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NURSING. Nursing has been practiced in Texas in a variety of forms, from the work of early lay nurses and midwives who performed their services in patients' homes to that of modern nurses with graduate degrees who work in a large variety of settings. In Texas, as elsewhere before the advent of formal nursing education, caring for the sick, injured, and women in childbirth was considered to be an integral part of the feminine role. By the very nature of the settlement of Texas and the scarcity of physicians, ill people were cared for by women in the household. Early settler Jane Longqv, the "Mother of Texas," for instance, was left behind on Bolivar Peninsula when James Longqv went to fight Spanish forces, and was nursed through illness and childbirth by the young slave woman Kian during the winter of 1820–21. Susanna Dickinson and Andrea Castañón Villanuevaqqv nursed the defenders of the Alamo during the Texas Revolution. These are among the many well-known women who provided care for the sick under difficult conditions in frontier settlements. Pioneer women presided at childbirth and tended illness and injury as part of their domestic responsibilities. They also got a lot of practice, since numerous diseases prevailed in the hot Texas climate and since accidents were frequent on the frontier.
Some women became recognized for their skill in caring for the sick and injured and were called upon to nurse others beyond the confines of their own homes. The first group of people who made a noticeable impact on nursing, albeit lay nursing, in the state were Catholic congregations of women. Bishop Jean Marie Odin, the French priest who became the first bishop of Galveston, visited Europe in 1845 to recruit teaching and nursing sisters for Galveston and San Antonio, but was unsuccessful in his mission to bring nursing sisters to Texas. In 1866 his successor, Claude Marie Dubuis, made another appeal to France, to Mother M. Angelique of the Monastery of the Incarnate Word in Lyons, for sisters to staff a hospital in Galveston. Three sisters from the Incarnate Word Convent at Lyons volunteered their services, journeyed to Galveston and opened St. Mary's Infirmary in October 1866 (see SISTERS OF CHARITY OF THE INCARNATE WORD, SAN ANTONIO, and ST. MARY'S HOSPITAL). The following year one of many yellow fever epidemics struck Galveston, with devastating impact. More than a thousand cases were cared for in and out of the little hospital. The sisters cared for the sick and buried the dead as well. The first superioress of the group died of the disease in the line of duty. In 1869, after the Civil War, a group of sisters from the order left Galveston to journey to San Antonio to establish a hospital there. By 1874 they had established Santa Rosa Hospital in the city and had separated from the motherhouse of the Sisters of Charity of the Incarnate Word in Galveston. Sisters from this order went on in years to come to operate hospitals in Beaumont, Texarkana, Fort Worth (St. Joseph Hospitalqv), and Amarillo. Subsequently schools of nursing were opened in all those hospitals. The Santa Fe Hospital at Temple was also established and conducted by Incarnate Word sisters. The Daughters of Charity of St. Vincent de Paul also had a profound influence on the establishment of hospitals and subsequent introduction of nursing schools in Texas (see CATHOLIC HEALTH CARE).
The first formal school of nursing in Texas was established at John Sealy Hospital in Galveston in 1890, seventeen years after the founding of the first formalized nurse-training schools in the country. John Sealy Hospital, made possible by an endowment from Galveston businessman John Sealyqv, opened in January 1890. It was initially staffed with attendants to provide bedside care. A group of prominent local women, including Mrs. John Sealy, formed a "Board of Lady Managers," which assumed the responsibility for raising funds needed to establish and support the John Sealy Hospital Training School for Nurses. Largely through their efforts, the school opened on March 10, 1890, with eighteen students. As the financial burden of the school became greater for the managers, they petitioned the Board of Regents of the University of Texas to assume control, and in 1896 the school was made a regular department of the University of Texas Medical Branch. The financial dependence of nursing schools on hospitals or medical schools dominated nursing education for many years to come. The John Sealy Hospital Training School for Nurses began as a two-year program that was extended to three years in 1907. Students at the school received lectures and demonstrations by the school superintendent on general principles of nursing: care of the ward or sickroom and care of the patient, including toilet, feeding, attention to excretions, application of lotions, stupes, poultices, and blisters, care and prevention of bedsores, baths, massages, cups, leeches, use of catheters, enemas, artificial feeding, disinfection, quarantine, and clinical observations and records. Faculty from the medical school lectured on anatomy, physiology, surgical nursing, elementary medicine, materia medica (dosage, poisons, and antidotes), obstetric and gynecologic nursing, fevers and respiratory diseases, diseases of children, nervous and mental diseases, and nursing in diseases of the eye, ear, nose, and throat. Classroom instruction was limited to less than six hours a week; most learning occurred in the wards.
