unlike in medicine, these women were not usually clinicians (in the sense that medical historians were); nursing historians were leaders. The function of this work, then and now, was to foster a sense of nursing's tradition, to emphasize the break with the old and the gains of new. It was the onwards and upwards kind of history that pleased its subjects—the commissioning institution or association. The institutional histories, biographies, and organizational histories that constitute most writing on nursing stem from this same urge and are heavily subsidized by the consumers of this discourse—the alumni members themselves. It is possible to sneer at such historical efforts as antiquated, but I suggest we must take care not to miss their function and the benefits to all kinds of historical endeavors that accrue from these efforts. First and foremost, these histories provide a record—a fundamental beginning for all historical scholarship. As someone who

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has waded through many meters of heroic hospital and community histories for my history of religious nurses, I have often had cause to bless the efforts, however partisan, of those who pulled together events, documents, and biography to write a record of what happened.22 The challenge for the historian is to understand the perspective of these sources, and the context in which they were produced, taking note of the blanks and silences. My work on the religious nurses has also made clear to me the primary function of such efforts: they were discursive activities in the most literal sense— they created meaning and identity through the creation of narrative. They were formative discourses, and of enormous importance to the "writing into being" of communities of nursing women. The nineteenth-century Roman Catholic Church understood well the power of the written word, and it was customary for each religious community to appoint an annalist who kept the record of events. This record then became a tool for the training and identity formation of novice members. Secular (nonreligious) nurses have generally produced a type of annalist of their own. In fact, as a profession, nursing has been remarkably well served by literate, historically conscious women. These women were aware, perhaps intuitively, of the role of history in professional identity formation. But even more important than the leading historians for the promulgation of nursing history were the alumni, for it was their role to transmit the nursing narrative. It was the training schools and associations that ensured that nursing training also involved the inculcation of a particular historical identity. The novice nurse was taught the genealogy of this nursing identity and given a family tree that generally linked back (perhaps obscurely) to Miss Nightingale. Thus the nursing narrative, the conventional nursing history of hospitals, training schools, and professional organizations, served a vital function from a historian's point of view—it created a historical consciousness in nurses. But that was in the past, in the days of training schools and lively alumni. What function do such accounts serve today? It is important to consider the impact of changes on the preparation of nurses when we consider the role of nursing history today. In Australia, the United States, and Canada, and now in Great Britain as well, the transfer of education into the tertiary sector has meant the gradual demise of the hospital alumni. As often as not, the old hospitals with their long traditions and proud histories have in recent years found themselves amalgamated, networked, or clear felled in the name of service expansion and resource rationalization. Nurses in Australia today, as a rule, have no idea of the history of nursing at the nursing school where they are educated as nurses, where they work, in their state, or nationally.23 Florence Nightingale is most likely the only nurse of whom they have ever heard.

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So what has replaced the old process of education in nursing history? How is a nurse created, and his or her professional identity shaped, if no longer by history? I have argued elsewhere that this professionalizing discourse moved from history to nursing theory.24 Rather than the nursing leadership, nursing scholars, through the development of nursing theories largely based upon humanist philosophies of caring, have been responsible for recreating nurses' understanding of who they are, what they do, and why. In fact, historian Christopher Maggs made this very point when he called for nursing historians to focus their research on "caring," in order to make it more relevant to nursing theory.2"1 Successful though these strategies may have been to the development of nursing scholarship and research, the science that nursing scholars created over the past three or four decades is largely ahistorical. As a consequence, the simple fact is that our education systems are producing nurses without a historical identity. What then is the relevance of any nursing history, whether it be the nursing history that places nursing centre stage, or a social analysis that emphasizes the context of nursing work, to nurses with no historical consciousness? In addition to the disappearance of the traditional audience for nursing history, there has been a second sequela of this shift to the tertiary sector and loss of alumni, which is also particular to nursing scholarship and its relationship to history. It is the way historical methods, most particularly but not exclusively oral history, have been absorbed into nursing research as a type of "qualitative method."26 To my mind this is an odd positioning for historical scholarship— somewhere between grounded theory and phenomenology on the method shelf! In my view, what this dilution of history to a method reveals is a lack of historical sensibility. Not only does it ignore the fact that history is a discipline, with a range of methodological approaches both qualitative and quantitative, but of even greater concern is the idea that one can undertake historical research without studying history. This is not an issue of purism. Nursing scholarship and the social sciences generally have been greatly enriched by the incorporation of diverse methodologies: participant observation methods from sociology, ethnography from anthropology, narrative analysis from literary studies, and so forth. But as nursing historians (and historians working in nursing), we need to understand and foster debate about the distinction between qualitative research and historical scholarship. In my view, qualitative research may use the recollections of nurses to analyze a particular phenomenon, but historical scholarship cannot operate in such a vacuum. Historical data are rendered meaningful only through the analysis of historical context. Historical sources are products of this historical context, and historical memory is fashioned by wider events, circumstances, and discourses.

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Thus, historical research that uses interview data of, for instance, nurses from the 1930s does not require a nursing science theoretical model, although an additional level of theorization is an option. What is essential, however, is a good understanding of the Depression, the economy, gender, race, national identity, social politics, militarism, the history of medicine, and so on—in fact, the very understanding students will gain from the formal study of history. The work of the historian is to make sense of the oral history interviews and the primary sources in the light of the 1930s world, not in the light of a nursing science view of the world. The theoretical work undertaken by the historian is to be found in the way he or she understands epistemology and the perspective taken on truth and evidence—history is in fact an intensely theoretical discipline.27 The historian also argues his or her case primarily with reference to the historical literature-again, not primarily the nursing science literature. In my view, the very idea of history as a qualitative methodology divorces history from its disciplinary nature and makes the research ahistorical. The data may be from the past, but the method is not history. I labor this point, aware that many may not agree, because I think it is important that nursing historians articulate and exemplify the highest standard of historical scholarship. We should be delighted that nursing students are interested in historical research and asking historical questions. The responsibility rests with nursing historians to set disciplinary standards and to provide training and support for nurses engaged in historical research. Nursing history does not need its own "method." It needs to be good history-rigorous, sophisticated, and compelling. In summary, my lament is that we are producing nurses without historical consciousness, nurses who equate nursing history with tales of Nightingale and old matrons, who are unaware of broader historical research that is being carried out by non-nurses in the area, and who are ignorant of the more traditional historical pursuits of nurses. Worse still, we have nurses involved in historical research from an ahistorical base. This truly is an iatrogenic pursuit, and its pitfalls are obvious— poor scholarship, an increasing divide between historians who work in the area of nursing and nursing history, and, worst of all, little to say of interest to a wider readership. This final point leads me to the fourth part of the paper.

Part IV Beyond the Boundaries of the Nursing Audience How can nursing historians talk to the public? I would like to focus for a moment on the Australian Nursing History Project (ANHP).28 This project began when the

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alumni of local teaching hospitals met with me to express concern about their uncertain state, their falling numbers, the difficulty they experienced in persuading the constantly restructured health services (which form and reform around them) that their archives need time commitment and money, and a guaranteed place. I curated an exhibition a few years ago and came to face to face with how bad things were. Moreover, everywhere I have been, people tell me the situation is the same. One partial solution we devised to this problem has been to join forces with a large Web-based science archive project-the Australian Science and Technology Heritage Centre (Austehc). The Austehc Web server is entirely dedicated to making available information about the history and heritage of Australian science, technology, and medicine from the earliest records to the late twentieth century. Of critical importance to us is that the Departments of Education in various states have formally embraced the Austehc Web-server infrastructure as a curriculum resource for senior secondary students and incorporated it into a government multimedia and web-based network for school students. Data collected by Austehc show that their Web resources have been receiving in excess of 400,000 hits per week (peaking at 500,000 in October 2000), corresponding to about 20,000 individual users per week.2'' These are large numbers for an Australian site. The key database in the Web-server infrastructure is the Bright Spares database. This site offers biographical details and archive register on prominent Australian scientists. Austehc data also show that students are particularly interested in women listed on Bright Spares. Women represent just over 10% of listings on Bright Spares, yet women constitute two out of the top five people whose listings are accessed each week. We are working with Austehc and nursing organizations to put nursing and nurses onto that site—making nursing history visible to high-school students and researchers. To achieve this, the ANHP is establishing an accessible Internet-based register of nursing historical resources, profiles of significant nursing individuals, technological achievements, organizations, and events. The Website also provides a forum for nursing exhibitions and nursing history features. Thus, through a Webbased platform of resources, students discover the contributions of nurses to Australian society, past and present, and the range of career possibilities offered in nursing. The project sets out to make nursing history relevant, accessible, and interesting to schoolchildren, members of the general public, and scholars. The Australian Nursing History Project is the good old-fashioned professionalizing narrative, and it is self-conscious about this function—it is discourse-creating, visibility-creating. However, the audience is not nurses, but the public. We talk to schoolchildren about what these (mainly) women did to make this society the way it is; how nurses have delivered health care to Australians over

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the past hundred years, from the bush to the city. As a science project, we aim to explore the science behind what nurses did (and do). We explore the roles of nurses in the wars, and Australian nurses' prominent roles during postwar reconstruction in Europe and Asia. In fact, we aim to cover all manner of nursing activities that constitute the social history of work, women, health, and community service. We are seeking funding for teaching aids, for exhibitions, and for a biography of Australian nursing, working with nurses in many states. I think it is politically and socially important for school students to have access to this information. It will help them to develop an appreciation of the skill and social importance of nurses. I also believe it engages Australian nurses, the alumni and the service nurses, in an important project that speaks to young people. Through nursing history we can give people a different view of the nurses of old, and of the possibilities that nursing did (and still does) offer. It is the nursing narrative with a new audience. It enables us to pull together nursing histories (local and national, amateur and scholarly) and offer them as resources to local historians, to schoolchildren, and to the general public. It utilizes the considerable historical resources of the alumni, stimulates oral history projects, and gets people involved in creating history. It is important work and serves vital objectives in the contemporary climate of growing irrelevance and invisibility of nurses, and at the same time takes advantage of the information revolution. Furthermore, this project keeps local stories, local histories, alive in the age of globalization. The World-Wide Web offers a tyranny of information. As with the view of the world created by Hollywood, it will be easy for consumers of the Web (such as schoolchildren) to get the impression that world history is an American story, with American actors and American images. This is where the Web can also be a powerful tool of local identity. It can cheaply and effectively tell the story of Scottish nurses, or Danish nurses, or Australian nurses.. .but only if we make it do so. Nursing historians, then, need to learn to talk to the general public—but that is only half the problem. There is perhaps an even more difficult task facing us. Nursing is out of fashion. I frequently go to history, medical history, and women's history conferences, and I seldom hear a paper on nursing history. Worse still, I talk to countless historians who are investigating topics in which an analysis of nursing would enrich their work by offering valuable insights into the lives of women, or health and medicine, or militarism, or labor history, or religious history, and so on. My historical colleagues are often genuinely surprised—and even enthusiastic—when I convince them of the relevance of nursing (and its abundant sources) to their question. Perhaps historians became bored with the idea of nursing. As a "traditional" role for women it is not a terribly sexy topic for many researchers. But we need to

