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The Evolution of Orthopaedic at the Hospital for Special Surgery The First Orthopaedic Institution in the United States

Barbara A. Kahn

The history of nursing began in London in the late 1800s with Orthopaedic nursing continues to evolve in a professional the reform of unsanitary conditions by Florence Nightingale. partnership with the Hospital for Special Surgery, a pre- During the same period, the United States was bitterly fighting mier orthopaedic institution in New York City, which was the Civil War. Nursing had not developed as a profession, the first orthopaedic hospital founded in the United States. and most of the duties performed by nurses were conducted by men. Casualties of war required rehabilitation and care. The Beginning of the Modern Crippled children were left to die because they were considered Nursing Movement a burden to society. Dr. James Knight founded the Hospital for In 1860, Florence Nightingale (1820–1910) established the the Ruptured and Crippled in his home on Second Avenue. This first school of nursing at St. Thomas Hospital in London. would later become a world-renowned orthopaedic institution Nightingale was considered the pioneer of the nursing with exceptional nursing care. A historical analysis of nursing profession because she brought unsanitary conditions to education and practice are reviewed, along with the evolution the forefront while trying to reform the British military of the first orthopaedic hospital in the United States. healthcare system (Audain, 2004). For her time, she was educated because her family believed that all their children, including their daughters, should study history, mathemat- he history of nursing and orthopaedic surgery dates ics, and multiple languages. She used her knowledge of Tback to the late 1800s. Both developed out of societal mathematics to interpret data collected during her serv- need, advances in medical science, and a will to help those ice in the Crimean War. Through statistical analysis she afflicted with disease. Crippling disorders have plagued proved that the incidence of preventable deaths was caused mankind since the beginning of time. These unfortunate by unsanitary conditions and that with improvement in people had no recourse except begging for survival. The sanitary methods, the death rate would decrease. As an same premise exists today in all disciplines of medicine. innovator of data collection, statistical analysis, and sani- Nursing has played an integral part in caring for those tary reform, Nightingale founded the nursing profession in need and affording patients, physicians, and hospi- and started what has become known as the Modern tals the ability to function dynamically and superiorly. Nursing Movement (Audain). Agnes Hunt was born in England in 1867. She devoted her life to the care of crippled children by opening the first open-air orthopaedic hospital. She knew too well the fate of those with chronic infirmity because she developed Orthopaedic nursing continues to evolve osteomyelitis of her hip at the age of 9 after a bout of sep- in a professional partnership with the ticemia (Shropshire routes to roots, 2005). Tuberculosis of Hospital for Special Surgery, a premier the joints and osteomyelitis were common untreatable ill- ness during this time. Ms. Hunt believed that continuous orthopaedic institution in New York City exposure to fresh air would help eradicate the transmission that was the first orthopaedic hospital of airborne diseases. Florence House, an outpost of the

founded in the United States. ▼ Barbara A. Kahn, BS, RN, ONC, Nurse Clinician, The Hospital for Special Surgery, New York, NY.

