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NURSING AND NURSING EDUCATION IN THE UNITED STATES
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THE MACMILLAN COMPANY
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NURSING AND
NURSING EDUCATION
IN THE UNITED STATES
Report of the ( Committee for the Study of Nursing Education
C.-E. A. WINSLOW, Dr.P.H., Chairman
MARY BEARD, R.N. MRS. JOHN LOWMAN
H. M. BIGGS, M.D. M. ADELAIDE NUTTING, R.N.
S. LILLIAN CLAYTON, R.N. C. G. PARNALL, M.D.
LEWIS A. CONNER, M.D. THOMAS W. SALMON, M.D.
DAVID L. EDSALL, M.D. WINFORD H. SMITH, M.D.
LIVINGSTON FARRAND, M.D. E. G. STILLMAN, M.D.
ANNIE W. GOODRICH, R.N. LILLIAN D. WALD, R.N.
L. EMMETT HOLT, M.D. W. H. WELCH, M.D.
JULIA C. LATHROP HELEN WOOD, R.N.
JOSEPHINE GOLDMARK, Secretary
and
Report of a Survey
by
JOSEPHINE GOLDMARK, Secretary
THE MACMILLAN COMPANY 1923
All rights reserved
FEINTED IN THE UNITED STATES OF AMERICA
MEDICAL CENTER
COPYRIGHT, 1923,
By THE MACMILLAN COMPANY.
Set up and printed. Published February, 1923.
Press of
J. J. Little & Ives Company
New York, U. S. A.
MEMBERS OF THE COMMITTEE C.-E. A. Winslow, Dr. P. H., Chairman
PROFESSOR OF PUBLIC HEALTH, YALE SCHOOL OF MEDICINE, NEW HAVEN, CONN.
Mary Beard, R.N.
DIRECTOR, INSTRUCTIVE DISTRICT NURSING ASSOCIATION, BOSTON, MASS.
Hermann M. Biggs, M.D.
COMMISSIONER OF HEALTH, NEW YORK STATE, ALBANY, N. Y.
Lillian S. Clayton, R.N.
DIRECTRESS OF NURSES, TRAINING SCHOOL FOR NURSES, PHILADELPHIA GENERAL HOSPITAL, PHILADELPHIA, PA.
Lewis A. Conner, M.D.
ATTENDING PHYSICIAN, NEW YORK HOSPITAL, NEW YORK CITY J PROFESSOR OF MEDICINE, CORNELL MEDICAL COLLEGE, ITHACA, N. Y.
David L. Edsall, M.D.
DEAN, HARVARD MEDICAL SCHOOL, BOSTON, MASS.
Livingston Farrand, M.D.
PRESIDENT, CORNELL UNIVERSITY; FORMER CHAIRMAN, CENTRAL COMMIT- TEE, AMERICAN RED CROSS
Annie W. Goodrich, R.N.
DIRECTOR OF NURSES, VISITING NURSE SERVICE, HENRY STREET SETTLE- MENT, NEW YORK CITY
L. Emmett Holt, M.D.
PRESIDENT, CHILD HEALTH ORGANIZATION OF AMERICA J PHYSICIAN-IN- CHIEF, BABIES' HOSPITAL, NEW YORK CITY.
Julia C. Lathrop
FORMER CHIEF, CHILDREN'S BUREAU, WASHINGTON, D.C.
Isabel W. Lowman
MEMBER, CENTRAL COMMITTEE FOR PUBLIC HEALTH NURSING, CLEVELAND, OHIO
M. Adelaide Nutting, R.N.
PROFESSOR OF NURSING AND HEALTH, TEACHERS COLLEGE, COLUMBIA UNI- VERSITY, NEW YORK CITY
Christopher G. Parnall, M.D.
DIRECTOR, UNIVERSITY HOSPITAL, UNIVERSITY OF MICHIGAN, ANN ARBOR, MICH.
Thomas W. Salmon, M.D.
FORMER MEDICAL DIRECTOR, NATIONAL COMMITTEE FOR MENTAL HYGIENE; PROFESSOR OF PSYCHIATRY, COLLEGE OF PHYSICIANS AND SURGEONS, COLUMBIA UNIVERSITY, NEW YORK CITY.
Winford H. Smith, M.D.
DIRECTOR, JOHNS HOPKINS HOSPITAL, BALTIMORE, MD.
E. G. Stillman, M.D.
PRESIDENT, HOSPITAL SOCIAL SERVICE ASSOCIATION OF NEW YORK CITY, NEW YORK CITY
Lillian D. Wald, R.N.
HEAD RESIDENT, HENRY STREET SETTLEMENT, NEW YORK CITY
William H. Welch, M.D.