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ensure that nursing does not return to the "comatose state" it was in before the golden eighties.50 I, for one, like to remind colleagues that the history they are writing is in danger of gross distortion if the largest female professional group, the largest single workforce in some instances, is left completely out of the picture. I think it is up to nursing historians to stimulate our colleagues' interest and to demonstrate that the complex history of women, work, and the professions is far from understood in the case of nursing. But to do this, nursing historians need to have a presence. We need to be at history conferences, seminars, and colloquia—it is the only way for us to enter the debate to make historians in this area rethink their assumptions about nursing. It is also the only way for us to keep abreast of historiographical debates and build opportunities for collaboration. More nursing historians should also attend history of medicine conferences, should join the societies and become involved, reminding their colleagues in that field that health history does not equal medical history. Furthermore, perhaps it is finally time to take a leaf out of the history of medicine's book, and engage in dialogue between nursing historians and historians of nursing at nursing history meetings. Let us understand that there will be different perspectives, and look forward to discussing them. At the same time as calling for these integrative efforts, I believe we need to strengthen our base as nursing historians. One means to achieve these aims is through a Nursing History Network, along the lines of the very successful Women's History Network, to foster scholarship, exchange, and conferences. This process has begun with a three-nation collaboration among nursing historians from Australia, the United Kingdom, and the United States, and I believe we can look forward to great things. 31 To summarize, nursing history needs to speak to the general community— including its own practitioners—about what nursing is, what its contributions to the health care system have been, and the way it opened up so much territory for women in science, women in the professions, and women in work. Men in nursing are often ignored in these discussions, and I think nursing history can also help the profession discuss its gendered boundaries—their history and their role. It's a discussion nurses very much need to have. We also need to engage in stimulating debate and discussion with historians beyond nursing and keep abreast of historiographical shifts. Finally, it is up to us to stop nursing from falling off the agenda of women's history and women's studies. I also believe that what I have termed the nursing narrative needs to be fostered and promoted. However, our challenge in this is to define our audience and to become self-conscious about the discourse we are creating, and to use it politically to foster awareness of nurses and nursing history. Through Web-based resources,

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teaching aids, and exhibitions, we can make visible the important and socially productive lives of nurses over the past century and a half. We also need to make the general public aware that this history is relevant and interesting to them. It is the story of their mothers, grandmothers, and brothers—and it has yet to be told.

SIOBAN NELSON, PHD, RN Research Fellow School of Postgraduate Nursing University of Melbourne 243-249 Grattan Street Carlton, Victoria 3053 Australia

Notes 1. John C. Burnham has grappled with this subject over the past few years, and I have structured the first part of this paper along the lines of his arguments in How the Idea of Profession Changed the Writing of Medical History. 2. I won't get into the notion of profession here. I am using it as a collective noun, something quite commonplace in nursing but problematic in the history of medicine these days. See John C. Burnham, "How the Concept of Professions Evolved in the Work of Historians of Medicine," Bulletin of the History of Medicine 70 (1996): 2. 3. latrogenic was coined by George Rosen, "Levels of Integration in Medical Historiography: A Review," Journal of the History of Medicine and Allied Sciences 4(1949): 460-67. 4. There is no need to rework Burnham's literature review here; see How the Idea of Profession Changed, 114-18. Suffice it to say, from Talcott Parsons to Michel Foucault, social scientists have been skeptical about the professions' claims to status and clinical and ethical authority. 5. Sioban Nelson, "Reading Nursing History," Nursing Inquiry 4 (1997): 229-36. 6. See, for instance, M. Adelaide Nutting and Lavinia Dock, A History of Nursing (New York: G.B. Putnam's Sons, 1974); Lucy R. Seymer, A General History of Nursing (London: Faber and Faber, 1932); Minnie Goodnow, History of Nursing, rev. byJ.A.Dolan, l l t h ed. (Philadelphia, Pa.: W.B. Saunders, 1963); Isobel Stewart, A History of Nursing From Ancient to Modern Times, 5th ed. (New York: Putnam, 1962). 7. See the 1838 and 1888 "before and after" images of nursing from Supplement to the Nursing Record, 20 December 1888, reprinted in Celia Davies, Rewriting Nursing History (London: Groom Helm, 1980), 6-7. 8. Nelson, "Reading Nursing History."

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9. Sioban Nelson, "A History of Small Things," in Advanced Qualitative Research for Nursing, Joanna Latimer (Oxford: Blackwell Science, forthcoming). 10. By the 1970s a great many scholars were revitalizing the history of medicine, working on its social and intellectual history. See, for instance, the work of Charles Rosenberg, George Rosen, George Vogel, Roy Porter, and William Bynham. 11. Monica Baly's empirical revisions of Nightingale have been extremely important, most notably Florence Nightingale and the Nursing Legacy (London: Groom Helm, 1986). 12. Barry Smith's history of Florence Nightingale is commonly described as iconoclastic. He characterized Nightingale as a deeply flawed personality whose image was carefully crafted in her day, and maintained by a steady stream of hagiography. See F.B. Smith, Florence Nightingale: Reputation and Power (London: Groom Helm, 1982). 13. Martha Vicinus, Independent Women: Work and Community for Single Women, 1850-1920 (Chicago: University of Chicago Press, 1985); Mary Poovey, Uneven Developments: The Ideological Work of Gender in Mid-Victorian England (Chicago: University of Chicago Press, 1988); Anne Summers, Angels and Citizens: British Women as Military Nurses, 1854-1914 (London: Routledge and Kegan Paul, 1988); Susan Reverby, Ordered to Care: The Dilemma of American Nursing, 1850—1945 (New York: Cambridge University Press, 1987); Barbara Melosh, The Physician's Hand: Work, Culture, and Conflict in American Nursing (Philadelphia: Temple University Press, 1982); Robert Dingwall, Charles Webster, and Anne Marie Rafferty, An Introduction to the Social History of Nursing (London: Routledge, 1988); Davies, Rewriting Nursing History (1980); Nancy Tomes, "'Little World of Our Own': The Pennsylvania Hospital Training School for Nurses, 1895-1907," in Women and Health in America: Historical Readings, ed. Judith Leavitt (Madison: University of Wisconsin Press, 1984). Anne Marie Rafferty is the sole nurse in this list. 14. Nelson, "Small Things." 15. Patricia D'Antonio, "Revisiting and Rethinking the Rewriting of Nursing History," Bulletin of the History of Medicine 73 (1999): 268-90. 16. See, for example, Julie Fairman and Joan Lynaugh, Critical Care Nursing: A History (Philadelphia: University of Pennsylvania Press, 1998); Judith Godden and Sue Forsyth, "Defining Relationships and Limiting Power: Two Leaders of Australian Nursing, 1868-1904," Nursing Inquiry 7 (1) (2000): 12-19. D'Antonio, "Rewriting of Nursing History," offers a full review of nursing historical literature. 17. Rosemary Stevens, American Medicine and the Public Interest (New Haven, Conn.: Yale University Press, 1971); Mathew Ramsay, "Review Essay: History of a Profession, Annales Style: The Work of Jacques Leonard," Journal of Social History 17 (1983): 319-38. 18. A large body of relevant work in the Foucauldian oeuvre could be cited here, but most pertinent are Michel Foucault's Birth of the Clinic, trans. A. Sheridan (London: Tavistock, 1973), and Discipline and Punish: The Birth of the Prison, trans. A. Sheridan (London: Pantheon Books, Random House, 1977). The former explored the relationship among knowledge, expertise, and clinical practice; the latter brought into focus the role of surveillance as a form of discipline. 19. Judy Giles, "A Home of One's Own: Women and Domesticity in England, 1918-1950," Women's Stud Internal Forum 16 (1993): 239-53; Sharon Harley, "For the

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Good of Family and Race: Gender, Work, and Domestic Roles in the Black Community, 1880-1930," Signs 15 (1990): 336-49. 20. D'Antonio, "Rewriting of Nursing History," 285. 21. Celia Davies, Gender and the Professional Predicament (Buckingham: Open University Press, 1995). 22. Sioban Nelson, Say Little, Do Much: Nurses, Nuns, and Hospitals in the Nineteenth Century (Philadelphia: University of Pennsylvania Press, forthcoming). 23. This is not the case in all undergraduate programs. The University of Sydney Faculty of Nursing does in fact teach nursing history at undergraduate and graduate levels. But in general, history is not in the Australian undergraduate nursing curriculum, nor is it taught at the graduate level. 24. Nelson, " Reading Nursing History," 233-34. 25. Christopher Maggs, "Nursing History: A History of Caring," Journal of Advanced Nursing 23 (1996): 630-35. 26. The frequent inclusion of history in qualitative methods texts, such as the one to which I am a contributor (see below), indicates this re-siting of history from a discipline to a free-standing method. For a full critique of this issue, see Nelson, "Small Things." 27. Historiographical debates rage constantly in history. "What is truth?" is the core question for historians above all other scholars. See, for instance, Michael Bentley, ed., Companion to Historiography (London: Routledge, 1997), for an extensive collection of historiographical essays; see also the aftermath of the Francis Fukuyama-inspired "After History"debate in Timothy Burns, ed., After History? Francis Fukuyama and His Critics (Lanham, Md: Rowman and Littlefield, 1994); or the erudite George G. Iggers, Historiography in the Twentieth Century: From Scientific Objectivity to Postmodern Challenge (Hanover, NH: Wesleyan University Press, 1997). 28. The Australian Nursing History Project is based at the School of Postgraduate Nursing, University of Melbourne, under the directorship of Dr. Sioban Nelson. See www.nursing.unimelb.edu.au/anhp. 29. Australian Science and Technology Heritage Centre usage statistics: www.asap.unimelb.edu.au/usage, 2001. 30. This was Janet Wilson James's description in her essay "Writing and Rewriting Nursing History: A Review Essay,"Bulletin of the History of Medicine 58 (1984): 568-84. 31.1 remain keen to pursue this idea with others.

