The present status of nursing education is full of diversity, having evolved into multiple levels of educational preparation and nursing practice. When, where, and how nursing education began in the United States provides the impetus for historical inquiry, and an interesting journey back in time.
Among the many distinctions that can be attributed to the New England Hospital for Women and Children, three historical events are of special significance for nursing:
* It was the first institution in America to conduct formal courses for nurses leading to a diploma.
* America's first trained nurse, Linda Richards, graduated from the New England Hospital for Women and Children on September 1, 1873.
* America's first trained black nurse, Mary Mahoney, graduated from the New England Hospital for Women and Children on August 1, 1879.
Both Richards and Mahoney received diplomas substantiating satisfactory completion of the nursing program with the confidence and approval of the hospital.
In 1859, Dr. Marie Zakrzewska, of German-Polish nationality, was appointed to the Chair of Obstetrics at the New England Female College of Boston. She advised the trustees of this college to establish a small hospital and clinical department in connection with the college. In addition to the practical experience the health facility would provide for female medical students, a major focus would be to receive and instruct women desiring to be trained as nurses. This small health facility eventually became the New England Hospital for Women and Children.
The New England Hospital for Women and Children, located in Boston, was organized by a group of women and incorporated by the legislature of Massachusetts on March 18, 1863. The purpose of the hospital was to:
* provide medical aid to women by female physicians,
* assist women who wanted to study medicine,
* train nurses to care for the sick, and
* prove that women can be good physicians and skillful surgeons.
This was clearly a feminist endeavor designed to counter the discrimination affecting women in medicine. However, the preparation of nurses was a key factor and an integral aspect of the hospital's purpose and design.
The hospital consisted of a dispensary, today known as an ambulatory out-patient clinic, and lying-in facilities for hospitalized patients. The immediate care of the patients was in the hands of women, and the resident and attending physicians were women. In contrast to the rejection female physicians received in other hospitals, the counsel and help of male physicians was gladly welcomed as attending physicians and surgeons. However, male physicians were always accompanied by female physicians, and patients had the option of selecting the female physician.
Zakrzewska cherished the idea of training nurses, and by 1862, she had trained six nurses. Zakrzewska's early methods of teaching were modeled after the nurses training at The Secular School of the Charity Hospital in Berlin where she studied midwifery and, later, medicine. These early attempts to train nurses had little or no distinct theory, and the major focus was practical experience. Zakrzewska was described as a strict disciplinarian with high standards of practical work; however, she was affectionately known as Dr. Zak. Her thorough methods produced experienced nurses that were described in the hospital's annual reports as excellent.
Prior to the Civil War, young women were adverse to giving 6 months of work without pay in order to acquire practical knowledge. However, the experience of the Civil War convinced all classes of society that training nurses was as important as all other professions and a crucial factor in health care.
In 1867, the hospital annual report reflects a 6-month nursing program with board and instruction which offered no diploma. By 1868, the hospital again considered the subject of educating nurses, offering the advantages of practice at the hospital with board and washing, and low wages after the first month of trial to those who wished to acquire skill in this important art (Annual Report, 1868). At this time there were few applicants who were able to spend 6 months, and the hospital was not willing to accept responsibility for a nurse who had spent less than 6 months training. By 1870, the hospital's annual reports reflect that there was a great demand for competent nurses. The few who faithfully served this time found more than they could do and took rank at once as superior first-class nurses.
Although these nurses did not receive a diploma, Zakrzewska had trained 32 nurses by 1872. Some of these nurses were hired by the hospital as head nurses and assistant head nurses, while others worked in homes.
A Formal Training Program for Nurses
On September 1, 1872, the hospital opened its school with a formal training program with a 1-year curriculum. This 1-year program was the innovative idea of Dr. Susan Dimock, modeled after the methods of nurses' training she observed at Kaiserworth, while studying medicine in Germany. Dimock was a 25-year-old physician who was an inspiration to pupil nurses (the historic term used for a nursing student). In order to fully carry out the purpose of preparing women thoroughly for the profession of nursing, the hospital made the following arrangements:
Young women of suitable acquirements and character will be admitted to the school of nursing for one year. This year will be divided into four periods, 3 months will be given respectively to the practical study of nursing, in the medical, surgical, and maternity wards, and night nursing. Here the pupil will aid the Head Nurse in all the care and work of the wards under the direction of the attending resident physicians and medical students.