DIRECTOR, SCHOOL OF HYGIENE AND PUBLIC HEALTH, JOHNS HOPKINS UNIVERSITY, BALTIMORE, MD.
Helen Wood, R.N.
DIRECTOR, TRAINING SCHOOL FOR NURSES, WASHINGTON UNIVERSITY, ST. LOUIS, MO.
21
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CONTENTS
PAGE
Introductory Note 1
Report of the Committee 7
Report of the Secretary 33
PART A. FUNCTIONS OF THE NURSE I. PUBLIC HEALTH NURSING
1. The New Trend in Public Health Work 39
Evolution of the Public Health Nurse 41
2. Some Achievements in Public Health Nursing 43
School Nursing 43
The Safeguarding of Motherhood and Infancy 46
Prenatal Nursing 48
Reduction of Maternal Mortality 49
Reduction of Infant Mortality 50
The Crux of Successful Public Health Nursing: Work in the
Home 50
Experience of the Metropolitan Life Insurance Company . . 52
3. Scope and Method of the Inquiry: An Intensive Study .... 53
Some Determining Factors in Public Health Nursing .... 53
Representative Nature of Organizations Studied 54
Urban and Rural Agencies Included 54
Geographical Distribution 55
Public and Private Agencies Included 55
Kinds of Nursing Service Included 55
Focus of the Study: The Individual Nurse 56
4. The Field of Public Health Nursing: Some Typical Days ... 57
An Example of Rural Nursing 57
Tuberculosis Nursing 57
A Day's Visits 58
Outside Activities: The County Fair 63
The Establishment of Clinics 63
The Expansion of a Nursing Specialty 64
Nursing in a Small Town 65
A Visiting Nurse in a Private Agency in a Large City ... 66
A Day's Visits 67
Scope of the Day's Work 72
Instruction in Bedside Care 72
Calling in the Physician 72
The Personality of the Nurse 73
An Instructive Nurse under a City Department 73
In phe Welfare Station 74
Home Visits 75
vii
LIBRARY
viii CONTENTS
PAGE
5. Organization and Administration oj Public Health Nursing
Agencies 76
Types of Communities Served: City and Country .... 77
Auspices of Agencies: Public and Private 78
Advantages of Public Control 79
Disadvantages of Public Control 79
Some Safeguards of Public Control 80
Advantages of Private Control 81
Kinds of Service Rendered by 37 Agencies 82
Number of Visits per Patient 89
Number of Visits per Day 89
Increase in the Number of Pay Patients 90
Cost per Visit 91
Differentiation between Public and Private Agencies : Preventive
and Curative Work 92
The Personnel of Public Health Nursing Agencies 93
The Director 94
Supervisors 94
The Staff Nurses 95
Students 96
Persons Other than Nurses 96
Clerical Workers 96
Trained Attendants 97
Size of Staff 98
Requirements for Staff Candidates 99
Hospital Training 99
Special Training in Public Health Nursing 100
Working Conditions in Public Health Nursing Agencies . . . 101
Salaries of Staff Nurses 101
Salaries of Supervisors 102
Vacations with Pay 103
Working Hours 103
Overtime 104
Sunday Work 104
Supervision of the Work 104
Number of Nurses per Supervisor 105
Accompanying Staff Nurses in Home Visiting 106
Efficiency Records 106
Written Instructions 107
Reporting at Headquarters 107
Meetings of the Staff 108
Case Conferences 108
6. Successes and Failures 108
A Rough Classification of 147 Nurses 109
Varying Degrees of Success and Failure 109
The Handicap of Poor Organization 110
Teaching Ability: Examples of Failure Ill
A Parody of Public Health Nursing Ill
No Knowledge of Preventive Measures 114
No Knowledge of Teaching Methods 115
Ignorance of Emergency Measures 116
Examples of Success 117
Clear Cut Questions and Explanations 117
Teaching in Communicable Diseases 120
Relation to Relatives and Friends 121
The Education of an Italian Husband 122
CONTENTS ix
PAGE
Other Examples of Assistance 123
Failure to Utilize the Assistance of Others 124
The Barriers of Language and Racial Customs 126
Relation to Physicians 127
Relation to Social Work and Social Agencies 130
Examples of Failure 131
Examples of Success 132
Failure on the Part of Social Workers 133
The Relative Merits of Instructive Nursing and Bedside Nurs- ing Combined with Instruction 134
Weaknesses in Generalized Nursing 135
Weaknesses in Instructive Nursing Alone 136
Capital Importance of the Contact 136
The Vantage Ground of Generalized Nursing 137
The Handicaps of Poverty 138
Instructive and Generalized Work under Official Agencies . . 139 Some Contrasting Results of Generalized and Specialized
Nursing 139
Some Disadvantages of Specialization 141
Demonstration of Special Needs by Specialist Organizations 143 Tendency towards Greater Inclusiveness in Specialized
Nursing 143
The Unit of Population Served 145
The Future Outlook 145
Educational Implications 146
