Nursing in the United States

This history of black professional nursing in the United States is part of the history of women's roles in black community health activism. The period from 1890 to 1910 was marked by local efforts to establish black hospitals (many of which also had schools of nursing), which collectively may be termed a social movement in that they: (1) had strong extra-professional (lay) support mobilized through already existing networks; (2) were tied to the community's other social and political concerns; and (3) exhibited similar leadership structures. With funds from John D. Rockefeller in 1886, Atlanta Baptist Seminary (later renamed Spelman College) opened the first African-American nursing school. Initially not affiliated with any hospital, it offered a two-year course of study leading to a diploma in nursing, and by the turn of the century it

boasted a comparatively large hospital with thirty-one beds. In the main, however, local movements to establish black hospitals and nursing schools were almost entirely internal to black communities, with black male physicians heading the efforts, though much of the leadership in fund-raising, advertisement, and community awareness fell to black women members of sororities, clubs, and church boards. The notable exception was the Phillis Wheatley Sanitarium and Training School for Nurses, established in 1896 by the women of the Wheatley Club of New Orleans, Louisiana, and later renamed the Flint-Goodridge Hospital School of Nursing. Because most municipalities refused to partially fund black hospitals, as they did white hospitals, community support was a continuing need.

Aside from the few who rose to the ranks of physician, educator, or professional social worker, the overwhelming majority of black women of any educational level found their occupational choices before the Second World War largely limited to domestic service or agriculture. Unfortunately, as one historian has observed, white professional nursing in the first half of the twentieth century may be characterized as exhibiting "no sorority of consciousness across the color line" (Hine, 1989, p. 98). Black nursing schools therefore sought to produce nurses who, in their training, were distinguished from domestic workers and equal to white professionals (even while overemphasizing Victorian gender conventions by barring married women and requiring applicants to provide letters attesting to moral standing). The nation's first black hospital, Chicago's Provident Hospital and Nurses Training School (1891), emerged in response to the rejection of Emma Reynolds from all of the city's white nursing schools.

Roughly a dozen nursing programs followed in short order, including those at Dixie Hospital Training School (1891, in Hampton, Virginia); Tuskegee Institute's John A. Andrew Hospital (1892); Provident Hospital in Baltimore, Maryland (1894); Freedmen's Hospital and Nursing School in Washington, D.C. (1894, affiliated with Howard University); the Hospital and Training School for Nurses in Charleston, South Carolina (1894); New York City's Lincoln School for Nurses (1896); St. Agnes Hospital and Nurse Training School in Raleigh, North Carolina (1896); Hubbard Hospital and School of Nursing (1900, within Meharry Medical College in Nashville, Tennessee); Lincoln Hospital (1901, in Durham, North Carolina); and the Mercy Hospital School of Nursing (1907, in Philadelphia). By 1920 there were thirty-six nursing schools for blacks nationwide, and by 1928 the aforementioned institutions had produced more than 80 percent of the roughly 2,800 black graduate nurses in practice. Black hospitals and nursing schools were typically small and underfunded, but within medical Jim Crow they were vital as centers of treatment, health promotion (headquartering the National Negro Health Week Movement, begun in 1915 at Tuskegee Institute), education, and intellectual exchange. Their graduates certainly encountered the color line. Mary Eliza Mahoney, the first black woman in the United States to receive a nursing degree (in 1879, from Boston's New England Hospital for Women and Children), spent most of her career in private duty, perhaps illustrating the extent to which even well-qualified black nurses were barred from hospital service. As it was in the American Medical Association, the color bar in the American Nurses Association (ANA; founded in 1896 as the Nurses' Associated Alumnae of the United States and Canada; it was renamed in 1911) operated with the requirement that membership be attained through state affiliates, many of which, especially in the South, were exclusively white.