BOOK REVIEWS

Review Essay: Telling the Stories of World War II Military Nurses They Called Them Angels: American Military Nurses of World War II By Kathi Jackson (Westport, Connecticut: Praeger, 2000) All This Hell: U.S. Nurses Imprisoned by the Japanese By Evelyn M. Monahan and Rosemary Neidel-Greenlee (Lexington, KY: University of Kentucky Press, 2000) Military nursing, especially that which takes place in the combat zone, typically evokes keen interest in professional nursing communities and with the lay public. The genesis of the fascination lies, at least in part, in the nature of the milieu. The profusion of heroic deeds; the ubiquitous fine line between life and death; the draining toil of long, hard hours and primitive conditions; the unifying spirit of patriotism; and the overriding stress and critical tenor of wartime all combine to produce compelling, yet instructive narratives. World War II, certainly the most massive war in the most war-filled century to date, also has produced a sizable body of historical literary work that continues to captivate an audience of curious readers. In the aftermath of such a cataclysmic event as World War II, the quality and quantity of published military nursing historiography has evolved and expanded with some peaks and troughs along the way. As decades have passed, generally the erudition of historical research has advanced and, as the generations who remember the events of World War II grow older, interest has piqued and an increasing number of researchers have turned their attention to this subject. Initially during the World War II years and immediately thereafter, historically centered writings were limited predominantly to personal, first-hand accounts or journalistic features that detailed the war nurses' experiences. These factual documents chronicled events, issues, ordeals, and sentiments while seeking only minimally to critique the historical events and extract lessons from the past occurrences. Nonetheless, one should not denigrate these first efforts. Indeed, they have informed the public about the contributions of military nurses and have served as vital underpinning for subsequent research efforts.

Nursing History Review 10 (2002): 189-210. A publication of the American Association for the History of Nursing. Copyright © 2002 Springer Publishing Company.

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After the brief surge of contemporary articles, scant few works appeared in the literature for several decades. This hiatus coincided with the era when vast legions of World War II military nurses put their pasts behind them and then embarked on new life adventures. Moreover, the onset of the Cold War, the travails of the Korean Conflict, and the debilitating circumstances of the Vietnam hostilities distracted the attention of the nation. World War II military nursing literature that did surface in this era consisted primarily of a few works of fiction and nonfiction for a mass-market audience of adults and children. However, as time marched on and a period of relative peace ensued, the attentions of historical researchers turned once again to the exploits of World War II military nurses. In the early days of this era, roughly in the 1980s, more manuscripts of interest appeared in the professional literature and similarly a number of volumes were published. These works were broad overviews that usually were based on more than one source of information. They synthesized these multiple viewpoints into a seemingly coherent history. Some of the better-quality manuscripts referenced the ideas and quotes contained within the text, thereby substantiating their sources. Others did not. A handful added some analytical thought to their work and arrived at some conclusions. Most did not. With the 1990s came the 50th anniversary of the war and the solemn recollections of its first day of infamy, the memorializing of its major campaigns, and once again the joyful celebration of its final victory. A welcome influx of new historical nursing scholarship emerged in this decade, offering fresh insights into past phenomena and articulating new knowledge achieved across the perspective of time. Simultaneously, the quality of the published historical nursing research became more refined. Hallmarks of this generation of World War II military nursing scholarship could be detected, to one extent or another, in the greater attention in manuscripts to accurate and perceptive analysis of historical truisms. Another unprecedented attribute of superior historical research surfaced in many manuscripts as well. At this time, the overlay and interweaving of the bigger picture, the context, throughout the narrative to enhance understanding became a device that was more frequently utilized in the more scholarly levels of this research genre. Finally, the identification and development of themes that emerged from the data became more a common practice. All of these features maximized the utility of the research, raised the level of scholarship, and energized the art and science of military nursing history research. With the new millennium, we are positioned on the brink and are ready to step into a new more refined methodological age. In this phase of the growth process, it is to be hoped that more military nursing history will become somewhat prescriptive or more highly predictive in nature. In other words, the new wave will not only document its sources competently, analyze past directions logically, and provide accurate background information upon which to make judicious, well-considered choices but will also suggest future challenges with fair certainty and propose strategies to deal with them. It is to be hoped that this level of military nursing historiography also will facilitate change in future nursing practice and policy by advocating courses of action. There are some historical researchers who presently do achieve this level of scholarship. Inevitably, more will follow in their footsteps. Two recently published books have joined the burgeoning complement of works focused on World War II nursing. They both make interesting contributions to the constantly growing body of knowledge about this complex, prodigious subject. The first of these, Kathi Jackson's They Called Them Angels, is a broad brush overview of military

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nursing in World War II. At the outset, the Jackson explains that her intent in writing the book is to "single out" military nurses from other female World War II veterans and to honor them "for all they did." Within the constraints levied by a text of only 170 pages, she manages to meet this objective. Jackson's clean, crisp writing style, coupled with short chapters liberally seasoned with quotes, makes this a highly readable book. Although clearly intended for a general audience, the professional community will also, without question, find the volume engaging. Jackson has organized her treatise into short, concise chapters arranged topically. At the beginning of almost every chapter she writes approximately one paragraph that summarizes the military and/or political context. She begins by looking at recruitment and describes the attributes of those nurses who joined the Armed Forces, further spelling out their motivation. The author then looks at the induction process, synopsizing the training received and the uniforms issued. A subsequent chapter briefly addresses the nurses' first experiences. Ensuing chapters then encapsulate the nurses' lives in the various combat theaters, i.e., the Pacific, Mediterranean, European, China-Burma-India, the continental United States, and the Western Atlantic. The focal point for the next chapter centers on nursing in the air, flight nursing, followed by a look at nursing on the seas, aboard ship. A chapter entitled "Camaraderie and Romance" concentrates on the array of relationships held by nurses. The last chapter deals with the nurses' reassignments after the war's conclusion or their departure from the service. It also provides a fleeting glimpse at AfricanAmerican military nurses and an even more succinct explication of the distressing plight of Japanese-American nurses. Interesting appendices, a full bibliography, and an abbreviated index conclude the book. On the one hand, Jackson's They Called Them Angels is a fine book that has a number of positive features. It makes good use of some excellent new primary source data. Moreover, it succeeds in its objective to laud the contributions of World War II nurses. It also catches and keeps the reader's interest while informing the general public. On the other hand, the volume could have been strengthened in a few areas in ways that would enhance its usefulness for a nursing history audience. For instance, it usually references only the direct quotes, not the paraphrased ideas or statements in the footnotes. Additionally, it does little analysis, and themes are not identified. In spite of these drawbacks, however, They Called Them Angels is an intriguing book for all to read. Evelyn M. Monahan and Rosemary Neidel-Greenlee's All This Hell is a second new volume on the World War II military nursing history landscape. Monahan and NeidelGreenlee's book has a narrower perspective in that it examines the story of the American nurses who became prisoners of war of the Japanese. The goals of this work, also intended for consumption by the general populace, are twofold. The authors strive to disseminate the story of these heroic POWs and to promulgate the idea that much must be sacrificed for our "right to be free." It too meets these goals in the short space of 178 pages of text. Monahan and Neidel-Creenlee arrange their books' chapters in chronological order, beginning with a description of the idyllic lifestyle of military nurses in the Philippines before the outbreak of war. The next segments deal with the enemy attack, the retreats, first to Bataan and then to Corregidor, the internment in Santo Tomas and Los Banos, and conclude with the nurses' liberation by American forces after years of detention and deprivation. Detailed appendices, brief endnotes, a bibliography, and a full, functional index follow.

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Overall, the positive attributes of All This Hell predominate. Its narrower focus results in a highly detailed narrative that appears factual and accurate. Its illustrations are numerous and certainly superb. Its inclusion of context is adequate. However, it, too, only documents sources of actual quotes, not ideas, in its endnotes, a source of frustration for history scholars. Furthermore, it offers little in the way of analytic thought. Themes, as such, are neither identified nor developed. While neither They Called Them Angels nor All This Hell meet the rigorous criteria our new methodological age demands, they are solid, creditable examples of military nursing history aimed at the general populace. Elizabeth M. Norman's We Band of Angels remains the "gold standard" of rigorous research into and careful anaysis of the experiences of World War II military nurses.1 But both They Called Them Angels and All This Hell contain valuable information and deserve to be read by those interested in the fascinating stories of military nurses.

MARY T. SARNECKY, DNSc, RN Contract Historian Office of Medical History, Office of the Surgeon General, U.S. Army 6953 Dusty Rose Place Carlsbad, CA 92009

Mending Bodies, Saving Souls: A History of Hospitals By Guenter B. Risse (New York and Oxford: Oxford University Press, 1999) In Mending Bodies, Saving Souls, Guenter B. Risse demonstrates that a history of medicine can be an integrated history of institutions, caretakers, and patients. Like Morris J. Vogel in The Invention of the Modern Hospital (1980) and Charles E. Rosenberg in The Care of Strangers (1987),2 Risse examines social and cultural influences in hospital development. In choosing his title, he emphasizes the historical importance of the hospital's medical and religious roles. His analysis also addresses hospitals' social control functions by considering them as places of discipline, rituals, and routines, designed to bring order in the midst of pain and illness. Risse traces the evolution of hospitals "from charitable guest houses" of the ancient Greek world to today's modern "biomedical showcases" (p. 4). Information is provided on a variety of topics relating to hospital history, including institutions' missions, architecture, rituals, patrons, staff, and organizational structures. The author breaks with traditional 1. Elizabeth M. Norman, We Band of Angels: The Untold Story of American Nurses Trapped on Bataan by the Japanese (New York: Random House, 1999). 2. Morris J. Vogel, The Invention of the Modern Hospital: Boston, 1870-1930 (Chicago: University of Chicago Press, 1980); Charles E. Rosenberg, The Care of Strangers: The Rise of America's Hospital System (Baltimore: Johns Hopkins University Press, 1987).

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histories in his use of primary data on patients' and caregivers' experiences within hospitals and with disease. Using sources in archives across Europe and the United States, he relies not only on official documents and texts but also on clinical records and patients' personal narratives. These provide the reader with a more humanistic account and, hence, a fuller understanding of healing places and practices. Risse's background as a trained historian and physician makes him uniquely qualified to write such a history. He is adept at selecting specific hospitals that illustrate representative themes of medical history. For example, he begins by examining pre-Christian medicine through a Roman intellectual's experience at an Asclepieion temple in the second century. Later, he highlights a Roman soldier's letters to his father that describe his experiences in an early military hospital. Both institutions had missions that operated within religious frameworks of ritual and supernatural healing. The two succeeding chapters show the emergence of Christian hospitals in Byzantium, established as charitable shelters for the poor and displaced during periods of famines and epidemics. Accounts of a tenth-century abbot in a Benedictine monastery, a twelfth-century poet at a hospital in Constantinople, and the religious order of the Hospitallers of St. John in Jerusalem emphasize the key theme of the interaction of sacred and secular healing. By contrast, Islamic hospitals were free of religious agendas. In later chapters, Risse investigates the changing definitions of disease and the shifting institutional roles of hospitals. The spread of leprosy and plague in fifteenth-century Europe led to a shift in society's understanding of disease as one of contagion (p. 200), in addition to commonly held humoral or religious perspectives. This new viewpoint reinforced the role of the hospital as a means of social control. For example, lazarettos and pesthouses became institutions of "segregation and confinement" (p. 167). In the Enlightenment period, we see the rise of teaching institutions in Edinburgh and Vienna and the growing importance of clinical medicine, anatomy, and surgery in Paris institutions. Although patients' voices are increasingly silent in clinical reports, William Cullen's records at the Royal Infirmary of Edinburgh illustrate the physician's incorporation of new knowledge about health and disease into medical theory. The case of a 27—year-old Viennese tailor with fever highlights the mercantilist reforms of Johann Peter Frank, spokesperson for the "medical police." Finally, R. T. Laennec's use of the stethoscope with a retired soldier in Paris exemplifies physicians' increased access to the human body and reveals a further "epistemological shift resulting from physical examinations of the sick" (p. 329). In addition to healing institutions, hospitals became sites for clinical training at the bedside and the autopsy room. Medicalization of hospitals grew especially in the nineteenth century with the expansion of surgery after general anesthesia and antisepsis became available. Case records at Massachusetts General Hospital describe an Irish domestic who was the first person to receive ether for major surgery. Margaret Mathewson's eyewitness account describes her experiences with Joseph Lister at the Royal Infirmary of Edinburgh. Yet Risse moves beyond a history of "great men" by illustrating medical limitations in the treatment of typhoid fever at Johns Hopkins and cholera at the Eppendorf General Hospital in Germany. Patient narratives, clinical and administrative records, and family interviews are used to illustrate the scientific and technological evolution of the twentieth-century hospital. Buffalo's Mercy Hospital, a Catholic institution, is the focus of one chapter. Comparative case studies of two patients with heart attacks, one in the 1950s and the other in the 1970s, provide insight into the blending of religious and medical care and the identity crisis that