Need of Clinical Training 147
Need of Special Public Health Training 148
Length of Training 148
7. Industrial Nursing 149
Scope of a Brief Survey 149
Types of Work 150
First-Aid Work and Its Development 152
Excessive Medication 153
Work with Employment Departments 153
Sanitation, Safety and Welfare Work 154
Lack of Records 155
Home Visiting 156
Following Up Absentees 157
Education in Hygienic Habits 157
Training for Industrial Nursing 158
Use of Lay Workers 159
II. THE NURSE IN PRIVATE DUTY
Her Function 161
Differentiation of Care 162
Protection of the Public through Nurse Registration Laws .... 163
The Need of a Subsidiary Group 164
Results of a Brief Survey 165
Unnecessary Employment 166
Kinds of Sickness Cared For 166
Waste of Nurses in Various Types of Sickness 166
Earnings of the Private Duty Nurse 168
Seasonal Unemployment 168
Living Expenses 169
Opinions of 52 Physicians in Private Practice 170
x CONTENTS
PAGE
The Number of Trained and Untrained Nurses in the United States . 171
The Standardization of a Subsidiary Group 172
Lessons in Home Nursing Care 173
Short Courses for Trained Attendance 173
Tendency to Disperse after Graduation 175
Primary Need of Licensing 177
The Place of Subsidiary Service in a Program of Nursing Education . 178
Education of the Public 180
The Outlook for Persons of Moderate Means 181
Community Health Programs 182
Use of Hospitals for Acute Disease 183
III. THE NURSE IN INSTITUTIONS
1. The Graduate Nursing Staff 184
2. Instructors and Administrators 184
PART B. TRAINING OF THE NURSE IV. THE HOSPITAL SCHOOL OF NURSING
1. Present Status of the Training School 187
Scope and Method of the Investigation 187
Basis of the Investigation: Hospital Training Schools Covered 189
Inclusion of the Best Schools in the Group Studied .... 190
Florence Nightingale and Nursing Education 192
The Dual Function of the Training School 194
The Conflict between Education and Care of the Sick: Records
of Actual Experience 196
Causes of Irregular Assignments 201
The Dilemma of the Training School Superintendent .... 201
The Relation of Superintendent and Students 202
The Superintendent of the Training School and Hospital Organ- ization 205
The Training School Committee 206
The Cost of the Training School 208
Financial Relation with the Hospital 208
The Balance between Cost and Services Rendered . . . 210
The Objectives of Training 212
2. Clinical Facilities in Hospitals of Different Type and Size . . . 213
Clinical Facilities Offered in 23 Hospitals Studied 214
Type and Size of Hospitals Studied 215
Municipal Hospitals 215
Private General Hospitals 215
Special Hospitals 217
University Hospitals 218
Conclusions 218
3. Entrance Requirements 219
Education 219
Age 221
Tuition Fees and Allowances 222
Previous Paid Occupations of Students 222
Number of Groups Entering Yearly 223
Credits for Advanced Standing 224
CONTENTS xi
PAGE
Credits for College Courses or College Degrees 225
Credits for Previous Experience 226
4. The Period of Preliminary Instruction 226
Disadvantages of the Apprenticeship System 226
The Preliminary Term 227
The Period of Probation 228
A Program for the Preliminary Term 228
5. The Teaching of Nursing Procedures 230
Their Central Importance 230
System of Teaching 231
Instructors 232
Assistance in the Use of Practice Material 233
Provision of a Demonstration Room 235
Equipment of the Demonstration Room 236
Adequacy of Supplies for Demonstration and Practice . . 237
Teaching Methods in the Classroom 238
Demonstration 239
Supervised Practice in the Classroom 240
Application of Classroom Instruction on the Wards . . . 242
Need of Prompt Application 242
Supervision 244
Examples of Successful Supervision 244
Examples of Inadequate Supervision 246
Lack of Co-operation 247
Inadequate Staffing 247
Other Methods for Securing Standard Technique .... 248
Use of Nursing Practice Card 248
Time Allowed to the Teaching of the Theory and Practice of
Nursing in 22 Schools 249
6. The Case for the Basic Sciences 249
General Benefits from Science Training 251
Need of Specific Sciences in Nursing Education 251
Why the Nurse Needs Anatomy and Physiology .... 252
Wlfy the Nurse Needs Bacteriology 253
Why the Nurse Needs Chemistry 254
Why Scientific Teaching Should Precede Instruction in Disease 256
7. Teaching of the Basic Sciences 256
General Characteristics of the Science Courses 257
Lack of Well-Equipped Teachers 257
Lack of Laboratory Training 257
Inadequate Time 258
Anatomy and Physiology 258
Hours and Year When Given 258
Teaching Staff 259
Methods of Teaching 260
