The American Battle for Control Over Standards of Nursing Education in Europe, 1918–1925

―The Idea of Better Nursing‖: The American Battle for Control over Standards of Nursing Education in Europe, 1918–1925 by Jaime Patricia Lapeyre A thesis submitted in conformity with the requirements for the degree of Doctor of Philosophy Graduate Department of Nursing Science University of Toronto © Copyright by Jaime Patricia Lapeyre (2013) ii ―The Idea of Better Nursing‖: The American Battle for Control over Standards of Nursing Education in Europe, 1918–1925 Doctor of Philosophy 2013 Jaime Patricia Lapeyre Lawrence S. Bloomberg Faculty of Nursing University of Toronto Abstract In the midst of the progressive era, American nursing and medical education witnessed tremendous reform. The increase in the number of hospitals during the early twentieth century brought a growing demand for nurses and led to varying standards in admissions and education within hospital training schools. In addition, the rise of the field of public health led to a campaign by a number of American nurse leaders to reform nursing education. This campaign included: the formation of several national professional organizations; gaining the support of prominent medical officials, including those close to the Rockefeller Foundation, an influential philanthropic organization; and successfully arguing against the sending of public health nurses overseas during the First World War. Although these steps were taken prior to the end of the war, the period immediately following the war, and the 1918 pandemic spread of influenza, provided fertile ground for reopening discussions regarding nursing education both nationally and internationally. Following the war, the involvement of numerous American-backed organizations, including the Rockefeller Foundation (RF), the League of Red Cross Societies (LRCS), and the American Red Cross (ARC), in the training of nurses in Europe highlighted the numerous ii iii and conflicting ideals of American nurses in regards to nursing education during this period. In particular, those who had campaigned for the training of public health nurses in the USA — led primarily by the formidable nurse Annie Goodrich — voiced differing ideals for the training of nurses than those American nurses who led the work of the RF, the LRCS and the ARC in Europe following the war. It will be argued here that, contrary to earlier theses that have suggested the spread of a singular ―American gospel‖ of public health nursing education, in fact there were several hotly contested ideas being conveyed in Europe by several different American individuals and organizations at this time. In particular, the RF‘s support of two opposing ideals — that of their own nursing representative, Elisabeth Crowell in Europe, and that of Goodrich in the USA — heightened this conflict. The eventual success of one set of these ideas depended on the alignment of congruent ideals in the training of health care professionals with influential individuals and organizations. Furthermore, this dissertation suggests that the outcome of this debate influenced the future direction of nursing education in both Europe and North America. iii iv Table of Contents List of Figures……………………………………………………………… v List of Appendices………………………………………………………… vi Chapter 1 Introduction..………………………………………………….... 1 Chapter 2 Organizing and Networking: The Pursuit of Public Health Nursing in the USA, 1912–1918………………………………….. 42 Chapter 3 Public Health Visitors or Public Health Nurses: Elisabeth Crowell and the Rockefeller Foundation in France, 1917–1920….. 76 Chapter 4 ―Rank Heresy‖: Growing American Conflict over the Training of Public Health Nurses in Europe, 1920–1923…………….... 96 Chapter 5 ―Wise as Serpents, Harmless as Doves‖: The Battle for Leadership of Nursing Education in Europe, 1923…………………… 141 Chapter 6 ―Elevating Influence‖: Asserting the Rockefeller Foundation‘s Approach to Nursing Education, 1925……………………. 177 Conclusion………………………………………………………………….. 224 Bibliography………………………………………………………………... 237 iv v List of Figures 2.1 Early twentieth century American nursing network, 1899–1912…………………… 49 2.2 Network of nurse leaders, 1912–1920………………………………………… 55 2.3 Public health nurse versus non-nurse health visitor…………………………. 70 3.1 Two-year bifurcated program as developed by Crowell ……………………... 93 4.1 Women delegates to the Nursing Section, Cannes Conference, 1919……….. 101 4.2 First class of graduates from League of Red Cross Societies International Public Health Nursing course………………………………………... 111 4.3 Telegram from Vincent to Crowell, February 28, 1921……………………… 124 4.4 ―Strasbourg Plan‖ vs. program suggested by the Committee on Nursing Education………………………………………………....132 v vi List of Appendices Appendix A: List of Primary Sources…………………………………………….. 