Beyond Nightingale

By Laura Stephenson Carter

It's with a sly chuckle that DHMC nurse Peter Nolette, B.S.N., R.N., notes that the earliest nurses were men—monks and other males in religious orders. It's not surprising that as one of only 11 male nurses to graduate from the now-defunct Mary Hitchcock Memorial Hospital School of Nursing (SON), Nolette would look for male roots in the profession that he loves.

"The beginning of nursing—we think of Florence Nightingale," Nolette says, admitting that "she may have started the first formal nursing program." One of history's most famous nurses, she established the Nightingale Training School for Nurses at St. Thomas's Hospital in England in 1860. Soon, nursing schools began popping up all over the U.S. The earliest ones were in Boston, Philadelphia, and New York. By 1893, when the Mary Hitchcock Memorial Hospital Training School for Nurses—and Mary Hitchcock Memorial Hospital itself—opened, there were about 200 such schools in the country.

Nolette, who graduated from the SON in 1977, has immersed himself in its history and remains an active alumnus. It was exactly 25 years ago that the Hitchcock School closed its doors, but its impact is still very much in evidence.

In the early days, hospital-based diploma nursing schools, like Mary Hitchcock's, had little formal instruction, no standardized curriculum, and no accreditation, but they provided on-the-job training. In 1893, the 36-bed MHMH was staffed by three doctors, two nurses, and two nursing students. An early application form specified that "candidates for admission to the Training School should be between the ages of 21 and 35"; explained that "instruction will be given by lectures and recitations, at the bedside in the Hospital and in the homes of patients, in contagious and non-contagious diseases"; and warned that "the profession of a nurse . . . calls for the exercise of self-denial, patience, gentleness, and good temper."

Students typically worked six and a half days a week in 12-hour shifts, including at night; took classes; and, if they were seniors, managed whole wards of patients. In the early years, students also worked in private homes in the Hanover area, caring for patients with typhoid fever, grippe, fractures, peritonitis, and heart disease. Students were treated like family, so they didn't seem to mind living in dorms supervised by housemothers, following strict rules, working hard, and wearing uniforms and caps. New student nurses were called "probies" because they served a two- to four-month probationary period before being accepted as first-year students. As student nurses toiled away, receiving only small stipends for their work, established nurses nationwide were forming professional organizations that fought to set standards for nursing schools.

But in the late 1800s and early 1900s, MHMH student nurses were oblivious to early efforts to improve nursing education. They were too busy preparing breakfast trays for patients; washing dishes on the maid's day off; making beds; stoking the ward fireplaces; polishing silver; dusting floors; cleaning bathrooms; and even arranging patients' flowers. And too focused on preparing mustard and flaxseed plasters to treat pneumonia or infection; giving patients cool baths to reduce fevers; administering enemas; and dispensing medications such as morphine, phenacetin (a sedative), mercury ointment (for syphilitic sores), and oil of wintergreen. Students had responsibilities in the operating rooms, too: sterilizing equipment, gloves, and gowns; making sponges and dressings; keeping the OR clean; and assisting during surgery by handing instruments to the physician.

The two-year program was changed to three years in 1905. The amount of time spent in classrooms increased, but students still worked long hours in the wards and operating rooms. They were supervised by senior nurses but were capable of handling things on their own when necessary.

During the 1918 flu epidemic, classes were suspended because so many flu patients were hospitalized that every nurse was needed. "Beds were placed in corridors, sunrooms, anywhere there was space," wrote Loretta Land in Hiram Hitchcock's Legacy. The nursing students "provided such good care that one report indicates that no person hospitalized for other reasons caught the flu. At times, though, the nurse could do little more than go from one patient to the next, giving fluids and trying to reduce fevers. . . . Very few nurses became ill, and those who did were not seriously afflicted."

However, "the following year, 1919, brought severe cases of influenza to the nursing school and hospital. Many students and hospital workers were stricken at once. When Miss Shepard and the head nurse were both ill, the hospital's nursing service was well managed by the students."

