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ACCESS TO CARE
The Army Nurse Corps1
Before World War II, training programs for Army nurses were few and were designed only to prepare nurses for clinical or functional assignments and not to provide military training. Indeed, between 1920, when they were granted relative rank as officers, and July 1944, when they received full commissions, nurses enjoyed only quasi-military status.2 Even membership in the Army's Reserve components, authorized for all other Medical Department corps, was denied them.3 Reasons offered for this peculiar arrangement in 1935 help to explain not only the absence of a Reserve corps for nurses, but also the quasi-military status of nurses and their lack of military training:
The creation of a formal Nurse Reserve Corps analogous to the Officers Reserve Corps would be difficult to defend * * *. The duties of a nurse in a military hospital do not differ in any important particular from the duties * * * in civil hospitals. Preliminary military training is not essential therefore and active duty training periods * * *, similar to those held for reserve officers, are not required. Marriage would terminate eligibility in too many instances and inject an almost prohibitive obstacle to the maintenance of such a corps. The War Department in lieu of a Nurse Reserve Corps relies almost entirely upon the American National Red Cross Nursing Service for the supply of qualified nurses during an emergency. This is eminently proper as the Red Cross recognizes this responsibility as one of its charter obligations and has the national set-up for such a mission.4
Even more to the point was a remark made by The Surgeon General, Maj. Gen. James C. Magee, to members of the National Medical Association in March 1941, in attempting to quiet their fears that military recruiting would strip the Nation of public health nurses: "After all there are 500,000 nurses in America and we are only asking for 1 to 1 1/2 percent." Before the war, planners considered nurses so plentiful that military requirements could be met without special programs or incentives.
As a result of these attitudes, there were few opportunities for either basic or advanced training during the interwar years. Peacetime appointments to the Army Nurse Corps were made a few at a time, and nurses received only an informal orientation to the Army at their first station. A few Army hospitals provided lim-
1Unless otherwise indicated, this chapter is
based on a study entitled "History of the Army Nurse Corps,"
by Lt. Col. Hortense E. McKay, USA (Ret.). [Official record.]
ited programs in anesthesia and other clinical skills. Most of this training was tutorial, on-the-job training comparable to that provided for enlisted specialists, and designed to meet the requirements of a specific hospital. Early in 1933, The Surgeon General required six general hospitals to conduct a course in "Medical Department Administration" for nurses with less than 3 years' service, and by the end of June, 236, about a third of the corps, had completed the program of 18 lectures.5 This appears to have been a "one-time-only" program for there is no evidence that the series was ever repeated. Finally, funds available under the 2-percent clause of the National Defense Act, as amended in 1920, were used to train Army nurses at civilian institutions. Until 1933, these funds were used primarily to train instructors for the Army School of Nursing. After the school was suspended, the funds were used to train nurse-anesthetists.6
Interwar programs left the Medical Department with fewer training precedents than it had for enlisted men, or even MAC (Medical Administrative Corps) officers. As the Army Nurse Corps grew from 672 on 30 June 1939 to 55,590 at the end of August 1945, the need for training became increasingly obvious, and wartime training methods evolved gradually through trial and error.7
BASIC MILITARY TRAINING
In contrast to the 9 months of postgraduate training provided for Medical Corps officers before the war, Army nurses received little training to prepare them for wartime nursing. The peacetime orientation of an Army nurse began with assignment to a station in the continental United States "to afford her an opportunity to become acquainted with military customs." Much of this initial orientation was spent in personal processing: obtaining uniforms, initiating records, and becoming acquainted with the military post, Army hospitals, and nurses' quarters. Instructing new nurses in regulations governing the Army Nurse Corps in "duties peculiar to Army work" was the responsibility of the chief nurse.8
Before World War II, the traditional techniques of orientation were reasonably effective. Their most serious defect was the complete absence of training for operation under field and combat conditions. Under the stress of expansion between 1939 and 1941, with newly recruited nurses arriving at stations almost daily, informal and tutorial methods became increasingly unsatisfactory. Chief nurses were heavily taxed by the responsibility for supervising nurses in varying stages of orientation. Individual nurses could not be assured of balanced and progressive basic training to prepare them for unit training.
5(1) Annual Report of The Surgeon General,
U.S. Army. Washington: U.S. Government Printing Office, 1933. (2) Adult
Education in the Army Nurse Corps. Am. J. Nursing 34: 725, July 1934.
After entry of the United States into the war, the system suffered a complete breakdown. The Medical Department had planned to use affiliated units to support combat units. After Pearl Harbor, the Medical Department found itself unable to mobilize and equip them in time to accompany combat forces being shipped overseas. The problem was further complicated by the need of task forces for station hospitals, an organization which had no counterpart among affiliated units. As a result, established hospital training units had to be shipped to the theater, and with them, many of the Army's most experienced nurses.
During 1942, numbered hospitals were usually activated at military posts where there was a large station hospital or general hospital at which the unit's officers and men could engage in parallel training. Under this system, members of the unit participated in a mixture of formal training and job-understudy designed to prepare them for their positions when the unit went into operation.9 If present during this phase, the unit's nurses were usually assigned to serve in the post hospital, and they received military training only at the hospital commander's discretion.
As an increasing number of nurses entered the Army, there was even less opportunity to fit them into an organization. Hospitals were too pressed to provide leisurely orientations, and many experienced nurses were being promoted and transferred. Many chief nurses had been recruited only recently from comparable civilian positions and had little more experience in military procedures than did their trainees. In short, the prewar pattern of on-the-job training proved as unwieldy for mobilizing the Army Nurse Corps as it had for other components of the Medical Department.