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Catholic institutions experienced with the exit of many nursing sisters. Some of the last case studies depict patients with renal transplants and illustrate the technological complexities that are so typical of modern hospitals. The final chapter is perhaps the most interesting. It concentrates on a special AIDS unit at San Francisco General Hospital in the 1980s. Risse describes the construction of AIDS as a disease, patients' emotions and clinical trajectories, and the increasing reliance on collaboration in patient-staff relationships. Nursing plays an important role in this history. The religious and lay brothers and sisters in the early monasteries, the Hospitallers in Jerusalem, the Sisters of Charity in France, the Nightingale nurses at the Royal Infirmary of Edinburgh, the intensive care nurses at Mercy Hospital, and those at San Francisco General are consistently portrayed as skilled, compassionate caregivers. Indeed, Risse attributes the low mortality of patients with typhoid fever at Johns Hopkins to "empathetic nursing" rather than to medical care (p. 421). And with the increasing impotence of regular medicine in the treatment of AIDS, nurses were placed "at the center of patient care" (p. 646). This book is not a dry historical study, as some readers might anticipate. Further, it can be a valuable resource to librarians, sociologists, historians of nursing and medicine, and medical anthropologists. I highly recommend it as a text, particularly for courses in medicine and nursing history. Through this interesting and informative account, the author illustrates his assertion that today's hospitals must remain "human-centered" (p. 685), even as they strive to provide the best medical care that modern science can deliver. BARBRA MANN WALL, PHD, RN Assistant Professor Purdue University School of Nursing 1337 Johnson Hall of Nursing West Lafayette, IN 47907-1337

Learning, Faith and Caring: History of the Georgetown University School of Nursing, 1903-2000 By Alma S. Woolley, RN, EdD (Washington, DC: Georgetown University School of Nursing, 2001) The history of nursing care and nursing education in Western civilization is deeply rooted in the church and religious orders that developed during its early history. The care of the sick in the monasteries and convents of Europe is well-known and provided a precedent for the care of the sick in the New World. After decades of Catholic hospital sponsorship of nurse training programs and following close behind pioneering efforts in the secular world of American health care, institutions of higher education under Catholic auspices began to consider and establish nursing programs leading to academic degrees. Some, like Boston College and Villanova University were new initiatives, while others, like Georgetown University were hospital schools that transitioned into collegiate programs.

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It is within this context that Alma Woolley's well-researched and documented history of the Georgetown University School of Nursing unfolds. Beginning with its antecedent, the hospital school at Georgetown Hospital (1903), Dr. Woolley, the former dean of the Georgetown University School of Nursing, tells the engaging story of the development, transition and transformation of nursing education in that institution throughout the twentieth century, using excellent primary sources and carefully selected, appropriate secondary sources. Through the clear and truthful lens of this former dean, objective data are provided that support and provide a framework for interpretation, analysis and formulation of conclusions by the reader. As in all historical inquiry, objectivity in the use of valid and reliable data provide the basis for chronicling events that eventually lead to unbiased, yet subjective interpretation which becomes the substance of true historical discourse. Dr. Woolley has achieved this end: her meticulous attention to sound historical method is clearly evident and well-executed. The significance of the subject is equally worthy. As the oldest Catholic institution of higher education in the United States, the experience of Georgetown's School of Nursing serves to inform as well as to reflect the experiences of similar programs that emerged from hospital diploma programs within church-related institutions. A recurring theme is that of struggle and survival. This hospital-based program was heavily influenced by various orders of women religious, who staffed the hospital, not the Jesuit sponsors of Georgetown University. The program was established as a support for the fledgling medical school and hospital, not as a deliberate expression of Georgetown's academic and religious mission. The school's development, transition and emergence as a degree granting academic unit was largely a result of trends in nursing education and external forces exerted by the NLNE, NLN as well as the developing accreditation mechanisms. The concern of a few of the university's Jesuit priests, who believed that the program should develop in line with the general trends in American education, was present, but not consistent. Throughout the book, Woolley reminds us that for most of its history, the nursing program was "in the university" but not "of the university." Over time, students became well integrated into the liberal arts and science courses and the student life of the university, but the faculty and the school itself was not. Partially, this was a result of the ambiguous nature of the school of nursing's administrative relationship with the undergraduate academic campus and Georgetown's professional, medically related entities, especially the medical school and hospital. Related to this was the confusion concerning administrative reporting mechanisms that made the deanship particularly challenging. Lack of resources and low priority on the agenda of most of the key administrators of the university served to compound the problems of the school of nursing. Nevertheless, the tenacity and leadership acumen of the nursing deanship and the commitment of faculty and alumni encouraged the school to develop and move ahead in line with professional trends in the field, despite the numerous obstacles it faced. In many ways the book is a political history that provides insights into the elements that both impede and promote a school's survival and development. The author artfully uses shaded inserts in the text that help to provide the social, temporal, and professional context for understanding events in the school's development. Excerpts from landmark reports on the profession, as well as brief vignettes that describe the experience of selected individual nursing students during various decades, illuminate

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the portrayal of the students, faculty, deans, curriculum and university administrators and the atmosphere within which nursing education at Georgetown existed. Surprisingly, the influence of the Jesuits as a positive force in the development of the school appears minimal, and their support of the school as an expression of the university's mission seems tentative. Based on the history that Woolley presents, it seems possible that Georgetown has never truly acknowledged nor understood how important the school of nursing has been in continuously communicating and transmitting the institution's values and its tradition of Christianity and Jesuit higher education. It seems possible that in focusing on its strong liberal arts tradition, which is the heart of Jesuit education, the university may have overlooked the school of nursing's contribution to its soul. Learning, Faith and Caring is not merely a chronicle of one hundred years of nursing education at Georgetown. It is a scholarly, well-written and thought-provoking history, which is a welcome addition to the documented history of nursing education. In addition, it provides the backdrop for the future achievements of a school of nursing that has earned its rightful place in the field and even more significantly, in the prestigious university of which it is a part. M. LOUISE FITZPATRICK, EoD, RN Dean and Professor, College of Nursing Villanova University 800 Lancaster Avenue Villanova, PA 19085-1690

Devices and Desires: Gender, Technology and American Nursing By Margarete Sandelowski (Chapel Hill: The University of North Carolina Press, 2000) Few historians have written about the relationship between nurses and technology with the facility of thought and the extensive documentation that Margarete Sandelowski accomplishes in this panoramic overview of American nursing in the twentieth century. In Devices and Desires: Gender, Technology and American Nursing, she examines the nurse/technology relationship, exploring how nursing has been identified "both with and against technology, and thus, in some ironic way, with and against itself (p. 178) over the last century. Analyzing data from a wide variety of primary and secondary sources, the author examines how technology both advanced the power, influence and "leverage" of nursing, while simultaneously reinforcing its subordination to medicine, demonstrating how "gender has persistently undermined the democratizing potential of technology" (p. 13). Sandelowski argues that the technological innovations which promised gender equality became the subject of a discourse within the profession which ultimately "reinstated the cultural association between technology and masculinity—that is, they reinstated gender [feminity = caring] as opposed to science and technology [masculinity = cure] as the factor that legitimized nursing" (p. 180).

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Throughout the discourse, Sandelowski describes nurses' ambivalence to accepting technology, noting that by the 1970s nurses began to depict nursing and technology as in opposition to each other, with nursing the humane antidote to technology (p. 9). Despite this depiction, throughout the 20th century nurses continued to turn away from using their own bodies [hands] as tools, and toward technology as " a cleaner, less visceral, less intimate, and more scientific form of caring" (p. 10). Finally, the author observes that "the signal links tying nursing and technology still trouble nurses and nursing" (p. 6) today. Of specific interest to those interested in the intersect of technology and childbirth, Sandelowski addresses the topic of electronic fetal monitoring in some depth. Noting that electronic fetal monitors were introduced into the labor room in the mid to late 1960s, the author asserts that fetal monitoring, which provided a "continuous and instantaneous visual record of fetal heart rate in temporal relation to uterine contractions" (p. 145) raised questions about how "true" nursing would be defined (p. 189). Touch, "the traditional practice in which nurses used their bodies, not machines, as tools to watch over and minister to their patients," became the metaphor for true nursing, and labor room nurses were concerned that as they spent increasing amounts of time observing the electronic monitors, they were "literally and figuratively" losing touch with the laboring women (p. 166). However, nurses were far from out of touch. As Sandelowski notes, "the nurse was the critical element in electronic fetal monitoring without which the use of machine monitors was pointless." (p. 155). On another topic, Sandelowski's thesis that technology both provided opportunity for the nursing profession to expand the boundaries of the discipline, while simultaneously "reinforcing the invisibility of nursing work" (p. 40) is well-stated. In my recent work on the use of technology by coronary care unit nurses in the 1960s, I have found that with the creation of the coronary care unit came a new respect for nursing and the nurses' new knowledge and clinical skills related to the technology. On the other hand, it was also accompanied by the new problem of "nursing invisibility" as the cost of nursing care was absorbed into the cost of the room in the CCU. Like private duty nurses of the past, the CCU nurses provided 1:1 care for patients. However, unlike the private duty nurses, the CCU nurses could not bill for their services. To further complicate the problem of invisibility, nurses themselves participated in the minimization of their role and their knowledge. According to Sandelowski, "even when nurses possessed greater knowledge than physicians [about the use of the new technology], this knowledge was either not recognized or minimized, even by nurses themselves . . . the practical knowledge of enactment and application was typically effaced, as nurses were perceived as merely carrying out the . . . therapy physicians had ordered" (p. 64). For too long, nurses have remained invisible, particularly in health care history, and Sandelowski's work highlights their achievements throughout a century. As she so aptly asserts: "Although nurses have typically appeared (if they appeared at all) as no more than footnotes in the history of medicine and medical technology, they were indispensable to the early-twentieth-century scientific and technological transformation of health care and medicine in the United States. . ." (p.l). Of equal importance is the author's assertion that "Technological innovations have undeniably enskilled nurses and enlarged the scope of nursing practice. . . . yet, they have

