ANA OJIN is a peer-reviewed, online publication that addresses current topics affecting nursing practice, research, education, and the wider health care sector.

Find Out More...


Letter to the Editor

  • Thank you very much for your thoughtful response to our article entitled, “Exploring Race in Nursing: Teaching Nursing Students about Racial Inequality Using the Historical Lens.” Certainly, this is a very large topic and indeed deserves our serious consideration. I could not agree with you more and am encouraged to find that young scholars are investigating diverse minority populations and addressing the gap that you so ably point out.

  • Continue Reading...
    View all Letters...

Sadie Heath Cabaniss and Professional School Nursing: Strategic Foundations to Promote Population Health

m Bookmark and Share
 

Bridget Houlahan, PhD, RN
Lilianna Deveneau, BA, BS

Abstract

School nursing began in New York City, and extended to the southern city of Richmond, Virginia from 1900-1920. Nurse leaders, including Virginia’s Sadie Heath Cabaniss, initiated and replicated community health programs to form and extend the early school nurse movement. This article describes the efforts of Cabaniss and her mentors, based on traditional historical research methods via a social history framework that included examination of numerous primary sources. Cabaniss often crossed lines of geography and culture to establish the Nurses’ Settlement of Richmond and impact school nursing in Richmond. Our analysis and discussion demonstrates that these leaders forged powerful alliances through which they established effective programs of public health. We introduce a framework of four synergistic concepts, the C.A.R.E. Model of Successful Nursing Initiatives. This model reflects the dynamic strategic approaches of collaboration, advocacy, research, and education that Cabaniss and her colleagues used successfully to impact population health through school nursing and considers the potential of the application for nurses of today.

Citation: Houlahan, B., Deveneau, L., (February 3, 2021) "Sadie Heath Cabaniss and Professional School Nursing: Strategic Foundations to Promote Population Health" OJIN: The Online Journal of Issues in Nursing Vol. 26, No. 2.

DOI: 10.3912/OJIN.Vol26No02PPT04
https://doi.org/10.3912/OJIN.Vol26No02PPT04

Key Words: school nursing; historical nurse leaders; school health; public health nursing history; professional nursing organizations; political action; school nurse role; Sadie Heath Cabaniss; school nursing in Virginia; female leaders in history; interprofessional collaboration; child health; culture; policy; evidence-based practice (EBP); C.A.R.E model

Nurse leaders...crossed lines of geography, race, class, and culture to initiate and replicate community health programs... Nurse leaders, including Virginia’s Sadie Heath Cabaniss, crossed lines of geography, race, class, and culture to initiate and replicate community health programs to form and extend school nursing in the Commonwealth and eventually across the United States of America (Instructive Visiting Nurse Association Papers [IVNA] Virginia Commonwealth University [VCU], n.d.*). These nursing groundbreakers forged powerful alliances through which they established effective programs of public health across the country.

Born in Petersburg, Virginia on October 9, 1865, six months following General Lee’s surrender less than 100 miles away, Sadie Heath Cabaniss’ childhood was inundated by the rebuilding of the war-torn South. Her family was wealthy and well-connected. Against their wishes, Sadie decided to attend Johns Hopkins Hospital Training School for Nurses (Koste, 2016). This decision was transformative not only for her personally, but for the entire South, the nursing profession, and the specialty of school nursing.

Our research investigated the development, spread, and impact of school nursing from a social history perspective through the engagement of personal and inter/professional relationships from New York City (NYC) to Richmond, Virginia at the turn of the twentieth century. By analyzing nurse leaders’ approaches to goal implementation, second author Deveneau created the C.A.R.E. (Collaboration, Advocacy, Research, Education) model, introduced herein. By applying the past dynamic approaches of these nurse leaders to public health of today, nurses have the ability to effect current policy, such as the expansion of student healthcare, and to direct contemporary evidence-based school nursing practice. This article discusses historical research that describes the impact of Sadie Heath Cabaniss, and her influence on professional and school nursing and introduces the resulting C.A.R.E. model.

The original research about the inception of school nursing (Houlahan, 2017; Houlahan, 2018; Houlahan & Deveneau, 2019) used traditional historical methods, with analysis of numerous primary and secondary sources. Included in the sample were local newspaper articles; published works written by prominent nursing leaders at the turn of the 20th century; two separate Lillian Wald Collections (Wald Papers, NY Library, 1889-1957; Columbia University Wald Papers, 1895-1936); the Archived Instructive Visiting Nurse Association papers ([IVNA papers], Virginia Commonwealth University [VCU], n.d.*) and the Alan Mason Chesney Medical Archives ([AMCM] papers, n.d.*) at Johns Hopkins Medical Institutions.