Despite these problems, a formal guide for training Army nurses was not issued by the Office of The Surgeon General until late 1942. Numbered hospitals training in the United States had guidelines for officers and enlisted men but none for nurses. In September 1942, the Training and Nursing Divisions of the Office of The Surgeon General recognized that hospitals destined for theater assignment required guidance in training nurses. A program was published in October that provided 4 weeks of instruction, including 16 hours of duty assignment in a 44-hour week for nurses in theater-of-operations units. Required instruction included military courtesy and customs; uniform regulations; dismounted drill; physical training defense against chemical, mechanized, and air attacks; Army and Medical Department organization; military administration; first aid, field sanitation, and communicable disease control; ward management; and routine hospital procedures.10
The limitations of this program soon became apparent. Nurses were frequently on duty in active hospitals while the rest of their unit was in training, unable to join them in time to participate in unit training, or to be trained according to the
9Smith, Clarence McKittrick: The Medical Department:
Hospitalization and Evacuation, Zone of Interior. United States Army in
World War II. The Technical Services. Washington: U.S. Government Printing
program. The number of those who actually received military training before their unit was shipped to the theater was further reduced when nurses assigned to a unit were withdrawn because of physical disqualification for overseas service or other reasons.
To reduce these problems, the Nursing Division recommended in January 1943 that Army nurses under 50 years of age be trained while assigned to Zone of Interior hospitals.11 This recommendation was approved by ASF (Army Service Forces) on 30 May 1943, and commanding officers of all hospitals of 250-bed or greater capacity in the Zone of Interior were directed to provide training under MTP (Mobilization Training Program) No. 8-10 to all members of the Army Nurse Corps under 50 years of age.12 The guide published for this program late in June reduced the age for such training to 45 and prescribed a list of topics that were nearly identical to those required under the earlier program.13 Two months later, this ASF directive was superseded by a War Department directive which extended the program to all hospitals, regardless of capacity, and added the "basic" to the title.14
Even with these changes, the program proved inadequate. Despite determined efforts, patient care continued to take precedence over training. Nurses reported to hospitals almost daily, making it difficult to fit them into the program. Training at hospitals with a capacity of less than 250 beds was still permissive, difficult to administer, and frequently intermittent. Finally, it became obvious that a new approach to basic training was required if nurses were to function effectively within the Medical Department. In the last half of 1943, the Training Division, Office of The Surgeon General, recognized the advantages of providing basic training for Army nurses before they were assigned to units with a responsibility for patient care. After a proposal submitted to Army Service Forces in August for the establishment of a single basic training center for nurses was disapproved, the Medical Department tried another tack that ultimately proved fruitful.15
Basic Training Centers
Following the rejection of its request to establish a centralized basic training center, the Office of The Surgeon General countered with a proposal to establish centers within the service commands under a standardized program of instruction. In late July, Maj. Gen. Brehon B. Somervell, Commanding General, Army Service Forces, authorized the establishment of a basic training center in each service command, and on 16 October, a formal syllabus was published. The earlier, local train-
11Memorandum, Col. Florence A. Blanchfield,
ANC, for Col. F. B. Wakeman, MC, Chief of Training Division, Surgeon General's
Office, 14 Jan. 1943, subject: Army Nurse Corps.
Source: Completed AG ASF Forms R-5218, dated 8 Nov. 1945. In Report-Flow of Trainees Thru Nurses Basic Training Centers.
ing program was retained for nurses with more than 60 days' service who had not completed training under previous programs, but all newly inducted nurses were required to participate in basic training.16
Most service commands responded enthusiastically to the establishment of basic training centers for Army nurses. Indeed, several service commands had already taken the initiative in establishing such centers as shown in table 9. Early basic training centers were established at hospitals, where the chief nurse had a dual assignment as school commandant and hospital chief nurse. They had the advantage of a close working relationship with the hospital but the disadvantage of placing dual, and sometimes conflicting, responsibilities on those charged with the program. Conditions at these pioneer centers were far from ideal. Later centers were established as separate organizations to increase the efficiency of the program in processing, outfitting, and training newly recruited nurses.
Army nurses assigned to small AAF (Army Air Forces) hospitals directly from civilian life were provided training when 11 AAF nurse training detachments were organized in November 1943. This type of training continued until 1944 when nurses
16(1) Memorandum, Lt. Col. Florence A, Blanchfield, Acting Superintendent, Army Nurse Corps, for Col. Francis C. Tyng, MC, Chief, Finance and Supply Division, Office of The Surgeon General, 26 May 1943, subject: Army Nurse Corps. (2) Letter, Maj. Gen. Norman T. Kirk, The Surgeon General, to Commanding General, Each Service Command, 30 July 1943, subject: Training Centers, Army Nurse Corps. (3) See footnote 15 (1), p. 130. (4) Letter, The Adjutant General to Commanding Generals, First to Ninth Service Commands, 16 Oct. 1943, subject: Course of Basic Military Training for Nurses.
were no longer recruited directly by the Army Air Forces.17 A basic training program for Negro nurses was established at Fort Huachuca, Ariz., but was in operation less than 3 months. After training for women at Fort Huachuca was suspended, most Negro nurses were sent to Camp McCoy, Wis., for training.18
Program of Instruction
The initial program of instruction prescribed for Army nurses encompassed a period of 144 training hours, including basic military training, administration, organization, military sanitation, and ward and clinic nursing. The largest single block of hours was devoted to such basic military subjects as military courtesy, care of clothing and equipment, dismounted drill, and physical training (fig. 12). A week was allowed for processing incoming students. With the passage of time, course content was adjusted to provide nurses with a broader and more balanced program. Hours devoted to Army and Medical Department organization and to the duties of the Army nurse were expanded. In response to reports from the field, increased emphasis was placed on field training, map reading, tent pitching, efficiency reports, and obstacle and infiltration courses (fig. 13). In April 1945, instruction in malaria control and tropical diseases was added to prepare nurses for duty in the Pacific theater. Hours devoted to hospital ward duty were gradually decreased to provide for the inclusion of these subjects. Other changes in the conduct of training included an increase in the time devoted to outdoor training from 19 percent to approximately 35 percent by June 1944 and an increased use of "applicatory" training and training aids to provide more realism.19 Training aids were usually locally fabricated and assembled, and their quantity, quality, and use by instructors improved as time passed.
