The beginning of the twentieth century brought about changes that have influenced contemporary nursing. Several landmark reports about medical and nursing education, as well as some contemporary reports, are discussed in the fol- lowing text. The establishment of visiting nurse associations and their use of protocols are discussed.
Flexner Report
With the support of a Carnegie grant in 1910, Abraham Flex- ner visited the 155 medical schools throughout the United States and Canada to assess the level of accountability in med- ical education and to bring about necessary reforms. The Flex- ner report brought about the following changes: closure of inadequate medical schools, consolidation of schools with lim- ited resources, creation of nonprofit status for the remaining schools, and establishment of medical education in university settings based on standards and strong economic resources.
Adalaide Nutting saw the value and impact of the Flex- ner report on medical education and, in 1911, together with other colleagues of the Superintendents’ Society, presented a proposal to the Carnegie Foundation to study nursing educa- tion. This foundation never allocated monies to study nurs- ing education, but it supported educational studies in other disciplines such as law, dentistry, and teaching.
Although the efforts of Nutting and other nursing lead- ers went unheeded, in 1906 Richard Olding Beard success- fully established a three-year diploma school of nursing at the University of Minnesota under the College of Medicine.
Early Insurance Plans
At the turn of the twentieth century, there were more than 4,000 hospitals and 1,000 schools of nursing. During this time, the concepts of third-party payments and prepaid health insurance were instituted. Third-party payments refer to sit- uations in which someone other than the recipient of health care (usually an insurance company) pays for the health care FIGURE1-6Mamie HalePHOTO COURTESY OF HISTORICAL RESEARCH CENTER,
UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES LIBRARY, LITTLE ROCK
services provided. Prepaid medical plans were started in Pacific Northwest lumber and mining camps, where employ- ers contracted for and paid a monthly fee for medical services.
This led to the establishment of the Bureau of Medical Serv- ices, where the employer contracted for medical services and the subscriber selected one of the physicians in the bureau.
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LUEC
ROSS ANDB
LUES
HIELD.
The Depression pro- vided the main impetus for the growth of insurance plans. In addition, the American philosophy of health care for all con- tributed to the growth of insurance plans. In 1920, American hospitals offered a prepaid hospital plan that led to the ‘‘Baylor Plan,’’ which eventually became the prototype of Blue Cross.Blue Cross was the result of a joint venture between hospi- tals, physicians, and the general public. The American Hospital Association (AHA) pioneered the development of an insur- ance company to provide benefits to subscribers who were hospitalized. Blue Shield was developed by the American Med- ical Association (AMA) to provide reimbursement for medical services provided to subscribers. In 1933, the AHA endorsed Blue Cross, and in 1938 the AMA endorsed Blue Shield.
The federal government became more involved in health care delivery in 1935 with the passage of the Social Security Act, which provided for (among other things) benefits for the elderly, child welfare, and federal funding for training of health care personnel. During World War II, the U.S. govern- ment extended the benefits for military services to include health care for veterans and their dependents.
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ISITINGN
URSESA
SSOCIATIONS.
In 1901, at the sug- gestion of Lillian Wald, the Metropolitan Life Insurance Company, which provided visiting nursing services to its pol- icyholders, entered into an agreement with the Henry Street Settlement. Wald worked with Metropolitan to expand the services of the Henry Street Settlement to other cities; thus, one form of managed care began.Nurses providing care in the home environment experi- enced greater autonomy of practice than hospital-based nurses (see Figure 1-7). This led to conflicts with some physicians regarding the scope of medical practice versus nursing practice parameters. Some physicians thought nurses were taking over their practice, whereas other physicians encouraged nurses to do whatever was necessary to care for the sick at home.
In 1912, in an effort to provide direction to home health staff nurses, the Chicago Visiting Nurse Association devel- oped a list of standing orders for nurses to follow in provid- ing home care. These orders were to direct the nursing care of clients when the nurse did not have specific orders from a physician. Thus, the groundwork for nursing protocols was established.