Use of Demonstration in Class 260
Obstacles to Good Teaching 260
Examples of Unsatisfactory Teaching 261
Examples of Resourceful Teaching 262
Lack of Demonstration 264
Equipment for Demonstration 264
The Essential Need of Laboratory Training and Equipment 265
Laboratory Facilities in the Schools Studied 266
xii CONTENTS
PAGE
Use of Outside Facilities 268
Bacteriology 269
Hours and Year When Given 269
Instructors 270
Methods of Teaching 270
Facilities for Laboratory Work 271
Equipment 271
Examples of Good Laboratoiy Teaching 272
Demonstration by the Instructor Only 273
Chemistry 275
Hours and Year When Given 275
Instructors 275
Methods of Instruction 276
Cram Courses 278
Courses of Limited Scope 279
Chemistry as an Entrance Subject 280
Dietetics . 281
Hours and Year When Given 283
Instructors 284
Methods of Instruction 285
The Need of Laboratory Training 285
Tendency to Over-Emphasize Cookery 286
Laboratory Equipment 287
Time Allowed to the Teaching of the Preliminary Sciences in
22 Schools 288
Laboratory Assistance in Science Teaching 289
Upkeep and Extension of Equipment 290
Science Requirements for Entrance and Credits for Science . . 291
Teaching of Preliminary Subjects outside the Training School . 293
Use of the High School and the Vocational School .... 293
Use of the Junior College 294
Experiments in Central Teaching 295
8. Practical Training 297
Ward Training 297
The Gradation of Training 298
Examples of Graded Training 298
Use of Seniors as Head Nurses 301
Omissions in General Care 301
Examples of Ungraded Training .' 303
Staleness in the Third Year 304
Disadvantages of Specialization 305
The Combination of Graded and Ungraded Training . . . 306
Instruction and Supervision on the Wards 307
Examples of Success 307
Examples of Failure 310
Examples of Premature Responsibility 312
Lack of Good Management 314
Methods of Recording and Checking Ward Work .... 314
Use of Case Records 316
Private Service 317
Diet Kitchen 318
Diet in Disease 318
Training in Infant Feeding 319
Time Allotted to Diet Kitchen Service 319
Instruction and Supervision 320
Diet Kitchen Equipment 320
CONTENTS xiii
PAGE
Conditions of Valuable Training 320
Classroom Instruction in Diet in Disease 321
Need of Correlation with Classroom Instruction .... 322
Necessity for Practical Experience with Disease .... 322
Need of Correlation with Ward Cases 323
Some Instances of Effective Correlation with Ward Cases . 323
Examples of Valuable Training in the Diet Kitchen . . . 325
Provision of Kitchen Help 326
Instances of Conspicuous Failure 326
Compromises between Education and Service 328
Percentage of Students Admitted to Diet Kitchen Service . 328
Conclusions 329
Dispensaiy 330
Greater Number and Range of Cases 330
Preventing Sickness through the Dispensary 331
Social Problems in the Dispensary 331
Evolution of the Dispensary 332
Dispensaries Studied 333
Length of Assignments 333
Failure to Utilize the Dispensary as a Teaching Field . . 334
Correlation between Clinics and Ward Experience . . . 334
Correlation with Class Teaching 335
Absence of Planned Dispensaiy Instruction 336
Assignment to Clinics of No Educational Value . . . 338
Failure to Use Case Records 340
Time Wasted in Non-Educational Duties 342
Delegation of Non-Educational Work to Permanent Staff 344
Needed Changes in Dispensary Training 345
Length and Content of Student Assignments 345
Need of Dispensary Instructors 346
Conclusions 346
Time Wasted in Non-Nursing Duties 347
Non-Nursing Duties on General Wards 349
Duties on Special Services 350
Miscellaneous Duties 351
Duties of Daily Care 352
Waste Time in Individual Assignments 352
Examples from Another Hospital 355
Assignment of Seniors to Non-Nursing Duties 355
Head Nurseships 356
Total Time Wasted at a Representative Hospital .... 356
Total Time Wasted at Other Hospitals 359
The Solution: A Permanent Staff 359
Employment of Graduate Nurses 360
Employment of Other Paid Workers 360
Status of the Movement: Municipal Hospitals .... 361
Improper Use of Attendants 362
Private Hospitals 363
Efficiency and Economy Combined 364
Cost of a Permanent Staff 365
A Fixed Charge on the Training School 366
9. Theoretical Instruction 367
Different Forms of Disease and Their Treatment .... 367
The Physician-Instructor 367
Failure to Stress Prevention of Disease 369
Methods of Teaching 370
xiv CONTENTS
PAGE
Correlation with Ward Training 370
The Bedside Clinic 371
The Use of Quizzes 372
Failure to Correlate with Ward Training 375
Psychology 376
Time Allowed to the Teaching of Different Forms of Disease