Facilities and Techniques
After October 1943, when training centers were established on an Armywide basis, the basic training program for nurses was better organized. Overhead personnel were authorized for administration and instruction, and tables of allowances were established for supplies and equipment. At first, classrooms at some centers consisted of converted hospital wards with space for 15 to 35 trainees. The program grew to larger proportions late in 1944, when as many as 750 trainees were present at one time, and plans were in process to train as many as 2,000 each month at
17(1) Annual Report of Personnel Division,
Air Surgeon's Office, fiscal year 1944. (2) Medical History of Second Air
Force, 1944. [Official record. U.S. Air Force, Research Studies Institute,
Maxwell Air Force Base, Ala.] (3) Link, Mae Mills, and Coleman, Hubert
A.: Medical Support of the Army Air Forces in World War II. Washington:
U.S. Government Printing Office, 1955.
FIGURE 12.-Army nurses in training, Camp Mccoy, Wis. (Top) Army nurses engage in calisthenics. (Bottom) Army nurses crawl through an obstruction on the obstacle course.
FIGURE 13.-Army nurses in training, Camp McCoy, Wis. (Top) Army nurses negotiate a rope ladder during basic training. (Bottom) Army nurse negotiates the simulated jungle river crossing.
some centers. To cope with the increased training load, methods used in Army Service Forces schools were adopted. Weekly schedules of instruction were published, lesson plans prepared, and instructor guidance programs instituted. Unfortunately, instructor guidance programs did not always include hospital ward nurses responsible for ward teaching, most of whom were more concerned with nursing service than with training. Inspections were instituted to point out strengths and weaknesses in instructional methods and to allow comparison of training between centers.
The facilities provided at basic training centers in 1943 proved inadequate for the training requirements of later years. Not only did the number of nurses in basic training grow, but also in 1944, the training load was further increased by the assignment of dietitians and physical therapists to centers originally intended for nurses. In all, 27,330 nurses received basic training between July 1943 and Sep tember 1945. To accommodate these trainees, some commands moved training centers within or between installations or provided an additional center during periods of heavy enrollment. When the number to be trained by one command exceeded its capacity, nurses were sent to other commands. The number of nurses recruited and assigned to training centers varied so much from month to month that a high degree of flexibility was necessary. Only four nurse training centers did not have to be relocated at some time during the war. Relocation was most often necessary because early centers, established at general hospitals, did not have the capacity to adjust to the 1945 training load. Plans were made in June 1945 to decrease the number of training centers, and by September, all centers were closed.20
From time to time, other problems plagued the program. One was the degree of realism and "ruggedness" to be injected into training. For a time, trainees were sent through infiltration courses, but this was later discontinued in the belief that general physical conditioning was more valuable.21 Other problems that were eventually solved included an initial shortage of qualified instructors, shortages of clothing, and inadequate training aids. At training centers, these problems were more readily identified and resolved than they could have been at scattered hospitals.
The Contribution of Basic Training
Directives and letters issued early in the war, outlining basic training plans for Army nurses, failed to realize their objectives. Initial directives required nurses assigned to field medical units to possess a satisfactory knowledge of basic military subjects broader than that required for duty in fixed hospitals. Because of inadequate prewar programs, instructors were rarely available. Directives permitting local program modifications, such as allowing nurses to spend half their basic training time in hospital wards, frequently weakened the program. This happened most often when nurses were assigned to fixed hospitals, which did not require a knowl-
20(1) Army Service Forces Circular No. 300,
7 Aug. 1945. (2) Army Service Forces Circular No. 323, 25 Aug. 1945.
edge of field techniques to function effectively, and which frequently had patient loads requiring 24-hour nursing service 7 days a week. Establishment of basic training centers with fixed programs guaranteed uniform and continuous training.
Perhaps the most obvious advantage was the high morale developed during basic training. Nurses graduating from such programs could be sure that they had learned their duties and responsibilities as officers, that their personnel records and immunizations were complete, and that they were correctly outfitted. Army nurses were all volunteers, trained in their technical specialties. Yet, it was possible to gain the maximum benefit from these skills only after nurses had become familiar with the Army and the Medical Department and could be confident that they had been trained to come to grips with the special problems of Army nursing.
In the interim between World Wars I and II, vacancies and promotions to chief nurse were rare. Examinations were required for promotion to chief nurse, and beginning in 1935, a few chief nurses were assigned for a short period to the Nursing Division, Office of The Surgeon General, to supplement knowledge gained in preparing for the examination with experience. Subjects included hospital administration, records administration, efficiency reports, personnel assignment, disciplinary action, nurses' rights and privileges, management of overseas nurse rosters, and the function of The Surgeon General, The Adjutant General, and the Inspector General. Such training was slow and limited to chief nurses who were changing stations. As the Army Nurse Corps expanded during 1940 and 1941, the authorization for chief nurses increased from 72 to 494. During 1941, 180 candidates selected for leadership and executive ability passed the qualifying examination.22
Informal, on-the-job techniques satisfied the requirements of the Medical Department until 1942, when the mobilization of theater units thinned the ranks of experienced nurses at fixed hospitals. At this point, the system broke down because too many candidates were studying under inexperienced chief nurses. But until late in 1942, on-the-job training remained the only technique available.