Landmark Reports in Nursing Education
During the first half of the twentieth century, a number of reports were issued concerning nursing education and prac- tice. Three of them, the Goldmark, the Brown, and the Institute of Research and Service in Nursing Education reports, are discussed here.
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OLDMARKR
EPORT.
In 1918, Adelaide Nutting, relent- less in her efforts to document the need for nursing education reform, approached the Rockefeller Foundation for support.Funding was provided and, in 1919, the Committee for the Study of Nursing Education was established to investigate the training of public health nurses. E. A. Winslow, professor of public health, Yale University, chaired the committee, com- posed of 10 physicians, two lay persons, and six nurses: Ade- laide Nutting, Mary Beard, Lillian Clay, Annie Goodrich, Lillian Wald, and Helen Wood. Josephine Goldmark, a social worker, served as the secretary to the committee.
As secretary, Goldmark developed the methodology of data collection and analysis for a small sampling of the 1,800 schools of nursing in existence. The study of 23 of the best nursing schools across the nation represented a cross-sample of schools—small and large, public and private.
The Goldmark report, entitledNursing and Nursing Edu- cation in the United States,was published in 1923. Goldmark identified the major weakness of the hospital-based training programs as that of putting the needs of the institution (serv- ice delivery) before the needs of the student (education).
Nursing tradition and the apprenticeship form of education reinforced putting the needs of the client before the learning needs of the student.
Some major inadequacies identified in nursing education by the study were limited resources, low admission standards, lack of supervision, poorly trained instructors, and failure to correlate clinical practice with theory. The report concluded that for nursing to be on equal footing with other disciplines, nursing education should occur in the university setting.
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ROWNR
EPORT.
In 1948, Esther Lucille Brown, a social anthropologist, publishedNursing for the Future and Nursing Reconsidered: A Study for Change. Several recommendations were put forth in this study, including the need for nurses to demonstrate greater professional competence by moving nursing education from the hospital to the university setting.Although published 20 years after the Goldmark report, the Brown report identified many of the same problems in FIGURE1-7A baby being weighed by a student nurse and a Junior League volunteer in 1929PHOTO COURTESY OF TOURO INFIRMARY ARCHIVES, NEW ORLEANS, LA
diploma education—nursing students were still being used for service by the hospitals, and inadequate resources and authori- tarianism in hospitals still prevailed in nursing education.
Brown recognized that nursing education in the univer- sity setting would provide the proper intellectual climate for the professional. Visionary nurse educators were securing necessary learning resources: libraries, laboratories, and clini- cal facilities. Professional endeavors such as research and publication were being implemented by nurse leaders.
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NSTITUTE OFR
ESEARCH ANDS
ERVICE INN
URSINGE
DUCATIONR
EPORT.
During the 1950s, there was a deficit in the supply of nurses as the post–World War II demand for nursing services increased. Some contributing factors to the dearth of nurses were the low esteem of nurs- ing as a profession, long hours with a heavy workload, and low salaries.The Institute of Research and Service in Nursing Educa- tion report resulted in the establishment of practical nursing under Title III of the Health Amendment Act of 1955. There was a proliferation of practical nursing schools in the United States to increase the supply of nurses.
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ANADIANR
EPORTS.
Through the joint efforts of the Canadian Nurses Association and the Canadian Medical Association, a nationwide study of nursing education in Can- ada was established in 1929. Under the leadership of George M. Weir, MD, the study pointed out serious weaknesses that existed in the hospital schools of nursing. TheSurvey of Nurs- ing Education in Canada (1932), also known as The Weir Report,recommended the following reforms: a higher educa- tion standard, increased affiliations between schools, increased employment of graduate nurses, student tuition, and qualified faculty (Donahue, 1985).In 1936 the National Curriculum Committee of the Ca- nadian Nurses Association published The Proposed Curricu- lum for Schools of Nursing in Canada. ‘‘The study and the later Supplement became valuable guides to assist with the establishment of a sounder educational foundation for nurs- ing in Canada’’ (Donahue, 1985, p. 391).
