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Between the Lines

Finding the Female Labor Story Inside A Coffee-Table Book Celebration Of Hopkins School Of Nursing

FINDING THEIR VOICES: (from left) Jeanne Borowicz, Dana Cohen Dias, and Karen Shank (class of ‘78) administer some silent treatment in a photo from Our Shared Legacy.

By Rebecca Alvania | Posted 10/4/2006

Earlier this summer the Johns Hopkins University Press published Our Shared Legacy: Nursing Education at Johns Hopkins 1889-2006, a chronicle of the evolution of the Hopkins School of Nursing. Edited by Mame Warren, director of Hopkins History Enterprises, a large portion of the book is an unsurprisingly self-congratulatory reflection on the great names in nursing who have graduated from Hopkins (the book was published in association with the School of Nursing Alumni Association). Yet nestled within it is also the story of a tumultuous battle waged for decades between the Hopkins nursing training program and Hopkins’ hospital and university powers-that-be. Though interesting as local history, Our Shared Legacy’s poignancy comes from the anecdotes and interviews with Hopkins nurses that illustrate the struggles they went through over the years to earn respect within one of the world’s most famous hospitals. These stories illuminate underlit and sometimes contentious histories of a university hospital that prides itself on being the best of the best.

The nursing program at Hopkins began at the behest of Johns Hopkins himself in the latter half of the 19th century. Written into his will were instructions on the foundation of a hospital and a university, with a diploma training school for female nurses attached to the hospital. At the time, the 1870s, student nurses served as the workhorses for the hospital. In addition to their classes, the students learned by simultaneously serving as nursing staff for the hospital.

"There was always this battle between education and service," remembers Trudy Hodges, a Hopkins alumna, in the book. "But when you realize you’re the only staff on the floor, you know you’re being used for service."

This service included 56-hour workweeks that involved doing much of the scut work in the hospital. In the early days student nurses were responsible for the cooking and housekeeping in the hospital as well as patient care, working seven days a week, and taking their classes in the evening. The intensive, apprenticeship-style training was grueling but made Hopkins one of the best nursing schools in the country.

The nursing school was financially dependent upon the hospital in its early years, an arrangement that resulted in education in return for service, which administrators recognized early on worked out better for the hospital than it did for the nurses themselves. Attempts to improve the training program’s scholastic elements were not a hospital priority, which made it clear that it relied on the nurses for their ability to shoulder a large workload but weren’t as interested in their intellectual contributions to medicine.

Ada Davis, an associate professor at Hopkins School of Nursing, tells Warren: "Nurses were always considered second-class citizens. Nursing was not regarded as a profession. . . . We were tolerated because we did a lot of the work and took care of the patients. . . . That was true here and it was true in every other hospital in the country."

Warren’s Legacy details the growth and changes that occurred to the Hopkins nursing program from its 1889 inception throughout the early 1900s, and one of the constant themes is nursing superintendents’ ongoing push to provide students with a stronger education in addition to the skills they learned on the wards. In 1920 the Committee for the Study of Nursing Education was funded by the Rockefeller Foundation to look at training programs across the county and make recommendations for nursing education’s future. Its report, known as the Goldman report, was published in 1923 and stated, "the training of nurses is an educational endeavor and should be supervised by educators, not just practitioners." The committee also recommended that nursing schools should be located in universities as opposed to hospitals to facilitate this switch to an educational emphasis.

This change meant that nursing schools could offer baccalaureate degrees rather than mere hospital diplomas, allowing them to continue to attract top candidates as college degrees became more commonplace and necessary for workplace advancement. Many schools adopted this approach early on, Yale being the first in 1924, but Hopkins resisted and ultimately wouldn’t meet this standard for another 60 years.

And one major point of contention for the university was that the undergraduate student body was all-male up until 1970. "[T]hey thought they would be lowering standards by letting in these nursing students," Paula Einaudi, former director of development for Johns Hopkins University School of Nursing, explains to Warren. The presence of nursing students on campus would be "going against the mandate of the university by admitting women to the undergraduate program."

From Betty Borenstein Scher, a Hopkins nursing alumna: "When Miss [Anna] Wolf [director, School of Nursing, 1940-’55] pushed for a collegiate School of Nursing, one of the things they told her was that nurses don’t have the intellectual ability that meets the Hopkins standard."

In addition to the university’s hesitation to change its admission rules, Hopkins Hospital physicians had their own reasons for not supporting a switch to a nursing baccalaureate program. Diploma-trained nurses had provided Hopkins physicians excellent support for years, and the doctors resisted requests to institute changes to a training program with which they were already happy.