Under pressure, stopgap methods were used to accelerate the training of chief nurses. Early in 1942, the Superintendent of Nurses, Col. Julia O. Flikke, ANC, revised instructions for training chief nurses to incorporate essential information on personnel procedures and administration. Training procedures were relaxed in April, when written examinations for promotion to chief nurse were abandoned. Commanders empowered to promote officers were authorized to promote nurses to
22 (1) See footnote 6 (4), p, 127. (2) Annual Report of The Surgeon General, U.S. Army. Washington: U.S. Government Printing Office, 1941.
the position of chief nurse to fill vacancies in units under their command and were required only to report the promotion to The Surgeon General. After a few months, even the requirement for a report was suspended.23 Late in 1942, an effort was made to give chief nurses short courses at four general hospitals, but because of patient loads, only one program was successful.24
Aside from this course, and one developed late in the war by the Army Air Forces, a formal training program for chief nurses did not evolve during World War II. Throughout the war, nurses at service command headquarters provided informal guidance through letters and visits, and some devised more detailed training. At the hospital level, chief nurses attempted to provide on-the-job training for potential candidates, but the mounting pressure of patient loads limited training to Army procedures at the expense of administrative principles and theory. Such training was ostensibly for duty in the theaters, but the duties of chief nurses in Zone of Interior hospitals were also emphasized. Nurses were selected on the basis of civilian administrative experience and physical ability to serve overseas. Those who had already been in the theaters and were qualified to return were also selected. Army Air Forces established a 4-week training course at Bowman Field, Ky., in the autumn of 1944, and later transferred it to the School of Aviation Medicine, Randolph Field, Tex.25
In contrast with basic military training, which could not be conducted efficiently in hospitals, the training of nurse anesthetists could be carried out only in a hospital with an active surgical load. The on-the-job training program for nurse anesthetists that evolved during World War II demonstrated that prewar techniques could be adapted to wartime training conditions in technical fields requiring a high degree of supervised practice.
The Prewar Program
The Army began training and utilizing nurses as anesthetists during World War I. Satisfied with the results, the Medical Department continued to use nurses in this capacity throughout the interwar years. No quotas were set, and peacetime training was limited to providing replacements, but in response to "occasion and necessity," a few Army nurses were sent to civilian hospitals or the Army Medical Center, Washington, D.C.26
23(1) War Department Circular No. 118, 23 Apr.
1942. (2) War Department Circular No. 202, 23 June 1942. (3) Army Regulations
No. 40-20, 15 Aug. 1942.
Between 1939 and 1941, Army expansion increased requirements for trained anesthetists. During this period, 15 nurses were sent to civilian hospitals, and 16 others were trained at general hospitals and the station hospital at Fort Sam Houston, Tex.27 Despite these efforts, training failed to keep pace with expansion.
The outbreak of war increased and sustained the demand for anesthetists. The first response of the Medical Department was to issue program guides that did little more than continue local programs on an expanded scale. Courses were authorized at Walter Reed General Hospital, Washington, D.C.; Army and Navy General Hospital, Hot Springs, Ark.; Fitzsimons General Hospital, Denver, Colo.; and Lawson General Hospital, Atlanta, Ga.; and at several station hospitals.28 More courses were added as new hospitals opened. In the absence of a standardized program, significant variations in course length and content developed.
The first clear outline of the duties and training of nurse anesthetists was provided by The Surgeon General in a directive issued to the service commands on 11 November 1943. Under this directive, course length was standardized at 6 months, and Zone of Interior training was limited to general hospitals. Administrators were required to submit the names of students to The Surgeon General when they entered training.29 Later, this stipulation was changed to require the names of nurses completing the course, accompanied by a statement of proficiency and the supervision they would require in their duties. The names of students failing the course and the reasons for their failure were also required.30 Nurses were to be trained to administer inhaled anesthetics and to care for patients under all other types. They were not expected to give intraspinal, intravenous, local, or endotracheal anesthetics, but were expected to be able to care for the instruments with which they were administered. By mid-1944, about 100 nurses had completed the program.31
Until July 1944, nurse anesthetists were not listed in hospital tables of organization, and the Medical Department could make only rough estimates of its requirements. Their incorporation into tables of organization clarified requirements, which in turn pointed out the need for a formal program of instruction. Such a program was prepared by the Training Division, Office of The Surgeon General, and approved by Army Service Forces on 17 August 1944 as "a general guide for the balanced training of members of the Army Nurse Corps in general anesthesia."32 Included in the subjects required were the principles of anesthesia, pharmacology in relation to anesthesia, the signs and stages of general anesthesia, and the effect of anesthesia on the body. Both pre- and post-operative patient care was covered
27See footnotes 6 (1), p, 128; and 22 (2),
in detail, as well as procedures in anesthetic emergencies and oxygen therapy. Instruction was also required in methods of obtaining medical supplies. The scope of instruction, methods of presentation, and details of subject and sequence were prescribed, and only minor modifications could be made without the approval of The Surgeon General. The staff and its methods were subject to inspection by Medical Department consultants in surgery and anesthesiology. Reports of course capacity, numbers enrolled, and course completion were closely supervised, and the practice of holding students for service after they had completed their training was prohibited. By these techniques, the Medical Department was able to standardize and control on-the-job training at a large number of widely scattered hospitals.
Before the standardization of programs, courses prepared locally exhibited marked differences in content and the time allotted to supervised practice. The course developed by The Surgeon General in 1944 was intended primarily to develop competence in the administration of inhaled anesthetics. Ninety percent of the course consisted of supervised practice. Students received highly individualized instruction, usually in formal conferences, and observed instructors administering anesthetics. Later, the student was allowed to practice partial, and then complete application. Students were required to administer a minimum of 100 anesthetics under supervision before completing the course, and some Army hospitals required a minimum of 300 practice cases. Despite the urgent need for trained nurse anesthetists, the availability of patients suitable for student practice limited course enrollments to between two and six students.