The Early School Nurse Movement

Impact of Nurse Leaders
The transition of school nursing from NYC to Richmond, Virginia and beyond can be credited to the perseverance and ingenuity of a small, committed cohort of graduates of Johns Hopkins Hospital Training School of Nurses. The alliance was “a professional relationship among three women that would grow to a personal friendship and would eventually influence the direction that the nursing profession would follow in the twentieth century” (Poslusny, 1989, p. 64). The group was comprised of Isabelle Hampton Robb (1859-1910), Lavinia Dock (1858-1956), and Mary Adelaide Nutting (1858-1948). A lesser known fourth member, Sadie Heath Cabaniss (1865-1921), was instrumental in leading the burgeoning nursing profession in the American South. Cabaniss was the catalyst behind the development of the Nurses’ Settlement in Richmond from which school nursing in Virginia would later emerge (IVNA papers, n.d.*).

These leaders formed professional national organizations still in existence today... Robb, Dock, and Nutting have been credited as the “architects of professional nursing education and the founders of the major professional organizations in nursing” (Poslusny, 1989, p. 64). They engineered the first collegiate Program of Nursing at Teacher’s College at the turn of the twentieth century and were prominent authors of esteemed nursing textbooks (AMCM papers, n.d.*). These leaders formed professional national organizations still in existence today to establish, protect, and expand nursing through education, public health policy initiatives, and research (Poslusny, 1989). Examples of these organizations include The Society of Superintendents of Training Schools, which became The National League for Nursing (NLN); the Nurses’ Associated Alumnae (NAA), which became the American Nurses Association (ANA), and eventually included the International Council of Nurses (ICN) (Poslusny, 1989, p. 64; ACM papers, n.d.*). With Robb elected first president of the ANA, the formation of the American Journal of Nursing (AJN) was an initial task of the organization; all three women were pivotal in the design (ANA, 2020; ANA, n.d.*) Another primary goal later actualized was passage of a bill to create the Army Nurse Corps, Female (ANA, n.d.*). Their encouraging and affectionate relationships, along with career accolades, are well documented in many personal and professional projects (ACM papers, n.d.*; Wald Papers, NY Library, 1889-1957; Columbia University Wald Papers, 1895-1936).

The Johns Hopkins Hospital School of Nursing opened its doors in October of 1889. Isabel Hampton Robb was the first Superintendent of Nurses after attending the Bellevue Training School (BTS) for nurses from 1881-1883. Robb remained at Johns Hopkins for the next five years until she married and resigned. She named Lavinia Dock, whom she knew well from BTS, as her Assistant Superintendent. Dock remained in her position until 1896 when she began working with Lillian Wald. Wald was a progressive nurse activist whose innovative project, the Henry Street Settlement (HSS), provided nurse lodgings and visiting home nursing services to poor immigrants in NYC (Houlahan, 2018). Mary Adelaide Nutting was a student in Hopkins’ first graduating nursing class who became Head Nurse in 1891 and in 1894 replaced Robb as the School Superintendent (Poslusny, 1989; AMCM papers, n.d.*). Sadie Heath Cabaniss attended Johns Hopkins from 1891-1893, during which time Robb, Dock, and Nutting all held leadership positions. Upon graduation, Cabaniss briefly replaced Nutting as Head Nurse when Nutting assumed the Superintendent role (Koste, 2016).

Cabaniss’ leadership in nursing was largely formulated through continued close friendships and collaborative projects with her esteemed colleagues... Cabaniss’ leadership in nursing was largely formulated through continued close friendships and collaborative projects with her esteemed colleagues from Johns Hopkins School of Nursing. She organized and became the initial Superintendent of the first Training School in Virginia (1895); was critical in forming the Virginia State Association of Nursing (1901) (now Virginia Nurses Association), serving as the first president; and in 1903 was persuasive in ensuring legislation such as “An Act to Regulate the Professional Nursing of the Sick” in Virginia (Koste, 2016). While not an author of nursing textbooks, Cabaniss did write numerous papers published in prestigious journals (AMCM papers, n.d.*). Furthermore, Cabaniss became an active member and officer in the NAA of the United States (now the ANA) along with Robb, Dock, Nutting, and Wald (AJN, 1902).

Figure 1. Sadie Heath Cabaniss: Superintendent of Virginia’s first Training School. Reprinted by courtesy and permission of the Eleanor Crowder Bjoring Center for Nursing Historical Inquiry, University of Virginia.

Reprinted with permission. (Kueter, 2019).

Impact of Geography and Culture
Politically, many Virginians held conflicting views.At the turn of the 20th century, less than 40 years since the Civil War concluded in 1865, northern and southern cities varied culturally, politically, and geographically. Virginia’s choice to secede from the Union prior to the war had tremendous consequences; land was given to Union-supportive northern states and the entire state split in two. Unwelcomed troops remained in Richmond until 1870, one of many cities requiring extensive reconstruction following the war and recent abolishment of slavery in 1865. Politically, many Virginians held conflicting views. And segregation was present in all areas of Richmond life, from schools and stores to neighborhoods and transportation (Hoffman, 2001; Green, 2005).