and Their Treatment in 22 Schools 378
Social Aspects of Disease and Its Prevention 378
Hours and Year When Given 379
Instructors 379
Training in Public Health Nursing in 22 Schools .... 381
Disadvantages of Undergraduate Training 381
Lack of Teaching and Supervision 381
Inadequate Time 382
Training in Hospital Social Service in 22 Schools . . . 383
Some Examples of Present Training 385
Need of Special Postgraduate Training 387
Need of General Social Interpretation for All Students . . 388 Time Allowed to the Teaching of Social Aspects of Disease
and Its Prevention in 22 Schools 389
Teaching of General Nursing Subjects 389
History of Nursing 390
Ethics 390
Time Allowed to the Teaching of General Nursing Subjects
in 22 Schools 392
10. Correlation of Class Teaching and Ward Work 394
Correlation in the First Year 395
Correlation after the First Year 396
The Educational Loss 397
The Danger to Health 397
11. Nursing in Three Special Branches 399
Nursing in Tuberculosis 399
Nursing in Venereal Diseases 402
Nursing in Nervous and Mental Diseases 403
12. Conditions of Work 406
Day Duty 406
Excessive Length of Hours 407
The Necessity for 24-Hour Service 408
The Necessity for 7-Day Service 408
Irregularity of the Work 408
A Group above the Average 409
A Common Basis of Comparison 409
Standing of Hospitals Studied 410
Relation of Meals to the Daily Schedule 410
Relation of Class Work to the Daily Schedule 411
Time of Class Work 411
Tendency to Include Class Work in Hours of Duty . . . 412
Time Off Duty 413
Notification of Time Off Duty 414
Weekly Hours of Duty 415
Adherence to Schedules of Hours 416
Hours of Duty in Special Services 416
Ratio of Patients to Students 419
Annual Vacations 420
CONTENTS xv
PAGE
Notice of Vacations 421
Relation of Hours to Health 421
Relation of Hours to Working Efficiency 422
Relation of Hours to Education 424
A Practicable Reduction 424
Eight Hours by Law 425
Night Duty 426
Comparative Educational Value of Services 428
Actual Assignments of Night Duty 428
Total Length of Night Duty Planned 431
Actual Duration 432
Length and Frequency of the Several Assignments . . . 434
Length of Intervals between Assignments 435
Hours of Night Duty 436
Provision of Sleeping Quarters 438
Provision for Class Hours 439
Ratio of Patients to Students 440
Length of Training before First Assignment 441
Supervision during the Night 441
Living Conditions 442
Living Quarters 444
Privacy: The Single Room 445
Toilet Facilities 446
Eating Arrangements 446
Home Life 447
Relaxation and Study 448
Social Life and Recreation 449
Social Relations with Medical Staff 450
Amusements and Exercise 450
Form of Government 451
13. Conclusions and Recommendations 452
Increased Cost of Training 453
The Need of a Permanent Paid Staff 454
A Proposed Curriculum 455
Differences between Schools 456
Affiliations for Small Schools 457
Entrance Requirements 457
Education 457
Age and Personal Qualifications 458
Hours of Duty 458
Reduction of the Present 3- Years' Course 459
Enrichment of the Present Course 460
Proposal for the Preliminary Term 461
Proposal for Practical Ward Training 463
Services Covered in the Proposed Program 464
Comparison with Actual Experience Records of Students . 466
Proposal for Theoretical Instruction during Ward Training . 469
Comparison of Proposed Course with Existing Curricula . . 470
V. TRAINING COURSES FOR THE SUBSIDIARY NURSING
GROUP
Capital Need of Regulation by a Licensing System 473
Places for Training 474
xvi CONTENTS
PAGE
Use of the Small Hospital 475
Limitations in the Use of Larger Hospitals Having Schools of Nursing 476
Length of the Course 478
Entrance Requirements 478
Practical Experience 479
Ward Training 479
Class Instruction 480
VI. THE UNIVERSITY SCHOOL OF NURSING
Evolution of the University School 485
Organization of the University Training Course 487
Standards 487
Field for Technical Training 487
Organization 489
Status in the University 489
Financial Basis 491
Financial Relations with Other Departments 491
Financial Relations with the Hospital 492
The Curriculum 493
Hospital Training 495
Credit 497
Degrees 498
VII. POSTGRADUATE COURSES
1. Public Health Nursing Courses 499
History and Development of the Courses 500
Number of Existing Schools or Courses 500
Courses Given prior to 1917 501
Courses Organized since 1917 502
Auspices and Financial Arrangements 504
Tuition Fees 504
Financing the Schools 505
Administration 506
Organization of the Course 506
The Director 507
General Education of Directors 508
Professional Training 509
General Standing . 510
Salaries of Directors 510