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Salop Infirmary in Shrewsbury, opened in 1900 with open- the tenement houses. Lillian Wald would not begin her mis- air sheds that served as patient wards. Hunt developed a sion at the Henry Street Settlement until 1893. During this friendship and professional partnership with Dr. Robert period, 20–30% of reported deaths resulted from tuberculo- Jones, an orthopaedic surgeon in Liverpool. Florence sis. As a result of these communicable diseases, there was House became the Shropshire Orthopaedic Hospital lo- an increase in bone and joint infirmity. The treatment of cated in Oswego. Long after their deaths, the hospital was these bone and joint diseases formed a large portion of renamed the Robert Jones and Agnes Hunt Orthopaedic orthopaedic practice during this period (Rang, 2000). Hospital and remains in Oswego servicing the commu- Only 150 hospitals were in existence in the 1860s, most nity (Carter, 2001). of which did not accept disabled or crippled individuals be- cause they were considered incurable. Dr. Knight, a physi- cian practicing in New York City, was compelled to rehabil- Only 150 hospitals were in existence in itate these unfortunate souls, mostly youngsters, and in 1863, he welcomed 28 children into his Manhattan home. the 1860s, most of which did not accept Ninety-Seven Second Avenue within the Lower East Side of disabled or crippled individuals because Manhattan would, from that time on, be known as the they were considered incurable. Hospital for the Ruptured and Crippled (Figure 1). Dr. Knight believed that bracing, exercising, and prayer would heal those afflicted because surgery had a high mortality The United States was also involved in conflict as the rate (Time and effort, skill and gifts, vision and faith, n.d.) Civil War began in 1861 and continued until 1865. There (Figure 2). Mrs. Knight, family members, and hired domes- were more than 600,000 casualties and an insurmountable tics provided the necessary care for patients because there number of wounded. Nursing was dominated by males be- was still no formal in the United States. cause society and military protocols mandated that women were too frail to cope with the demands of caring for the sick and injured (Stein, 2004). As a profession, nursing was still in its infancy because no formal nursing schools had yet been established. Casualties continued to increase, forc- ing the demise of gender restrictions. Seizing this opportu- nity, women immediately sprung into action. was named Superintendent of the Women Nurses of the U.S. Army by the Secretary of War. Dix had no formal train- ing as a nurse, yet she set the standards for nursing appli- cants. Nurses were paid 40 cents per day and given food, housing, and transportation. Their male counterparts re- ceived $20.50 per month with superior benefits. In 1862, Clara Barton, who would become the founder of the American Red Cross, brought food, clothing, and medical supplies to the battlefields of the Union Army (Stein). Although the Civil War ended in 1865, it was not until 1892 that the U.S. Congress recognized how valuable nurses were to the war effort. This prompted the passing of a bill that provided a $12 per month pension to military nurses (Archer & Goehner, 1982). Even with these acknowledgments, nursing was still considered a matronly profession based on moral charac- ter, virtue, and discipline rather than education and skill. It was becoming more socially acceptable to be a nurse, de- spite the intensity of the work load combined with the in- decent wages. Still, it did not attract aristocratic women to the profession, and the role of the nurse remained oppres- sive and subservient (Archer & Goehner, 1982).

The First American Orthopaedic Institution Infection from tuberculosis and polio spread rampantly through the community because the industrial revolution led to overcrowding and unsanitary conditions in New York City. Although tuberculosis had first been described by Hippocrates in 300 BC, it became known as the “White FIGURE 1. Dr. Knight’s home at 97 Second Avenue was the first Plague,” and those who contracted it rarely survived. home of the Hospital for Special Surgery, known then as the Pasteur discovered the germ theory of disease in 1861, and Hospital for the Ruptured and Crippled. Reprinted with permis- yet only a few blocks away from Dr. Knight’s home stood sion from the Hospital for Special Surgery.

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FIGURE 2. Children with crooked spines are shown using an FIGURE 3. A nursery school tailored to the physical limitations exercise apparatus. Dr. Knight believed that bracing, exercise, of patients with cerebral palsy. Reprinted with permission from and prayer would heal the afflicted. Reprinted with permission the Hospital for Special Surgery. from the Hospital for Special Surgery.

