Leslye Long
RGN, CritCareCert, DipAppSci (Nursing), B App Sci (Nursing), Health Administration
(UNSW), PhD (Flinders), MRCNA
ISBN Number: 0-86396-647-0
The University of Adelaide
Department of Clinical Nursing
1998
Joan Durdin Oration
Paper Series Number 4
The Joan Durdin Oration is an annual event initiated and sponsored by the Department of Clinical Nursing at the University of Adelaide. It is intended to serve as an occasion of celebration of nursing's past achievements and to focus on visioning the future. Orators are distinguished nurses who have made a major contribution to the development of Australia's vibrant nursing profession.
As well as focusing on nursing as a profession which is central to effective health service delivery, the Oration honours the contribution of Joan Durdin, a South Australian who has played a major role in uncovering the historical legacy of nursing and in the advancement of nursing through the development of advanced education in the higher education sector.
The Joan Durdin Oration brings together all nurses of South Australia as well as leaders from all fields associated with the health and well being of South Australians to celebrate nursing's past achievements and anticipate the further evolution of nursing in the future.
Dr Leslye Long has been a registered nurse for more than 25 years. Her formal qualifications include a PhD, a Master of Health Administration, Bachelor of Applied Science (Nursing) and a Diploma in Applied Science (Nursing). Since qualifying as a registered nurse, Dr Long has worked mainly in practice in cardio-thoracic surgical nursing. She worked on the first Royal Adelaide Hospital Accreditation team and was Recruitment Coordinator in 1984 during a period of acute nursing shortage. Since 1985 she has been involved in Nursing Administration and has recently been appointed to the position of Director of Nursing and Patient Care Services at the Royal Adelaide Hospital.
Dr Long is also a member of the course advisory team for the Graduate Diploma in Oncology Nursing, a Clinical Lecturer with The University of Adelaide, Department of Clinical Nursing and supervises Masters students.
The Department of Clinical Nursing was established in 1995 in collaboration with the Royal Adelaide Hospital.
The Department is unique in Australia focusing exclusively on postgraduate studies and high quality research in nursing practice. It has one of the largest doctoral enrollments in nursing and has one of the highest per capita staff publication rates. The Department has a well established team of research staff and an extensive funded research program.
The Department of Clinical Nursing also incorporates The Joanna Briggs Institute and Midwifery. The Institute is a major international research and development group based at the Royal Adelaide Hospital and is linked to centres in Queensland, New South Wales, Victoria, Tasmania, Western Australia, Northern Territory, New Zealand and Hong Kong.
Time present and time past
Are both perhaps present in time future
And time future contained in time past
Four Quartets, Burnt Norton, 1
T.S. Eliot (1888-1965)
It is a great honour for me to have been invited to present the 4th Joan Durdin Oration. Like many other South Australian nurses I have been aware of the influence that Joan Durdin as a nursing educator, has had on shaping nursing in this state. More recently, however, I have come to appreciate the contribution that she, as a nursing historian, will make to future generations of nurses.
In today's society, there is a tendency to focus on the future and look for new ways of doing things to meet the demands ahead. We always seem to be planning what we are going to do next. There is a sense of urgency about moving towards the year 2000, the next Olympic Games, and being catapulted into the new millennium. I too spend a great deal of my professional time worrying about what to do next, how to be more creative and what I need to do to adapt to the rapid changes happening around me.
The health care sector is one where change is rapid and there is increasing pressure to contain costs, to do better and to prove that what we do does make a difference. The challenge for health care is to find ways of doing more for less. Concepts such as hospital in the home, coordinated care and home care for the elderly are being promoted as initiatives to better manage health care needs both nationally and internationally. The recent federal election has seen funding being promised to support carers to look after the infirmed, disabled and aged in the home environment.
These initiatives are touted as the new way of providing health care and are being pursued for several reasons. Firstly public hospitals are becoming increasingly expensive to run and maintain.
