Nursing history is replete with narratives of professional pioneers who have shaped the profession... Nursing history is replete with narratives of professional pioneers who have shaped the profession; some, like Florence Nightingale, Isabel Hampton Robb, and Lillian Wald, are more well-known than others. This article is about Laura R. Logan, one of the lesser known visionaries who, with courage and foresight, influenced nursing education and thus, nursing practice. Logan served as a nurse, administrator, educator, and leader in the profession during the first half of the 20^th century.

Logan’s Education and Early Professional Journey

Logan graduated with a Bachelor of Arts degree in English from Acadia University in Wolfville, Nova Scotia in 1901. She moved to New York to enroll at Mount Sinai Hospital School of Nursing and earned her Diploma in Nursing in 1904. Logan worked as a private-duty nurse before accepting a position, in 1907, as supervisor and instructor at her alma mater, Mount Sinai. This position launched her career in nursing education and hospital work. In 1908, Logan earned a Bachelor of Science degree in Home Economics from Teachers College, at Columbia University. In the 46 years between her first hospital position and her retirement in 1953, Logan served in numerous educator and administrative roles at hospitals and schools across the United States. For more details about Logan’s nursing career, readers are advised to consult Glass’ (1988) authoritative biography, briefly summarized in Table 1 which details a chronological list of her positions.

Table 1. Logan’s Professional Nursing Education Career

[View table] (Glass, 1988)

These futuristic ideas, and her commitment to them, were quite bold in the context of her time. Rather early in her career, Logan accomplished great change for nursing education. Logan’s vision was the belief that entry-level preparation for nurses should include a liberal studies education in combination with clinical training in the care of the sick and prevention of disease (Logan, 1925a; Logan, 1931). She also believed that instruction of theoretical underpinnings should be coordinated with the clinical training (Logan, 1923; Logan, 1931). Logan advocated that if every nurse was prepared in this way, graduates would gain the foundation needed to assume roles not only in hospitals, but also in the community (Logan, 1925b; Logan, 1931). Her goal was to equip nurses with an education that would prepare them to evolve into educators, administrators, advocates, and leaders, and thus continue to improve nursing education and the professionalization of nursing practice (Logan, 1925b). These futuristic ideas, and her commitment to them, were quite bold in the context of her time.

Nursing Education and Practice in the Early 20^th Century

The exploitation of students as workers in hospitals resulted in inconsistent and substandard training The early 20^th century presented major challenges for nurse leaders working to standardize nurse training in order to protect the title, nurse, and professionalize nursing practice. The exploitation of students as workers in hospitals resulted in inconsistent and substandard training. Efforts to standardize training were further complicated by the need for improved and expanded education for the existing and emerging roles of the nurse. A closer look at the context is provided here to help readers who may be unfamiliar with this time period.

After the inception of Florence Nightingale’s nurse training model in America in 1873, students in these schools proved to be valuable commodities by providing nursing care in hospitals. As the value of student labor was recognized, hospital training schools proliferated (Rosenberg, 1987). Thus, “nursing education and nursing service became synonymous terms in American hospitals” (Ashley, 1976, p. 24) and “the need for ward work superseded every other pedagogical goal” (Rosenberg, 1987, p. 226). In 1893, at the Chicago World’s Fair, school superintendents discussed the rapid expansion of training schools, the lack of educational standards among them, and a loss of autonomy over nursing practice (Hanson, 1988). At the conclusion of the meeting, the American Society of Superintendents for Training Schools of Nurses (which became the National League for Nursing Education in 1912 and the National League for Nursing [NLN] in 1952) was formed to “establish and maintain a universal standard of training” (NLN, 2020; Stewart, 1950, p. 150). Important issues to address included insufficient admission requirements, varying lengths of the training programs, inconsistent opportunities for diverse patient case variety, inadequate theoretical instruction, and minimal supervision of students (Nutting, 1966).