Another factor limiting the number of students was the practice of retaining qualified anesthetists in student status to provide service at the hospital. After this practice came to the attention of The Surgeon General, it was discouraged by allowing inspecting officers discovering cases of excessive retention to recommend the transfer of one of the offending hospital's experienced anesthetists. When students were unable to gain enough clinical experience at a hospital, The Surgeon General was notified.
After January 1944, when the course was confined to general hospitals, an MC officer was designated course director and was assisted by selected nurse anesthetists. The selection of instructional personnel was closely supervised by the Surgeon General's Office, and practicing anesthetists were encouraged to become course directors.
Nurse anesthetists were also trained in theaters of operation, but programs outside the Zone of Interior failed to achieve the standardization of those in the continental United States. Nurses in the Mediterranean theater, for example, were trained on a continuing basis at four general hospitals. The program theoretically required 3 months in residence, but in practice varied from 1 to 3 months, depending on the time a nurse could be spared from a unit.33
33Medical Department, United States Army. Surgery in World War II. Volume II. General Surgery. Washington: U.S. Government Printing Office, 1955.
Selection of Students
Before World War II, the Superintendent of the Army Nurse Corps selected student anesthetists from nurses who demonstrated aptitude and interest. After the establishment of the Army Service Forces, responsibility for selection rested largely on hospital commanders. Inequalities of supply and demand were resolved by liaison at service command level. Selection procedures became more formal in August 1944, when courses were standardized. Students were required to be volunteers from the Army Nurse Corps who had completed the basic training course. Consultants to service command surgeons were encouraged to expand their activities to include selection. Consultants were encouraged also to check on the progress of students they selected so as to overcome the conflict of interest created by assigning students to facilities that were responsible also for patient care.34
Strength and Utilization
Early in World War II, hospitals were not required to report nurses with specialized training, and the training of nurse anesthetists was well underway before training requirements could be estimated. To determine the number of nurse anesthetists actually serving in the Army, two surveys were conducted by The Surgeon General in April 1943. The first requested service commands to list the hospitals doing major surgical work and the names of anesthetists at each station with their grade and an evaluation of their work.35 As the need for anesthetists became increasingly acute, a second survey was made by personal letters requesting the names of nurses who had completed the anesthetists course and a statement of their proficiency. In September 1943, the Medical Department estimated that 2,495 nurse anesthetists would be needed for numbered units and Zone of Interior installations. With only 273 reported on duty, 2,222 would have to be recruited or trained.36
Recruiting experience revealed that 3.7 percent of the nurses entering the Army had postgraduate courses in the combined areas of neuropsychiatry, operating room procedures, and anesthesia, but there was no report of the number who were qualified anesthetists. The Medical Department hoped to train 260 annually and to recruit the remainder by assuring them of proper assignments on entry into the Army. This goal was not even approached in 1944. Prospects were brighter in 1945 because of the pace set during the first 6 months. It was estimated that 2,000 qualified nurse anesthetists were in the Army in July 1945. Approximately 220 completed training in Zone of Interior hospitals between December 1941 and December 1945.37
34Letter, Brig. Gen. Fred W. Rankin, Chief
Consultant in Surgery, Office of The Surgeon General, to Lt. Col. Bradley
L. Coley, MC, Headquarters, Eighth Service Command, 24 July 1944.
As a result of the decentralization of training, withdrawals from the course can only be estimated. For the short period in which records are available, the number was not excessive. In common with other programs, they rose sharply after the surrender of Japan, even though courses were not suspended. Hospitals were notified in September 1945 that courses in session would be completed but that future courses would be canceled, and nurses were allowed to withdraw from the course to separate from the service.38
Before World War II, there was little need for trained psychiatric nurses in the Army. Psychiatric cases were kept in Army hospitals only until arrangements were made for them to be sent to either St. Elizabeths Hospital, Washington, D.C., or other institutions providing long term custodial care and treatment. At the outbreak of the war, there were no special training programs for Army nurses in neuropsychiatry and no plans for developing such programs. During the war, courses were established at various Army hospitals, but the development of a full-blown program was frustrated by the War Department's refusal to authorize an Armywide school. The problem persisted despite efforts by both the Nursing Division and the Neuropsychiatry Consultants Division to convince other divisions of the Surgeon General's Office and the War Department that a formal program was essential. In common with most developments in psychiatry during World War II, each step forward was a limited victory for those attempting to educate higher authorities.
In the wake of the passage of the Selective Service Act, new hospitals were built. Typical hospitals had closed neuropsychiatric wards designed to give maximum security. The nurses' office was separated from the patient area by a locked iron grillwork, and patients were housed in wards behind this partition. Space and facilities for anything other than custodial care were severely limited. Attempts were made to screen incoming nurses for previous experience, but many chief nurses questioned the need for nurses to care for patients who were neither physically ill nor confined to a bed. The nurse, nominally assigned to psychiatric wards, often spent much of her time in surgical wards or performing administrative tasks. Little time was spent in locked-ward sections. This lack of recognition of the role of psychiatric nursing resulted in patients being under the care of nurses with a variety of backgrounds; some nurses qualified neither by training, experience, nor desire for their duties. Others, with desirable backgrounds, were malassigned.
