LESSONS LEARNED FROM AN HISTORICAL SAMPLE OF NURSING EDUCATION‐PRACTICE PARTNERSHIPS Compiled by Dr. Martha Mathews Libster DATE HISTORICAL EXAMPLES AND SUMMARY OF LESSONS LEARNED THAT WOULD REFORM HEALTHCARE 1633 THROUGH THE DEVELOPMENT OF PROFESSIONAL NURSING Partnerships with Religious Communities 1633 – Louise de Marillac and Vincent de Paul founded a “confraternity” of women in Paris, the Daughters of Charity (DC), whose work included nursing the sick poor in their homes. Although the DC was not a religious order (i.e. Nuns) per the doctrine of the Catholic Church, they were religious women whose education was grounded in Catholic tradition, specifically the ministry and teachings of Vincent de Paul. Their ministry led them to strive for humility, simplicity, and charity. The founding of the DC was a boon to women and charitable work in community. Vincent de Paul wrote that it had been “eight hundred years” since women had held public roles in the Church. The Common Rules written documents that directed the nurses’ lives and service “ultimately became a prototype for many religious communities and nursing leaders” such as Florence Nightingale of England and Amelia Sieveking of Germany. i The Common Rules “represented the values and virtues of the members of a Community from which the image of DC was constructed and made recognizable for the public.” ii This nursing tradition was formative to the establishment of professional nursing in the United States as well through the American counterparts of the DC, the Sisters of Charity who began in 1809. The teachings supported the corporal as well as spiritual needs of the sick poor. The sister‐nurses’ charity included sanitation and administration of sick‐rooms and hospitals, preparing the sick diet, formulating and administering herbal remedies (tisanes and syrups) and topical treatments, spiritual care, and assessment and monitoring of patients. iii The spirituality of the nurses’ education led to a wisdom in caregiving grounded in ability to think and act “judiciously” and with “discernment” – a practice today identified as evidence‐based practice. Summary: Professional nursing education has been supported historically by religious tradition emphasizing the spiritual and corporal care of patients. Nurses have successfully worked (originally as part of) with religious communities to pioneer the development and administration of a new community nursing services. “Nurse‐run clinics” have been nurses’ heritage since the 17th century. Clinics have historically served as educational facilities for learning hands‐on nursing care ‐ a practice now referred to as service learning. Other historical examples of education‐practice partnership with Churches include: 1. Ireland – early 19th century ‐ Careful Nursing Model devised by Catherine McAuley. iv 2. United States – mid‐ 19th century – Education conducted by Latter‐Day Saints (Mormon) nurse pioneers through their community Council of Health and Relief Society. v 3. United States – 18th and 19th centuries – Education of nurses conducted in the infirmaries of numerous Shaker “families” (communities). vi 1 LESSONS LEARNED FROM AN HISTORICAL SAMPLE OF NURSING EDUCATION‐PRACTICE PARTNERSHIPS Compiled by Dr. Martha Mathews Libster 1823 1840 Partnerships with Medical Colleges/Educational Programs for Physicians 1823 – One of if not the first partnership of its kind in the United States was the partnership between the American Sisters of Charity from Emmitsburg, MD and the medical faculty of the Medical College of Maryland (now the University of Maryland Medical Center). The Sisters, who had established an excellent reputation as nurses, were invited to staff the Baltimore Infirmary, which was established for the education of physicians. The Sisters, through their Bishop, established the terms of agreement for their services which included the room and board they received and the definition of what constituted respectful behavior by patients and medical students toward the nurses, and the parameters of their authority with patients and medical students. In return for their service, the Baltimore Infirmary served as an educational hub for the Sisters’ nursing missions. Most of the Sisters missioned during the 19th century did some training at the Infirmary. The Sisters were exposed to cutting edge developments in medical education, treatment, and surgery. vii 1838 – The Sisters of Charity were missioned to open another infirmary at the Richmond Medical College in Virginia. Dr. Augustus Warner, a founding physician of the College had been a medical student in Baltimore and worked with the Sisters in the tent hospitals during the 1832 cholera epidemic. It was he who requested