Nursing the Great Society: The Impact of the Nurse Training Act of 1964

Abstract

This article, first presented as the Kate Hurd-Mead Lecture, is one aspect of my exploration of twentieth-century transformations in American nursing practice and education. At times I am tempted to argue that there are two distinct eras in the history of nursing; a ninety-year history from about 1860 to 1950, followed by a fifty-year history from 1950 to the turn of the present century. Of course, I won't pursue that, because it is a kind of nonsense. But I am fascinated by the busy decades after World War II. Indeed, the period between 1950 and 1980 was a time of erratic but fundamental change in every arena of nursing. What we see by 1950 is a public and professional consensus about two things related to the nursing profession in the United States. Most nurses were not well enough educated for the demands of their work. And, in any case, nurses were too scarce to meet the rising health care expectations of Americans. These complaints about nursing were not new. What was new was both the political energy and an emerging set of public/private coalitions willing to do something about it. I will return to this later. First, though, I want to look briefly at two influences inside nursing that I think helped channel reform; we can see these influences at work beginning in the 1930s. Influences inside Nursing The more obvious of the two internal influences was the gradual development of staff nursing in hospitals. Fully trained but poorly paid nurses ultimately replaced the pupil nurses who, since the inception of organized nursing, had been the main caregivers for hospital patients. As hospitals hired graduate nurses, the orientation of nursing practice changed from the earlier entrepreneurial private duty model, where the patient paid the nurse, to an institutional model, where the patient or insurance company paid the hospital for the work of the graduate nurse on its staff. This transition from entrepreneur to employee might have worked out all right for nursing. Unfortunately, for the first twenty years or so, the design of staff nursing in hospitals mimicked the inhibiting style of the traditional nurse training school. The early conception of staff nursing placed heavy emphasis on supervision, hierarchical relations, and procedural conformity. It stifled the investigation of problems and certainly did not encourage innovation in nursing practice. In turn, such an unsatisfying and inadequate nursing system led to an incessant turnover of nurses in hospital work and severe quality problems in patient care. Thus, a system of top-down control originally designed to manage pupils caring for the sick and intended to ensure safety for patients became more and more dysfunctional. The strains and shortages of World War II effectively prevented attention from being given to these problems, and they remained to plague the nursing and hospital leaders of the 1950s. In spite of the problems in staff nursing, however, the field slowly abandoned its largest work group, private duty nurses, in favor of hospital-paid staff work. The other influence on nursing dating from the 1930s was a nascent challenge to the traditional, authoritative teaching of nursing commonly found in the hospital-based training schools that dominated nursing education. The traditional curriculum emphasized learning standard methods of doing the work: ward management, medical diagnosis and treatment, and sanitation. Challenges to this tradition came from a few nurse faculty members such as Martha Ruth Smith at Simmons College and Virginia Henderson at Teachers College, Columbia University (later at Yale University). There seem to be two faces to their critique of education for nurses. First, they argued that nursing education should be about studying nursing practice and changing the way nurses cared for patients, not about preserving a traditional, authoritative standard of care. That is to say, for them, learning nursing meant developing the ability to give a provable reason for taking nursing action in a particular instance. …