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NURSING. The story of the advancement of nursing in Cleveland is one of multiple challenges, as nurses have sought to improve nursing practice through upgrading standards for nursing education. Cleveland's nursing community has been in the forefront at the state, national, and international levels, providing the vision for many innovations in nursing practice, education, and research and in PUBLIC HEALTH. During the first 7 decades of Cleveland's development, ill people were cared for at home by their families or untrained nurses who also functioned as maids. The few existing hospitals (see HOSPITALS AND HEALTH PLANNING) were primarily for the poor and homeless or for CIVIL WAR casualties. The public believed hospitals were places to die. Untrained men and women, with little or no general education, were employed to care for the sick. A few dedicated caregivers chose nursing as a vocation. The SISTERS OF CHARITY OF ST. AUGUSTINE served as nurses and administrators at St. Vincent Charity Hospital (see ST. VINCENT CHARITY HOSPITAL & HEALTH CENTER) which opened in 1865.The social consciousness of Cleveland's leaders in the late 19th century led to the building of more hospitals, following the development of anesthesia and aseptic techniques. The need for an organized system to improve patient care led to the rise of modern nursing in Cleveland. Modern nursing had originated about 40 years earlier in England, when Florence Nightingale established a training school for nurses, which became the model for American schools.

Cleveland is recognized as the site for the origin of modern nursing in Ohio. The Cleveland Training School for Nurses (later HURON RD. HOSPITAL School) was established on the Nightingale model in 1884. Guided by national nursing leader, ISABEL HAMPTON ROBB, Lakeside Hospital opened, in 1898, as a school which featured a 3-year curriculum, an 8-hour workday, and a regular course of lectures, placing it at the forefront of nursing education of its day. The city's first Roman Catholic nursing school opened in the same year at St. Vincent Charity Hospital. As new hospitals were built, some organized nursing schools to provide a nursing labor force at little or no cost. Each hospital controlled the financial operation of its school: the students' educational needs yielded to the hospitals'. Hospitals employed few graduate nurses, who worked primarily as private-duty nurses or in public health. Hospital economics, lack of qualified candidates for admission, and the absence of an organized body for enforcing standards prevented the early Cleveland nursing schools from achieving the desired standards established by Florence Nightingale. Some nursing school directors became discouraged and left their positions: City Hospital had 4 directors in 5 years. Nurses employed traditional and nontraditional measures to upgrade their profession. They wrote to their legislators on matters of importance to nursing, even though, as WOMEN, they could not vote. Nurses at CLEVELAND HOMEOPATHIC HOSPITAL went on a "sit-down" strike in 1908 to protest unsatisfactory conditions. This strike may have been one factor leading to the closure of the hospital for a year.

Nurses also organized to accomplish goals. The nursing directors of early Cleveland schools frequently were college-educated women who subsequently sought nurses' training. Many provided the leadership for upgrading standards for nursing education and practice in Cleveland and Ohio. These leaders recognized that as individuals they lacked the power to influence hospital administrators to accept minimum standards. To define plans for action that were both comprehensive and achievable, they established the Graduate Nurses' Assn. of Cleveland (now the GREATER CLEVELAND NURSES' ASSN.) in 1900 with the support of Isabel Hampton Robb. From its inception, the local association promoted high standards of health care and the advancement of nurses' professional, educational, and economic welfare. State regulation of nurses was one means of raising professional standards and improving nursing services. Many local hospitals and physicians opposed these efforts because they feared their cheap labor supply would be lost. By 1916 the first Ohio nurse-practice act had been enacted. Cleveland nurses, however, opposed the act as passed because it gave control of the profession to the all-male state medical board (women could not yet hold office on a state board). The impact of this law was felt for years on nurses' income, living conditions, and status.