There is an increase in the number of aged in the community and drug and alcohol related diseases and the mental health services have been integrated into the community. This is placing further burden on a health system that is already over stretched and health care in the home environment is seen as an alternative to treatment in hospital. Secondly, recent studies suggest that hospitals pose a risk to patients and that iatrogenic disease is a significant problem. Adverse drug effects and hospital-acquired infection are two significant contributors to in-hospital mortality and initiatives that keep individuals out of hospital are currently considered to be attractive. However, these type of problems and the innovations suggested are not necessarily new.
The escalating costs of health care have also placed attention on the role of health professionals. Replacing or supplementing trained nurses with untrained care assistants has been seen as a cost-effective move and has occurred in many hospitals nationally and internationally. There is also an increasing need for nursing to explain and define its role to funders to ensure that the role is not compromised or eroded.
In this stressful environment there is little time to reflect on what we have done, where we have been and to refer to our past for some of the answers for our future. Yet there is much in the past of medicine and nursing that is relevant in the year 2000 and the new millennium and is worthy of consideration and review. It has been suggested that we "...are the products of our time...[and] conditioned by its greater movements. Therefore to understand the development of any group some time should be devoted to studying the movements on which it depends for its origin and growth" (Griffin & Griffin, 1973:3). Raftrey is a medical historian who teaches medical students. She suggests that "...it is not possible for students to really understand the nature of the health care system and the health industry ... nor appreciate the social and political values which underlie and are served by our present health care arrangements, unless they know some history" (1991:223). I believe that the need to refer to our history is not confined to students but to all of us when considering major change in health care.
I was introduced to the history of nursing during my recent studies. In preparing the background for my study of radiation therapy, I turned towards the medical history books to look at the history of cancer and how nursing fitted in. I found myself becoming absorbed in the history of medicine and the emergence of nursing. What struck me in this process was the familiarity of some of the very early concepts and their relevance in nursing today and I got the feeling that what goes around comes around. I became fascinated by accounts of nursing activities of previous eras that are re-emerging in the nursing of today. The philosopher Heidegger (1962) suggests that past experiences shape our present and our futures and I pondered on this as I noted the similarity between some aspects of modern day nursing, supposedly new health care innovations and those in previous centuries.
I would like to share with you an overview of the history of nursing and then highlight some of the past experiences in nursing care that are re-emerging today. Although the culture, economic and physical environment and social milieu may differ there is often similarity in the reasons for introducing the changes.
The evolution and growth of nursing has been has been profoundly influenced by the developments made during the periods of history known as the Crusades, the Renaissance, the Reformation, the Industrial Revolution and Modern Times. However, the emancipation of women was the greatest influence of all because it freed them to be able to develop and participate freely in community interests. There is little mention of nursing as a separate occupation in ancient historical times. The emergence of nursing as a vocation appears in the centuries following Christ. One of the tenets of the early Christian church was to give succour to orphans, travelers, the poor and most importantly, the sick and for centuries nursing was linked to the church where the ideals of self-sacrifice, brotherhood, charity and service prevail. For the first thousand years after Christ, there were no significant attempts made to organise nursing. During the Middle Ages, three organisations developed and these still exist, in some form, today. These organisations were; the military, mainly the Knights of the Crusades; the regular or the religious orders; and, secular orders (Griffin & Griffin, 1973; Donahue, 1985).
History indicates that women have been the main providers of nursing care in every century and in every country (Lyons and Petrucelli, 1979). Although women have been the presumed to be the main providers of nursing care during the second and third centuries AD, and the crusades, the care of the sick was conducted equally by men and women (Lyons and Petrucelli, 1979; Donahue, 1985). However, while nursing care has been considered as a predominantly female occupation, there have been periods when males dominated it. In the third century AD men in Rome organised a hospital and traveled throughout the world, nursing victims of the Black Plague. During the crusades (1095-1291) groups of males, such as "the Hospitalers of St John, the Teutonic Knights, and the Knights of St Lazarus, performed nursing duties. The role of women at that time did not allow them to travel with the men and it is relatively recently that women have played a role in tending the sick and injured on the battlefields. Male members of the mendicant orders of St Dominic (the black friars) and St Francis (the gray friars) also acted as nurses in the Middle Ages" (Lyons and Petrucelli, 1979:543). Many cultures required that males care for males, females for females. Some of these cultural influences still persist and are of significance to nursing in an increasingly multi-cultural environment such as Australia.