The Hitchcock SON was growing, so in 1920 the Billings-Lee building was constructed to house student nurses. Dora-Jane Johnson, R.,N., a 1929 graduate of the school, was typical of students of the 1920s. She went on to work at MHMH as a teacher and supervisor, retiring in 1973. A 1987 article in a DHMC newsletter described what nursing school was like then: "Dora Jane was tossed immediately into work. Her supervisor took her to the Dartmouth students' ward to give a bed bath. With some advice from her supervisor, and cooperation from the rather amused student, Dora-Jane's nursing career was launched.

"Most probies lived in rooms on the third floor of the rotunda, which the students called 'French flats.' As space became available, students moved to the relative luxury of rooms in Billings-Lee.

"On successful completion of probation, students got a nursing cap and kerchief and could expect to earn $8 per month for the remainder of the first year of training. Second-year salary rose to $10 per month, and the final year the amount rose to a hefty $12 per month.

"Most of the students were happy under these conditions, which seem severe and restrictive by today's standards. Rules were adhered to closely—a student caught smoking faced expulsion, and marriage was considered beyond the pale of students. A 12-hour shift was the norm. . . . Uniform inspection and a brief chapel service began the day before the 6:30 a.m. breakfast and 7:00 a.m. start of the shift. For entertainment, one night each week students could . . . stay out until 11:00 p.m."

In its continuing effort to keep up with national trends in nursing education, the Hitchcock SON was among the first to volunteer to be graded by the national Committee on the Grading of Nursing Schools, in 1929. School officials weren't surprised to learn that they needed to address several problems: lack of student supervision; limited student understanding of medical and surgical nursing; lack of opportunities for student rest and recreation; excessive work hours for students; student fatigue; and a lack of funding or endowment for the school. In response, officials expanded the curriculum by getting senior nurses to teach more classes. It was still at least 100 hours short of the 885-hour minimum required for accreditation, however. But MHMH found it impossible to shorten the workday to the recommended eight hours until 1938, and even then only in certain wards.

An addition to Billings-Lee was completed in 1937 and given the appropriate, if not very creative, name of Building 37. Although there was more emphasis on education by that time, the Hospital still counted on having student nurses do the bulk of the patient-care work.

Dorothy Coutermarsh, B.A., R.N., a 1940 alumna, laughs as she recalls how right after her capping ceremony, where students received their nursing caps, she had to report for night duty on one of the wards. "I was alone as a three-month student in charge of a whole 32-bed unit of female patients. Students were the only staff that they had in the hospital except for this one R.N. who circulated." Student nurses were so busy that they "didn't even have time to sit down," continues Coutermarsh. "When we came on [duty], the food came up in a truck and we had to serve all those trays. . . . We had to take bath basins to the bedside so patients could do their own baths. We had to bathe them, we had to [change and] clean the sheets every day because patients were in bed from 12 to 14 days. The head nurse was responsible for making sure the assignments for the day were carried out. She had to make rounds with the doctors. . . . But as a student we had all that work to do, plus we had to make classes at 7:30 in the morning. If you were on nights, it didn't matter—you made a class at 7:30 in the morning and sometimes you had one at 10:30 in the morning and another one in the afternoon." Occasionally, Coutermarsh would accompany one of the doctors to Woodstock, Vt., to do "tonsillectomies in the town hall." In a foreshadowing of same-day surgery, patients would be sent home to recover with ice bags around their throats. "Once in a while we'd go out on a home delivery," Coutermarsh adds, "but it wasn't standard practice."

The way doctors and nurses interacted with each other hadn't changed much since the late 1800s. "If you saw a doctor, you'd have to stand back against the wall and let them go by," Coutermarsh recalls. But sometimes it was hard for new nurses to distinguish orderlies from doctors, because both wore white pants and tops. "So when you first came in as a probie, you didn't know who people were and you were standing back and letting the orderlies go by," she laughs. When Coutermarsh worked in the operating room, she was the suture nurse and had to be sure to hand the correct thread—there was A silk and B silk, one finer than the other—to the surgeon. "Dr. Bowler used to scream at us if we gave him the wrong silk. He stuttered a lot, so he had difficulty getting it out to us. But we knew what he was saying. No one did correct him," even if he was wrong. The doctors "were disciplinarians," continues Coutermarsh. "They were the ones who gave the orders. They were the ones who made the decisions. . . . Nurses never even thought about disagreeing with a doctor."