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both advanced and thwarted the fulfillment of nurses' desires." (p. 193). This dichotomy captures the essence of Sandelowski's most recent work. Devices and Desires makes a distinctive contribution to the literature. It is recommended to all professional nursing students, historians of nursing, and scholars of health care history. ARLENE W. KEELING, PHD, RN Associate Professor of Nursing Associate Director, Center for Historical Inquiry University of Virginia School of Nursing Charlottesville, VA 22901

Hearts of Wisdom: American Women Caring for Kin, 18501940 By Emily K. Abel (Cambridge, MA: Harvard University Press, 2000) Emily Abel begins Hearts of Wisdom: American Women Caring for Kin, 1850—1940 by pointing out that despite the volume of recent research on nineteenth- and twentiethcentury health care, little scholarly attention has been paid to a largely unseen dimension, that of "informal" caregiving, defined as care provided by family and friends as opposed to professionals. The purpose of Abel's study is to analyze the way in which the delivery of informal care changed between 1890 and 1940, a period that saw the bacteriological revolution, new concepts of disease causation, the transformation of the formal health care system, the spread of domestic technologies, and profound social and cultural shifts in the United States. Abel strives to understand the conditions that made caregiving meaningful, as well as those that made it onerous throughout this time period. Portions of four of the nine chapters in the book have been adapted from previously published articles, though they are newly unified under the framework of informal caregiving. Abel has been remarkably successful at the ambitious task of exploring this hidden activity, a daunting endeavor because she did not just focus on one specific disease or population, but studied informal chronic illness care across many different conditions, seeking to understand how it varied over time and differed by race, ethnicity, class, geographic region, and to a certain extent by relationship to the ill individual. The book looks only at women's experiences, as Abel argues convincingly that informal caregiving is heavily intertwined with prevailing notions of femininity. Abel puts forward a clear rationale for why the book should be of interest to contemporary readers, noting that the past decade's turmoil in American health care has halted the twentieth-century trend toward institutional care, resulting in greater caregiving responsibilities on the part of family and friends. A major strength of this book is that Abel avoids the seductive trap of romanticizing informal care and does not set up a "good guys/

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family and friends" versus "bad guys/nurses, physicians, charity workers, etc." thesis. Rather, her nuanced analyses of power, knowledge, and negotiation between and among the various actors provide the reader with insight into this elusive and complex story. Abel draws from a wealth of primary and secondary sources. Although she is careful not to overgeneralize her findings to all women during this era, two overarching themes arise from her data and pervade the book. The first is that family and friends actively negotiated with health care providers to assert their own roles as well as obtain the formal care they thought necessary for the individual in question. Thus, the actual work of informal caregiving was not determined passively, nor merely defined as that which nurses, doctors, and other professionals deemed outside of their purview. The second major theme is that the development of a formalized system of health care delivery in the United States did not erode informal care; it merely altered its components. The narrative is organized both chronologically and thematically. Part One focuses on informal caregiving between] 850 and 1890. In this section Abel illuminates the nineteenth-century world of familial caregiving through the diary of Emily Gillespie, explores the caregiving experiences of enslaved African American women, and analyzes the struggles for power between doctors and White women. Because female caregivers in this era employed many of same diagnostic and therapeutic practices as trained professionals, outcomes between the two were often difficult to distinguish. Bacteriologic and technologic advances altered this parity by the late nineteenth century, and the relationship between informal care providers and trained health care professionals grew more complex, and in many ways more unequal. Part Two explores informal caregiving between 1890 and 1940. This section uses the above themes to delve deeper into the way scientific rationality, technology, consumer goods, and the explosion in the numbers of institutions and trained professionals affected informal caregiving. These chapters explicate a variety of people and groups: the experiences of a Kansas woman who cared for various family members over the course of her life; mothers' letters to the Children's Bureau seeking help for their children as well as advice on childrearing; family members' correspondence with prominent tuberculosis specialist Lawrence Flick; negotiations between caregivers of indigent New York City tuberculosis sufferers and the Charity Organization Society; letters seeking aid for family members from Eleanor and Franklin Roosevelt during the Great Depression; an analysis of the interactions between American Indian caregivers on reservations and public health nurses; an exploration of mother's responses to pressure from society to institutionalize children labeled feebleminded or epileptic; and an examination of the struggles of mothers who sought care for their deaf children. While the narrative is strengthened by including the perspectives of so many different types of caregivers, Part Two is so diverse that the reader might have benefited from a formal introduction to the section in which Abel details for the reader how and why the various examples were selected and the way in which each case supports facets of her central arguments. In the conclusion, Abel briefly sketches the changes to informal caregiving since 1940 and discusses the ways in which this historical study can be used to improve informal and formal caregiving today. She alludes to her recent research on contemporary women's experiences caring for elderly parents. A more full description of this study, as well as the ways in which it influenced her historical research, would have been very interesting. For example, one finding from her study of adult daughters' experiences caring for elderly

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parents today was that some women found themselves slipping back into old patterns of the original parent/child relationship. Did she find any evidence that this was also true of women from 1850 to 1940 who cared for their parents? If not, what does she make of this difference? The book ends with call to respect informal caregiving, consideration of some of the systemic impediments in the United States to doing so, and a somewhat Utopian prescription to overcome these obstacles. Hearts of Wisdom: American Women Caring for Kin, 1850—1940 is well worth reading because it spotlights family members and friends of the ill, people who often bear the brunt of sickness, but a group which has frequently been invisible to society. Abel's clearly written book fills an important gap in the nineteenth- and early twentieth-century historical scholarship pertaining to health care and women. CYNTHIA A. CONNOLLY, PHD, RN Instructor in Nursing University of Pennsylvania School of Nursing Philadelphia, PA 19104

No One Was Turned Away: The Role of Public Hospitals in New York City Since 1900 By Sandra Opdyke (New York: Oxford University Press, 1999) Sandra Opdyke's No One Was Turned Away: The Role of Public Hospitals in New York City Since 1900 is an impressive analysis of the ways in which public hospitals have contributed to civic life. This book is a case study of Bellevue, one of the oldest and largest public hospitals. To balance her analysis, Opdyke includes a comparison examination of a voluntary institution, the New York Hospital. Both hospitals share a locality, a 200-year plus history and recognition as world-renowned academic medical centers. The author uses her data to make a strong and compelling argument that public hospitals serve a critical and much-needed role in the diverse life of its community. Opdyke skillfully weaves discussion of what she identifies as four major distinguishing features that characterize public institutions into her chronological narrative. These qualities are: inclusiveness of services to all members of society, continuity of services over time, responsiveness to public input, and public visibility of the needs of all citizens. For Opdyke, these defining characteristics make public hospitals valuable to society and separate them from their private counterparts. Both Bellevue and New York Hospital began as institutions providing care to a fairly homogeneous patient population group, the very poor. By 1910, the rise of scientific medicine created a climate in which New York Hospital vigorously promoted its services to a different class of patients, those who could pay. Bellevue also aspired to achieve

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prominence as an academic medical center, but faced constraints in this quest due to its legal and traditional commitment to care for all sectors of the community. Opdyke depicts how the respective missions of Bellevue and New York Hospitals diverged throughout the twentieth century. During the Great Depression, Bellevue frequently placed patients in hallways once ward space ran out. The more selective New York Hospital chose to close revenue-losing ward beds as part of a Depression-era tactic to reduce expenses. In the post-Wo rid War II period, a financially solvent New York Hospital exercised great discretion in charting its own course as it planned programs and services. Bellevue, always constrained by its politically labile funding base, continued its open-door policy, despite shortages of everything from staff to rubber gloves. Opdyke details Bellevue's neverending battles to meet demands and pressures from community groups, municipal unions, politicians, medical schools, investigators, and patients. By the 1970s Medicare and Medicaid placed private hospital care within the reach of the previously uninsured. The flow of patients to the voluntary sector combined with the mid-1970s New York City financial crisis placed municipal hospitals in jeopardy. Debate raged over whether it was time for the city to get out of the hospital business. Bellevue remained open, but efforts to put the city's financial house in order resulted in a more streamlined institution, one that maintained its commitment to all. Although renewed efforts to close municipal hospitals reappeared in the 1990s, Bellevue continues to operate and in Opdyke's opinion remains a critical component of city life. Opdyke describes in ample detail the many social, political and economic changes occurring in New York City over the twentieth century, linking them to the ways in which each institution responded to societal and environmental changes. She discusses the impact of urban redevelopment programs, the unionization of hospital workers, and health insurance prospective payment systems on acute care hospitals, both private and public. Her analysis of the city's attempts to improve delivery of services in municipal hospitals was cogent and illustrative of the unique complexities found within a politically controlled system. Although Opdyke credits the voluntary hospital system with a long and distinguished record of public service, she poses a critical question. If municipal hospitals did not exist, could the voluntary system provide the same amount of care to all residents of New York City? In the absence of universal health care, this is a very legitimate question to ask. Opdyke's answer is a resounding no. She cites the presence of public hospitals in many of America's largest cities as validating her view that public institutions continue to supply a necessary safety net, not just for those less fortunate, but for many who find themselves using specialized services not provided by the private sector. She argues that public institutions also benefit private institutions that continue to exercise the right to deny hospital to care to some knowing that institutions such as Bellevue will turn no one away. Opdyke's work should be of interest to a wide audience. This book is an excellent examination of how governmental agencies do supply needed services to the public. I found Opdyke's documentation very thorough, her argument persuasive. She challenges the contemporary view that a diverse range of community services, from garbage collection to education to Social Security, would be better delivered through privatization. In an era when criticism of government programs is endemic, this book considers how community

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life might differ without governmental programs that have demonstrated a long history of benefiting all sectors of society. JEAN C. WHELAN, PnD, RN Postdoctoral Fellow Center for Outcomes and Policy Research University of Pennsylvania Philadelphia, Pennsylvania 19104