Cabaniss, as a Southerner, was fundamental in conveying the importance of professional and school nursing development in the South. Great divides thus existed, including southern people’s resistance to adopt initiatives from the prosperous North. Cabaniss, as a Southerner, was fundamental in conveying the importance of professional and school nursing development in the South. She gained community support through her background and friendships with Robb, Dock, and Nutting. Cabaniss’ education, participation, and friendships with these nurse leaders from the North, as well as her cultural status, elevated the professional nurse in the South where few nursing leaders had yet to emerge. School nursing began in 1902 in NYC, the urban mecca of the North. Through Cabaniss, it made its way from NYC to Richmond, VA (Green, 2005; Koste, 2016).

The Nurses’ Settlement of Richmond

The idea for the Nurses’ Settlement of Richmond began while Cabaniss was a student. All Johns Hopkins nursing seniors provided care in the homes of Baltimore’s poorest citizens (Koste, 2016). Students administered services and instructed patients on treatments, hygiene, and healthful living (AMCM papers, n.d.*; Koste, 2016). Serving as a visiting nurse in the district while a student fostered her ongoing commitment to meet the needs of the sick and poor.

The idea for the Nurses’ Settlement of Richmond began while Cabaniss was a student. Cabaniss worked at Johns Hopkins for one year following her graduation. In fall 1894, as recommended by her mentor Robb, she returned to Virginia as the head nurse of the Old Dominion Hospital operating room in Richmond. Shortly thereafter, administrators requested that Cabaniss utilize her nursing and leadership skills to establish hospital nurse training. She developed and became the initial superintendent for the first nurse training school in Virginia (AMCM papers, n.d.*; Koste, 2016). Drawing on her experience, Cabaniss included visiting nursing to the curriculum (IVNA papers, n.d.*). This was approved by the hospital’s board of managers in 1896, though based primarily on financial reasons as the hospital charged student service fees to those who could pay.

The need for visiting nursing services in Virginia’s capital was indisputable. At the turn of the 20th century, Richmond’s quickly growing population brought many health concerns, such as limited affordable housing options, contaminated water sources, sewage in the streets, and insufficient police protection (Green, 2005). The Black population lived in worse conditions than did Whites, and Richmond’s mortality rate was higher than any other city of its size in the country (Green, 2005). In addition, “[t]housands of working-class families teetered on the brink of poverty…according to the U.S. Commissioner of Labor in 1888, average weekly wages in Richmond were the lowest in the nation” (Green, 2005, p. 279).

The need for visiting nursing services in Virginia’s capital was indisputable. Cabaniss urged seven members of the class of 1900, her last graduating cohort as Old Dominion Hospital Superintendent, to found the Nurse’s Settlement of Richmond that year, including Nannie Minor. Minor and Cabaniss held similar beliefs about caring for sick poor patients. They had developed a lifelong bond that became instrumental in the ongoing success of the Nurses’ Settlement of Richmond and establishment of Virginia’s school nursing (IVNA papers, n.d.*).

As the new graduates were setting up the Nurses’ Settlement under the guidance of Cabaniss, Richmond’s hospitals were changing. In 1899 a wealthy philanthropist raised funds for a competing teaching hospital. By 1901, Old Dominion was abandoned and Cabaniss joined her former students at the Nurses’ Settlement (Koste, 2016). Minor became the Acting Chief Nurse, with Cabaniss as Superintendent of The Nurses’ Settlement, later known as the Instructive Visiting Nurse Association (IVNA papers, n.d.*).

The Subsequent Establishment of the Instructive Visiting Nurse Association (IVNA)
Cabaniss’ familiarity with Henry Street Settlement was well known Cabaniss’ familiarity with Henry Street Settlement was well known (IVNA papers, n.d.*). The Nurses’ Settlement in Richmond was seen as “the only one whose visiting nurse work is in any way comparable to that done at Henry Street Settlement” (Brainard, 1922, p. 254), despite the lack of initial financial support. By October of 1900, the group secured lodging as each nurse agreed to pay five dollars monthly for rent. Nurses thus held private duty positions; visiting services for the poor were conducted on their rotating days off and after traditional business hours (IVNA papers, n.d.*).

In 1902, Minor spoke at the Richmond Woman’s Club meeting in the home of Mrs. Lila Valentine to publicize their mission within the community and secure financial backing. Minor did so by associating those at the Nurses’ Settlement with the prominent and thriving civic-minded HSS from the sophisticated North, thus demonstrating the likelihood of their success. She also specified “over the past year they had completed 300 visits to Charity patients….and up to this time we have only been able to devote what leisure time there is between pay cases, for we have to earn the money to pay our house rent and expenses…literally without a penny in our pockets” (IVNA papers, n.d.*). Minor discussed their angst in finding a philanthropic organization to oversee funding of the Settlement to allow full-time care for sick poor (IVNA papers, n.d*). She emphasized the importance of their work for Richmond, based on benefits seen in NYC. Finally, she described the impact of the Henry Street nurses, who “go in and out among these people freely and unharmed. Murder, theft, drunkenness, immorality is prevented and lessened. Epidemics are controlled and prevented, and the entire welfare of the city aided” (IVNA papers,n.d.*).

