Stuttgart 2008 Report

Report on 2nd. International Conference on Nursing History in Stuttgart

Institute for the History of Medicine of the Robert Bosch Foundation Stuttgart

March 12^th to 14^th, 2008

The theme of this second international conference on the history of nursing organised by the Institute for the History of Medicine of the Robert Bosch Foundation was the history of every day nursing. The organisers along with many historians of nursing were of the opinion that the history of nursing care has been neglected in favour of the history of professionalization. So the conference provided a timely opportunity for a focus on this significant topic. And with twenty papers over three days and the discussion generated following each paper, the area was thoroughly explored.

The conference was not about the ‘great names' of nursing instead there was a celebration of ‘ordinary' nurses doing core nursing work in different settings and under diverse circumstances.

One such setting was nursing in the community, delivered directly in the homes of patients. According to national terminology this was variously described as district, visiting or parish nursing in UK, US and Germany respectively. As with other subject areas presented at the conference, after taking into account the national context, there were more similarities than differences across geographical boundaries. Much of this nursing work was for people with long term, chronic conditions. Thus as Susanne Kreutzer illustrated in her paper on parish nursing in Germany post 1945 nurses built up relationships with the patients and their families. In her oral data the nurses felt that they saw the patient as a whole person when looking after them at home. As these nurses were protestant deaconesses of the Henriettenstifung, religious conviction underpinned their work which also involved officiating at children's religious services. For the nurses this was a counterpoise to their heavier work with elderly people. They regretted that holistic nursing was lost after changes in the 1960s which led to a more functional nursing service. The cognitive dissonance that nurses from religious orders experienced was demonstrated in Karen Nolte's paper on care given to the body and soul in 19^th century Germany. For the deaconesses of Kaiserswerth the care of the soul was as important as physical care, so they were disconcerted when those patients they referred to as ‘faithless' did not welcome their spiritual ministering along with nursing care and Rumford soup. Yet home nursing gave young middleclass women a more realistic and sympathetic knowledge of the lives and home conditions of the poor.

This was a theme in Stuart Wildman's paper on 19^th century home nursing association in the English Midlands. The interventions of home nurses, including the provision of nutritious meals, allowed members of the ‘deserving poor' to regain their health and return to the workforce. This prevented the worker and his family from sliding into poverty.

As Arlene Keeling demonstrated in her paper on the role of American visiting nursing in the 1918-19 influenza epidemic it was nursing care that saved many victims of the disease. The nursing response to the emergency was rapid and organised. In the decentralised response to the epidemic it was visiting nurses who co-ordinated the services of several branches of community nursing to give multi facetted care including hygiene advice and the provision of the ubiquitous soup.

Renate Lunde in her paper on the work of the Church Missionary Society in Egypt showed how these skills were exported to ‘colonial' settings. Working in the Old Cairo Hospital British missionary nurses established a mother and baby clinic which later became the model for Egyptian government welfare centres. In a contemporary film we saw the health education posters, songs and activities employed to teach mother craft. Again the through their interaction with local women at the clinic many nurses modified their judgemental views on the life styles of their clients.

Helen Sweet gave us a paper on mission nursing in KwaZulu Natal a space of nursing she described as located at an institutional crossroads where mission meets nursing. Medical provision was one way of getting the Christian message accepted. As teachers of skills and employers the mission hospitals also played a role in the nurturing the careers of black nurses. Initially they were managed by less experienced white head nurses, but women like Duduzile Byela were influential and prestigious women in their own communities. And with the defeat of apartheid they were ready to take up key positions in South African health provision.

Another aspect of race and culture in nursing was covered by two papers on the contribution of South Asian particularly Korean women to the German health care system. Ulrike Winker's paper dealt with the recruitment process of the German Evangelical Hospital Association and its partner the Diaconic Association of Korea. Nursing work in Korea was more technical than in Europe; relatives carried out tasks such as washing and feeding patients. Highly qualified Korean nurses were shocked to find that these tasks would be part of their duties, which led to aspersions against the Koreans that they were not behaving in an expected manner.

In her paper Young-sun Hong was keen not to see these nurses as victims, archival evidence she cited shows that they organised a protest as early as 1963. But their presence in the story of health care has been erased from the discourse. She reminded delegates that it is important to consider other images of the ‘global' woman migrant worker than the mail order bride.

What actually constituted nursing tasks may have been in contention in the context of Korean nurses in Germany, but it is a subject that has exercised nurses across time. This was demonstrated by Julie Fairman in her paper on the development of the role of the nurse practitioner in the US. Although physicians and nurses had different perspectives on the direction the role should take they managed to work together and the nurse practitioner role has been accepted by patients, nurses and physicians because of its positive impact on health care.

Nursing in Psychiatric hospitals

Another facet on the doctor nurse relationship was explored by Sabine Braunschweig in her paper on how nurses at the psychiatric hospital in Basel dealt with the challenges of sexually aroused patients. Junior doctors who had the arrogance to disregard the advice of experienced nurses found themselves in potentially compromising positions vis a vis female patients. Patients undergoing therapies such as insulin coma therapy needed careful observation while unconscious and one to one therapy as they regained consciousness. In her study of the Friends Asylum in Philadelphia Patricia D'Antonio also covered the strategies used to bring order to the chaotic minds of psychiatric patients. Despite hopes for the success of ‘moral therapy' over the first half of the nineteenth century it was replaced by a more mediatised model of care. This was because it left staff with few resources with which to contain disturbed patients other than seclusion or restraint. She made the link through time and place of the constant dilemma for nurses between the commitment to a patient on an individual level and the need to uphold the therapeutic environment that is needed for his/her recovery. More day to day nursing in psychiatric hospitals at the turn of the twentieth century was illustrated (and indeed graphically by photographs and excellent maps) by Carlos Watzka. Using the records of the main institution in the Duchy of Styria, Austria he gave a picture of an institution where resources in terms of staff and funding could not keep pace with the demands of the service expected of it. Again aspects of this situation had had echoes across time and place.

