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.

Now for the first time in the history of medical science can its orders be carried out faithfully, fully, and at all hours. The uselessness of expecting such obedience from even intelligent persons who have not been trained is well illustrated by the remark of a lady of position and education, concerning the orders given her by the physician for her child’s diet. “I shall do just half of what the doctor said,” she observed, “as I always make a discount for each doctor’s own particular fad.”

This obedience to orders, founded on principle and animated by an intelligent interest, is the dominant characteristic of the new system of nursing, and is the secret of its success in its professional work. Without it the most desirable and charming qualities would be useless to the nurse; but with it, the value of her practical work to the hospital is at once and widely demonstrated.

There is much evidence to show that the material prosperity of the hospital is largely due to the work of the training school. To just what extent this is true would perhaps be impossible to say, for where a dawning rationalism in medicine, antisepsis in surgery, a growing intelligence of public opinion, and trained nursing are con temporaneous, each stimulating and being stimulated by the others, no one could candidly ascribe results to one isolated influence. Yet, whether it be only a coincidence or not, in this country, at least, a definite impetus and advance in hospital work dates from the foundation of trained nursing. The testimony received from over forty hospitals is unanimous on this point, not one exception having been met with. “Our results are better both in medicine and surgery,” they say; “the work of our hospital has extended in every direction. There is a marked diminution of the popular dread of hospitals. Private patients come in greater numbers, and many ascribe their willingness to enter to the presence of the nurses. The difference in the general comfort and happiness of the patients alone would be enough, if there were nothing more, to secure the gratitude of the hospital to the school, while the difference in the death-rate marks an era in the treatment of the sick.”

To illustrate these general statements, the experience of two small hospitals, selected at random, may be cited. One, a hospital for children, had for years under the old regime the character of an orphan’s home. Thirty or forty little ones with chronic diseases collected in it; acute or serious cases were rare; operations infrequent; public interest was languid. Within three years after the introduction of trained nursing, the medical staff and general management being unchanged, new wards were built, an operating room was added, and an active service of acute medical and surgical cases kept 80 beds constantly filled and constantly changing. The other is a hospital for gynecological and obstetrical patients. In former times only those applied who had no other resource, and half the beds were empty. The nursing was reformed. A few years after the change the statistics showed in one year 38 operations and 143 births; the same number of year safter the change, 144 operations and 257 births. Such facts show the practical value of the school in a strong light, and tend to modify the statement sometimes made by hospital boards that the school is an expensive luxury. The difference made in the value of the hospital as a field for clinical medicine is alone sufficient to repay the debt of the school. The actual cost of the school is not always easy to demonstrate. Hospitals supporting their own schools do not as a rule keep separate accounts, and the only definite statistics to be found are those of the independent schools, which receive so much from the hospital for services rendered. The old plan of nursing cost much less than the new. Nurses were paid from $12 to $20 a month; two or three were considered enough for 30 or 40 patients, for as they could do but little, but little was expected of them. Their lodgings were in any spare corner of the hospital, and their table was coarse and cheap. But in the race of competition this economical system had to be given up for one that would give better results, and the hospitals had to consider the practical question of how to get their nursing done. To secure graduate work would be at this stage an impossibility. The supply is not sufficient; moreover, the graduate who receives on an average of $20 a week at private duty, naturally will not toil for an hospital for a smaller sum, unless some inducement is offered, such as a position of responsibility, or further training in the line of some specialty. Even leaving the money out o the question, it would be precarious to attempt the nursing of a general hospital, or even a ward, with graduates, for their different methods would produce irregularity and unevenness in the work, and their independence of the hospital would permit untimely changes and general insecurity. The training school offers the hospital the most practicable way out of the difficulty. The expenses are undoubtedly large in comparison, for while the actual sum paid monthly to the pupils as an allowance is, per capita, smaller than that paid the old-time nurses, yet the number necessary to do the work according to a revised standard is fully three times as large.

Moreover, comfortable and healthful surroundings and proper food are now understood to be necessary pro visions to make for nurses, and finally, some expense must be incurred for theoretical instruction, so that the whole difference in cost may be roughly estimated as about I to 5. Nevertheless this plan offers the hospital distinct advantages. The training school is a flexible instrument, and though more expensive than the old method, is less so than graduate nursing would be. The promise of an education secures a steady supply of intelligent women, thus eliminating all uncertainty on that score. The discipline and strict subordination of the school make it possible for the hospital to exact from it an amount of work which it would be quite impossible to demand from women over whom it had no special hold; while the chain of responsibility and the careful supervision of the school secure an average quality of work as good, if not even better than that which would be obtained from nurses working merely as employees.

