The Search for Legitimacy: Nurses' Registration in British Columbia 1913-1935 JO ANN WHITT AKER The value of having your RN is to distinguish Nurses from other types of frauds. 1 1 V Nursing education was an apprenticeship system. In the earliest years, pupil-nurses arrived at a hospital, donned a uniform and began learning on the job. Doctors usually gave them lectures in anatomy and physiology, medicine, surgery, obstetrics and pediatrics. The superintendents of nurses lectured on nursing arts, bandaging and dietetics. Lessons were squeezed into the end of long, busy days. By the end of the first decade of the twentieth century, more progressive hospitals recognized the wastefulness of this method. Instead, instructors were hired and students were given a probationary period of one to four months, or even six, in order to learn basic theory and practical nursing skills. However, there were no set admission standards for training, and there were no standards regarding the length of the training course or the practical experience necessary to produce the professional nurse. Registration acts were the legal means by which nurses could set these standards and then distinguish the "trained" nurse from the "un-trained" nurse. The movement for the registration of nurses began in Great Britain but soon included Canada and the United States. In 1903, several states enacted registration legislation. 2 In Canada, Ontario nurses attempted to get a registration act in 1905. 3 Nova Scotia enacted the first law in Canada to register nurses in 1910. Manitoba followed in 1913, with New Brunswick and Alberta in 1916 and British Columbia in 1918. 4 This essay will examine the registration of nurses in British Columbia: the struggle to obtain a registration act, its enactment and, finally, the circumstances that added status and legitimized the profession of nursing. Barbara K. Latham and Roberta J. Pazdro, Eds., Not Just Pin Money Victoria: Camosun College, 1984 316 Nurses Registration The president of the Graduate Nurses' Association of British Columbia (GNABC) described the unsuccessful struggle, begun in 1909 in British Columbia, to obtain a nurses' registration act. She explained to the 1917 convention of the Canadian National Association of Trained Nurses (CNATN): This doctor. .. was our Provincial Secretary and also Minister of Education, and the nurses introduced the bill and we took it up to him and asked him to do something with it. I never knew what happened. We never knew what happened or what influence was brought to bear. We went away feeling that our bill was being taken care of, but it had not been touched. The next year he said he was going to help us. We found that he was working against us. Our bill last year, as many of you may have known, got up to its third reading. If it had ever gone through, the nurses in British Columbia would be five times worse off than they are today.s On August 10, 1909, Dr. Helen MacMurchy, the editor of Canadian Nurse, addressed the Victoria Nurses' Club. She believed no woman should be prevented from nursing, yet she also believed that no one other than a professional nurse should be allowed to wear the uniform and call herself "trained" without first having learned the practices formally. She suggested that the nurses organize themselves into a larger group, then, draw up and present a bill to the government regarding their legal status. Believing "trained" nurses needed practical experience "under proper guidance," 6 she warned them about nurses who had graduated from correspondence courses. Trained nurses had to compete with correspondence school graduates. These "short-order" schools originated in the United States. In Canada, Dr. MacMurchy warned against these schools again in 1911. The Dominion School of Nursing, for example, trained women in six to eight months. Classes were held for two to three hours, three days per week; practical experience was provided by "paid subjects [ who took] the place of the sick.,.., In 1913, the Toronto Telegram deplored these schools, stating that "[p]ublicity should undertake the duty that legislation fails to discharge. "8 No figures are available about the numbers of these graduates in Canada; however, nurses did move freely between Canada and the United States. In an April, 1913, article in the Canadian Nurse, Annie Goodrich, a nursing leader from the United States, warned that there were 100,000 women practising nursing in that country, yet only ten percent were graduates from hospital schools of nursing. 