In Australia the early nurses in colonial Victoria were equally males and females (Cushing, 1993; Pearson, Taylor & Coleborne, 1997). In South Australia this was also the case and at the Adelaide Hospital (now Royal Adelaide Hospital) in 1864 two of the eleven nurses were males (Schultz, 1991). However, this pattern changed over time and the number of males significantly fell with the remaining few working as psychiatric nurses. Since the 1950's there has been a gradual increase in the number of males entering nursing (Durdin, 1991). Following the move to equal pay for females, nursing has become a more attractive occupation for males who are often the main bread winner. The added status of nursing as a University course and more defined career pathways may also make it more acceptable as an occupation to males. Current literature suggests that males are now occupying senior posts in nursing (Evans, 1997). To date males only represent about 10% of the nursing workforce but with the rise in unemployment and the introduction of women into formally male dominated occupations this number may increase. In Australia women make up almost 50% of the work force in medicine, although they are predominantly employed in general practice. It is possible that nursing will follow a similar line and we will see a continuing increase in the number of male nurses.
From the 4th century the care of the sick was the responsibility of the monastic orders. The nuns of religious orders were the main providers of nursing in medieval and even later times. In the fifteenth century, the Reformation caused the introduction of a secular system and freed hospitals from the control of, or connection to, the church (Lyons and Pertucelli, 1979; Donahue, 1985). During this time, the charitable services provided by the nuns and secular groups were often replaced by poorly paid workers unsuited to nurse the sick. Filthy, germ infested hospitals caused infections among the sick, which often was the cause of death. Those who could afford to were cared for at home. At this time the reputation of nursing was tarnished. Medicine was also poorly regarded and quackery abounded.
During the 18th and 19th century there was a move towards secular nursing. In order for secular nursing to be established it was necessary that physicians, hospital administrators and the public understood the contribution that good nursing could make to the health of the community. This was a difficult task because the public opinion of those who attended the sick was not a good one. Charles Dickens (1812-1870), in his novel Martin Chuzzlewit (first published in 1844), epitomised the nurse, or attendant of the sick, in his characters Sairey Gamp and her colleague Betsy Prig as sloppy, dissipated, careless, gabby old women. This appeared to be the general description of those who nursed the lower classes during this period. The upper classes were still tended predominantly by family and servants.
Currently there is a move to introduce care assistants into hospitals and health care institutions to reduce the costs of nursing salaries. While I do not suggest that the concept of care assistants will give rise to a new generation of Sairey Gamp's I do believe that we should be cautious in introducing unqualified carers to provide nursing care. Unless strict regulation and standards of care are introduced for unqualified nurses there is a risk that the reputation of qualified nursing may be affected (Johns, 1998). This is already a significant problem in the nursing home sector.
Nursing care in most countries, before the 19th century, was very basic and unstructured (Lyons and Petrucelli, 1979). There were two major forces that further hastened the development of nursing. They were the scientific advances in medicine and the various wars during the 19th century. The establishment of a small number of reputable nursing training schools was the beginning. Theodor Fliedner (1800-1864), influenced by the work of Elizabeth Fry, established an Institute at Kaiserswerth, Germany in 1836, "... in which the character, health and education of nurses achieved a high standard" (Lyons and Petrucelli, 1979:544). Elizabeth Fry became one of his early students and prepared the way for Florence Nightingale (Calder, 1971).
Florence Nightingale's influence on the development of nursing is well known by all nurses. One of her significant contributions was establishing the credibility of the nurse in the role of Hospital Administrator, a role now ably performed and recognised by nurses throughout the world. In South Australia, as early as 1864, the role of the nurse was valued at the Adelaide Hospital. The resident surgeon of the day, Dr Spicer, argued that the matron should be given more authority to manage her staff. Indeed, Royal Adelaide Hospital now has a nurse, Kaye Challinger, as its Chief Executive Officer. This is not only a personal success for Kaye but a source of pride for Royal Adelaide Hospital and South Australian nurses. Dr Spicer also advocated for more nurses and attributed the poor standard of care that prevailed at the time to inadequate staffing rather than the quality of the nurses, an argument that is topical in today's hospitals (Schultz, 1991).