Attempts to Establish Formal Courses
During the first year of the war, the Medical Department attempted to satisfy its requirements by drawing on nurses who had received psychiatric training at
38Memorandum, Col. Florence A. Blanchfield,
Superintendent, Army Nurse Corps, to Col. Floyd L. Wergeland, MC , Director,
Training Division, Office of The Surgeon General, 10 Sept. 1945.
civilian hospitals before entering the Army.40 When this proved inadequate, members of the Nursing and Psychiatric Consultants Division directed their efforts toward establishing an Armywide training course. Planning for the course began early in 1943, shortly after the establishment of the School of Military Neuropsychiatry at Lawson General Hospital, Atlanta, Ga.41 In the summer of 1943, the officer in charge of preparing program guides for the course reported: "All plans are made and we have nurses ready to send, but Army Service Forces had not approved it so we can't go ahead until they do."42 At least part of the difficulty in gaining approval for the program arose from the inability to justify training on the basis of tables of organization: even a 1,000-bed general hospital for neuropsychiatric patients overseas was authorized only one neuropsychiatric nurse, the same strength authorization approved for a nonspecialized general hospital.43 For some reason, the Training Division of the Surgeon General's Office also refused to approve the program.44
In October 1943, the School of Military Neuropsychiatry was moved to Mason General Hospital, Brentwood, N.Y., and plans were again made to conduct a post graduate course for nurses. Finally, in February 1944, a 12-week program in neuropsychiatry was established under the authority of the Second Service Command, without Army Service Forces approval as an Armywide school. An overstrength of 10 nurses was authorized for the hospital, and the hospital commander was directed to give them "such didactic instruction as may be feasible with their duty assignment."45
In the absence of an Armywide school, hospitals began to establish local programs. Early in April 1944, Lt. Col. Ruth I. Taylor, ANC, Headquarters, First Service Command, was informed that a course in neuropsychiatric nursing had been started at the Station Hospital, Camp Edwards, Boston, Mass. On 3 June
40(1) Letter, Maj. Julia O. Flikke, Superintendent,
Army Nurse Corps, to Capt. Ida W. Danielson, ANC, Assistant Superintendent,
Headquarters, Sixth Corps Area, 28 Nov. 1941. (2) Letter, Capt. Ida W.
Danielson, ANC, Assistant Superintendent, to Maj. Julia O. Flikke, Superintendent,
Army Nurse Corps, Office of The Surgeon General, 13 Dec. 1941. (3) War
Department Circular No. 34, 1 Feb. 1943.
1944, Colonel Taylor informed The Surgeon General that 15 nurses would complete the first course on 30 June 1944 and that, because of the reduced number of patients at Camp Edwards, the school would be transferred to Cushing General Hospital, Framingham, Mass., on 1 July. Colonel Taylor recommended that three full-time nursing instructors be assigned to Cushing General Hospital and that the school be approved by The Surgeon General so that an authorized certificate could be presented upon satisfactory completion of the course.
On 16 June 1944, Maj. Gen. Norman T. Kirk concurred with the establishment of a course in the First Service Command, but added that he did "not deem it advisable to authorize or approve a neuropsychiatric nursing school."46 While The Surgeon General did not object to the issuance of a certificate of completion, he advised that a local certificate be used because the "Certificate of Proficiency, Various Courses, Special Schools, U.S. Army" (MD Form 60e) was not to be used for local courses.
In December 1943, authority was given to provide a 3-month affiliation in neuropsychiatric nursing at Fitzsimons General Hospital, for student nurses from St. Joseph's Hospital School of Nursing, Denver, Colo. In May 1944, Army and cadet nurses were also accepted in the course.47 In June, The Surgeon General authorized official recognition for the course by issuing a certificate to Army Nurse Corps officer graduates.
Because of continued failure to obtain approval for an Armywide postgraduate course, commands were encouraged to establish their own schools in the fall of 1944. By the summer of 1945, each service command had established at least one course for nurses. A total of 585 nurses and 296 cadet nurses completed these courses in service command hospitals.48
OPERATING ROOM NURSES
The training of operating room nurses was seldom mentioned in hospital and service command reports. All nurses received operating room training and experience in their basic program, but the number with advanced skills and experience was below wartime requirements. On-the-job training was required to sharpen unused skills and to develop competence in specialized fields of war surgery.
A formal course in operating room techniques was established at Cushing General Hospital in August 1944 to prepare nurses for duty with surgical teams and for overseas assignment. The course was initially 3 months, and concentrated on training nurses for general surgery, neurosurgery, and plastic surgery. Included were 75 hours of lectures, demonstrations, films, and discussions. The basic principles of operating room technique were reviewed, and, under careful supervision, nurses
46Letter, Lt. Col. Ruth I. Taylor, ANC, Chief,
Nursing Service, Headquarters, First Service Command, to Commanding General,
Army Service Forces, 3 June 1944, subject: Report of Neuropsychiatric Nursing
School 3114 SCU, FSC, Camp Edwards, Mass.
became experienced in the administration of blood and plasma and in scrubbing and circulating duties. Training was also received in orthopedic, urological, and vascular surgical procedures.49 The course was increased to 4 months in May 1945 to provide instruction in operating room administration. Thirty-six nurses completed the course.50
The amount of operating room training conducted on-the-job at Zone of Interior hospitals and hospitals overseas is unknown. No reporting procedure was established, and courses were never standardized. Course length varied from 75 to 85 hours of classroom work and from 295 to 420 hours of clinical experience. In July 1945, the Office of The Surgeon General began preparation of an outline of a 4- to 6-month course in operating room technique that included some 50 hours of classroom instruction. The length of the clinical phase depended upon the facilities available at the hospital conducting the course.51 Work on the preparation of the course stopped at the end of the war.
FEVER THERAPY NURSES
Fever therapy was one of the few specialties in which the Army Nurse Corps was able to meet its training. In part, this was due to the priority given this treatment for sulfonamide-resistant gonorrhea early in the war, and in part, because the advent of penicillin reduced the requirement for fever therapy. Until the effectiveness of penicillin in treating gonorrhea was demonstrated in 1943, fever therapy training was an important part of the postgraduate program for nurses.
