Lessons Learned From a History of Perseverance and Innovation in Academic–Practice Partnerships

Lessons Learned From a History of Perseverance and Innovation in Academic–Practice Partnerships

LESSONS LEARNED FROM A HISTORY OF PERSEVERANCE AND INNOVATION IN ACADEMIC–PRACTICE PARTNERSHIPS MARTHA MATHEWS LIBSTER, PHD, RN, CNS⁎ Nurse leaders to...

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LESSONS LEARNED FROM A HISTORY OF PERSEVERANCE AND INNOVATION IN ACADEMIC–PRACTICE PARTNERSHIPS MARTHA MATHEWS LIBSTER, PHD, RN, CNS⁎ Nurse leaders today are faced with a pressing concern to reevaluate established community resources and models for academic–practice partnerships that have been used in the preparation of new and advanced practice nurses. Nursing reform in education and practice is not achieved as a simple series of decisions in the present moment with future direction as its object. It is a process in which the outcome is ultimately evaluated within the context of history. Academic–practice partnerships are part of a nursing heritage that has persevered for hundreds of years. This article is a brief synopsis of examples from the historical records that evidence the lessons learned from the experiences of nurses who have formed innovative academic–practice partnerships with religious communities, medical colleges and physicians, government, hospitals, institutions of higher learning, and nursing organizations. (Index words: Nursing history; Academic–practice partnerships; Nursing education; Innovation; Health care reform) J Prof Nurs 27:e76–e81, 2011. © 2011 Elsevier Inc. All rights reserved.

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URSE LEADERS TODAY are faced with a pressing concern to reevaluate established community resources and models for academic–practice partnerships that have been used in the preparation of new and advanced practice nurses. Contemporary leaders are faced with an age-old challenge to create change and address a call for nursing reform in education and practice. Reform is not achieved as a simple series of decisions in the present moment with future direction as its object. It is a process in which the outcome is ultimately evaluated within the context of history. The very nature of approaching the reconstruction of nursing seems to require at its very essence historical perspective as an opportunity to increase the possibility of sound judgment and discernment when creating a plan for the future in which lessons learned from past experiences can be clearly articulated and integrated. Nelson and Gordon (2004, p. 259) have suggested that nursing often ignores its history. They write of a professional pattern that they identify as a “rhetoric of ⁎Director and Chair of Nursing, College of Health and Human Services, Governors State University, IL. Address correspondence to Dr. Libster: College of Health and Human Services, Governors State University, 1 University Park, University Park, IL 60484. E-mail: [email protected] 8755-7223/11/$ - see front matter e76 doi:10.1016/j.profnurs.2011.07.005

rupture” in which the history of the profession is marginalized for the “new and improved” and the contributions of previous nurses' practice and educational strategies devalued. Delving into the collective history of a profession is not an easy task in that it requires engagement in a reflection of the human experience with all of its perceived mistakes as well as triumphs. The task at hand to reform nursing education and practice and the call to develop and sustain effective academic–practice partnerships would be best supported by an understanding of the history of past partnerships. Although they may have not been specifically referred to throughout history as “education or academic–practice partnerships,” the concept is not novel, and in this case, the nursing history related to the concept is replete with innovation, power, and success. Academic–practice partnerships are part of a nursing heritage that spans hundreds of years. Historical records evidence the experiences of nurse leaders who have formed innovative partnerships with religious communities, medical colleges and physicians, government, hospitals, institutions of higher learning, and nursing organizations as a means of bridging education and practice in an effort to promote quality health care and preparation for nursing practice. The following are examples of those partnerships and brief synopses of the lessons that might be learned from nursing history as reformers embark upon their task.

Journal of Professional Nursing, Vol 27, No. 6 (November–December), 2011: pp e76–e81 © 2011 Elsevier Inc. All rights reserved.