Nurses in Nazi Germany: Moral Choice in History By Bronwyn Rebekah McFarland-Icke (Princeton: Princeton University Press, 1999). Bronwyn Rebekah McFarland-Icke presents a dispassionate, unsparing, searing analysis of the perversion of the ethics and values of psychiatric nurses in Nazi Germany. The author taps a variety of sources, some of which became available only in recent years after the collapse of East Germany. They include postwar trial testimonies, municipal records, hospital administration documents, and nursing literature from early twentieth-century Germany. McFarland-Icke examines the role of psychiatric nurses from late nineteenth through early twentieth-century Germany, and she depicts the step-by-step progression of their descent into hell as willing agents in the Nazi-engineered mass murder of psychiatric patients. Between 1939 and 1945, an estimated 100,000 to 200,000 patients in Nazi Germany's psychiatric institutions were deemed to have "lives unworthy of living" (p. 6265) and were systematically put to death. In the first phase of this program, known as T4 (1939-1941), groups of patients were herded into transports and shipped off to various destinations. Upon arrival, they were placed in rooms, disguised as showers, where they were gassed. This operation was the model for what later became standard operating procedure in the Nazi extermination camps. At first, the T-4 program was carried out under a centralized scheme, in which nurses rounded up patients and organized the transports that culminated in 70,000 murders. In 1941, the program entered a new, decentralized phase, in which nurses took an active role in killing as an everyday practice in their own institutions. What combination of circumstances enabled these nurses—men and women with ethical training—to abandon their principles and to adapt to murderous activities? This profoundly troubling question lies at the heart of McFarland-Icke's work, and there is no simple, succinct answer. Interestingly, documents examined by the author led her to declare that nurses had "precious little to gain from their involvement, and nothing to lose in case of refusal" (p.l 1). Still, these people were not monsters—they were ordinary human beings to whom it did not occur that what they were doing was an abomination. Their judgment and morals were eroded by their loyalty to Volk, Vaterland, and Heimat, the clarion

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call of the National Socialist regime in its demand for unflagging devotion to Adolf Hitler. The author traces the development of psychiatric nursing in Germany in an era of general nursing reform. An early twentieth-century reform movement in nursing in Germany was spearheaded by Sister Agnes Karll, who was highly respected in international nursing circles. McFarland-Icke draws a distinction between psychiatric nursing and general nursing, calling attention to the special concerns of psychiatric nurses. She focuses on principles of psychiatric care and nursing that were established under the liberal Weimar Republic of the 1 920s, principles that were later perverted and recast to conform to the heinous goals of the Third Reich. The author targets certain qualities and characteristics, citing "low morale among psychiatric nurses, high staff turnover, and a poor reputation among the public." (p. x) The nurses were identified, on one hand, as the personnel who had the most intimate contact with patients; on the other hand, they were at the bottom of the institutional hierarchy. Nursing textbooks claimed a humanitarian agenda for these nurses, who, however, were plagued by timidity, uncertainty, lack of assertiveness, and subservience to the physician. Patients' needs and nurses' rights were often incompatible. The author refers to the "thankless character of nursing" (p. 49) and she notes that demands on nurses for self-sacrifice were not balanced by a show of public respect or esteem. Through union organizations, nurses attempted to establish their work as a professional activity and not as an act of charity, but were only partially successful. The author pointedly remarks that "if nurses were unable to manifest their will in the political arena on their own behalf, they were not likely to do so later on behalf of their patients" (p. 32). By 1933, of course, the unions were destroyed. In the end, a certain self-delusion permeated the ranks and leadership of nursing in Nazi Germany. It was even delivered to our shores, where it found a receptive audience. Gertrud Kroeger's "Nursing in Germany," which appeared in the American Journal of Nursing in May, 1939, enthusiastically claimed that "since 1933, important changes have taken place in Germany, first, in the organization of nurses; secondly, in their education and in the practice of nursing." What Kroeger, herself a nurse, was describing, of course, was the infusion of Nazism into the practice of nursing, first through the policies adopted in 1933, and, more specifically, in her article, through the passage of the Nursing Act of 1938. There was no mention of the despicable racial, ethnic, or eugenics factors that had already become institutionalized in German society and were an accepted part of nursing practice. Self-delusion certainly played a role in the ultimate abandonment of moral and ethical principles by nurses in Nazi Germany. The author of this book, which is not an "easy read" but a very essential one, points out in her concluding remarks that "the National Socialist regime's most devastating power lay not in its ability to mobilize people against its victims through propaganda but rather in its ability to deploy propaganda in conjunction with specific physical, discursive, and hierarchical arrangements so that the desire for psychological comfort would prevail over courage" (p. 264). EVELYN R. BENSON, RN, MPH Independent Scholar Havertown, PA 19083

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Letters From Belsen 1945: An Australian Nurses Experiences With the Survivors of War By Muriel Knox Doherty Edited by Judith Cornell and R. Lynette Russell (Sydney: Allen & Unwin, 2000) The Bergen Belsen Concentration Camp became infamous throughout the world as a horror camp when liberated by the British forces toward the end of World War II. Letters from Belsen, a collection of letters written by Muriel Knox Doherty describing her work at Bergen Belsen as a member of the United Nations Relief and Rehabilitation Administration (UNRRA), provides insight into the chaos facing the rescuers as well as the survivors in Bergen Belsen in the immediate postwar period. In particular, Doherty, an Australian nurse, offers a compelling story of what it meant to be a nurse in the face of such horror. Letters from Belsen begins in June 1945 when Doherty joined UNRRA. Prior to that, she had served her country during World War II on active duty with the Royal Australian Air Force Nursing Service, rising to a post as its Principal Matron. The letters continue with details regarding processing and rather confusing orders and travel arrangements to Germany, culminating in her arrival at the Bergen Belsen camp. The liberation of Bergen Belsen, which had taken place several months earlier, is described in Doherty's letters, with details provided by a number of physicians as well as poignant accounts from some of the survivors. These letters describes in detail the site of the original camp, with its mass graves of over ten thousand unknown victims, buried rapidly by the British forces, noting the sickening odor that still pervaded the area. Doherty's anger at the suffering she encountered is almost palpable when reading her accounts. Hand-drawn maps and artwork by several survivors illustrate these sections of the book and enhance the content. Routine nursing procedures seemed anything but routine. Some of the nursing problems encountered by Doherty during her initial days included the difficulty in convincing patients that they would not be killed by the injections delivered by the staff. More than once, survivors were certain that they were about to be murdered, having witnessed human experimentation in other camps. Hysteria occurred in her descriptions of attempts to bathe survivors, certain that they were about to be taken to gas chambers, similar to those they had witnessed in Auschwitz. Doherty also continually battled to convince survivors that their modest diet was sufficient and nutritious: overfeeding the survivors at the initial liberation had killed a number of them, as they were no longer able to consume rich food. She also dealt with considerable resentment at having German nurses assigned to her staff. Neither the survivors nor the nurses were pleased with this arrangement, the survivors accusing several of the nurses of stealing food and the nurses resentful in having to care for the victims. Throughout all this, the frustration of having to deal with staff and patients in a variety of languages becomes evident. Yet, she never considered leaving her post. During Doherty's tenure at Bergen Belsen, medications were short in supply, as were basic items such as bedpans, sheets and other bedding. Moreover, maternity and children's sections of the hospitals, as well as infectious disease areas, were all part of the huge relief effort undertaken

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with insufficient staff. Doherty describes her tour of one of the facilities in which she encountered patients with tuberculosis and typhus packed into corridors and cloakrooms. "1 shall never forget the first day 1 walked round this ward with the QAIMNS (Queen Alexandra's Imperial Military Nursing Service) Sister and saw the gaunt emaciated pallid skeletons, some too ill to observe, others giving a passing smile or glimmer of recognition— a few with brighter. Death was stalking, but no one noticed—death meant nothing to these who had lived, eaten and slept among the dead for so long." (p. 71—72). Both frustrations and successes are detailed in the letters. Some frustrations included a riot in one of the wards, with patients accusing some of the German nursing staff of being ardent Nazis. Water and electricity would be cut off without warning, compounding the difficulties faced by Doherty and her staff. Such events are described with humor and sadness. She savored her successes. Her delight in the rehabilitation of her patients includes both pictures and text describing the various articles crafted by them. Doherty also attended war crimes trials, and her letters provides details about the proceedings. She notes the hanging of a number of the accused towards the end of the book, and towards the end of her service at Bergen Belsen. Several appendices provide detailed information about the workings of the UNRRA, food ration scales in Bergen Belsen, and a summarized report on feeding patients. The book provides insights for historians interested in the immediate time period after the liberation of the camp, as well as a number of incidents and details that would be of considerable interest to nurses with an interest in the era. Letters from Belsen is unique as an account written during the liberation time period and it is, perhaps, one of the few Australian nursing documents that provides so much rich detail. ELLEN BEN-SEFF.R, RN, MN Doctoral Candidate Macquarie University Sydney, Australia Lecturer in Nursing University of Technology Sydney Faculty of Nursing, Midwifery and Health Sydney, Australia

An American Health Dilemma: A Medical History of African Americans and the Problem of Race-Beginnings to 1900 By W. Michael Byrd and Linda A. Clayton (New York and London: Routledge, 2000) Racism and the expressions of it in our society, including slavery, lynching, and segregation, to name but a few, are antithetical to the founding principles of this democratic society. Yet most people who live in this nation are well aware that racism remains a stain that is indelibly

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locked into the fabric of our society. In the context of An American Health Dilemma, racism is defined as the tendency of a society to degrade and do violence to people on the basis of race and by whatever mediations may exist for this purpose. In this first of two volumes, W. Michael Byrd, and Linda A. Clayton, both obstetricians and gynecologists who have concentrated in academic medicine, health policy and management, relate the story of the history of racism from its earliest roots. They particularly trace its transformation over time as it has become ingrained in our society. These professionals take us from ancient through contemporary historical periods to illustrate how and why racism started and why it persists in the health care system. Part I of the book is a lengthy but detailed background that traces the earliest threads of racism. Byrd and Clayton's extensive investigation delves into how, why and when racist dogma first entered the life sciences. The authors first examine the history of science during the Mesopotamian, Egyptian, Greco-Roman and Arabic eras. These same historical eras are then reexamined, adding the history of medicine to that of science. Later historical periods, including the Middles Ages, Renaissance, and Reformation, the Age of Reason and Enlightenment, and the nineteenth and twentieth centuries further examine race, science and medicine. It is at the end of Part I that the main agenda of this book, examining the health care system through the prism of race first appears. Part II examines race, medicine and health in the North American Colonies. Byrd and Clayton recount how slaves brought to the American continent were at an immediate health disadvantage. They came through the trauma of the slave trade and were vulnerable to diseases that were foreign to the African continent. Those who survived as slave labor on the plantations were vulnerable to tuberculosis, pneumonia, and cold injuries and to epidemic diseases such as plague, influenza, typhoid fever, and yellow fever. Their living conditions were poor and their nutrition inadequate. There were not many physicians available during the early years of the colonies. As a result slaves used healers living among themselves, such as midwives, root doctors, and spiritual healers. In some instances, they also received limited care from the people who owned them. More doctors meant that medical care gradually became more widely available. However, black people were treated as second-class citizens and were exploited by White physicians to enhance their reputations. Separate and inferior institutions served Black people, and in the South they were either denied access or placed in outbuildings, attics, basements, or, at best, segregated wards. Moreover, Byrd and Clayton argue, the medical profession has always been interested in the biological difference between Blacks and Whites, assuming that the former were inferior to the latter. Correspondingly, the belief prevailed that if Black people were less than Whites, physicians did not have to offer them the same level care, concern, and respect in the health care system as they did their own kind. Although Parts I and II are well documented and edifying, it is in Part III that the reading becomes most satisfying. We learn about the years from 1812 to 1900. The picture remains one of inferior health care, but we then we begin to have individual Black physicians, dentists, lawyers emerge. Their accomplishments become visible as they struggle to practice their professions and work to improve the conditions of their fellow Black citizens.