Faculty 511
Advisory Committees 511
Entrance Requirements 512
General Education 512
Professional Education 513
Previous Education of Students in 16 Schools 514
Ages at Entrance 515
Length and Number of Courses Offered 515
CONTENTS xvii
PAGE
Relation of Field Work and Class Work 516
Giving Field Work and Class Work Concurrently .... 516
Field Work Preceding Class Work 518
Class Work Preceding Field Work 518
An Introductory Period of Field Work 519
Apportionment of Work in Courses Studied 519
Relative Amount of Time Devoted to Class Work and Field
Work 520
Field Work 520
Technique of Bedside Care in the Home 520
The Family as Unit of Care 522
Relation with Other Social Agencies 523
Apportionment of Time and Services 523
Observation in the Field 525
Field Work in 16 Schools 526
Supervision 529
A Successful Teaching District 530
The Curriculum 532
Content of the Courses 535
Methods of Instruction 535
A Suggested Curriculum 537
Nursing Subjects 538
Social Subjects 538
Pedagogical Subjects 539
Scientific Subjects 539
2. Courses for Teachers and Administrators 540
The Teaching Staff 540
Ideal Requirements 540
Development in Recent Years 541
The Superintendent 542
Qualifications of the Superintendent 543
Academic Education 544
Assistant Principal and Superintendent 544
Instructors 545
Equipment and Training 545
Conditions of Work 547
Length of Yearly and Weekly Programs 548
Number of Subjects 548
Outside Duties 549
Salaries 550
Need of Standardization 550
3. Teachers College and Its Influence on Nursing Education . . 551
History of the Department 551
Facilities 553
Organization 553
Classification of Students 553
Curriculum 554
Required Courses 554
Electives 556
Future Possibilities 556
Inclusion of Public Health Nursing 557
Type of Students 558
The Larger Aim of Postgraduate Instruction 559
Appendix ,. 56i
NURSING AND NURSING EDUCATION IN THE UNITED STATES
INTRODUCTORY NOTE
In December, 1918, at the invitation of the Rockefeller Foundation, a conference of persons interested in the develop- ment of public health nursing in the United States was called in New York. About 50 persons attended this conference, — physicians, representatives of public health agencies and public health nursing organizations, leaders in nursing education, hospital administrators, and other persons prominent in public health work. The primary object of the meeting was a dis- cussion of the status of public health nursing in the United States and of the education desirable for training the needed personnel. On these two points all shades of opinion were ex- pressed by those present; there was substantial agreement, how- ever, that the usual three years' hospital training was not, in and by itself, satisfactory for preparing public health nurses. Accordingly, by request of this initial conference and from nominations by ballot at the conference, a committee of seven was appointed by the president of the Rockefeller Foundation to study the questions raised and to prepare a definite proposal for a course of training for public health nurses, financial support for the investigation being provided by the Foundation. The committee consisted of the following persons:
Miss Mary Beard, Boston
Dr. H. M. Biggs, New York
Miss Annie W. Goodrich, New York
Miss M. A. Nutting, New York
Miss Lillian D. Wald, New York
Dr. William H. Welch, Baltimore
Professor C.-E. A. Winslow, New Haven In March, 1919, this committee, organized as the Committee for the Study of Public Health Nursing Education, elected as chairman Professor C.-E. A. Winslow, and added to its member- ship the following persons:
Dr. Livingston Farrand, Washington
Dr. L. Emmett Holt, New York
Miss Julia C. Lathrop, Washington # Mrs. John Lowman, Cleveland 1
2 NURSING AND NURSING EDUCATION
Somewhat later, by the vote of the Committee as thus con- stituted, there were added to its membership: Dr. David L. Edsall, Boston Dr. E. G. Stillman, New York
The Committee was peculiarly fortunate in being able to place the actual conduct of its investigation in the hands of Miss Josephine Goldmark, whose eminent achievements in social re- search, as in the study which formed the basis of the decision of the United States Supreme Court in the Oregon case, and in more recent studies on industrial hygiene for the United States Public Health Service, peculiarly fitted her for such a task. Miss Goldmark was appointed secretary of the Committee in June, 1919, and in October began the actual organization of the investigations which form the basis of the following reports.