Contemporary Reports
During the 1980s, several important studies were commis- sioned to examine the areas of nursing education and practice.
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ATIONALC
OMMISSION ONN
URSING.
The National Commission on Nursing was created in 1980 by the AHA, the Hospital Research and Education Trust, and the American Hospital Supply Corporation to study nursing education and related issues in hospital management, nursing practice, and nursing education. The commission’s conclusions addressed the need for:• Adequate clinical education for students
• Baccalaureate education and educational mobility
• Involvement of nurses in collaborative institutional and clinical decision making
• Improved working conditions, specifically, salaries, flexible scheduling, and differentiated practice
As a result of the commission’s study, attention was given to the need for prescribing practitioners and nurses to enter into collaborative practice.
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NSTITUTE OFM
EDICINE.
Concurrent with the National Commission on Nursing study, another study was initiated by Congress in 1979 and conducted by the Institute of Medicine (IOM). The study, Nursing and Nursing Educa- tion: Public Policies and Private Actions, focused on the need for continued federal funding to nursing education.The findings indicated that there was not a shortage in the general supply of nurses, but there was a serious shortage of nurses in research, teaching, administration, and advanced clinical practice. A significant nursing shortage existed in pre- ventive and primary care for older adults and disadvantaged people in inner cities and rural areas.
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ECRETARY’
SC
OMMISSION ONN
URSING.
Although the IOM study indicated that there were sufficient numbers of staff nurses, based on supply and demand, hospitals con- tinued to report severe shortages. As a response to hospitals’recruitment and retention challenges, Health and Human Services Secretary Otis R. Brown, MD, established the Secre- tary’s Commission on Nursing, which made the following recommendations related to nursing practice:
• Nurse compensation
• Health care financing
• Nurse decision making
• Development, use, and maintenance of nursing resources This commission recognized that the federal govern- ment alone could not correct the problems facing nursing and health care but rather that the concerted efforts of health care organizations were needed for the implementation of the report’s recommendations.
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EALTHYP
EOPLEI
NITIATIVES.
Healthy People initia- tives have become the nation’s health agenda. These initiatives began with a report entitled Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention in 1979. The report described Healthy People as the nation’s health agenda to guide policy on public health initiatives for health promotion and disease prevention activities during the decade 1980–1990. See Chapter 16 for a complete discussion of Healthy People initiatives.P
EWH
EALTHP
ROFESSIONSC
OMMISSION.
The scien- tific base for nursing practice demands competencies (the ability to function in a particular way) from multiple sources:philosophy and ethics; physical, economic, behavioral, and social sciences; nursing science; and biomedicine. Additional competencies in collaboration, coordination, and the interdis- ciplinary practice activities of exchanging knowledge and techniques are critical to nursing practice and health care delivery. These competencies raise questions about the sin- gle, discipline-specific method of educating the nursing work- force and offer alternative scenarios for nursing education.
The Pew Health Professions Commission (O’Neil, 1993; Pew Health Professions Commission, 1995; Shugars,
O’Neil, & Bader, 1991), in its widely referenced and distrib- uted reports, has recommended that academic institutions investigate whether the providers of educational experiences in health care are addressing the needs of clients. See the accompanying display that lists the Pew Health Professions Commission’s Health Care Professionals’ Competencies.
Nursing leaders have embraced these competencies as consistent with the values and issues raised inNursing’s Agenda for Health Care Reform(ANA, 1991). To ensure that the nurs- ing workforce is educated sufficiently to demonstrate these competencies, schools are being challenged to redefine their educational core. To accomplish this goal, schools of nursing, health science centers, and institutions of higher education are refining mission statements, developing strategic plans and implementation activities, and examining curriculum activities, faculty competencies, educational methods and technologies, and sites and populations for clinical experiences.