However while the science of medicine developed, the Industrial revolution in the 18th and 19th century resulted in a set back to the advancement in public health. The poor condition of factory workers and the formation of slums contributed to the prevalence of epidemics. As social and environmental conditions improved the focus of public health shifted. However, public health issues are still significant and not an issue for complacency. Recent outbreaks of infections resulting from poor methods of food processing and contaminated water supplies reinforce the continued need for public health vigilance. Although antibiotics have been one of the great medical discoveries their overuse by physicians and the agricultural sector have seen the emergence of life-threatening bacteria that have developed a resistance to the common antibiotics.
The implementation of Hospital in the Home has been embraced widely in North America and has been introduced, in varying degrees throughout Australia. It is being introduced for a range of reasons that include the overuse of public hospitals, hospital acquired infections and patient satisfaction. Recent reports of the high number of adverse effects happening in hospitals suggest that hospital may not be the safest place for someone who is sick. However, this concept is not new. Neither are the reasons for the introduction of hospital in the home, some of which have previously, been mentioned.
During the 17th century St. Vincent de Paul (1576-1660) organised a small group of noble women in France to visit the sick in their homes and provide food and care. As the group, originally called the Ladies of Charity and later the Sisters of Charity, became larger they expanded their work into the hospitals and under contract provided care of the patients in return for board and lodgings (Bullough & Bullough, 1979). Elizabeth Fry (1780-1845) introduced hospital in the home in 1840 following a period of training under Theodor Fliedner at Kaiserwerth in Germany (Calder, 1971). She found the high mortality of hospital patients to be intolerable due to a lack of aseptic techniques, linen shortages, overcrowding and poor care ( Bullough & Bullough, 1979). Elizabeth Fry introduced care in the home as an alternative way of caring for the sick and it is probable that home nursing increased the chance of recovery. She organised the Society of Protestant Sisters of Charity, who provided home nursing care to the rich and poor (Lyons and Petrucelli, 1979).
In Australia the Sisters of Charity and Mercy were established in the middle of the 19th century. These sisterhood's were directly descended from the Daughters of Charity of St Vincent de Paul and followed the French model of providing care in the home (Longhurst, 1992). So even in Australia care in the home is not new.
Throughout the centuries, until after the middle of the 18th century, overcrowding in hospitals was a problem. It was not uncommon for more than one patient to be assigned to a bed and, in the 17th century,a Viennese surgeon is reported to have "....found four patients in one bed - one dead, two dying, and one convalescent" (Edwards-Rees, 1965:27). There is a touch of familiarity about this issue with current hospital bed pressures. Although it is unheard of in today's hospitals to put two patients in the one bed, there are often occasions when a patient who is to be discharged is sat in a chair to free the bed for an incoming patient.
During the 18th century there was a move towards hygiene and humanitarianism and unhygienic practices, such as two to a bed, ceased. The Industrial revolution in the 19th century resulted in poor conditions for factory workers and the development of slums contributed to the increase in infectious diseases. The technique of vaccination was introduced into England by Lady Montagu (1689-1762) who had observed the practice in Turkey. Recently there has been a move away from vaccination as parents challenge the risks and need for vaccination and argue their rights against compulsory vaccination. However, the re-emergence of potentially life threatening childhood diseases such as whooping cough and measles and the increased incidence in diseases previously almost eradicated in Western Societies for example tuberculosis and polio have led to a reassessment of vaccination programmes by governments. Nurses play an integral role in vaccination and there is an opportunity for the role of the Nurse Practitioner in this area.
In 1851, Florence Nightingale (1820-1910) trained at Pastor Fliedner's Institute (Griffin & Griffin, 1973; Donahue, 1985). Besides nursing the sick she organised a band of trained nurses to undertake the administration of the hospitals, and reformed them. She was committed to providing highly skilled and humane treatment of the ill. Her innovations for improving hygiene and sanitation have become the basis for the profession of nursing (Lyons and Petrucelli, 1979). According to Florence Nightingale, the nurses in our colonial hospitals were old, weak, drunk, dirty, untrained and "... too bad to do anything else" (Nightingale cited Abel-Smith, 1960).