pling diseases and long recoveries. To accommodate these children, the Hospital for the Ruptured and Crippled estab- Nursing Education lished classrooms so the children could continue their ed- Bellevue Hospital School of Nursing, the first Nightingale- ucation while hospitalized. Manhattan Public School 401 influenced nursing school in the United States opened its was established on the children’s ward with special desks doors in 1873 (Christy, 1970). Nursing duties in 1887 con- and equipment enabling the patients to do homework, sisted of sweeping, mopping, cleaning windows, dusting take tests, and return to school on discharge (Time and the wards, bringing coal to the furnaces, filling lanterns effort, skill and gifts, vision and faith, n.d.) (Figure 3). with kerosene to supply light for assessments, and writing nurse’s notes to assist the physicians. Nurses were expected Orthopaedic Nursing to work 7 days per week. Graduate nurses were given one evening off per week, two if you went to church regularly. From 1929 to 1960 Any nurse who smoked, drank, or frequented a beauty The depression during the 1930s brought on a rapid shop or dance hall had her professional intentions scruti- change in the nursing profession. Economic instability nized (Nursing history: Nurses’ duties and job description forced nurses out of the private-duty sector and into the in 19th century, 2004). hospital. The financial deficits made it difficult for institu- tions to pay wages to nurses; therefore, student nurses were caring for hospitalized patients and hoped to become Orthopaedic Nursing graduates (Oermann,1997). According to Lynaugh (1993), From 1870 to 1920 the passage of the Works Progress Administration (WPA) In 1870, the Hospital for the Ruptured and Crippled moved bill in 1935 provided nurses with greater work opportuni- into a formal institution on 42nd Street and Lexington ties. The Social Security Act changed the traditional domi- Avenue. The first recorded Supervisor of Nursing was nation of business-oriented entrepreneurial self-sufficiency Miss. Ella S. Murdock, of Nursing for the insti- in healthcare and provided for government-supported tution (Levine, 2004). Dr. Knight passed away on October health and welfare (Lynaugh). The end of the 1930s altered 24, 1887, and Dr. Virgil Gibney filled the position in 1888. nursing practice yet again. Nursing organizations sought His philosophy differed in that he viewed the Hospital to improve educational and practice standards when World for the Ruptured and Crippled as an active surgical insti- War (WW) II began in 1939, causing an acute shortage tution, not merely a convalescent home for the disabled. He of nurses. Medical treatment radically changed as sulfon- increased the number of surgical procedures exponen- amide, the first systemic bacteriostatic antibiotic, became tially and opened the first adult ward in 1903 (Time and available in 1935, followed by penicillin in 1940 and chlo- effort, skill and gifts, vision and faith, n.d.). A polio epi- ramphenicol in 1947 (Rang, 2000). demic in 1907 served as a major challenge for the small in- stitution because it could not possibly provide care for all Nursing and Orthopaedics of those afflicted. During this period, nursing salaries climbed to $50 per During WWII month for 12-hour shifts. In 1909, there were only 7 grad- Under the leadership of Dr. Philip D. Wilson Sr., Surgeon uate nurses on staff, including the Matron. By 1912, the in Chief of the Hospital for the Ruptured and Crippled, hospital again required expansion and moved to 42nd six physicians and three nurses sailed for England to be- Street between 1st and 2nd Avenues. More than 18,000 pa- come the first American hospital group to serve overseas. tients were being cared for on an inpatient and outpatient (Hospital Unit of Allied Relief Fund, Inc., Off to Britain, basis. Many of the inpatients were still children with crip- 1940) (Figure 4). At first they provided care in a mobile