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There is, however, one large group of health professionals that is essentially left out of this discussion—nurses. The only references to nurses are to Harriet Tubman, a slave bill of sale indicating that a slave woman was a nurse, and an oblique reference to the Sanitary Commission during the Civil War. An American Health Dilemma fills an important gap in our understanding of racism and the African American medical experience. While one might assume that racism historically pervaded the medical community as it has other American institutions, Byrd and Clayton cite specific examples of medical malpractice based on racial differences. This book should be required reading for all medical and public health and nursing students. Finally, it would behoove all health professionals, and especially those who practice in those remaining large indigent care facilities, to read this book and think seriously about how they care for their patients. CARLA SCHISSEL, I'nD, RN Nurse Practitioner Grady Health System Atlanta, GA 3033s)

Enduring Issues in American Nursing Edited by Ellen D. Baer, Patricia D'Antonio, Sylvia Rinker, and Joan E. Lynaugh (New York: Springer Publishing Co., 2001) Enduring Issues in American Nursing, edited by four distinguished nurse historians, introduces students of nursing history to recurring conflicts in American nursing, their significance over time, and attempts made toward their resolution. Through the reprinting of previously published writings culled from periodicals like the Bulletin of the History of Medicine, the Nursing History Review, and Medical Humanities Review, together with chapters from several notable books, the editors provide the reader with a veritable cornucopia of provocative themes. Divided into sections that explore issues such as nursing's identity, nursing's power and authority, and the nature of nursing knowledge, the book raises challenging questions about the role of nursing itself in the perpetuation of those issues, and reinforces the importance of historical analysis in increasing awareness of why they persist. In her introduction to the first section, Ellen Baer traces several historical exemplars for contemporary situations. Dilemmas underlying gender, status, apprenticeship and autonomy, among others, are identified as germane to nursing's ongoing struggle with "conflict and divisiveness." The section that follows examines the development of the nurse persona from the perspective of the training school at the Johns Hopkins Hospital during the 1890's and early twentieth century vs. the identity crisis encountered by nurses in the practice field. In the former setting, conflicts generated by demands for obedience and discipline created camaraderie among students. Through the process of shared experience,

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students were able to support each other, find acceptance, and complete their education, irrespective of the barriers inherent in the training school model. In the latter arena, however, demands for standardization, efficiency, and technical skill created a dichotomy, whereby the nurse's ability to deliver humane care was compromised by the need to conform to the regulations of the employing institution. Similarly, the current caring vs. technology dilemma challenges the nurse's personhood again and again. The section on power and authority comprises examples of nursing's failed quest for control of its practice and destiny. Selected essays describe the prevailing social climate in which nurses practiced, the lack of support for nursing's empowerment, and the nursing community's reluctance to redefine and reinforce its independent role. The inability or unwillingness of nurses to present a unified position on issues affecting education and practice resulted in missed opportunities for advancement as a profession. Interestingly, nursing's ambivalence survives and is, perhaps, heightened by the complexities of presentday practice. What do nurses really need to know is the question addressed in the section on nursing's knowledge. A review of varying educational philosophies takes the reader back to modern nursing's infancy, when many nursing educators subscribed to the rigid, taskoriented training method. Others stressed the importance of discipline and moral behavior as the sine qua non of nursing. Among the more enlightened educators, compassion and caring emerged as desirable traits of the trained nurse; in later years the need for a sciencebased curriculum was espoused. Amongst those sometime conflicting ideologies, intellectual development was largely ignored. The notion that nursing's intellectual field must expand beyond clinical skill to encompass societal issues that impact patient care is particularly relevant in an environment where the patient is no longer the center of the health care universe. Enduring Issues in American Nursing identifies the roots of contemporary issues and provides compelling assessments that inspire discussion and debate. Nursing needs to confront questions like: • What are the prospects for humanitarianism in an increasingly technological world? • How can the nursing community change a social order that continues to place nursing at the lowest level of an ordained hierarchy? • Can nursing find realistic solutions to the enduring issues described in this volume? In this reviewer's judgment, the book is a "must read:" a feast for the mind. I hope the editors will consider a future work that addresses enduring ethical dilemmas and issues surrounding the disenfranchisement of minorities in nursing.

NETTIE BIRNBACH, EoD, RN, FAAN Professor Emeritus State University of New York at Brooklyn Brooklyn, NY 11203

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Challenging Professions: Historical and Contemporary Perspectives on Women's Professional Work Edited by Elizabeth Smyth, Sandra Acker, Paula Bourne, and Alison Prentice (Toronto, Buffalo, and London: University of Toronto Press, 1999) Challenging Professions is a collection of 13 essays focused on debates about gender and power. The title evokes a "play on words" related both to the challenges women faced in gaining entry to the professions and the ways by which they in turn, challenged traditional understandings of a profession. The introduction contains a succinct and insightful historiography of women's professions, highlighting current debates in the literature. The individual authors are members of a Canadian interdisciplinary network on women and professional education, brought together through the Ontario Institute for Studies in Education of the University of Toronto. Their essays reflect research situated in different provinces and regions, as well as different methodologies, sources, and tools for analysis. They explore issues of ethnicity, class, gender, regionality, sexual orientation, and religion among other variables of difference. Strategies used by women who pioneered entry into the professions at the turn of the twentieth century constitute one unifying theme for the essays. Based on social history research, the collective argument in Challenging Professions suggests that women succeeded not only through their willingness to accept subordinate roles within a discipline, but also through their achievements as super-performers and innovators (p. 11). Traditional criteria (or characteristics) of a profession have been based on the male model of a lifelong, uninterrupted career, with access to higher education. As feminist historians point out, acceptance of this model excludes most of the jobs that women did and still do. Through the essays, it becomes clear that "professions, and what is commonly referred to as 'professionalization' in any given occupation, are historically and culturally contingent" (p. 4). Thus, Challenging Professions shifts traditional thinking about what constituted women's professions to include a broader set of experiences that better reflects women's realities. The first four essays are biographical studies and examine the experiences of women who engaged in Pentecostal evangelism, university teaching in the field of social work, female medical missionary work, and musical composition. The second group of studies are called "group biographies." They deal with comparisons and the diversity among women in response to professional opportunities in their chosen fields: physics, dietetics, forestry, and public health nursing. In the third set of studies, women's experiences are examined as larger "collectivities": women in medicine, accountancy, pharmacy, teaching, as professed women religious, and as academics. In these studies, some historians compare men's professions with women's professions, while others question what difference organizational or corporate size makes related to control over women's work. Meryn Stuart's essay, "War and Peace: Professional Identities and Nurses' Training, 1914-1930," will be of particular interest to the history of nursing audience. Stuart argues that First World War Canadian military nurses "parlayed the heroic, dutiful image and their unique front-line experience into new careers in public-health nursing, and . . .[that] university education became a limited, although ultimately compromised, reality for these

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women" (p. 171). She points out that public health flourished in the postwar social context and stimulated university certificate programs for nurses in public health. These programs, however, failed to result in fully integrated baccalaureate nursing programs. Stuart builds her argument on an analysis of military nurses' expanded roles and shifting professional identity, as a strong preparation for increased independence and the role of health reformer (p. 184-185). She concludes: "Universities were unwilling to give degrees to nurses because of the status of nursing as a menial, if romanticized, occupation. As for nursing leaders, they were ambivalent about degrees because they did not see them as a goal for all nurses" (p. 187). Readers interested in nursing history will also find it useful to pay attention to the essays on women in medicine, pharmacy, dietetics, and social work. Too often, nursing history has been presented in isolation from other professional groups, neglecting important questions that arise within the larger context of women's work experience. Challenging Professions makes a significant contribution to social history, gender history, and nursing history because of its multidisciplinary approach to the concept of "profession." It also provides a valuable basis for comparison of American and Canadian women's experiences, as well as an exploration of women's difference based on regionality within Canadian contexts. CYNTHIA TOMAN, RN, PHD CANDIDATE School of Nursing, Faculty of Health Sciences University of Ottawa 451 Smyth Road Ottawa, Ontario, Canada K1J 7N4

NEW DISSERTATIONS

Doctoral dissertations are the hidden treasures of current scholarship. They represent the latest academic investigations in a myriad of disciplines, including the history of nursing and women's health issues. Regrettably, the vast majority of these dissertations will spend their existence on a library shelf, since less than half will ever be published as monographs or even distilled into journal articles. With the invaluable help of Professor Jonathon Erlen of the University of Pittsburgh, Nursing History Review hopes to improve our readers' access to some of these currently unknown scholarly works. Almost all these titles are available directly from Bell & Howell in Ann Arbor, MI, who have taken over as keeper of doctoral dissertations from University Microfilms, Inc. For the few dissertations that cannot be ordered directly from Ann Arbor, we recommend contacting the degree-conferring institution. We offer this list of relevant titles with identifying information and a brief summary of the abstract.

Author: Patricia Ann Connor-Ballard Title: Angels of the Mercy Fleet: Nursing the 111 and Wounded Aboard the United States Navy Hospital Ships in the Pacific During World War II School: University of Virginia Adviser: Barbara Brodie Pub No: 9975400

ISBN: 0-599-81056-4 Date: 2000 Pages: 355 Abstract: The purpose of this study was to examine the experiences of nurses aboard navy hospital ships in the Pacific during World War II. By reconstructing and analyzing their experiences, factors promoting significant postwar changes in American nursing were identified. Findings of this study showed the ability of nurses to function effectively under stressful and adverse conditions. Nurses entered the military in large numbers, and the reality of war mandated brief military orientation. Clinical skills and knowledge came from continuous exposure to the ill and wounded. Nurses developed collaborative relationships with chief nurses and physicians aboard ship. The close rapport with physicians led to joint learning opportunities, mutual discussions about patients, and a team approach to clinical management. Nurses became more active in assessing and intervening in patient care and learned to practice and manage the work of others at a level beyond the traditional realm of nursing.

Nursing History Review 10 (2002): 211-216. A publication of the American Association for the History of Nursing. Copyright © 2002 Springer Publishing Company.