Graduates of training schools frequently entered community-based private-duty nursing, which often offered minimal supervision Given the concerns within training schools, the state of nursing practice presented new considerations for nursing education as well. The rapid growth of “reliable knowledge in the physical and social sciences” required nurses to obtain an education “beyond the bounds of technical knowledge or expertness” (Russell, 1959, p.7). Advances in medical sciences demanded “more knowledge and more independent judgment on the part of the nurse” (Hanson, 1988, p.51). Graduates of training schools frequently entered community-based private-duty nursing, which often offered minimal supervision (Buhler-Wilkerson, 2001). Private-duty nursing required a nurse who could use clinical reasoning, think independently, and adapt to the various patient cases presented (Hanson, 1988). Nurse leaders, focused on these issues, attempted to standardize nurse training to improve nurse education within hospital training schools.

Heightened attention on nurse education coincided with a new role for the nurse, the public health nurse. This new role was a response to a concern for public health due to the increase in immigration, urbanization, and industrialization (Hanson, 1988; Reverby, 1987). The nurse, found to be one of the most valuable workers in the public health movement, was found lacking, however, in educational preparation for such an expanded practice (Stewart, 1950). The public health nurse assumed several roles, including nurse, teacher, counselor, and friend, thus requiring a broad knowledge that only a liberal studies education could provide (Melosh, 1982). The reality of the emerging public health nurse role, and the inadequacy of the hospital training schools to prepare graduates for it, were discussed in three of the presidential addresses between 1912 and 1916 at the annual conventions of the American Society of Superintendents for Training Schools of Nurses, and the National League for Nursing Education (Birnbach & Lewenson, 1993).

The National Organization of Public Health Nursing, organized in 1912, and hospitals, rejected attempts to integrate disease prevention and public health education into the hospital training school curriculum (Hanson, 1988; Melosh, 1982; Stewart, 1950). Post-graduate specialty education was created and became the intended educational pathway for the public health nurse; however, a documented gap existed between the educational requirements and the public health nurses’ actual qualifications (Melosh, 1982).

Heightened attention on nurse education coincided with a new role for the nurse, the public health nurse In summary, issues confronting nurse leaders were that hospital training schools lacked standardization and quality; the practice roles required nurses to receive more education; and the post-graduate courses for public health nurses were not utilized by all nurses entering public health. Considering the state of nursing education and practice during this time period, Logan’s vision for nursing education was logical and bold, but could not be easily nor widely implemented.

Logan’s Influence on Nursing in Cincinnati

An Opportunity for Nursing: Efficiency and Economy
Logan officially entered the scene in Cincinnati on September 1, 1914 when she was hired as the new Superintendent of the School of Nursing and Health within the newly constructed Cincinnati General Hospital (CGH) (Officers, Boards, and Departments, 1914). She was hired with the assurance that the school would become a part of the University of Cincinnati [UC] (Rosnagle, 1940). The situation in Cincinnati that fueled this assurance was unintentionally spearheaded by a physician, Christian Holmes (1857-1920).

Holmes was instrumental in transforming the culture of medicine in Cincinnati. First, he was the primary force for the city’s multi-million dollar construction of the new CGH completed in 1914, and the new College of Medicine completed in 1916 (Fischer, 1937). Holmes summoned funding and support from Cincinnati’s citizens for construction through newspaper stories, explaining the impact a new hospital and medical college would have on the health of the city. Second, he achieved reform of medical education using the city’s new hospital and college that in turn, elevated medical care in Cincinnati. Responsible fiscal use of the new structures to improve the health of Cincinnatians propelled these changes for medicine and also provided Logan an opportunity to reform nursing education.