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The School of Practical Nursing On January 7, 1955, The Hospital for Special Surgery School of Practical Nursing (HSSSPN) admitted its first class under the direction of Miss Dean Smith (Time and Effort, Skill and Gifts, Vision and Faith, n.d.). The school was nondiscriminatory and graduated more than 50 stu- dents per year (Figure 5). The purpose of the school was to provide nursing students with the knowledge and skill needed for bedside care under the supervision of the reg- istered nurse (RN) and physician. In 1956, 45 licensed practical nurses (LPNs) were employed at HSS under the supervision of only 25 RNs (Clapp, 1961). The philosophy of the school’s faculty supported continued education. As a result, 75% of the LPN graduates furthered their nursing education and completed an associate degree in nursing that enabled them to obtain RN licensure. As the hospital ventured toward acute care, the need for RNs increased, and in 1961, there was almost a threefold increase in RN employment (Clapp). HSS developed a Nursing Pathways FIGURE 4. A group of physicians, nurses, and ancillary per- Program where nurses could acquire funding to support sonnel headed for England under the direction of Dr. Philip D. their advancement to the associate-degree level in exchange Wilson Sr. (top left). Reprinted with permission from the Hospital for a 2-year work commitment after graduation. for Special Surgery. Miss Smith became the director of nursing in 1965. She was an outstanding nursing leader within the institution, well respected and fondly remembered by several nurses unit designed for orthopaedic cases. As Dr. Wilson would who had been working at HSS for more than 30 years. explain, 60% of war casualties were injuries sustained by RNs Pat Reeves and Carol Crescenzo both worked as prac- the bones and joints. Additionally, he believed that antibi- tical nurses under Miss Smith. They describe her during otic medications would prove to be invaluable in saving an interview as, “a person who exhibited the ultimate in the lives and limbs of those with open wounds (Hospital warmth and professionalism. She was a disciplinarian Unit of Allied Relief Fund, Inc., Off to Britain). By 1940, a who knew every nurse’s name and upheld standards of 500-bed American hospital functioned under Dr. Wilson’s nursing yet, she was approachable and supportive of her direction. Eighty American nurses were recruited to staff staff.” According to both nurses, “there were no registered the hospital in Basinstoke, England. Nurses working floor nurses on the night shift back in the 1970s. The floors overseas were required to be members of the Red Cross Nursing Service and willing to remain in England for a minimum of one year (Finds Doctors Needed, 1941).

Nursing and Orthopaedic Leadership Back in New York, the Hospital for the Ruptured and Crippled continued to service the community as a specialty hospital dedicated to the science of orthopaedics. In 1940, it would change its name to The Hospital for Special Surgery (HSS). The hospital leaders acknowledged that the institution would need to affiliate with a major medical center to become world renowned. Dr. Wilson also realized that orthopaedic conditions were becoming more complex and would require the support of other specialties if it were to provide competent care to its patients (Time and Effort, Skill and Gifts, Vision and Faith, n.d.). The affilia- tion between HSS and New York Hospital-Cornell Medical Center occurred in 1949 with the fourth and last relocation of the hospital to 70th Street and the East River in 1955. During this time, the United States prospered under the leadership of President Eisenhower. Interest rates were low, oil was inexpensive, and the average length of stay for FIGURE 5. The hospital’s School for Practical Nursing, under patients treated at HSS was 25 days. Orthopaedic treat- the direction of Miss Dean Smith. The graduates of this yearlong ments revolutionized the field as the first total joint re- course assume an important role in the hospital’s program of placements and arthroscopic procedures were being done nursing care. Reprinted with permission from the Hospital for in the operating rooms (Sculco, 1987). Special Surgery.

