WHAT WAS NURSINGS ROLE IN THE NEW MEDICAL CENTER ON 168th street? An answer of sorts can be found in the official opening-day photographs, which show Helen Young, director of both the Presbyterian Hospital nursing school and the hospitals nursing service, standing firmly at Columbia-Presbyterians front entrance, flanked by the president of the hospital and the chairman of the board.
It wasnt a hollow public relations gesture. Miss Young wielded enormous power at Presbyterian Hospital. Her students and staff were the bedrock of the institution. Nurses not only ran the wards and delivered most of the day-to-day care, they were also responsible for ensuring proper hygiene and sanitation, particularly important duties in the days before antibiotics. Now, at the dawn of this great experiment in health care, Miss Young was needed more than ever. On her shoulders fell the task of staffing the vast new facility, a daunting task given the scarcity of highly trained graduate nurses. With her help, Presbyterian was operating at full capacity in eight months instead of the projected three years.
In many respects, however, this would be nursings last hurrah. While medicine would quickly embrace the academic model of health care that powerful synergy of practice, education, and research pioneered at Columbia-Presbyterian nursing, for a host of reasons, would remain tethered to its service origins. Slowly, the school would lose power and prestige, a trend that would continue until the closing decades of the 20th century.
Rooms of Their Own
As plans for the medical center coalesced, the Presbyterian Hospital School of Nursing began raising funds for its new home in Washington Heights. When contributions lagged, the graduates called on Anna C. Maxwell, the schools founding director, to reinvigorate the campaign. Miss Maxwell dutifully cut short her retirement travels in Europe to take up the challenge, ultimately raising a half-million dollars.
Anna C. Maxwell Hall, which sat atop a bluff with views of the Hudson River and New Jersey Palisades (the current site of the Milstein Hospital Building), was the first of the medical center units to open. Visitors marveled over the amenities, including a pool, auditorium, classroom, dining hall, library, and infirmary. The hall was more like an elegantly appointed club than an institutional residence, in the words of one student. Similarly impressed, the New York Times called Maxwell Hall the last word in student housing... The training of nurses is one of the newer phases of education, but it has got far beyond that period in which the novitiate was looked upon as part maid servant and part student. This new home ... is a recognition of her status.
Meanwhile, the school was plotting an even bigger move: to academe.
Since its founding in 1892, the school was regarded as one of the top nursing programs in the country. Few other programs placed so much stress on the fundamentals of theory and practice. But there were limits to how much time the students could spend in the classroom. The primary mission of the school, a diploma program, was to assure its parent hospital a steady supply of inexpensive labor; academics came second.
By the 1920s, however, the diploma model of nursing education was becoming obsolete. Where can a nurse prepare as director of schools of nursing, acquire knowledge of civic and social and educational conditions to enable her to develop rural nursing, community activities, and the multitudinous fields of work into which she is invited? asked Miss Maxwell in a 1924 speech. There seems to be one answer. Admission to our universities.
Nevertheless, the schools academic ambitions would be delayed and delayed again, first by the construction of Columbia-Presbyterian, then by the Great Depression, and all along by the reluctance of the hospital to relinquish control of the student nurses.
Finally, in 1937, the school was accepted into Columbia University with strings attached. Students were still required to work long hours on the wards, performing many tasks that had nothing to do with higher education. Another slight: The nursing program was made a department within P&S, not a full-fledged school. As Dr. George E. Vincent, former president of Rockefeller University, told the 1936 graduates, You are an auxiliary to the medical profession. They would remain so for decades.
World War II would further delay the schools academic progress. As the hostilities approached, hundreds of staff and graduates joined the war effort, including 72 who enlisted in Presbyterians overseas unit, the 2nd General Hospital. Led by Lt. Colonel Marjorie Peto26, the nurses of the 2nd General served for more than three years in England, Ireland, and France, including long stretches in miserable field hospitals that were perilously close to the front lines. By wars end, they had tended to 22,000 soldiers.
On the home front, the school trained a record number of nurses to help alleviate the domestic nursing shortage, participated in civil defense activities, and raised money for war relief.
Despite all the distractions, the schools educational standards never slipped. From 1935 to 1944, Columbias student nurses compiled the highest pass rate on New York state licensing exams, surpassing 107 other nursing programs.
The Overeducated Nurse?