The proposal also included a new dual diploma/Bachelor of Science (BS) degree program of study for nursing The opportunity to advance the profession of nursing began on June 2, 1914, a few months before Logan’s hire, when Cincinnati’s Director of Public Safety proposed to the UC Board of Trustees a secure cooperation between the CGH School of Nursing and Health and the UC “in the interest of efficiency and economy” (UC Board of Trustees, 1914a, p. 96). The proposal requested all degrees and diplomas granted to graduates of the CGH nursing school be conferred by the university. The proposal also included a new dual diploma/Bachelor of Science (BS) degree program of study for nursing (UC Board of Trustees, 1915b). The nursing school was owned and operated by the hospital, and the medical school was owned by the university, but both the hospital and the university were operated and financed by the city. These fiscal facts tightly bound the UC, with its College of Medicine, and the CGH, with its nursing school, together financially. Moving the CGH School of Nursing and Health to the UC College of Medicine to share financial, facility, and faculty resources appeared to be both an efficient and economical approach. The proposal was not readily approved; the Board of Trustees decided to postpone decision until they could investigate nurse training schools connected with other university medical colleges (UC Board of Trustees, 1914b; 1914c).

Offering a BS degree in addition to a diploma was a new idea even for training schools connected to medical colleges The Director of Public Safety’s proposal was eventually declined by the UC Board of Trustees eight months later, on February 2, 1915 (UC Board of Trustees, 1915a). The fact that the proposal included a new dual diploma/BS degree program of study may have been the reason for this decision. Offering a BS degree in addition to a diploma was a new idea even for training schools connected to medical colleges. The University of Minnesota training school, one of the two schools investigated by the UC, did not include a BS degree program of study for nurses at that time (UC Board of Trustees, 1914c; Powell, 1937). The UC, focused on its upcoming new medical college and reforming medical education, chose not to commit its resources to advancing the education of nurses with a BS degree. Despite this setback, Logan had already begun to initiate change in the CGH School of Nursing and Health as the new superintendent.

School of Nursing and Health of the Cincinnati General Hospital
Logan strategically instituted changes that aligned with the city’s interest of efficiency and economy. She took steps to adopt a new pedagogical philosophy and expand educational offerings that aligned with professional, liberal studies education in a university setting. Logan also demanded professional accountability and standardization of care to not only promote positive patient outcomes but to demonstrate the value of educating nurses under the newly adopted philosophy. Her every decision and action was deliberate to support the cooperative agreement proposal, to advance the education of nurses, and prepare nurses for the expanding roles in the community.

Logan strategically instituted changes that aligned with the city’s interest of efficiency and economy Prior to Logan’s arrival at CGH, the training school curriculum included only seven months of daily lectures in addition to practical work on the wards (Officers, Boards and Departments, 1913). Borrowing from the UC College of Engineering, Logan introduced a pedagogical philosophy of cooperative education that she described as “an exercise in integration, the synthesis of theory with experience, of personal development with intellectual growth” (Logan, 1941, p. 14). The cooperative education system was based on a “major idea…of balanced training” alternating theory in the classroom and practice in the laboratory or workplace (UC, 1947, p. 11). Within months after hired, Logan was credited by the Hospital Superintendent/Medical Director in creating “an organization equal to that of the best schools in the country, and should take its place at the head of nurse training and instruction” (Officers, Boards and Departments, 1914, p. 392).

Logan championed major curricular changes...To align with the cooperative education philosophy, Logan championed major curricular changes. Credit hours were earned for practice courses as well as theory courses; 15 hours of practice work per week per semester, or one month of nursing of at least eight hours per day, was equivalent to one credit hour of practice work (Matthias, 2017; Rosnagle & Darrington, 1950). Logan divided the school’s program of study into 43 credits of theoretical instruction in the classroom, and 29 credits of practice work (Matthias, 2017). She established relationships with UC College of Medicine professors and negotiated their assistance with various lectures and demonstrations (Matthias, 2017). She added lectures to nursing courses, expanded elective course offerings, and established a course for nursing students on the university campus (Matthias, 2017). See Table 2 for a list of specific subjects and courses that were augmented or added.