At the beginning of World War II, there was a wide disparity between the recommendations of experts and the average care given patients with gonorrhea. Beginning in June 1940, cooperative efforts by the Surgeons General of the Army and the Navy, and the Subcommittee on Venereal Diseases, Division of Medical Sciences, National Research Council, produced a series of directives standardizing treatment. Among the developments resulting from their efforts was the establishment of fever therapy centers at designated general hospitals in 1942 and an expansion of the program to other types of hospitals in 1943.52
The first known training program for nurses followed the establishment of a Department of Fever Therapy at Walter Reed General Hospital in 1941. Eight nurses were reported trained that year.53 As fever therapy centers were established, nurses either were trained on the job or were sent to other hospitals for an unspecified period for training. After September 1942, The Surgeon General took an active part in arranging for the training of doctors and nurses in this specialty. When hospitals did not have trained personnel to operate fever therapy cabinets (hyper-
49Poole, R.: Army Courses in Operating Room
Technic, Am. J. Nursing 45: 270-271, April 1945.
therms), they were required to submit the names of two nurses selected for training to The Surgeon General.54 Once a program of fever therapy had been established at a hospital, replacements were trained as needed.
The purpose of fever therapy training was to teach nurses to produce an artificial fever by the use of therapy cabinets. Skilled nursing was required during all phases of therapy from preparation, through the induction of a fever ranging from 106o to 107o F., until post-fever recovery. Nurses had to be trained to detect the signs of irreversible physiological reaction. Treatment time usually exceeded 8 hours, and one patient was treated daily. Medical officers were on call for emergencies. No reports were required, and no attempt was made to keep statistical records.
The absence of a standardized training program produced a wide variety of courses. Some medical officers held the opinion that a minimum of 3 months in a busy clinic was required, while others defended the observation and treatment of a minimum of 25 cases. With special selection and careful supervision, course length could be reduced to 1 week. Courses established at Army hospitals varied from 1 week to 3 months.
Before World War II, proposals for the training of flight nurses received an unsympathetic response from both the Air Corps and the American Red Cross. At the beginning of the war, air evacuation was not an accepted practice, and it was not until terrain problems in Alaska, Burma, and New Guinea made it expedient to transport patients by air that attention was focused on developing an evacuation system.
On 18 June 1942, the Army Air Forces was assigned responsibility for developing an air evacuation system, and primary planning responsibility was delegated to the Air Surgeon. As a result of initial efforts, the 349th Air Evacuation Group, Headquarters and Headquarters Squadron, was activated on 6 October to control and train flight surgeons, flight nurses, and enlisted personnel for air evacuation. The table of organization, issued in November, set up the squadron as a unit composed entirely of medical personnel, having no planes assigned. The 349th consisted of three squadrons, each with a headquarters section and four evacuation flights. The headquarters section included the Commanding Officer, a Chief Nurse, and a MAC officer. Each flight, headed by a flight surgeon, consisted of six flight nurses and six medical technicians, one nurse and one technician to a team. On 30 November, an urgent appeal was made for graduate nurses with experience in aviation to volunteer for the Army Nurse Corps and subsequent assignment to the AAF Evacuation Service. On 18 February 1943, a formal graduation ceremony was held for the first 39 nurses to complete 4 weeks of flight training.
The original 4-week course consisted of military indoctrination, air evacuation and tactics, survival, physiology, mental hygiene, and loading procedures. In
54Circular Letter No. 86, Office of The Surgeon
General, U.S. Army, 18 Aug. 1942, subject: Fever Therapy in the Treatment
February 1943, after the graduation of the first class, the training period was expanded to 6 weeks, and in November, it was lengthened to 8 weeks. The additional time allowed the inclusion of instruction on ward management, operating room technique, sanitation, and patient care, and 2 weeks of specialized training at hospitals in Louisville, Ky. The amount of in-flight training depended upon the availability of evacuation planes.
Flight nurse training remained under the control of the 349th Air Evacuation Group until June 1943, when the AAF School of Air Evacuation was activated at Bowman Field, Louisville, Ky. At that point, it was placed under the administrative control of the Commanding General, AAF, and the Air Surgeon was charged with the responsibility for supervising curriculum and research. In October 1944, the School of Air Evacuation was absorbed into the School of Aviation Medicine, Randolph Field, Tex.
At the time of its transfer to the School of Aviation Medicine, the course was extended to 9 weeks and divided into three equal phases. The first two phases consolidated material from the previous curriculum, and the last 3 weeks were devoted to participating in evacuation under the guidance of an experienced instructor. Course content gradually expanded to include familiarization with the types of airplanes used in evacuation, methods of loading and unloading, and the use of supplies and equipment provided for in-flight care. Special instruction in aeromedical physiology provided a foundation for further training in the use of oxygen equipment in high-altitude flights. Because doctors did not usually accompany patients in flight, nurses were prepared to treat shock, hemorrhage, and other emergencies without the assistance of a flight surgeon. Problems in the transportation of neuropsychiatric patients also received consideration. Course length did not change again until 20 August 1945, when each of the phases was shortened to 2 weeks to increase the number of flight nurses available for deployment to the Pacific theater.
Because nurses accepted for flight training were volunteers who met rigid standards, the rate of attrition was remarkably low. Under standards published in December 1942, applicants were required to be members of the Army Nurse Corps, between 21 and 36 years of age, between 105 and 135 pounds in weight, and between 62 and 72 inches in height. Applicants had to certify their willingness to participate in regular and frequent flights and to indicate any previous flying experience. Previous supervisors were required to certify the applicant's professional qualifications, personality, and judgment. Later, 6 months of experience in the Army Nurse Corps was also made a prerequisite. Between December 1942 and October 1944, 1,079 flight nurses graduated from the School of Air Evacuation at Bowman Field. An additional 435 students graduated from the School of Aviation Medicine between November 1944 and June 1946. Only 15 students failed to graduate.