Practically, then, the hospital secures nursing for $12 a month on its pay-roll, which at its market value would bring at least $15 a week, while the living expenses are little or no greater in the one case than in the other, the cost of lectures and educational appliances being the only additional outlay in the support of the undergraduate school. There are those hospitals which, in the desire to economize, find ways of minimizing cost at the expense of the school. The outlay for teaching purposes is cut down, and the number of nurses reduced by giving to each the longest possible hours of duty. Yet in comparison with hospitals and training schools in other countries, it is gratifying to find how much more generous a spirit is, on the whole, shown in those of our own country. Among the foremost there are comparatively few, and among the most prominent only one or two, that make their nurses a source of revenue by working them outside. The returns on this point are imperfect, yet are sufficient to show there are many small hospitals compelled by actual poverty to bring in an income from private duty, and others where poverty is less evident and where the school is evidently founded on a mercenary basis; while among those that are larger, yet still not in the front rank, one reports earnings covering one-eighth of its expenses; two earn two-thirds each; three earn one-half each; while two schools report earnings which cover almost the entire cost of their maintenance and tuition. In  other words, these different schools bring in incomes varying from $300 to $5000 and $6000 a year. In the two latter cases it is quite evident that the schools, besides giving the hospitals an amount and quality of work which the hospitals could not possibly secure if they had to pay for it, really support themselves and pay for their own tuition at the same time — a rather remarkable arrangement, one must confess, and one which the hospital surveys with the utmost complacency, keeping the school in the meantime in an attitude of the strictest subserviency, as though the hospital were the benefactor and the school the grateful recipient of benefits. A survey, then, of the whole subject compels one to believe that financially the school is not the debt or of the hospital. Although it is costly, yet its economic value is not measured by the dollars spent upon it. Its part in building up or adding to the prestige of the hospital is not computed and paid for, yet it is vast, and has a definite money value in there turns of the hospital.

Of all the attributes of the school its moral strength is the most easily demonstrable, and its reformatory work is the part of its whole work in which it can most securely stand on its own merits. Other forces may seek to divide with it the diminished death-rate and better results in medicine and surgery, but the changes wrought in the moral atmosphere of the once foul old hospitals we have all known of are peculiarly and entirely its own. Those who know the internal affairs of institutions are aware that people outside can form no idea of what conditions formerly existed within the walls of, say, some great city hospital where the city paupers were collected. The misery of the neglected sick was one thing, the depravity and moral degradation another. The one could be described; the other was indescribable. The badness was worse, even, than the sufferings of the sick, for they ended with death. No nurse who has had some such hospital service could eve r tell all of her experience, yet she has gone in and worked through many such places, and they can never again return to what they were before. In these old hospitals the medical profession labored unselfishly over the diseases of the body; ministers of the church passed in and out and strove with souls; charitable women brought flowers and food and a temporary cheer fulness, but degraded and vile they remained throughout until the youth, strength and energy of the training school assailed them and, by coming to live among them, transformed them. “This place used to be like hell,” said an old hospital patient to the newly established nurse, “but now it is like heaven.”  

Even among hospitals of the better class have been found many where, under an outward appearance of decorum, there was rampant a coarse vulgarity, or an utter lack of principle, or a spirit of tyranny, from the highest to the lowest. These have presented the most difficult and delicate tasks of regeneration, for such evils are subtle, resistant, and well organized. Many battles have been fought by the training schools against all these hostile forces; battles of which few people will ever know. Many victories have been gained, each one of which makes the future easier and more promising. Many nurses have laid down their health, or their lives, in such struggles, as uncomplainingly as the soldier in time of war.

The last division of my subject, the responsibility of the hospital to the training school, and the way in which the school meets the demands of the hospital, will be so forcibly treated in another paper that it is not necessary to take it up here. It will be shown that the whole responsibility of the hospital is to give the school a thoroughly good education and time in which to assimilate it. It will be shown that the shortcomings of the school are largely due to imperfect preparatory training, and to the crowding of work and study into the short period of two years time. With a fuller comprehension on the part of the hospital of the real work and the actual purposes and the aims of the training school, and with renewed patience and energy on the part of the school, there will gradually die away that mistrust on the one hand, and something like aggressiveness on the other, which have marked the relative relations of many hospitals and schools, and which are already beginning to disappear. In the cordial co-operation of the future, as outlined in the paper mentioned, lies the hope of those who are working toward what they know to be the possibilities of nursing.

Source: Papers and Discussion in the International Congress of Charities, Correction and Philanthropy, Section III, Chicago, June 12th to 17th, 1893 (Baltimore: Johns Hopkins Press) 1894.