[Minor] emphasized the importance of their work for Richmond, based on benefits seen in NYC. The wealthy patronesses offered their blessings and funding. Furthermore, Valentine called upon other prominent Richmond women to administratively and financially support the nurses; from there, she, Cabaniss, and Minor formed the Instructive Visiting Nursing Association (IVNA). In February of 1902, the Virginia Assembly incorporated the Nurses’ Settlement with the IVNA. The IVNA board oversaw and coordinated necessary nursing services funds and other charitable social endeavors. This financial support included employing Cabaniss and Minor at $37.50 a month, allowing them to proceed full-time (IVNA papers, n.d.*; Green, 2005; Koste, 2016). School nursing would become an expansive enterprise stemming from the IVNA.

Impact of Relationships

The wealthy patronesses offered their blessings and funding. As a senior student, Cabaniss had the opportunity to work with Robb, Dock, and Nutting on the development of organized professional nursing in the United States. Robb was asked to direct the nursing exhibition at the International Congress of Charities, Corrections, and Philanthropy (ICCCP), scheduled alongside the 1893 World’s Fair. A number of student nurses from the Training School helped to staff the Fair emergency room (Koste, 2016). Robb presented papers with Dock and Nutting, introducing the blueprint for the professionalization of nursing, including establishing alumnae associations, training of school superintendents, and creating national organization of nurses (Koste, 2016; Houlahan, 2017). While there, Dock met Lillian Wald, and they formed a lasting friendship. Dock left Johns Hopkins three years later to work with Wald and live at HSS until 1915; she became Wald’s closest nurse friend for over 40 years (Koste, 2016).

She likely heard firsthand about the successful NYC school nurse experiment... Through an ongoing friendship with Dock, Cabaniss became familiar with Wald’s work at HSS. She likely heard firsthand about the successful NYC school nurse experiment led by Wald and Lina Rogers, one of the HSS nurses. This knowledge later served as a model for Cabaniss’s development of the Richmond Nurses’ Settlement and visiting nursing services (IVNA papers, n.d.*), which also included caring for children in schools.

Cabaniss relied on these strategic friendships to promulgate the nursing profession in Virginia and throughout the South. In a letter to Cabaniss in 1901, Robb wrote “I am very glad to do anything that you may ask me if I can at all times…I am very sure you are doing good work and always on the alert…to find better ways of doing, that is what nursing work needs” (IVNA papers, n.d.*). Robb closed by asking if she would see Cabaniss at the NAA meeting in June (IVNA papers, n.d.*). Cabaniss had recently obtained an HSS fellowship, most likely due to her continued friendship with Dock, but was unable to accept the honor as she remained in Virginia to care for her seriously ill mother until her death (Koste, 2016).

Cabaniss relied on these strategic friendships to promulgate the nursing profession in Virginia and throughout the South. Cabaniss’ bond with Dock was well publicized. While living and employed at HSS, nationally renowned Dock visited Cabaniss in Richmond, probably for personal and professional matters. The publicly anticipated affair was published in both local newspapers on February 27, 1902, a testament both to its importance and the citizens’ respect for the work of these nurses (Richmond Dispatch, 1902; The Times (Richmond), 1902). Of significance, the school nurse movement in NYC and Dock’s visit transpired the same year. Cabaniss maintained life-long friendships with Robb, Dock, and Nutting, collaborating with them often. She also worked with Wald on national committees promoting the visiting public health nurse role (IVNA papers, n.d.*).

As the distinction of visiting nursing services flourished, so did the need to disseminate the innovation rising from these efforts. Initially the only vehicle for communication among nurses was the AJN; Wald and Dock published articles about visiting nurse services in its first issues. By 1902, numerous articles regarding the origins of district nursing in England; the HSS visiting nurse services; school nursing in London; and the NYC school nurse experiment were published therein. In April of 1906, the Charities and the Commons dedicated an entire publication to the public health nurse movement and contained articles by Wald, Dock, Rogers, and Cabaniss, who described the Nurses’ Settlement of Richmond (Charities and the Commons. 1906).

Initially the only vehicle for communication among nurses was the AJN... As the Second Vice-President of NAA in May 1907, Cabaniss urged the group to hold its 10th Annual Convention in the South (Richmond) for the first time since its institution in 1896 (ANA , n.d.*). Dock, Nutting, and Robb were all in attendance. The acting president requested Cabaniss to report on the status of the nursing profession in the South and afterward noted, “I suppose there is no question in the minds of any present as to who has stood at the head of the nursing profession in the South for the last twelve years” (AJN, 1907, p. 86).

School Nursing in Richmond

Though school nursing in Richmond officially began in the fall of 1909 as an IVNA outreach, services were provided as needed for several years prior. Echoing Wald’s home visits, the IVNA nurses noticed large numbers of ill children who were absent from school. Many presented with correctable ailments, yet most went without proper treatment (IVNA papers, n.d.*). Upon this discovery, the health of school children became an area of special focus. IVNA nurses conducted informal visits in some of Richmond’s poorest schools, addressing illness and contagious disease while encouraging corrective work for the children (IVNA papers, n.d.*). Nurses also provided health education for parents and guardians in the family home as needed, often taking those requiring treatment to the necessary specialist (IVNA papers, n.d.*).