THE SENIOR CADET NURSE CORPS
The concept of a Senior Cadet Nurse Corps first emerged during World War I, when the Medical Department planned to train senior students from civilian nursing schools to utilize their services and simultaneously prepare them for military
service after graduation. The end of the war terminated the program before it could be put into effect.56 After the Army School of Nursing closed in 1933, the Army had neither the facilities nor the personnel to train student nurses. Reestablishment of the school was never seriously considered during World War II because experienced Army nurses were reluctant to take on the added burden of training students when it had been demonstrated that civilian nurses could be utilized after a brief orientation to military life. As a consequence, the Cadet Nurse Corps of World War II was developed primarily to meet the needs of civilian hospitals. As the Corps history states: "Perhaps the strongest case for the Cadet Nurse Corps was the plea of hospital authorities that nursing care in civilian hospitals was in a desperate state. Since the military forces took only graduate nurses, it was not expected that the Cadet Nurse Corps would directly or immediately aid the Army and Navy, except in the use of advanced students * * * they would help to replace graduate nurses enlisting for military service."57 For its part, the Medical Department hoped that an increased supply of civilian nurses would aid Army recruiting and that, in any event, senior cadets in Army hospitals would temporarily ease the shortage of nurses.58
Authority for the formation of the U.S. Cadet Nurse Corps was provided on 15 June 1943 by the Bolton Act which made the U.S. Public Health Service responsible for its administration.59 The purpose of the program was to allow schools of nursing to expand their primary training capacity by sending senior students to Federal hospitals for their last 6 months of training. At the same time, participating schools were required to accelerate their programs and provide student nurses with their primary training within a period ranging from 24 to 30 months.
Anticipating the passage of the Bolton Act, the U.S. Public Health Service called representatives of the Federal nursing services together in early 1943 to coordinate planning. On 5 April 1943, Lt. (later Lt. Col.) Mary C. Walker, ANC, was assigned by the Surgeon General's Office to organize and supervise the program in Army hospitals and coordinate plans with other agencies.60 Broad policies were formulated at a series of conferences and disseminated through U.S. Public Health Service regulations, guides, and bulletins. The Surgeon General sent the first specific instructions to Army hospitals in November 1943.61
Under the program worked out through these conferences, schools and State boards retained their traditional prerogatives, while Federal hospitals recruited cadets and provided facilities. The U.S. Civil Service Commission acted as the clearing house for Cadet Nurse Corps applicants. Students appointed to the U.S. Cadet Nurse Corps were pledged to remain in essential military or civilian nursing during the war, although the pledge was not binding.
56See footnote 26 (2), p. 137.
FIGURE 14.-Senior cadet nurses in training. (Top) three senior cadet nurses, right, receive training in operating room procedures at the Station Hospital, Camp McCoy, Wis., Army Nurse Corps officer, left, administers anesthesia. (Bottom) Senior cadet nurse, center, receives supervised on-the-job training in the dressing room on a neurosurgical ward at England General Hospital, Atlantic City, N.J., August 1944.
The Program in Army Hospitals
The program began with a survey to determine the quality and quantity of facilities available to cadets. State boards of nurse examiners then used these surveys to evaluate the hospital nursing staff, clinical, educational, and recreational facilities, and living conditions. Representatives of the State boards also visited Army hospitals on invitation. State boards had the power to withhold approval until the Army corrected conditions that did not meet their standards. Usually, hospitals were cooperative, since it was estimated that each student would provide services equal to 80 percent of those expected from a graduate nurse.
The first senior cadets were assigned to Army hospitals on 15 June 1944. By 1 October 1945, the U.S. Civil Service Commission had submitted 9,891 applications to The Surgeon General, and 5,688 applicants had been accepted and assigned to Army hospitals. Of these, 1,674 were still in training on 1 October 1945, and all but 61 of the balance had completed the course.62 A total of 44 Army hospitals had participated in the program before the Medical Department withdrew in February 1946.63
Techniques of Instruction
The assignment of cadet nurses within a hospital depended upon the needs of the hospital. At first, efforts were made to plan clinical instruction for individual cadets (fig. 14), but this was discontinued. In the 6-month cadet period, about 120 hours of instruction were provided, including 2 hours of ward teaching each week and a total of 70 hours of Army basic training. The time spent in basic training was later reduced to 50 hours. Periods of instruction were included in a 48-hour work-week, but physical training was done during off-duty time. Records were sent to the home school when cadets completed their training, including a summary of the cadet's instruction and clinical experience, a record of illnesses, and an efficiency report.64
Results of the Program
Despite the quotas established for Army hospitals, the number of cadets assigned to them varied. Early estimates indicated that 50 percent of the senior cadet nurses could be trained in Federal hospitals, but in practice, only 15 percent enrolled, and only 6.4 percent of these were assigned to military hospitals. The Army trained 85 percent of those assigned to military hospitals, even though it participated for only 20 of the 64 months the program was in operation.65
For most purposes, the senior cadet program came too late to be of use during World War II. Even after the Bolton Act was passed, cadets could not be assigned
62See footnote 3, p. 127.
to Federal hospitals until Congress amended the Act to provide a stipend. At the beginning of the program, the Army optimistically agreed to train 1,500 senior cadets every 6 months and agreed to limit acceptance to 50 percent of each class. Such precautions proved unnecessary because of the strong influence of nursing schools on their students. Student interest increased only after the President proposed drafting nurses in January 1945.66 Available evidence does not permit measurement of the program's impact on civilian nursing, or on recruitment rates. Even the number of students graduated is not a measure of impact, because the senior cadet's promise to remain in nursing throughout the war was not legally binding.
Direct recruiting was not a primary objective of the program, but the Medical Department did make efforts to interest cadets in Army nursing. Despite efforts to make them "feel a part of it," very few cadets were ultimately persuaded to remain in the service. There is no record of the number of cadets who accepted appointment, but only 93 had been commissioned by 1 January 1945.67
66Congressional Record, vol. 91, pt. 1, p.
67. 79th Congress, 1st Session.