In response to Jim Crow nursing, Martha Minerva Franklin (an 1897 graduate of Philadelphia's Woman's Hospital Training School for Nurses) and others organized the National Association of Colored Graduate Nurses (NACGN) in 1908. Even at its peak, the NACGN was never able to organize all black nurses (it had only 125 members in 1912; 500 in 1920; 175 in 1933; and 947 in 1949), but the early years of organization were followed, after 1933, by ones of renewed activism. In 1934, the nursing leader Estelle Massey Riddle (1901–1981), the first black person to obtain a masters of arts degree in nursing (from Teachers College, Columbia University, in 1931), was elected president of NACGN. She hired the association's first paid executive director, Mabel Doyle Keaton Staupers (1890–1989), a 1917 graduate (with honors) of Freedman's Hospital School of Nursing in Washington, D.C., and, in 1920, of Philadelphia's preeminent tuberculosis research facility, the Henry Phipps Institute. In New York, Keaton had been instrumental in the organization of Harlem's first inpatient tuberculosis treatment facility for blacks (the Booker T. Washington Sanatorium), serving as superintendent between 1920 and 1922. Until 1934 she was the nurse-executive of the Harlem Committee of the New York Tuberculosis and Health Association.

Emma Reynolds and Provident Hospital

In 1889 Emma Reynolds, a young woman who aspired to be a nurse, was denied admission by each of Chicago's nursing schools because she was black. Her brother Louis Reynolds, a pastor of St. Stephen's African Methodist Episcopal Church and prominent member of the black community, turned to Daniel Hale Williams for help. A respected black surgeon, Williams tried to use his influence to get Emma into the white nursing schools, but was unsuccessful. The men decided to coordinate their efforts and create a nursing school for black women.

In 1890 Williams gathered a group of black ministers, physicians, and businessmen to pitch the idea of founding an interracial hospital and nursing school in Chicago. Winning their support, he and Louis Reynolds began the project. Prominent whites in the community, acknowledging the benefit of having medical treatment available to their black employees, also contributed to the project.

The project seemed destined for success when the Armour Meat Packing Company donated the down payment for a house. The three-story brick house became Provident Hospital and Nurses Training School in 1891. The generosity of the community's residents was a critical factor in sustaining the facility as, at the time, a hospital responsive to the black community did not generate enough income to support itself. Emma Reynolds was one of the school's first three graduates in 1894.

Both Riddle and Keaton had worked in black-white cooperative circles, illustrating the role of white philanthropy in the NACGN's efforts. After the 1915 to 1920 period of social unrest (the "Red Summer" of 1919 was particularly bloody in its antiblack and antiradical state and mob violence), an era with a focus on "race relations" dawned. The new era emphasized cooperation between black professionals and their more enlightened white counterparts and wealthy white benefactors, in an effort to curtail further uprisings through moderate reforms in education, labor, social services, and health care. Nationally, the Rockefeller Foundation's General Education Board, and especially the Julius Rosenwald Fund (which, between 1929 and 1942, allocated $1.7 million for such efforts, including the support of no fewer than seventeen black hospital and nursing school projects), were among the most prominent funders of black health and educational work. On the local level, too, lesser industrialists (such as the racially paternalistic Duke family in North Carolina, or Philadelphia's Henry Phipps, who sponsored the formal training of black pioneer public health nurses and anti-tuberculosis work among blacks and whites in Baltimore and Philadelphia) also provided support, and in many cases had laid the groundwork before World War I. The role of white philanthropy can be overstated, however. When in 1925 the Rockefeller Foundation hired English-born academic nurse Ethel Johns to conduct a survey of black nursing and nursing education in the United States, the resulting indictment of institutional racism and official neglect was so precise and unequivocal that the Rockefeller Foundation refused to release her report or implement her recommendations, fearing reprisal from the ANA and the National League of Nursing Education (NLNE). White philanthropists' gradualist strategy instead consisted of the offer to states and municipalities of matching funds for black education, and of the underwriting of numerous re-search and career development projects. Cumulatively, these efforts had the effect of helping to produce a cadre of black health-care and social-science leaders whose expertise would be integral to many of the New Deal's social programs as they affected blacks. Direct support proved integral to the NACGN's success in integrating the ANA in 1950.