the Sister‐Nurses staff the infirmary at Richmond. viii 1840 – The Sisters of Charity hired Dr. William Aiken a doctor and chemist with the Maryland College of Pharmacy to give lectures on chemistry and botany to the Sisters at the Central House in Emmitsburg. ix Summary: Nurses and physicians have a reciprocal relationship in terms of educational need. Bedside learning has been fundamental to both disciplines. Partnerships with Physicians 1840 ‐ The Sisters of Charity opened their own Asylum for the Insane called the Mount Hope Retreat. They hired a “consulting physician” Dr. William Hughes Stokes to partner with them in their quest for establishing a more humane form of mental health care which at the time was a health reform movement known as “moral therapy.” They also invented their own restraints and treatment protocols setting their hospital apart from others in Maryland. Dorothea Dix identified the Mount Hope Retreat in 1852 as one of two successful institutions in the State. x Initially, they and Dr. Stokes were aggressively opposed by some of the members of the burgeoning Association of Medical Superintendents of American Institutions for the Insane (now the American Psychiatric Association). Stokes continued as consultant to the Sisters for fifty years. The Mount Hope Retreat closed in 1973. xi This endeavor of the Sisters in Baltimore reflected similar arrangements of their predecessors in France. Summary: Nurses and Physicians have had successful, though not un‐challenged, creative entrepreneurial partnerships that have often inaugurated and supported significant health reform. 2 LESSONS LEARNED FROM AN HISTORICAL SAMPLE OF NURSING EDUCATION‐PRACTICE PARTNERSHIPS Compiled by Dr. Martha Mathews Libster 1860 1869 ‐ 1874 Partnerships with Government 1860 – American Civil War ‐ Individual nurses such as Mother Mary Ann Bickerdyke of Illinois and communities of nurses such as those within the Catholic church entered into service agreements with agents of the United States government particularly during times of war. Caregiving for casualties of war presented numerous educational opportunities for nurses. Summary: Decisions in nursing education have often been influenced by demand for nurses incurred by war. Partnerships with Hospitals (Physicians and Administrators) 1869 ‐ Some of the findings of AMA Committee on the Training of Nurses critical turning points: 1. “Every large and well‐organized hospital should have a school for the training of nurses, not only for the supply of its own necessities, but for private families, the teaching to be furnished by its own medical staff, assisted by the resident physicians.” 2. “Combine religious exercise with nursing…establishment of nurses’ homes under the direction of deaconesses, or lady superintendents…” The report had found that preparation for nurses of non‐Catholic Christian denominations had been “singularly neglected”. The AMA called for the training of “thousands of nurses”. 3. Called for “district schools…placed under the guardianship of county medical societies in every State and Territory in the Union.” Physicians were to teach the art and science of nursing, hygiene and “every other species of information necessary to qualify the student for the important, onerous, and responsible duties of the sick‐room.” The sick room had been the domain of the nurse and nurse educator heretofore. xii 1872 – Report included Letter from Florence Nightingale to Dr. Gill Wylie of the Hospital Committee of the State Charities Aid who spearheaded the reform of nursing education at Bellevue Hospital. Miss Nightingale details the “dangers” of equating nursing with medicine and that nursing education (and discipline of students) not be placed under the direction of doctors but “under a woman, a trained superintendent” a nurse also called a “matron”. Nightingale also cites the “disastrous consequences” experienced in German hospitals in which a chaplain and the female superintendent were “virtually masters of the hospital.” xiii The Bellevue School was incorporated in 1874. Summary: Nursing is a distinct and complementary discipline from medicine. Nursing education carried out in hospitals must address historical issues of professional boundaries and power (identified as “obedience” in the 19th century). 