Table 2. Curriculum Changes in the School of Nursing and Health at Cincinnati General Hospital

[View table] (Matthias, 2017)

Along with curricular changes, Logan expected professional accountability and responsibility from the students and hospital staff nurses. In December 1915, these heightened expectations gained publicity in the local newspapers after Logan dismissed two nurses for patient abandonment, and reduced two senior student nurses to the level of probationers for arriving late to work, using a hospital ambulance to get there (Times Star, 1914; Enquirer, 1915). The newspaper articles noted that Logan determined the consequences for the nurses’ behaviors, and the hospital superintendent and the Director of Public Safety supported her decisions. This illustrated a shared vision for the school and hospital, and a partnership between the city, the hospital, and Logan.

Logan committed to standardize nursing practice in the hospital Logan committed to standardize nursing practice in the hospital. To do so, she scheduled demonstrations twice a week in the surgical amphitheater, requiring attendance of all students and nurses (Logan, 1919a). In 1915, the City of Cincinnati purchased a “life-sized doll” or manikin for $150 to assist students in cultivating their nursing skills and techniques (Cincinnati Post, 1915). These resource investments of time, space, and money provide evidence that Logan’s efforts to standardize nursing procedures were supported by the city and the hospital.

Logan understood the changes required to transform training to education Logan’s commitment to public health guided her belief that institutions that educated nurses possessed a responsibility to prepare them not only for hospital work, but also as professional citizens involved in the overall health and welfare of their community (Logan, 1920; Matthias, 2017). Clara D. Noyes (1869-1936), president of the National League for Nursing Education from 1914 to 1916, stated it simply in 1916, noting “It has taken many of us a long time to learn the difference between training and education, but we are learning” (Birnbach & Lewenson, 1993, p. 125). Logan understood the changes required to transform training to education.

Cooperative Agreement and Dual Diploma/BS Degree
Logan had to convince those at UC with the power to approve the cooperative agreement that adding the new dual diploma/BS degree program should be an integral piece of the agreement. Her decisions and actions also supported the city’s interest of efficiency and economy. She initiated strategic changes within the CGH School of Nursing and Health to prepare administrators, students, university professors, and physicians for the new program of study.

With construction completion of the new College of Medicine on the horizon, the same cooperative agreement with the dual diploma/BS degree program was proposed again, on June 26, 1916, and received approval (UC Board of Trustees, 1916). Logan became the second professor of nursing in the United States (Glass, 1988), and the UC School of Nursing and Health began to offer a three-year diploma program that would also provide the student with two years of college credit toward a BS degree (Logan, 1919b). Students could combine their three-year diploma program with two more additional years of liberal studies college work, either before or after the diploma program, and earn a BS degree from the UC.

She successfully established relationships and negotiated with hospital administrators and university faculty Logan strategically designed the three-year diploma program of study to include nursing courses and some liberal studies courses to provide the graduate with courses that would be acceptable for two years of college credit. She embraced the cooperative education philosophy and rotated clinical training with focused academic study. Additionally, she reserved the last four months of the students’ diploma program for intensive study in a nursing specialty of their choice, including but not limited to, public health nursing, hospital administration, and private-duty nursing (Logan, 1919b).

The cooperative agreement between the hospital and university and thus, the nursing school and medical college, was not approved for the sole purpose of reforming medicine or nursing education, but rather primarily approved in the interest of efficiency and economy. The multi-million dollar hospital and college buildings motivated this interest. Logan strategically seized the opportunity of newly available resources and the interest of efficiency and economy in Cincinnati. She focused on improving nursing care in the hospital and making curricular changes in the CGH School of Nursing and Health to better prepare graduates for roles in public health, private-duty, and institutional nursing that graduates were reported to assume (Officers, Boards and Departments, 1914). She successfully established relationships and negotiated with hospital administrators and university faculty. She developed and maintained standards of care within the new hospital for students and staff nurses alike. These successes provided evidence to support advancing the education of the nurse. The nurses at CGH and Logan frequently appeared in articles within local newspapers, keeping Cincinnati citizens informed about nursing.