The Depression and war years were pivotal. Excluded from better-paying jobs and most labor unions, blacks were economically the most vulnerable after 1929. Although known to blacks for decades, the health effects of racism (including intractably high rates of tuberculosis and infant and maternal mortality) were now inescapably apparent to the national government. At the same time, as Staupers and Riddle agitated for the lowering of color restriction within nursing, hardship had reduced the number of black nursing schools to twenty-seven by 1941, and to only twenty in 1944. Aside from these, fewer than thirty nursing schools accepted African Americans. The state nursing associations of some sixteen southern states and Washington, D.C., remained color exclusive, while many of the northern associations, too, were unsupportive (prompting black registered nurses in 1932 to found the Chi Eta Phi Sorority). President Franklin Roosevelt's always shifting and often tenuous New Deal coalition, however, included many black national and local leaders who found positions from which they could influence national policy. Both Riddle and Staupers held positions in the National Nursing Council for National Defense (established in July 1940), and Staupers served in the Federal Security Agency's subcommittee on Negro health. Though born of wartime need for nurses and for black political support, such appointments would have been unimaginable during the First World War, when the American Red Cross refused to accept more than a handful of applications from black nurses. On the advent of the 1943 passage of the Bolton Bill, creating the U.S. Cadet Nurse Corps (within the U.S. Public Health Service), NACGN leaders Staupers, Riddle, and others successfully pressed Congress for an antidiscrimination amendment. Under the Bolton Act, the USPHS provided funds to 1,225 schools, including the major black institutions. Just as important, some white institutions discarded their color-exclusion policies in order to qualify for Bolton funds. By 1945, black students in nursing programs numbered roughly 2,600 (an increase of 135 percent over 1939), and the number of black or mixed-enrollment nursing schools had increased from twenty-nine in 1941 to forty-nine in 1945 (the same year in which the NACGN successfully pressed the Army and Navy to abandon color exclusion in the armed forces). The election of Riddle (then a member of the faculty of New York University) to the ANA's Board of Directors in 1948 signaled the end of the association's Jim Crow policy (in 1950). Less than a year after this occurred, the NACGN voted to disband.

The Postwar Era

"Soap operas and scholars," one historian has noted, "seem to agree that hospital workers are doctors and nurses" (Sacks, 1988, p. 2). However, due to various federal and state hospital construction initiatives, the emergence of market-oriented or hybrid health-insurance plans (Blue Cross and Blue Shield in the 1930s, then Medicare and Medicaid in the 1960s, and managed care systems in the 1970s), and the concomitant rising demand for hospital services, hospitals arose within an expanding postwar health-care network as complex institutions characterized by bureaucracies, specialized wards, intricate payment plans, large-scale research divisions, and hierarchically segmented workforces in which the role of the registered

nurse shifted to that of supervisory position over nonprofessional nursing personnel who performed tasks once performed by nurses. By 1970, thirty-seven cents of every dollar expended on health provision went to hospitals, the largest sector of an increasingly corporatized industry.

Federal, state, and privately funded "manpower development" strategies after the late 1940s brought about a greater range of training programs designed to meet the growing need for health provision personnel. Short-duration courses and community college and baccalaureate programs in nursing gradually replaced diploma-granting schools as the greatest sources of credentialing. Hierarchies in education, prestige, and wages emerged in which blacks and Hispanics were found largely in the ranks of licensed practical nurses (LPNs), licensed vocational nurses (LVNs), and nurses assistants, while nursing's aristocracy—registered nurses (RNs)—added people of color to their numbers, but not nearly at the same rate as did the lower grades. During the decades of professionalization, between 1900 and 1940, the proportion of registered nurses among all nursing personnel increased from 11 percent to 73 percent, but postwar segmentation left RNs as only 44 percent of all nursing workers in 1980. Meanwhile the role of the nursing assistant, the lowest grade (and with the highest nonwhite representation), had expanded the most rapidly between 1940 and 1980, from 9 percent to 41 percent of all nursing personnel.

