Looking Back Looking Forward

Find out just how far nursing education at Johns Hopkins has come since the school’s founding, when dust was public enemy No. 1 and “cocoa cordials” were a part of every good nurse’s arsenal.

Written by Greg Rienzi

Spurred by advances in medicine and technology, the School of Nursing’s academic curriculum has taken quantum leaps in the past 115 years. “Technology has changed health care tremendously,” notes Linda Pugh, director of the school’s baccalaureate program and a member of its curriculum review committee. “Look at how the Internet has grown in the past 10 years, for instance. And in genetics the progress has been remarkable. We are constantly working to make sure our curriculum is keeping pace with this rapid rate of advancing knowledge.”

In the late 19th century and early 1900s, nurses–especially ones in training–spent an inordinate amount of time dusting, scrubbing, sterilizing equipment, and boiling, filtering, and then bottling water for hospital use. Care-giving duties around this time were usually limited to giving baths, inserting catheters, dressing wounds, and monitoring a patient’s appearance. Even the act of taking a blood pressure was the job of the physician.

The 1902 notebook of student Elizabeth Norment included the instruction that every good nurse “should anticipate” doctors’ wishes and “have dressings in readiness, pins out, etc.” One can only imagine what the nurses of 1902 might think to see their counterparts today assertively question their physician colleagues in an effort to improve patient safety and prevent medical errors.

Students in the school’s early days–when it was known as the Johns Hopkins Hospital Training School for Nurses–took copious notes during lectures, since their notebooks would be graded and used as quasi-textbooks. Many of these notebooks are preserved today at the Alan Mason Chesney Medical Archives, and they provide an unfiltered record of what students learned in the days before antibiotics and MRIs, says Phoebe Letocha, coordinator of processing at the Chesney archives and overseer of the Johns Hopkins Nursing Historical Collection.

In the segments that follow, we’ve drawn from these notebooks, and a variety of other valuable primary sources, to show just how much difference 115 years have made in the field of nursing education.

Dusting away disease

Cleanliness might be next to godliness, but it could also be a matter of life or death, or so turn-of-the-century students in a Hygiene and Sanitation course learned.

“To get the right idea of dusting,” begins Elizabeth Norment’s 1902 notebook entry from the course lecture, “learn to consider each atom of dust as injurious to the welfare of the patient and must therefore be carefully dispersed, removed and thrown away.”

Nurses learned that “dust contains many poisonous germs and is especially dangerous in a hospital where a number of sick are concentrated and where excretions contain certain poisons.” Banish the dust, the notes continue, with a soft, dampened cloth.

But dusting wasn’t the only front line of defense against the spread of germs and disease. Beds should be “thoroughly carbolized” once a week. The air could be “cleansed” by opening windows–patients were also instructed to stick their head out of the window. Floors needed to be scrubbed. Stains removed. Utensils and instruments meticulously and regularly cleaned.

Nurses during the period were extremely concerned with the spread of influenza and tuberculosis, or consumption. Those with TB, referred to as “vicious” (because the infection could be transported through the air), were dubbed “recalcitrant” if they would not abide by hospital rules.

“Now we call these types of patients non-adherent,” says Kate Lears, who teaches Community Health Nursing to undergraduate students and is a member of the Health Promotion/Disease Prevention Council.
In the days before antibiotics, measures such as simple hand washing were paramount.

Today all nurses in training learn the importance of taking universal precautions (hand washing and the use of gloves and masks) when dealing with any patient, to protect against possible infection from HIV/AIDS, hepatitis A, and other infectious diseases. The realities of our post 9/11 world have raised the specter of bioterrorism in Lears’ courses. Students learn in detail about biological agents such as anthrax, smallpox, and botulism–how they are disseminated and what health care guidelines must be followed if exposure occurs.

Says Lears, “We also teach students how to factor in the ‘panic quotient’–just how the public will react to a particular outbreak.”

Some arsenic a day…

At the turn of the century, pharmacology was still in its infancy. The first department of pharmacology had been founded in 1890–at the University of Michigan, with John Jacob Abel (a longtime Johns Hopkins professor) as its chair. Penicillin would not be invented until 1928. Shortly after her arrival at Hopkins in 1890, Lavinia Dock wrote the first textbook for nurses on the subject, Materia Medica, a guidebook of instructions on the properties and uses of drugs. Among other things, students learned how to prepare and classify drugs in order to handle them in a hospital setting. Small doses of arsenic were still considered a viable remedy for ailments ranging from constipation to syphilis.

The school’s first nursing students dealt more with elements, not drug compounds, as we now know them. They learned about the preparation of mercury and lead–which would never be given to patients now–and learned about herbs and plants as remedies, according to student notebooks of the day. While some of these natural remedies have fallen out of favor, others “have come back into favor as more people turn to alternative medicine,” notes Diane Aschenbrenner, the current instructor and course coordinator for the school’s Principles of Pharmacology class.

In the early 1900s, drug use was primarily restricted to the hospital, whereas today drug therapy is often conducted in a home setting, with patients‚ family members taking on the role of a primary caregiver. “Before encouraging more family involvement in home drug therapy,” says Aschenbrenner, “today‚s nursing students need to understand how a drug works and be able to maximize its therapeutic effects and minimize its  adverse effects.”

From the 1930s onward, drug development has skyrocketed. Today, there are some 30,000 drug combinations, and new ones come out monthly. To keep on top of the changes, some students have turned to Palm Pilots loaded with a drug database so that they can reference it in a clinical setting.

“Students find pharmacology a very time- consuming and challenging class, but they know it’s a very beneficial course for them,” Aschenbrenner says. “We want our students to learn a framework so that when a new drug comes out on the market they can understand it in principle–like knowing that drug X is a beta-blocker–and then put it into practice.”

The recipe for effective care…

For the 1891 final exam in dietetics (or invalid cookery), nursing students like Emma Cleaver needed to know such particulars as what a protein is, how to make wine jelly, what produces the “delicious” flavor in coffee, and, if given only one box of English cocoa, how would you prepare enough for a group of four?

Students in the 19th-century’s Dietetics and Household Economy course were primarily taught about food’s manufacture, preservation, and preparation–“with a healthy dash of basic chemistry tossed in. They learned, among other things, how to prepare eggs, broil a chicken, and serve up a cocoa cordial (a mixture of cocoa, wine, sugar, and boiling water, which is “excellent after a bath or when a patient is chilly and exhausted from any cause”).

Carol Miller, instructor of the school’s Family Nutrition and Principles of Nutrition courses and a registered dietitian, notes that today’s students still need to know the basic principles of nutrition “such as what a nutrient is and the chemical composition of carbohydrates, fats, and proteins.”

“Regulating a person’s diet is part of total patient care,” says Miller. Nurses need to know what a patient is eating, since certain foods can have unexpected reactions with different drugs. Or, if a doctor has prescribed a diet low in sodium or high in protein, “a nurse needs to know which foods to encourage or discourage,” Miller says.

What’s changed, says Miller, are the federal recommendations for a balanced and healthy diet. It’s also safe to say that food is prepared in a much lighter fashion than it was in 1890. “Consumers now have the benefit of food labeling to know what they are eating, something that certainly wasn’t around back then,” she says.

Miller encourages her students to apply what they learn in class about a particular nutrient to their own daily eating habits. “When they look at themselves first, and what they eat, it makes it easier to apply that knowledge when they are working with patients,” she says.

In terms of food safety, nursing students of yesteryear learned early–and often–about the importance of boiling water to kill off bacteria. In Miller’s discussions today, she talks about the government’s role in protecting the safety of what Americans consume. Her course also covers such 20th-century innovations as the globalization of food and the rising popularity of organic foods.

Electrifying advances

Emma Cleaver, in her May 1890 notes covering a nursing lecture on the “Application of Electricity,” wrote, “For medical purposes, two kinds of electricity are used–static and current electricity.” At the time, scientists and physicians hailed electricity as the medical tool of the future. Studies were conducted on the physiological effects of alternating currents, and time-varying electric and magnetic fields. Medical professionals wanted to know electricity’s impact on muscle stimulation, pulse changes, perspiration, and nervous stimulation.

The 1890 nursing lecture on electricity included explanations of batteries (how they work and how to handle them) and currents (how to calculate them and increase or lessen their force). “[Electrodes],” Cleaver wrote, “should be covered with absorbitant [sic] cotton because a metal point burns the skin, and burns from this cause are hard to heal.”

Clearly, the advent of electricity held unimagined possibilities–and the potential for countless medical breakthroughs–for doctors and nurses at the turn of the 20th century. In today’s health care arena, perhaps no other area holds as much promise for medical advances as the exploding field of genetics.

Sharon Olsen, assistant professor at the school and an expert on adult clinical cancer genetics and disease prevention, says that it is essential that nurses attend to clinical and epidemiological research in genetics.

Nurses today, she says, focus on both patients and families and are concerned with holistic responses to diseases.

“Evolving research that links genetics, lifestyles/behaviors, and environmental exposures is critical for nurses to understand,” says Olsen, who is a liaison for the International Society of Nurses in Genetics. “Inherited risk identified by taking a good patient and family health history can be combined with an analysis of high risk behaviors, such as smoking or poor diet, and possible exposures, like sunburns or cockroaches, to identify risk factors for cancers or asthma.”

Today’s nursing students collect and use this family history information, Olsen says, to make recommendations for prevention and screening, even referral for genetic testing. Because genes and lifestyles are family issues, nurses also help families understand these familial risks.

“It’s crucial that patients and families understand that genes, for the most part, do not define their destiny for disease and that adopting healthy behaviors can likely have a very big and positive impact on their long-term health,” she says.

Olsen regularly attends meetings of the National Advisory Council for Human Genome Research at NIH, in addition to congressional meetings on genetics privacy and nondiscrimination policy. She shares what she learns with her students and makes sure they observe and interact with genetic counselors in order to learn how to counsel their own patients on genetic issues.

Olsen sees great value in arming students with genetic research, even if it may be something that is so theoretical that its application might be far off in the future.

She cites as an example a class discussion generated by the following quote from the National Institutes of Health Roadmap for the 21st Century Web site: “In the future, health care professionals may administer preventive biosensors, possibly constructed of minute, self-assembling nanotubes, that scan the body, seek out early molecular signs of disease, and eliminate them.” Students considered the quote and used it in their discussion about access to care, health disparities, family dynamics, and the greater good.

Just like the real thing

The first term of schooling for students in the late 1800s included “practical nursing,” later to become “elementary nursing.” Aspiring nurses learned to become familiar with the various appliances and utensils used in nursing, the preparation of dressings, and the care of instruments and materials. The 1904 course catalog says that the course’s objective was “to provide the student, before she is brought into contact with her patient, with some of the fundamental knowledge upon which nursing depends… [The course] ensures the teaching of correct and uniform methods from the very beginning.

Before today’s students are “brought into contact” with real patients, they first hone their basic nursing skills on a lifelike substitute. Introduced in fall 2003, the computer-controlled “SimMan” is a manikin that can literally talk, breathe, cough, and even moan. Students use it to learn to take vital signs and blood pressure, among other skills. Attached to a personal computer and controlled by software, the patient scenario can be changed for each student, says Diane Aschenbrenner.

“We can change his pulse, or make him wheeze, or raise his blood pressure,” she says. “We can do a basic skill assessment with this tool. It might be a little contrived, but these scenarios help establish a nurse/patient relationship. SimMan can be programmed to respond poorly if a student takes too long checking a pulse. And if the patient has some respiratory distress, we can program it to get well after the nurse has done X, Y, and Z. If the student follows the right steps, the patient gets better. It’s added another layer of enrichment to the curriculum.”Another new simulation tool, the IV insertion simulator, allows students to practice inserting IVs. “Students can get the feel of putting one in: learn to feel the pop and see how to guide it through a child’s arm or the skinny arms of an elderly woman,” says Aschenbrenner. “And they can do it over and over again. It’s a skill you lose if you don’t practice and keep up with it.”Yet another new experience was introduced this fall to students in pediatrics with a new child manikin, which students used to practice caring for a child with an acute asthmatic attack. While simulation could never replace training done with real patients, Aschenbrenner says it has been a valuable addition.”Who knows where this technology can go?” she adds.

Greg Rienzi writes from Baltimore.

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