How one could once become a registered nurse in the United States without going to a hospital training school

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1 Nursing Inquiry 2004; 11(3): Feature Blackwell Publishing, Ltd. How one could once become a registered nurse in the United States without going to a hospital training school Vern L. Bullough Accepted for publication 2 February 2004 BULLOUGH VL. Nursing Inquiry 2004; 11: How one could once become a registered nurse in the United States without going to a hospital training school Distant learning in nursing is both a new and old concept. This paper examines an early example of correspondence schools in nursing, namely the Chautauqua School which over the course of its existence enrolled over students. Its closing was due in large part to the opposition of organized nursing which had become institutionalized in the hospital training school. It was not until the 1990 s when license recertification was required that long distant nursing again assumed importance. Key words: Chautaugua, distant learning, nursing by mail. There is kind of a popular myth of nursing history in the United States that modern American nursing began with the foundation of three Nightingale-oriented schools in 1873 and nursing quickly adopted this model, raising the standards of nursing education across the country. Unfortunately, the myth is mostly not true. Though the first Nightingale schools of nursing were opened in 1873, schools of nursing that did not follow the Nightingale patterns existed both before this and after. Linda Richards, for example, who erroneously called herself the first trained nurse in America, enrolled in a training school organized by the New England Hospital for Women and Children in Boston in 1872 (Bullough 1988). The number of schools increased rapidly after 1873, though the actual numbers of schools are not reliable. Standard estimates put the number of schools at 432 by 1900, 1 but the actual number is probably much Correspondence: Vern L. Bullough, 3304 West Sierra Drive, Westlake Village, CA , USA. <vbullough@adelphia.net> 1 See JE Watson. 1 The evolution of nursing education in the United States: 100 years of a profession for women. Journal of Nursing Education 16: 34. Her figures were based on the on the report of May Ayres Burgess, who directed and wrote up the findings of the Committee on the grading of nursing schools, nurses, patients, and pocketbooks, New York: The Committee, 1928, 35. higher. Wendell Odekirk (1985), for example, found at least 117 more schools in 1900 than had previously been reported in the literature. The problem in writing about early nursing education is not counting the number of schools, but also determining what is meant by the term nurse and just exactly what kind what kind of institution can be classed as a nursing school. The term nurse was widely used to describe a number of different things from wet nursing, to bedside attendant, to physician s assistant and everything in-between. In the hospital setting, almost all tasks, including cleaning, were done by student nurses. Though they were called students, there were few lectures, and most of the training, if it can be called that, was through the apprenticeship system, with the older students teaching the younger. Often the only nurse was the head nurse or superintendent. Almost all the lectures were given by physicians, and in most schools it was the physicians who decided the curriculum. This practice was sometimes called the Waltham plan after the program established by Dr Alfred Worcester at Waltham, Massachusetts. Worcester (1927) argued that since nursing was a subordinate branch of medical practice, it was only natural that physicians decide what it should be, since the nurse was first, last, and all the while only the doctor s assistant. The Nightingale schools theoretically did not accept this and 2004 Blackwell Publishing Ltd

2 VL Bullough emphasized instead a female hierarchy, headed by a matron who answered to a nursing board. Unfortunately, few hospitals in the US had nursing boards, and instead the matron answered directly to a hospital board, controlled by the physicians. Inevitably, probably despite the efforts of the matrons, ward duty always took precedence over lectures (Bullough and Bullough 1978, ). A major reason for the rapid surge in the number of nursing schools in the 1890s and the first two decades of the twentieth century was not only the growth in the number of hospitals during the period, but the fact that schools of nursing proved to be financially advantageous to hospitals. It was nursing students who provided the care of the patients, and advanced student nurses supervised the activity of the new nurses on the floor. Few professional nurses, other than the director of nursing, were employed in the hospitals. Hospitals with as few as 20 beds established nursing schools, although some of these, recognizing their deficiencies, sent students to other hospitals for part of their training. In even the best schools, the duty of the student was to her patients, and formal lectures and classrooms were usually secondary to on-the-job experience. Educational standards varied tremendously, depending in large part on the needs of the hospital. 