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Author: Susan Elaine Elliott Title: Missionary Nurse Dorothy Davis Cook, 1940-1972: "Mother of Swazi Nurses" School: University of San Diego Adviser: Patricia Roth Pub No: AAT 9967338 Date: 2000 Pages: 243 Abstract: The purpose of this study was to investigate the ministry and service of Sister Tutor Dorothy Davis Cook, Church of the Nazarene missionary nurse in Swaziland, 1940 to 1972. Mrs Cook obtained her basic nursing education and training in the United States. Following her arrival in Swaziland, she earned her midwifery certification and Sister Tutor diploma. She upgraded nursing education and established the first state registered nurse program in Swaziland. She wrote four nursing texts which became the gold standard for similar nursing programs in surrounding countries. She held leadership roles in the High Commission Territories' Nursing Council, the Swaziland Nursing Council, and Swaziland Nursing Association, and co-authored the 1965 Swaziland Nurse and Midwifery Act. For the majority of her service years, Mrs. Cook lived with the Swazi nurses. She educated several hundred Swazi Christian nurses who continue to influence the health, socioeconomic status, and spiritual well-being of Swaziland today.

Author: Natalie Marie Fousekis Title: Fighting For Our Children: Women's Activism and the Battle for Child Care in California, 1940-1965 School: The University of North Carolina at Chapel Hill Adviser: Peter G. Filene, Jacquelyn D. Hall Pub No: AAT 9968592

ISBN: 0-599-73422-1 Date: 2000 Pages: 302 Abstract: When the federal government announced its plans to close child care centers at the end of World War II, women in California protested. Their activism helped preserve public child care services in California as such services vanished elsewhere. This study looks at the informal networks, grassroots organizing, and personal stories of mothers and educators. As they set out to convince the state of their child care needs, these women were drawn into politics and learned to assert their authority in the public realm. This study traces these activists during a key period of transition—from the possibilities created during and immediately after the war through the repressive political environment of the cold war to the social protests of the sixties. This cross-class coalition of reformers advocated for child care in a political climate in which demanding these services as a woman's right would have undermined their cause. They relied on more traditional and family value arguments. This study adds to recent scholarship that has complicated our understanding of women in the postwar United States.

New Dissertations

213

Author: Juanita M. Joy Title: The History of the Associate Degree Nursing Program at Portland Community College (Oregon) School: Oregon State University Adviser: Larry Roper

Pub No: 9973883 ISBN: 0-599-79282-5 Date: 2000 Pages: 137 Abstract: This study describes the development of the Associate Degree nursing program at Portland Community College by women faculty members in a male-dominated organization. Eleven participants gave a very rich description of this nursing program. Six themes were identified: the use of power, governance, informal networks, work ethic, psychological climate, and external influences.

Author: Thomas Jude Poundstone Title: Court-Ordered Cesarean Sections: A Case Study in Medical Ethics and Moral Theology School: University of Notre Dame Adviser: Maura A Ryan Pub No: ATT 9969797 ISBN: 0-599-74718-8 Date: 1999 Pages: 447 Abstract: This dissertation examines when, if ever, a pregnant woman may be ordered by a court of law to undergo a cesarean section. The uniqueness of the maternal-fetal relationship is that it involves two patients with access to one through the other. In no other situation are physicians or courts faced with one patient literally inside the body of another. Without the pregnant women's consent, there may be no way to protect the fetus without violating the pregnant woman's asserted rights. The first chapter examines the history and current practice of cesarean sections. The second chapter reviews the known cases in which a judicial court order has been sought for a cesarean. The third chapter examines the broader legal context in which court-ordered cesareans fit. The fourth chapter focuses on the contributions of Roman Catholic moral theology to the discussion. The fifth chapter examines the critiques of court-ordered cesareans in recent medical and legal journals. The final chapter asserts that, though the case against court-ordered cesareans is strong, it is not decisive. It then proposes and applies a standard to see what kind of paradigm might be established.

214

New Dissertations

Author: Abigail Riggs Spangler Title: The Politics of Disease: Social Movement Responses to AIDS, Breast Cancer, and Prostate Cancer in the United States School: Columbia University Adviser: Lisa Anderson, Robert Shapiro ISBN: 0-599-75252-1 Date: 2000 Pages: 527 Abstract: In the late 1980s and 1990s three social movements emerged and focused on disease. They pressed the government and medical establishment to significantly increase research funding to combat these diseases and to increase societal awareness about them. These movements greatly influenced the health policy process in the United States. There were four main reasons why these disease-oriented social movements emerged: the natures of the diseases, the degree of social stigmatization surrounding the diseases, the governmental and medical organizational response to each disease, and the particular communities affected. This dissertation is based on more than 70 interviews with disease activists and public policy makers and is the first systematic comparative political analysis of the healthrelated social movements of the era.

Author: Tricia Ann Starks Title: The Body Soviet: Health, Hygiene, and the Path to a New Life in the 1920s School: The Ohio State University Adviser: David Hoffman

Pub No: 9971643 ISBN: 0-599-76728-6 Date: 2000 Pages: 269 Abstract: In 1917, the Russian Revolution hoped to create an entirely new society. Central to its Utopian dreams was a reformulation of the daily life of the Soviet citizen. One aspect of these programs was hygiene education which took many forms. Pamphlets and posters trumpeted a new, hygienic way of life, while lectures in workers' clubs and factory campaigns hailed the positive effects of fresh air, sunshine, and exercise. More than just a Utopian impulse, the creation of a healthier population coincided with the need of a modern state to be strong militarily and industrially. Additionally, the study of Soviet health programs reveals many commonalities with public health programs in the United States and Britain and other European countries.

New Dissertations

215

Author: Paula Grace Dunn Tropello Title: Origins of the Nurse Practitioner Movement, An Oral History School: Rutgers—The State University of New Jersey—New Brunswick and UMDNJ Adviser: James J. Chambliss Pub No: ATT 9970979 ISBN: 0-599-76032-X Date: 2000 Pages: 150 Abstract: The purpose of this study was to document establishment of the nurse practitioner model within nursing to create a foundation for better understanding of advanced practice nursing roles. It preserves oral histories of instrumental figures involved. Eight original participants in the movement were interviewed; the interviews were taped and transcribed. Supportive papers, correspondence and files, along with secondary sources, enhance the oral histories. Author: Lynn Y. Unruh Title: The Impact of Hospital Staffing on the Quality of Patient Care School: University of Notre Dame Adviser: Charles Craypo Pub No: ATT 9969789 ISBN: 0-599-74^02-1 Date: 2000 Pages: 224 Abstract: This study uses data from the universe of general, acute-care Pennsylvania hospitals from 1991 to 1997 to examine the changes in nursing staff and the impact of nursing staff/patient load and skill mix on the rates of adverse events among all patients. I find that licensed nurse/adjusted patient days of care and licensed nurse/nurse ratios fell from 1991 to 1997, and that lower ratios are associated with greater rates of cardiac arrest, complications, pressure sores, pneumonia, post-treatment infections, and urinary track infections. This relationship is thought to be due to the overintensity of nursing care, inadequate nursing resources, inappropriate task divisions, and staff exhaustion and demoralization. Author: Barbra Mann Wall Title: Unlikely Entrepreneurs: Nuns, Nursing, and Hospital Development in the West and Midwest, 1865-1915 School: University of Notre Dame Adviser: Christopher Hamlin Pub No: AAT 9967299 ISBN: 0-599-71912-5 Date: 2000 Pages: 531 Abstract: This is a comparative history of the nursing activities of three orders of Catholic nuns from 1865 to 1915, concentrating on their establishment and administration of hospitals. All were primarily Irish and Irish-Americans, with each order focusing on a

216

New Dissertations

different region of the West or Midwest. It examines the relationship between the sisters' religious world views and their practices, and how they shaped health care in the United States. To understand what the nuns were doing, the notion of hospitals as inevitably medical institutions must be discarded. Catholic sisters' hospitals were both medical and religious institutions. They oversaw budgets, obtained financial backing for construction, raised money, competed for clients, and won approval of the medical community. Physicians held more visible authority, necessitating that sisters develop positive relations with them. But nuns, in their roles as hospital owners and administrators, actually held greater institutional power than doctors. Working relationships developed into an uneasy, yet mutually beneficial partnership. Sisters' hospitals became the pattern for the modern hospital of private, fee-paying patients. Catholic hospitals were both businesses and charities as nuns created hospitals to further their nursing missions. Author: Jean Catherine Whelan Title: Too Many, Too Few: The Supply, Demand, and Distribution of Private Duty Nurses, 1910-1965 School: University of Pennsylvania Adviser: Karen Buhler-Wilketson Pub No: AAT 9965594 Date: 2000 Pages: 452 Abstract: This study focuses on the distribution of nurses through the professional nurse registry system. Professional nurse registries, operated by, or in close affiliation with professional nurse associations, served to connect patients with nurses and nurses with patients. Private duty nursing was the occupational sector in which most early twentieth century nurses worked. It was private duty nursing that established patterns determining nurse compensation and other conditions of work. This study examines the problems nurses encountered as they attempted to secure a firm place in the labor market. Primary source data from New York City and Chicago reveals some of the solutions used by nurses to seize control of the conditions of their work. Editors 'Note: We want to express our gratitude to our history colleague, Professor Erlen, for suggesting we list these dissertations. Moreover, he graciously shares the information on new work as it becomes available. This is a generous service to us, to our readers and to the young scholars whose work is recognized. Thank you, Jon.

INDEX

Brazil, 33-36, 39-47 Child health nursing, 25, 34, 38, 41, 113, 116, 127, 130-132, 135137, 141-149, 199 Concentration camps, 51, 69, 70—71, 73-78, 204-205 Fenwick, Bedford, 21, 26 Heart Mountain Hospital, 52, 55-57 History of nursing, 37, 175, 179, 180, 194, 196,209,211 Holocaust, 69, 71-78 Home care, 107n81 Hourly nursing, 83-100 International Council of Nurses, 6, 11,21,22,24,26 Japanese American student nurses, 49, 52-64 Japanese American internment, 49,

50-52,55,57-58,61,63-64 National Council of Nurses of Great Britain and Northern Ireland, 24 National Japanese American Student Relocation Council, 58—60 Nisei nursing students, 49, 52—55, 58, 62 Nurse practitioners (NPs), 159-170

Nurse registry, 86-87, 94, 216 Nurse-physician, 171n2 Preventorium, 127-128, 130-132, 141-148 Private-duty nursing, 84-86, 88, 133, 148 Professional nursing organizations, 21, 28,91 Professional practice, 177 Professionalism, 64, 209-210 Public health, 33-41, 43, 55, 90-91, 95, 116, 127-128, 130, 132-140, 141-143, 146-148, 199, 200202, 207, 209-210, 214 Relationships, 14, 57, 160, 161, 163, 166, 168, 191, 194,211,216 Royal College of Nursing of the United Kingdom, 21, 25, 27-31 Schools, 6, 10, 22, 23, 35-36, 38, 4041,43,49,50,58,60-63,84, 109, 114, 119, 122, 127, 134135, 147, 163, 180, 194, 200 Supply and demand, 103n24 Trained nurses, 109, 112-118, 120, 122, 132-133 Tuberculosis nursing, 134—141 Workforce, 88, 99, 185

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