...the IVNA nurses noticed large numbers of ill children who were absent from school In 1906, Richmond’s most significant health ailment was tuberculosis (TB). That year Richmond’s City Health Department was reorganized. The new Chief Health Officer, [Ernest Coleman] Levy immediately instituted two dispensaries, one for blacks and one for whites. Levy enlisted IVNA nurses to promptly identify and refer anyone with symptoms (IVNA papers, n.d.*).

In October 1908, after several high school students died of TB, Levy requested IVNA’s voluntary assistance for two schools of differing races. The nurses realized the importance of “prompt recognition of this fatal malady” and “cheerfully assisted in this work at very great inconvenience and considerable tax upon their time and strength” (IVNA papers, n.d.*).

Many presented with correctable ailments, yet most went without proper treatment In November 1909, the IVNA received a generous donation for one full-time school nurse salary (IVNA papers, n.d.*). Anne Gulley, a founding member of the Nurses’ Settlement and respected friend and colleague of both Cabaniss and Minor, was appointed. Gulley began her work in the new John Marshall High School, and was transferred to Jefferson Elementary by February 1910. Over the next three months the school board appealed to the Richmond City Council to appropriate a permanent high school nurse salary from public funds while Gulley continued her work in the elementary school (IVNA papers, n.d.*).

The community quickly recognized the benefits of the school nurse. “In Richmond, as elsewhere, advances in public health were often closely tied to economic and political developments in the city” (Hoffman, 2001, p. 177). The community quickly recognized the benefits of the school nurse. Gulley examined 750 students, referring 291 to specialists (IVNA papers, n.d.). The school board applied to the city council for the high school nurse salary, yet the request was denied. Hoping the city council might reconsider, the IVNA funded Gulley to remain through the fourth month before withdrawing her to fulfill a board of health request for measles epidemic assistance (IVNA papers, n.d.).

The city council decision infuriated Richmond residents... The city council decision infuriated Richmond residents; the papers published their concerns. “Nurses Withdrawn from City Schools: Patrons Protest Against Abandonment of Precautionary Measures” reported “Richmond is at the mercy of a measles epidemic which is being diligently fought by the Board of Health. Nevertheless, the most valuable combative power in the schools has been withdrawn” and assured “[a] vigorous effort will be made to have the Council rescind its action and replace the nurses in the schools” (Nurses withdrawn from city schools, 1910). Six South Richmond physicians volunteered to inspect all district schools, stipulating a full-time nurse to assist. The principal requested the nurse salary to the School Board (IVNA papers, n.d.*).

School health work in South Richmond proved so successful that the Richmond School Board asked for financial approval for two medical inspectors and four nurses. In the summer of 1910, governing budgetary organizations approved funding for the school nurse program (IVNA papers, n.d.*). By 1916 Richmond public schools employed eight school nurses who visited homes (Ranson, 1917).

Analysis and Discussion

Understanding the crucial functions of the school nurse, and advocacy and funding of the role, continue as significant concerns of today.What can we learn from early nurse leaders to provide a framework to expand student healthcare and direct contemporary evidence-based school nursing practice? This history is important. Understanding the crucial functions of the school nurse, and advocacy and funding of the role, continue as significant concerns of today. The National Association of School Nurses (NASN) advocates that “a professional registered school nurse be present in every school all day, every day” (NASN, 2018, para. 2). However, 25.2% of U.S. schools do not employ a school nurse, and only 35.3% of schools employ a part-time nurse; 39.3% of schools employ school nurses full-time (Willgerodt, Brock, & Maughan, 2018).

Amidst nationwide budget cuts, the role of school nurse is among the first to be dismissed, especially in states where school nurses are not mandated (IOM, 2011). Additionally, NASN calls for Advocacy Skill Building, asserting “[t]he role of the school nurse is not always understood by teachers, administrators, parents, elected officials, and the community at large” (NASN, 2020, para 1). “Only school nurses have the insight to educate stakeholders” which is why communicating nurses’ importance to stakeholders remains a critical challenge for today’s healthcare providers (NASN, 2020, para 1). NASN encourages school nurses to “find opportunities to meet with elected officials; including school board members, city councilors, mayors, and state and federal legislators to drive home important information” (NASN, 2020, para 3). Understanding how early nursing leaders initiated and extended the role of the school nurse, and school health programs, is important to inform the advancement of school health policy and support evidence-based practice of school nurses today.

