1. The Limits of Collaborative Relationships By: E. Brian Hall

2. The following presentation will illustrate nursing as it existed through the early 1900’s and into the Great Depression, as well as the challenges faced through these difficult times and how collaboration was sought.

3. The “Limits of Collaborative Relationships” began through varied opinions of what constituted a “nurse”. Hospitals in the early 1900’s grew by over 50% and nursing by over 700%, causing much debate over what was ultimately best for the care of society and nursing.

4. The Debate in the Early Stages  Annie Goodrich believed in the profession of nursing. She believed in professional nurse training, which included civilian training, training courses for currently educated college women, and also an Army school for nurses.  The other side was the American Red Cross, which aligned with Dr. S.S. Goldwater and believed nurse aides should come from volunteers. Goldwater believed in having women from a more educated and wealthy lifestyle be nurses so after the war they could return to their lives and leave nursing to the professionals.  Both agreed in the college educated, but had varied views of how to reach their goals Goodrich wanted to keep the college educated women in nursing, while Goldwater wanted them to return to their pre-war lives. Ultimately Annie Goodrich won, however, the Army initially rejected the school, but within months approved it.  Eventually we will see a complete change and progression in nursing through an established grading and evaluating committee.

5. Civilian Nursing and the Flu Pandemic  The flu pandemic caused more deaths than World War I (WWI) and posed a valid question to the nation: Do we have enough nurses?  Toward the end of the war, the Red Cross sought to reinstate it’s plan of using aides to fill the voids caused by the Flu.  The shortage of nurses looked like it would be a benefit, however, it turned out to be a negative. The idea of using a cheap worker or servant re-surfaced.  Dr. Charles Mayo of the Mayo Clinic sought to lower the requirements for nurses and appeal to women that were “born to nurse”.  However, nursing leaders refused Mayo’s idea and aligned with influential college and medical professionals as they responded to Dr. Mayo.

6. The Great Hope for Nursing Nursing headed in a new direction around 1920 when the Rockefeller Foundation sought to improve medicine and the public’s health. Through Josephine Goldmark and the Goldmark report, nursing would see some recognition. The report outlined a need for increased science courses, a standard time for instruction, funding, and a replacement of students in hospital based programs with graduate nurses. An opponent of Goldmark was Winford Smith he disagreed with the training, comparing it to medical school, even arguing that medical schools were moving from a theoretical training to a practical training. Now nursing was moving into theory and out of the practical training. Smith, however, did agree nurses should trained, but not by sacrificing the needs of the hospital. The debate continued about the subsidiary worker, as Goldmark argued for different grades of service to leave the nurse available to make quick decisions.

7. Hope & The Subsidiary Worker Mary Beard a nursing association director and other leaders in the nursing profession agreed nurses should have less skilled workers who were responsible for the delivery of patient care. However, many in nursing opposed this idea and wanted no less trained workers. Again nursing leadership was at a disagreement of what was best for nursing. Some worried these “less skilled” workers would be mistaken as nurses.

8. Grading and the National League of Nursing Education The National League of Nursing Education Committee (NLNE) received Goldmark’s report and began pushing forward with financial and political support. About the same time the American Medical Association (AMA) was seeking to evaluate nursing curriculum as well. The AMA finally agreed to a joint committee including representatives from Columbia University, Johns Hopkins Hospital-Winford Smith, and individuals from other major health organizations. In 1926, these groups completed the formation of the Committee on the Grading of Nursing lasting a period of eight years. By the end of the report the committee found issues with nursing, such as under educated personnel, dissatisfaction with work, and an average retention in the profession of only 17 years. The AMA responded that they disagreed nurses needed to be college educated.

9. Grading and the National League of Nursing Education Continued During the grading period the committee was met with public attitudes such as “Why don’t you nurses do what the doctors tell you to do?” This was an attitude of a population without a true understanding of nursing and nursing’s responsibility. By the second grading, nursing schools responded to 75 items on the committees questionnaire and over 80 percent of schools were participating. However, the grading committee had fallen short in educating the public on the best schools for nursing. The grading process had some success but standards outlined were somewhat restrained. Through the Depression the committee hoped the weaker schools would be closed from lack of funding. It seemed the grading committee and nursing were fraught with continued debate over what was right for the profession.

10. May Ayers Burgess Summation of the Committee’s Work Burgess believed in better training for fewer nurses and felt that the committee pushed for overproduction. Overproduction caused a dissatisfaction in the nursing profession and a decline in morale. Burgess also felt the women going in to nursing were undereducated, not professional, dropouts, and less inclined to accept leadership from their more educated counterparts. She sought to keep these low socio-economic, undereducated women out of nursing. Adelaide Nutting was tiring from so many of the same issues resurfacing in nursing and worried the committee had failed at enacting change. The American Nurses Association in 1932 also was frustrated and pushed for nursing to get organized and take hold of its problems.

11. In Conclusion The Depression was worsening and by 1932 it was estimated that over 60% of nurses were unemployed. Many ideas and people had worked through WWI and the Depression to improve nursing and establish standards. In the end the committee determined that there were too many nurses of varied experience, not enough trained, and not enough professionally minded nurses. The hospitals now were unable to staff using volunteers, or hospital nursing students and needed to seek a viable option. The nursing system tried to collaborate between many ideas and agencies through times that were troubled, but it led to no real improvements in the end.

12. References Nursing. Retrieved November 29, 2013, from https://www.google.com/images. Reverby, S. M. (2004). Ordered to care. New York, NY: University of Cambridge.