During the last decade of the 19th century, a few trained nurses had entered public health. In 1901 the local nurses' association helped enlist the aid of prominent Clevelanders to establish the VISITING NURSE ASSN. (VNA) OF CLEVELAND the following year. A scholarly journal developed by local VNA nurses in 1909 soon became the official publication of a national-public health nursing organization. In 1917 the VNA, the Cleveland Health Department (see CLEVELAND BOARD OF HEALTH), Western Reserve Univ., and other agencies collaborated to establish the Univ. Public Health Nursing District. Its purpose was to prepare well-qualified nurses for public-health service, provide nursing services in one city district, and set standards for public-health nursing. This district became recognized nationally and internationally as the model for public-health nursing programs. Nursing services included maternal and child health care, home visiting with instruction on the proper care of the sick and on how to stay healthy, school and industrial health care, and communicable-disease control. Cleveland nurses, in the early part of the 20th century, helped establish another nursing specialty, nurse anesthesia. At Lakeside Hospital, AGATHA HODGINS opened the nation's first formal postgraduate anesthesia program in 1915; the American Assn. of Nurse Anesthetists developed out of the school's alumnae association.

According to the Cleveland Hospital and Health Survey, nurses' training in 1920 was "a rather sorry picture of mingled exploitation of willing labor and amateurish teaching." The report strongly supported the local nursing leaders' drive to upgrade the standards for nursing education. Many nurses, hospital administrators, and physicians, however, continued to oppose raising standards because of the perceived cost to hospitals and out of fear that nurses would trespass on the province of the physician. Every major move by nurses to upgrade the profession in this century provoked such opposition. As a result of the recommendations from the above survey, in 1923 WRU established in collaboration with the Lakeside Hospital school the first collegiate nursing school in Cleveland, precursor of the Frances Payne Bolton School of Nursing of CASE WESTERN RESERVE UNIV. This school was considered one of the outstanding schools in the country from the 1930s on. The establishment of a collegiate nursing program, however, did not reduce the exploitation of nursing students by hospitals. The needs of hospitals for low-cost care continued to take precedence over education in most nursing schools until the 1950s. The Depression and the nursing shortage during WORLD WAR II helped change the situation. In 1934, for example, the local nurses' association deliberated a request for nurses to work without pay during the Depression. Their reply to a local medical society reflected the belief that since hospital administrators and physicians received pay, nurses should not be expected to provide free services.

In the latter part of the 1930s, a shortage of nurses for full-time home care of invalids existed. To compensate, the Central School of Practical Nursing, the first such school in Ohio, was established as a 1-year training program. Later, practical nurses were trained to provide care for patients with stabilized conditions in a variety of health-care agencies under professional direction. The opportunity to study toward a Master of Science in Nursing degree became available in 1938 at WRU. The focus of this degree altered over the years to keep pace with changes in the complexity of health-care needs and treatments, in undergraduate nursing education, and in the need for nurse educators, supervisors, administrators, clinical specialists, and researchers. Following World War II, an acute shortage of nurses existed. Nursing was not attractive to young adults because of its low pay and heavy demands, with minimal opportunity for job satisfaction. Drastic reforms in nursing education and practice were recommended. Higher education for nurses was becoming valued. The Cleveland Catholic Diocese's ST. JOHN COLLEGE established Cleveland's second B.S.N. program in 1947, continuing the traditional involvement of Catholic institutions in health care and nursing. Federal assistance for nursing education was introduced in 1956, thus facilitating the attainment of advanced education for many Cleveland nurses. With the establishment of a national accrediting body for nursing, standards for educational programs were developed and enforced. Local schools broke their hospitals' dependence on student labor, leading to the employment of more graduate nurses by local hospitals, many of which were rapidly enlarging. The American Nurses' Assn. and its local affiliate, the Greater Cleveland Nurses' Assn., continued to work toward improving educational standards, nursing practice, and the economic welfare of nurses. The association became the collective bargaining agent for nurses in some Cleveland healthcare agencies. Local nurses' salaries gradually improved.