Amidst nationwide budget cuts, the role of school nurse is among the first to be dismissed... ...prominent nurse founders at the turn of the 20th century understood that Wald’s Henry Street Settlement, and the ensuing school nurse experiment in NYC, transformed child and community health Findings from this historical research revealed that prominent nurse founders at the turn of the 20th century understood that Wald’s Henry Street Settlement, and the ensuing school nurse experiment in NYC, transformed child and community health. Together they used their personal and professional relationships to forge powerful alliances to initiate and replicate already successful health programs across the country, including the Richmond Nurses Settlement and school nursing in the Commonwealth. Nurse pioneers succeeded based on their ability to collaborate; advocate; execute research to demonstrate benefits of program implementations; educate peers about best practices; ensure consistency in services; and disseminate their achievements to communities and stakeholders to gain and maintain support for sustained initiatives.

The C.A.R.E. Model of Successful Nursing Initiatives

The founders of professional and school nursing utilized a synergistic, multifaceted approach to establish and extend successful health initiatives. The founders of professional and school nursing utilized a synergistic, multifaceted approach to establish and extend successful health initiatives. It is this approach from which the C.A.R.E. model that we described herein was derived. This framework includes four concepts: Collaboration, Advocacy, Research, and Education. Consideration of these concepts offer suggestions for school nurses of today. 

Figure 2: C.A.R.E. Model to Promote Successful Population Health Initiatives

[View full size] Source: Created by author, Lilianna Deveneau 

Collaboration
First, early nurse leaders like Robb, Dock, Nutting, Wald, and Cabaniss understood the significance of collaboration. Their success was based on the ability to cooperate with peers to develop professional organizations. This in turn worked with local and state governments, school boards, communities, parents, physicians and philanthropists to advance community health initiatives. Collaboration included defining their purpose, role, and educational and practice standards to ensure that all nurses were engaged in the same understanding and pursuits. Creating national platforms such as the Society of Superintendents of Training Schools for Nurses, now the NLN, established standards for training and practice that legitimized nursing as a profession. Additionally, in creating the NAA, this cohort joined nurses from across the country to learn from each other. They learned strategies to promote change, such as how to work with governing bodies, community leaders, physicians and parents to establish new policies to institute programs of health.

Their success was based on the ability to cooperate with peers to develop professional organizations. With today’s large-scale approach using technology and social media, often this face-to-face personal community engagement is lacking. What differs between the approaches of early nurse founders and of those today? These historical leaders were an integral part of the community they served, which personalized their call to implement change. Nurse founders called and built upon their contacts and their communities, to create grassroots initiatives, and to fund new health policies, professionalizing the role. They were involved politically with ‘boots on the ground,’ collaborating as change agents with the stakeholders who had the power to implement changes. For example, Minor reached out to her contacts for funding and the Nurses Settlement of Richmond garnered community support for health programs. This was accomplished face-to-face by meeting in people's homes and clubs, alongside family and friends. With today’s large-scale approach using technology and social media, often this face-to-face personal community engagement is lacking. Professional nursing organizations can continue to build upon this understanding of personalized collaboration to establish ongoing pursuits with community members and stakeholders to improve the health and wellbeing of school children today.

Advocacy
They understood that once communities could see the benefits from programs...funding and other support would follow. Early nurse leaders demonstrated Advocacy for their role and for patients. They understood that once communities could see the benefits from programs such as school nurse services, funding and other support would follow. The Richmond Women’s Club decision to financially support the Nurses Settlement of Richmond, from where school nursing emerged, is one example. Likewise, according to the Times Dispatch (1910), patrons complained to city officials to support the school nurse; subsequently funding was allocated by the Richmond School Board. In portraying the initiative’s importance regarding student health and the benefits perceived by the greater community, common ground can become clear, and achievement thus much more likely.

Research
...early school nurses improved student health outcomes through evidence-based corrective measures Advocacy for the nursing role and those most needing services closely aligned with research. Early nurse leaders collected outcome data to demonstrate health benefits through research. They insisted upon quality improvement, and were able to treat specific communities by looking at outcomes data and tracking the reduction of epidemics. They maintained statistical data on all patients examined, noting who received interventions. By doing so, early school nurses improved student health outcomes through evidence-based corrective measures. Once benefits were evident, funding was obtained from stakeholders. Fundamentally, the HSS, NYC’s school nursing experiment, and the Nurses’ Settlement of Richmond/IVNA began as leadership research projects whose successes were later evaluated, documented, and replicated. School nurses of today engaged with innovative projects aiming to improve student health outcomes are encouraged to do the same.

Education
Cabaniss learned how to initiate visiting nurse services, and subsequently school nursing, through her personal and professional alliances... Early nurse leaders understood the significant need to provide education for peers, community, and stakeholders about best practices to ensure consistency in nursing services and outcomes. Cabaniss learned how to initiate visiting nurse services, and subsequently school nursing, through her personal and professional alliances with Robb, Dock and Wald. The findings of our research support the fact that Cabaniss and Minor were privy to specific details about creating a nurses’ settlement based on Wald’s endeavors. By using an already successful model in NYC to create visiting and school nursing in Virginia, they had strong data to support their project’s success. School nurses of today can take advantage of reliable and professional educational opportunities to promote evidence-based practice in their communities and in turn improve stakeholder buy in for their services.