9 Lack of licensing or weak registration acts made it difficult to regulate nursing which led to a low professional image and status. British Columbia nurses were not slow to respond to MacMurchy's challenge. Ethel Morrison, a graduate of the Vancouver General Hospital and president of the Victoria Trained Nurses Club, was very aware of the need for registration. In an article in Canadian Nurse, she outlined the benefits: In what way will [registration] advance the profession of nursing? First. If the law requires a higher standard, our training schools for nurses will have to train and WHITT AKER 317 pass only nurses of that standard. Second. For the working together of all graduate nurses for a thorough registration, and equal exam and, if ever necessary, the expelling of unworthy members. Third. To receive from the medical association the same respect for our registration bill that they give to their own. 10 In 1910, the Graduate Nurses' Association of Vancouver attempted to organize all British Columbia nurses. Th~ir executive committee met with the executive of the British Columbia Medical Association on December 22, 1910, to draft an act of registration. At the same time, they planned the formation of a provincial nurses' association. The bill which was not presented to the legislature in 1911, 11 had included a provision for an Examining Board consisting of two doctors and four nurses to ensure that registered nurses had attained certain standards of nursing education in theory and practical experience. 12 In order to be a more powerful force, the nurses had to be united. Their efforts, in 1912, were devoted to organizing a provincial association and to fund raising for a registration bill. The Victoria nurses arranged a meeting for September 1912, which attracted sixty-eight nurses from Victoria, Vancouver, New Westminster and Kamloops. They formed the GNABC and immediately struck a committee to draft a bill for registration. 13 By August 1913, the GNABC had readied their bill. The proposed bill would have incorporated the GNABC which was to be governed by a twelve-member council elected from the membership. The GNABC would have had the power to examine nurses, to approve training schools, to keep a current register and to set the standards for applicants to be registered.1 4 The Committee outlined the bill to the membership at the annual meetings of the GNABC and assured the membership of the support of the medical profession for passage of their bill. Yet, the bill was not presented to the Legislature in 1914. The GNABC reported to the nurses of Canada that their bill had been "thrown overboard," 15 but it had really been withdrawn as a government measure. Dr. Young, member for Atlin, a medical doctor and the Minister of Education, was to have presented it to the Legislature. Instead, he suggested H.H. Watson present it as a private member's bill. Yet, in the end, Young advised the GN ABC that "it was not a convenient season"to bring the bill forward. 16 The First World War soon started and nurses were involved. While many women in Canada spent time in activities related to the war, they did not abandon attempts to obtain the vote. Significantly, the organizations which worked for the franchise, also supported the nurses' hopes for professionalization. Local Council of Women (LCW) groups in Victoria and Vancouver were very active in this regard. Nurses' groups locally had affiliated with the LCWs and the GNABC had affiliated with the CNATN in 1913. This organization had affiliated with the National Council of Women of Canada (NCWC) in 1909. 17 While LCWs supported provincial graduate nurses in their efforts towards registration, in 1914 the NCWC set up a standing committee on nurses "to work for the improvement of nurses' education, the elimination of exploitation and the attraction of better recruits."18 Thus encouraged and supported, the GNABC decided at their March meeting to press again for registration. 318 Nurses Registration On March 23, 1916, H.H. Watson introduced Bill 11: An Act Respecting the Profession of Registered Nurses. 19 On second reading, the Nelson MLA opposed the bill, stating: Graduate nurses [are] fairly well treated now and [need] no more protection. Some of our grandmothers ... were better than any graduate nurse who ever got papers in British Columbia, especially in maternity nursing and children's diseases. 20 However, at the Committee of the Whole, April 6, 1916, there was little objection to the first twenty sections of the bill. A. Macdonald (Vancouver) disliked the section which gave the GNABC the right to set the qualifications of an applicant and the right to refuse the admission of a "qualified" candidate, though he did not define the term. The bill's sponsor, H.H. Watson, replied that the section was similar to those found in the Medical and Legal Society Acts. 21 Dr. Young moved an amendment to place the bylaws and regulations of the GNABC under the control of doctors, as he felt it was not sufficient to have two doctors on the Examining Board. Watson reminded Young that he had not practised for some years and was no longer aufait with the wishes of the medical profession. Young retorted that "it was not necessary to be in practice to hear stories of the actions of irresponsible nurses. "22 Parker Williams "contended that nurses were adjunct to the medical profession and the doctors should have a word in the framing of their rules and standards.''2 3 Fortunately, Young's amendment was overturned, but the angry doctor was not finished. The next day, May 12, 1916, the Victoria Daily Colonist called the Nurses' Act "that disturber of legislative calm." 24 First there arose a controversy over the vote on Young's amendment. It had been taken after 6.00 p.m., contrary to the rules of the Legislature. Then, Young wanted the bill to also include registration of midwives and maternity nurses, 25 a contentious point. While nurses had obstetrical training and worked in homes as maternity nurses, they had no skill or training in actual deliveries. The issue was not a new one. Maternal care for Canadian women and their infants had been of concern for many years. Suzann Buckley, in her article, "Ladies or Midwives? Efforts to Reduce Infant and Maternal Mortality", points out the opposition of both nurses and doctors to the introduction of midwives to Canada. 26 Thus, Young's actions are curious. Was he trying to anger the nurses and force them to withdraw their bill? Or, did he simply see the amendments as a way of incorporating his Bill 97, concerning midwives, with the nurses' bill? In any case, two clauses from Young's Bill 97 were inserted into Bill 11, and passed. Midwives were to be registered with the GNABC. 27 Then, to add insult to injury, he added further amendments. Young proposed to change the subjects on which the nurses should be examined. He deleted bacteriology, contending that this was the province of doctors only, and, rather pettily, substituted "infectious" for "contagious." 28 In addition, waivers for examination for registration were added. Doctors now could also determine the membership of some nurses in the GNABC. Then, Parker Williams objected to theGN ABC's control over nongraduate nurses. 29 It was , l ' 1•/)J WHITTAKER " 319 not considered objectionable for doctors, who were mostly men, to try to control nurses, who were women. It was, however, unacceptable for registered graduate nurses to control nongraduates! Watson indeed had a very difficult time of it. The legislative report from the Victoria Daily Times described it thus: There was another breeze over the nurses' bill this afternoon and Dr. Young took occasion to administer a verbal castigation to H.H. Watson, who had the bill in charge, and who has had such a strenuous time with it that he says he is not anxious to pilot another bill through for a long time.3o On May 17, 1916, Bill 11 was approved with Young's amendments. But the Legislature prorogued before final reading of the bill. The nurses were relieved. The president of the GNABC, previously quoted, concluded: "That is just how near we came to having midwives in British Columbia." 31 Opponents of registration felt that nurses were creating a closed shop which was too close to trade unionism. There was also the fear that, by regulating nursing, sick persons could not be nursed at home by family members and friends. 32 The doctors argued that, by setting the standards too high, persons of modest means could not afford to hire nurses. However, the doctors themselves were then in the process of increasing their training from one year of medical school to five years with an additional year of hospital internship. This increased standard of education made doctors more expensive, but they did not seem to worry about that. 33 Further, doctors objected to nurses being independent. Although one of the subjects taught to student nurses was ethics, the main theme of the course was obedience to the doctors 34 who did not want nurses to be able to make their own rules. Instead, nurses should continue to defer to doctors. In 1916, Bowser's Conservative government which successfully opposed the vote for women was in its final year. While Bowser did push through two bills in May, 1916, on prohibition and women's enfranchisement,35 the bills only called for a decision by referendum at the general election--by male voters. Happily, voters disenchanted with Bowser and the Conservatives defeated them in November 1916, but passed the referendums. Women had supported the opposition Liberals to help defeat Bowser and to pass the enfranchisement referendum. 36 The new government granted the women of British Columbia the franchise and the right to be elected to the Legislature on April 5, 1917.37 In the new atmosphere of 1918, the GNABC decided it was time to present another registration act to the Legislature. Bill 68 was introduced on April 10, 1918. The GN ABC had held their annual convention in Victoria the previous week in order to get some advance publicity for the new bill. In her address to the members, president Helen Randal stressed that the bill did not refer to those who nursed friends or relatives "nor to any person nursing the sick for hire who does not in any way assume to be a registered nurse."38 Also in an address to them, Dr. Barrett, president of the Victoria Medical Association, assured the nurses that their bill had the Association's "wholehearted approval."39 Dr. Sutherland (Revelstoke) introduced An Act 320 Nurses Registration Respecting the Profession- of Nursing. 40 There were very few changes to the bill: the provisions for control of nongraduate nurses and for midwives were omitted; experience in nursing contagious diseases was deleted. The other major change was in the qualifications for membership. 41 Nurses now had much more control over their own group. The standards for admission to a school of nursing did not require a definite number of years of schooling or an age limit. However, the Council had the right to approve a school of nursing. This vague clause was ultimately very important. Bill 68 passed quickly through the Legislature and was given Royal Assent on April 23, 1918. 42 Because the GNABC was obliged to keep a register, the Council appointed a Registrar, Helen Randal. 43 The Registration Act was vague, so Randal and the Council established their own standards of education and minimum age of prospective student nurses. They decided the minimum education necessary for an applicant was one year of high school and the minimum age was nineteen. The age limit was set to attract women who were staying in school longer. Schools were urged not to accept younger women "in the interests of the student as well as the profession. "44 Randal's first task after her appointment was to prepare a report of the training schools in British Columbia. Thereafter, she inspected the schools yearly. As she went about her inspection trips, Randal addressed the high school students in the towns she visited. 45 She continued to do so throughout the twenties and thirties. At first, the shortage of nurses that occurred immediately after the First World War necessitated this activity. Then, as the shortage eased after 1921, she continued her addresses in order to attract "the best types of students. "46 To this end, the educational requirement was increased to two years of high school in 1924. Middle-class families could afford to allow their daughters to remain in school and it was to them that the GNABC directed its energies. For Helen Randal, the value of inspecting training schools was to provide a "closer understanding of what pupils must have in the school" and a "better understanding of the difficulties the hospital boards have in financing this department of the hospital. "47 She pointed out to hospital boards the inadequacies of their training schools such as poor housing and mediocre laboratory and library facilities for the students. She explained the problems of the superintendents who were usually in charge of both nursing education and nursing service and were thus forced to balance the needs of the student nurses against the demands of the institution. Randal recommended that boards hire better qualified superintendents and also hire instructors qualified to teach. 48 However, not all hospital boards were attentive. The Royal Jubilee Hospital hired an instructor who was admittedly not qualified to teach, but the GNABC was powerless in this situation. The Association lawyer agreed with the hospital, but felt that the nurses had a right to object! 49 Yet, Randal believed that, on the whole, her efforts were rewarded. She noted that there was a marked improvement in housing, working conditions and hours of work. Boards appeared to understand that they had an obligation to provide an education, so practically all hospitals that were unable to provide sufficient practical experience affiliated with the Provincial Royal Jubilee Hospital or the Vancouver General Hospital.5° Small training WHITTAKER " ' ,, 321 schools (those with twenty to thirty beds) that offered affiliation attracted better applicants as was evidenced by girls applying who had two years of high school. 51 Educational standards remained the foremost preoccupation of the GNABC. In 1924, the Nursing Education Committee drew up a curriculum and standard necessary for an accredited school.5 2 Nurses believed that between 1920 and 1930 this increased standard forced the closure of small schools of nursing. 53 Admittedly, some did close, but the Depression was likely a major reason. In 1930, there were seventeen training schools in British Columbia,54 but by 1939, only seven schools were located in Victoria, Vancouver, Kamloops, New Westminster and Cranbrook. In 1930, after the number of credits required to obtain a high school diploma was changed, an increase in the educational requirements for admission to schools of nursing occurred. Previously, the GNABC had been demanding two years of high school out of a three-year course. 55 Now, the educational requirements would be the third year of a four-year course. On October 24, 1930, the Council voted to: Endorse the recommendation of the Educational Committee that following June, 1931, 90 credits towards matriculation for entrance standing and after June, 1933, junior matriculation be required. This Committee recommend[ed] that the commercial course be not accepted as a satisfactory substitute for the general or matriculation course. 56 In 1927, the Canadian Medical Association and the Canadian Nurses' Association (CNA, formerly CNATN) agreed to finance a survey of nursing. The doctors wanted the relationship between doctors and nurses examined, but the emphasis for the nurses was an examination of the current nursing education system. The committee, chaired by Dr. George Weir of the Department of Education at the University of British Columbia, had three representatives from each Association. Having toured schools of nursing in Canada, they produced their remarkable report in 1930. Written by Weir, the report confirmed that nursing was a profession. The minimum educational requirements for admission to the nursing profession, as accepted by Weir, were four years of high school, followed by three years of nursing training.57 He recommended that junior matriculation be the minimum education requirement to schools of nursng by June 30, 1935. 58 Weir was very sympathetic to the nursing profession's aspirations. According to him, the lack of higher education resulted in "using the doctor's brains and nurse's hands and feet. "59 In order to prevent a glut of graduate nurses, he recommended that all schools of nursing connected to hospitals with fewer than seventy-five beds and a daily occupancy rate of less than fifty patients be closed. 60 In order to raise nursing standards and educational requirements in British Columbia, the Nurses' Act would have to be revised. In 1934, the Legislation Committee of the GNABC drew up a new bill. After the Council accepted it, a copy was forwarded to Weir "for his advice at the 'next Session of the Provincial Legislature."61 Fortunately, Weir had become the Provincial Secretary in the Liberal government of T. D. Pattullo 322 Nurses Registration and he introduced Bill 67, as a government measure, on March 13, 1935.62 Only Sutherland, predictably, objected to the increase in the educational standard, while Dr. J .J. Gillies contested the minimum age of nineteen years. On a rather silly note, H. Savage objected to the abbreviation "R.N." He said that it was often confused with the Royal Navy and "therefore should be altered!"63 Bill 67 received Royal Assent on March 23, 1935.64 This bill changed the name of the GNABC to the Registered Nurses' Association of British Columbia (RNABC). (This was very important because it was the last provincial association to use the word "registered".) To ensure a thorough background in the five required clinical areas, the daily minimum occupancy rate in a hospital connected with a school of nursing was to be fifty patients. More importantly, all the nurses working in these hospitals had to be registered. One of the weaknesses of all three Acts was the voluntary nature of membership in the Association. Thus, students could have been working with graduates who were not "qualified". Most importantly, Bill 67 legitimized the minimum age limit of nineteen years and set the educational requirement at junior matriculation. British Columbia nurses could then gain entrance to university programs. This was an important step in the nurses' quest for professional status. As well, two members of the British Columbia College of Physicians and Surgeons could be members of the Board of Examiners, but in 1939 no doctors were appointed. 65 The struggle for recognition of the professional status of nursing has been continuous. The nurses have been hampered by groups of men, doctors and legislators, who objected to women having control over their own profession. Then, as women were enfranchised, nurses were given a weak registration Act. Changes in the attitudes of the public to education and the lucky coincidence in the career of the sympathetic Weir helped nurses to increase the standards of education for admission and then the nursing education process itself. However, nurses were able to set only these standards. There was no mention of working conditions or hours of work, either for students or for graduates. That would have savoured of trade unionism. To improve the status of the profession, nurses--women--had to make sacrifices and often settled for less in order to establish their legitimacy. WHITT AKER 323 Footnotes l. "Rx Chuckles P.R.N.", Canadian Nurse (hereafter cited as CN) 44{January 1948): 67. (The quote is an answer taken from an R.N. exam. P.R.N. is short for the Latin to "take as necessary". It is frequently used in doctors' instructions.) 2. Veronica Driscoll, Legitimizing the Profession: The Distinct Mission of the New York State Nurses' Association (New York: New York State Nurses' Association, 1976): 14. 3. "Ontario Graduate Nurses' Association Annual Meeting", CN 2 (June 1906): 29. 4. "Digest of Laws and Regulations Governing the Registration of Nurses in the Dominion of Canada", CN 26 (December 1930): 657-659. 5. "Report of the Sixth Annual Meeting of the Canadian National Association of Trained Nurses", CN 13 (August 1917): 437-438. 6. Victoria Daily Times (hereafter cited as VD1), August 11, 1909: 12. 7. "In Our Midst", CN 7 (March 1911): 169. 8. "Editorial Toronto Telegram", CN 9 (June 1913): 380. 9. Annie Goodrich, "The Need of Orientation", CN 9 (April 1913): 221-222. 10. Ethel Morrison, "Registration for Nurses", CN 7 (January 1911): 6-7. 11. CN7(Aprill911): 155-156. 12. CN 7 (December 1911): 611. 13. "The Graduate Nurses' Association of British Columbia", CN 8 (November 1912): 612. 14. "Annual Meeting of the Graduate Nurses' Association of British Columbia", CN 10 (August 1913): 515. 15. "Hospitals and Nurses", CN 10 (April 1914): 224. 16. "Graduate Nurses' Association of British Columbia", CN 10 (June 1914): 328. 17. Veronica Strong-Boag, The Parliament of Women: The National Council of Women of Canada (Ottawa: National Museum of Man, 1976): 112. 18. Ibid.: 235. 19. British Columbia Legislative Assembly (hereafter cited as BCLA), Journal 1916: 27. 20. VDT, March 31, 1916: 11. 21. Victoria Daily Colonist (hereafter cited as VDC), April 17, 1916: 3. 22. VDC, May 11, 1916. 23. VDT, May 11, 1916. 24. VDC, May 12, 1916. 25. Ibid. 26. Suzann Buckley, "Ladies or Midwives? Efforts to Reduce Infant and Maternal Mortality", in A Not Unreasonable Claim: Women and Reform in Canada, 1880s1920s, ed. Linda Kealey (Toronto: The Women's Press, 1979): 131-149. 27. British Columbia, Bills 1916. 28. VDT, May 12, 1916. 29. Ibid. 30. Ibid. 31. "Report CNATN", CN 13 (August 1917): 438. 32. "Registration of Nurses", CN 7 (November 1911 ): 571. 33. "Nurse Education", CN 12 (February 1916): 92. 34. M. Chayer, "The Trail of the Nursing Textbook", American Journal of Nursing 50 (October 1950): 606. 35. Catherine Cleverdon, The Woman Suffrage Movement in Canada, 2nd ed. (Toronto: University of Toronto Press, 1974): 95-96. 324 Nurses' Registration 36. Ibid. 37. Ibid.: 100. 38. VDC, April 2, 1918. 39. Ibid. 40. BCLA, Journal 1918: 143. 41. British Columbia, Bills 1918. 42. BCLA, Journal 1918: 223. 43. Helen Randal was a graduate of the Royal Victoria Hospital, Montreal, where she had worked on staff, after graduation, for two years. She moved to California and arrived in Vancouver in 1912. From her arrival, until 1916, Randal was the superintendent of nurses at the Vancouver General Hospital. In 1916, she became the editor and business manager of Canadian Nurse, a position she retained until 1924. The registration of nurses was of very great interest to her. She helped draft the 1913 bill and as the president of the GNABC she helped pilot the 1918 bill through the Legislature. Helen Randal retired in 1941 but, in the years from 1919 to 1941, she was an indefatigable worker for the GNABC. For more information, see Nora Kelly, Quest for a Profession: The History of the Vancouver General Hospital School of Nursing (Vancouver: Evergreen Press, 1973): 25-26. 44. GNABC, Minutes, November 11, 1930: 126. 45. "The Canadian National Association of Trained Nurses Convention", CN 17· (July 1921): 441. 46. GNABC, Minutes, August 18, 1930: 116. 47. Helen Randal, "Inspection of Training Schools in British Columbia", CN 18 (February 1923): 82. 48. Ibid.: 80. 49. GNABC, Minutes, November 18, 1927: 16. 50. "CNATN Convention": 442. 51. Randal: 80. 52. CN 20 (February 1924): 103. 53. "Nursing Round-up", CN 49 (February 1953): 90. 54. Vancouver Sun, April 20, 1930: 22. 55. GNABC, Minutes, September 28, 1930: 118. 56. Ibid., October 24, 1930: 122. 57. G.M. Weir, Survey of Nursing Education in Canada (Toronto: University of Toronto Press, 1932): 5. 58. Ibid.: 218. 59. Vancouver Sun, February 23, 1932: 2. 60. "Some Features of the Report of the Survey of Nursing Education", CN 28 (March 1932): 127. 61. GNABC, Minutes, May 18, 1934: 258. 62. BCLA, Journal 1935. 63. Vancouver News-Herald, March 21, 1935: 2. 64. BCLA, Journal 1935. 65. RNABC, Minutes, January 20, 1939: 415. WHITT AKER 325 Bibliography Primary Sources Government Documents "An Act respecting the practice of nursing," Statutes of British Columbia, Victoria, 1935. "An Act respecting the profession of nursing," Bills of British Columbia,Victoria, 1918. "An Act respecting the profession of registered nurses," Bills of British Columbia, Victoria, 1916. 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