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Religious Communities In 1633 in France, Madam Louise de Marillac partnered with a priest named Vincent de Paul to organize and operationalize a “confraternity” or community of women in Paris, the Daughters of Charity (DC), whose work included nursing the sick poor in their homes. Their educational preparation included guidelines for the production of remedies and treatments, ethical and legal parameters for practice in health care facilities and communities, defining emerging professional roles and personal responsibility, and a framework for the corporal and spiritual care of persons, as well as instruction on creating and maintaining practice partnerships, that is, relationships with physicians and hospital administrators (Libster & McNeil, 2009). It was this 17th century model of nursing education and practice in community that propelled the confraternity of women to a centuries-old international professional reputation that was subsequently the magnet for 19th century nurse reformers such as Florence Nightingale of England and Amelia Sieveking of Germany. Although the DC was not a religious order (i.e., Nuns) per the doctrine of the Catholic Church, they were religious women whose education was grounded in Catholic tradition, specifically the ministry and teachings of Vincent de Paul. Their ministry led them to strive for humility, simplicity, and charity. The founding of the DC was a boon to women and charitable work in community. Vincent de Paul wrote that it had been “eight hundred years” since women had held public roles in the Church. The Common Rules, the written documents that directed the nurses' lives and service, “ultimately became a prototype for many religious communities and nursing leaders” such as Nightingale and Sieveking (Libster & McNeil, 2009). The Common Rules “represented the values and virtues of the members of a Community from which the image of DC was constructed and made recognizable for the public” (Libster & McNeil, 2009, p. 23). This nursing tradition was formative to the establishment of professional nursing in the United States as well as through the American counterparts of the DC, the Sisters of Charity, whose community was founded in 1809. The Sisters of Charity nurses under the direction of Mother Elizabeth Ann Seton and head nurse Sister Ann Gruber partnered as early as 1815 with Mount St. Mary's College and Seminary providing nurses for their infirmary. The Sisters of Charity prepared all nursesisters to provide a care that supported the corporal and spiritual needs of the sick poor. The sister-nurses' charity included sanitation and administration of sick rooms and hospitals, preparation of the sick diet, formulation and administration of herbal remedies (tisanes and syrups) and topical treatments, spiritual care, and assessment and monitoring of patients (Libster & McNeil, 2009; Sullivan, 1991). The spirituality of the nurses' education led to wisdom in caregiving grounded in ability to think and act “judiciously” and with

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“discernment”—a practice today identified as evidencebased practice.

Lessons Learned Professional nursing education has been supported historically by religious tradition emphasizing the spiritual and corporal care of patients. Nurses have successfully worked (originally as part of) with religious communities to pioneer the development and administration of a new community nursing services. Nursemanaged clinics (also referred to as infirmaries, homes, and hospitals) have been nurses' heritage at least since the 17th century. Clinics have historically served as educational facilities for learning hands-on nursing care—a practice now referred to as service learning. Other historical examples of academic–practice partnership with religious communities include the following: • Ireland, early 19th century—Careful nursing model devised by Catherine McAuley (1778–1841) with the Sisters of Mercy (Meehan, 2003). • United States, mid 19th century—Education conducted by Latter-Day Saints (Mormon) nurse pioneers through their community Council of Health and Relief Society (Libster, 2004) led by nurses and midwives, such as Patty Bartlett Sessions (1795–1892). • United States, 18th and 19th centuries—Education of nurses conducted in the infirmaries of numerous Shaker “families” or communities (Libster, 2004).

Partnerships With Medical Colleges and Educational Programs for Physicians The Sister of Charity nurses' expertise in education and practice was sought beyond their Catholic community just as had been the case in France. One of the first partnerships between nurses and a medical college or educational programs for physicians in the United States was that which was established in 1823 between the American Sisters of Charity of Emmitsburg, MD, and the Protestant hospital administrators and medical faculty of the College of Medicine of Maryland (now the University of Maryland Medical Center). The Sisters, who had established an excellent reputation as nurses, were invited to staff the Baltimore Infirmary, the facility established for the bedside education of physicians (Libster & McNeil, 2009, p. 53). In return for providing on-site clinical education for medical students, the Sisters received many educational and practice opportunities, including surgical observation. The Sisters, through their Bishop, established the terms of agreement for their services, which included the room and board they received and the definition of what constituted respectful behavior by patients and medical students toward the nurses and the parameters of their authority with patients and medical students. The Baltimore Infirmary served as an educational hub for the Sisters' nursing missions. Most of the Sisters