3 LESSONS LEARNED FROM AN HISTORICAL SAMPLE OF NURSING EDUCATION‐PRACTICE PARTNERSHIPS Compiled by Dr. Martha Mathews Libster 1948 ‐ 1951 Partnerships with Universities and Colleges 1948 – After World War II there was a serious nursing shortage, the Carnegie Foundation commissioned Dr. Esther Lucille Brown to study nursing education. Her report titled, “Nursing for the Future” recommended that nursing students be educated in colleges and universities rather than in hospitals where they were subjected to the requirements of the employee. The same year, the Conference on Catholic Schools of Nursing was formed to “foster higher educational standards in conjunction with college programs. About 90,000 sisters teaching in American schools also needed to upgrade their credentials. By 1954, 150 centers had been established to assure that all teachers would receive bachelor of arts degrees before beginning their teaching assignments.” xiv Secularization of nursing education moved to a new level. xv ADN‐ Dr. Mildred Montag defines a “practice continuum” and differentiated practice; however ADN graduates were not used in practice settings as intended by Montag’s research. xvi Summary: Implementation of educational policy and andragogical strategies as well as education research is translated in the practice arena. 1965 – Partnerships with Nursing Organizations (Private and Public) present The National League for Nursing Education, Association of Collegiate Schools of Nursing, and the day American Nurses Association have contributed to the debate to define nursing educational preparation and practice. In the mid‐20th century there were two levels of nursing preparation – the professional and technical nurse. The ANA published a position paper asserting that minimum entry level for professional practice to be the BSN and technical practice to be the Associate Degree. The ANA also conducted a series of studies of nursing “functions” in which they sought to “define nurses’ work and determine how nurses’ time was distributed among specific, named activities.” xvii The term “technical nurse” was replaced with “ADN”. Currently the issue is framed as a “BSN in 10” initiative. Community Colleges in some states are being authorized to provide BSN degrees. Currently, there is new debate over the implementation of the DNP. Technology, Distance Learning, and Simulation Skills Lab are now prevalent foci in nursing education. Some historical evidence suggests an achievable bridge between technology and nursing care traditions. xviii Other evidence demonstrates a call for futuristic models of self‐directed education in which student accountability for learning predominates and nursing graduates are prepared for “more opportunities in employer‐based, community‐driven, clinic‐based and ambulatory settings for nursing service delivery.” xix Summary: Practice settings have historically been community‐driven, ambulatory and Infirmary/clinic‐based. The debate over entry‐level into practice is now decades old. 4 LESSONS LEARNED FROM AN HISTORICAL SAMPLE OF NURSING EDUCATION‐PRACTICE PARTNERSHIPS Compiled by Dr. Martha Mathews Libster i
Libster, M. and McNeil, B.A. (2009). Enlightened Charity: The Holistic Nursing Care, Education, and Advices Concerning the Sick of Sister Matilda Coskery, 1799‐1870. Golden Apple Publications: www.Goldenapplepublications.com. p. 22. ii
Ibid. p. 23. iii
Ibid.; Sullivan, L. ed. and trans. (1991). Louise de Marillac Spiritual Writings: Correspondence and Thoughts. New York: New City Press. iv
Meehan T.C. (2003) Journal of Advanced Nursing 44(1), 99–107. v
Libster, M. (2004). Herbal Diplomats: The Contribution of Early American Nurses (1830‐1860) to Nineteenth‐
Century Health Care Reform and the Botanical Medical Movement. Golden Apple Publications: www.GoldenApplePublications.com. vi
Ibid. vii
Libster and McNeil. viii
Ibid. p. 80 ix
Ibid. x
Dix, D. (1852). Memorial of Miss D. L. Dix to the Hon. General Assembly in Behalf of the Insane of Maryland. Archives of the State of Maryland. Website, http://www.msa.md.gov/. xi
Libster and McNeil. xii
Gross, S. D. (1869). Report of the Committee on the Training of Nurses. American Medical Association, The Transactions of the American Medical Association, 20, 161‐174. Archives of the American Medical Association, Chicago Illinois. xiii
Dock, L. (1901). History of the Reform in Nursing in Bellevue Hospital. American Journal of Nursing, 2(2), 89‐98. xiv
McNamara, J. (1996). Sisters in Arms: Catholic Nuns through Two Millennia. Cambridge, MA: Harvard University Press, p. 627. xv
Libster and McNeil. pp. 300‐324. xvi
Matthias, A. (2010). The Intersection of the history of associate degree nursing and “BSN in 10”: Three visible paths. Teaching and Learning in Nursing, 5, 39‐43. xvii
Lynaugh, J. and Brush, B. (1996). American Nursing: From Hospitals to Health Systems. Cambridge, MA: Blackwell Publishers. p. 19. xviii
Sandelowski, M. (2000). Devices and Desires: Gender, Technology and American Nursing. Chapel Hill: University of North Carolina Press. xix
Porter‐O’Grady, T. (2001). Profound Change: 21st Century Nursing. Nursing Outlook, 49, 182‐186. 5