In 1854, Florence Nightingale set forth for Scutari, to nurse the soldiers of the Crimean war. When she got there she found that the conditions were appalling and the death rate was 42 per cent. In two months she had transformed the hospital and within six months the death rate had dropped to a staggering 2 per cent. She achieved this through improving the sanitary conditions and providing good nursing care and set the standard for nursing in the 20th century. Her method of work has been described as one of untiring thoroughness in reading, assembling, observing, testing and analysing everything to be had on the subject at home or abroad, and then lining up the facts with the obvious intent to produce action. She used the scientific method of gathering data and was a skilled statistician, presenting the factual evidence in a most graphic way. In fact her ability in statistical scientific methods secured her election to the Royal Statistical Society in 1858 and honorary membership in the American Statistical Association in 1874 (Dolan, 1968). This was not only an incredible achievement for a woman in the 1800's but particularly for a nurse. In fact, Florence Nightingale could be considered as one of the pioneers in the Evidence Based Practice Movement.
The 20th century has seen marked improvement in the standards of living in most Western countries. As medicine identified the causes of many diseases and has advanced in the development of new technologies life expectancy has increased posing a new problem for health care in the number of frail aged in the community. Nursing has emerged as a profession in its own right and has adopted more scientific methods of teaching and incorporates science into nursing practice. (Lyons & Petrucelli, 1979). At the turn of the 20th century the number of schools of nursing increased in Europe, North America and Australia. The evolving role of the nurse has occurred concurrently with the change in women's' role in society. Women have increasingly assumed a greater role in all aspects of Western Society and have taken on administrative and policy making roles. The first professor of nursing was a North American nurse named Adelaide Nutting, in 1907 and as early as 1910 the need to establish university nurse training was being advocated in the United States of America (Dolan, 1968). It was almost 70 years later that South Australia achieved this status. During the 20th century nursing has evolved alongside the medical professions and moved towards specialisation.
There is a great deal of debate currently among Australian nurses about the issues of credentialling and defining their product. The earliest definitions of what constitutes nursing are found in the second and fourth centuries after Christ. In the 2nd century, an Indian scholar named Charaka summarised four qualifications for those attending the sick. "They are that the individual have; knowledge of the manner in which drugs should be prepared or compounded for administration, cleverness, devotion to the patient waited upon, and purity (both of mind and body)" (Lyons and Petrucelli, 1979:543). These four qualifications are similar to those required by today's nurse if the notion of purity is translated to be ethical and moral integrity and an understanding of the principles of hygiene. I believe that patient's today would want their nurse to be clever and have an understanding of the treatments that are being given
Two centuries later, Susruta suggested that the four essential factors of a course of medical treatment were; the physician; the patient; the medicine; and, the nurse. Further "... that person alone is fit to nurse or to attend the bedside who is cool-headed and pleasant in his demeanor, does not speak ill of anybody, is strong and attentive to the requirements of the sick, and strictly and indefatigably follows the instructions of the physician" (Bullough & Bullough, 1979:11-12).
The introduction of technology as led to additional qualities and skills being added to the definition of the nurse. However, I would argue that the basic qualifications remain the same as those described almost two thousand years ago. If these qualities of caring, support and "being-there" are not present then one could argue that the role becomes that of a technician and does not require a nurse.
This abbreviated history of nursing has traced the emergence of nursing from a duty, to a vocation, to a profession. Nursing has moved from being solely a practical experience to one that also embraces science and is responsible and accountable for its own practice.
The history of medicine and those associated with the care of the sick is well documented by medical and nursing historians. In nursing we are fortunate to have insightful colleagues who have seen the importance of documenting our history and ensuring that we record our professional development for subsequent generations of nurses. The writings of South Australian nurses such as Joan Durdin and Annette Summers have been significant in recording the history of nursing in South Australia. The foresight of other nurses in collecting relics of our past to create a museum for the nurses of the future is essential for the growth of the profession. The Royal Adelaide Hospital has indeed been fortunate to have committed individuals like Mary Sloggett, Bernard Nicholson, Mr Ricketts and Leonnie Lambert to ensure that this happens.