Nurses caring for patients in the hospital were much concerned with providing effective treatment to their patients. Hygiene, nutrition, rest, and medication were important aspects of care. Nurses were also concerned with treatments that alleviated symptoms or discomfort of illness. Maude Macalpine, superintendent of nursing at St. Mary's Infirmary, described both the hygienic and therapeutic effects of various types of baths: the shower bath for cleansing, the cold tub bath and cold packs for the reduction of temperature in fevers, particularly typhoid fever, the mercurial vapor bath for the patient in the eruptive stages of syphilis, the mud bath for arthritic patients, and the steam bath for patients suffering from kidney disorder. In addition to working in the wards, nurses assisted in the hospital operating room and at surgeries done at home. Care of equipment and preparation of supplies was an important responsibility of nurses before the advent of plastics and disposables, in both wards and operating rooms. In a series of articles on "Preparation of Op. Room Supplies" Hanna Kindbom, clinical instructor of nursing of the John Sealy Hospital Training School (1896–1900), describes the vital role the nurse played in preventing postsurgical infection through her responsibility to sterilize surgical equipment. She discussed proper methods for sterilizing silk, horse-hair, and catgut suture material as well as instruments by washing them, then boiling or soaking them in disinfectants. Nurses made dressing materials by cutting, folding, and sewing bleached gauze to make cotton sponges. Plaster of Paris bandages for casts were made by spreading lengths of gauze bandage with dry plaster, which were stored as dry bandage rolls and moistened to apply. Like all hospitals throughout the state and the rest of the nation, the John Sealy Hospital was staffed almost entirely by student nurses under the supervision of head nurses and the school superintendent, who directed both the school and nursing service. Graduate nurses sought employment primarily in private-duty nursing until the Great Depression greatly reduced employment opportunities in this area. Other graduate nurses worked in visiting and public-health nursing and occupational medicine. This pattern of employment continued until the late 1930s and 1940s, when hospitals began to employ greater numbers of graduate nurses. Until after World War II, it is difficult to separate hospital nursing practice from nursing education, since students were the principal caregivers.
Because the only educational requirement to superintend a training school for nurses was to be a trained nurse, graduates from John Sealy as well as other early training schools were recruited by other hospitals to initiate nursing programs throughout the state. Early schools of nursing in Texas include St. Joseph's Hospital School of Nursing in Fort Worth (founded in 1906), King's Daughters Hospital School of Nursing in Temple (1903), St. Paul's Hospital School of Nursing in Dallas (1900), Hotel Dieu Hospital School of Nursing in El Paso (1898), Gainesville Sanitarium School of Nursing in Gainesville (1901), Providence Hospital School of Nursing in El Paso (1902), Seton Infirmary School of Nursing in Austin (1902), Physicians and Surgeons Hospital School of Nursing in San Antonio (1903), Scott and White Hospitalqv in Temple (1904), and Baylor College of Nursing (1909). As the number of hospitals in the state increased, the demand for trained nurses grew. Hospitals were quick to recognize the economic advantage of an unpaid student labor force, and training schools proliferated. This phenomenon occurred throughout the country, as the number of training schools increased from a total of 132 in the United States in 1890 to 549 in 1900. This rapid growth was not without problems, however. The majority of nurses from Sealy and other nursing schools throughout the state were left to fend for themselves for employment. While some nurses found jobs in industry and public health, most graduate nurses found employment as private nurses for patients both in the patients' homes and in hospitals in competition with the "practical nurses" already engaged in such employment, who had gained their nursing knowledge and skills through experience. The situation was common throughout the country. Consequently, tensions arose between the school-trained and the practical nurse, with the general public not really knowing the difference between the two.