Our plan is to train them thoroughly theoretically and practically. At the end of the year, if we are satisfied with their behavior and knowledge, we shall give them certificates signed by the hospital doctors. In order to enable women entirely dependent upon their work for support to obtain a thorough training, the nurses will be paid for their work from one to four dollars per week after the first fortnight, according to the actual value of their services to the hospital. (Annual Report, 1872)
At this time on September 15, 1872, the hospital moved to new buildings in Roxbury, the same community where Mary Mahoney lived with her family. This was the third and final location, the hospital having outgrown the prior facilities. The new buildings consisted of a main hospital building which would accommodate 60 patients, with a suite for the resident physician and rooms for interns and nurses. The servants lived in a small cottage near the main building.
Linda Richards, who had previously worked as an untrained nurse, entered the school of nursing on the first day it opened. Within 6 weeks, four more pupil nurses entered the school; thus, a class of five students entered the first formal program. These five students were a happy and united group. However, Richards reminisced that she received a cool reception from the previous graduates who did not receive diplomas (1915). Richards theorized that the prior graduates realized that the formalized program would produce better nurses.
There were 12 lectures on position and manners of nurses in families, physiological subjects, food for the sick, surgical nursing, child-bed nursing, disinfectants, and general nursing. In addition to the 12 hours of required lectures, women interns taught the pupil nurses to take vital signs, how to bandage, and how to perform various procedures. While most of the teaching done at the bedside appeared to be free-flowing, an interesting unexplained mystique existed. Pupil nurses were not allowed to know the names of medications given to patients, and medication bottles were labeled by numbers.
Richards summarized that the instructions usually amounted to a consultation between the intern and the pupil regarding the best way to perform a procedure. The first group of pupil nurses had no entrance exams, textbooks, or final examination. This first group of pupil nurses had no specific uniform; however, they were instructed to wear dresses that were washable. While this training appears to be primitive, it was an initial attempt to produce a formal training program. And, it was far better than what had previously existed, and surpassed any attempts by other American hospitals to train nurses. Upon completing the 1-year requirement, each of the first five pupil nurses were called, one by one, and quietly given their diploma.
In her memoirs, Linda Richards (1911) substantiated the quality of nursing taught to her at the New England Hospital. She stated that she received the affectionate interest and cooperation of Dimock and other members of the New England Hospital for Women and Children. In addition, Linda Richards conveyed the long hours required while in training. She said the student nurses' rooms were between the wards and at first they were required to care for patients day and night. The hours of duty were from 5:30 a.m. to 9 p.m., with no particular appointed time off duty.
After the first formal class concluded in 1873,* the hospital acclaimed having achieved great success in its new training methods and the 12 lectures. These lectures were required for pupil nurses and open to women in the community who desired this knowledge. These lectures were so well-attended by women in the community that tickets had to be issued for admission.
The philosophy of this institution was that the education of nurses was as important as the education of their female physicians. A current issue today for nurse educators and the profession is the image of nursing. In addition to the importance placed on nursing education, this institution historically considered the role and image of nursing equally important to that of the physician.
Our second object is the training of nurses for their duties. This is hardly less important than the first; for the life of the patient often rests quite as much in the hands of the nurse as of the physician. A physician is nearly powerless if his orders are executed by unfaithful or unskilled hands. Nursing should be considered a high and noble work, into which men or women fitted by nature and inclination may enter, without any loss of refinement or social position, and in which they should receive ample compensation for superior and trained ability (Annual Report, 1874).
In 1875, the curriculum was extended to 16 months, that which was in effect when Mary Mahoney entered this school of nursing. According to annual reports, this extension was thought to be a step in the right direction. By this time, nursing at the New England Hospital for Women and Children was being done almost entirely by pupil nurses. The 1875 Annual Report stated that graduates of the program found employment at once and received high commendations.
Mary Mahoney, who had previously worked as an untrained nurse, was enrolled at the New England Hospital for Women and Children on March 23, 1878. Mahoney's acceptance at this school of nursing was unique in contrast to American society at a time when black women were not accepted in white schools of nursing. Mahoney's graduation predates the existence of black schools of nursing. The hospital's philosophy was that sect, party, color, or nationality would not be recognized as distinctions for admission to its benefits. The New England Hospital for Women and Children was progressive in its philosophy and took pride in a racially mixed patient population.
Our lying in patients have been of various classes. We have had several colored patients . . . who rejoiced over the Little Ones born into freedom. It is very funny to see the little black head and fair white baby peeping out of their cribs side by side. One Indian patient was brought to us in labor . . . so that the three great races which divide the continent were represented in our wards (Annual Report, 1867).