The socialisation of nurses into what their superiors considered the embodiment of the ‘good' nurse was discussed by Ulrike Gaida in her study of the training summaries of nurses at the Protestant Social Welfare Association 1918-1933. Women regarded as ‘theorists'  stood out as not conforming to the more practically orientated work which was also regarded by senior nurses as  ‘a labour of love'. Ironically enough it was the women described as ‘loners' who stayed longest in the employ of the association.

Whether nurses questioned their superiors was raised by Susan Benedict in her paper on nurses involved in ‘euthanasia' programmes of the mentally ill under the National Socialist regime. She used the trail of the nurses at the Meseritz-Obrawalde psychiatric hospital as a case study. Certainly the expectations of a nurse would be not to take life. Although some did this with zeal she argued that others found themselves involved in killing because of a tradition of obedience to doctors and senior nurses. Ultimately nurses, whether for good or evil reflect the society within which they function.

Nurses ‘breaking the mould'

Other papers gave examples of how nurses could act against expectations in a more positive way. The nurses at the Colonial Women's School in Rendsburg near Hamburg, presented by Sünje Prühlen were certainly in this category. In 1938 nurse training was added to the curriculum which already included childcare, carpentry, agricultural work and motor maintenance. A course at the school was intended to equip young women to work in the African colonies although after 1939 some graduates of the school went to the new colonies of Eastern Europe. But wherever their destination they had a training which was at odds with the National Socialist ideal of women's skills and given them at this remarkable institution under the very eyes of the regime.

John C. Kirchgessner's work on the economics of health care at the University of Virginia Hospital 1945-65 gave us another example of historical facts overturning suppositions. Using Benson's monetary model he showed how nursing instead of being a drain on hospital resources as previous thought by the administration was in fact contributing to the profits of many other hospital departments. This was achieved because nursing staff stepped in and did the work of members of these departments ‘after hours' at evenings and weekends. Unfortunately owing to nurses' lack of business acumen this work was never acknowledged. Could similar exercises could be used to argue for more nursing resources in a contemporary setting we pondered?

The effect of their work on nurses

Sometimes everyday nursing work went beyond heavy physical demands and brought dangers such as catching infectious diseases. In the context of Germany and Austria 1890-1930, Sylvelyn Hähner-Rombach showed how the high tuberculosis (TB) rates among nurses as opposed to other occupational groups were initially ignored. But Roman Catholic nursing nuns provided a static research group to illustrate the incidence of TB among nurses. Stephanie Kirby explored the impact on nurses of working with dying TB patients in British TB hospitals. Although nurses had their own informal support networks they were often comforted by patients and ancillary staff. She asked delegates to consider if there was less holistic care with the advent of a chemical cure for TB.

For nurses working on the battle front in World War I exhaustion was compounded by a heavy emotional toll. Using the writing of both trained nurses and volunteers (VADs) Christine Hallett explored their perceptions of the trauma they encountered and their coping mechanisms. The nurses wrote of their experiences in private diaries while the VADs often intended their histories for publication. Again the issue of socialisation of nurses was raised in that there was more ‘matter of factness' and less reflection in the writings of the professional nurses.

Nursing Knowledge

For all their work in whatever setting nurses needed a knowledge base. Although much nursing knowledge was learnt at the patient's side the turn of the twentieth century saw a growth in the written dimension of nursing theory. Using two journals Carol Dealey investigated the theoretical basis of the prevention of ‘bedsores'. Although she found little consistency in advice for prevention, equipment such as pressure relieving mattresses featured in this earlier period of nursing, demonstrating the enduring opportunities for commercial ventures in healthcare.

So historiography finally appreciates the everyday work of nurses, and in a cost conscious climate nurses need to be able to provide evidence of their value to health care. They can call on the historians of nursing who are not always appreciated by their clinical colleagues for help in this task.

English speakers were relieved that English was the language of the conference and were suitably humbled at the erudition of our German, Austrian and Norwegian co delegates expressed in English. However at least we were able to express our appreciation of papers by substituting our clapping for the more robust German method of table banging. Delegates, like some patients discussed, were cared for in a holistic manner with body -marvellous and plentiful food, mind -rigorous discussions after the papers and spirit- the welcome from our hosts at the Institute for the History of Medicine, all catered for. The smooth running of the conference owed much to the organisational skills of the staff of the Robert Bosch Institute particularly those of Sylvelyn Hähner-Rombach and Steffi Adam and I know I speak for all the delegates in thanking them for inviting us to take part in such a stimulating event and offer them in the English manner a (virtual) bouquet. A future conference was mentioned by Sylvelyn Hähner-Rombach in her concluding remarks and is eagerly anticipated.

Stephanie Kirby, University of the West of England, Bristol, UK