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missioned during the 19th century did some training at the Infirmary where they were exposed to cutting-edge developments in medical education, treatment, and surgery (Libster & McNeil, 2009). In 1838, the Sisters of Charity were missioned to open another infirmary at the Richmond Medical College in Virginia. Dr. Augustus Warner, a founding physician of the College, had been a medical student in Baltimore and worked with the Sisters in the tent hospitals during the 1832 cholera epidemic. It was he who specifically requested that the sister-nurses staff the infirmary at Richmond when it opened (Libster & McNeil, 2009, p. 80). In 1840, the Sisters of Charity hired Dr. William Aiken, a doctor and chemist with the Maryland College of Pharmacy, to give lectures on chemistry and botany to the Sisters at the Central House in Emmitsburg (Libster & McNeil, 2009).

Lessons Learned Some of the largest medical centers today struggled in their early days and would not have had the wherewithal to train physicians if they had not invited early nurses to partner with them. Nurses in religious communities, such as the Sisters of Charity, offered opportunities for intellectual, scientific, and professional exchange. Bedside learning and theoretical coursework have been fundamental to both disciplines. For centuries, nurses and physicians have had a reciprocal relationship in terms of educational need.

Partnerships With Physicians In 1840, the American Sisters of Charity opened their own asylum for the insane called the Mount Hope Retreat. They hired a “consulting physician,” Dr. William Hughes Stokes, to partner with them in their contribution to establishing a more humane form of mental health care, which at the time was a health reform movement in Europe known as “moral therapy.” They invented their own restraints and treatment protocols used in providing a care, which set their hospital apart from others in Maryland. Advocate and reformer, Dorothea Dix, identified the Mount Hope Retreat in 1852 as one of two successful institutions in the State (Dix, 1852). Initially, the model of care used by the Sisters and Dr. Stokes was aggressively opposed by some of the members of the burgeoning Association of Medical Superintendents of American Institutions for the Insane (now the American Psychiatric Association). Nevertheless, Stokes continued as consultant to the Sisters for 50 years. The Mount Hope Retreat ultimately closed in 1973 (Libster & McNeil, 2009). The nurse–physician partnership of the Sisters in Baltimore reflected similar arrangements of their predecessors in France.

Lessons Learned Physician-created facilities have supplied space and opportunities for the education of nurses. Nurses and physicians have had successful, mutually beneficial, although not unchallenged, innovative entrepreneurial

partnerships that have often inaugurated and supported significant health reforms.

Partnerships With Government During the American Civil War in 1860, individual nurses, such as Mother Mary Ann Bickerdyke of Ohio, and communities of nurses, such as those within the Catholic and Protestant Churches, entered into service agreements with agents of the federal and state government. Mother Bickerdyke, for example, began her nursing care of wounded Union soldiers with supplies from the Chicago Sanitary Commission. Mother Bickerdyke had nursing experience prior to entering into her wartime duties. She was appointed matron of large hospitals in Cairo and Bird's Point, IL, that cared for the soldiers. Her success in saving the lives of hundreds of wounded led to recognition and admiration of her services by nurses, physicians, sanitation officers, and patients. Even General Sherman stated that Mother Bickerdyke “had more power” than he in supplying hospitals and attaining resources for nursing the wounded (Livermore, 1889). The skill and reputation of religious sister-nurses also grew as a result of their wartime service. Although Mother Bickerdyke served the “boys in blue,” Catholic sisters, such as the DC, nursed both union and confederate soldiers (Libster & McNeil, 2009). According to Mrs. Mary Livermore's My Story of the War, surgeons, medical directors, and ward masters openly declared their preference for Catholic Sisters. Despite some physician's “prejudice” for Catholic nurses, Dorothea Dix commissioned many Protestant nurses who were dedicated to serving the wounded even if it meant that they had to “appeal to the Secretary of War” for the right to do so (Livermore, 1889, p. 225). All nurses' engagement in later conflicts, such as the World Wars, continued to contribute to public understanding of the value of nursing care and the growth of the profession. One specific example of that growth from nursing history is the development of the nurse-anesthetist role, which has been traced to the practice of Catherine S. Lawrence and other nurses during the Civil War. The government has contributed to growth in nursing practice and education. Under the G.I. Bill of Rights, army nurses have received additional education. Military nurses have also contributed their valuable field hospital experiences to civilian educational programs.

Lessons Learned Caregiving for casualties of war has presented numerous learning opportunities for military and civilian nurses alike. Demand for nurses during wartime to meet the acute needs of the wounded has driven partnerships with state and federal government and spawned changes in nursing practice and education, such as the creation of nurse-anesthetist programs. Nurses returning from wartime duties have carried valuable experiences with

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them, which have been translated into opportunities for student learning.

Partnerships With Hospitals (Physicians and Administrators) The findings of the American Medical Association (AMA) Committee on the Training of Nurses published in 1869 as “critical turning points” included the following statements: 1. “Every large and well-organized hospital

should have a school for the training of nurses, not only for the supply of its own necessities, but for private families, the teaching to be furnished by its own medical staff, assisted by the resident physicians.” 2. Nursing “combine religious exercise with nursing…establishment of nurses' homes under the direction of deaconesses, or lady superintendents…” The report had found that preparation for nurses of non-Catholic Christian denominations had been “singularly neglected.” The AMA called for the training of “thousands of nurses.” 3. That “district schools…be placed under the guardianship of county medical societies in every State and Territory in the Union.” Physicians were to teach the art and science of nursing, hygiene, and “every other species of information necessary to qualify the student for the important, onerous, and responsible duties of the sick-room.” The sick room had been the domain of the nurse and nurse educator heretofore (Gross, 1869). An 1872 report included a letter from Florence Nightingale to Dr. Gill Wylie of the Hospital Committee of the State Charities Aid who spearheaded the reform of nursing education at Bellevue Hospital in New York. In that letter, Miss Nightingale detailed the “dangers” of equating nursing with medicine and that nursing education (and discipline of students) not be placed under the direction of doctors but “under a woman, a trained superintendent,” a nurse also called a matron. Nightingale also cited the “disastrous consequences” experienced in German hospitals in which a chaplain and a female superintendent were “virtually masters of the hospital” (Dock, 1901). The Bellevue School was incorporated in 1874. Some nurses during the same period and in present day choose not to partner with hospitals. They may be devoted to public and community health or outpatient care. Professional nurses in America prior to the Civil War practiced within their communities for the most part. Although some nurses and educators pursued partnerships with hospitals and administrators who were growing in social and cultural power, others such as the Shaker nurses found strength in community partnerships.

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Lessons Learned Nursing is a distinct and yet complementary discipline from medicine that is practiced in hospital and community settings. Nurses like American Shaker Prudence Morrell, 1849 have articulated the nature of the relationship between disciplines in their writings. Sister Prudence wrote in 1849, for example, that “the great art or skill in curing up the sick and afflicted does not always depend on the knowledge of the Physician, it some times [sic] partly depends on perseverance,” which she went on to define as one of the acts of her “conscience” in caring for others, which “would not let her give up on them” (preface p. 1). Nurses make life-saving contributions through those caring acts of conscience. In addition, nursing education carried out in hospitals and communities continues to confront the historical issues of professional boundaries, conscience, and power (identified as “obedience” in the 19th century), particularly with physician colleagues.

Partnerships With Institutions of Higher Learning There was a serious nursing shortage after World War II. The Carnegie Foundation commissioned Dr. Esther Lucille Brown to study nursing education. Her report titled, “Nursing for the Future,” recommended that nursing students be educated in colleges and universities rather than in hospitals where they were subjected to the requirements of the employee. The same year, the Conference on Catholic Schools of Nursing was formed to “foster higher educational standards in conjunction with college programs. About 90,000 sisters teaching in American schools also needed to upgrade their credentials. By 1954, 150 centers had been established to assure that all teachers would receive Bachelor of Arts degrees before beginning their teaching assignments” (McNamara, 1996, p. 627). Secularization of nursing education moved to a new level (Libster & McNeil, 2009, pp. 300–324). During the mid 20th century, Dr. Mildred Montag, in her doctoral dissertation, defined a “practice continuum” and differentiated practice; however, associate degree nurse graduates were not used in practice settings as intended by Montag's research (Matthias, 2010).

Lessons Learned Implementation of educational policy and andragogical strategies as well as education research is translated in the practice arena. That translation can present challenges and controversy. Controversial professional issues, such as entry level into practice, can be identified in the historical documents of educational institutions and practice facilities and professional associations. Resolving these issues is part of the redefinition of the profession and its dynamic partnerships with education, a process which has occurred in the past and is now being revisited.

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Partnerships With Nursing Organizations The National League for Nursing Education, Association of Collegiate Schools of Nursing, and the American Nurses Association (ANA) have contributed to the debate over defining nursing educational preparation and practice. In the mid 20th century, there were two levels of nursing preparation: the professional and technical nurse. The ANA (1965) published a position paper in asserting that minimum entry level for professional practice to be bachelor of science in nursing (BSN) and for technical practice to be associate degree in nursing (ADN). The ANA also conducted a series of studies of nursing “functions” in which they sought to “define nurses' work and determine how nurses' time was distributed among specific, named activities (Lynaugh & Brush, 1996, p. 19). The term technical nurse was replaced with ADN. Currently, the debate has evolved into the “BSN in 10” initiative. Community colleges in some states are now being authorized to provide BSN degrees. There is also some debate over the implementation of the doctorate in nursing practice. Technology, distance learning, and simulation skills lab are now prevalent foci in nursing education. Some historical evidence suggests an achievable bridge between technology and nursing care traditions (Sandelowski, 2000). Other evidence demonstrates a call for futuristic models of self-directed education in which student accountability for learning predominates and nursing graduates are prepared for “more opportunities in employer-based, communitydriven, clinic-based, and ambulatory settings for nursing service delivery (Porter-O'Grady, 2001).

Lessons Learned The debate over entry level into practice is now decades old. Partnerships are reflected in the practice settings nurses use in education of students. These academic– practice settings have historically been in community, hospitals, and ambulatory centers such as infirmaries or clinics.

Conclusion Sharing resources and partnering to expand knowledge have been demonstrated historically to strengthen communities and broaden public accessibility to health care. History also demonstrates that times of intense challenge such as war and epidemics like cholera and yellow fever often propel people into partnerships. Because of their historic role and reputation in society and their heritage of developing and maintaining education–practice partnerships, nurses are well positioned to address the reforms called for in the 21st century. Innovative academic or academic–practice partnerships have been a cornerstone in the evolution of the discipline of nursing. Nurses have bartered education with physicians and hospitals for centuries to expand their healing networks and knowledge of

health, medicine, and caregiving, as well as their access to patients. Nurses, until the 20th century, liberally created educational and practice opportunities for themselves and others. They answered the calls of the sick poor and mentally ill in a time when people were not insured rather than underinsured. One gets the sense from early American nursing history that nurses had greater opportunities for professional development and designing and administering infirmaries and hospitals than in contemporary society. The autonomous innovation of earlier centuries in nursing has started to be recaptured in the advanced practice movement and the burgeoning federal and state support for “nurse-managed clinics.” Although nurses have a history of documented success as highly creative, autonomous problem solvers for some of the toughest health-related problems in society, there is still work to do to remove Victorian myth and propaganda of a supposed history of obedience and lack of power (Libster, 2004; Libster & McNeil, 2009). One of the biggest changes in the past century that may bode well for nursing reform is that nurses occupy many of the leadership positions in health care institutions, as did their earlier predecessors. New partnerships between academe and health care institutions will be negotiated by nurses. There is always a risk of repeating the past particularly if the history is unknown. Nelson and Gordon (2004) suggest that success in nursing is often equated with “newness.” Reframing success in nursing, particularly in terms of the task of forging academic–practice partnerships, is important. Therefore, leaders engaging in the next round of dialog on academic–practice partnerships may want to review materials that will place their decisions in historical context, thus adding the dimension of evidence for choices made that is based on the wisdom of experience. Some of the lessons learned from history may be applicable to present circumstances. Nursing reform requires high levels of innovation and creativity. Although the ideas that surface may be historical, they need not be rejected. Previous nursing reforms have involved the redesign of historical structures. For example, the early American Sisters of Charity nurses cultivated a sense of purpose and mission as well as pioneering spirit in each other by seeking guidance from the community records of those who had been successful centuries before them, thus adding their own special twist of ingenuity based on patient need at the time. Their institutional, educational, and practice reforms, some of which started with the support of a single dollar, may have in fact been successful because that success was defined quite simply as sick people were helped, nurses learned, and the profession grew in societal rapport. Although specific models of historical partnerships may or may not be applied to the modern dilemma, there is something that history offers those who may be courageously considering entering into the dialog. History, the stories of collective endeavor, contains