The Committee desires to make special record of its deep appreciation of the services rendered by Miss Goldmark in the conduct of her study of the difficult and complex series of prob- lems with which she has had to deal. Such value as the report of the Committee may possess is primarily due to the tireless and skilful and constructive labor of its secretary; and the Committee believes that Miss Goldmark's detailed report, pre- sented as a supplement to the brief report of the Committee it- self, will prove of fundamental value in the development of nursing and of nursing education in the future.
It was originally decided to make a twofold inquiry; to study on the one hand typical examples of public health nursing and public health education carried on by persons other than nurses in various parts of the country, urban and rural; and on the other hand to study the education for such workers afforded by hospital training schools, graduate courses for public health nursing, and special schools of a non-nursing type.
In February, 1920, again at the invitation of the Rockefeller Foundation, a second conference on nursing education was called. At this second conference, discussion centered on the proper training of nurses engaged not in public health work, but within hospitals and on private duty. In effect, the entire trend of nursing education was considered. Following the conference, the Committee on the Study of Public Health Nursing Educa- tion was asked by the Rockefeller Foundation to widen its scope so as to include the entire subject of nursing education. In accordance with this request, and upon assurance of further financial support from the Foundation, the Committee agreed
INTRODUCTORY NOTE 3
to widen its scope as requested and added to its membership six members including superintendents of hospitals and of nursing schools, a clinician and a representative of mental hygiene. The members added in June, 1920, were the following:
Miss S. Lillian Clayton, Philadelphia
Dr. Lewis A. Conner, New York
Dr. C. G. Parnall, Ann Arbor
Dr. Thomas W. Salmon, New York
Dr. Winford H. Smith, Baltimore
Miss Helen Wood, St. Louis In the course of the investigation Miss Goldmark was assisted by the following staff:
During the first year of work, October, 1919, to October, 1920, Miss Anne H. Strong, R. N., director of the School of Public Health Nursing, conducted by Simmons College and the In- structive District Nursing Association, Boston, acted as assistant secretary of the Committee, and was in charge of the investiga- tion of public health nursing and of the graduate training courses. She has continued her connection with the work as consultant.
During the second year of the work, the assistant secretary was Miss Carolyn E. Gray, R. N., formerly superintendent of nurses, City Hospital, New York, who has also continued in close touch with the work.
In order to secure disinterested and impartial opinions on controversial subjects, both nurse and lay investigators were employed in the field work.
The field work for the study of hospital training schools was carried on by Miss Elizabeth G. Burgess. R. N., inspector of training schools, of the New York State Department of Edu- cation; Mrs. J. B. Piggott, R. N., Maryland state inspector of training schools; Miss Carolyn E. Gray, head of the Depart- ment of Nursing Education, Western Reserve University; Miss A. H. Turner, professor of physiology, Mt. Holyoke College; Miss F. G. Gates, formerly dean of women, University of the State of Illinois. Miss Turner also made a study of post- graduate courses for teachers and administrators in schools of nursing.
In compiling data for the chapter on hospital training schools assistance was rendered by Miss Edith R. Hall, Mrs. M. P. Gaffney, and Miss P. K. Angell. Miss Hall also assisted in writing up- various phases of the work. The statistical work
4 NURSING AND NURSING EDUCATION
was done by Mrs. S. Lowenthal. Various sections were written and much editorial revision done by Miss Mary D. Hopkins, who has had wide experience in teaching and research. Miss Hopkins is largely responsible also for the chapter on the uni- versity school of nursing.
For the study of public health agencies, the field work was carried on, for varying periods of time, by the following persons: Miss Grace R. Bolen, Miss Christina C. Miller, and Miss Elsa M. Butler, who were not nurses but were experienced in public health work, and Miss Helen Ross, experienced in industrial investigation; Mrs. B. A. Haasis, R. N., and Miss Janet R. Geister, R. N.., secretaries of the National Organization for Public Health Nursing, and Mrs. A. M. Staebler, R. N., secretary of the Massachusetts Committee on Health in Industry.
The statistical work for the chapters on public health nursing and on training courses for public health nursing was done by Miss Henriette R. Walter, who aided also in the preparation of these two chapters.
In the study of private duty nursing the field work was car- ried on by Mrs. J. David Thompson and Miss Adda Eldridge, R. N. Thanks are due to Miss Sara E. Parsons, R. N., for special assistance.