Shortages continued to plague the nursing profession after the war, rekindling debate about how much education nurses truly needed. Typical of the day, the Medical Society of the County of New York complained that nurses are now more concerned with the theoretical aspects of nursing problems than with the fundamentals. Fanning the flames, the society asked, if all nurses obtained degrees, would the sick patients receive care?
But nurses did need to know more theory. Scientific knowledge was growing exponentially, splintering health care into specialties and subspecialties. The nurse must master a great variety of skills, argued Dr. Dorothy Reilly, a 1947 nursing graduate and a member of the faculty. She must acquire more technical knowledge...[and] be informed about the complexities of social structure, so that her contribution, rather than depending on intuition, may be based on conscious knowledge.
After several in-depth studies of the curriculum, the school added more scientific content to courses, broadened the range of clinical experiences, and wove three major threads into the overall program mental health, public health, and communicable disease. And in a bold affront to their critics, the faculty raised the bar even higher, joining with the Maternity Center Association of New York in 1955 to create the countrys first graduate program in nurse midwifery.
No matter what others believed, the faculty were intent on producing the best possible clinicians, not theoreticians. As faculty member Helen Pettit36 noted, The professional nurse will never be very far from the patient.
Not Quite a Revolution
In terms of campus life, surprisingly little had changed since the schools founding in 1892. Even in the 1960s, students were required to live in the dormitory (unless married), get permission to marry, obey a strict curfew, and wear starchy, old-fashioned uniforms. While the residents of Maxwell Hall were attending afternoon teas, students on other college campuses were burning bras, protesting the war, and occupying administrative buildings.
As the decade unfolded, the school loosened the reins. Other careers and other lifestyles were opening to young women, and few had any interest in the cloistered life of the student nurse.
It wasnt long before the first women of color enrolled and then the first men. The student body was starting to reflect American society.
Meanwhile, under Elizabeth Gill37, the faculty continued to enrich the curriculum, adding more content on acute care, long-term care, and leadership. In 1966, the graduate program was expanded to add a second clinical specialty, psychiatric-community mental health nursing, a response to postwar advances in pharmacology.
The More Things Change...
Even after all this time, the school had not freed itself of its obligations to the hospital. In fact, the director of the school still served as the director of the nursing service, creating increasingly awkward conflicts of interest. Presbyterian, facing yet another nursing shortage, pressed the school to start a program for licensed practical nurses, the lowest rung on nursings clinical ladder. The school resisted, preferring to raise, not lower, the entry point into the profession. The hospital on its own opened the Edna McConnell Clark School of Nursing in 1968, which provided two-year training leading to an associate degree in nursing.
Miss Gill retired that same year and was succeeded by Margaret Crawford. Hopes for change were high. Dr. Crawford was the embodiment of the scholarly nurse a teacher, clinician, researcher, administrator, writer, and consultant. She was first of the schools directors to hold a doctorate she had an Ed.D. degree and the first from outside Columbia-Presbyterian.
The highlight of Dr. Crawfords tenure was a novel series of multidisciplinary seminars on the psychosocial aspects of patient care, bringing together students from all health sciences schools. Despite Dr. Crawfords scholarly credentials and best intentions, the curriculum retained its heavy clinical focus, research continued to be a secondary pursuit, no new graduate programs materialized, and the faculty remained too insular and undercredentialed. Any hope for reform at the school was quashed by University budget cuts and the full withdrawal of hospital support. Dr. Crawford resigned from the school in 1976, when a medical center task force recommended a split in the governance of nursing education and nursing service.
Enrollment remained high throughout this period, even though new occupations, many with better salaries and better opportunities for advancement, were opening to women. But ominously, the quality of the applicants began to erode. Tough times were ahead.
And the Walls Came Tumbling Down
Once grand and glorious, Maxwell Hall began to show its age in the late 1970s. Maintenance suffered as the hospital (which still owned the building) washed its hands of the school but not of the real estate. In 1984, Maxwell Hall was demolished to make way for the hospitals new building, and the school was unceremoniously relegated to an old, incompletely renovated apartment house across the street from the emergency room. The symbolism of the move could not have been clearer: The school had outgrown its hospital origins but still did not warrant a home in academe.
Helen Pettit, who had been with the school since the 1930s, was the next leader of the school. She added advanced clinical degrees and a dual masters program with public health.