A hallmark of Logan’s strategic leadership was positioning herself in the right place at the right time A hallmark of Logan’s strategic leadership was positioning herself in the right place at the right time. Holmes’ unwavering efforts to create change and opportunity for medicine set the stage for Logan to create change and opportunity for nursing. The two had an undeclared partnership; the decisions and concerted actions of one indirectly supported the other. They worked to institute reform within their respective disciplines, but the local context and shared resources created an opportunity to propel their separate agendas in tandem.

Logan Becomes a Nurse Leader

Throughout her long career Logan continued as a strong advocate for a university and liberal studies education for nursing. She was a frequent speaker and author who relied on her experiences in nursing education “to ensure not only a broad cultural background for the nurse, but a sounder scientific foundation for her professional work” (Logan, 1921, p. 622). Nearly a decade after Logan began her strategic efforts at UC, the Committee for the Study of Nursing Education (1923) report , commonly referred to as the Goldmark Report, was published and recommended educational reform for hospital training school programs to better prepare nurses for public health practice. The report also recommended that university nursing programs better prepare nurses for leadership positions in education and administration (Committee for the Study of Nursing Education &Winslow, 1923). Logan’s dual diploma/BS degree program, launched in 1916, had already put these recommendations into play. The Goldmark Report noted that there were “no less than 13” dual diploma/BS degree programs (Committee for the Study of Nursing Education &Winslow, 1923, p. 24). The number of undergraduate nursing degree programs within universities did not grow rapidly; Logan’s success was rare.

Throughout her long career Logan continued as a strong advocate for a university and liberal studies education for nursing Before Logan’s resignation in 1924, 241 nurses had earned a diploma from UC which was integrated with liberal studies, and 13 nurses had earned a BS degree in addition to their diploma (UC, 1917 though 1924). Later, Logan became the founding Dean of the new Cook County School of Nursing in Chicago. Again, through negotiations and relationships with neighboring hospitals, organizations, schools, and universities, Logan developed a unique curriculum to educate nurses who could care for the sick; prevent disease and promote health; educate future nurses and the public; administer limited resources; and research problems of nursing (Logan, 1932). Logan remained an active member and leader in nursing organizations at the state and national level, providing her a means throughout her career to advocate for the standardization of nursing education to improve nursing practice.

Logan’s Influence on Contemporary Nursing

Laura Logan’s vision for the entry-level preparation of the nurse was grounded in establishing a foundation for the nurse to develop into an excellent clinician, educator, and leader. As she demonstrated in the early 20^th century, nurse educators have a tremendous responsibility to prepare students to assume existing and emerging roles for the nurse. She also demonstrated the significance of the nurse educator who designs, develops, and delivers the curricular foundation for every nurse role.

...nurse educators have a tremendous responsibility to prepare students to assume existing and emerging roles for the nurse Over 100 years ago, Laura Logan’s vision for entry-level nursing education was bold and her ability to realize it through strategic action can benefit nursing today. Following her example, nurses are advised to develop proficiency in collaborating and sharing resources in the interest of efficiency and economy to ensure excellence toward the ultimate goal, positive patient outcomes. Logan’s skills as negotiator, leader, educator, and interprofessional partner illustrate the courage required for today’s nurses to make history in the contemporary chaotic and constantly changing healthcare environment.

Author

April D. Matthias PhD, RN, CNE
Email: matthiasa@uncw.edu

Dr. April Matthias is an Associate Professor of Nursing and Program Coordinator for the Master’s in Nursing – Nurse Educator program at the University of North Carolina Wilmington. She earned a Bachelor of Science in Nursing from Waynesburg University in 1997, a Master’s of Science in Nursing Education from Duke University in 2004, and a PhD in Nursing from East Carolina University in 2011. She is a Certified Nurse Educator through the NLN and has worked as a nurse educator for 20 years. Dr. Matthias’ research includes historical and contemporary study of professional identity and role development of the nurse through various educational pathways and pedagogies. Her historical research has focused primarily on early entry-level educational pathway programs to nursing practice. She has studied a diploma program, 1873; correspondence course program, 1902-1936; dual diploma/Bachelor of Science degree program, 1916; accelerated baccalaureate degree program, 1945; and associate degree program, 1952.