Owing to a special appropriation granted for publishing the Report of the Committee, the publishers are enabled to offer it at a substantially reduced price.
REPORT OF THE COMMITTEE FOR THE STUDY OF NURSING EDUCATION
REPORT OF THE COMMITTEE
Objects and Scope of the Investigation
The Committee which presents the following report was first appointed by the Rockefeller Foundation in January, 1919, to conduct a study of "the proper training of public health nurses."
It was, therefore, the pressing need for more and for better nurses in the field of public health that first suggested the de- sirability of such an investigation. It soon became clear, how- ever, that the entire problem of nursing and of nursing educa- tion, relating to the care of the sick as well as to the prevention of disease, formed one essential whole and must be so considered if sound conclusions were to be attained. A year later, in February, 1920, the Foundation requested us to broaden the scope of our inquiry to include ^a study of general nursing education, with a view to developing a program for further study and for recommendation of further procedure." We have attempted, therefore, 'to survey the entire field occupied by the nurse and other workers of related type; to form a conception of the tasks to be performed and the qualifications necessary for their execution; and on the basis of such a study of function to establish sound minimum educational standards for each type of nursing service for which there appears to be a vital social need.
The Role of the Nurse in Public Health
Since it was the obvious need for more adequate nursing service in the field of public health which brought to a head the demand for a comprehensive study of nursing education, long- felt and first voiced by the official organization of nurses, it seems natural to begin with a consideration of this phase of the broader problem.
It is obvious that the public health movement has passed far beyond its earlier objectives of community sanitation and the control of the contact-borne diseases by isolation and the use of sera and vaccines. Major health problems of the present day, such as the control of infant mortality and tuberculosis, can be solved only through personal hygiene — an alteration in the daily habits of the* individual — and through the establishment of new
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8 NURSING AND NURSING EDUCATION
contacts with the public, contacts which shall permit the appli- cation of the resources of medical science at a stage in disease when they can produce a maximum effect. Such changes in the daily habits of the people and in their relation to their medical advisers, can be accomplished by but one means — education. In its present phase of emphasis on personal hygiene, the public health movement has thus become during the past two decades pre-eminently a campaign of popular education.
The new educational objectives of the health administrator may be approached to a limited extent by mass methods. The printed page, the public lecture, the exhibit, the cinematograph, the radiogram, help to prepare the ground and to make success easier. The ultimate victory over ignorance is, however, rarely attained in such ways. Direct personal contact with the con- ditions of the individual life is essential to success in a matter so truly personal as hygiene. We have sought during the past twenty years for a missionary to carry the message of health into each individual home; and in America we have found this messenger of health in the public health nurse. In order to meet generally accepted standards we should have approximately 50,000 public health nurses to serve the population of the United States, — as against 11,000 now in the field. All public health authorities will probably agree that the need for nurses is the largest outstanding problem before the health administrator of the present day.
In view of this fact, public health authorities, both in this country and abroad, have naturally considered the possibility of finding a short way out of their difficulties by the employment of women trained in some less rigorous fashion than that in- volved in the education of the nurse. It was, therefore, to the question of the necessary and desirable equipment of the teacher of hygiene in the home that we first directed our attention. There are at present two distinct types of public health nursing practice in the United States — that in which the nurse confines herself to the teaching of hygiene, and that in which such in- structive work is combined with the actual care of the sick. A third type of visiting nursing, in which bedside care is given with no educational service, may be observed in individual in- stances. It results, however, from temporary limitations rather than considered policy, since practically all visiting nurse asso- ciations, in theory at least, stress hygienic education in their official program.
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The question whether the public health nurse should or should not also render bedside care has been hotly debated during the past few years. The arguments for purely instructive service rest mainly on two grounds, the administrative difficulties in- volved in the conduct of private sick nursing by official health agencies and the danger that the urgent demands of sick nursing may lead to the neglect of preventive educational measures which are of more basic and fundamental significance. Both of these objections are real and important ones. Yet the observa- tions made in the course of our survey indicate that both may perhaps ultimately be overcome. Several municipal health de- partments have definitely undertaken to provide organized nursing service for bedside care combined with health teaching, while in other instances instructive nurses, under public auspices, combine a certain amount of emergency service with their fundamentally educational activities. So far as the neglect of instructive work is concerned it results from numerical in- adequacy of personnel and can be avoided by a sufficiently large nursing staff.
On the other hand, the plan of instructive nursing divorced from bedside care suffers from defects which if less obvious than those mentioned above are in reality more serious because they are inherent in the very plan itself and therefore not sub- ject to control. In the first place the introduction of the in- structive but non-nursing field worker creates at once a duplica- tion of effort, since there must be a nurse from some other agency employed in the same district to give bedside