To broaden clinical experiences for the students, in 1944, the Hitchcock SON established an affiliation with the New Hampshire State Hospital in Concord, where students did a three-month rotation in psychiatric medicine. Students also were allowed more time for recreation, so they could attend baseball games, go on picnics, ride bicycles, watch movies, go to dances—students were no longer banned from Dartmouth fraternities—and concerts, write for the school newspaper, and participate in student government.

The Hospital adopted a 40-hour workweek in 1953. In 1955, one of the first intensive care units in the country was established at MHMH, and soon there were other specialized units, where nursing students could get on-the-job experience. One of the major changes that showed MHMH's growing commitment to nursing education occurred in 1957, with the reorganization of the Department of Nursing into separate entities for service and education. Two more affiliation programs were added in the mid-1950s: in obstetrics at Boston Lying-In Hospital and in pediatrics at Boston Children's Hospital. Some students loved being able to spend nine months away from MHMH; others couldn't wait to return.

Sandra Charbono, R.N., a 1960 graduate of the SON, enjoyed her affiliation experiences but was surprised that people behaved more formally than at Hitchcock. In Boston, "you didn't talk to [doctors] unless spoken to," she says. And a nurse was expected to give up her seat to a doctor if there weren't enough chairs for everyone in a room. But "that wasn't the case at Hitchcock," she says. And when MHMH nursing students appeared in street clothes at a meeting with the nursing director in Boston, "we were sent back to get our uniforms on," Charbono recalls. At Hitchcock, however, it wasn't unusual for students to wear their bathrobes to evening meetings with the director of nursing education.

By the 1960s, nursing leaders across the country were vigorously debating the relative merits of diploma schools (such as Hitchcock's), associate degree programs, and baccalaureate programs. Some argued that diploma schools produced better nurses because they got more clinical experience during their training. But others realized that as medicine became more complex, nursing education belonged within the college system. In 1965, the American Nurses' Association Committee on Education recommended that the minimum preparation for nurses be a baccalaureate degree.

Meanwhile, at MHMH new trends in nursing were taking hold—like team nursing, in which teams of nurses and assistants provided patient care. Still, the nursing school seemed caught in a time warp. Against the backdrop of the turbulent 1960s, some nursing instructors clung to old ways. Rosemary Swain, R.N., who graduated in 1966 and retired recently, has fond memories of instructors like "Miss Cummings," whose white uniform was so starched "it could have stood up by itself" and who "stood up when a doctor came in," recalls Swain. "She would never offer an opinion. She was from the days when nurses stoked the fireplaces and did it all." Even so, nurses in the 1960s were still expected to stand when a physician entered a room. "There was a distance. You didn't work as part of a team," she says. "Now at DHMC, nurses are respected members of the team."

But new ways were evident, too. In 1965, the first male student was enrolled. Some lived off campus, but others, like Nolette, lived in the dorms with the female students. His room was in Building 50, a nurse residence built in 1950. "First year I was terrified," he says. "Second and third years, it was a blast. I'd do it all over again in a second if I could." He loved caring for patients as well as the classroom work. "We knew the drugs that were out there forward and backward, what they did, how they interacted," says Nolette. He enjoyed participating in student pranks, too—like sitting their instructional mannequin, nicknamed Mrs. Chase, at the housemother's desk.

The growing sentiment that diploma schools were no longer the best way to train nurses was gaining ground as well. By 1973, MHMH was a 420-bed hospital and a component of the newly created Dartmouth- Hitchcock Medical Center. That year, the National League for Nursing put the SON on warning for failure to meet national standards. Full accreditation was restored the next year, however. Nursing administrator Marilyn Prouty, M.S., R.N., who had been hired in 1972, introduced "participatory nursing" as well as the concept of the clinical nurse specialist—a nurse with an advanced degree who is an expert in a specialty. Then, in 1974, she led a future-of-nursing-education conference, which produced a report—endorsed by SON and Hospital officials—that recommended the diploma school be phased out. In 1977, the MHMH Trustees added their endorsement.

