History of Nursing Education

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History of NursingEducation
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• The history of nursing education is inextricably
  shaped by
• Class
• Gender
• Many of its historic and contemporary challenges
  are a result of this reality

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• Emergence of modern nursing tied to emergence of
  the modern hospital
• Prior to early 19th century
• Hospitals charitable institutions for the poor,
  not providers of health care
• Attendants to the sick were other paupers

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• Most attendants were elderly former patients who
  stayed on
• Transition to continuous staffing with fully
  trained nurses took over 100 years
• Reform of nursing began prior to Nightingale

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Social/Medical Context

• 1. Medical social views about the education of
  women
• Womens response to this view

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• 2. Oxford movement
• Movement to reform the Church of England begun at
  Oxford University in 1833
• Retrieved many Catholic traditions
• Brotherhoods/sisterhoods
• Monasticism

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• 3. Medical education reform
• Kings College Hospital reform led by Robert
  Bentley Todd
• Students lived in residence
• Religious instruction
• More contact with teachers

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• 4. Middle class womens involvement in charitable
  work
• Only option open to respectable women

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Pre-Nightingale Reforms

• Initial early 19th century reforms instituted by
  physicians working with religious groups
  (Helmstadter)
• Most famous example is the Sisters of St. Johns
  the Evangelist, or St. Johns House

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• St. Johns House founded in 1847 by Todd others
• Women lived at St. Johns House
• Sent to hospital for training

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• Objectives
• Provide working class women with training to
  enable them to elevate their social position
• Provide upper class women with an opportunity to
  work, without pay, to train these nurses

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• All probationers had 1 year of training in
  technical nursing
• Classes from nursing sisters
• Lectures from physicians
• Sisters (never working class) had 2 years of
  intensive training in nursing hospital
  management

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• St. Johns House sent trained nurses out to work
  in hospitals the community
• Took over nursing service of Kings College
  Hospital in 1856

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• Hospital nursing was a parallel system for much
  of 19th century
• Trained nurses during day (more as time went on)
• Untrained attendants night watchers at night
• Eventually night watchers replaced by student
  nurses
• Mid-20th century before all shifts comprised of
  trained nurses

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• Nightingale well aware of St. Johns House
  nursing reforms
• St. Johns nurses accompanied her to the Crimea

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The Nightingale Reforms

• Impact of Florence Nightingale (1820-1910)
• Generally portrayed as founder of modern nursing
• Re-fashioned it as a respectable occupation for
  young middle class women

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• Nightingales work in the Crimea made her a
  celebrity
• Establishment of Nightingale Fund to establish
  systematic nurse training in Britain
• Originally conceived as a type of college

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• Changed to the advantage of hospitals
• First training school established at St. Thomas
  Hospital in 1860

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• From the onset, both gender class shaped
  nursing education
• Class differences in training
• Admitted 2 types of women
• Respectable working class women
• Highly educated middle class women

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• Middle class women called lady probationers
• paid for their training
• Wore different uniforms
• Shorter training period
• Different duties
• Lower class probationers received training in
  return for room board

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• Differences in opportunities persisted after
  graduation
• Ladies quickly promoted to positions of authority
• Commended higher salaries once it become
  acceptable for them to be paid

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• Working class students posed problems for the
  training schools
• Lacked appropriate social graces
• Elite nursing leaders confused manners with
  education
• Much of the training for working class
  probationers an exercise in instilling
  appropriate behaviour

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• Nightingale schools proliferated in Britain, UK,
  Canada
• Tradition of the lady probationer did not cross
  the Atlantic
• First US schools opened 1873
• By 1923, 6,830 hospitals in US 25 had training
  schools attached

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• First Canadian school at Macks Hospital, St.
  Catherine ON, 1874
• In 25 years, 24 more schools
• By 1909, 70 Canadian nursing schools

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• Students in these programs drawn from
• Lower middle class/agricultural
• Working class
• Few middle class students
• Respectable middle class women did not work

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• Nursing educators focussed on shaping character
  behaviour rather than developing the students
  knowledge
• Routine drilling in conduct the hallmark of
  nursing education
• Task oriented
• Heavy moral overlay

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• Students lives were heavily controlled
• Reinforced by 2 aspects of hospital training
• Living in residence
• Uniforms

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Contested Sites Where Should Nurses be Educated?

• Control of education was a contest between
• Hospitals
• Physicians
• Elite nursing leaders

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• Hospital training schools were a clear advantage
  for the modern hospital physicians
• Less clear that they were an advantage for nurses

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• Apprenticeship model
• This in itself was not unusual
• The problem was whose needs came first
• The learner? Or
• The hospital? Or
• The physicians?

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• Students education was fitted around service
  duties
• Clinical education controlled by physicians
• Behavioural/deportment training done by nursing
  instructors

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• Elite leaders wanted nursing education out of the
  hospital
• Would then be free from
• Service obligations
• Interference from physicians
• Preferred location was the university

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• The downside?
• Many women could not afford university
• Service for education, room, board was their
  only option
• Many women were not eligible to apply for
  university
• Many universities would not admit women

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• Teachers College, Columbia University offered 1st
  program for nurses
• 1898
• Graduate studies
• Undergraduate programs at universities
  established in US in early 20th century
• A bit later in Canada

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• Important Canadian developments
• 1. Red Cross Funding
• Used to establish post-diploma studies in public
  health after First World War
• Offered at 5 universities
• Provided a base to introduce baccalaureate
  programs into these universities

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• 2. 1st baccalaureate program at UBC
• Established 1919
• Sandwich program
• One year of university
• Then regular nursing training at St. Pauls
  Hospital
• Then back to university for studies in public
  health, teaching administration

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• Resistance to the improvement of the quality of
  nursing education continued
• 3. Weir Report (1930) Survey of Nursing Education
  in Canada
• Joint project of the CNA/CMA
• Report was highly critical of nursing education

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• Recommendations
• Removal of control of nursing education from
  hospitals
• Closure of small nursing schools
• Improved entrance standards
• Improved working conditions for students

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• Very little done for the next 30 years
• Closure of smaller schools accelerated in the
  1940s
• Larger schools didnt translate into better
  education
• CNA survey in 1975 found that only 16 of nursing
  schools met national standards

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• Why the inertia?
• Hospital based programs provided a cheap
  education for women
• Parents believed that their daughters were safer
  in the controlled environment of the nursing
  school

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• Communities had significant emotional attachment
  to their teaching hospitals resisted any
  criticism of them
• Politicians hospitals were getting trained
  nurses at a bargain price

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• Physicians and others continued to prefer the
  obedient trained nurse to the alternative
  espoused by elite nursing leaders
• Social views about the nature of education for
  women had not changed significantly

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• Continued pressure from professional associations
  re-shaped the education offered by hospital
  schools
• Less service
• More qualified nursing instructors
• Introduction of new learning material
• Introduction of standardized external examinations

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• These innovations cost money
• Eventually, having a hospital school of nursing
  became too expensive for most hospitals

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• Diploma programs gradually moved from hospitals
  to community colleges
• Diploma education remained the norm for much of
  the 20th century

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• Meanwhile, the battle for university education
  for nurses went on . . . and thats another story

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• Yet another story, which is not unique to
  nursing, is the tension between theoretical
  practical education
• Has deeply divided the profession along
  educational lines
• Diploma vs. baccalaureate

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• I think that what both sides have failed to
  notice is the extent to which social values
  (gender, class) and professional agendas outside
  of nursing have contributed to this division