This philosophy flowed to the school of nursing and by 1899 there were five other black graduates of the hospital's school of nursing.†
Pupil nurses were required to report 2 weeks earlier for a probationary period. By the time Mahoney entered the school, the women physicians had some 15 years of experience in the preparation of nurses. Admission requirements were that the applicant must be well and strong, between the ages of 21 and 31, and have a good reputation as to character and disposition. Mahoney was 2 years above the top age limit; however, personal interviews were employed in the selection of applicants.
Applicants came from women of high class in respect to character, intelligence, and kindness, of which all efforts were made to obtain only the best. New students were placed in a position of responsibility and observed to determine if they had the qualities of a nurse.
The resident physician, Dimock, stated:
A fair trial is given, and if they show themselves deficient, we consider that their place is not in this hospital. We are glad of the confidence and approbation which our trained nurses have earned in every direction, and while we feel that much is owing to our system of training, we know that more is due to the high characters and good hearts of the women who have entered our school (Annual Report, 1874).
No fee was required for entrance, and the hospital did not consider that payment for services was being made. An allowance was given of $1 a week for the first 6 months, $2 for the second 6 months, and $3 for the last 4 months. This they felt would provide the requisite pupil nurse's uniform for hospital service, a simple calico dress and felt slippers. Twelve of the 16 months of experience were to be spent in medical, surgical, and maternity wards. The student had 16-hour days and 7 -day weeks, and night duty was required. The last 4 months were to be used to prove the students' competency in all these clinical areas by sending them into the homes of the community for private duty under the direction of the school. By 1877, the school was under the direction of Crawford; however, all bedside teaching was done by Zakrzewska (Annual Report, 1977).
Demands for performance at the school were high and the critical element for success. Of the 42 nurses who entered the school in 1878 with Mahoney, only four made the grade for graduation. (Annual Report, 1879)Each nursing student was in charge of a ward of six patients and was responsible for their complete care. Students made rounds with the doctors every morning and received orders for the patients' care. Physicians were precise, requiring good care for the comfort of their patients.
The head nurse's responsibility and list of duties, according to Helen Kimbel, a head nurse when Mahoney was a student, was to assist in the education of nursing students. Head nurses at the New England Hospital for Women and Children were always graduate nurses. Kimball's recordings reveal that nursing students were not left without assistance. The head nurse's role, included among varied clinical administrative responsibilities, was specifically to instruct and assist all students with their work. Although the major responsibility for teaching the nursing program was with the doctors, the head nurse was involved in teaching and supervising the pupil nurses' clinical practice, thus providing a role model for emulation (Cheney, 1876).
In addition to being a pioneering institution for nursing education in the United States, the New England Hospital for Women and Children is credited with two graduates who emerged as leaders in nursing. Richards and Mahoney were a credit to their school of nursing. After graduation, Richards and Mahoney embarked upon two different career paths. Richards was a pioneer in mental health nursing and in nursing education in the United States and in Japan. Mahoney was a private duty nurse who gained a notable reputation for quality nursing care, and she was a pioneer for racial equality in nursing. Richards and Mahoney both rose to national prominence through their professional endeavors and involvement in nursing organizations. In 1976, Richards and Mahoney were posthumously admitted to Nursing's Hall of Fame.
Although the historic New England Hospital School of Nursing no longer exists, this facility continues its legacy through providing comprehensive health care. This facility has been renamed the Dimock Health Center in honor of the resident physician and surgeon who taught nursing at this hospital. This faculty remains unchanged in its 19th century architecture and landscape, providing a sense of the physical environment in which formalized American nursing education began. The main administrative building is named in honor of Richards, and this building houses the Mary Mahoney Clinics and Health Care Center.
- Annual Report of the New England Hospital for Women and Children. (1867). Boston: Author.
- Annual Report of the New England Hospital for Women and Children. (1868). Boston: Author.
- Annual Report of the New England Hospital for Women and Children. (1872). Boston: Author.
- Annual Report of the New England Hospital for Women and Children. (1874). Boston: Author.
- Annual Report of the New England Hospital for Women and Children. (1875). Boston: Author.
- Annual Report of the New England Hospital for Women and Children. (1877). Boston: Author.
- Annual Report of the New England Hospital for Women and Children. (1879). Boston: Author.
- Cheney, E. (1876). The training of nurses. In The History and description of the New England Hospital for Women and Children. Boston.
- Richards, L. (1911). Reminiscences of Linda Richards, America's first trained nurse. Boston: Whitcomb & Barrow.
- Richards, L. (1915). Early days in the first American training school for nurses. American Journal of Nursing, 16, 174-176.