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were run by the practical nurses under the direction of the Baccalaureate Education nursing supervisor and although the work was hard no- In 1985, the American Nursing Association (ANA) rec- body wanted to leave HSS to work anywhere else.” One ommended that state nursing associations establish the can still sense the gratification and comradeship experi- Bachelor of Science in Nursing (BSN) degree as the min- enced by nurses working during this time. imum educational requirement for RN licensure and as- sociate-degree nursing as the minimum for practical level licensure (Lewis, 1985). In 1984, according to Martha Standards of Nursing Practice Rogers, nursing theorist and Professor Emerita at New Educational Requirements York University, there was limited progress in support of Doreen Johnson graduated from the HSSSPN in 1969. She an educationally sound and socially motivated system of experienced a spectrum of orthopaedic nursing and nurs- higher education in nursing proportionate with changing ing education while at HSS. Johnson continued to Pace times and human need. She also believed that nursing had University and graduated with an associate degree in 1973. three levels of practice but only two levels with licensure She then received her baccalaureate degree in nursing requirements because the profession has never licensed for from Pace University in 1981. She completed a Master’s in the baccalaureate degree. The baccalaureate level, in her Nursing Administration degree from Hunter University in opinion, was the cornerstone of nursing’s educational sys- 1994. Johnson has been an active member of the National tem (Rogers, 1984). Association of Orthopaedic Nurses since 1970 and has held many executive board positions. Her nursing experience at HSS started with practical nursing, then progressed to reg- istered nursing on the adult orthopaedic unit as she con- In 1985, the American Nursing tinued in her nursing education. She went on to become Association (ANA) recommended that an assistant head nurse and a head nurse and then as- sumed her current role as for the institu- state nursing associations establish the tion. Ms. Johnson had experienced an array professional Bachelor of Science in Nursing (BSN) and educational levels available to the orthopaedic degree as the minimum educational nurse. The author’s interest in her personal career was sparked by the controversy over standards of nursing requirement for RN licensure and practice and education. When Ms. Johnson was asked associate-degree nursing as the how she felt about the upward mobility of nurses and the need for higher education requirements, she passion- minimum for practical level licensure. ately remembered bedside nursing “back in the day” under the supervision of Miss Smith. She believed that there was a certain pride and camaraderie shared by all According to Jacqueline Kostic, MS, RN, CNAA, for- nurses that is not as visible today. She recollected a loy- mer Vice President of Nursing at the HSS, there has been alty to the profession and a dedication to the patient and an evolution of nursing at HSS as educational require- to one’s fellow colleagues. “Nurses helped each other in a ments for nurses grew in response to the complexities of shared community.” She acknowledges that the longer patient needs and orthopaedic advancements. Practical length of stay facilitated nurse-patient relationships, and nurses provided excellent care for patients with chronic this is something that is not readily available today. Ms. illnesses, but now the orthopedic patient is treated more Johnson also expressed her feeling that, “the core of acutely (J. Kostic, personal communication, November nursing is at the bedside and that practical nurses en- 12, 2004). Kostic had been at HSS for the past 14 years joyed bedside nursing” (D. Johnson, personal communi- until her recent retirement. Under her leadership, there cation, November 11, 2004). The author also chose to in- has been an increase in baccalaureate-level nurses to terview Pat Reeves and Carol Crescenzo, RNs who more than 65%. She has implemented the professional recounted more than 30 years of memorable moments at practice model that requires master’s-prepared nurses for HSS as they continue to work on the same-day surgery leadership positions and a BSN for staff nursing posi- unit. They shared a feeling that nursing had become de- tions. Currently, there are 230 BSNs and 20 practical professionalized and that patient care would become in- nurses providing patient care. This is a monumental shift creasingly compromised by the lack of bedside nursing of care compared with the staffing ratio reported in 1965. and staffing shortages (P. Reeves & C. Crescenzo, per- The satisfaction of the nursing staff has been maintained sonal communication, November 12, 2004). as there was only a 7% turnover of RNs in 2003 compared Diploma schools throughout the country began to falter with the national average of 15.5%. in the 1960s as more associate and baccalaureate pro- The hospital was awarded Magnet status for nursing grams became available. The HSSSPN remained an active excellence by the American Nurses Credentialing Center teaching facility until 1996, when it graduated its last (ANCC) in 2003 under the direction of Kostic. Magnet sta- class. The hospital continued to grow under the direction tus was developed in 1993 and is defined as an acknowl- of Dr. Philip Wilson Jr. Staff appointments were increas- edgment of those institutions committed to the delivery of ing, and the number of patients treated in 1988 far sur- quality nursing, excellence in the provision of nursing passed prior years, with the addition of new operating services while providing an environment that recognizes rooms. The average length of stay in 1988 was down to and rewards professional nursing (Magnet Award Status, 10 days, a substantial decrease from 30 years ago when the 2004). Additionally, Magnet status signifies that the average stay was 25 days (Sculco, 1987). Magnet-awarded institution promotes autonomy and in-