246 Appendix B: Tabulated Statement Re: Pupils Admitted to Training Centres, January 1, 1919 to December 31, 1919……………………. 250 Appendix C: Recommendations by the ICN Advisory Board to the LRCS, 1924….. 251 vi Chapter 1: Introduction The era upon which we are entering is often spoken of as the age of preventive medicine. It will be most creditable to the present generation if historians, in the retrospect, accept the term as one properly applicable to the period. It is certain, at any rate, that much of the wisdom, the wealth, the energy, and the good-will of the present and of the rising generation, will seek outlet in the field of hygiene. What does this signify to the medical profession and to nurses? To my mind it signifies the gradual shifting to [the nurses‘] shoulders of much of the responsibility for dealing with disease which now rests upon the medical profession.1 In the opening decades of the twentieth century, at the same moment that the American medical community was grappling with the conclusions of the Flexner Report,2 nursing also found itself facing the issue of educational reform. The rapid increase in the number of hospitals in the USA had led to a growing demand for nurses, bringing with it varying standards in admissions and education within hospital training schools. In response, the leaders of nursing‘s professional organizations, the American Nurses Association (ANA) and the National League for Nursing Education (NLNE), stood to attention, calling for increased standards in both nursing education and practice. By 1910, medical officials such as Dr. S.S. Goldwater (quoted above) predicted a coming shift in the medical field from a focus on disease and sick care to one on prevention and hygiene. Goldwater suggests that with this change in medicine, the nursing profession will be required to cover the gap left in disease 1 Dr. Sigismund S. Goldwater, Proceedings of the Thirteenth Annual Convention of the Nurses‘ Associated Alumnae of the United States, NYC, May 19-20, 1910, American Journal of Nursing 10, no. 11 (1910): n.p. 2 Published in 1910, the Flexner Report was a survey of medical education in the USA, named after the principal investigator Abraham Flexner. The results of the survey suggested that there were too many medical schools in the USA, and that too many doctors were being trained. Flexner thus recommended the reduction in the number of medical schools from 155 to 31 as well as increased admissions standards and tighter state regulation of medical licensure. Although Flexner‘s report was contested by some, nearly half of all medical schools either merged or closed following the publication of this Report. Although some scholars have argued that the Flexner Report led to revolutionary changes in American medical education, others have argued that changes in education were a result of a mixture growing professionalism, increased private funding and the advancement of research techniques during this same period. 1 2 care, creating an expanding role for nurses. What Goldwater did not anticipate was the simultaneous drive within the nursing profession to also expand the nursing role into the area of hygiene and public health. This drive included the formation of a national organization on public health nursing, gaining the support of prominent medical officials — including those close to the Rockefeller Foundation (RF), an influential philanthropic organization — and successfully arguing against the sending of public health nurses overseas during the war. Although these steps were taken before the end of the First World War, the period immediately following the war and the 1918 pandemic spread of influenza provided fertile ground for reopening discussions regarding nursing education both nationally and internationally. The mass destruction caused by the First World War, compounded by the pandemic spread of influenza beginning in 1918, led to a devastating public health crisis which called for a major international relief effort. Numerous organizations, both national and international, became involved in the provision of relief in Europe during this period, which included programs aimed at the prevention of tuberculosis and other infectious diseases, as well as maternal and child health. However, the success of many of these programs was dependent upon the availability of trained nurses. Two American-led relief efforts, one by the RF and one by the League of Red Cross Societies (LRCS), became the largest providers of international training programs for public health nurses during the interwar period. Despite both of these initiatives being led by American nurses, intense debate developed over this period regarding standards in nursing education. Scholars have examined the involvement of American organizations in the training

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