While the institutional wrangling within Hopkins continued, the School of Nursing’s diploma program was becoming obsolete across the country as other nursing programs gradually began to trade in their hospital-based training for baccalaureate degrees. In the book, Stella Shiber, the first associate dean of undergraduate education at Hopkins University School of Nursing, brings up the fact that across town from Hopkins was another hospital diploma school, the University of Maryland, which switched to the baccalaureate program in the 1950s, and its graduates were soon more competitive in the marketplace than Hopkins’.

Almost contemporaneously, the end of World War II heralded a nationwide nursing shortage that further exacerbated the School of Nursing’s problems. Post-war, women could earn almost twice as much as seamstresses as they could as registered nurses, resulting in more than 40,000 nursing vacancies by 1948.

Eventually, admission standards were lowered in order to keep enrollment levels high, which resulted in the school being plagued with high attrition rates due to academic failures throughout the 1960s. Finally, in March 1970, a report that laid out the school’s then-current state, titled "The Future of the School of Nursing," was circulated to the school’s advisory board. The numbers of applications and graduates was in a state of constant decline, as was the ability to attract competent faculty. The report suggested only two possible futures: accept mediocrity or close.

Einaudi elaborates on the problem in the book: "These feisty alumni said, ‘We have a choice here. We either continue as a hospital school and watch the caliber of the students continue to go down until the school of nursing becomes--heaven forbid--second-rate, or we close the school.’ The alumni were actually in favor of closing the school rather than see further deterioration."

After much discussion, a proposal to close the school was recommended to the hospital board of trustees, which approved a plan to shut down the school, effective June 1973.

After this setback, a few attempts were made to rebuild a successful nursing program at Hopkins. Kay Partridge directed one such effort, when a Nursing Education Program was initiated within the School of Health Sciences. The program ended up closing in 1979 after struggling with accreditation and a particularly unsupportive physician dean. As Partridge says in Legacy: "At Hopkins, physicians are god. . . . It’s just a fact of life. They assumed the doctors could take care of everything. It was their world and their resources. . . . It’s just how they viewed the world."

Eventually, the tides shifted. The School of Nursing Alumni Association unrelentingly pushed for the formation of an accredited and respected school of nursing, and advocates for a strong nursing program gradually emerged from within the hospital administration. Ultimately, continued nursing shortages and the lack of a strong in-house training program had negatively affected the hospital to the point that in 1981 rumblings of a baccalaureate nursing education program at Hopkins re-emerged.

In the book Shiber recalls that "Hopkins had to rely on somebody else to educate nurses. It got to be harder and harder to recruit to the hospital the kind of people that they really needed to make the whole picture complete. If you are one of the top hospitals, nursing is an extremely important part of that hospital."

In 1984 the School of Nursing reopened within the Johns Hopkins University as a baccalaureate program. The need for highly educated and qualified nurses finally appeared to be recognized, but some physicians’ attitudes toward nursing education remained largely unchanged. Shiber recalls to Warren resistance to recognizing nursing as an area of specialized expertise: "When I was putting the curriculum together . . . I told the chairman about the curriculum, [and] he interrupted me. He told me that they were the expert teachers and that they would decide what the nurses needed to be taught. I was stunned. I had my doctorate and I’d been an educator for twenty-five years. The whole time he called me Ms. Shiber. He’s the only person in my whole career to whom I’ve ever said, ‘Excuse me, that’s Dr. Shiber.’ He was absolutely typical. . . . Their sense of collaborating or helping was, ‘We’ll tell you how it should be done.’"

Despite the early hurdles, the nursing program that opened in 1984 has been a huge success. Today the School of Nursing offers not only a baccalaureate degree but also master’s degrees, combined degrees with a business administration or public health master’s, and Ph.D.s with research in subjects ranging from chronic disease to domestic violence. In 2005 Jerilyn Allen, RN and associate dean of research at the School of Nursing, received $2.5 million to study cardiovascular disease, the largest grant in the school’s history.

Warren’s Legacy does an admirable job of providing an exhaustive account of the struggles that Hopkins nurses went through to be respected as peers and skilled medical professionals in the health-care system. It’s filled to the brim with facts and dates and portraits of famous faces in Hopkins nursing history. But the most interesting story is what is interspersed throughout, the frustration and the determination in the voices of the women interviewed, the candid photos that show the realities of nursing life and how the field has changed over the past century. These are the things that prove Warren’s thesis most effectively--that skilled nurses have always have been, and always will be, one of the most critical components in hospitals, whether doctors want to admit it or not. H

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