So the last class entered in 1977. The curriculum remained strong even in the final years. One of the most challenging courses was anatomy and physiology (A&P), which had been a mainstay of the curriculum since the early 1900s. "Everybody will remember A&P because it was taught by an extraordinarily talented and bright woman—Nan Green—and Nan was tough," says Susan Reeves, M.S., R.N., a member of the SON's final Class of 1980 and now a vice president at DHMC. "You could not get by one of her quizzes or exams having snoozed through a class or having not read your assignment or not having studied your brains out. . . . I loved her class. She was enthralling as a teacher" and a "wonderful illustrator," too. To show how the kidney filtration system worked, for instance, "she would draw an elaborate kidney on the board in intricate detail." A few years later, her notes from that class helped Reeves pass an exam that exempted her from taking anatomy and physiology in a baccalaureate program. "I remember writing [Green] a thank you note," says Reeves.

Afew days before the final graduation ceremony, Prouty and other SON administrators talked about the closing on a local radio show, Breakfast at the Hanover Inn. "We're the only profession on the health-care team which does not require a baccalaureate degree to start," Prouty explained. "We are feeling that this is really essential. The nurses have to make so many decisions now. . . . They're not any more following orders blindly as they maybe did in the past. . . . They make many very, very important decisions."

While Hospital and SON officials were preparing for the closure of the school, they were also engaged in discussions with the University of New Hampshire (UNH) and Colby-Sawyer College in New London, N.H., regarding the establishment of baccalaureate and graduate nursing programs. In 1981, Colby-Sawyer began a bachelor of nursing program—with the college offering the classroom instruction and DHMC a site for clinical rotations. Many of the program's students were starting their training from scratch, while others were already registered nurses, including MHMH graduates, who wanted to add the bachelor's degree to their credentials.

"I remember in particular Sue [Reeves] and Marilyn [Bedell], who were my classmates, who brought a very different perspective to learning about nursing than the other students in the class," says DHMC nurse Polly Campion, M.S., R.N., who was in the first nursing class at Colby-Sawyer. The diploma graduates "were very grounded in what it meant to take care of a group of patients on a daily basis. The rest of the students were naive when it came to what it meant to be working moment by moment with very ill people. [The diploma students] informed the learning and the conversation with a richness that came from knowing what it was like to be up in the middle of the night with a patient reaching the end of life, while you're trying to manage five other patients who are also ill." Campion is now the director of Clinical Improvement and of the Office of Patient Safety at DHMC.

Reeves agrees that diploma-school nurses, because they had so much more clinical experience than college-educated nurses, could "hit the ground running" when they got hired. But the college-educated nurses acquired skills quickly. "Not only did they meet the level of practice of the diploma graduates, but they were able to be good conceptual thinkers [and] see health-care problems in different ways because of their background and experience and training as nurses," says Reeves, who got a B.S. in nursing from Colby-Sawyer in 1988 and an M.S. in nursing administration from UNH in 1991. "I'm a strong believer that nursing education is sophisticated enough now that it belongs in the collegiate environment."

As nursing education was becoming more sophisticated, so too were the interactions between doctors and nurses as they began to think of themselves as part of the same health-care team. "I always felt as if my input and my opinion were considered as much as possible," says Campion, who was a staff nurse in the hematology-oncology inpatient unit in the 1980s. "We'd round with the physicians, whenever they were rounding. They looked for input from the nurses about how patients were doing in order to make decisions about what the next step was for them."

DHMC's involvement in nursing education has remained strong even since the SON closed in 1980. "Just because we were closing the school, we were not compromising our commitment to nursing education," says James Varnum, president of MHMH since 1978. If anything, the commitment was strengthened. Today, DHMC has affiliations with a number of colleges and schools that train nurses and other health-care professionals. "An academic medical center is not just a place that trains doctors," Reeves points out. "We train physical therapists, occupational therapists, respiratory therapists, radiology technologists," as well as nurses. "If it's a profession or a discipline within health care, we have all of those students here all the time."

DHMC recently instituted its own nurse residency program for newly minted nurses. It used to be that new nursing graduates went through an orientation period after they were hired. They were matched with preceptors and spent several weeks gaining experience before they were considered "a stand-alone, bootson- the-ground nurse," says Reeves.

