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CHAPTER 5 On the Ward: Hospital Nurses since 1930 In the 1930s, graduate nurses began to move from freelance private duty to hospital staffjobs. Nursing practice took its modern form as hospitals hired increasing numbers of graduates for general ward duty. Once run by students or attendants supervised by a single graduate nurse, hospital wards rapidly became the province of graduates. The transition took place within the space of fifteen years. In 1927, nearly three-quarters ofhospitals with training schools relied exclusively on students for ward nursing services; a decade later, most reported that they had begun to employ some graduate staff nurses. By 1940, nearly half of all nurses were employed in hospitals, and by the end of World War II, a decisive majority of active nurses held hospital jobs.1 Hospital employment had complex implications for nursing practice, creating a set of new possibilities and limits that reshaped nurses' experiences on the job. Exchanging freelance work for institutional employment, nurses discovered the decidedly mixed blessings of a bureaucratic workplace . They soon confronted the disadvantages of their new positions. Managerial innovations redesigned the hospital, changing its physical arrangement, the flow of work, the division oflabor, even the performance of individual procedures . Nurses occupied an influential niche in the new order, but they also faced fundamental changes in their work, imposed from above, which undermined traditional skills and ultimately threatened the very identity ofnursing itself. Hospital nurses found themselves in the service of a Faustian bargain, for even as the work enhanced their opportunities 160 CHAPTER 5 within the bureaucratic structure, it undercut both leaders' hopes for professional autonomy and ordinary nurses' aspirations for craft control. Yet despite the all-too-obvious problems of hospital work, this new setting represented a distinct improvement for nurses. Institutional jobs eased nurses' living and working conditions, replacing the irregular work ofprivate duty with a modicum of security. The technological environment of the hospital buttressed nurses' claims to special expertise. The content and organization of hospital work gave nurses new leverage in their relationships with patients and doctors. In the ward setting, nurses gained the sociability and support of small work groups; if hospitals imposed new constraints on nurses, they also provided abundant resources for resisting them. Most ofall, nurses' expanding responsibilities and technical expertise supported a growing sense ofentitlement that led to new challenges to hospital management and medical authority. I. THE HOSPITAL IN TRANSITION The move to graduate staffing was one phase in a larger transformation in hospital management and in the organization of medical care. In the 1920s and 1930s, administrators self-consciously introduced rationalization to the hospital, drawing parallels between hospital care and industrial production . However, conflict among managers and resistance from doctors and nurses indicated the persistence of older conceptions ofhospital management, and even the most enthusiastic rationalizers were careful to note that the principles ofindustrial management could not be transferred uncritically to the hospital. As in other industries, scientific management was used selectively and reinterpreted to fit the special circumstances of hospital work. But by the 1920s, efficiency and rationalization were prominent management considerations that were discussed often in hospital journals, and the chang- ON THE WARD 161 ing face ofthe hospital reflected the assumptions and ideology of scientific management. The rhetoric of efficiency was not altogether new. The "once-charitable institution," as David Rosner has called it, had already modified its philanthropic ethos with a business sensibility. As Rosner and others have suggested, considerations of order and discipline had begun to reshape American hospitals by the late nineteenth century. The concept ofstewardship gradually gave way to more concrete principles of financial management as administrators sought a broader clientele and looked to patients' fees to underwrite alarger part ofoperating costs. Yet the decentralized character ofhospitals made it difficult to apply industry-wide principles ofrationalization , and managers themselves still held to an older conception ofthe hospital as a home, with a concomitant reliance on the paternalistic authority of the nineteenth-century family. 2 By World War I, the scope ofhospital care had expanded, and, with improvements in diagnosis and treatment that depended on sophisticated technology, hospitals extended their dominance over medical care. Doctors used hospitals more for private patients: surgery and childbirth, for example, took place at home less often, and even routine diagnostic procedures moved from home to hospital as equipment costs rose. By the 1930s, it was clear that private contributions and patients ' fees could no longer cover the expenses ofhospitals. At the same time, the local...


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