Postwar segmentation produced a downward pressure on the income of lower-grade workers in voluntary (nonprofit) hospitals. Because of the exempting provisions of the Labor-Management Relations (Taft-Hartley) Act of 1947, these workers remained largely nonunion or only nominally organized. As a result, the disproportionately black and Hispanic staff in hospital food, janitorial, clerical, nurses aide, and vocational and practical nursing divisions—in comparison to other service sector employees—earned less, worked more, and (ironically) enjoyed fewer health benefits. Whereas the NACGN's struggle had been largely professional, black healthcare workers' struggles in the postwar decades were closely allied with the civil rights movement, whose roots could be found in the black labor struggles of A. Philip Randolph and the Brotherhood of Sleeping Car Porters, black unionists in the Congress of Industrial Organizations (CIO), and the wartime movement to support the Fair Employment Practices Commission (FEPC). In those cities where Local Hospital Workers' Union Local 1199 (based in New York City) publicly interpreted the labor struggle as a civil rights struggle, it realized the most success throughout the 1960s and 1970s. With some success, black women with grassroots experience in the civil rights movement mobilized workers at Duke Medical Center in Durham, North Carolina, in the 1970s. Inspired by the Student Nonviolent Coordinating Committee (SNCC), twenty black nurses aides in 1966 successfully struck the Lincoln Nursing Home in Baltimore, Maryland, forming (with support from the Congress of Racial Equality [CORE]) the Maryland Freedom Union. Also in Baltimore, Local 1199, CORE, and the Southern Christian Leadership Conference (SCLC) supported the demands of black workers at Johns Hopkins University Hospital for better wages, reasonable work hours, workplace respect, career development opportunities, and the integration of Hopkins Nursing School. At the same time, the civil rights movement spawned the Medical Committee on Human Rights (MCHR, the medical wing of SNCC's 1964 Mississippi Freedom Summer project), the Student Health Organization (SHO) and several other black, brown, and white New Left student health profession and community health action groups that arose to bring issues of medical neglect and health worker compensation to the fore. Finally, feeling that the desegregated ANA had remained negligent of black community health issues, in December 1971 eighteen members formed the National Black Nurses Association (NBNA), which in 2005 had 150,000 members in seventy-nine chapters (Chi Eta Phi Nursing Sorority, Incorporated, maintains 8,000 members).

At the time of the 2000 census, 93.1 percent of the more than 2 million registered nurses were women; about 12 percent (333,368) of all RNs were of ethnic minorities, including non-Hispanic African-Americans (133,041), Asians (93,415), Hispanic/Latino (54,861), and Native Americans/Alaskan Natives (13,040). Although this is nearly triple the number of nurses estimated to be of these categories in 1980 (when minorities were roughly 7 percent of RNs), much of the growth came after 1996 and may be artificial, traceable to the federal government's provision of "multiple race" categories in census data collection in the late 1990s. Black women remain underrepresented among professional nurses outside of cities with large black populations, and they remain overrepresented among LVNs, LPNs, nurses aides, and lower-grade hospital workers.

See also Black Hospitals in the U.S.; Nursing in the Caribbean

Bibliography

Carnegie, Mary Elizabeth. The Path We Tread: Blacks in Nursing, 1854–1984. Philadelphia: Lippincott, 1986.

Fink, Leon, and Brian Greenberg. Upheaval in the Quiet Zone: A History of Hospital Workers' Union, Local 1199. Urbana: University of Illinois Press, 1989.

Glazer, Nona Y. Women's Paid and Unpaid Labor: The Work Transfer in Health Care and Retailing. Philadelphia: Temple University Press, 1993.

Hine, Darlene Clark. Black Women in White: Racial Conflict and Cooperation in the Nursing Profession, 1890–1950. Bloomington: Indiana University Press, 1989.

"News and Views: The State of African Americans in Nursing Education." Journal of Blacks in Higher Education 13 (September 1996): 52–54.

Sacks, Karen Brodkin. Caring by the Hour: Women, Work, and Organizing at Duke Medical Center. Urbana: University of Illinois Press, 1988.

Smith, David Barton. Health Care Divided: Race and Healing a Nation. Ann Arbor: University of Michigan Press, 1999.

Smith, Susan L. Sick and Tired of Being Sick and Tired: Black Women's Health Activism in America, 1890–1950. Philadelphia: University of Pennsylvania Press, 1995.

samuel roberts (2005)