A second problem was the lack of educational and practice standards. Nationally, by the turn of the century the emerging leadership of trained nursing sought some mechanism to regulate nursing practice as well as nursing education through legal channels, and a push for legislation to license nurses began. The first such laws were enacted in 1903 in four eastern states. A group of Texas nurses met in Fort Worth on February 22, 1907 to form the Graduate Nurses' Association of Texas (see TEXAS NURSES ASSOCIATION). Lavinia Dock, a nationally recognized nursing leader, commended the work of that delegation: "The immense extent of this state with its few scattered nurses gives special prestige to the valiant work they did in organizing a society." The first goals of the TGNA were passage of a nurse practice act for state registration and admission to the National Associated Alumnae, both of which were realized in 1909. The first Texas nurse practice act provided a legal structure for regulating nursing education and practice. It mandated that nurses graduating from a training school offering a two-year program with a "systematic course of instruction" and "presided over by a graduate nurse" were allowed to take an examination to become registered nurses. Only nurses who had passed the examination were allowed to use that title. The law also provided for the revocation of a nurse's license "for gross incompetency, dishonesty, habitual intemperance, or any act derogatory to the morals or standing of the profession of nursing." Another provision was for formation of a Board of Nurse Examiners, one of many examining boards in the state government, to supervise administration of the mandates of the law. The intent of the nurse advocates of licensure was to establish the formally trained nurse as the accepted provider of care, thus eliminating the untrained nurse and improving the standard of nursing care. During its first ten years, the leadership of TGNA achieved expansion of the membership, delineation of local districts, discussion of needed legislative action to strengthen the practice act, and increased knowledge about nursing work in all areas of patient care.
The Texas League of Nursing Education was organized at the 1913 annual meeting of the Texas Graduate Nurses' Association. The first goals of the league were to secure an eight-hour day for student nurses, to establish a standard three-year course in all schools of nursing in the state, to raise entrance requirements, to standardize and improve curriculum, and to improve the preparation of nursing-school instructors. The papers presented at TGNA annual meetings reflected the issues of concern to the members. "Public Health Work Among the Tuberculars in El Paso," "Ethics of Private Duty Nursing," "What is a Trained Nurse?," "The Open Air Treatment for Sick Babies," "College Nursing," "Operating Room Technique," and "The Nurse as Public Health Educator" were among the topics discussed at annual meetings between 1909 and 1917. The majority of graduate nurses worked outside hospitals in private-duty or public-health nursing, as this range of interests suggests. In 1922 TGNA granted an entire evening session to private-duty nurses, and in 1923 a Private Duty Section was organized. TGNA was concerned throughout its early decades with improving the quality of nursing education as an essential condition for improving nursing practice. Despite the efforts of nursing leaders throughout the country, the quality of training provided in most schools was inadequate. The Committee for the Study of Nursing Education was commissioned in 1920 by the Rockefeller Foundation to study nursing in public-health, hospital, and private-duty work and the educational preparation of nurses in these fields. The committee found that in most schools, instruction of students was secondary to long hours of ward duty with little supervision, teaching facilities and preparation of instructors were inadequate, standard curriculum was nonexistent, and classroom instruction and clinical work were poorly correlated. TGNA members were well aware of this problem and worked hard to achieve legislative passage, on April 4, 1922, of a revised State Nurses' Registration Bill, which provided for inspection and accreditation of nursing schools in the state. During the 1920s and 1930s, TGNA supported education by providing scholarships, establishing an educational loan fund, surveying universities on the possibility of instituting college courses for nurses and, in 1936, raising funds to establish a baccalaureate degree program in nursing education at the University of Texas.
The establishment of other professional organizations improved standards for nursing practice. Texas nurses joined the national movement toward organization for the advancement of nursing. A group of superintendents of nurse-training schools attending the International Congress of Charities, Correction and Philanthropy at the World Columbian Exposition in Chicago in 1893 laid the groundwork for establishment of the American Society of Superintendents of Training Schools for Nurses, now the National League for Nursing, the most important national standard-setting and credentialing body for nursing education. In 1899 Hanna Kindbom became the first superintendent from Texas to join this organization. The meeting at the 1893 congress also led to the formation of the Nurses' Associated Alumnae of the United States and Canada, now the American Nurses Association, which met for the first time in 1897.