2 Lectures, when they were given, were scheduled at the convenience of the hospital or the doctor and not of the nurse. Moreover, nurse training in the hospital during the first part of the twentieth century could be and was both strenuous and stressful, with student nurses putting in long hours, often 56 hours or more per week on the floor, and then trying to study in their free time. Timing for lectures was often haphazard, and exhausted students coming off a shift would often fall asleep in the middle of the class. Some nurses, such as the Marxist militant, Emma Goldman, received their nurse training in a prison hospital while in jail. Beginning the 1890s, the forerunners of the American Nurses Association and National League for Nursing began agitating for nursing licensing or registration to raise standards. In this they were ultimately successful and by 1923 all 48 states had established some form of licensing or registration. This sounds good on paper, but what constituted a nurse varied from state to state, because each state had different standards and different power blocks. Some 2 See, for example, M. Adelaide Nutting, Educational Status of Nursing, US Bureau of Education, Bulletin 1912, No. 7, Washington DC Government Printing Office, Even as late as 1923, Josephine Goldmark in the Report of the Committee for the Study of Nursing Education, Nursing and Nursing Education in the United States, New York: Macmillan, 1923, indicated that instruction in large number of schools was casual and uncorrelated, and that the education needs and health and strength of students were frequently sacrificed to practical hospital exigencies. laws provided for little enforcement of standards, and those enforcement provisions that existed were often haphazardly enforced. Bonnie Bullough, in her discussion of nursing licensing, emphasized that once the laws were on the books the nursing organizations, recognizing the deficiencies, agitated for upgrading them and gradually achieved improvements over the ensuing years until a second wave of nursing registration began just before World War II. This new wave followed the complete revision of the nursing act of New York, which dealt with the scope and practice of nursing and was widely imitated by most other states (Bullough 1975). Still, during World War II, the civilian hospital ran mostly on student nurses, with lectures often still being subordinate to the needs of patients. There were some nursing schools which had comparatively high standards. Johns Hopkins University, the Illinois Training School in Chicago, Massachusetts General in Boston and Pennsylvania Hospital in Philadelphia set the standards and furnished most of the leaders in nursing. Most nurses, once they had graduated, even in the best of the schools, did not work in a hospital except as a private duty special but rather did private duty in people s home or worked individually with a physician. Since this was the case, it would seem logical that many would-be nurses questioned the importance of the hospital experience, particularly if they had any experience in dealing with sick people. Many undoubtedly wondered why they should spend 2 months scrubbing floors (the job of the two-month probationary nurse), or exhaust themselves working long hours without any real time for study. Many searched for other alternatives. This was made easier by the fact that employment after graduation for most nurses was in private duty nursing, and one of the powers that physicians often had was to either choose or recommend a nurse for his patients. Many physicians trained their own nurses, but they undoubtedly preferred to find their candidates to have some knowledge of both medicine and nursing. Correspondence schools, where the theory and justification for standard nursing procedures could be learned, were regarded by many physicians, as well as many would-be nurses, as a highly satisfactory alternative. Moreover, graduates of at least some of the correspondence schools were recognized as nurses in most of the states (nursing registration differed from state to state) but in any case the decision of whether to accept a person as a nurse was often up to the physician. How many such alternative mail order schools there were is something that is almost impossible to determine, because all kinds of schools emerged, many of them not lasting very long, and the documentation is fragmentary. Some, however, had long histories. The most well known, and probably the best Blackwell Publishing Ltd, Nursing Inquiry 11(3),

3 Nursing without hospital training of such schools, was the Chautauqua School of Nursing in Jamestown, New York. Undoubtedly, part of its influence came from its name because the nearby Chautauqua Institute on Lake Chautauqua in western New York State was not only nationally, but also internationally known. The original Chautauqua Institute had started in 1874 as a summer assembly for training of Sunday school teachers and church workers. At first the program had been mainly on religious topics, but it quickly expanded into a summer-long educational experience with lectures, dramatic performances and musical events. The Institute also established a national correspondence school and a publishing house and established national tours for some of their lecturers. So influential was the Institute that some 400 of its offshoot assemblies, simply called Chautauquas, had been established in almost every state and served as host for traveling lectures, plays, and performances on what came to be called the Chautauqua circuit. In its peak year of 1924 traveling Chautauquas visited approximately communities and their lectures and performances were attended by more than people. 3 In short, the mere name of the Chautauqua School of Nursing served to emphasize its integrity and quality. Although the nursing school was not directly connected to the Chautauqua Institute, it obviously operated with the knowledge and consent of the Chautauqua group. The nursing school founded in 1900 grew rapidly through advertisements in such popular magazines as the Ladies Home Journal. In 1915, it claimed to have enrolled more than students (How I became a nurse 1915). This would have made it the largest single source of trained nurses in the United States, a claim which it made for itself (How I became a nurse 1915, 124; inside back cover). The cost for the complete three-part course in nursing general nursing, obstetrical, and surgical nursing was $75 in advance, a hefty fee since people making a dollar a day considered themselves lucky. If the student wanted to spread out the payments, they had to pay $15 upon enrollment, and make 