But under the old system, explains Suzanne Beyea, Ph.D., R.N., director of nursing research at DHMC, "it could take months to get the experiences." So Beyea and others launched a residency program in 2004, with funding from the U.S. Department of Health and Human Services. Now, new graduates come into a structured residency program and fine-tune their skills by practicing on human-patient simulators, sophisticated mannequins that respond physiologically like real patients. "We like to think we're one of the few hospitals in the country using simulators for nurse orientation," says Beyea.

DHMC's nursing programs can boast of a number of other firsts, too. "We were one of the first organizations in the country to adopt the concept of the clinical nurse specialist and then foster that role," says Nancy Formella, M.S.N., R.N., senior nurse executive at DHMC. "We as an organization built a system of shared decision-making on our units called shared governance. We've had nursing research going on here for longer than most organizations. We have more advanced- practice nurses—ARNPs, nurse practitioners—here than at most academic medical centers. Our relationship with the Medical School is excellent and there are opportunities within there as well." For example, DMS offers a nurse-shadowing elective aimed at helping medical students better understand nurses' role to foster collaboration with each other.

"The richness of this environment and the ability to grow and develop and move into different areas as a nurse in this setting is really unique," says Formella. In 2003, the American Nurses Credentialing Center awarded DHMC its "Magnet" designation in recognition of nursing excellence. "When you really dig into what's going on in nursing here, and what has gone on over the past few years, it's a gem."

Medicine has come a long way from the days when nurses stoked the fires and changed the beds. Today, nurses can consider careers as nurse practitioners, nurse researchers, nurse administrators, nurse educators, nurse entrepreneurs, and more.

There probably won't ever be another MHMH School of Nursing, nor will there ever need to be. Peter Nolette is doing a pretty good job of keeping the old one alive in the hearts of all its alumni.

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A Timeline of Milestones in Nursing History (national and international events are in italics)

1860	Nightingale Training School for Nurses is established in England.
1883	U.S. has 22 schools of nursing.
1893	36-bed Mary Hitchcock Memorial Hospital and MHMH Training School for Nurses open.
	American Society of Superintendents of Training Schools is founded.
1905	MHMH nursing course increases from two to three years.
1906	Graduate Nurses of New Hampshire formed; group lobbies for state registration of nurses.
1907	Psychiatric rotations at New Hampshire State Hospital begin (end in 1914). State's first Nurse Practice Act passes.
1908	First formal SON graduation held.
1909	First college nursing program opens.
1910	Alumnae association formed. First state board exam given.
1920	Billings-Lee opens as a nurses' dorm.
	U.S. has 3,000 diploma schools.
1923	Committee for Study of Nursing and Nursing Education decries exploitation of student nurses as cheap labor.
1924	School starts admitting students in classes instead of one at a time.
1927	Hitchcock Clinic founded.
1928	Word "training" deleted from SON name; it's now the MHMH School of Nursing.
1929	MHMH is among first to undergo voluntary assessment by Committee
	on the Grading of Nursing Schools. First catalogue published.
1937	Building 37 opens as a nurses' dorm.
1940s	Nursing research begins to be done.
1943	MHMH participates in U.S. Cadet Nurse Corps program.
1944	Affiliation made with New Hampshire State Hospital in Concord (ends in 1964).
1947	First yearbook is published.
1950	Building 50 opens as a nurses' dorm.
1952	SON temporarily accredited by National League for Nursing (NLN).
	The Journal of Nursing Research, the first such journal, is established.
1955	Affiliation made with Boston Lying- In Hospital (ends in 1962). MHMH opens one of the nation's first ICUs.
1956	Affiliation made with Boston Children's Hospital (ends in 1968).
1957	Department of Nursing organizes as two entities: service and education.
1958	SON gets full NLN accreditation.
1960s	Team nursing, a national trend, is a clinical requirement at MHMH.
1963	NLN accredits SON for only two years, indicating serious problems.
1964	Psychiatric affiliation made with Danvers (Mass.) State Hospital.
1965	First male student enters SON (11 graduate by the time it closes). NLN renews accreditation.
	American Nurses' Association says the minimum preparation for nursing should be a bachelor's degree.
1970s	MHMH has 420 beds.
1973	MHMH becomes part of DHMC.
1974	SON faculty holds a conference on the future of nursing.
1976	SON issues a report recommending the school be closed.
1977	MHMH Trustees accept closure recommendation. Last class enters.
	Since 1967, diploma programs have dropped from 840 to 428, baccalaureate programs risen from 188 to 329.
1980	Last class graduates. MHMH has trained 1,850 nurses in 87 years.
1981	Colby-Sawyer College, in affiliation with MHMH, begins a bachelor's program in nursing.
1985	National Center for Nursing Research opens at National Institutes of Health.
1991	DHMC moves to Lebanon, N.H.
1994	Dartmouth-Hitchcock Air Response Team begins operation; team includes flight nurses.
2003	American Nurses Credentialing Center awards DHMC "Magnet" status, recognition of meeting the highest standards of nursing excellence.
2004	DHMC starts a nurse residency program using patient simulators.