Efforts to improve the quality of nursing schools led to the closure of schools throughout the state and thus exacerbated the shortage of nurses. The Committee on the Grading of Nursing Schools found that the supply of nurses in Texas-seventy-three per 100,000 in 1920-was among the poorest in the country. Though the ratio increased dramatically over the years, a shortage of qualified nurses remained a chronic problem for the state, complicated by its size and large number of sparsely populated rural counties. Private-duty nursing was the principal area of employment for graduate nurses in Texas until the shift to hospital utilization of graduate nurses in the 1940s. Private-duty nurses cared for many types of patients within the home or on special duty in the hospital: those recovering from childbirth or surgery, those with medical problems including cardiac and renal disease, tuberculosis, and pneumonia, those suffering from nervous and mental diseases, and, less often, children. Nurses obtained cases by referral from physicians or through registries that kept lists of private-duty nurses and referred them to cases. Private-duty work offered nurses freedom from the more restrictive hospital environment, good wages, and the opportunity for variety and professional growth. It could also provide periods of unemployment, long hours, and difficult working conditions.
As medical care became more technologically complex and health insurance more available, hospitals increasingly became the preferred arena for care of the acutely ill. Advances in obstetrics and anesthesia shifted most births from the home to the hospital in the 1930s. As hospitals increased their staff or graduate nurses, the need for private-duty nurses in hospitals decreased. The field declined in the decades immediately after World War II. Subsequently, however, independent nursing has grown with the rise of nursing agencies that link nurses to hospitals and health-care facilities needing additional staff on a per diem or contract basis, much as the original nurse registries did. Contemporary nurses who choose this type of employment seem to value the good salaries and freedom to choose work opportunities and work schedules, as their predecessors in private-duty nursing did.
Public-health nursing has long been another important field for Texas nurses. Public health nursing in Houston began with the formation of the Houston Settlement Association by a group of women who opened a dispensary in a small cottage and employed a visiting nurse in an effort to provide care to the poor. The Visiting Nurse Association of Houston, the Nursing Division of the Houston Health Department, and nursing in the Houston Independent School District can trace their beginnings to this early effort to bring care to people in their homes, schools,and workplaces. Public-health nurses have traditionally provided a wide range of services: health teaching and health promotion, immunization and well-baby care, home visits, and communicable-disease control. Texas was one of the earliest states to offer college study in public-health nursing, at the University of Texas beginning in the 1920s. When the course was threatened because of low enrollment, the Texas Graduate Nurses' Association voted in 1924 to establish a $1,000 loan fund. The Texas State Organization for Public Health Nurses was established at the meeting of the TGNA in Fort Worth in 1922 to promote high standards and cooperation among nurses in public health. The duties of the nurses employed by the Houston Health District in the early 1940s were representative of work in the field. They made home visits for patients with communicable diseases, often tuberculosis, taught families how to prevent the spread of infection, made antenatal and postnatal home visits, well-baby visits, gave immunizations, visited crippled children and made referrals for them and paid visits to venereal-disease patients and their contacts. Public-health nurses continue to perform many vital functions in community settings through work with visiting nurse associations, health districts, school districts, home health agencies, hospices, and many other organizations.
A related field is that of industrial or occupational-health nursing, which emerged nationally in the 1890s. Shelby Green Tengg, an early industrial nurse at the Alamo Iron Works, cared for injured and sick employees in the plant's dispensary. The Pure Oil Company in Mexia had its own hospital and infirmary, staffed by graduate nurses. The industrial boom during World War II saw a significant expansion in the field of occupational-health nursing nationwide, and it is an important nursing specialty area in Texas today. Emergency care for occupational injury and workplace illness is only one aspect of the nurse's work, which is largely focused on risk management, workplace safety, and health promotion.