15 monthly payments of $5 each, for a total of $90. Those wanting just general medical nursing paid $50 ($60 if paid in installments). The combined courses on obstetrical and surgical nursing cost the same amount. The school supplied all study materials and paid the postage on the return of all examination papers after correction. If after 2 months of trial study the student for any reason was dissatisfied, the entire amount paid for tuition would be refunded. This guarantee of refund served two purposes: it 3 See the article on Lyceums and Chautauquas, Encyclopedia Britannica, Chicago: Encyclopedia Britannica, 1968, 14, encouraged students to take a chance, but it also ensured the school that those pupils who continued would derive real and lasting benefit. Quite clearly, they did not want dissatisfied students and if they worked diligently in 15 months, students could gain their nursing certificate. The whole operation, at least on the surface, implied integrity. Though there is no indication of the approval of the school by any nursing organization, it did claim approval of the medical community. The claim was, however, selfsolicited, and limited only to one group in one state. At the request of the school, a commission of prominent physicians was appointed by the New York Medical Journal, one of the better medical journals, to evaluate the success of the method of instruction and administration. Their report, based on responses from 618 physicians in New York State, was published in that journal in May, A total of 599 (97%) of the physician respondents certified the efficiency of the Chautauqua nurses and, according to the Chautauqua school self-report, the Commission believed that the education offered by the Chautauqua School to its students was of a high order as to quality, completeness, and practical value (How I became a nurse 1915, inside front cover). It is indicative of the standing of nurses to physicians, that no nursing group was ever asked to give an evaluation. Neither was the evaluation process repeated again. There were, however, many testimonials by its graduates to publicize their success. One practical nurse stated that she thought entering a hospital training school would be a waste of 3 years time, because with her experience all she needed was some supplementary instruction in theory. She wrote: I must confess I had very little faith in the efficiency of correspondence schools, thinking they were merely money making schemes. I here acknowledge my error and take pleasure, every opportunity I get, to refute people s erroneous ideas in this respect. I feel the possession of the lectures alone well worth the cost of the courses (How I became a nurse 1915, 6). Another reported that she had a position as nurse in a city hospital for the past 4 months and, although all of the other nurses had several years hospital experience, she felt she was as competent as they were. In fact, she wrote, some of her fellow nurses said I must have had hospital training or I could not have secured a position with those who had several years training (How I became a nurse 1915, 7). The nursing school regularly published a brochure of testimonies from women on how they became a nurse through their correspondence course at Chautauqua. A promotional booklet from 1915 included letters by satisfied students (with names of cities) from most of the 48 states, 2004 Blackwell Publishing Ltd, Nursing Inquiry 11(3),

4 VL Bullough Canada, England, and New Zealand. The respondents, all women, wrote that they chose the Chautauqua school for a variety of reasons: because they were too old to enter a hospital school (i.e. over 35); they could not leave their homes to undertake hospital training; they were married and could not gain entrance to a hospital school; they were practical nurses seeking to upgrade their credentials to become registered; they lived in an isolated area where there was no available hospital school. Several had started in hospital schools but gave up because of illness and found correspondence schools a less strenuous way of becoming a nurse. Economic reasons were also important. Many wrote that they felt nursing offered better pay than anything else they could do. Some who wrote in this vein were widows with children who wanted to upgrade their earning capability, others took the course simply because there were no nurses in the area in which they lived and they felt nursing offered them opportunities for employment. Some took the course for domestic or familial reason. Several wrote that they took the Chautauqua course because they felt it would help them to be a better mother. Others reported they did not want to be a professional nurse but wanted to know better how to nurse their own families and loved ones. One respondent said that after completing the course, she hired a maid and took on the nursing duties in her family, adding that it was cheaper and easier to hire a maid than a nurse, and besides she gained a great deal of satisfaction from caring for the needs of those who were ill in her family (How I became a nurse 1915, 15). Many of them began working for a local physician, while taking the course to acquire more clinical expertise as they advanced in their lessons. Such a practice also served as an entry for future employment. One nurse says she took the Chautauqua course to gain the theoretical basis for nursing that her hospital training failed to give her, and claimed she learned more from the printed lectures and texts than all the time she was in the hospital school (How I became a nurse 1915, 90 1). Actually, such a claim had a great deal of validity, since the textbooks in the three areas did offer a good basic overview of their subject. It is also true, however, that the school made every effort possible to see the student finish the course. Exams were on the honor system, and like the questions in today s short extension courses printed in the American Journal of Nursing