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dependent decision making by the nursing staff and re- success, and HSS will continue to strive for excellence flects excellence in recruitment and retention of these and outstanding nursing care in the years to come. nurses (Kuhar et al., 2004). When considering whether to apply for the Magnet award, the institution must aspire to REFERENCES the 14 standards defined by the ANCC (Kuhar et al.). It is Archer, S., & Goehner, P. (1982). Nurses a political force. a remarkable achievement for any institution to receive. Monterey: Wadsworth Health Sciences Division. Audain, C. (2004). Florence Nightingale. Retrieved August 22, 2004, from http://www.agnesscott.edu/riddle/women/ nitegale.htm. Magnet status was developed in 1993 Carter, M. (2001). From open air to high tech care: Ortho- paedic nursing at Oswego 1921–2000. Orthopaedic Nursing, and is defined as an acknowledgment 20(5), 13–16. of those institutions committed to the Christy, T. (1970). Portrait of a leader, Lillian D. Wald. Nurs- ing Outlook. Retrieved October 27, 2004, from http:// delivery of quality nursing and excellence blackboard.pace.edu. in the provision of nursing services Clapp, M. (1961). Report of the director of nursing. New York: Hospital for Special Surgery, Department of Nursing. while providing an environment that Finds doctors needed. The New York Times, March 9, 1941. recognizes and rewards professional Hospital unit of allied relief fund, Inc., off to Britain. New York Herald Tribune, August 23, 1940. nursing. Kuhar, P. A., Lewicki, L. J., Modic, M., Schaab, D., Rump, C., & Bixler, S. (2004). The Cleveland Clinic’s magnet experi- ence. Orthopaedic Nursing, 23, 385–390. Levine, D. (2004). Looking back. Echo, 6, 8–9. The Future Lewis, E. (1985). Taking care of business: The ANA house of delegates. Nursing Outlook, 33, 239–243. The future of orthopaedic nursing and nursing in general Lynaugh, J. (1993). Legacy of leadership: Presidential ad- provides the evolution toward critical thinking, technology, dresses from the Superintendents’ Society and the National planning, and education. Ms. Kostic (J. Kostic, personal League of Nursing Education 1894–1952. In N. Birnbach communication, November 12, 2004) expanded on the & S. Lewenson (Eds.) (pp. 215–229). New York: National need for role adaptation of the nurse toward critical think- League of Nursing. ing and planning rather than execution of patient care. Magnet Award Status. Retrieved November 15, 2004, from She believes that advanced technology will play a greater http://www.intranet/nursing/Bulletin/Magnet.htm. role in supporting nurses and physicians. She also ac- Nursing history: Nurses duties and job description in 19th knowledges the importance of educating ancillary per- century. Retrieved October 21, 2004, from http://www. care-nurse.com/memories/1887.html. sonnel because as the role of the nurse changes, so should Oermann, M. (1997). Professional nursing practice. Stamford: that of the entire team. The ability of supportive staff to Appleton & Lang. provide patient care will be essential. Ms. Hunter sees Rang, M. (2000). The story of orthopedics. Philadelphia: WB nursing becoming a dominant profession within the Saunders. healthcare system because we are still striving to become Rogers, M. (1984). In patterns of education: The unfolding of respected professionals within our society. nursing. New York: National League of Nursing. HSS is a far cry from the Hospital for the Ruptured and Sculco, T. (1987). Changing the face of orthopedics Crippled located within the house of Dr. Knight on 1955–1988. Echo, 12–16. Second Avenue in the 1860s. It is an institution that had a Shropshire routes to roots. Retrieved, March 16, 2005, from vision, tremendous leadership, and the ability to become http://www.shropshireroots.org.uk. Stein, A. (2004). The north’s unsung sisters of mercy. one of the premier orthopaedic institutions in the entire America’s Civil War Magazine. Retrieved, November 6, country. Through specialized knowledge, skill, and adher- 2004, from http://www.womenshistory.about.com/library/ ence to values and ethics, professionals have provided serv- prm/blunglungsisters1.htm. ice to our medical community for more than 140 years. Time and effort, skill and gifts, vision and faith. (n.d.). New Professional nursing practice remains paramount in its York: Hospital for Special Surgery.

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