Texas nurses also cared for the sick and wounded during wartime. A number served in France during World War I, and some died on duty. Far greater numbers served during World War II. The war years were a critical period in the development of the nursing profession, when the national crisis brought a great demand for nurses both in theaters of combat and in hospitals in the United States. A bill introduced by Congresswoman Frances Payne Bolton of Ohio, a long-time supporter of nursing, proposed formation of the United States Cadet Nurse Corps. The Bolton Act, passed in 1943, provided complete educational subsidies for nursing students who joined the Cadet Nurse Corps, as well as funds for schools to upgrade teaching capabilities. Many Texans were able to obtain nursing education because of the support of the Cadet Corps. A number of graduates went on to serve in the armed forces. Texan Annette Gleason, a World War II flight nurse, survived a parachute jump over the mountains of China. Dolly Vinsant, a graduate of the John Sealy College of Nursing Class of 1940, joined the Army Nurse Corps and was killed in action in April 1945. While serving as a flight nurse on a medical evacuation plane that crashed, she became the only Texas woman killed in the European Theater of Operations as a direct result of enemy action. On the home front, the TGNA worked to meet the increased need for nurses in health-care institutions. They formed a speakers' bureau to help recruit nursing students and Red Cross volunteers and sponsored refresher courses to help get older nurses back into active service. The pressing need for nurses during the war led to the rapid growth of training programs for practical nurses. These usually provided a nine-to-twelve-month course in basic nursing skills. The contributions of nursing to the war effort led to a positive public image of the profession. The expansion of the nursing workforce through intense recruitment and increased funding, the positive public image projected by nurses' wartime contributions, and the increased demand for health care after the war led to tremendous growth in nursing.
Nursing practice is often highly specialized in hospitals, where nurses work in critical care, renal dialysis, oncology, trauma treatment, rehabilitation, geriatrics, and other fields. Nurses also provide care in nursing homes, health-maintenance organizations, day-surgery centers, dialysis centers, and day hospitals. They support a wide variety of professional specialty organizations. They can also seek certification in specialty areas, thus signaling expert knowledge in a specific field in nursing. In the community, nurses work with home-health agencies, occupational-health services, health districts, schools, clinics, and mental health centers. The tremendous advances in required nursing knowledge and skill have been accompanied by continual evolution of education and practice standards. The 1993 Nurse Practice Act reflects the scope of nurses' responsibilities to provide safe and effective care. The act defines nursing practice, establishes practice standards, defines unprofessional conduct, establishes guidelines for licensure and accreditation of nursing schools, and defines the composition and responsibilities of the Board of Nurse Examiners. With a mandate to develop rules and guidelines to regulate nursing, the board has in recent years developed rules guiding the delegation of nursing activities to unlicensed personnel, the reporting of unsafe care, peer-review mechanisms, and mandatory continuing education. The demands of a highly technological and rapidly changing health-care environment have contributed to expansion of educational programs and an emphasis on continuing education for nurses. In 1890 the state began with one hospital training school; it now has twenty-six baccalaureate programs, as well as associate-degree programs and two diploma programs. Large numbers of nurses pursue master's and doctoral study in nursing at Texas universities. The number of applicants to nursing schools in the state is at an all-time high, a fact that reflects a continued high demand for nurses. Student populations include increasing numbers of men, minority students, and older students pursuing nursing as a second career. Clearly, nursing is a profession that is highly regarded by the public and increasingly seen as a desirable career.
Texas nurses have built on a long and proud tradition of service to the health of the state's residents. In 1994 more than 130,000 professional nurses provided care in a wide variety of settings within hospitals and in the community. The skills, knowledge, work settings, and activities of nurses have changed greatly over the last century. More change is likely to occur as the current movement for health-care reform leads to greater demand of all sorts of nurses, particularly those prepared for advanced practice roles as nurse practitioners, nurse midwives, and nurse anesthetists. Even as nurses move forward to new roles in the future, the commitment to serving the health of the people of Texas is a lasting legacy from the past. See also HEALTH AND MEDICINE, MIDWIFERY.
BIBLIOGRAPHY:Eleanor McElheny Crowder, Nursing in Texas: A Pictorial History (Waco: Texian Press, 1980). A. Louise Dietrich et al., History of the Texas Graduate Nurses' Association (El Paso: Hughes-Buie, 1932). Texas Graduate Nurses' Association, Texas Graduate Nurses' Association Fiftieth Anniversary, 1907–1957 (El Paso?, 1957). Cary D. Wintz, "Women in Texas," in The Texas Heritage, ed. Ben Procter and Archie P. McDonald (St. Louis: Forum Press, 1980; 2d ed., Arlington Heights, Illinois: Harlan Davidson, 1992).
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