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numerous pearls of wisdom that appear as patterns over time that can potentially inspire exploration of new levels of professional identity and meaning. There is one pattern in nursing history that seems most appropriate for reflection as nurse leaders circle back to forge a new level or revision of academic–practice partnerships. That is the pattern of the quality of perseverance. Nurses have a history of perseverance. Nurses, like the Sisters of Charity have cared for and healed people with mental illness when partners in society relegated them to chains and torture. Nurses, like Shaker Prudence Morrell, have partnered with physicians to save the lives of patients deemed destined for death by medical estimation, and nurses continually strive to change public perception of the skill and decision-making capacity of the profession. Perseverance is just one of the historical momentums available to leaders who would seek to come to consensus on how, when, where, and why nursing will partner in the 21st century.

References American Nurses Association. (1965). A position paper. New York: American Nurses Association. Dix, D. (1852). Memorial of Miss D. L. Dix to the Hon. General Assembly in Behalf of the Insane of Maryland. Archives of the State of Maryland Web site http://www.msa.md.gov/. Dock, L. (1901). History of the reform in nursing in Bellevue Hospital. American Journal of Nursing, 2, 89–98. Gross, S. D. (1869). Report of the Committee on the Training of Nurses. American Medical Association, The Transactions of the American Medical Association, 20, 161–174. Chicago Illinois: Archives of the American Medical Association. Libster, M. (2004). Herbal diplomats: The contribution of early American nurses (1830–1860) to nineteenth-century health care

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reform and the botanical medical movement. North Carolina: Golden Apple Publications. Libster, M., & McNeil, B. A. (2009). Enlightened charity: The holistic nursing care, education, and advices concerning the sick of Sister Matilda Coskery, 1799–1870. North Carolina: Golden Apple Publications. Livermore, M. (1889). My story of the war: A woman's narrative of four years of personal experience as nurse in the Union Army, and in relief work at home, in hospitals, camps, and at the front, during the War of the Rebellion. Hartford: A.D. Worthington & Co. Lynaugh, J., & Brush, B. (1996). American nursing: From hospitals to health systems. Cambridge, MA: Blackwell Publishers. Matthias, A. (2010). The Intersection of the history of associate degree nursing and “BSN in 10”: Three visible paths. Teaching and Learning in Nursing, 5, 39–43. McNamara, J. (1996). Sisters in arms: Catholic nuns through two millennia. Cambridge, MA: Harvard University Press. Meehan, T. C. (2003). Careful nursing: A model for contemporary nursing practice. Journal of Advanced Nursing, 44, 99–107. Morrell, P. (1849). A choice collection of medical and botanical receipts. Winterthur, Delaware: Winterthur Library Shaker Manuscripts. Nelson, S., & Gordon, S. (2004). The rhetoric of rupture: Nursing as a practice with a history? Nursing Outlook, 52, 255–261. Porter-O'Grady, T. (2001). Profound change: 21st century nursing. Nursing Outlook, 49, 182–186. Sandelowski, M. (2000). Devices and desires: Gender, technology and American nursing. Chapel Hill: University of North Carolina Press. Sullivan, L. (ed). and trans. (1991). Louise de Marillac spiritual writings: Correspondence and thoughts. New York: New City Press.