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The Relation of
Training Schools to Hospitals


June 17, 1893 – Hall of Columbus, Columbian Exposition, Chicago IL


The establishment of training schools in America dates back only twenty-one years, and the entire modern system of trained nursing, beginning with the foundation of Kaiserswerth in 1827, is not yet sixty years old. Hospitals, on the other hand, have existed for hundreds of years. In this, the present day, training schools are numbered by the score, and each year sees new ones opened, as one hospital after another falls into line and issues its curricular announcing that “arrangements have been made to provide two years training to women desirous of learning the art of caring for the sick.” Did the hospital, then, call the training school into existence? Strangely enough, it did not, though the two seem now so fundamentally united. The training school idea did not originate within the hospital, but was grafted upon it by the efforts of a few inspired ones outside, who saw the terrible need of the sick, who knew the inadequacy of the care they received, and who bravely knocked at the hospital doors, first closed, but gradually opening more and more widely.

The mutual need of one for the other was not, at the outset, equally felt by both. The hospital was absolutely necessary to the school; the school was not necessary to the hospital, according to the crude and ignorant idea of what was sufficient for the sick, under which hospitals had been mismanaged for centuries. Good nursing is indeed necessary for the best results and for the fully perfected work of the hospital, and it was to this truth that different honored members of the medical profession bore witness long before the time when the half unwilling hospital accepted the training school on sufferance. The first attitude of the school was, therefore, that of an applicant, and its work experimental. After a few years trial it has so well proved itself that the hospital is now the one to hold out inducements, and the consequent growth of the school as been so phenomenally rapid as to give rise on the one hand to congratulations, and on the other to the question: is it built on a strong foundation?

A study of the present conditions existing between hospitals and training schools is at first sight dispiriting. In their relations to each other may be discovered a formlessness, a lack of tradition, and adoption of hasty and tentative methods, and an acceptance of imperfect results, for which the training school is often blamed, though much of the fault lies with the hospital. But discouragement over this state of things, thought natural, need not be severe, when we remember that the hospital has had hundreds of years in which to develop, while the training school has had but little over half a century. Medicine is old, while nursing thought one of the most ancient of occupations is the very youngest of professions. Moreover, on closer observation of what seems at first a heterogeneous mass, there may be seen in it elements of order and strength and permanence.

There are three points of view from which the relation of the school to the hospital should be considered. The first shows an outline of the material and financial connection between the two, and considers the value of the school as an economic factor in the history of the hospital. The second sees the school as a moral force. The third faces the responsibility of the hospital to the school, and the way in which the school meets the demands of the hospital.

The training schools of America may be broadly separated, as to their outward form, into two classes: those which are an integral part of the hospital, and those which are independently organized and attached to the hospital by contract. The first is quite the larger class, and in it, with but few exceptions, are found the schools established by those hospitals in which, from their general characteristics, one would naturally expect to find expression to some degree of the reforming spirit of the times; the private and endowed hospital, church, college or university; and a small number of municipal hospitals.

The independently organized schools were the pioneers. First in the line of advance, they most triumphantly illustrate the moral force at work in the development, still rudimentary, of nursing. These are the schools which, by the courage and goodness of women preeminently, have been affixed to those hospitals that need them most and want them least – the city or county hospitals, where local politics grow at the expense of the neglected sick poor – in all ugliness, contemptuous of disinterested work, and hating to be interfered with. Individual ability and determination alone have mad it possible to fore the purifying influence of the training school into these places; for it may be safely asserted that in no instance has the political element of any municipal hospital ever voluntarily introduced reform into the nursing, or yielded to it save on irresistible pressure brought to bear from outside by those who had no political capital to make, who feared no one, and who were determined to succeed.

No stronger contrast could be shown than that between typical schools of these two classes: the one established by an enlightened and humanitarian hospital – a peaceful existence secured to it; the other a pioneer – its position insecure, its history full of exciting vicissitudes. In the one instance may be found union in an almost complete degree. There may be identity of interests and of aims; a recognition of mutual benefits; a sense of mutual obligation; a reciprocal feeling of personal pride, admiration and attachment. The other is an example of the “incorporated union,” which Gladstone declared can never become perfect. The training school attached to the political hospital can never truly become one with it until in the evolution of the civic virtues local politics either change their nature or are removed from the field.

The standard and aims of the school are absurdities to the hospital controlled by politics; the methods and tone of the hospital are odious to the school. From first to last its history is one of struggle and strenuous effort to obtain decent conditions, to resist degradation, and to do good work in the face of obstructions and difficulties always great and sometimes enormous. At the same time the line must be drawn with prudence, for it is in the power of the hospital to terminate its agreement, or to make conditions such that it is impossible for he school to continue its work. Such a course annihilates the training school, and shows the bare hardness of the fact, once stated, that it is not necessary to the life, only to the improvement of the hospital. This possible destruction of the school is not an imaginary catastrophe ; on the contrary it has occurred in more than one instance. As, however, not all political hospitals, even the most unscrupulous, are immediately likely to overthrow their training schools, and as not all private hospitals realize the ideal, there are some advantages claimed by the independent school over the others. For one thing, it is possible for it to become (as one of our largest schools is at this moment) self supporting; always a more dignified position than that of being supported, and to be so recognized. Moreover, it is free to live its own life, uninfluenced by what may be cramped and mean in that of the hospital, and to develop unhindered in whatever lines of progress may open up to it. But among those which are the personal property of hospitals of illiberal and narrow policy, what half-dead training schools we see their scope and possibilities closely repressed, their educational advantages selfishly restricted, their outlook limited and their influence a drag. How easily are the rightful claims of the school then sacrificed for the benefit of the hospital, and how difficult to defend themselves against injustice and even oppression when the relation is only that of owner and property. But beyond all this, the independent school has this advantage over the other, that the very isolation and difficulty of its work brings out and strengthens in it those hardy virtues, endurance, frugality, self-denial, and courage, which are not easily cultivated in a softer atmosphere…

On one field only does the school properly come under the command of the medical profession, and that is in the direct care of the sick. Here indeed the command is absolute. The whole purpose of the school centers around this point, and the pride of the well drilled nurse is to make this service perfect ….



Source: Dock, Lavinia Lloyd. “The Relation of Training Schools to Hospitals.” Papers and Discussion in the International Congress of Charities, Correction and Philanthropy. Baltimore: Johns Hopkins Press, 1894.