The schools achievements, however, were drowned out by a chorus of complaints about the schools academic shortcomings. Medical center leaders responded by assembling a task force to chart a new direction for the school, recommending more emphasis on advanced study, continuing education, and fuller use of university resources. The call for a more scholarly school sounded impressive but rang hollow without resources to support such changes.
JoAnn Jamann, a nationally recognized authority in gerontology, took over in 1980. Again, it seemed the University was serious about welcoming the school into the academic community. Columbia President Michael Sovern spoke of bringing the school to pre-eminence in service, research, and training, and Dr. Jamann was made a full dean, the schools first, giving her parity with other academic leaders at the University.
However, Dr. Jamann faced the same pattern of neglect, made all the worse by a constant changing of the guard at the medical center. Few administrators paid attention to the school, and those who did doubted its academic potential. Dr. Jamann also had the misfortune of serving during the move from Maxwell Hall, a huge distraction. On the positive side, she instituted the schools first core curriculum at the graduate level, new masters programs, and assorted measures to attract non-traditional students.
Mary O. Mundinger, the next dean, inherited a school on the brink of extinction. Dr. Mundinger, a noted expert in gerontology and health policy, brought many skills to the role and she had the political savvy to make things happen, gleaned in part from experience in a Robert Wood Johnson Health Policy Fellowship, during which she served on Capitol Hill as a health policy adviser to Sen. Edward Kennedy.
While many at the University wanted to downsize the nursing program, or eliminate it altogether, Dr. Mundinger set out to rebuild it from the ground up. One of her first initiatives was to institute a universal practice plan, requiring all full-time faculty members to engage in a scholarly clinical practice or to conduct funded research. On the curriculum front, Dr. Mundinger made the masters degree the entry level to professional practice (in keeping with other professional schools at the University). A few years later, the school created a doctoral program in health policy and health-services research, the only one of its kind.
Next, the school joined with Presbyterian to create the Center for Advanced Practice (CAP), one of several clinics opened by the hospital to improve primary care in the local community. What distinguished CAP was that it was run by nurse practitioners who had full admitting privileges at Presbyterian (a first at a major teaching hospital), and the care was based on the nursing model, emphasizing health promotion, disease prevention, and patient education in addition to providing primary health care.
The clinics not only provided a much-needed source of health care for the community, but also a unique research opportunity to see how nurse practitioners compared with physicians in independent primary care practices. The resulting study, led by Dr. Mundinger and published in the January 2000 Journal of the American Medical Association, found no statistical differences between the health outcomes of patients managed by the physicians and those managed by the nurse practitioners.
Buoyed by CAPs success, the faculty aimed even higher, offering its unique brand of primary care to commercially insured patients in a new practice in midtown Manhattan, the heart of physician country. Now in its sixth year, the practice Columbia Advanced Practice Nurse Associates, or CAPNA is thriving.
So is nursing research. All told, the school has more than $10 million in research grants, with projects ranging from screening for emotional and behavioral disorders in children to hand hygiene and nosocomial infection in neonates, alternative therapies for chronic diarrhea in HIV patients, inmate and child outcomes in prison-based nurseries, nursing informatics, and emergency preparedness. In recent years, the school has established four major research programs: the Center for AIDS Research, the Center for Health Policy, the Center for Evidence-Based Practice in the Underserved, and the World Health Organization Collaborating Center for International Development in Advanced Nursing Practice. The school now ranks first among nursing schools in per-capita faculty funding by the NIH.
The school has drawn up a proposal for a second doctoral program, leading to the Doctor of Nursing Practice degree, which would prepare nurses for the kind of practice pioneered at CAP and CAPNA. The rationale for the program: Nurses at their highest level of practice should earn a doctorate (which is the case in all other health professions), and health-care consumers should have more access to nursings distinctive brand of primary care and be assured of the quality of their providers. As the proposal states, Never have nursings unique contributions a focus on the patient in a family and social context, disease prevention and health promotion, incorporation of patient education as an integral part of care, and patient advocacy been more needed, and more in demand.
As Columbia-Presbyterian Medical Center celebrates 75 years of progress and accomplishment, the School of Nursing is rightfully and permanently at home in academe.
Gary Goldenberg, a free-lance writer based in Westchester, is the author of Nurses of a Different Stripe: A History of the Columbia University School of Nursing, 1892-1992. He was a staff writer for P&S in the 1980s and edited The Academic Nurse for the School of Nursing through 1995.