In sum, the founders’ emphasis on the dissemination of their collaborative research and successes was the means through which they could educate peers and constituents, and thereby advocate to gain professional and community support. They developed a method to effectively communicate their accomplishments with the first nursing journals and, in doing so, laid one of the professional foundations of nursing. These insightful nurse leaders also used their organizations to create policy change at the political level through education of the public and dissemination of research. This further promoted engagement with philanthropic-minded organizations and prompted sharing of successful collaborative endeavors. The originators of nursing in the United States also disseminated information about evidence-based practice through news outlets and interprofessional journals such as the Charity and the Commons.

By using an already successful model...they had strong data to support their project’s success. Thus, one can see how the concepts in this framework combine for success. The intersection of these C.A.R.E. principles marks the fertile environment school nursing founders discovered to be most conducive to success. The historical success of this approach to create the specialty of school nursing provides evidence for the potential to further expand the impact of school nurses and improve the health of our children and nation.

Conclusion

Nurses shape the health of school children, their families, and entire populations. This is particularly so for vulnerable populations, those that led to the first practice of school nursing in the HSS, and those of today. The function and successes of early nurse leaders have transformed the nursing profession; changes implemented through the dedicated collaborative efforts of a handful of women. It is now easier than ever for nurses to use their contemporary voices, training, and skills while following in the founders’ footsteps through endorsing population wellness on a grander scale.

The potential and ability for nurses to create positive change in patient outcomes and politics to improve population health, care, and education is embedded within the very history of the profession. Politically astute inter/professional team-based collaboration and leadership can continue to advance the education, practice, scope, and outcomes of nursing. The potential and ability for nurses to create positive change in patient outcomes and politics to improve population health, care, and education is embedded within the very history of the profession. Replicating the successful strategies of Robb, Dock, Nutting, and Cabaniss, nurses can continue to promote the wellbeing of citizens for generations to come.

Authors

Bridget Houlahan, PhD, RN
Email: houlahba@jmu.edu

Bridget Houlahan, PhD, RN is an assistant professor at James Madison University (JMU), Harrisonburg, VA, USA. She received a BSN from Ohio Wesleyan University, an MSN from Kent State University with a concentration as a Pediatric Nurse Practitioner and a PhD from the University of Virginia, with a specialization in Nursing History. She currently teaches pediatric nursing. Her dissertation work, “A History of School Nursing: From its Origin in New York City to Implementation in Virginia, 1900 – 1925,“ has resulted in two publications in the Journal of School Nursing. She is passionate about the promotion of child health, particularly through advocating for school health programs and school nurses.

Lilianna Deveneau, BA, BS
Email: ldevenea@gmu.edu

Lilianna Deveneau is a Sociology Master of Arts student at George Mason University. She received a bachelor’s degree in Sociology from The University of Southern Mississippi with certificates in Mass Communication Studies and Women & Gender Studies. She also holds a bachelor’s degree in French from the University of Wisconsin - River Falls with a certification in Communication & Media Studies. In addition to two decades of experience in various healthcare roles, especially for society’s most vulnerable populations, Ms. Deveneau is the editor of an undergraduate nursing textbook for which she coauthored four chapters. She has other peer-reviewed publications and has served as JMU School of Nursing’s sole editor for several years. Ms. Deveneau is interested in equality through population health, community-engaged research and social justice, and like many nursing founders and organizations, views healthcare as a human right.

References

Alan Mason Chesney Medical Archives (AMCM papers) of the Johns Hopkins Medical Institutions. (n.d.*). Biographical Files. Retrieved from: https://medicalarchivescatalog.jhmi.edu/webcat/request/Action?ClientSession=-4ae7f762:17573985481:-7fdc&TemplateProcessID=6000_3355&CMD_(SearchRequest)[12]=&PromptID=&ParamID=&RequesterType=SearchTemplate&browseData=1&bCachable=1&Keyword=0&POI31_1878=-KEY_59900&fromTitle=Archival%20Record%20-%20Biographical%20Files

American Journal of Nursing (AJN). (1902). Fifth annual convention of the Nurses’ Associated Alumnae of the United States: Minutes of the proceedings. The American Journal of Nursing, 2(10), 744-746. Retrieved from: https://journals.lww.com/ajnonline/Citation/1902/07000/Nurses__Associated_Alumn__of_the_United_States.2.aspx

American Journal of Nursing (AJN). (1907). Tenth Annual Convention of the Nurses’ Associated Alumnae of the United States: Minutes of the proceedings. The American Journal of Nursing, 7(11), 792. Retrieved from: https://journals.lww.com/ajnonline/Citation/1907/08000/PROCEEDINGS_OF_THE_TENTH_ANNUAL_CONVENTION_OF_THE.1.aspx

American Nurses Association (ANA). (n.d.*). ANA expanded historical review. Retrieved from: https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwiTp8-r7dHtAhUmvlkKHaSiAwgQFjAAegQIAxAC&url=https%3A%2F%2Fwww.nursingworld.org%2F~48de6f%2Fglobalassets%2Fdocs%2Fana%2Fana-expandedhistoricalreview.pdf&usg=AOvVaw1xdZMIDJU2lt4mEO-B4BrU