and other nursing journals, the grading was based on an open text examination. Still, the nurse student kept the text and could often refer to it when she began her career (all the students I have been able to find were women). The surviving Chautauqua materials make it clear that a person in the United States in the first part of the twentieth century could become a nurse in a variety of ways, and that the hospital training school was not the only way. Once practicing as a nurse, it was probably difficult to distinguish them from others since, like other schools, Chautauqua had its own cap, and its graduates had their own pin. The fact that New York State, one of the more progressive states in nursing education and registration, was home to the largest correspondence training school in the United States which did not require on-the-job experience and the graduates of which practiced all over the United States, only emphasizes the long and arduous task nursing had to upgrade itself. It also serves to remind us just how much of nursing history needs to be explored in-depth before we can get a full portrait of American nursing and nursing education in the past. The brief history of such a school only emphasizes how difficult the struggle was for nursing knowledge and expertise to be accepted. There was a gradual raising of standards in the United States during the 1920s and 1930s, but the crisis of World War II resulted in the nursing in most civilian hospitals being done by student nurses, as indicated above. There were few graduate nurses on the floors and most instruction remained in the hands of the physician. My long-time collaborator on nursing history, Bonnie Bullough, had become a head nurse on a floor of a major hospital in her third year of nurse s training. While college-educated nurses had appeared as early as the 1920s, many of them went into public health or into administrative roles. Still, organized nursing spent much time and energy trying to close such schools as Chautauqua. They finally managed to get it closed in the 1920s, but this was only a tentative step to raise the level of education which was a long and difficult struggle, a struggle that still continues. Interestingly, in light of current trends in nursing education, the Chautauqua school can be looked at positively as an early experiment in distance education. For the nurses at the time, who were trying to strengthen their own control over nursing education, it was a trend that had to be stamped out. Only later, when nurses had greater power over their profession, and when television and the computer opened up greater opportunities for distance education, and when new developments in nursing demanded continuing ongoing education, could they accept distance education as one means of communicating these changes. History sometimes repeats itself and a new generation reinterprets and adopts practices which it had once condemned Blackwell Publishing Ltd, Nursing Inquiry 11(3),

5 Nursing without hospital training REFERENCES Bullough B, ed The law and the expanding nursing role. New York: Appleton Century Crofts, 1 2. Bullough VL Linda Ann Judson Richards. In American nurses: A biographical dictionary, vol. 1, eds VL Bullough, O Maranjian Church and A Stein, New York: Garland Books. Bullough VL and B Bullough The care of the sick. New York: Neale Watson, Prodist Press. Oderkirk WW Setting the record straight: a recount of late nineteenth-century training schools. Journal of Nursing History I: Worcester A Nurses and nursing. Cambridge: Harvard University Press. How I became a nurse: A collection of actual experiences by graduates of the Chautauqua School of Nursing Paper 126. Jamestown, NY: Chautauqua School of Nursing. Nursing Inquiry Call for papers Special issue: Virtual Nursing Practice and Inquiry Guest editor: Dr Margarete Sandelowski, Cary C. Boshamer Professor, University of North Carolina, USA Among the most dramatic features of western healthcare is the increasing turn to virtual environments for practice and inquiry. Clinical practice and research are now comprised of an array of tele-encounters between persons who do not share the same physical space. The patient is no longer necessarily the corporeal person behind the screens, but rather the hypertexted, hyperreal representation on screen: the rhythm strip, the black-and-white or colorized image, or the numeric, graphic, digital, schematic, or other visual display. The clinician is no longer necessarily the flesh-and-blood person next to the bed or examining table, but rather a voice on the telephone, an correspondent, an on-line presence, or the tele-image of a face or hand holding a medical instrument. Researcher and research participant now increasingly meet each other on the internet and in cyberspace. Accordingly, the editors of Nursing Inquiry invite scholarly works of any kind theoretical or philsophical papers, reports of empirical research, creative/visual works that address any topic in the realm of virtual nursing practice or virtual nursing research, including such topics as tele-nursing, nursing informatics, and virtual ethnography. All works should address the distinctive features and significance of the move to virtual environments for caregiving and inquiry for nursing practice, nursing research, or the evolution of nursing as a profession. The editors strongly encourage works that address virtual practice and research along key axes of difference: e.g., gender, culture, race/ethnicity, nationality, and geography. The deadline for submission of completed works is: 31 December Please send completed works to The Editor, Nursing Inquiry, School of Nursing, University of Melbourne, Melbourne 3010, Victoria, Australia; ninquiry@nursing.unimelb.edu.au. Please direct all inquiries to Margarete Sandelowski at msandelo@ .unc.edu. For guidelines regarding presentation of articles, please see: unimelb.edu.au/ninquiry.htm Blackwell Publishing Ltd, Nursing Inquiry 11(3),