Cleveland City Hospital had been the first area hospital to admit AFRICAN AMERICAN students to its R.N. diploma school in 1930. Cleveland's first black R.N.s had their own professional organization, a local affiliate of the National Assn. of Colored Graduate Nurses and the state-level Buckeye Graduate Nurses Assn. After the latter was dissolved in 1950, and the NACGN absorbed by the ANA in 1951, Cleveland's black nurses were admitted to the GCNA. Also during the 1950s, Cleveland hospitals began "importing" nurses from abroad. Although at first most foreign-trained nurses came from northern Europe, changes in immigration law in the mid-1960s shifted attention to Asian countries like the Philippines where nurses were educated in English.

The Univ. Public Health Nursing District closed in 1962 when the knowledge and skills acquired through that course of study became a requirement within the curriculum of baccalaureate nursing programs. CUYAHOGA COMMUNITY COLLEGE established a 2-year nursing program in the 1960s and awarded an associate degree. With the opening of the Kent State Univ. School of Nursing, some Cleveland hospitals closed their nursing schools the same decade. CLEVELAND STATE UNIV. opened a program in the early 1970s for registered nurses to earn a baccalaureate degree in nursing. When St. John College closed in 1975, its nursing program was moved to URSULINE COLLEGE. In 1979 CASE WESTERN RESERVE UNIV. established the first professional doctoral program in the world for entry into nursing practice and awarded the N.D. degree; at the same time, it discontinued its baccalaureate program. In the 1960s Cleveland was the site of one of the first nursing research development programs in the country, and in 1972 a Ph.D. in nursing was established locally. The first nurse midwifery graduate program in Ohio and the 14th in the country was established in Cleveland in 1983.

Nursing education in Cleveland in the 1980s presented a confusing picture. The American Nurses Assn. had taken the position in the mid-1960s that preparation for entry into the practice of professional nursing should be at the baccalaureate level. Although mandatory licensure in Ohio was achieved in the 1960s, the nurse-practice act did not specify one type of rigorous, systematic educational preparation. Four types of nursing programs (hospital-based, A.D., B.S.N., and N.D.) existed in Cleveland to prepare nurses to take the same licensing exam. The lack of a standardized rigorous system of nursing education led some to believe that nursing had not yet reached the status of a profession, especially in the legal sense of the term. The outcome of 2 local studies conducted in the early 1980s revealed wide local support for the development of a state-supported baccalaureate program in Cleveland; Cleveland State Univ. established such a program for entry into nursing in 1985. The high cost of maintaining hospital nursing schools resulted in some local hospitals closing their schools in the 1980s. In 1990 CWRU again began admitting B.S.N. candidates to a new baccalaureate program. The program was established in conjunction with UNIV. HOSPITALS OF CLEVELAND, the CLEVELAND CLINIC FOUNDATION, and MetroHealth Medical Center. The hospitals provided clinical experience, scholarship aid, and summer work-study to students; in exchange, scholarship students committed themselves to work at one of the hospitals after graduation.

Nursing practice in the 1980s and 1990s reflected improvements made in nursing education over the years. The tasks and procedures that nurses performed, still considered important, became not the ends, but the means through which nurses achieved their goal of assisting people to attain their optimal level of health whether well, ill, or dying--the goal originally envisioned by Florence Nightingale. As medicine and other professions became more open to women, attracting them away from nursing, a slowly increasing number of men were entering nursing. More nurses became involved in home health care in the community when shorter hospitalizations necessitated professional nursing supervision at home. In some local hospitals, nurses assumed responsibility for the nursing care of their own caseload of patients, from admission to discharge. More Cleveland nurses sought advanced preparation and/or certification in specialties. Nurses with master's degrees assumed head nurse positions in some agencies. Some health-care institutions offered horizontal promotions for nurses to remain in direct patient care rather than move up the administrative ladder. Finally, some nurses became primary healthcare providers, "nurse practitioners." Several studies revealed that these nurses provided cost-effective primary care without jeopardizing quality. In fact, nursing care in general has contributed immensely toward achieving positive outcomes for patients and the health of communities like Cleveland.

Evelyn M. Lutz

Kent State Univ.

Greater Cleveland Nurses' Assn. Records, WRHS.

Rodabaugh, James H., and Mary Jane Rodabaugh. Nursing in Ohio (1951).

See also MEDICINE.