American Nurses Association (ANA). (2020). Isabel Adams Hampton Robb (1860-1910) 1976 Inductee. Retrieved from: https://www.nursingworld.org/ana/about-ana/history/hall-of-fame/1976-1982-inductees/

Brainard, A. M. (1922). The Evolution of Public Health Nursing. W. B. Saunders Company. Retrieved from: https://books.googleusercontent.com/books/content?req=AKW5Qaec8plmWhcDIw5pDzQIzLKh_r89gaG1RQypaRceqgVWO3rk3OUWbPxJKZolESmZzQPH1dIba0TiWWWHPCdJX3kVvncaRW8_-vztIzVKLfd9NZMNEJHPWFNMqxKOpCHPM58bCea2i2sx5BR5TkGlQYtnkZe-y0b2z33VPOIkVBaO6QZ5fw3_0L8z_4hsxN-UjM5MVpLtB3eCZeT0u5LoUEKZt905zp3tU56c3b7EPTaUJP83A4MA1IEm1fz1FuxFj42AMYiXe_R2X24Tk2skgPaZq19P6UFEDl-I4iYHm2ONC7Vo4-8

Charities and the Commons: A weekly Journal of Philanthropy and Social Advance. (April 7, 1906). “Visiting Nursing Special Issue,” 16.

Green, E. (2005). Gendering the city, gendering the welfare state: The Nurses’ Settlement of Richmond, 1900-1930. The Virginia Magazine of History and Biography, 113(3), 277-311. Retrievedfrom: https://www.questia.com/library/journal/1P3-915211841/gendering-the-city-gendering-the-welfare-state-the

Hoffman, S. J. (2001). Progressive Public Health Administration in the Jim Crow South: A case study of Richmond Virginia. Journal of Social History, 35(1), 175-194. Retrieved from: https://www.jstor.org/stable/3789268

Houlahan, B. (2017). A History of School Nursing: From its Origin in New York City to implementation in Virginia, 1900 – 1925. [Doctoral dissertation, University of Virginia]. LibraETD. doi: 10.18130/V3RS5Z

Houlahan, B. (2018). Origins of school nursing. The Journal of School Nursing, 34(3), 203-210. doi:10.1177/1059840517735874

Institute of Medicine (IOM). (2011). The Future of Nursing: Leading change, advancing health. IOM (US) Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, National Academies Press. doi: 10.17226/12956

Instructive visiting nurse association papers (IVNA). (n.d.*) Special Collections and Archives, Tompkins McCaw Library, Virginia Commonwealth University (VCU).

Koste, J. L. (2016). Sadie Heath Cabaniss: Mother of professional nursing in Virginia. In C. Kierner & S. Gioia Treadway (Eds.), Virginia women their lives and times (volume 2). University of Georgia Press.

Kueter, C. P. (2019, June 14). Flashback Friday—A chair of nursing for the South. University of Virginia School of Nursing. Retrieved from https://www.nursing.virginia.edu/news/flashback-cabaniss/

Lillian D. Wald Papers. (1895–1936). Columbia University Rare Books and Manuscripts Library (Physical description 30,000 items, 96 boxes). Collection has been published on microfilm (112 reels).

Lillian D. Wald Papers. (1889–1957). New York Public Library, Humanities and Social Sciences Library, Manuscripts and Archives Division. 50 boxes total. Collection is available on microfilm (37 reels).

National Association of School Nurses (NASN). (2018). About NASN. Retrieved from https://www.nasn.org/nasn/about-nasn/about

National Association of School Nurses (NASN). (2020). Advocacy skill building. Retrieved from https://www.nasn.org/advocacy/advocacy-skill-building

Nurses withdrawn from city schools. (1910). The Times Dispatch. Retrieved from: https://virginiachronicle.com/?a=d&d=TD19100724.1.21&srpos=8&e=-------en-20--1--txt-txIN-nurses+withdrawn+1910

Poslusny, S. (1989). Feminist friendship: Isabel Hampton Robb, Lavinia Lloyd Dock and Mary Adelaide Nutting. Journal of Nursing Scholarship, 21(2), 64. doi: 10.1111/j.1547-5069.1989.tb00099.x

Ranson, J. (1917). Appendix VI Public Health Nursing. Annual Report of the Commissioner of Health to the Governor of Virginia year ending September 30, 1916, 138. Williams Print.

Willgerodt, M.A., Brock, D. M., & Maughan, E.M. (2018). Public school nursing practice in the United States. Journal of School Nursing, 34(3), 232-244. doi: 10.1177/1059840517752456

Author note: *Supporting archival documents are available in the referenced collection, but may not be organized in specific files by date.


© 2021 OJIN: The Online Journal of Issues in Nursing
Article published February 3, 2021


Related Articles

From: 
Email:  
To: 
Email:  
Subject: 
Message: