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The development of practical nursing in British Columbia : a social historical perspective, 1940-1980 Caputo, Shari Andrea 2016

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  THE DEVELOPMENT OF PRACTICAL NURSING IN BRITISH COLUMBIA: A SOCIAL HISTORICAL PERSPECTIVE, 1940 – 1980.  by  SHARI ANDREA CAPUTO  BScN, University College of the Cariboo, 2001    A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF  THE REQUIREMENTS FOR THE DEGREE OF   MASTER OF SCIENCE IN NURSING    in    THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES    THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)      April, 2016 © Shari Andrea Caputo     ii  Abstract            This thesis examines the development of the practical nurse (PN) role within the British Columbia (BC) health care system focusing on the years between 1940 and 1980. This project is significant due to the scant amount of Canadian research on this topic. The hidden role of PNs prior to 1940 is discussed, followed by an examination of socio-political contexts that encouraged their development in Canada. Subsequently, PN education and their emerging role in health care in BC is explored. Of relevance to BC, the significant delay in legislation is addressed, as well as organized responses by groups, such as several BC government ministries, the national and BC Registered Nurses Associations, the hospital union and the PNs themselves. Nursing relations, such as registered nurses endorsement of and collaboration with PNs, as well as themes of power and tension amongst practical and registered nurses are explored. Examination of the career of Florence Wilson, a former BC PN and legislation advocate, are interwoven in this discussion, constituting a minor biographical component within the thesis.   A historical research methodology is utilized and key sources of primary data include the Canadian Nurse journal, and many archival documents and reports from professional RN associations, government ministries and related health care organizations. These were obtained mainly from the BC Archives. Secondary sources include multiple research articles and books. To conclude, the thesis points out that within the context of twentieth century health care and hospital expansion, practical nursing proved an essential component of the nursing workforce. Subsequently, practical nursing became formalized as a legitimate professional group with its own distinct organizational and legislative basis. Additionally it is noted that the politics of PN development is inseparably linked to contemporary nursing issues such as scope of practice, role ambiguity and nurse substitution.   iii  Preface  This master`s thesis is an original intellectual product of the author, Shari Caputo. The requirement to obtain approval from the ethics committee was not necessary for this thesis due to the nature of the study design (Historical research using publicly available documents).     iv  Table of Contents Abstract ........................................................................................................................................... ii Preface ............................................................................................................................................ iii Table of Contents ........................................................................................................................... iv List of Figures ............................................................................................................................... vii List of Abbreviations ................................................................................................................... viii Acknowledgements ........................................................................................................................ ix Dedications ..................................................................................................................................... x Chapter One: Introduction .............................................................................................................. 1 Background ................................................................................................................................. 2 Problem Statement ...................................................................................................................... 3 Purpose and Research Question .................................................................................................. 4 Sub-questions. ......................................................................................................................... 5 Theoretical Framework and Methodology: A Social History Perspective and Approach .......... 5 Historical Evidence and Primary Sources ................................................................................... 6 Ethical Considerations ................................................................................................................. 8 The Chapters in Brief .................................................................................................................. 9 Chapter Two: Hidden Existence- Practical Nurses Prior to and Into the Early 1940’s ................ 11 Identifying the Naming of Practical Nurses in the Canadian Nurse ......................................... 11 Influencing Social and Political Factors .................................................................................... 13 Socio-Political Contexts That Encouraged Canadian PN Development ................................... 14 Social influences. ................................................................................................................... 15 Political influences. ............................................................................................................... 17 Professionalization. ............................................................................................................ 17 Chapter Three: The Development of Practical Nursing in Canada and British Columbia ........... 22   v  Early Practical Nurses: Training and Experience ..................................................................... 24 Demographic Profile of the Early PNs ...................................................................................... 25 Statistics. ................................................................................................................................ 25 Race and ethnicity. ................................................................................................................ 25 Gender. .................................................................................................................................. 27 Male practical nurses. ........................................................................................................ 27 Early PN Employment .............................................................................................................. 31 Emerging: Practical Nurse Development From 1940 Forward ................................................. 34 The Canadian Nurses Association. ........................................................................................ 34 The Registered Nurses Association of BC. ........................................................................... 36 The Vancouver Vocational Institute (VVI) ............................................................................... 38 The initiation of PN training at the VVI. ............................................................................... 39 Practical Nursing Education ...................................................................................................... 41 Chapter Four: Organized Responses and the Advocacy Work of Florence Wilson and the PNABC ......................................................................................................................................... 47 Florence Wilson ........................................................................................................................ 47 The Practical Nurses Association (PNA) .................................................................................. 50 Legislation of Practical Nurses in BC ....................................................................................... 51 Advocacy for the PN Act .......................................................................................................... 55 Letter campaign. .................................................................................................................... 57 Motivations for Provincial Government Enactment of the PN Act .......................................... 61 Enactment of PN Legislation .................................................................................................... 64 BCCPN ...................................................................................................................................... 65 The Canadian Nurses Association ............................................................................................. 68 The RNABC Responses to Practical Nurses ............................................................................. 71   vi  PN and RN Collaboration and Division .................................................................................... 74 Factors that Complicated the RN and PN Relationship ............................................................ 78 Government Initiatives and Regulations Related to Practical Nurses ....................................... 82 Seminars. ............................................................................................................................... 82 Stipends ................................................................................................................................. 84 Union Involvement in PN Integration: The Hospital Employees’ Union ................................. 85 Chapter Five: Conclusion ............................................................................................................. 91 Research Questions ................................................................................................................... 92 Limitations ................................................................................................................................ 96 Contribution to Historical Literature ......................................................................................... 97 Remaining Questions and Future Research Directions ............................................................. 99 Conclusion ............................................................................................................................... 100 References ................................................................................................................................... 102   vii   List of Figures Figure 1 Florence Wilson, Practical Nurse Graduation, 1952 ...................................................... 48 Figure 2 Practical Nurse Graduation Pin from VVI, 1952 ........................................................... 49 Figure 3 Florence Wilson, First Licensed Practical Nurse in BC, 1965 ....................................... 49     viii  List of Abbreviations  AR  Annual Report BCCPN British Columbia Council of Practical Nurses BCHA  BC Hospital Association BCHIS BC Hospital Insurance Service CNA  Canadian Nurses Association  HEU  Hospital Employees’ Union  LPNABC Licensed Practical Nurses Association of British Columbia NA  Nurse`s Aide PN  Practical Nurse PNA  Practical Nurses Association PNABC Practical Nurses Association of British Columbia PNTAC Practical Nurse Training Advisory Council RN   Registered Nurse RNABC Registered Nurses Association of British Columbia VVI  Vancouver Vocational Institute        ix  Acknowledgements  Thank you to my supervisory committee. Dr. Geertje Boschma, it was your passion for and knowledge of nursing history that inspired me to see the many opportunities in historical nursing research. I am extremely grateful for all of your encouragement, guidance and wisdom throughout this journey of thesis completion. Dr. Susan Duncan, I greatly appreciate all of your positive support, feedback and interest in this topic. Dr. Linda Quiney, thank you for providing clarity to my writing and for your enthusiasm and advice in regards to my research.  Thank you to BC History of Nursing Society and the Canadian Association for the History of Nursing each for providing me with a scholarship to support the financial aspects of a master`s program.  To the many colleagues who have provided encouragement and sympathy along the way. Particularly to Andrea Sandberg and Debra Clare who gave me the push (shove) I needed to try teaching and begin the journey of pursuing an MSN.    x  Dedications A heartfelt thank you to my family for all of your love and support. To my mother, Sue Holmes, who demonstrated the strength and resilience that inspired me to push through difficult situations and pursue higher education. To my husband Paolo, for your unending patience, support for and pride in my studies and work. To my children, Marina, Giovanna and ‘JJ’, for your understanding and patience with the time I’ve spent away from you. Finally, thank you to my extended family, for all of your interest and support for my thesis.     1  Chapter One: Introduction   For the past seventy five years, the majority of Canadian acute care hospitals and home care organizations have employed both Registered Nurses1 (RN) and Practical Nurses2 (PN) as nursing staff (Hall, 1945; Torrop, 1952). A clear demarcation between the roles has not materialized, however, and in reality the differentiation between the RN and PN roles continues to be a matter of debate. In addition, a clear understanding of the processes that led to the development and incorporation of PNs into the nursing workforce is lacking.    There is little historical analysis concerning the origins and development of the PN role in Canada during the early half of the twentieth century. Twohig (2011, 2015) has explored their growth in Nova Scotia from 1940 to 1970, while Hartley (1992) examines the history of the practical nursing program at Vancouver Community College.  Within the professional literature of the latter half of the twentieth century PN practice is discussed more frequently in regard to staffing and skill mix, scope of practice and professional identity (Johnson, Cowin, Wilson & Young, 2012; Kalisch, Tschannen & Hee Lee, 2011; ten Hoeve, Jansen & Roodbol, 2014; Tourangeau, et al, 2007). However, the literature mainly focuses on the ideal ratio of RN to PN staffing levels in hospitals, as well as the international trends in PN role development. While some literature discusses current practical nursing professional practice and the role of PNs in the Canadian health care system, a documented history of their functional and professional development in Canada is lacking. In this thesis I explore the history of the PN role in one Canadian province, BC, and I examine the historical influences that shaped the formalization of practical nursing as a distinct and eventually licensed domain of nursing practice in this                                                      1 Prior to registration for Canadian nurses in the mid 1920’s, RNs were historically called Professional or Graduate Nurses, but for the purpose of simplicity in this study, they will be referred to as RNs (CNA, 2008, p 36). 2 Historically in Canada, this group has been called Practical, Assistant, Attendant, Auxiliary or Subsidiary Nurses. Currently in BC, this nurse is titled Licensed Practical Nurse (LPN) but for simplicity will subsequently be referred to as a Practical Nurse (PN).   2  province. In Canada the health care system is provincially based. Therefore, a focus on developments in one particular province is a good place to start and provides a feasible scope for this study.  Background  The last fifteen years, nursing scholars have witnessed a growing scholarship of historical research in nursing (Boschma, 2003; Buck, 2007; Duncan, Leipert & Mill, 1999; Helmstadter, 2003; Mansell, 2004; McPherson, 1996, 2005; Melchior, 2005; Toman 2007). This scholarship speaks to the growing interest in and importance of nursing history. Still, the majority of this work pertains to the history of practical nursing and the role development of PNs. Given that scant analyses of PN development exist within the BC health care system, investigating this process in BC constitutes an essential contribution to the growing body of nursing history literature. This examination benefits RNs, PNs and others who work within the Canadian health care system, as well as scholars investigating the history of nursing in Canada. Stearns (2013) offers several significant reasons for the importance of providing historical context from a social historical perspective. Social historical inquiry explains the factors that have contributed to societal changes and provides perspective on the continuum from the past to the present practice. It provides identity for groups, whether family, a profession or an institution, based on the analysis of their historical development. Most critical however, is how the knowledge of an historical event or development informs the understanding of contemporary issues.  As Stearns (2013) argues, “Because history provides an immediate background to our own life and age, it is highly desirable to learn about forces that arose in the past and continue to affect the modern world” (p. 5).   3  Canadian health care has encountered many contentious issues throughout its history. Changes such as the regulation and licensing of PNs (Ridgely Seymer, 1956), rationalization and professionalization (Melosh, 1982), multiskilling (Mansell, 2004) and healthcare cutbacks of the 1990s (Pringle, 2009), reflect complex social processes of change and are not without challenges or impacts on those who experience the changes. An understanding of the effects of these processes may be useful to understanding and managing current issues in the Canadian health care system. Furthermore, better historical understanding may enhance the current and future relationship between RNs and PNs. Problem Statement  Research into present day problems without adequate search into the past to examine the course of events which produced the present problems, or to bring to light past investigations of the same or similar problems by nurses or others, results in research which only scratches the present surface and may even duplicate previous work (Newton, 1965, p. 23). This statement succinctly summarizes the importance of this project. Foremost, I seek to identify the origins and early development of practical nursing in BC and explore these within the context of the time. Further I will examine the factors that promoted as well as constrained ongoing PN development in order to more clearly inform current debates about present employment and scope of practice in practical nursing work. An examination of practical nursing history may also elucidate some of the past and current tensions in the relationship between these two nursing groups, PNs and RNs, which have evolved concurrently since the early twentieth century. Particularly with the expansion of the Canadian health care system following World War II (WWII), practical nursing expanded and became formalized as a distinct professional   4  group within the larger domain of nursing. The main time period of focus in this study, therefore, is 1940 – 1980. Several pertinent shifts in relation to PNs occurred in the late 1970s, including newly emerging discussions about attrition of PNs and apprenticeship. 1980 therefore formed a logical endpoint for the study. Additionally, co-ed training for female and male PN students in BC was initiated in the late 1970s, shifting but also consolidating the education of PNs.  Historical nursing issues have tremendous bearing on contemporary nursing issues (Duncan, Leipert & Mill, 1999). For instance, issues such as educational requirements, scope of practice, nurse substitution and skill mix. Given the scant information on the development and impact of practical nursing on the nursing workforce during the mid-twentieth century, nursing in general will benefit from a historical examination. An awareness and understanding of the way political, economic and social factors have affected nursing’s past is useful in traversing the often challenging and complex issues that face nursing today (Lewenson & Krohn-Hermann, 2008). Connolly explains that this knowledge “…can lead to an informed appraisal of both the intended and unintended outcomes of previous actions and policies” (2005, p. 152). The power of historical knowledge can thus be employed by contemporary nurses to direct current actions, decisions, work, lobbying and research (Pringle, 2009). Purpose and Research Question  The purpose of this study is twofold. Primarily, it is to explore the history of the development of the practical nursing role in BC. Secondly, it will incorporate a social history framework to examine social influences such as gender, class and race, as well as the influence of pivotal changes in health care upon practical nursing role development. Social influences are pertinent to the analysis of PNs in BC due to disparities, particularly of class and race, between PNs and RNs; trends that are currently still evident. Gender is an important theme in nursing and     5  deserves further examination, especially in regards to the strict gender roles prescribed for PNs and orderlies during the mid-twentieth century. Currently, gender division continues to play a central role in the nursing workforce. The latter examinations also will throw light upon the evolution of professional relationships between PNs and RNs. Therefore, the following research question guides this examination: How did the PN role develop within the health care system of BC during the years from 1940-1980?  Sub-questions.  1. What social and political factors contributed to the expansion of practical nursing in BC?  2. In what ways did PNs assert their independence as a related but distinct group from RNs in BC? 3. How has the historical development of the PN role affected the history and practice of RNs? 4. What is the significance of this research to the understanding of current conflicts between RNs and PNs, such as role ambiguity, nurse substitution and overlapping scope of practice? Theoretical Framework and Methodology: A Social History Perspective and Approach   The guiding theoretical framework for this research project is social history inquiry, which assists in identifying the particular social influences that shape the direction and nature of a phenomenon. In particular, this project seeks to clarify the multiple factors that led to the rise and expansion of the PN role in Canadian health care throughout the twentieth century. This includes the social factors of gender, class or ethnicity.  Social history endeavors to look at societal developments through the experiences of ordinary people, women and men who contribute to history equally, or more so than the elite   6  (Stearns, 2003). The sociological lens of gender, class, race and ethnicity are applied to further analyze how these factors contribute to shaping the outcome of a phenomenon. New information and insights into human behavior in the past can be revealed through a social history deconstruction (Buck, 2007; Lewenson & Krohn-Herrmann, 2008; Lynaugh, 2006; Stearns, 2003).  Several areas in the literature require further research. As previously discussed, there is a lack of research specifically addressing the PN role development in Canada. Other than the work of Twohig (2011, 2015) and a few brief descriptions cited by RNs, I have not as yet uncovered a thorough analysis of PNs historical origins throughout Canada, nor specifically in BC. Hartley, (1992) has started an examination of practical nursing in BC in her thesis on the PN education at the Vancouver Vocational Institute. This study builds upon these beginning studies.  I utilize a historical research methodology for this study. The aim of historical research is to explain past occurrences within the context of their time and the way they may have shaped current circumstances. Polit and Beck define it as the"... systematic collection, critical evaluation and interpretation of historical evidence" (2012, p. 500). This type of research does not incorporate any type of model or intervention, but rather utilizes a theoretical framework that gives direction to the types of research questions being asked. Moreover, identification, evaluation, and analysis of primary documents form the core methodology in connection with a historical framework. The framework of social history will be the guiding theoretical frame for this study. Historical Evidence and Primary Sources In order to obtain a variety of primary sources for this project, multiple libraries and archives were searched. Visits were made to the Vancouver and the Kamloops city archives, as   7  well as the BC Archives in Victoria and the archival collection of the BC History of Nursing Society (BCHNS) at the University of British Columbia (UBC). Online archival research included the Library and Archives Canada, Memory BC, Internet Archive and HathiTrust Digital Library. Research within libraries occurred at UBC, Thompson Rivers University and the College of Registered Nurses of BC (previously titled the Registered Nurses Association of BC or RNABC 3 ) in Vancouver (College of Registered Nurses of British Columbia, n.d.). Additionally, I completed research at the Vancouver Community College library (formerly titled the Vancouver Vocational Institute, which initiated education for PNs in BC). Both primary and secondary sources were examined throughout this project. A primary source is preferred, consisting of an original document, object, or photo, created during the pertinent historical era, whereas secondary documents are analytical discussions written for the purpose of exploring and examining the dimensions of a historical event (Polit & Beck, 2012). In addition to the above primary sources drawn from archives and libraries, I included relevant journal articles in the Canadian Nurse (CN), the Canadian Hospital, and the Canadian Journal of Public Health, as well as documents from the Canadian Nurses Association (CNA) and from the BC provincial government. Pertinent archival sources included reports and governmental committee meeting minutes about PNs (BC Archives)4, the F. Wilson fond (BC History of Nursing Society), the RNABC Annual General Meeting reports and the World Health Organization (WHO) reports. Relevant primary source books included Nursing Education in a Changing Society by Russell (1970) and Education for Nursing Leadership, by Lambertson (1958), nursing textbooks amongst several others less utilized.  Research articles from multiple contemporary Canadian                                                      3 To maintain historical accuracy, this organization will be referred to as the RNABC throughout the remainder of the thesis.  4 Government records were accessed at the British Columbia Archives in Victoria BC. Records that were accessed included the Ministry of Education Executive Records, the Department of Health Deputy Minister, the Department of Health Services and Hospital Insurance, the British Columbia Hospital Insurance Service and the Ministry of Health Hospital Consultation and Inspection Division.   8  and American journals on nursing and history were used as secondary sources, in addition to books on topics ranging from nursing history, politics, nursing research methodologies and sociology. Several secondary sources proved invaluable, including a thesis on The history of practical nursing education at Vancouver Community College (Hartley, 1992), Twohig`s (2011, 2015) publications on the history of nursing assistants in Nova Scotia, as well as the centennial document The Canadian Nurses Association, 1908-2008, one hundred years of nursing service (Elliott, Rutty & Villeneuve, 2013). The alphabetized reference list for this thesis contains some primary sources and all of the secondary sources utilized herein, while specific archival documents are referenced in footnotes for clarity.  One particular challenge included the inability to access pertinent documents from the early practical nursing association in BC – these could not be located. The bulk of historical evidence I have been able to examine was publicly available. Some of the BC government documents that I gained access to in the BC Archives were restricted and therefore only the names of government representatives are referenced within these documents, while any names from the general public remain confidential. Ethical Considerations  Ethical considerations are a requisite step in any type of research undertaken. For the majority of projects, any research involving human participants, whether clinical or behavioral, must apply for and receive acceptance of the UBC research ethics board (UBC Office of Research Ethics, 2013). However, given that historical documents were the primary source of data for this project, approval from the research ethics board was not necessary (UBC Office of Research Ethics). This is consistent with the information provided in the Tri-Council Policy   9  Statement (TCPS) Article 2.2, which clearly defines any research of “…publicly available information… that is appropriately protected by law…[or when]….there is no reasonable expectation of privacy” (Tri-Council Policy Statement, 2012). For accessing the documents of the BC Archives, established archival procedures were followed. Nevertheless, there are other ethical issues in historical research that require attention. Lewensen, et al. (2008) discuss multiple ethical considerations that must be addressed by nurses undertaking historical research.  The “Ethical Guidelines for the Nurse Historian” and “Professional Conduct for Historical Inquiry in Nursing” (Lewensen, p. 167) provide guidance in traversing the ethical issues of historical research.  Each addresses the relationship, or responsibility, the researcher has to seven key areas: sources, subjects, colleagues, students, community, the canons of research and the conduct of historical inquiry (p. 169-172). While these responsibilities may seem obvious, they ensure the honest, judicious, accountable and scholarly actions of historical nurse researchers. Lewensen, et al. (2008) also recommend following five guiding principles while completing historical nursing research, including: remain truthful about the data; ensure you stay focused on the purpose of the research; make equitable decisions; complete an institutional review process and consult with other historians. These actions are key to successful and professional thesis completion, and ones which I have striven to comply with during my research. Pertinent to this is the fact that my thesis committee members consisted of a nurse historian, a nurse scholar and a historian.  The Chapters in Brief   In chapter two numerous socio-political contexts that coalesced to form the gap in nursing services PNs began to fill in the mid-twentieth century are explored. Factors such as   10  Word War II (WWII) with a concomitant and subsequent RN shortage, evolving medical advancements, increasing government support for hospital infrastructure and educational opportunities and RNs efforts towards professionalization all led to circumstances that necessitated the formal inclusion of PNs into the Canadian health care system. Then in chapter three, I discuss the process of PN development nationally, but with a greater focus on developments in BC. This chapter begins with an exploration of the backgrounds and demographics of early PN employment prior to 1940, followed by a post-1940 stepwise progression of national PN development. A detailed examination of PN training in BC ensues looking at how the PN program was initiated, the curriculum and early PN scope of practice. Subsequently in chapter four, Florence Wilson, the biographical figure within the thesis is introduced followed by a discussion of her involvement during the long process to gain enactment of PN legislation in BC. The many responses to PNs by organized groups are reviewed, such as the PNs themselves, national and provincial RN associations, provincial government ministries, male PNs and the Hospital Employees’ Union (HEU). In chapter five, I summarize the main arguments of the project and discuss how the research questions have been addressed. Furthermore I consider the study`s contribution to the historical nursing literature and make several recommendations for future research endeavors.     11  Chapter Two: Hidden Existence- Practical Nurses Prior to and Into the Early 1940’s  Identifying the Naming of Practical Nurses in the Canadian Nurse  An initial exploration of the Canadian Nurse, up until the late 1940s was conducted early on in my research in order to identify when the title ‘practical nurse’ began to appear in the professional literature and how the term was understood at the time. The preliminary search revealed only scant attention to practical nursing in this journal. Brief references in the journal to PNs were mentioned throughout the first half of the twentieth century, however references were more frequently noted after WW II (Baker, 1941; Brooks, 1961; Brown, 1962; Dickrager, 1950 & Torrop, 1952). Topics such as the nursing shortage and PN training and licensing were found, while Ridgely Seymer (1956) noted international developments in the utilization of PNs. Widespread need for nurses also seemed to have structured the role of PNs, sometimes also referred to as auxiliary nurses.  The Canadian Nurse refers to PNs in the late 1930s mostly as either nurses who did not complete their RN training or as graduate nurses who completed lesser quality RN training in small hospitals (Johns, 1938). The first reference to formalized PN training was noted in Ontario, wherein the local Nursing Registry, who employed private duty nurses, foresaw the growing demand for PNs and initiated their own training program (Baker, 1941). Other references to PNs in the Canadian Nurse were made in uncomplimentary tones, such as describing PNs as a problem to be dealt with (Mallory, 1946; Taylor, 1940; Wilson, 1941).    Through WWII and into the post-war era, there was greater discussion in the Canadian Nurse journal on various PN issues. Important topics such as licensing, and the regulation and training of PNs, began to be discussed in greater depth in the Canadian Nurse journal in 1944 (Fidler, 1944), although throughout the 1940s many provincial RN Associations reported   12  discussions of training and licensing of PNs in the Canadian Nurse. Internationally, Ridgely Seymer (1956) briefly highlights PN issues in countries such as the United States, Japan, Finland, New Zealand and England. Through the mid-twentieth century, legislation for and licensing of PNs swept throughout North America (Kerr, 1946; Ridgely Seymer). Another early source revealing the origin and first use of the term and title ‘practical nurse’ is in the national nursing survey conducted in 1932 by George Weir, sociologist and professor of education at the University of British Columbia (McPherson, 1996; Weir, 1932). Undertaken by the Canadian Nurses Association (CNA) and the Canadian Medical Association; the survey arose out of serious concerns regarding RN unemployment and the variation in the quality of nursing education between hospitals. Elliott, Rutty and Villeneuve (2013) report the Weir Survey as having “…a wide ranging overview and analysis of the social, economic and educational aspects of Canadian nursing” (p. 53). The survey, which took nearly six years to complete, had a tremendous positive impact on the future development of nursing education. In this significant study, Weir (1932) utilizes the title PN when referring to experienced lay women who acquired general knowledge by caring for the ill but did not attend and graduate from a RN program. To distinguish between RNs and PNs, Weir recommended reserving the use of the word nurse for RNs only, and for PNs to be called ‘attendants’. It can, therefore, be concluded from this preliminary search that the term ‘practical nurse’ was likely in common use either prior to or during the 1930s, to distinguish between nurses who traditionally learned basic nursing skills through experience and those who obtained formal training as an RN. While PNs experience or knowledge was not acknowledged in any formal way during this period, the need for nursing was such that the work and experience of PNs remained in demand. As the health care system expanded during the mid-twentieth century, the continued shortage of nurses   13  eventually formed the main context for a formalization of the PNs role along with a distinct licensing and registration system for PNs as this thesis will make clear.  Influencing Social and Political Factors  An examination of the particular circumstances that further contextualize PN development in North America is necessary. A pertinent context that consolidated the continued presence of PNs in the nursing workforce was the way health care developed during and following WWII. The latter war drastically changed the nursing scene, with many RNs going overseas to work or volunteer their services, leaving gaping holes in the Canadian nursing workforce (Elliott et al., 2013). Nursing leaders believed that once the war ended, nurses would return to their pre-war employment, thereby partially rectifying the nursing shortage. This proved to be a fallacy, adding to a continued exacerbation of the nursing shortage after the war ended and will be discussed more elaborately in the next section under social influences (Elliott, et al).   Pertinent social factors further shaping the development of the PN role include both the class and ethnic origins of nurses in the twentieth century. Melchior (2005) notes the dominant socio-economic characteristics of RNs during the early twentieth century, as being English speaking, white, primarily of British heritage and tending towards a higher social class. This trend was evident even during WW II, when female civilians were chosen for voluntary nursing services (Toman, 2007). This leads to questions about the class and ethnic origins of PNs, which are further discussed in chapter three.  Another significant theme is that of the enduring power and territorial struggles between RNs and PNs over the past seventy–five years. For example, role ambiguity, nurse substitution and overlapping scope of practice between RNs and PNs has produced tensions between the two groups. This overlap has resulted in the trend to replace RNs with PNs, for increased economic   14  efficiency in the health care system (Pringle, 2009).  In my professional capacity, I have witnessed such tensions in the form of negative remarks between the two nursing groups, as well as through various union tactics attempting to portray each other in a negative light (British Columbia Nurses Union, 2012; Hospital Employees’ Union, 2011).  Some of these incidents arise from the fear of substitution by one group for the other, issues that have evolved both historically and contemporarily and as such developments in nursing mirror similar struggles over professional authority common in other professional groups (Abbott, 1988; Ellis, 1996, Fortems, 2011; Konda-Witte & Toth, 2010; Taylor, 1940).   Cash and Croft (2012) are one example whereupon they examine the workplace nursing relations between RNs, PNs and Registered Psychiatric Nurses, and describe actions such as maintaining a hierarchy, exclusion, and scrutiny as forms of bullying, some of which can be attributed to the groups jostling for position in the health care system. The history of PN development is characterized by such intra-professional tension, which is particularly relevant to understand current RN and PN workplace tensions. This issue is ongoing and requires careful attention however a historical examination might inform ways to find solutions as it acknowledges the rightful contribution of each professional group and places such tensions in the context of time and place.  Socio-Political Contexts That Encouraged Canadian PN Development  In this section I will further explore particular circumstances that further advanced PN development in Canada. Most salient are the varied social and political factors, however economic and geographical factors also played a notable role.    15  Social influences.  Multiple factors related to RNs contributed, albeit some unwittingly, to PN development from the years 1920 to 1950. Elliott et al., (2013) describe the complete about face in RN employment from the early 1920s through to the WWII years. During the 1930s, there was much discussion about the abundance and underemployment of RNs in Canada. Several reasons existed for this situation, mainly the hospitals increasing demand for the services of nursing students, who constituted their primary, and inexpensive, nursing workforce. Notwithstanding this, once graduated the RNs were expected to seek employment in private duty homecare in which applicants were increasingly competing for a limited number of jobs. The economic depression of the 1930s exacerbated this situation, given that fewer and fewer households could afford the cost of a private duty nurse. Many RNs were unemployed during this time and some left for the United States of America (USA) to obtain nursing work as well as better wages (McPherson, 1996, p. 144). Often PNs presented themselves as a more economically viable option over RNs, especially for lower socioeconomic status Canadian families throughout the 1930s and 1940s (Boschma, 2004; McPherson, 1996) Jamieson, Sewall and Gjertson (1959) describe how WWII was a dominant social factor that drove the demand for PNs. Throughout the war, a significant shortage of RNs existed primarily due to their war work abroad. Thus North America was left to fill some of its nursing needs with PNs. Professional RN associations voiced their hopes that after the war ended, RNs would return to their former jobs. However, for reasons of weariness or illness following their war work, or due to more enticing nursing or educational opportunities, many RNs did not return to bedside nursing, leaving considerable post-war vacancies (Twohig, 2011). Additionally, many previously untrained, volunteer war nurses chose to enter practical nursing, attracted by the   16  reduced requirements of time and money for training along with financial encouragement from the federal government (Jamieson, et al; Stewart and Austin). The federal government recognized the need to assist many of the returning Armed Forces veterans in their transition back to civilian life. Therefore, it was through a joint effort between the Department of Veterans Affairs, the Departments of Health and Welfare and both national and provincial nursing organizations that funding was provided for Service Women to undertake PN training (Russell, 1970)5.  Although it may seem somewhat paradoxical, an inadvertent contribution to the development of the PN role was the push for the professionalization of RNs. From the early twentieth century, RN nursing leaders have sought to improve their power and status in the health care system by pursuing a professional identity, despite internal conflict and external criticism over this issue (Elliott, Rutty & Villenneuve, 2013; Mansell, 2004; Melosh, 1982). This process, also known as a professional project, will be further analyzed later in this chapter (Witz, 1991). Nevertheless, this latter process also stimulated the demand for PNs. This transition served further to differentiate the education, and the role of RNs and PNs, already promoted in the early report on nursing education by Weir (1932). The post WWII boom in medical technology and pharmaceuticals had a direct effect by expanding the RNs scope of practice, which consequentially increased their need for further education (Boschma, 2005; McPherson, 1996). These developments occurred at a time when increasingly more post diploma education was available in Canada, including baccalaureate degrees, of which only a small portion of RNs went on the University. The RNs who took advantage of the educational opportunities left additional spaces in an already stretched nursing workforce, resulting in the addition of a ‘new’                                                      5 RNABC, (ca 1948-1949). Fact Sheet on Practical Nursing [Brochure]. Department of Health Executive Records (GR 0678, Box 43, File 3, Student Practical Nurses). British Columbia Archives, Victoria, BC   17  type of nurse, the PN. Many nurses in leadership and administrative positions supported the utilization of PNs in hospitals. This was partially due to the workload relief they provided. McPherson (1996) proposed that the addition of PNs allowed RNs to take a step back from the domestic duties of nursing, such as personal care which naturally strengthened the professional public image they were seeking. Political influences.  Professionalization.  RNs took the process of professionalization to heart throughout the twentieth century (Mansell, 2004). One could argue that in a complementary professionalization process, PNs also undertook a search for professional recognition and registration similar to the ways RNs developed professional jurisdiction over their work.  From a sociological perspective, Abbott (1988) explains that initially a profession seeks public approval for a certain area of work. This effort is consistent with the early positive image encouraged by the nursing profession (Helmstadter, 2003; McPherson, 2005).  The challenges PNs experienced in striving to professionalize are comparable to those of RNs during the first half of the twentieth century, most of whom were white, Anglophone and middle class (Melchior, 2005; Melosh, 1982).  The credentialist approach is described as a professional closure strategy and consists of utilizing academic diplomas and degrees and the process of accreditation to create professional boundaries (Witz, 1991). Such a striving for professional status can be recognized in the move of RN education from hospitals to colleges and universities, and the eventual requirement of a baccalaureate degree as entry to practice as an RN in Canada (Canadian Nurses Association, 2003). Subsumed within the credentialist strategy is that of the registration and licensing of   18  professionals. While this was a later occurrence for female professionals, historically it was utilized as a primary means of upwardly mobilizing a profession. Social influences shaped professionalization efforts in nursing and the enactment of two levels of employment, registered and practical nursing had to be negotiated in the workplace (Melosh, 1982).  The expansion of the PN role was an indirect result of the push towards professionalization and upward mobility of RNs (Witz, 1991). From the early twentieth century, the nursing profession has worked to improve its power and status in the health care system by pursuing a professional identity, despite internal conflict and external criticism (Mansell, 2004; Melosh, 1982). Brown (1977) describes how post WWII proved to be an opportune time to continue the promotion of RN professionalization. The insertion of PNs into the health care system forced RNs to differentiate their role, and advocate for their place, in the hierarchy. The mid-twentieth century brought a simultaneous push for improvements in the quality of nurse’s training, as well as an overall increase in the numbers attending college and university. These factors not only resulted in a proportion of RNs searching for higher education, but also transformed work at the bedside. RNs took on new specialized roles or sometimes also resulted in their leaving bedside nursing (McPherson, 1996).  Finally, with regard to professionalization, nurse educators were committed to removing professional education from the apprenticeship model, and into post-secondary training institutions. This slow transition served further to differentiate the education, and the role of RNs and PNs.  Several trends in health care occurred throughout the twentieth century which also affected the development of the PN role. An increased demand for hospital services, general awareness and the expectation of the public for medical care, and advancements in medical technology, all contributed to an increased demand for nurses (Lynaugh, 2006). The subsequent   19  increase in the specialization and administrative duties of RNs after WWII also led to a greater utilization of PNs (Seymer, 1946; Brown, 1962; Johns, 1946).  Furthermore, several federal acts supplemented funding for nursing, including PNs. An additional factor that helped to secure the place of PNs in healthcare was the business trend of rationalization to increase efficiency and cost saving attempts by health care organizations. Throughout the intra and post WWII years, the higher wages of Canadians allowed them to spend more income on health care services. Access to health insurance augmented this phenomenon, both through private companies and several provincial programs in the 1940’s (McPherson, 1996). Responding to the rising public demand for health care services, the federal Ministry of Health and Welfare introduced health grants across Canada in 1948, with shared funding between national and provincial governments. The health grants were a result of previous failed attempts to initiate national public health insurance during WWII and were targeted to increase hospital construction, to improve public health research and development and some professional education (Elliott et al., 2013).  The trend of Canadians to access more and more health care services necessitated greater numbers of nurses, thereby severely exacerbating the post war shortage, which opened spaces for PNs to fill basic nursing roles where needed. Coinciding with the growth of Canadian hospitals was the expansion of long term care and veterans homes, both of which employed PNs (Feldberg, Vipond & Bryant, 2010)6. Concurrent to this phenomenon during the mid-twentieth century, was an explosion in medical research resulting in advancements in many avenues for the treatment of diseases, which in turn drove the increased specialization of many health care professionals (McPherson, 1996).                                                      6 See also RNABC, (ca 1948-1949). Fact Sheet on Practical Nursing [Brochure]. Department of Health Executive Records (GR 0678, Box 43, File 3, Student Practical Nurses). British Columbia Archives, Victoria, BC   20  As more specializations and both undergraduate and graduate education was pursued by RNs, more gaps in the health care system were left to be filled by PNs (Seymer, 1946; Russell, 1970).  In 1957, the precursor to the present day Canada Health Act came into effect, then called the Hospital Insurance and Diagnostic Services Act, of which all ten provinces were participants of by 1961 (Ostry, 2012). This legislation resulted in enormous expansion of hospital care and in fact, the numbers of hospital beds increased by over sixty percent for the fourteen years preceding 1960 (Ostry). As a result, hospitals continued to struggle to meet a constantly growing demand for services, including nursing, even with the additional health insurance funding (McPherson, 1996).  The introduction of additional vocational education was a partial government response to meet demands for more qualified health care personnel. The Technical and Vocational Training Assistance Act of 1960 provided supplemental funding for vocational programs across Canada, which included practical nursing (Hartley, 1992). The Act`s economic effects on PNs in BC is discussed in greater depth in chapter four. Rationalization, an economic efficiency approach, embraced by hospital administrators throughout the mid-twentieth century, heightened RNs’ concerns over their place in health care (McPherson, 1996; Melosh, 1982), but also stimulated further demarcation and distinction between different levels of nursing work. Factors of cost further exacerbated the distinction between RN and PN realms of practice. The dual trends of rising health care costs and the demand for increased nursing efficiency, have persisted through to the present, creating a divide between more highly skilled RN duties and basic PN duties, ultimately leading to greater utilization of PNs within the health care system (Henderson & Winch, 2009; Mansell, 2004).    21   This chapter began with a discussion on the use of the title practical nurse in the early to mid-twentieth century which was noted primarily in the Canadian Nurse journal, as well as in the Weir survey of nursing education. Subsequently, chapter two highlights the salient social and political factors that have influenced the development of the PN role throughout the mid-twentieth century. Topics included were unemployment in private duty nursing, the nursing shortage and WWII, RN professionalization and role expansion and finally the growth in health care services post WWII. Chapter three will explore practical nursing development in Canada, followed by a more focused discussion in BC. The demographics of early PNs are addressed, as well as the influence of nursing organizations on PN development and the process of PN training in BC.     22  Chapter Three: The Development of Practical Nursing in Canada and British Columbia The purpose of this chapter is to discuss the early development of the PNs role; the chapter provides an enhanced understanding of the events, both socially and politically that contributed to the more formalized education and regulation of PNs. First I will discuss the history of the evolution of PNs in Canada followed by a discussion of the progression of PN education in BC.   In 1946, nurse leader and editor of the Canadian Nurse (CN) journal, Ethel Johns (Johns, 1946), reflected on the existence of PNs in Canada in 1917; a presence that was established by World War I (WWI) and the resulting RN shortage. The Canadian Nurses Association (CNA), the national professional body for RNs, was aware of the controversies around the need for the proper training and licensing of PNs at this time. Johns argued, however that as WWI ended, the CNA, a relatively young and small organization at that time, was unable to address these controversies, due to many other more immediate needs. Other sources also note the presence of PNs as early as 1918 (Pringle, Green & Johnson, 2004).  Several reports in the CN mention the existence of PNs in the early twentieth century. The approval for training nurse attendants in Manitoba in 1919, for example, was highlighted, however further details were not provided (Resolutions, 1919). This information is corroborated in a CN article which discussed PN history in Winnipeg, whereupon in 1921, the registry for physicians and nurses was reorganized and included PNs for home services (exact services by PNs was unspecified) (Waugh, 1947). Parker, an RN from the Montreal General Hospital Training School, saw a great need for PNs during the post-WWI period in Montreal. After seeking guidance on her endeavor by visiting the Young Women`s Christian Association (YWCA) PN program in New York City, she opened the Parker School for Trained Attendants   23  in Montreal in 1921 which operated until 1947, when it closed to allow for public PN training programs (see section Emerging below) (Anonymous, 1933; Parker, 1946; “Parker School ”, 1947).   Numerous references to early models of the PN exist in Canadian nursing literature, most of which are referred to by a variety of names such as aide, assistant, attendant, auxiliary, subsidiary, orderly,  vocational, nursing housekeepers, practical women or practical nurses (Agnew, 1930; Davis, 1914; Smellie, 1937; Weir, 1932). In the early twentieth century literature on nursing these terms were used loosely for any person who assisted a RN. Without legislation or licensing for PNs, there was great inconsistency as to their purpose and scope of practice. In his 1932 landmark survey on nursing education in Canada, Weir describes the training of PNs as varied, but some had up to eighteen months of training. Additionally he reported, based on contemporary expert definitions of what a profession constitutes, that in summary, the PN was lacking the proper professional conduct of an RN which refers to the selflessness, moral integrity and intellect necessary to graduate and consider oneself part of a profession (Weir).  In the Weir survey (1932), physicians voiced mixed opinions regarding the value of the PN which included terms such as “…an “abomination”, and a “curse” or a “positive menace” to the community” (p. 229). These physicians were clearly seeing the RN as the ideal nursing professional. Other physicians admitted that for a variety of reasons the PN filled a gap in convalescent and chronic care left by RNs. Such a gap had emerged, they noted due to both the higher cost of having a private duty RN in one’s home as well as the RNs disdain for doing housework that was considered below their level of professional training. Furthermore, when asked to rate the value of the PN to the health of the community, physicians rated PNs as being slightly more a benefit than a danger (Weir, p. 232). The physicians’ opinions only highlight the   24  urgency of proper training and supervision of PNs in their work. Additionally, while there was a surplus of RNs in larger cities across Canada in the 1930`s, according to Weir, there was a deficit of RNs in rural areas. Significantly, physicians noted in the survey that an approximately twenty percent increase of PNs who could work in rural areas would be of immense benefit (p. 254). Regardless of the physician’s conclusions regarding PNs at that time, the PNs prior to 1940 had found a small niche in the nursing workforce. While there was pressure from professional groups as well as the Red Cross to increase the number of experienced RNs in rural areas,  for example by expansion of outpost nursing, their numbers did not fully meet the need (Elliott, 2004). Although their backgrounds in terms of practice experience were diverse, PNs were nonetheless in demand.   Early Practical Nurses: Training and Experience  Sources from the early twentieth century refer to PNs as having a variety of backgrounds. Davis (1914) described several of the categories she encountered in her experience of running a home care registry in the USA. Some PNs working for this registry had limited training in nursing, while others were widows who relied on skills gained in the home such as housekeeping and the care of sick family. Based on these skills they were able to gain employment as a PN. Alternatively, some had limited training in small hospitals or via correspondence, and yet other PNs had incomplete training as an RN (sometimes referred to as an undergraduate) (Davis, 1914; Russell, 1970). Lavinia Dock, an American nursing leader, reported some PNs were disqualified nurses or midwives from the USA or Great Britain and were deemed as a nuisance to the professional RN, who was emphasized as the preferred and qualified nurse (Dock et al. 1912).  This previous comment indicates that responses to PN practice were mixed, largely depending on the viewpoint of the commentator. From a standpoint of professionalism, PNs seemed to form a   25  threat to RN practice, yet from the perspective of those requiring nursing personnel PNs seemed a legitimate solution in a time when large segments of the population could not afford RNs or did not have access to them. Demographic Profile of the Early PNs   Statistics. Early profiles of PNs in Canada show a marked increase in their numbers during the mid- twentieth century. Weir (1932) reported an educated guess of about 10, 000 PNs and untrained attendants working in Canada between 1929 and 1930. In 1931, the Canadian census (as cited in Gibbon & Mathewson, 1947) reports the number of PNs as 4, 698 and by 1941 PNs in Canada had risen by seventy percent at 7, 973, according to the same source.  In 1953, this number had risen to 10,780 and by 1957 there were 11, 639 Practical Nurses in Canada7. It is difficult to account for the differences in the statistics for the years 1930 and 1931. I hypothesize that the first source included all untrained and semi-trained attendants and aides, while the second source accounted for only self-declared PNs, however a definition of a PN was not provided within the census statistic. Yet, regardless of which number might be closer to the actual number, it is clear from these sources that PNs had a substantial presence in the Canadian nursing workforce.  Russell (1970) reports over 30,000 PNs in Canada by 1970, which equates to a six fold increase over forty years.  Race and ethnicity.  The racial and ethnic background of the PNs working in Canada varied, although it is difficult to determine a clear breakdown of each from existing documents. Data from the                                                      7 Canadian Nurses Association, 1960.  Facts and figures about nursing in Canada. [Brochure].University of Alberta Hospitals, School of Nursing Archives, (RT 6, A1, F33, 1960). University of Alberta Hospitals, Edmonton, ALB.     26  Canadian census (as cited in Gibbon & Mathewson, 1947) from 1941 shows that 88 % of PNs were Canadian, 10% were from the British Isles, less than three percent were from the USA, less than two percent were from Europe and finally less than one percent were from Asia.  These percentages are also mirrored in the statistics for the origins of RNs in Canada.  The ethnicities included in the RN and PN census data reflect a similar anglo-centric profile of who constituted as a nurse (McPherson, 1996; Melchior, 2005), however Canadian ethnicity does not necessarily imply Caucasian racial background.  Thus far, data specifying the number of PNs with Aboriginal heritage working in Canada in 1941 has not been uncovered although the Aboriginal Nurses Association of Canada (2007) report that some were employed as attendants in remote and Aboriginal hospitals8. Furthermore, throughout the first half of the twentieth century, Aboriginal women encountered many barriers to entering any kind of nursing programs, although certainly a few did succeed (Aboriginal Nurses Association of Canada; Meijer-Drees, 2013).  The predominate exclusion of visible minorities, such as Aboriginal, Asian, or African-American peoples from the nursing census data reflects the traditional Eurocentric notion that only white, Canadian born women (preferably middle to upper class) had the respectability and “…superior sense of sexual and social behavior…to act appropriately while caring for their social ‘equals’ or ‘superiors’…or to serve as role models for their social ‘inferiors’, such as immigrants and non-Whites” (McPherson, 1996, p. 17). Nevertheless, ‘minority’ women were encouraged to go into nursing, but only to return to their home community and provide local nursing service (McPherson, 1996; Meijer-Drees). This trend was noted specifically for Aboriginal and Asian women in BC who managed                                                      8 Meijer-Drees (2013) attributes several other possibilities for the above exclusion. It may be due to the fact that most Aboriginals had subordinate positions in health care and their names were not part of official documents or perhaps that Aboriginal workers were not distinguished from non-Aboriginal health care workers.   27  to obtain either RN or PN diploma (McPherson, 1996, p. 211; Meijer-Drees, 2013). In fact, throughout the 1950s Aboriginal women were sponsored in the practical nursing program at VVI by the Department of Indian Affairs (Aboriginal Nurses Association of Canada, 2007; Meijer-Drees, 2013) and by 1962, over 250 had completed the PN program (Here and There, 1962). McPherson (1996) reports statistics from 1961 that showed the ethnic breakdown of PNs to be dynamic throughout this time. For instance, 71% of PNs were of British or French descent while the other 24% were immigrants, demonstrating a significant change from the aforementioned 1947 statistics. Indeed some of the immigrant women working as PNs were professional nurses in their country of origin, however they could not work in Canada as RNs, due to the differences in licensing standards (McPherson, 2005). Gender.  Practical nursing consisted of a predominately female nursing workforce however PNs also had a male counterpart, the so-called orderlies. This topic requires a more in-depth discussion, particularly on the transition of including men in practical nursing training. Male practical nurses. As PN practice expanded in the mid-twentieth century, the position of PNs not only had to be aligned with RNs, but the relationship with their male counterparts in the hospital system, the so-called (male) orderlies, also had to be clarified and negotiated. Not much is known about the history of orderlies in the hospital system, but they have maintained a presence from the early days of the establishment of BC hospitals in the late 19th century. Developments in BC paralleled patterns within hospital developments more broadly. Historically men have worked as nurses since ancient times (Ridgely Seymer, 1956; O’Lynn, 2007). In a recent history on the role of   28  men in nursing, O’Lynn (2007) emphasized that already in ancient Greece Hippocrates had initiated training for male nurses some time during the fourth century BC, while Hindus in the third century BC considered only men to be “pure” enough to become nurses. Throughout the early Christian era, male nurses cared for the sick, those with contagious diseases, or the elderly (Healy, 1911; O’Lynn).  Several military orders had male nurses to care for the ill and injured, primarily during the 11th and 12th centuries, while non-military orders, some affiliated with religious organizations, existed predominately during the middle ages and used either all male or mixed gender nurses (O’Lynn). Presence of men in care of the sick was being maintained throughout the 18th and 19th centuries, in part due to the lack of female nurses allowed on or within proximity to the war field (O’Lynn). Male orderlies in Canada performed particular duties in health services form the late 19th century onwards, as male attendants did so before them.   Traditionally in Canada, men had worked as orderlies, sometimes as PNs and rarely as RNs within the hospital setting at least since the beginning of the twentieth century (McPherson, 1996). During the early twentieth century, the RN school in Halifax accepted male students, for example, due to the large number of sailors who required male nursing care when hospitalized (McPherson, 1996). RN programs that accepted male students were scarce, while few male-only classes existed, primarily for work in psychiatric institutions (Boschma, Yonge & Mychajlunow, 2005; Ross-Kerr, 2011).  More common throughout Canada during this period, was the orderly, whose role usually encompassed the physical care of male patients and the heavier physical work within the medical and mental hospital settings (McPherson, 1996; McPherson, 2005). Considering the strict sexual norms and gendered cultural role society placed on female nurses throughout the early to mid-twentieth century, it was common for female nurses during this period to consider any part of caring for male genitalia abhorrent, thereby necessitating the   29  continued presence of the male orderly or assistant nurse (McPherson, 1996). It wasn`t until the mid-twentieth century that men began to be accepted into RN and PN programs in Canada (McPherson, 2005; Hartley, 1992).  Yet once accepted, the presence of male PNs actually expanded. The Canadian census reporting that in 1951, over 7000 male practical nurses were working in Canada and by 1961, the number had risen to over 13,000 (as cited in McPherson, 1996, p. 321). Due to the lack of the census’ qualifying definition of a PN (on the job versus formal training), it is difficult to determine how many male PNs within these statistics were formally trained. As practical nursing programs became commonplace during the mid-twentieth century, men also desired the lengthier training, legal protection and status that came with the PN diploma and they began to advocate for better training. The CNA committee on auxiliary nursing personnel recommended to provincial associations in their 1951 report that the need for male nursing assistants be studied and consideration of training for such men9. By 1965, at least six of the provinces had men who had graduated from their practical nursing programs10. Some provinces reported that male PN students took the same training as the female students, whereas other provinces made distinct arrangements with regard to particular areas of practice, providing, for example, clinical experience in urology and pediatrics instead of obstetrics for male PNs. The wage differential for male PNs and orderlies became a contentious issue because traditionally orderlies who trained on-the-job were paid a higher wage than the trained female PNs, and therefore male PN graduates were paid a lower wage than orderlies. In Saskatchewan, some male PN graduates sought employment as orderlies to obtain a higher wage, although they reported disappointment                                                      9 Russell, M.G. (1951, April 5). Report of the special committee to study auxiliary nursing personnel. [Report]. Canadian Nurses Association Fonds (MG 28, I 248, Vol 65, File 19). Library and Archives Canada. Ottawa, ON. 10 Nordlund, E.E. (1965). Correspondence. Practical Nurses Information – Out of Province. (GR 0380, Box 15,  File 4, Practical Nurses). British Columbia Archives, Victoria, BC.   30  at not having their formal PN training recognized in their job title10. This dilemma is confirmed by several other sources, where on average male PNs and orderlies received thirty percent higher wages than female PNs and ward aides11 (McPherson, 1996)12. Such a wage disparity speaks to the commonly held belief throughout the mid-twentieth century that men required a higher wage to support a family, whereas women who were employed outside the home brought in a supplemental income, thus not requiring the higher wage (Brandt, Black, Bourne & Fahrni, 2011).   In BC, discussion about men working as PNs started as early as 1946, when a physician suggested that male attendants could be trained similarly to the PNs to be employed on male wards (Seymour, 1946). In 1954, the newly formed Nursing Orderly Association of BC requested from the PN Training Advisory Council that investigation of more comprehensive training for orderlies be initiated and further research of this possibility was to be pursued, however it is currently unknown if such training was ever initiated13. It is also unclear when men were first accepted into PN training programs in BC, however, one graduating class in 1965 had four men according to correspondence from the BC Council of Practical Nurses. This same correspondence raised discussion of whether to establish an orderly training program or simply open the PN vocational programs to men14. The integration of male orderlies into PN training                                                      11 McPherson (1996) describes nurse’s aides as another category of auxiliary worker, originally created for assisting RNs during crisis situations such as war, and later maintained in hospitals for the personal care of patients, as well as for housekeeping and cleaning duties on the ward. Training was typically short, either on-the-job or up to eight weeks. Historically, the title and functions of nurse’s aides has been ambiguous because it was often used interchangeably as a title for PNs throughout the first half of the twentieth century. 12 Lyle, W.J. (1966, January 3). [Letter to E. Martin]. British Columbia Archives (GR 0380, Box  15, File 4, Practical Nurses), Victoria, BC. 13 Practical Nurse Training Advisory Committee (1954, October 26). Minutes of a practical nurse trade advisory committee meeting. [Meeting Minutes]. Practical Nurses (GR 0119, Box 21, File 3 Title H-29-4). British Columbia Archives Victoria, BC. 14Nordlund, E.E. (1965, April 13). [Letter to G.E. Johnson (Requesting Orderly training program information].  British Columbia Archives (GR 0678, Box 43, File 3, Student Practical Nurses), Victoria, BC.   31  remained a matter of debate throughout the 1960s and responses varied across the different programs. It was not until 1970 that the first all-male practical nursing class was initiated at the vocational institute in Victoria, whereupon thirteen male PNs graduated and were to receive a PN license with the designation of ‘Nursing Orderly’15. Correspondence from the BC Hospital Association to other interested parties noted their concerns about licensing male PNs due to the potential demand for increased wages from other hospital support staff and a subsequent meeting was arranged to discuss the matter16. Documents outlining the results of this meeting have not yet been found, but it is likely that hospitals may have feared the increasing costs that would occur if female PNs would bargain for similar pay rates as their higher paid male counterparts once orderlies, became PNs.  Likely under the influence of broader social changes in gendered divisions in work and education during the 1960s and 1970s, education for PNs opened up to men as well in the late 1970s in BC.   Early PN Employment PNs were employed in a variety of workplaces. The early 1930’s saw PNs primarily working independently in private duty home care, with some working in smaller less established hospitals and very few in mental or tuberculosis institutions (Weir, 1932). Russell (1970) concurs with this information, however, she reports that the majority of PNs, both male and female, worked in mental institutions17.                                                        15 Cameron, A.H. (1971, June 9). [Letter R.R. Loffmark]. British Columbia Archives, (GR 0678, Box 58, File 9, Practical Nurses and Nursing Orderlies), Victoria, BC. 16 Bradford, J.D. (1971, September 17). [Letter to D.M. Cox]. British Columbia Archives, (GR 0678, Box 58, File 9, Practical Nurses and Nursing Orderlies), Victoria, BC. 17The exact years of this statement is not specifically referred to in the book, however it is discussed right before WWII, so it could be inferred that the time frame may be prior to WWII.    32   Data from the 1932 Weir survey indicated that the majority of nursing registries at that time did not employ PNs for home care, and of the few who did only one admitted to having an unofficial registry for PNs (p. 305). It is not entirely clear from the survey but it would seem that it was the standard practice for registries to preferably employ RNs. Data in the Weir report revealed that approximately thirteen percent of private duty nurses were PNs. Further research by Weir revealed that nearly half of the patients chose a PN for home care because of their willingness to do housework, while another quarter of patients chose a PN for financial reasons (Weir). As previously mentioned, supply and demand played a significant role in the recommendation of whether to utilize an RN or a PN, dependent upon an urban or rural location. Weir describes the PN as a “quasi-combination of charwoman, housemaid, cook and bedside attendant” (p. 398). “The practical nurse’s chief title to recognition appears to be the omnibus household load she is willing to assume” (Weir, p 399). Ultimately, the survey recommended continuing to utilize PNs for home care work and to ensure both mandatory registration and close supervision (Weir). It was suggested to create a ‘super registry’ in order to provide a range of nursing services. Confirming these recommendations was public opinion whereupon fifty percent reported that PNs were of much benefit to the community (Weir). Particular circumstances caused bitterness on the part of private duty RN’s who reported in the Weir Survey (1932) that some PNs were charging the same fees as RNs, even up to $3.50 a day by one PN who took maternity and post-surgical cases into her home. On average, however, it seemed PNs charged about twenty percent less than an RN to work as a private duty nurse (Weir). Considering that PNs were performing some of the basic tasks of the RNs, these sources seemed to suggest that there was rivalry for work in private duty between RNs and PNs.    33  As noted earlier, the CN journal during the mid-1930’s only made scant references to PNs however after WWII started, each subsequent year brought more frequent discussion and references to PNs. Some of these reports mentioned nursing registries that were utilizing PNs as part of their staffing to better meet patient needs. Prior to 1940, nursing directories advertised for employees in the CN but only RNs were sought, however the addition of PNs to these advertisements is a significant trend noted after 1940. This trend peaked in 1943 and subsequent advertisements were less frequent, disappearing altogether by 1946. It is difficult to hypothesize why the ads disappeared after 1946, although several theories could be speculated upon. By the end of WWII expectations prevailed that RNs would return to the job market; PN education and regulation was either being planned or implemented in some provinces. Further, PNs may have been anticipated as more easily accessible; registries might have sought potential employees directly through nursing schools; or perhaps the CN journal stopped the ads for unknown reasons. With an astute understanding of the complexities of utilizing PNs in health care, Ethel Johns commented on the topic in a CN article.  “Here is an issue the implications of which may yet shake the profession of nursing to its foundation” (Johns, 1936, p. 501). By closely monitoring nursing issues in the USA where PNs were already more established, Johns indicated that it was through RNs efforts to improve their own professional standing that PNs originated via necessity. Upon discussing the future plans of the CNA to advance RN education, she duly cautions and encourages Canadian nurses to expect the uptake of PNs in Canadian health care and to forthrightly embrace the controversies surrounding them.  Nevertheless, it would be some time before the CNA initiated a committee to explore the issue of PN qualifications and to determine the most appropriate training for PNs (Wilson, 1942b).    34  Emerging: Practical Nurse Development From 1940 Forward The Canadian Nurses Association. The outbreak of WWII forestalled the Canadian Nurses Association’s (CNA) discussions and plans to study the role of the PN, but provincial and federal initiatives forced the organization to revive their plans and a Committee on Subsidiary Nursing Groups was formed (Russell, 1970; Wilson, 1942b). By 1941 many provinces were either discussing the use of PNs or some home care registries were already employing PNs. Ontario had initiated a PN ‘Demonstration’ course, and as the first of its kind, the course was a joint effort between a nursing registry and the RN Association of Ontario, and was so successful that the training program expanded significantly by 1943 (Baker, 1941; Wilson, 1943). The nursing shortage was severely exacerbated by the war, necessitating additional health care workers. Pressure to consider formalization of PN training and registration also came from the federal Department of Pensions and National Health. A report in the CN noted that this department was organizing to submit a Health Insurance Act that included nursing service, and recommendations were made that the CNA take immediate action in regards to the preparation, licensing and control of PNs (Ahern, 1942). Apparently the need for nurses generated pressure to seriously consider the regulation and education not only of RNs but also of PNs. Such pressures may have triggered the formation of the CNA committee on subsidiary nurses, who issued the following statement: It is understood that it is the wish of the Executive Committee of the Canadian Nurses Association that this Committee include, in the study being made of subsidiary nursing groups, the preparation of a syllabus for guidance of Provincial Associations in the   35  training of such workers and, that in any form of control, plans be made for the inclusion of those already in the field (Wilson, 1942b, p. 928).  The CNA Executive Committee passed a resolution in 1943, advising provincial nursing associations involved in the training of subsidiary workers that protective legislation should also be pursued (Mallory, 1943). The following year, the CNA ‘Committee on Subsidiary Nursing Groups’ released a detailed twelve page report to all provincial associations 18 . The report covered topics in regards to subsidiary nursing groups such as: that the recommended title be nurse’s aide; their functions include “…relieving the professional nurse by caring for the non-acutely ill, well children and others who do not require highly skilled nursing care, both in hospitals and homes” (p. 1); necessary qualifications such as age, health, academic and references; the preparation of a training program including length, teaching centers, teaching personnel, course content and practical experiences; and lastly recommendations regarding the licensing and control of subsidiary nursing groups.  Additionally, an outline for the course was included that detailed the nursing theory and skills to be taught; the prescribed time frame for each topic; the length of and whereabouts of practical experiences; and a suggested bibliography and reference material for the instructor19.   Subsequent reports by the committee, now called ‘The Special Committee to Study Auxiliary Nursing Personnel’, were released in 195120, 195221 and 195622 and with input from provincial                                                      18 Canadian Nurses Association, (1944, June). Report of committee on subsidiary nursing groups. [Report]. Canadian Nurses Association Fonds (MG 28, I 248, Vol 66, File 1). Library and Archives Canada, Ottawa, ONT. 19 Canadian Nurses Association, (1944, June). Report of committee on subsidiary nursing groups. [Report]. Canadian Nurses Association Fonds (MG 28, I 248, Vol 66, File 1). Library and Archives Canada, Ottawa, ON. 20 Russell, M.G. (1951, April 5). Report of the special committee to study auxiliary nursing personnel [Report]. (MG 28, Series 248, Vol 65, File 19, Special Committee on Auxiliary Nursing Personnel. Library and Archives Canada, Ottawa, ON.   21 Russell, M.G. (1952, February). Report of the special committee to study auxiliary nursing personnel –Revised [Report]. (MG 28, Series 248, Vol 65, File 19, Special Committee on Auxiliary Nursing Personnel. Library and Archives Canada, Ottawa, ON.     36  associations, the scope of recommendations grew with each report. By 1956, the CNA endorsed the title ‘Nursing Assistant’ for all auxiliary nursing personnel and additions were made regarding the size and location of schools and hospitals,  instructor qualifications, curriculum, uniforms, examinations, the issuance of diplomas or certificates and salaries.  I will now turn to a more detailed discussion of the professional development of PNs in BC, wherein the provincial nursing association had already initiated steps to address PN development. The Registered Nurses Association of BC. In BC, the RNABC was actively involved in the establishment of PN education beginning in the early 1940`s and continued to stay involved throughout the time period examined in this thesis. Directives from the CNA regarding PNs were closely followed by the RNABC. Details specifying the RNABC`s reasons for their involvement and their ongoing control of PN education will be elaborated upon in chapter four, whereas this section discusses the specific actions the RNABC took regarding training and legislation of PNs.  As early as 1942, the RNABC recognized the place of and need for subsidiary nurses and following an intensive study of nursing care in BC, one of their recommendations was to ensure that duties for subsidiary nurses employed in BC hospitals were clearly outlined (Wilson, 1942a). In response to the increasing nursing shortage in BC in 1943, RNABC recommended the use of subsidiary nursing personnel, either paid or voluntary (Wilson, 1943). By 1945, the RNABC legislation committee created a special committee, for the purposes of carrying “…on an educational and publicity program throughout the province similar to that carried on last year in connection with the Registered Nurses Act” (Creasor, 1945, p. 13). The committee developed                                                                                                                                                                            22 Russell, M.G. (1956, October). Report of committee to study auxiliary nursing personnel - Revised [Report]. (MG 28, Series 248, Vol 65, File 19, Special Committee on Auxiliary Nursing Personnel. Library and Archives Canada, Ottawa, ON.     37  a brief, titled “Should Practical Nurses be Licensed,” which was mailed to all RN members, service clubs and interested community groups (Creasor, 1945). The brief requested the endorsement of PN licensing, and if agreeable, to forward the brief on to the Minister (unspecified which Minister, but likely the Minister of Health). The following year, the special legislation committee renewed efforts to secure public support for PN legislation, by sending out a letter to all stakeholder clubs and organizations. The letter re-iterated the importance of such legislation for reasons such as-public protection; re-training opportunities for ex-servicewomen; prevention of exploitation of PNs whom lacked legal status; as well as the growing demand for more basic nursing services for chronic and convalescent care (Creasor, 1946). The RNABC approved a one year experiment to employ PNs within an RNABC run home care directory in the Vancouver area (Registered Nurses Association of BC, 1946; Braund, 1947). A subsequent report outlined the success of the experiment and addressed pertinent facts, such as the insufficient number of PNs to fill all requests for work and the observation that no work was taken away from RNs through the experiment23 (Braund). Subsequently, in 1947 the RNABC Placement Service Committee reported on developments that spoke to the more permanent integration of PNs within the Placement Service for home care nursing. These developments included a thirty-five percent increase in calls for private duty nurses, the notification of Vancouver doctors of the enrollment of PNs within the Directory and a new fee schedule for PNs working in home care (Grundy, 1947). PN fees ranged from $3.50-4.50 for eight hours up to $5.50-6.50 for twenty hours24 (dependent on the experience of the PN) and                                                      23 The same Annual Report estimates a shortage of 407 RNs in BC during 1947, which thereby increases the veracity of the statement that work was not taken away from RNs during the PN experiment (Wright, 1947, April, p. 33). 24 To provide a rough comparison, the PN fee equates to approximately 43-56 cents an hour, whereas an RN working full-time in the hospital, receives approximately 80- 96 cents an hour, dependent on experience (RNABC, 1947, p. 62).    38  included meals (Grundy). Additional reports in 1948 continued to praise the success of the experiment, noting that PN graduates of newly established vocational programs were the most suitable due to their `more rounded preparation` and that patients and families alike appreciated the careful screening and selection of PN personnel (Grundy). In approximately 1948 to 1949, the RNABC sent out a Fact Sheet (below), seeking the approval and endorsement of PNs (Morrison, 1948). This sheet was based on observations noted from the establishment of PNs in the USA, and the sheet clearly noted the need to educate RN members and other relevant groups on their training. Furthermore, in sub-committee discussions it was noted that the Fact Sheet foresaw, and hence seemed to endorse, the use of PNs within the hospital setting (Davis, 1948)25.  The RNABC Executive Council focused part of one regular monthly meeting in 1951 on the PN training unit at Vancouver Vocational Institute (VVI) and a presentation was given on PN training and utilization at the institute (Wright, 1951).   As previously described, the RNABC continued to advocate for the enactment of PN legislation. In 1956, the RNABC President and the Executive Secretary met with the Minister of Health to voice their concerns over the issue of legislation and a letter was subsequently sent to the Minister re-iterating the views of the RNABC regarding the need for legislation regulating practical nursing (Wright, 1956). The Vancouver Vocational Institute (VVI) There were multiple organized influences on the initiation of PN training at VVI in 1948. These included the local, provincial and federal governments and various interest groups at the                                                      25 The back of the Fact Sheet listed the references used to create the pamphlet and the majority of these were from the USA. Therefore, the foresight of the RNABC for the use of PNs in the hospital setting was likely based on this research where a significant number of PNs were already utilized in the hospital setting.    39  provincial level, as well as the CNA. In 1946, under the direction of the RNABC Executive, the Joint Planning Committee on Nursing was formed with the intent of studying the nursing needs of hospitals and communities in BC. Representation from other important groups was invited and members then included the RNABC, both the Ministries of Health and Education, the BC Hospitals Association, the BC Medical Association, the Department of Veterans Affairs, the Office of the Provincial Secretary26 and the Community Chest and Council of Greater Vancouver (Wright, 1947)27.  Within their mandate to address the nursing shortage in BC was the more specific goal of studying the use of auxiliary nursing personnel to supplement the services of RNs. Within their first year of existence, the Joint Planning Committee was exploring possibilities to initiate a PN training program in BC and they created the first draft of the PNs Act, which outlined the training, control and licensing of PNs in BC. The committee had the intention to submit the Act to the provincial government when “…the moment seems auspicious” (Wright, 1947, p. 28). The first passing of the Act occurred in 1951 however the lengthy delay in the full promulgation of the Act is discussed in more detail in chapter four.  The initiation of PN training at the VVI.  By 1948 the Joint Planning Committee on Nursing had been advocating for the initiation of PN training at the vocational school level for several years, while the provincial and federal governments recognized the need to provide vocational skills training for the returning WWII veterans (Wright, 1947; Hartley, 1992). Federal funding for vocational schools played a large                                                      26 The Office of the Provincial Secretary in BC held the Great Seal of the Province and kept all registers and archives of the present and previous provincial governments. The office was renamed the Ministry of Government Management Services in 1988 and some of the former duties were transferred to other ministries (Memory BC, 2016) 27 The Community Chest and Council Organization of Greater Vancouver, was part of a wider group of agencies throughout North America, whose purpose was to improve the social welfare of the community. The ‘Chest’ section of the agency focused on fundraising efforts while the ‘Council’ section worked on policy development (Aghai, 1958).    40  role in their growth throughout the 1940s. Two pieces of federal legislation provided significant funding to build new vocational schools across Canada, as well as assist in the funding of the various programs (Lyons, Randhawa & Paulson, 1991; “Parker School”, 1947). In conjunction with provincial and federal support and funding, vocational school training offered by the Vancouver School Board grew immensely after WWII. The first PN training program started temporarily out of the Vancouver Technical High School in 1948, continuing until the new VVI building was complete in the fall of 1949 (Hartley, 1992). The program was initiated as a demonstration to determine if the graduates would be suitable for work in private duty home care.  The first class of eight PNs graduated in December of 1948, out of thirteen students who had started the program (Hartley, 1992). After being deemed successful (not specified by who), the program continued, with three intakes a year. The PN students completed an educational program consisting of four months of classroom theory and eight months of clinical practice in a variety of hospitals. Upon graduation, PNs received a PN certificate and a pin (see end of chapter three for images of these).  The green cross became an enduring symbol for PNs in BC throughout their development in the mid-twentieth century28.  A 1953 VVI brochure for the PN program cites the total cost of the program as $60, (each month of theory cost $15). PN students did not pay for their clinical practicums, but instead were paid a stipend, as they were considered apprentices under government policy29. The stipend began at $14 a week and was increased by $2 bi-monthly. Admission requirements                                                      28 The use of a green cross has historically been associated with nursing care. The religious Hospitaller Order of St Lazarus in Jerusalem used the green cross as their emblem  during the twelfth century (Hyacinthe, 2013) and in the Netherlands, the Green Cross home nursing organization has existed throughout most of the twentieth century (van der Boom, 2008). 29 Vancouver Vocational Institute, (1953, February 11). Vancouver Vocational Institute Course for Practical Nurses [Brochure]. Vancouver, BC: RNABC. (GR 0119, Box 21, File 3, Practical Nurses). British Columbia Archives, Victoria, BC.   41  specified that applicants must be between 18-45 years of age, have completed a minimum of grade ten and undergo an interview26. By 1966, PN training had expanded to five more of the larger cities in BC under the same apprenticeship model and continued to grow. Programs had been established in Victoria, Nanaimo, Prince George, Castlegar and Kelowna (Hartley, 1992)30. By that same year annually 310 PNs were graduating in BC and there seems to have been an interest and possibility for increasing seats in some programs as the majority of graduates easily gained employment as PNs28. Theory and clinical instructors were RNs, as were the supervisors of PN employees in home care and the hospital (Hartley, 1992). Practical Nursing Education This section encompasses practical nursing education including details on theory and clinical, resources and exams utilized and how the PN scope of practice evolved throughout the thirty year span addressed in this thesis. To date, I have not found any data that discusses the general practical nursing textbooks written by Canadian authors which would have been used for PN training during the early to mid-twentieth century31. An American textbook, the “Home Nurse’s Handbook of Practical Nursing” (Aikens, 1922) was commonly used at the YWCA PN training school in New York during the early twentieth century and also may have been used as a manual for the Parker School of Trained                                                      30 Nordlund, E.E. (Office of Director of Technical and Vocational Education) (1966, September 11). [Memo to Donald M. Cox (Deputy Minister Hospital Insurance Services)]. British Columbia Archives (GR 0679, Box 3, File 57, Practical Nurses – Training of). Victoria, BC. 31 It may be that none existed at this time, given that PN education was just beginning to be established during the mid-twentieth century in Canada.    42  Attendants in Montreal.32 Likely the new programs in BC may have drawn on similar sources. The Public Health Journal (“Reviews and Acknowledgments”, 1912) published a positive review of the first edition of the handbook and recommended the text for anyone involved in the care of the sick within the home, but specifically for mothers, PNs and trained attendants. The chapters within the book demonstrate the multitude of topics discussed throughout the twenty-six chapters of the book, including topics on the basic care of the sick including bathing and feeding, cooking and cleaning, administering treatments and medicines, bandaging, how to manage common sicknesses and emergencies and more detailed chapters on specific care for special populations such as maternity and baby care (Aikens, 1922). The Weir survey (1932) reports several topics of training for the ”Trained Attendant” or “Practical Woman” (p. 61) including “The Theory and Practice of Household Science; Home Hygiene; and The Care of the Sick” (p 61) however no sources or further details are provided. The first CNA report and recommendations regarding PNs education released in 1944 specifically outlines the subjects to be covered in PN classroom theory, including the number of hours to be dedicated to each subject, which totaled 230 hours. Each subject is further divided into very specific units. Elementary procedures in the care of the sick was by far the most comprehensive subject, and included theory and skills for basic first aid, care of the sick, administering oral medications, simple solutions, basic disinfection and sterilization. Basic monitoring of the sick patient was also covered and included how to take temperature, pulse, respiration and pertinent symptoms to observe for and report. Other less comprehensive sections                                                      32 This is an assumption as I haven’t found any references to confirm this, however, the book was used in the American YWCA PN training program and the Parker School for trained attendants in Montreal closely followed their training program (Parker, 1946).   43  included personal hygiene, working relationships, housekeeping, cooking, care for children, for convalescent, aged and chronic patients, as well as for mothers and newborn infants33.  The guidelines also gave direction with regards to practical experiences. Each PN student was expected to conduct clinical practice in both an institution and in the private home with mildly ill or convalescent patients, as well as working with well children in a day nursery (see footnote 33). Hartley (1992) reported based on personal interviews with several 1962 VVI graduates, that various facilities were utilized for PN student placements. These placements ensured experience in medical, surgical, obstetrical, pediatrics and geriatric nursing, utilizing the many hospitals and care facilities throughout Vancouver. It is unclear if other facilities were regularly utilized by the VVI PN program, but the Coqualeetza tuberculosis hospital, outside of Vancouver and home care nursing under the direction of a public health nurse were other reported placements (Hartley). A former student, Judy Henderson, remembered that awards were given to select PN students at VVI as incentives, including academic achievement, bedside manner and popularity (Hartley). The CNA recommendations were consequently implemented in PN education in BC. The theory portion of the PN program is described in the 1953 VVI brochure as covering basic housekeeping, cooking, nutrition, first aid, health prevention, infection control, functions of the human body, basic care of the sick and making solutions and poultices34. The 1951 CNA report35 on PNs recommended standardized examinations which should be administered to PN students,                                                      33 Canadian Nurses Association, (1944, June). Report of committee on subsidiary nursing groups. [Report]. Canadian Nurses Association Fonds (MG 28, I 248, Vol 66, File 1). Library and Archives Canada, Ottawa, ONT. 34 Vancouver Vocational Institute, (1953, February 11). Vancouver Vocational Institute Course for Practical Nurses [Brochure]. Vancouver, BC: RNABC. (GR 0119, Box 21, File 3, Practical Nurses). British Columbia Archives, Victoria, BC. 35 Russell, M.G. (1951, April 5). Report of the special committee to study auxiliary nursing personnel [Report]. (MG 28, Series 248, Vol 65, File 19, Special Committee on Auxiliary Nursing Personnel. Library and Archives Canada, Ottawa, ON.     44  and indeed provincial examinations were written by students in order to graduate, however it is unknown what year the examinations were initiated at the VVI (Hartley, 1992). The examinations were developed by the provincial Department of Education through a committee of nursing instructors and were so well written that other provinces purchased them from the Department of Education (Hartley; Hall, 1977). According to the CNA reports on subsidiary workers, nationally their scope practice changed little throughout the specified time period of this thesis.  Subsequent reports released by the CNA describe only minor additions to the recommended theory and skill set for PNs (see footnote 35).  In 1951, the technique of how to prepare and administer subcutaneous hypodermic injections was included, due to the increased number of patients requiring these in the home.  Specific instructions were outlined noting that these procedures occurred only with an order and only when a physician or RN was unavailable to administer the injection. Additionally, the PN was instructed not to prepare any hypodermic injection requiring calculations (see footnote 35). By 1956, aspects of psychiatric nursing were added to the theory portion of PN education, as well as an emphasis on incorporating the World Health Organization (WHO) definition of health that included physical, mental and social well-being as a core concept of PN education36. While the aforementioned changes in PN scope of practice were recommendations made by CNA, as yet it is unknown if they were incorporated into PN education in BC.  After the full enactment of the PN Act in 1965, the BC Council of Practical Nurses (BCCPN) was designated whose purposes included making pertinent decisions regarding the training, regulation and licensing of PNs in BC, as well as their scope of practice. The following                                                      36 Russell, M.G. (1956, October). Report of committee to study auxiliary nursing personnel - Revised [Report]. (MG 28, Series 248, Vol 65, File 19, Special Committee on Auxiliary Nursing Personnel. Library and Archives Canada, Ottawa, ON.     45  year, the BCCPN released a document titled the “Outline of the duties to be used as a guide in the employment of the Licensed Practical Nurse in BC” to be used as described in the title37. The outline was provided to all BC hospitals and institutes that did or might employ PNs38. A subsequent outline was released in 1972, which varied little from the previously described education of PNs, except for several changes. In 1970, the taking and recording of blood pressures was added to PN education, and male PN students were required to complete an urology rotation instead of an obstetrical one, which included the skill of catheterization39. A contentious issue in the early 1950s in BC was the decision of whether to allow PNs to administer medications (Goldstone, 1981).  The College of Physicians and Surgeons endorsed PNs administering medications under the direct supervision of the physician, however the RNABC and the BC Hospital Association were opposed (Goldstone). Despite the CNA’s recommendation that this skill be included in PN training, it is apparent that it was not incorporated into their training in BC as demonstrated by later documents from the PN Association (see footnote 37). The standard uniform for PN students at the school was a green dress with either an embroidered crest or lettering on the left sleeve, identifying the student as a V.V.I. PN. During clinical hours, the PN student wore a striped white and green dress, and upon graduation, the uniform changed to a white dress with the traditional PN green cross on the left sleeve and the cap band (see Figure 1 of Wilson) (Hartley, 1992).                                                      37 BCCPN (1966). Outline of duties to be used in the employment of the Licensed Practical Nurse in BC. [Outline]. Executive Records (GR 0678, Box 58, File 9, Practical Nurses and Nursing Orderlies). British Columbia Archives: Victoria, BC. 38 Thompson, R,H, (Public Information Officer, BC Hospital Insurance Services) (1966, December 14). [Letter to W.J. Lyle (Hospital Finance Manager, BC Hospital Insurance Services)]. Executive Records (GR 0678, Box 58, File 9, Practical Nurses and Nursing Orderlies). British Columbia Archives: Victoria, BC. 39 BCCPN (1972). Outline of duties to be used in the employment of the Licensed Practical Nurse in BC (Revised Edition). [Outline]. Executive Records (GR 0678, Box 58, File 9, Practical Nurses and Nursing Orderlies). British Columbia Archives: Victoria, BC.   46  In the following chapter, the reader is introduced to the subject of the biographical portion of this thesis, practical nurse Florence Wilson. Her involvement in PN political issues in BC embodies the struggles that PNs encountered throughout the mid-twentieth century. Additionally, the chapter explores the various responses from organized groups, such as the PN and the RN associations, the Hospital Employees Union and several branches of the provincial government.     47  Chapter Four: Organized Responses and the Advocacy Work of Florence Wilson and the PNABC  In this chapter, I address the viewpoints of PNs themselves. Their role in the enactment of PN legislation, their training as well as their role in the establishment of their own professional organization is examined. As their role became formally recognized and regulated, the voice of PNs themselves also grew stronger. In addition, reactions of other organized groups as well as their responses to the evolving role of PNs is addressed. Florence Wilson         The nursing career and advocacy work of Florence Wilson exemplifies the voice of the PNs and closely follows the progression of PN growth and establishment in BC. Wilson was not only a graduate from the first PN program in BC, but she also played a key role in seeing the PN Act proclaimed in 1965 (Hartley, 1992) 40 . Wilson had always hoped to become an RN, but circumstances prevented her from doing so earlier in her life. It was after becoming a widow with five children that Wilson decided to pursue PN training for economic reasons. When she started the PN training program she was already working as a nurse’s aide at Vancouver General Hospital. VVI held only two sessions of evening classes in practical nursing, once in 1950 and again in 1952, specifically for nurse’s aides41 who wanted to become PNs and credit was given for their nursing experience as an aide (Hartley, 1992). Thus while working as a nurse’s aide at Vancouver General Hospital, Wilson attended night school at VVI, and at the age of fifty-one,                                                      40 British Columbia History of Nursing Society (2012, April). Florence Wilson (Nee Jago) 1901-1991, Biographical History [Biography]. Florence Wilson (Fond 24, File 4). British Columbia History of Nursing Society, Vancouver, BC. 41 See footnote 11; It is unknown if the PN evening classes held at VVI were designed specifically for nurse’s aides with formal training, or for those trained informally on the job, or both.    48  with her family and first grandchild attending the ceremony, she graduated with her PN diploma on March 23rd, 1952 (Hartley) (see footnote 40).         The Canadian Cancer Institute was her primary employer for some time where she worked both as a PN then a dietician. She later went into private home care nursing, and continued to work until she was eighty-three years of age (Hartley, 1992) (see footnote 40). Wilson was part of the BC Council of Practical Nurses designated in 1965, as well as an early member of the PNs Association of BC (PNABC) and remained active within the association until 1974 (Hartley, 1992) (see footnote 40).  Figure 1 Florence Wilson, Practical Nurse Graduation, 195242                                                       42[Photograph of Florence Wilson]. (1952). Florence Wilson (Fond 24, File 4). British Columbia History of Nursing Society (hereafter called the BCHNS). University of British Columbia, Vancouver, BC. Copyright BCHNS – Reproduction used with permission.    49   Figure 2 Practical Nurse Graduation Pin from VVI, 195243    Figure 3 Florence Wilson, First Licensed Practical Nurse in BC, 196544                                                       43[Photograph of Vancouver Vocational Institute (VVI) Practical Nurse graduation pin received by Florence Wilson]. (1952). Florence Wilson (Fond 24, File 4). British Columbia History of Nursing Society, Vancouver, BC. Copyright BCHNS – Reproduction used with permission.  44[Photograph of the first Licence for a Practical Nurse in BC issued by the BCCPN, and received by Florence Wilson]. (1965). Florence Wilson (Fond 24, File 4). British Columbia History of Nursing Society, Vancouver, BC. Copyright BCHNS – Reproduction used with permission.    50   After the first passing of the first PN legislation in 1951, PNs organized themselves. They worked hard to create their own professional nursing association and to gain the full enactment of the PN act, with Florence Wilson as a primary force in this movement.  Additionally, many organized groups, including the RNABC, CNA, the BC Hospital Association, the Hospital Employees’ Union and the provincial and federal governments, played a role in the establishment of PN in BC. The purpose of this chapter is to explore these processes in more detail and highlight the PNs own role in the enactment of the legislation. The Practical Nurses Association (PNA)  The Practical Nurses Association (PNA) was formed in 1951 under the Societies Act. It was the professional association for PNs in BC (Hartley, 1992). The PNA has undergone several changes to its name and mandate since its inception in 196545. Mrs. K. Johnstone, a RN and chief instructor for PNs at VVI since its inception, was instrumental in the formation of the PNA and in guiding PNs throughout the early years of the association. This organization was founded on her conviction that PNs needed a guiding professional body, similar to RNs who were organized in the RNABC at that time. Securing full enactment of the PN legislation was a critical issue for the association for nearly a decade and a half. Registration with the PNA was voluntary, however membership steadily increased during the fifties and sixties46. Florence Wilson was the president for much of the 1950s and monthly meetings were held at VVI (Hartley).                                                      45The PNA was the professional association for the advocacy of Practical Nurses in BC since 1951, however when the PN Act was finally enacted in 1965, the PNA became the LPNABC and duties included both advocacy and regulation of Practical Nurses. In 1996, the BC government created the Health Professions Act, whereupon the duties of LPNABC became strictly advocacy, and the newly created College of Licensed Practical Nurses of BC (CLPNBC) became the regulatory body for Licensed Practical Nurses in BC (BC Government, 2016).  46 Registration with the PNA and LPNABC was voluntary until 1989 when the Practical Nurses Act changed registration to be mandatory for all Licensed Practical Nurses in BC (Licensed Practical Nurses Association of British Columbia, n.d.).    51  At some point in the 1950s (date unspecified by Hartley), a newsletter was developed by the PNA and sent to it’s over 200 members. The newsletter eventually developed into a quarterly publication and included messages from the President and Council (after its re-establishment in 1965), meeting reports, graduations and awards47. Initially operating as a lone body based in Vancouver, new PNA chapters followed the opening of PN schools on Vancouver Island and in the Interior during the 1960s. With the full enactment of the PN legislation early in 1965, the PNA officially changed its name to the Licensed Practical Nurses Association of BC (LPNABC) and the cost of membership by this time was two dollars per year (Hartley, 1992).  Legislation of Practical Nurses in BC  The enactment of PN legislation in BC was a drawn out process that took over thirteen years to fulfill. As described earlier, the first draft of the PN Act was created sometime in late 1946 or early 1947 by the Joint Planning Committee on Nursing and after much advocacy by multiple groups (as will be subsequently discussed), the Act passed first reading in the BC Legislature in April, 1951. The first Council for Practical Nurses was designated by the Lieutenant-In-Council in July of 1952, whose ten members represented various organizations who had a vested interest in PNs48. Currently, evidence is lacking that outlines the mandate of the PN council, however  it would likely have been to provide guidance on practical nursing matters  but specifically in relation to PN training and licensing,. The council members were nominated by individuals such as the Minister of Health and Welfare and the Minister of Education, as well as organizations such as the College of Physicians and Surgeons, the RNABC                                                      47 Gilchrist, K. (1965, September). Newsletter of the Licensed Practical Nurses Association of British Columbia [Newsletter]. Department of Health Services and Hospital Insurance (GR 0380, Box 212, File 3, Title H-29-4). British Columbia Archives, Victoria BC.  48 Hall, G.M. (1952, January 23). [Letter to the Members of the Special Committee to Study Auxiliary Nursing Personnel]. Canadian Nurses Association Fonds (MG 28, I 248, Vol 65, File 19). Library and Archives Canada. Ottawa, ON.    52  and the BCHA. The members` terms on council expired in July of 1955, and as yet there is no evidence explaining if reappointments were made 195549. It is unclear what happened to or within this council and to date the evidence suggests it simply fell by the wayside likely due to the significant delay in the PN legislation. There is only minimal evidence of the council  meetings, however in a 1954 letter from a sub-committee of the Vancouver School Board, the PN Training Advisory Committee (PNTAC) addressed the health minister that: You will recall, also, that this Council did meet and did make very detailed recommendations to the Minister of Health with respect to the licensing of Practical Nurses, and that, to date, the recommendations of the council have not been acted upon50.  Other PN council duties would have been the re-drafting of regulations, appointing a Registrar for record maintenance of the Licensed Practical Nurses and appointing a Board of Examiners to carry out PN licensing exams. Any such regulations or appointments would have been put forward to the Lieutenant-Governor-in-Council, to be fully enacted in the BC legislature however several provincial government figures, including the Deputy Provincial Secretary confirmed their lack of existence (see footnote 49)51. RNABC annual reports did little to shed light on the activities of the PN Council. The reports from 1952-1955 mention RNABC`s representation on the Council but do not elaborate further on its activities or decisions, only that there were no meetings  of the PN Council held during the year preceding June 1954 (Wright, 1953; Wright, 1954; Wright, 1955). Subsequent efforts to have the PN Act fully enacted were                                                      49 Wiper, K. (1957, October 1). [Letter to J. Mainguy]. British Columbia Archives (GR 0679, Box 3, File 57, Practical Nurses – Training of), Victoria, BC. 50 Rossiter, E.E. (1954, November 9). [Letter E. Martin]. British Columbia Archives (GR 0119, Box 21, File 3, Practical Nurses), Victoria, BC. 51 Wallace, L.J. (1959, January 29). [Memo to E. Martin]. British Columbia Archives (GR 0119, Box 21, File 3, Practical Nurses), Victoria, BC.   53  stalled for over a decade until finally in late 1964 the PN legislation was finally provincial government announced their intention to finally proclaim the Act. This section examines and seeks to explain the drawn out process of gaining full proclamation of the PN Act.  It is unclear exactly why the PN Act was stagnant for so many years, particularly when a few provinces had enacted legislation controlling the education, regulation and licensing of PNs as early as 1947. By 1963 five out of the ten provinces had enacted legislation for their PNs52 (Territories not listed).  The PN Association of BC (PNA) (as cited in Hartley, 1992, p. 11-12) contended that the Social Credit Party (colloquially called the ‘Socreds’) in power during the 1950s and 1960s was the impediment to the enactment of the PN Act, but no further explanation is provided in the source. Heretofore, the historical data lacks any direct evidence of this claim, however I argue several possible theories might be at play. First, it is plausible that the PNA’s contention regarding the Social Credit party is legitimate. The Social Credit ideology actively functioned under a variety of organized political identities at different times in several Canadian provinces. As an organized political party it only gained real power provincially in BC and Alberta during the early to mid-twentieth century forming the government in each province for thirty and twenty-eight years, respectively (Mitchell, 1983). The party’s appeal to voters was related in part to its populist stance, and conservative fiscal policies, particularly following the hardship of the Great Depression in the 1930’s (Mitchell).   In regard to PN legislation in BC, an interesting parallel can be drawn to Alberta, whose Social Credit government fully enacted PN legislation in 1947 (College of Licensed Practical Nurses of Alberta, 2015; Social Credit, 2015). This marked contrast in the                                                      52 Canadian Nurses Association (1963, January). Information Re: Certified Nursing Assistants [Document]. British Columbia Archives (GR 0380, Box 15, File 4, Practical Nurses), Victoria, BC.   54  evolution of PN legislation between the two provinces requires further research, but is not within the scope of this thesis. It should be noted that Social Credit had been in power for some ten years in Alberta when PN legislation was enacted there, in contrast to the political environment in BC during the early 1950s, as subsequently will be discussed. Additionally, the economic climate in Alberta was much different than BC, due to the boom in oil production starting in the late 1940s (Finch, 2014). Alternately, it could be argued that rather than the Social Credit party being the main impediment to enacting the PN legislation, the delay had more to do with unfortunate timing. The provincial election in 1952 brought significant changes to the BC government. It was the first provincial victory for the Social Credit Party under W.A.C Bennett, and as such a new Cabinet was appointed (Mitchell, 1983; Turnbull, 1987/88). Only two members of the new cabinet had any legislative experience, Bennett and Tilly Rolston, whom was the first female cabinet minister in Canada (Mitchell). It is entirely plausible that the abrupt changes to the provincial government and a new political agenda, coupled with a relatively inexperienced cabinet could easily have placed the PN legislation in abeyance.  A third hypothesis that could explain the delay in PN legislation in BC may be due to the change in Ministers of Health after the 1952 provincial election. The portfolio of Health and Welfare Minister was transferred to the Honorable Eric Martin, (a Social Credit MLA from Vancouver-Burrard), whose background included accounting (Parliament of Canada, n.d.). Several theories regarding the Health Minister could explain the stagnation of the PN Act. Perhaps he may have been overwhelmed with the pressure of work in a new ministerial post. Martin was a relative newcomer to politics, having been first elected in 1952. Early on, a   55  significant amount of his time as Health Minister was spent opening new hospitals53, for which funding was partially provided in the 1948 Federal Health Grants (Mitchell, 1983; Turnbull, 1987/88; Webb, 1994).This final argument, however, does tie in with some of the historical accounts suggesting that early on Martin may have lacked either the time, the power or the incentive to take further action on the PN legislation issue; alternatively he may have been simply stalling for unknown reasons54. Florence Wilson, a member of the PNA executive, and two other PNs, Kaye Gilchrist and Florence Deschner (also VVI graduates), had a strong belief in the importance of the final enactment of the PN legislation and worked tirelessly to advocate for this cause (Hartley, 1992)55. Several times a year during the 1950s, these three PNs, acting on behalf of the PNA, prepared and sent briefs, and met with the Minister of Health to reiterate their cause. Each time, however, he maintained the stance that more PN graduates were necessary to gain full promulgation of the PN Act (Hartley). Many other individuals and groups advocated to the Minister of Health for the same cause, as will be subsequently discussed. Nevertheless, despite this advocacy work, the PNA maintained that Martin continuously did not take action on the enactment of the PN legislation throughout the 1950s (Hartley). Advocacy for the PN Act  In addition to individual PNs and the PNA, others were also interested in seeing the PN legislation enacted and worked towards the same end. The principal of VVI, Mr. S.V. Clarke, also met with Minister Martin several times throughout the 1950s to advocate on behalf of PNs,                                                      53 Ostry (2012) reports that the number of hospitals built in Canada between 1945 and 1959 increased by one third.  54 Martin, E. (1958, November 20). [Letter to Member of Legislative Assembly F. Richter]. British Columbia Archives (GR 0119, Box 21, File 3, Practical Nurses). Victoria, BC. Martin, E. (1957, October 4). [Letter to Anonymous Representative of South Vancouver Island Women`s Institutes]. British Columbia Archives (GR 0119, Box 21, File 3, Practical Nurses). Victoria, BC.  Wright, A.L. (1956, January 9). [Letter to E. Martin]. British Columbia Archives (GR 0119, Box 21, File 3, H-29-4, Practical Nurses) Victoria, BC. 55 Hartley (1992, p. 13-14) obtained this research data through personal interviews with multiple former PN students for her Master`s thesis on the history of Practical Nurses at VVI.   56  however Martin`s response remained the same as for the PNs (Hartley, 1992). RNABC remained committed to this cause and several briefs with the RNABC`s resolutions were sent to the Health Minister throughout this period (Hartley)56. Additionally, the Practical Nurse Training Advisory Committee (PNTAC), whose multiple government, hospital and nursing representatives advised the Ministry of Education about PN training, also sent letters in 1954 advocating for PN legislation57. Pertinent reasons why it was desirable for the PN legislation to be enacted were provided by these groups. For example, the inability of VVI or the department of education to definitively answer questions regarding the job market for new PN graduates from VVI caused difficulty. Furthermore, many nurse’s aides (see footnote 11) within BC hospitals had questions regarding the effect of PN licensing on their jobs, as it was unknown whether or not the formally trained and ‘on-the-job’ trained nurse’s aides would be grandfathered under the new legislation; and finally PNs wondered about the likelihood of losing their jobs within Federal hospitals in BC, due to the Federal hiring mandate to have only licensed PNs (whereupon licensed PNs from other provinces were being given priority in hiring (see footnote 56)58. Notably, with the letter from the PNTAC to the Health minister, a bulletin from the Federal Department of Health and Welfare had been attached, and it was pointed out that the federal Department was under the impression that the PN Act was already in effect in BC (see footnote 57). In this same letter, the PNTAC points out that the provincial ministries that supported the PN training program, such as                                                      56 Wright, A.L. (1956, January 9). [Letter to E. Martin]. British Columbia Archives (GR 0119, Box 21, File 3, H-29-4, Practical Nurses) Victoria, BC. 57 Minutes, (1954, October 26). Minutes of a Practical Nurse advisory committee meeting. British Columbia Archives, (GR 0119, Box 21, File 3, H-29-4, Practical Nurses), Victoria, BC  Rossiter, E.E. (1955, November 29).  [Letter to E. Martin]. British Columbia Archives (GR 0119, Box 21, File 3, H-29-4, Practical Nurses) Victoria, BC.   58 Rossiter, E.E. (1954, November 9). [Letter E. Martin]. British Columbia Archives (GR 0119, Box 21, File 3, Practical Nurses), Victoria, BC    57  the Ministries of Education and of Labour, would be concerned with PN employment issues after graduation (given their contributions to PN training in BC).  The BC Hospital Association (BCHA) was another organization with a vested interest in the progress of the PN Act. It is noted that during the 1963 annual meeting, the members, representing various BC hospitals, passed a resolution in support of the implementation of the PN Act, and communicated their position to the Minister of Health in a meeting that same year59. Nevertheless, there is conflicting information regarding BCHA`s support for such legislation, as discussed in a subsequent section. Letter campaign. During the years 1955 through 1958, PN representatives and supporters with a vested interest in PNs started a remarkable letter campaign launched at the Health Minister urging the full enactment of the PN Act. It seemed the PNs and their supporters were impatient if not frustrated about the lack of action from the part of the government. The stimulus for the letter campaign may have also resulted from a recommendation in the 1951 CNA brief on PNs, given to all provincial RN associations. In reference to the recruitment of PN students, the recommendation encouraged the RN associations to maintain contact with various agencies involved in the well-being of, career prep for, or employment of young women, including local women`s organizations 60 . Two streams of letters were noted, which involved the groups                                                      59 British Columbia Hospital Association (1964, April 8).  A report on an extraordinary meeting of the education committee [Report]. (GR 0678, Box 43, File 3, Student Practical Nurses). British Columbia Archives, Victoria, BC. 60 Russell, M.G. (1951, April 5). Report of the special committee to study auxiliary nursing personnel [Report]. (MG 28, Series 248, Vol 65, File 19). Special Committee on Auxiliary Nursing Personnel. Library and Archives Canada, Ottawa, ON.     58  mentioned in the previous section, but also one large group of letters coming from two key women’s organizations and the second group coming from Victoria and the surrounding area61.  The first group of letters was written by various chapters of the BC Women’s Institute (BCWI) and the Provincial Council of Women of BC (PCWBC)62. The mandate of  each organization varied somewhat but primarily they both focused on social and health advocacy and policy work, especially on issues pertaining to women (British Columbia Women`s Institute, 2015; National Council of Women of Canada, 2015). Both organizations passed resolutions at their respective annual conference to promote the enactment of PN legislation and local chapters wrote letters to either the health minister or the local Member of the Legislative Assembly                                                      61 It is significant to note that many more letters in the archived government file were read by the writer, however copies were not obtained of all them (others were from concerned citizens and current PN students). 62 Anonymous (1956, November 29). [Letter from anonymous representative of the Victoria Council of Women to Minister of Health, E. Martin]. British Columbia Archives (GR 0119, Box 21, File 3, H-29-4, Practical Nurses) Victoria, BC. Anonymous (1956, December 6). [Letter from anonymous representative of the Lake Hill Women`s Institute to Minister of Health, E. Martin]. British Columbia Archives (GR 0119, Box 21, File 3, H-29-4, Practical Nurses) Victoria, BC. Anonymous (1957, October 2). [Letter from anonymous representative of the South Vancouver Island Women`s Institute to Health Minister E. Martin]. British Columbia Archives (GR 0119, Box 21, File 3, H-29-4, Practical Nurses) Victoria, BC. Anonymous (1957, April 9). [Letter from anonymous representative of the Brentwood Women`s Institute to Health Minister E. Martin]. British Columbia Archives (GR 0119, Box 21, File 3, H-29-4, Practical Nurses) Victoria, BC. Anonymous (1957, February 9). [Letter from anonymous representative of the Victoria Women`s Institute to Medical Health Officer, anonymous]. British Columbia Archives (GR 0119, Box 21, File 3, H-29-4, Practical Nurses) Victoria, BC. Anonymous (1957, February 13). [Letter from anonymous representatives of the Lake Hill Women`s Institute, the Red Cross Homemakers Service of Victoria and the Victoria branch of the Victorian Order of Nurses to Minister of Health E. Martin]. British Columbia Archives (GR 0119, Box 21, File 3, H-29-4, Practical Nurses) Victoria, BC. Anonymous (1958, August 4). [Letter from anonymous representative of the Beresford Women`s Institute to Member of Legislative Assembly P.A. Gaglardi]. British Columbia Archives (GR 0119, Box 21, File 3, H-29-4, Practical Nurses) Victoria, BC. Anonymous (1958, October). [Letter from anonymous representative of the Testalinda Women`s Institute to Member of Legislative Assembly F. Richter]. British Columbia Archives (GR 0119, Box 21, File 3, H-29-4, Practical Nurses) Victoria, BC.   59  (MLA) to this end. The briefs urged the provincial government “…to implement the Practical Nurse’s Act forthwith”63.   As discussed previously, it is likely that the RNABC might have requested the support of the BCWI and the PCWBC to advocate for the full enactment of PN legislation in BC. This is feasible because several women had cross appointments on various PN committees, and as such, may have had influence with other organizations who could also promote the enactment of the PN Act. Mrs. Rex (Fraudena) Eaton was one such woman as she was the original chairperson on the PN Advisory Council appointed in 195264. According to Rose (1990), Eaton had been appointed to the PN Advisory Council by the then Minister of Health and Welfare, Mr. A. D. Turnbull. Prior to 1942, Mrs. Eaton had served on the Executive council of the Vancouver Council of Women, a local chapter of the PCWBC. Furthermore, Eaton was involved in many other community and government groups that supported civil liberties and received an award for her services (“President to present”, 1954). More than likely this speaks to continuing membership or ties she may have kept with the PCWBC and might have requested their support in advocating for PN legislation in BC.  In response to a letter from a BCWI chapter, Martin wrote in November of 1958 that  …there is nothing to prevent the Practical Nurses from forming their own association and drawing up their own constitution and by-laws in order to place their work on an organized basis. It is our contention that this should be done voluntarily as, in the main, it                                                      63 Anonymous (1958, October). [Letter from anonymous representative of the Testalinda Women`s Institute to Member of Legislative Assembly F. Richter]. British Columbia Archives (GR 0119, Box 21, File 3, H-29-4, Practical Nurses) Victoria, BC. 64 Hall, G.M. (1952, January 23). [Letter Members of the Special Committee to Study Auxiliary Nursing Personnel]. Canadian Nurses Association Fonds (MG 28, I 248, Vol 65, File 19). Library and Archives Canada. Ottawa, ONT.; See also Order-in-Council 1621 (1952, July 4). British Columbia Archives (GR 0119, Box 21, File 3, H-29-4, Practical Nurses) Victoria, BC.   60  is the responsibility of the hospitals to determine whom they shall employ. Your letter is returned herewith65. This was a questionable response from Martin, given that he had been receiving communications from, and meeting with the PNA and other organizations for at least four years regarding PN legislation (Hartley, 1992). Albeit, it is unknown if the PNA had such a constitution or by-laws as Minister Martin suggests.  The authors of the second group of letters from the vicinity of Victoria, also varied, from high school students, secondary education counselors, the Union Board of Health, the Victorian Order of Nurses and the Red Cross homemakers club, however this group had secondary motive in that they were also urging for the implementation of a PN training program in the vicinity, as yet none existed outside of Vancouver66. A PN training program did finally open in Nanaimo in 196167.                                                      65 Martin, E. (1958, November 20). [Letter to F. Richter]. British Columbia Archives (GR 0119, Box 21, File 3, Practical Nurses). Victoria, BC. 66 Anonymous Secretary of the Victoria Council of Women (1956, November 29). [Letter to E. Martin (Minister of Health]. British Columbia Archives (GR 0119, Box 21, File 3, Practical Nurses). Victoria, BC. Anonymous Acting Secretary of the Lakehill Womens` Institute (1956, December 6). [Letter to E. Martin (Minister of Health]. British Columbia Archives (GR 0119, Box 21, File 3, Practical Nurses). Victoria, BC. Anonymous Secretary of Counsellors` Sub-Section Greater Victoria Teachers Association (1957, February 9). [Letter to E. Martin (Minister of Health]. British Columbia Archives (GR 0119, Box 21, File 3, Practical Nurses). Victoria, BC. Anonymous Superintendent of the Victorian Order of Nurses, Anonymous Pioneer in Forming the Red Cross Homemakers` Service of Victoria and Anonymous Chairman of the Social Welfare Committee of the Lake Hill Womens` Institute (1957, February 13). [Letter to E. Martin (Minister of Health]. British Columbia Archives (GR 0119, Box 21, File 3, Practical Nurses). Victoria, BC. Anonymous Secretary of the Victoria-Esquimalt Union Board of Health (1957, February 20). [Letter to E. Martin (Minister of Health]. British Columbia Archives (GR 0119, Box 21, File 3, Practical Nurses). Victoria, BC. Anonymous President and Secretary of Mount View High School Future Nurses` Club (1957, February 20). [Letter to E. Martin (Minister of Health]. British Columbia Archives (GR 0119, Box 21, File 3, Practical Nurses). Victoria, BC. 67 Wiper, K.G. (Administrative Assistant, Hospital Insurance Services). (1961, September 27). [Letter to D.M. Cox (Deputy Minister, Hospital Insurance Services)]. British Columbia Archives (GR 0678, Box 3, File 57, Practical Nurses - Training of). Victoria, BC.   61  In addition to these two important groups of writers, there was support even from within Martin`s ministry from the BC Health Insurance Services (BCHIS)68. The Commissioner for BCHIS communicated to Martin in 1958 his belief in having a safety net of legislation in regard to public protection from untrained PNs, however he acknowledged the difficulties that the legislation could create such as increased wage demands for licensed Practical Nurses. The letter ended by requesting that should such proceedings begin, that a representative from the BCHIS participate in amendments to the Act and upon enactment, be ensured a place on the PN council to ensure their voice was heard regarding any PN decisions.   It is assumed that the PNA became frustrated with the lack of progress in advocating to the health minister for the enactment of PN legislation and sought legal advice. Documents reveal that a meeting between a law firm, their client, the PNA Executive, and the Minister of Health was agreed upon for Nov 3, 1958. The purpose of the meeting was “…to discuss the question of the Practical Nurses Act which we understand has been passed but is not yet in force”69. The results of this meeting are currently unknown, as further documents were not available. Yet the initiative to consult a law firm indicates that the PNs were not intending to give up on their cause easily.  Motivations for Provincial Government Enactment of the PN Act  It is unclear what the impetus was for the Social Credit government to finally reconsider the PN Act, however in 1960 Martin wrote to the Deputy Minister of BCHIS informing him of their wish to re-examine the regulations of the PN Act and that a BCHIS representative be                                                      68 Cox, D.M. (1958, February 17). [Letter to E. Martin]. British Columbia Archives (GR 0119, Box 21, File 3, Practical Nurses). Victoria, BC. 69 Greer, D. M. & Hine, H.R. (1958, October 24). [Letter to E. Martin]. British Columbia Archives (GR 0119, Box 21, File 3, Practical Nurses). Victoria, BC.   62  appointed to the committee for the completion of this work70. A myriad of reasons may have existed for this change in regard to the PN legislation. The late 1950s saw rising Canadian unemployment rates as the post WWII economic boom faded, and the federal government subsequently increased support for vocational training through the 1960 Technical and Vocational Training Assistance Act (Crompton & Vickers, 2000; Hartley, 1992, p. 17). Furthermore, a report from the World Health Organization (WHO) brought to light the international trend of underutilizing PNs in health care despite their important contribution to patient care (World Health Organization, 1959).   The ongoing political activism of the women’s organizations for the enactment of the PN Act likely played a role in the final push for legislation in 1965. The PCWBC, the BCWI and RNABC steadfastly worked to increase public awareness about issues that were stalling the enactment of PN Act. “Prompted by renewed efforts….to have the Practical Nurses Act implemented in British Columbia, [Victoria Daily] Times staffer Pat Dufour has been gathering facts, for and against, such implementation” (Dufour, 1963, May 16, para. 1). Reasons for support included how licensing would increase the status of PNs it would ensure protection for the public and it would be a method upon which to assess applicants for employment. In a series of articles published in the Victoria Daily Times over three days in May, 1963 Dufour articulated the reasons behind opposition to and the subsequent delay in the enactment. The Minister of Health reported that the BCHA and Hospital Employees’ Union were the primary opponents to PN legislation, as described herein (Dufour, 1963, May 16; Dufour, 1963, May 17; Dufour, 1963, May 18). It is impossible to confirm all statements in these articles without concrete evidence to corroborate them, and this is not within the scope of this project.                                                      70 Martin, E. (1960, November 14). [Letter to D.M. Cox]. British Columbia Archives (GR 0119, Box 21, File 3, Practical Nurses). Victoria, BC.    63  The principal issue for both organizations was attributed to potential economic losses upon legislation and licensing of PNs in BC. The BCHA was reported to be divided about a grandfather clause that would allow licenses to be granted to PNs working prior to the legislation, but who did not attend an accredited PN program. It is not explicitly stated within the article, however it is intuited that this would cause hardship on hospital budgets due to foreseeable salary increases. This argument is plausible given that similar protests delayed the legislation of nurse attendants (equivalent to PNs in BC) in Nova Scotia from 1948 to 1957 (Twohig, 2011). This stance is supported as well, in a later internal health ministry document in 197271.  The education committee of the BCHA held an extraordinary meeting in 1964 with forty delegates from around the province whose facilities were being utilized for PN training. The minutes of this meeting illuminate the complexities of the quickly expanding PN training within the province and brought forth many questions regarding safety in PN training. The meeting ended with a motion to further study the PN Act to ensure proper standards in training and licensing for PNs72.  The Hospital Employees’ Union (HEU) was reported to have differing opinions on the issue, with a Vancouver Island spokesperson supporting the PN Act and a second spokesperson from Vancouver opposed to such legislation (Dufour, 1963, May 18). Reasons provided for the opposition were concerns for Hospital Employees’ Union members who might be negatively affected by such legislation, including nurse’s aides (NA) who feared job replacement by PNs or                                                      71 Elliot, G.R.F. (1972, November 26). [Letter to D. Cocke, Minister of Health Services]. Executive Records (GR 0678, Box 58, File 9, Practical Nurses and Nursing Orderlies). British Columbia Archives: Victoria, BC. 72 British Columbia Hospital Association (1964, April 8). A report on an extraordinary meeting of the education committee [Report]. (GR 0678, Box 43, File 3, Student Practical Nurses), Victoria, BC.   64  being forced to take PN training to retain their employment. An HEU document73 written to the Health Minister confirms this last stance on PN legislation. The letter goes on to discuss several large hospitals within the Vancouver area, each of which ran a NA training program and consequently also employed a greater number of NAs over PNs (see footnote 11). Therefore it is questionable whether the union itself or the hospitals in question were truly opposed to the PN Act as it is unknown which may have had more to lose from its implementation. Additionally, the Victoria Daily Times reporter Dufour asked the HEU spokesperson  point blank if the union`s concerns were related to the potential loss of union members, specifically if licensed PNs were to organize and form their own bargaining unit however this question was answered with a definitive `no` (Dufour, 1963, May 18). Although to date, documents have not been found to either support or refute this topic or HEU’s stance on it, the debate in the newspaper indicates the intense interest in the need for proper legislation within a context of rapidly expanding PN employment and training programs in several BC hospitals.  Enactment of PN Legislation  The process of enacting the PN Act finally began in 1964, and continued into 1966. December 8th, 1964 was an exciting day for the PNA when the full promulgation of the six page PN Act in the BC Legislature finally occurred (Executive Council of the Province of British Columbia, 1964).   Interestingly, Minister Martin notified Florence Wilson personally to ensure that she heard the announcement on the news, and invited Wilson and two other advocates, Kaye Gilchrist and Florence Deschner from the PNA for lunch the following week at the parliament                                                      73 Black, W.M. (1956, January 9). [Letter to E. Martin]. British Columbia Archives (GR 0678, Box 58, File 9, Practical Nurses and Nursing Orderlies). Victoria, BC.   65  buildings (Hartley, 1992). It was at this lunch that Martin issued the first three licenses for PNs in BC, with the number one license going to Wilson. Subsequently, Martin invited all three PNs to sit as representatives on the new Council of Licensed Practical Nurses (Hartley). The BC Council of Practical Nurses (BCCPN) was formally legislated on February 19th, 1965 (Executive Council of the Province of British Columbia, 1965) whereupon the ten members were officially recognized with each representing various entities with a vested interest in PNs. In addition to Wilson, Gilchrist and Deschner, the other seven BCCPN members included Mr. A.H. Cameron and Miss E.E. Nordlund, both representing the Department of Health Services and Hospital Insurance; Dr. L.L. Palk representing the College of Physicians and Surgeons of BC; Miss E. Rossiter and Miss E. Graham representing the RNABC; Mr. V.E. Rickard representing the Minister of Education and Mr. G. Frith representing the BC Hospital Association (Executive Council of the Province of British Columbia, 1965). BCCPN  The first meeting of the BCCPN was held on March 15, 1966 in Vancouver and meetings continued thereafter (of unknown frequency) (Hartley, 1992).  As laid out in the PN Act, the council had several significant duties to complete throughout its first few years of existence, such as approval of PN schools and establishment of licensure and the PN scope of practice as will be subsequently discussed. A communication to the Education Minister in November of 1965 notes that the council had passed a resolution giving provisional approval for the courses offered for PNs at six locations within BC, however this was to be followed up with a professional evaluation at a later date74.                                                       74Cameron, A.H. (1965, November 1).  [Letter L.R. Peterson]. British Columbia Archives (GR 0380, Box 15, File 4, Practical Nurses), Victoria, BC.   66   The second duty of the council was in regard to licensing. Using a grant provided by the BCHIS, the BCCPN hired a RN in the registrar position where she was to review documents and issue licenses to PNs, including applicants from other provinces and countries. Several documents confirm that by mid-November, 1965, licenses had been issued to approximately 125 Practical Nurses, and consequently the title of Licensed Practical Nurse (LPN) was legally allowed75. For some PNs however, licensing was not a straightforward issue, and therefore section 4.02 of the PN Act had several clauses attached to clarify licensing for anyone without PN training from an approved school in BC (see footnote 75). The council had the discretion to determine who had satisfied the requirements under 4.02 (c) or (d) and subsequently could be issued a license to work as a PN. Those who had been doing the work of a PN for a time period of “…not less than two years within a period of five years immediately prior to the date of application, such application to be submitted not later than December 31, 1966” (see footnote 75) would be issued a license.  Alternatively, those who satisfied requirements such as supplementary training or work experience in practical nursing, and were approved by the council, would also be issued a license as a PN (see footnote 75).   Currently, there is no evidence to explain how the BCCPN determined such supplementary training or work experience in order to issue PN licenses, as defined in section 4.02 (d) of the PN Act. It is believed that the importance for the council to clarify the licensing clauses for PNs and NAs was likely due to financial reasons. It is possible that the earlier concerns of the BCHA and HEU of the potential for other NAs and/or orderlies to demand increased wages if it was believed that their work was comparable to a licensed PN. To provide                                                      75 Cameron, A.H. (1965, November 1).  [Letter L.R. Peterson]. British Columbia Archives (GR 0380, Box 15, File 4, Practical Nurses), Victoria, BC.; Nordlund, E.E. (1965, November 12).  [Letter A.H. Rose, Inspector of Hospitals]. British Columbia Archives (GR 0380, Box 15, File 4, Practical Nurses), Victoria, BC.   67  context to this discussion, it is worth looking more closely at the way wages of hospital staff were determined. In the early 1960s, hospitals bargained with unions for salaries in isolation of one another, and as such the wages of any type of nurse could vary from hospital to hospital (Webb, 1994). As a result, clarification of PN licensing for NAs was required, and it is assumed that this is why the document titled “Clauses respecting Practical Nurses appearing in hospital lay staff contracts” was created76. On the first page of the document definitions of eight different clauses are described. One clause addressed the fully licensed PN who possessed a diploma from a recognized PN school and would receive the maximum PN wage rate at that facility. Another clause addressed NAs who, if proven to meet the clause in regards to their training and experience, would receive the current or maximum PN wage at that particular facility (see footnote 76). The second page of the document presents a table listing 56 hospitals in BC (unknown if this is an inclusive list) and specifies which clauses are applicable to each individual facility. For example, some hospitals employed only fully licensed PNs, most had multiple categories of licensing, and some thirty percent lacked clauses within their auxiliary nursing contracts. Part of the BCCPN’s duty was to bring order in this chaotic context by inserting better criteria, guidelines and regulations.   A third duty of the BCCPN was to clarify the scope of practice for licensed PNs. The BCCPN set out to do so by creating an informational document which provided a guideline describing the scope of practice for a licensed PN in BC.  In a five page document the BCCPN listed the basic procedures taught in an approved school for Practical Nursing in BC. This concluded with four duties that should NOT be delegated to a licensed PN, including giving medications, taking blood pressures, inserting catheters or charting of any kind except for                                                      76 (1965, October 20). Clauses respecting practical nurses appearing in hospital lay staff contracts (p. 1-2). British Columbia Archives (GR 0380, Box 15, File 4, Practical Nurses), Victoria, BC.   68  temperature, pulse or respirations77. The outline was to be provided to all hospitals and institutes throughout the province that might employ licensed PNs78. The subsequent version of the outline released in 1972 did not include these four restrictions and did in fact allow PNs to take blood pressures, however medication administration was not addressed in any other way79. It is evident from this discussion that clarifying the distinction between scopes of practice of RNs versus PNs was a core function of the Council’s duty from the outset. However, this was likely an inherited function, initiated by the Joint Planning Committee on Nursing, who had representation from the RNABC and the BCHA in the late 1940s and who drafted the first PN Act (Wright, 1947).  The Canadian Nurses Association  The CNA had a significant and positive influence on the formal development of PN training and regulation across Canada during the mid-twentieth century, as described in detail in chapter three. Although the CNA had recognized the need to address the issue of untrained or semi-trained PNs within the health care system-for reasons already explained, the CNA did not have the opportunity to fully address the matter and subsequently the start of WWII preempted their plans to investigate the issue more thoroughly. By the early 1940s, provincial associations were independently initiating PN training and there was much national discussion regarding health insurance at the federal level. With pressure mounting to address the PN issue, and keeping in mind the guiding principal of upholding high standards of nursing practice, the CNA assumed immediate action to investigate the matter of PN practice in 1942.                                                       77 BCCPN (1966). Outline of duties to be used in the employment of the Licensed Practical Nurse in BC. [Outline]. Executive Records (GR 0678, Box 58, File 9, Practical Nurses and Nursing Orderlies). British Columbia Archives: Victoria, BC. Copyright British Columbia Archives. Reproduced with permission.  78 Thompson, R.H. (1966, December 14). [Letter to W.J. Lyle]. British Columbia Archives (GR 0380, Box 15, File 4, Practical Nurses), Victoria, BC.   79 BCCPN (1972). Outline of duties to be used in the employment of the Licensed Practical Nurse in BC (Revised Edition). [Outline]. Executive Records (GR 0678, Box 58, File 9, Practical Nurses and Nursing Orderlies). British Columbia Archives: Victoria, BC   69   External influences likely impacted the CNA support of and actions taken regarding PNs in Canada throughout the 1940s and 1950s. In particular the CNA`s mother and sister associations, the International Council of Nurses (ICN) and the American Nurses Association (ANA) in the USA likely provided information and guidance for both the international and North American contexts. PNs were already fairly well established in the USA and in Great Britain, and it was customary for the CNA to seek advice on such topics, as well as to regularly publish articles on nursing current events in the US and Great Britain (“The Royal College”, 1942). Furthermore, international relationships between nursing leaders existed throughout the twentieth century, which also served to strengthen communications amongst international nursing leaders. From the international correspondence published in the Canadian Nurse, it is clear that the health care systems in many Western countries faced the matter of differentiation between various levels of nursing and competing interests of RNs versus PNs. For example, American nurse leader Effie Taylor spoke on the topic in her speech to the Canadian hospital matrons in 194080. In this speech entitled “The Auxiliary Worker in the Care of the Sick” and published in the CN in 1940, Taylor (1940) discusses several aspects of the PN role at length. Included in her discussion was the circumstances that brought the auxiliary work into existence and she compared and contrasted training and regulation in the USA and Canada. The end of the article emphasized to the RN reader the importance of ensuring the proper training and regulation of this worker, as well as public education.    Furthermore, the CNA committee studying subsidiary nursing groups utilized a vast amount of American nursing literature (see footnote 18). References included in the first report                                                      80 Effie Taylor was Canadian born and educated but emigrated to the US, became Dean of Yale University School of Nursing and was the longest serving ICN president (Elliot, Rutty & Villeneuve, 2013, p. 6)    70  in 1944 listed over thirty five journal articles and multiple American books and studies published by leading American nursing associations, both professional and educational (see footnote 18).  In a letter from a member of the CNA special committee to study auxiliary nursing personnel that was addressed to the committee members, it was requested that all provincial nursing associations be involved in further study of the issues surrounding the education and legislation of PNs81. Additionally, it suggested that a special meeting be called just prior to the executive meeting, so that further updates and changes could be added to the later 1952 report (see footnote 81). The letter ended by noting that all expenses incurred from the travel to the CNA in Montreal for the special meeting would be covered by the association. These actions speak to the serious intent of the CNA to include those directly involved or close to the issue at hand being studied. Furthermore, the actions demonstrate the committee`s continued efforts to ensure proper and accurate recommendations were presented unilaterally across Canada in the updated 1952 committee report82. It is interesting to note that the CNA committee studying subsidiary nurses had a local connection from Vancouver. Mrs. Johnstone, an RN and instructor for the practical nursing program at VVI, was a member of this CNA committee, thereby having some influence on national decisions regarding PNs83.  It is clear from the significant efforts and multiple recommendations made to the provinces by the CNA committee to study auxiliary personnel during the mid-twentieth century that the CNA supported the PN role within health care system. Nevertheless, they also sought a                                                      81 Hall, G.M. (General Secretary Treasurer, CNA) (1952, January 23). [Letter to the members of the special committee to study auxiliary nursing personnel]. (MG 28, Series 248, Vol 65, File 19, Special Committee on Auxiliary Nursing Personnel. Library and Archives Canada, Ottawa, ON.   82 Russell, M.G. (1952, February). Report of the special committee to study auxiliary nursing personnel –Revised [Report]. (MG 28, Series 248, Vol 65, File 19, Special Committee on Auxiliary Nursing Personnel. Library and Archives Canada, Ottawa, ON.   83 Russell, M.G. (1951, April 5). Report of the special committee to study auxiliary nursing personnel [Report]. (MG 28, Series 248, Vol 65, File 19, Special Committee on Auxiliary Nursing Personnel. Library and Archives Canada, Ottawa, ON.      71  certain level of control by issuing guidelines and recommendations regarding the regulation, licensing and scope of practice for PNs. The similar efforts of RNABC also demonstrate their support for the development and regulation of PNs in BC.    The RNABC Responses to Practical Nurses   It is apparent from actions taken by the RNABC on behalf of PNs that the RN professional association was in support of formalizing the PN role. A more in-depth examination of the motivations behind why the RNABC was involved in organizing the training and legislation for PNs shows that the support went hand in hand with the assertion of a certain level of control. An examination of the RNABC`s motivation also throws light upon the methods by which RNs had control over the practice of PNs. To date, I have noted few negative inferences made in regards to PNs, as discussed earlier in this thesis. For example, in a 1946 discussion about the difficulties of nursing shortages due to WWII, the RNABC president acknowledged the role of PNs. Much of the private duty nursing in homes is already being done by the “practical nurse,” (when she can be obtained) because professional nurses are not available. For years we have been talking about the “problem of the practical nurse”. Is there a need for her? What should be her duties and responsibilities? Where and how should she be trained? And while we discuss the problem, lay groups initiate courses for the training of Practical Nurses! (Mallory, 1946, p. 202). While it is difficult to ascertain the implications of this statement, one could simply take this to mean that the RNABC was well aware of the contributions of PNs and the imminent need for decisions regarding them. Common themes noted throughout the sources were the urgent need to protect the public from unregulated health care workers (Creasor, 1946).  However the   72  RNABC`s involvement was also to ensure RNs were in control of the supervision, education, and regulation of PNs in BC (Graham, 1952; Paulson, 1952). Job security may have been another more subtle motive reflecting the RNs desire to distinguish themselves from PNs in order to also secure their own roles. Furthermore, RNs may also have distanced themselves from PNs due to the PNs membership in the Hospital Employees’ Union, an association with which most RNs preferred to avoid, as will be subsequently discussed.  Concurrent with the 1946 experiment of utilizing PNs for home care in a RNABC Vancouver nursing directory, discussed above, more comprehensive efforts were being undertaken by the RNABC, with regard to the existing shortage of nursing services and planning needs for the future. In 1946, the ‘Joint Planning Committee on Nursing’ was established, whose focus was on the services of both RNs and PNs (Wright, 1947). As described previously in the section under legislation, this committee created the first draft of the PN Act, which was later submitted and first passed in 1951, but not fully enacted until much later in 1965.   From the evidence collected thus far, it is difficult to determine the extent of RNABC`s involvement in the initiation of the PN training program at VVI, although it may have been indirectly involved through the Joint Planning Committee on Nursing. Nevertheless, the experiment undertaken by the RNABC directory in utilizing PNs indicates the association`s cautious and thorough approach in studying the need for and fit of PNs within nursing services.  The 1949 RNABC Presidential Address once again discussed the national nursing shortage and what needed to be done to alleviate the situation. Included in her address, Mallory indicated her support for the expansion of the PN program at VVI, noting that RNs embrace PNs in health care, and that there is a need for “…the skillful use, AS A TEAM WORKING TOGETHER, of a variety of nursing personnel…” (Mallory, 1949, p. 14-15). These comments   73  indeed indicate RNABC’s support and acknowledgement of the practical nursing role as the health care system could simply not do without them.  Throughout the 1950s, the RNABC continued its efforts to be informed of, and contribute to, practical nursing developments. In 1950, the CNA made recommendations to the provincial associations that an advisory committee on PNs should be organized with the purpose of acting  …in an advisory capacity to the Director of the Nursing Assistants` School in matters pertaining to the selection, specific problems, policies, etc and, when necessary, it shall make recommendations to the governing body of that school84.  While it is unknown how and exactly when this committee was established, the 1952 RNABC  Annual Meeting report mentions the existence of such a committee (Paulson, 1952). The ‘Trade Advisory Committee on the Practical Nursing Program` at VVI had representatives from key stakeholders, such as the RNABC, the Vancouver School Board, the VVI Principal, the practical nursing faculty at VVI, and various hospitals and agencies that received PN students for clinical experience (Paulson, 1952) 85 . A representative from the RNABC continued to sit on this committee, which existed at least into 196886. This committee membership demonstrates one of the mechanisms by which the RNABC continued to participate in major decisions influencing the training of and policies around practical nursing.                                                      84 Russell, M.G. (1951, April 5). Report of the special committee to study auxiliary nursing personnel, p. 3 [Report]. (MG 28, Series 248, Vol 65, File 19, Special Committee on Auxiliary Nursing Personnel. Library and Archives Canada, Ottawa, ON.   85 Goard, D.H. (1954, October 26). Minutes of a practical nurse advisory committee. (GR 0678, Box 58, File 9, Practical Nurses and Nursing Orderlies). British Columbia Archives, Victoria, BC. 86 Dunford, F. (1968, January 16). Correspondence from Dunford to E. Nordlund (outlining the agenda for the next meeting of the Practical Nurse Advisory Committee. (GR 0678, Box 58, File 9, Student Practical Nurses). British Columbia Archives, Victoria, BC.    74   Other methods by which RNs, and indirectly the RNABC had control over PNs was through RN involvement in the training of and supervision of PNs. RNs provided the bulk of the instruction for the practical nursing students in BC 87 . Additionally, RNs were to maintain supervision over the work of PNs, significantly framing their work as `auxiliary`, whether in home care or the hospital setting. The first Registrar for the licensing of PNs in BC was also an RN (decided upon by the BCCPN), who would be able to oversee the work of reviewing documents and the licensing of nurses from other provinces and countries. The position was advertised and Ivy McGowan was hired; starting Sept 1, 1965 and remaining until 1984 when she passed away (Hartley, 1992). Goldstone (1981) notes that in 1968 and 1969, the RNABC expressed their concerns to nursing directors, the BC Hospital Association (BCHA) and the BC Hospital Insurance Service (BCHIS) that PNs remain employed only as auxiliary personnel. This action emphasizes the earlier statement that it is difficult to ascertain if the motivation behind the RNABC’s concerns was altruistic or out of fear of substitution or both.  PN and RN Collaboration and Division As is clear from the above discussed emergence of the regulatory frame for PN practice, the collaboration amongst, and division between, PN and RN nursing groups are themes that exist both historically and currently.  As mentioned earlier, despite some RNs early criticisms about the addition of PNs to bedside nursing during the first half of the twentieth century, RNs as an organized body supported the education and legislation of PNs. Some RNs had strong opinions regarding the usefulness of and utilization of the ways in which RN roles were changing in health care and regarding the how and why of practical nursing. Nevertheless, the RN professional associations provided strong guidance, clarified boundaries, and worked hard to                                                      87 Province of British Columbia (1965). Regulations under the Practical Nurses Act. [Legislation]. British Columbia Archives (GR 0380, Box 15, File 4, Practical Nurses). Victoria, BC.    75  develop clear roles to delineate and to accommodate the position of PNs in the health care system. The concept of team nursing was one approach that came out of new American nursing research to improve the utilization and co-operation of both nursing groups in the hospital setting (Lambertson, 1958). Lambertsons` research on team nursing was preceded by two other influential US studies. In 1948, two large research projects produced influential reports in USA with a strong impact on the direction of the practice and education of nursing. The projects had broad representation, including a variety of specialties within medicine and nursing, as well as from the government, education, economics and the social sciences (Lambertson, 1958; Bullough & Bullough, 1967). The main goal of these projects and Lambertsons` research on team nursing was to provide an organizational framework for nurses employed in hospitals at different levels of employment to work together in teams to meet patient needs. The idea of team work for nurses was a new phenomenon in the 1950s to accommodate to a rapidly changing work environment in the general hospital as well as to a transforming system of nursing education that no longer solely relied on hospital-based training schools. The reports credit the speed with which the PN formally multiplied within the health care system as a main cause leading to a lack of awareness regarding the PN role and utilization by RNs, physicians and employers (Russell, 1967). Both reports recommended retention of the PNs, as well as a more comprehensive effort in organizing a team approach to nursing, and as a result of these studies, the team nursing concept was born.  This method recognized that individuals with various levels of education and skills could be used more effectively as a team to care for a group of patients than in separate assignments according to the kind of patient to be cared for. If appropriately carried out, it also reduces the number of nursing personnel who contribute to the patient`s care, and   76  provide for a continuity of care, with more satisfaction for the patient and for the worker. (Russell, 1970, p. 140).  Inherent in any major change within an organization is the necessity for trial and error as well as research and education. Lambertson (1958) reported that if uncertainty and confusion about a profession`s functions existed, then consequently disagreement and confusion would occur regarding other aspects of the profession as well. It became apparent in the early 1950`s that further research on the functions of professional nurses, as well as factors impacting the implementation of those functions was necessary, therefore multiple studies88 on the function of the nurses as well as on team nursing were completed for this purpose (Lambertson). This occurred for the dual purposes of providing clear boundaries between RNs and PNs, as well as direction in the supervision of and delegation of skills to PNs (Lambertson, 1958).   Given the lack of such large scale nursing research projects in Canada, where the context of graduate nursing education to provide for such research did not yet exist, the nursing team concept from their USA colleagues was subsequently adopted throughout the nursing community in Canada (Gerard, 1952; Goyette, 1961)89. Aware of the lack of knowledge around the role and utilization of PNs by other health professionals, employment agencies, and the public, the CNA Special Committee to Study Auxiliary Nursing Personnel (1951) made several recommendations. Use of the team nursing concept was encouraged in order to 1. make possible better nursing care to a greater number of patients.                                                      88These included the Brown Report from 1948 and the Ginzberg Report from 1949.  89 RNABC, (ca 1948-1949). Fact Sheet on Practical Nursing [Brochure]. Department of Health Executive Records (GR 0678, Box 43, File 3, Student Practical Nurses). British Columbia Archives, Victoria, BC.   77  2. make the most economical use of both the professional nurse and the nursing assistant. 3. provide more responsibility for the general staff nurse. 4. provide greater satisfaction for all members of the team85.   The team nursing concept began to be disseminated into Canadian health care as of the early 1950`s. In a convention of the Canadian Hospital Association, for example, nursing Superintendent Gerard, gave an oral address on PNs and team nursing highlighting the benefits and importance of utilizing team nursing within the hospital setting, as well as encouragement that through proper planning, legislation of PNs, and with the spirit of co-operation, the place of PNs and the concept of team nursing could be very successful (Gerard, 1952). Moreover, the 1953 RNABC annual report mentions team nursing, both in the presidential report and the health insurance committee recommending further study on the use of the team approach in nursing. In subsequent RNABC reports the team nursing concept was revisited regularly throughout the 1950s. The concept did not ensure, however, that ongoing tension over the demarcation of tasks and functions between RNs and PNs would disappear.  Still, as the reader will learn in the ensuing section on government support for PNs, several activities demonstrate both the BC government`s commitment to both establish and smooth the transition from a majority of RN to a mixed PN and RN nursing workforce within the health care system.       78  Factors that Complicated the RN and PN Relationship Despite the ongoing support of national and provincial associations representing RNs and PNs, tension between both nursing groups existed early on and continues even today.  The variety of reasons for such tension will be subsequently explored.   As discussed earlier (in the thesis), the professionalization of RNs may have contributed to the rise of practical nursing in a multitude of ways. One difference that mattered for example was the contrast between PNs and RNs with regards to the place of their training. One of the initial recommendations made by the CNA was to initiate PN clinical experiences in hospitals where RN students were not present (Elliott et al., 2013). This move, while perhaps made with the intention of preventing encroachment onto RN training territory, unfortunately impeded early opportunities for RN and PN students to develop familiarity, collaboration and collegial working relationships.  In addition to differences in place of practical training, a distinction in educational context added to the construction of a hierarchical relationship between the two groups. In the effort to improve the quality and breadth of RN education, by 1970 most RN training programs had moved from apprenticeship style training within hospital schools to colleges, (Goldstone, 1972; Elliott et al., 2013) and some universities, whereas PN training continued to be based in the vocational school system. Training completed within the vocational system was associated mainly with trade level entry occupations, in contrast, college based education was usually associated with semi-professional or professional careers, an intentional association by RN leaders (Elliott et al., 2013; Apprenticeship, 2016).   79  A further issue that may have divided PNs and RNs was that of unionization. In particular, British Columbian PNs were part of a hospital union from the mid-1940s on, however RNs were reluctant to embrace such a move and did not form their own union until 1981 (Elliott et al., 2013). It was a highly contentious issue for RNs, for several reasons. To assert their status as a profession, they sought to disengage themselves from occupations that relied on unions for improved employment conditions and wages, such as industrial and trade unions, particularly because of the assumed association the public might make-that nursing was a trade (which RNs had been working hard to elevate themselves above). Kealey (2008) describes how RNs recognized the advantages of collective bargaining and embraced unionization in the 1960s. Nevertheless, many resisted the idea of strike action as a bargaining tactic, for example, and RN unions differed significantly from ones in which PNs were members (Kealey).   Professionalization may have inadvertently (or perhaps intentionally) somewhat removed RNs from the bedside. When promoting the team nursing concept, the benefits to RNs were highlighted-such as freeing up time to complete more advanced skills and attend to managerial tasks. The assumption or portrayal of the RN as being ‘better’ or smarter, is implied within such discussions as the differential in education as well as function between RNs and PNs also necessarily set up a hierarchical relationship and power differential.   The theme of control and power further divided RNs and PNs. RNs initiated and maintained control of PN training, legislation and regulation, as well as providing ongoing supervision within the work setting. As discussed previously, the CNA made the initial recommendations to provincial RN associations, whereby RNABC carried out these tasks. Although it made sense to have well established, experienced and knowledgeable RNs involved in ensuring the proper development and ongoing supervision of the newer category of PNs, it   80  also set up a power differential that created new tensions. The RNABC backed their influence by arguing that this control was in the best interest of the patients, an assumption clearly reflected in the team nursing concept for example. An interesting comparison could be drawn to the early training of RNs at the turn of twentieth century, when physicians taught RNs.  When the PN Act was finally promulgated in 1965, PNs gained some autonomy in regulating their own profession. Pringle, Green and Johnson (2013) confirm this fact when they describe how PNs had been subject to “…top down control from RN professional organizations….”  (p. 24) but were liberated from RN association and government control through legislation and the development of their PN professional associations. Nevertheless, RNs continued to have input into PN education and registration, both by having a delegate on the PN council, as well as through the registrar for the PN Association who was an RN.  Additionally, RNs continued to provide supervision in the workplace and had a key role in PN education. When a particular group maintains control in some capacity over another, naturally tensions arise that complicates the relationship. As outlined above, several elements contributed to the ongoing divisiveness of the PN and RN relationship, including changes to scope of practice and government and institutional health care practices and decisions.  As practical nursing became more formally established in BC, its scope of practice slowly expanded through the twentieth century. The PN role began to take on more of the tasks of RNs, and as the scopes of the two groups increasingly overlapped, boundaries had to be continually re-negotiated (Pringle, et al., 2013).   Munroe succinctly summed up the crux of the issue between RNs and PNs when she stated in 1946 that the PN “…through attempting to meet a public need will usurp the work which the professional nurse claims as her right” (cited in Elliott et al., 2013, p. 72).  Despite the   81  RNs fears of replacement at this time, the PNs were strongly promoted as serving to assist the professional nurse, and were to be closely supervised (Elliott, et al).  Nonetheless, as the nursing shortage eased during the 1960s, the federal government capped the health care transfer payments. This action forced hospital administrators to utilize efficiency measurements to maximize nursing services, which in the late 1970s seemed to imply that RNs were given the preference over PNs when nurses were hired, as will be subsequently discussed. These new pressures unsettled PNs as they began to fear for their jobs. In several of the letters written to the Minister of Health by the LPNABC in 1977, the topic of attrition was highlighted, and the association expressed its dismay over this alleged practice of purposely not hiring PNs by hospitals90. The explanation provided in the Health Minister’s response informed the association that the boards of hospitals independently decided the type of nursing staff they hired, that the Ministry had no control over this matter, and that his office was unaware of any form of targeted attrition against PNs91 . Although tensions continued to exist, the regulatory framework for practical nursing developed during the mid-twentieth century clearly consolidated practical nursing as an essential component of health and nursing service throughout the health care system.                                                        90 Wallace, B., (Member of Legislative Assembly, Cowichan-Malahat) (1971, November 17). Letter to R.H. McLelland (Minister of Health) [Letter]. (GR 2665, Box 14, File 3, Practical Nurses). British Columbia Archives; Victoria, BC.  Magnone, A. (LPNABC President) (1977, September 14). Letter to R.H. McLelland (Minister of Health) [Letter]. (GR 2665, Box 14, File 3, Practical Nurses). British Columbia Archives; Victoria, BC. Magnone, A. (LPNABC President) (1977, November 4) Letter to R.H. McLelland (Minister of Health) [Letter]. (GR 2665, Box 14, File 3, Practical Nurses). British Columbia Archives; Victoria, BC. 91 McLelland, R.H. (Minister of Health) (1977, November 10). Letter to A. Magnone (LPNABC President) [Letter]. GR 2665, Box 14, File 3, Practical Nurses). British Columbia Archives; Victoria, BC. McLelland, R.H. (Minister of Health) (1977, December 5). Letter to A. Magnone (LPNABC President) [Letter]. GR 2665, Box 14, File 3, Practical Nurses). British Columbia Archives; Victoria, BC.   82  Government Initiatives and Regulations Related to Practical Nurses Seminars.   Several government initiatives demonstrated a commitment to the successful integration of PNs into the health care system. One such measure was the introduction of institutes and seminars on the role and function of PNs, specifically to familiarize RNs with the PN training and scope of practice. Following the expansion of PN training centers into the interior and farther north into Prince George during the early 1960s, concerns began to emerge among RNs regarding the quality of clinical training experiences some PN students were receiving at a few of the smaller hospitals in these areas92. Such concerns may have signaled tension but likely also unawareness about the potential role of PNs. These concerns were voiced to both the RNABC and the BC Hospital Association (BCHA). The RNABC formed a committee to further investigate the issue, which resulted in the invitation of the delegates from the BC Hospital Insurance Service (HIS), the Department of Technical and Vocational Education (DTVE) and the BCHA (which later withdrew for unknown reasons). In a combined effort to disseminate further information about PN training, as well as to increase communication and dialogue on the topic of PN scope of practice and supervision of in the workplace, a series of regional institutes were developed for RNs and supported by the BCHIS. The purpose of the institutes was succinctly stated, for example, in a letter from the BC Department of Education to one Director of Nursing of a local hospital in Prince George:  “…the BC Hospital Insurance Service proposed that a series of seminars or institutes be carried out in key centers to acquaint Registered Nurses working in participating                                                      92Fleming, F.M. (Institute Director) (1965, June). Report of institutes related to the clinical experiences of practical nurse students [Report]. Department of Health, Deputy Minister, Executive Records. (GR 0678, Box 43, File 3, Student Practical Nurses). British Columbia Archives, Victoria, BC.    83  hospitals as to their relationship and responsibilities toward those Practical Nurses in training with whom they may come in contact”93. The primary funding for the institutes came from the BCHIS, consisting of both travel and lodging expenses for a number of nursing supervisors, head nurses or senior RNs from various hospitals who would attend the institutes as delegates, as well as funds to cover relief staff within the hospital. The DTVE provided invitations and communications regarding the institutes to the various hospitals, while also arranging for a classroom within regional vocational schools for the institutes. Finally the RNABC took responsibility for providing the Institute Director, as well as some of the educational materials needed for the institute. The RNABC already had experience with this kind of educational program, when commencing institutes on rehabilitation nursing in 1955 (Creasor, 1955). The planning and organization of the institutes was extensive and included objectives and a detailed outline for the two day institute, followed by a six page report summarizing the institutes, their successfulness and recognizing all parties involved (see footnote 92).   As a result, ten institutes were completed in five communities that had PN training programs, and a total of 212 RNs attended in the mid-1960s (see footnote 92). Multiple actions and decisions came out of the institutes, such as better accessibility to reference material for RNs to utilize when theory or scope of practice issues would arise on the ward, an improved form for the evaluation of PN students by the RN ward supervisor, guidelines for instructors to provide students with a detailed orientation to the clinical area and to create methods for improved communication between hospital staff and PN instructors.                                                      93 Rickard, V.E.  (Assistant Director of Technical, Education and Vocational Education) (1965, January 13). [Letter to Anonymous of the Prince George Regional Hospital].  British Columbia Archives (GR 2665, Box 14, File 3, Practical Nurses), Victoria, BC.   84  Stipends  Stipends paid to PN students during their clinical experiences was another example of government support. It is believed that these stipends were a result of the 1944 Vocational Training Co-ordination Act, whereupon the federal and provincial governments partnered to provide financial assistance to apprentices (Apprenticeship, 2016). As such, apprentices received a prescribed percentage of the wage of a journeyman or certified tradesperson, which usually increased in percentage as the training proceeded.   The brochure titled Fact Sheet on Practical Nursing (see chapter three) from the late 1940’s noted that PN students would receive a wage during their hospital experience, which referenced Section 4 of the BC Female Minimum Wage Act (see footnote 18).  The brochure for practical nursing  from the early to mid-1960`s, reported stipends paid weekly were $14 per week for the first two months, $16 per week for the second two months, $18 for the third two months and finally $20 per week for the final two months of hospital experience (see footnote 18). The stipend agreement was based on the premise that the PN students required remuneration for the cost of living and travel during their clinical experiences, which implies that students may have been required to travel to various hospitals to undertake their training94.   In 1964, the stipend was a shared cost between the hospital which received practical nursing students (who were then reimbursed by the BC Hospital Insurance Service), and fifty percent from the Department of Education (see footnote 94). By 1966, the stipends were increased to a flat rate of $22 per month throughout the eight months of hospital experience (Hartley, 1992)94. By 1972, BC was following in Ontario’s footsteps by transitioning nurse’s                                                      94 Lyle, W.J. (Hospital Finance Manager) (1966, April1). [Letter to V.E. Rickard (Assistant Director, Office of the Director of Technical and Vocational Education)]. British Columbia Archives (GR 0678, Box 43, File 3, Student Practical Nurses) Victoria, BC.   85  training from hospital based to colleges and therefore the government had cut stipends altogether 95 . Correspondence noted the resulting financial difficulties experienced by PN students after the stipends were cut. For example, it was reported that some students had to use the services of welfare agencies to complete their PN training, while others were encouraged to apply for student loans96. Union Involvement in PN Integration: The Hospital Employees’ Union  PNs were longtime members of the Hospital Employees’ Union (HEU) in BC. As a result the HEU became another stakeholder in the effort to regulate PN’s integration into BC health services in the 1960s. The HEU  originated in 1936, as two separate male and female unions within the Vancouver General Hospital (VGH), which subsequently merged as one union in 194497. It is difficult to ascertain exactly when PNs became members of this union, because although Webb (1994) reveals that PNs began to be employed in BC hospitals sometime between 1939 and 1945, a specific date for the membership of PNs in HEU is not provided.  Given that practical nursing training was not formally initiated in BC until 1948, is most likely that the nurses specified as being part of the early union by Webb (1994) were nurse’s aides (see footnote  12). Conventional titles for nurse’s aides may have confounded this issue, given that nurse’s aides may have had a variety of training ranging from on the job to partial RN training to trained PNs from other provinces or countries (as discussed previously in chapter three). Still, from the                                                      95 Lyle, W.J. (Hospital Finance Manager) (1972, August 29). [Letter to All Hospitals, Re: Practical Nurses in Training (Serial Letter No. 72-6)]. British Columbia Archives (GR 2665, Box 14, File 3, Practical Nurses) Victoria, BC. 96 Rickard, V.E. (Assistant Director, Division of Technical and Vocational Services, Department of Education) (1972, June 2). [Letter to E.E. Nordlund (Hospital Consultation Division, BC Hospital Insurance Services)]. British Columbia Archives (GR 2665, Box 14, File 3, Practical Nurses) Victoria, BC. 97 In 1944, the original conjoined union was titled the Vancouver Hospital Employees Federal Union (VHEFU), Local 180. In 1956 the union title was formally changed to the Hospital Employees Union (HEU) but Webb (1994) notes union members often referred to their union as  HEU, even as early as 1944.    86  History of the Hospital Employees’ Union it appears that ward assistants were part of the union’s very first members (“History of”, 2016). Working conditions within the VGH during the 1930’s were very poor for many employees, including nurse’s aides and RNs. Nurse’s aides98 worked six and a half days a week, ten hours a day while night shift nurses worked up to 70 hours per week, and furthermore paid sick time was not provided and failing to comply with a supervisor’s demands meant potential dismissal (Webb, 1994, p. 10-12).  This was during the Great Depression when unemployment rates were up to 30% at times and employers had their pick of employees (Rae-Brown, Sousa & Contin, (2010); Webb, p. 10).  Additionally, Webb contends that the wages for VGH employees were low, even when compared to standards wages during the Depression.  The HEU has defended the employment rights of its members since its inception in 1944 and made significant gains on their behalf during the 1950s and 1960s as far as wages were concerned. The benefits of union membership for all hospital employees were substantial in this regard, including for PNs. From the early formation of the union in 1936 to 1953, members’ wages increased on average by 400 percent and total number of hours worked per week was reduced by 20 percent (Webb, 1994). Incidentally, parallel improvements in RN wages and hours in BC were also noted, however were much slower to materialize and in fact were not similar until 1968 (McPherson, 1996, p. 233).   By 1968, HEU membership had increased to include the majority of BC hospital employees and provincial bargaining was initiated between the union and the BCHA, which resulted in the first ever unified provincial agreement (Webb, 1994).  This was a stark contrast to                                                      98 The training of nurse’s aides discussed within this source is unspecified by the Webb during the 1930s at VGH.   87  previous negotiations which were initially done with individual hospitals, and then regionally throughout BC (Webb).   The HEU’s bargaining on behalf of its female members, PNs included, over wage standardization and discrimination was substantial. After a dispute between the HEU and the BC Hospital Association went to conciliation in 1967, a decision was announced that lay staff wages amongst twenty lower mainland hospitals would be standardized99.  As such, the HEU also contributed to standardization of PN practice. Interestingly, the HEU’s bargaining efforts also had implications for the gendered division of work for female PNs and their male counterparts in most hospitals, the orderlies. In this regard, an exceptional win occurred in 1973, when after multiple arbitrations, the Health Minister agreed to wage parity between female PNs and male orderlies, whereupon the PNs monthly wage increased by $144.25, an increase of 20 percent (Hospital Employees’ Union, 1973, August). Partial credit for the willingness to negotiate such a comprehensive agreement is given to the newly elected New Democratic Party, who the HEU noted to have “…a fresh outlook…” and a willingness to “…right the wrongs of the past” (Hospital Employees Union, 1973, August).    In contrast to these gains for PNs’ wages, the HEU did not always support the evolution of practical nursing. The unions’ disapproval of the promulgation of the PNs Act in BC during the 1950’s was one example, as discussed earlier in chapter four. More documents would need to be obtained in order to further explore the union’s true intentions and motivations for this stance, which unfortunately, was not possible within the time frame of this project.                                                       99 Bradford, J.D. (1967, May 24). Press Release. British Columbia Hospitals’ Association.  Practical Nurses Training of (GR 0679, Box 3, File 57). British Columbia Archives, Victoria, BC.   88   Another longstanding issue for the HEU was its promotion of apprenticeship for Practical Nursing students. During the early 1970’s, there was a big push to establish an apprenticeship program for practical nursing students, with representatives from the HEU and the BCHA. It was claimed that apprenticeship would provide practical nursing students with better training and would align with the provincial standards of apprenticeship for trades groups. Hospitals, worried about the financial implications, did not endorse apprenticeship. Furthermore, the HEU filed grievances with the Labour Relations Board, citing practical nursing students as employees of hospitals, due to the stipends paid to them during their studentship. A massive campaign against the HEU’s position on the employee status of practical nursing students’ ensued and many letters were written in objection of the student PN apprenticeship model100. Despite the HEU`s efforts to implement the PN apprenticeship program, the provincial government would not provide the                                                      100 PN students of The College of New Caledonia (1973, September 23). [Letter V.E. Rickard (Assistant Director, Technical and Vocational Branch, Division of Post-Secondary Education)]. British Columbia Archives (GR 1561, Box 5 (No file number)), Victoria, BC. Chief PN Instructors of Six Community Colleges in BC (n.d.). [Brief to V.E. Rickard (Assistant Director, Technical and Vocational Branch, Division of Post-Secondary Education)]. British Columbia Archives (GR 1561, Box 5 (No file number)), Victoria, BC. PN students of The College of New Caledonia (1974, January 28). [Telegram to E. Dailly (Minister of Education)]. British Columbia Archives (GR 1561, Box 5 (No file number)), Victoria, BC. PN students of Selkirk College (1974, January 30). [Telegram  to E. Dailly (Minister of Education)]. British Columbia Archives (GR 1561, Box 5 (No file number)), Victoria, BC. PN students of Malaspina College, classes # 37 & 38 (1973, December 6). [Letter to B. King (Minister of Labor)]. British Columbia Archives (GR 1561, Box 5 (No file number)), Victoria, BC. PN students of Malaspina College, classes # 37 & 38 (1973, December 6). [Letter to E. Dailly (Minister of Education)]. British Columbia Archives (GR 1561, Box 5 (No file number)), Victoria, BC. PN students of Malaspina College, classes # 37 & 38 (1973, December 6). [Letter to D. Barrett (Premier of BC)]. British Columbia Archives (GR 1561, Box 5 (No file number)), Victoria, BC. PN students of Malaspina College, classes # 37 & 38 (1973, December 6). [Letter to D. Cocke (Minister of Health)]. British Columbia Archives (GR 1561, Box 5 (No file number)), Victoria, BC. PN students of Malaspina College, classes # 37 & 38 (1973, December 6). [Letter to Editor of Nanaimo Daily Free Press]. British Columbia Archives (GR 1561, Box 5 (No file number)), Victoria, BC. Hospital Board Administrator (Anonymous) Mount St. Francis Hospital, Sisters of St. Ann (1973, November 12). [Letter to B. King (Minister of Labor)]. British Columbia Archives (GR 1561, Box 5 (No file number)), Victoria, BC. Hospital Board Administrator (Anonymous) Mount St. Francis Hospital, Sisters of St. Ann (1973, November 12). [Letter to E. Dailly (Minister of Education)]. British Columbia Archives (GR 1561, Box 5 (No file number)), Victoria, BC.    89  funding for hospitals to pay PN apprentices, thereby effectively derailing the program by 1978 (Registered Nurses Association of BC, 1978).  The HEU’s motivations for wanting to implement the apprenticeship program for PN students were equivocal. While the union stated that such a move would benefit patients and PNs alike, and indeed this could be plausible, nevertheless it could be argued that the HEU may have had gained financially from such a program, due to the collection of union dues from PN students. Given the changes in the PN job market throughout the 1960s, perhaps it also was a way to reinforce their position in health care system. Then HEU’s Secretary-Business Manager, Ray McCready, reported that the HEU was simply responding to a request by PN students themselves. “They came to us for help in the first place…And we readily supplied it even though they weren’t dues paying members…And we’ll do the same whenever we find victims of an injustice in need of our assistance” (Hospital Employees’ Union, 1973, November, p. 16). The injustice McCready referred to was the 1972 cessation of stipends paid to PN students, which left some students in financially difficult situations to complete PN training. Thus far, evidence to confirm this statement has not been found.   Chapter four explores a multitude of issues and perspectives regarding practical nursing throughout the 1950s and into the late 1970s. The biographical portion of the thesis discusses Florence Wilson, a PN and strong advocate for her profession who was later awarded the first practical nursing license in BC. The history of the PNA is introduced and the association`s role in pushing for PN legislation in BC is explored, as well as the significant letter campaign pressuring the BC government to implement the PN Act. The letter campaign illustrates the growing support for enactment for such legislation, as a result of the need to protect the public from fraudulent caregivers who misrepresent themselves as being a trained PN. The full   90  enactment of the PN Act finally occurred in 1965, and the ensuing discussion touches upon the Council of PNs and its responsibilities. Working out both the education and scope of practice of the newly trained PNs were top priorities of the newly appointed BC Council of Practical Nurses.  One approach to create a framework for RN and PN collaboration was enacted by means of a team nursing approach. Lastly, chapter four explains the organizational responses to PN regulation and establishment in hospitals by RN groups, who were in support but also sought to maintain control over PN role development, by government ministries and by the Hospital Employees’ Union.   91  Chapter Five: Conclusion This thesis has explored multiple influences on the development of practical nursing, initially within the national Canadian context and then primarily in BC between the years 1940 to 1980. PNs throughout this time period progressed from being mainly untrained and informally employed to their current status as a regulated professional group, complementing other groups of regulated nursing professionals, such as RNs, within the health care system. The first chapter of this thesis provides the background for the purpose and focus of the research and poses the main research question and four sub-questions. Social history inquiry is used as the guiding theoretical framework for the thesis and chapter one concludes with a discussion of collecting evidence and ethical considerations in historical research.  Chapter two explores early developments in practical nursing prior to 1940 and identifies the multiple social and political historical factors, such as ethnicity, class and gender that contributed to formal PN training in Canada. The third chapter acquaints the reader with national trends which influenced the training, legislation and the regulation of PNs in BC during the specified time period. Furthermore chapter three discusses the initiation of PN training at the Vancouver Vocational Institute, the curriculum and other program details. Chapter four introduces the biography of Florence Wilson, a central leader in the movement towards enactment of the PN legislation and registration in BC, and a key biographical figure in the thesis, illustrating the PN leadership on this matter. The chapter also addresses the variety of organizational responses to the establishment of PNs in BC by organized RN groups, PN groups, various provincial government ministries and the Hospital Employees’ Union. Additionally, the fourth chapter explores a variety of potential reasons for the thirteen year delay in the full enactment of PN legislation in the province of BC and circumstances which demonstrate PN and RN collaboration and division   92  within organizations and between individual nurses. Lastly, this fifth chapter provides a brief summary of the thesis and returns to the thesis questions as the basis for understanding the implications of the findings for present issues and for future research.  Research Questions  I return to the five questions that guided the direction of my research and discuss how they have been addressed. The primary question focused on how the PN role developed within the context of the BC health care system from 1940 to 1980 while the four sub-questions had more specific goals, such as delineating which social and political circumstances contributed and how PNs claimed independence as a separate group from RNs. The final two sub-questions addressed how PN development affected RNs history and practice, as well as exploring how this research contributes to the understanding of contemporary tensions amongst PNs and RNs.  This research pointed to the way a broad variety of social and political factors noted to have contributed to the expansion of PNs in BC. For example, most pertinent of the social factors was the severe shortage of RNs both during and after the WWII years. This fact coupled with the post WWII explosion of medical advancements ensuing nursing specialties and the dramatic increase in the public`s utilization of hospitals, drove the necessity for a new type of nursing assistant. Additionally, the cyclical nature of supply and demand of nurses, influenced by socio-political factors contributed to the role definition and development of the PN. Numerous political factors coalesced into forming the opening for a new type of health care worker, the PN. Primarily government legislation provided new educational opportunities for demobilized veterans returning to civilian life and later for more vocational technical programs and funding for hospital expansion was increased, including for veterans and seniors. Additionally, the professionalization of RNs, an ongoing movement since the early twentieth century and   93  rationalization, the new cost saving approach to increase health care productivity both opened up space and positions within nursing for PNs who possessed more basic training.   As PNs started to become an established group in BC, they began to assert their independence in various ways. The Practical Nurses Association (PNA) formed early in the 1950`s and continued to grow and develop as the years passed. The PNA acted as a professional association, both maintaining communications between members and highlighting important topics affecting PNs throughout the province. A key action undertaken by the PNA throughout this time was the advocacy for the enactment of PN legislation, which finally occurred in 1965. Subsequent to this important occurrence, the PNA officially became the Licensed Practical Nurses Association of BC (LPNABC) and the association became a stronger voice for many PNs in the province, as evidenced by their participation on the PN Council, assistance in licensing of PNs and ensuring the association’s ongoing participation in practical nursing issues.  It is through the formalization of the training, employment and the practical nursing association and PNs ensuing participation that provided an avenue for PNs to have a voice on the issues affecting their training, employment and practice. This is demonstrated in multiple ways, both through the PNAs member’s newsletter, their participation on the BC Council of PNs and in their advocacy work for the full enactment of the PN legislation. Florence Wilson’s biography illustrated these trends. She played an integral role in the development of PNs professional voice and presence in BC throughout this time period. A less dominant theme noted throughout the research is the interdependence of PNs and RNs for their work in both acute and community care, which has evolved as scopes of practice have changed over time and had to be renegotiated as circumstances changed.   94  The development of the PN role historically has impacted RN history and practice in various ways. The position of the PNs in the health care system assisted RNs with the more basic tasks of nursing care, most especially with chronic and convalescent clients. In general, the RN scope of practice slowly grew to encompass further knowledge and skills, while some RNs pursued higher education or specialization to accommodate to this need for more specialized knowledge. In the best interest of quality patient care, it could also be argued that RNs were obliged to assume leadership over the education, licensing and regulation of PNs, as well as a supervisory role in the practice environment. Additionally, RNs had to accommodate the permanent excursion of PNs into an area that RNs previously dominated, which required that the RNs in BC were accepting of their new co-worker, were willing to work harmoniously and were flexible to supervise the new health care worker. Given the role of the RNABC in an advisory and regulatory capacity for RNs professional practice, it perhaps was most expedient for the RNABC to provide the same services for PNs. RNs were most immediately qualified to initiate and instruct PN education, as well as provide supervision in the work place. Through various measures, such as the aforementioned seminars, the RNABC in collaboration with the BC Hospital Insurance Service sought to enhance RNs familiarity in the supervision of this newer category of health care worker.  As a result of the growing numbers of PNs working with RNs, tensions arose over several issues, most of which related to shared areas of practice. The final research question sought to explore the significance of this research to the understanding of current tensions between RNs and PNs, especially in relation to topics such as role ambiguity, nurse substitution and overlapping scope of practice. The research highlights some of the factors that have likely led to, exacerbated or maintained ongoing tensions between RNs and PNs. A primary contributor, still occurring today in BC is the separate education of PNs   95  and RNs, both within educational institutions and often in the clinical facilities as well. Once a Bachelor of Science in Nursing degree (BScN) became the educational requirement for RNs in Canada (except Quebec), RN education moved out of colleges, whereupon in many places a practical nursing diploma programs moved into BC colleges (both private and public in BC). As described within the thesis, early PN clinical education was intentionally placed in hospitals that did not have RN students training, which had a lasting influence on collaboration between the two groups.   During the mid-twentieth century, when PNs were new to BC, their uniform and basic scope of practice more easily distinguished them from RNs. As the numbers of PNs proliferated, the public was likely becoming more familiar with their role as the twentieth century progressed into its last three decades. In comparison to the present time, there are no distinguishing uniforms for RNs or PNs and rarely are professional association pins worn by either nurse. The College of Licensed Practical Nurses of BC (CLPNBC) recommendation in 2004 that all practicing PNs in BC must upgrade to full scope, has somewhat positioned PNs to fill the widening gap left by having fewer diploma prepared RNs (Pringle, Green & Johnson, 2014). Subsequent to this change, the negotiation of professional boundaries between PNs and RNs continues today as PNs scope of practice is gradually expanding into acute care, putting into the question of feasibility of earlier models of team nursing. This transition has created both confusion for the public and conflict within the workplace, as the public often does not see or recognize the skill and knowledge differences between PNs and RNs, especially when currently it seems that both perform many of the same functions of nursing. As the education and scope of practice of both PNs and RNs has evolved throughout the early twenty-first century, questions have arisen how to most equitably utilize mixed nursing   96  staff for the purpose of competent, safe and quality client care. In response to this ongoing dilemma, the Canadian Nurses Association (CNA) reviewed and updated the document “Evaluation Framework to Determine the Impact of Nursing Staff Mix Decisions” (2012) which provides an evidence informed approach to guide mixed nursing staff. Nevertheless, the solution is not always simple and obvious. The myriad of competing social and political influences that shape nursing throughout the last seventy-five years have had deep and long lasting influences on current discussions of role ambiguity, nurse substitution and the difficulty to demarcate the scope of practice between PNs and RNs.  It is evident that as health care has advanced and evolved, many complex social and political factors have influenced the historical and current conflicts and tensions amongst PNs and RNs, and subsequent renegotiation of their working relationship has ensued. Yet, the research also has clearly shown that PNs have become a permanent part of health care and nursing during the course of the twentieth century (Pringle, Green & Johnson, 2004). Additionally, PNs provide an essential contribution to health services across clinical settings emphasizing the need for ongoing collaboration between the two groups (Pringle, Green & Johnson).  Limitations  Some limitations have endured throughout my project. Primarily, I encountered difficulty finding key documents, most significantly those belonging or pertaining to the early PN Association and PN Council. These documents might have added important and contextual details to the analysis of particular events or decisions however this is an unforeseen and uncontrollable factor.  Furthermore, within the scope of a master’s thesis, I had to keep the research restricted to and focused on the selected questions outlined above. As discussed previously, any remaining questions are potential research endeavors.    97  Contribution to Historical Literature  Practical nursing has had many ups and downs that have affected it`s establishment and ongoing development in BC throughout the forty year time span explored in this thesis. Many political and social factors have both positively and negatively impacted the development of practical nursing. Despite the many similarities and at times, co-operation between PNs and RNs, nevertheless, this relationship has been complicated by union, government and hospital politics and policies that have often separated and aggravated their relationship.  This thesis makes several pertinent contributions to historical literature. Ongoing themes from the research include the need for intra-disciplinary collaboration amongst both nursing groups, as well as factors that aggravate the PN and RN relationship. This research underscores Twohig`s argument that questions around scope of practice and demand for different levels of nursing expertise often arise out of workforce issues and the need for qualified nursing within an expanding health care system (Twohig, 2011, 2015). Given the fundamental purpose of nursing, it is apparent that PNs and RNs have much in common, however, both groups have traditionally and currently still are educated and regulated in relative isolation from one another. My research confirms contemporary discourses that address the need for greater collaboration amongst nursing groups, whether educational, regulatory or amongst nurses themselves. Butcher and MacKinnon (2015) report that “It does seem somewhat perplexing that against the predominating healthcare culture of collaborative practice, there seems to be little collaboration among educators of practical and registered nursing students” (p. 236). Other researchers confirm this theme by highlighting the common health care discourse of inter-disciplinary collaboration amongst various health care professionals, however, they note a distinct lack of intra-disciplinary collaboration amongst nursing groups (Pringle, Greenwood & Johnson, 2004). This thesis has   98  offered several explanations of the way such difficulties and barriers are historically situated and are better understood within their historical context. Still the research also has confirmed that PNs are not a new phenomenon but rather have been part and parcel of the nursing workforce since the early twentieth century.  Aggravating factors such as union, government and hospital politics and policies have historically had multiple negative impacts on the relationship between PNs and RNs. My research has demonstrated the resulting tension amongst both nursing groups, for reasons such as role ambiguity, fear of substitution, and more recently overlapping scope of practice. This in turn, accentuates the importance of my historical research to enhanced understanding of current tensions amongst nursing groups. Certainly, there have been instances of co-operation amongst nurses, such as RNs guidance and efforts in the development of PN training and regulation in BC, however these instances have often been confounded by the aforementioned aggravating factors.   My research has, in part, illustrated the power dynamics and unpredictability of the health care system in regards to nursing, also outlined in historiography on the role and history of registered nursing labour in Canada (McPherson, 1996). This thesis expands current nursing history by adding a perspective on the influence and viewpoints of PNs themselves about practical nursing role development and education most notably exemplified in the leadership and advocacy role of Florence Wilson and the PNA. Currently, there is an increasing emphasis on cost effectiveness in health care and the incursion of newer groups of unregulated health care workers only accentuates the evolving and ongoing process of nursing role development. It is salient that an awareness of nursing history informs the present and future decisions and actions taken in regards to health care practices and policies. This thesis has contributed significant areas   99  of new knowledge to historical nursing literature and the ensuing paragraphs discuss potential areas for future research projects.  Remaining Questions and Future Research Directions  Multiple avenues for future research opportunities have been generated from within this thesis. Out of necessity, I chose 1980 as a logical endpoint for my research, however, there is potential for several future research projects in relation to PNs, such as exploring the topic of apprenticeship and the HEU in the 1970s. Further questions to be examined would be about the way the establishment of PNs in BC has impacted RNs scope of practice and employment, especially between the years of 1970 and 2010, as this was when the PNs scope of practice expanded most dramatically. Furthermore one could address how the various hospital and governmental policies affected the supply and demand of both types of nurses throughout this time period.  The evolving professional relations between RNs and LPNs could be explored, along with an analysis of collaborative or divisive actions that has positively or negatively impacted their relationship over the years. This could be addressed provincially, nationally or even internationally, since many countries also have two or three types or levels of nurses. Another research endeavor could be undertaken on how the roles of orderlies and male PNs intersected during the mid to late twentieth century in BC, and how the reverse gender bias inherent in traditional nursing programs (both RN and PN) affected their responsibilities, salaries, status and employment opportunities.  Finally, it is interesting to note the trends that occur in health care as professions and technology advance, necessitating the creation of new categories of health care workers. It appears that delineating the scope of practice is a continuously evolving process when one   100  compares nurse’s training from the mid-twentieth century to now. Currently in BC, a Health Care Assistant (HCA) receives approximate comparable training, both in scope and length to what PNs received in the mid-twentieth century (Thompson Rivers University, 2016). Pringle, Green & Johnson (2014) suggest that current PNs working full scope have taken over the role of the former diploma prepared RN who trained during the mid to late twentieth century. An alternative research endeavor could explore the establishment of HCAs in BC, along with the factors that precipitated their development, and both the resulting effects on PNs and their responses to HCAs. The aforementioned topics would all be relevant projects worth exploring in future nursing history research, especially with the intention to monitor the quality of patient care and health.  Conclusion  I argue that the development of practical nursing in BC during the mid-twentieth century is a significant historical topic that continues to impact current PN and RN relations and the health care system throughout the province today. The methodology of historiography utilized within this thesis, provides valuable and significant understanding of how historical developments contribute to contemporary societal issues and practices.   This research topic came about due to my own curiosity regarding the influences upon the inclusion of PNs into the health care system. As a new BScN nurse at the turn of the twentieth-first century, I pondered the relevance of having both types of nurses, PNs and RNs, in health care. I felt unprepared to supervise PNs, especially considering the BScN was the new educational requirement in BC to practice as an RN, which further complicated RN and PN relationships. I was challenged by experienced PNs whom likely had mixed feelings about a new BScN nurse maintaining supervision over their practice. When PNs in BC were mandated to   101  upgrade their skills in order to practice full scope, I saw the gap between RN and PN scopes narrow over the last decade. For me, the themes identified in this thesis highlight the importance of ongoing research into nurse’s intra-disciplinary collaboration in education and the workplace to increase familiarity, to improve and maintain collegiality and perhaps to lessen some of the hospital and government policies that divide rather than unite nurses together.   It is evident from the previous conclusions that increasing health care demands and new contexts of practice prompt the necessity to redefine and re-establish nurse’s relationships and scopes of practice. 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