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Changing Fashions in Nursing Garb

Nurses' uniforms emerged from nuns' habits," explains nursing researcher Suzanne Beyea, Ph.D., R.N. "Florence Nightingale was always in competition with the nuns."

Through much of the 20th century, nurses wore starched white dresses and white caps. But by the 1970s, the white dresses were being replaced by white polyester pantsuits. Nurses found pants were more practical and easier to move in. In the late 1960s and early 1970s, nurses in pediatrics began to wear colorful tops patterned with cartoon characters, teddy bears, flowers, or other designs. It wasn't long before colored pants were available, too.

By the 1980s, nurses were wearing scrubs, first in the operating room and later in intensivecare units. Today, most nurses wear patterned or solid-colored scrubs, although some do wear whites occasionally. Other hospital staff—aides, dietary workers, and housekeeping staff—also wear colorful tops and pants, so patients can sometimes have a hard time figuring out who the nurses are. Now, "in some facilities, there is a push for white uniforms to distinguish who is the nurse," says Beyea.

Nursing caps began going out of style in the 1970s, and by the 1980s hardly anyone wore them. "It was always difficult to keep it on your head," says Beyea. "As medicine became more complex, caps got more in the way." Rosemary Swain, R.N., MHMH '66, agrees. She was one of the few Hitchcock nurses who still wore a cap and white uniform in the 1980s. "I was one of the last to take [the cap] off," she says. It "wasn't practical and would catch on curtains and such." She soon gave up the dress, too, in favor of scrubs.

Nursing students had their own uniforms to differentiate them from staff nurses. At MHMH, the student uniform changed little until the 1960s, except for the hemline rising and falling depending on the times. It was made up of separate pieces that all had to be starched: gray dress, apron, kerchief, collar, cuffs, and bib. A black wool cape could be worn outside or in the wards at night when it was chilly.

The "probie" uniform consisted of a blue-andwhite- striped or -checked dress with a white apron and detachable white collar and cuffs. Students wore black stockings and shoes until the late 1940s, when they were allowed to wear white ones like staff nurses. By the 1960s, the uniform was more practical, without as many separate pieces, and finally it was short-sleeved and made of a permanent-press cotton blend. Male students wore white pants, gray shortsleeved tops with white cuffs and collars, and white shoes. The graduate uniforms for both men and women were white.

Diploma schools, like MHMH's, each had unique caps and pins to set their graduates apart from those of other schools. Nursing students were not allowed to wear their caps until they had completed the probationary period, and they received a gold cross pin upon graduation. So the capping ceremony was a special occasion, much like the white coat ceremonies at medical schools today.

Students in different classes were distinguished from each other by the stripes on their caps. At MHMH, freshman caps had no stripes, second-year caps had a thin gray stripe, and third-year caps had a thin black stripe, while the caps of graduates had a thick black stripe.

"It was probably like stripes in the military," says 1980 MHMH graduate Susan Reeves, M.S, R.N., who is today a vice president of DHMC. "Your stripes changed as your rank changed. And the symbol of going to a thick black stripe was that you were now a graduate nurse." But, she adds, "you didn't become an R.N. until you successfully completed your board exam."

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Selected Nurse Leaders at Mary Hitchcock