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The origins and development of collective bargaining by nurses in British Columbia, 1912-76 Goldstone, Irene Lynn 1981

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THE ORIGINS AND DEVELOPMENT OF COLLECTIVE BARGAINING BY NURSES IN BRITISH COLUMBIA 1912-76 by IRENE LYNN GOLDSTONE BN., McGil l Un ivers i ty , 1972 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in THE FACULTY OF GRADUATE STUDIES (The Department of Health Care and Epidemiology) We accept th is thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA October, 1981 © Irene Lynn Go^ldstone, 1981 In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t of the requirements f o r an advanced degree a t the U n i v e r s i t y o f B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and study. I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e copying of t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the head of my department o r by h i s o r her r e p r e s e n t a t i v e s . I t i s understood t h a t copying or p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be allowed without my w r i t t e n p e r m i s s i o n . Department of Health Care and Epidemiology The U n i v e r s i t y o f B r i t i s h Columbia 2075 Wesbrook P l a c e Vancouver, Canada V6T 1W5 Date October 15, 1981 i i ABSTRACT Co l lec t i ve bargaining by nurses in B r i t i s h Columbia began in the mid 1940's, but the or ig ins of concern about the terms and conditions of employment of nurses are i den t i f i ed as ex is t ing p r io r to the founding of the Registered Nurses Associat ion of B r i t i s h Columbia. The Board and Annual minutes, 1912-76, of the Associat ion were examined and selected materials such as journals and interviews were reviewed to tr iangulate the va l i d i t y of the data. Applying grounded theory (Glaser and Strauss, 1967) to the data, dominant and secondary themes re f l ec t ing the Assoc iat ion 's a c t i v i t i e s and concerns emerged. Analysis of the themes generated the categories of control of the work force, control of work pract ice and control of the work environment. That i s , during the period under study, the Associat ion struggled to exercise control over an uncertain environment. A ser ies of strategies which the Associat ion pursued are examined. Two groups within the Associat ion are i den t i f i ed ; cosmopolitans and loca ls (Merton, 1957). Discontent amongst the l o ca l s , the importance of which was recognized by the cosmopolitans resulted in the ef for ts of the Associat ion sh i f t i ng to concentrate on the control of the work environment. This process resulted in the entry of the Associat ion into co l l e c t i ve bargaining. The categories which emerged from the data were compared with selected l i t e ra tu re on nurses in Canada, England and United States. The interpretat ion of the minutes, and addit ional sources appears to be val idated by th is comparative evidence. Consideration of selected paradigms from the l i t e ra tu res of socia l po l icy analysis and sociology was Undertaken in an attempt to explain.the events, processes, and trends ( Smith, 1976) in a 1argercontext. The study concludes with a consideration of the ideologies of nursing and the ro le these ideologies played. Geertz's (1964) interpretat ion of the role of ideology is used to examine the evolution of these ideologies. The evolution of the ideologies of both the cosmo-pol i tans and loca ls is traced to vocational ism, in the t rad i t i on of Nightingale. Vocational ism conferred a sense of sanct i ty on both the patient and the nurse. Professionalism succeeded vocational ism and focused on the c l i n i c a l procedures and observations resu l t ing in the loss of sanct i ty of both the nurse and pat ient (Wil l iams, 1974). Lat ter ly an ideology accepting co l l e c t i ve bargaining as a means of negotiating the qua l i ty of nursing care, which has both vocational professional aspects, and the economic reward of the nurse has emerged. Adherence to vocational and professional ideologies in the face of changes in the health care system such as the end of pr ivate duty nursing, the development of a hierarchy in nursing, the increased use of technology and the establishment of a th i rd party payment scheme as well as changes in society such as the recognit ion of the i v inequitable ro le of women, and discrepancies in the value of certa in types of work in re la t ion to economic reward impeded the entry of nurses into co l l e c t i ve bargaining. Ul t imately, the s t ra in (Geertz, 1964) f e l t by the loca ls resulted in confrontations with hospita ls and government. As a consequence the f i r s t s t r i ke votes (1957, 1959) endorsed by the Associat ion occurred. Success in improving the economic reward of nurses through co l l e c t i ve bargaining has continued in the 1960's and 1970's. It remains to be seen whether issues related to the vocational and professional nature of nursing w i l l be negotiated, and with what success. These data and the i r interpretat ions should provide important basic information for health pol icy makers in B r i t i s h Columbia. V TABLE OF CONTENTS Page ABSTRACT i i TABLE OF CONTENTS v LIST OF TABLES v i i ACKNOWLEDGEMENTS v i i i ABBREVIATIONS ix CHAPTER 1 Introduction 1 The Purpose 1 The Problem 2 The Signi f icance 2 The Data Base ' 3 L imitat ions of the Study 4 Methodology 4 A P ro f i l e of the Text of the Study 5 CHAPTER 2 The Fai lure of Moral Suasion: 1912-42 7 Introduction: Events, Processes, and Trends 7 The Struggle for Regist rat ion: 1912-18 10 Education: The Essential Minimum: 1919-32 16 Dispar i ty: The Rise of Mi l i tancy: 1933-42 27 Conclusion: The Fai lure of Moral Suasion 43 CHAPTER 3 To Protect the Qual ity of Nursing: 1943-76 44 Introduction 44 The Legit imation of Co l lec t ive Bargaining: 1943-54 46 The Legit imation of Mi l i tancy: 1955-64 . 66 Adjustments to Growth: 1965-76 80 Conclusion: To Protect the Quality of Nursing: 1943-76 97 CHAPTER 4 Methodology 99 Introduction 99 Problems of Social Research 99 Grounded Theory 102 The Appl icat ion of Grounded Theory to the Data Conclusion 1*16 vi. Page CHAPTER 5 Analysis and Discussion 118 Introduction 118 The Concept of Control 119 Negotiation with Internal Forces: 'Cosmopolitans and Locals ' 121 Negotiation with External Forces 126 Postures of Control 134 Conclusion 137 CHAPTER 6 L i terature Review 139 Introduction 139 Control of the Work Force 140 Control of Work Pract ice 144 Control of the Work Environment 151 Conclusion 171 CHAPTER 7 Explanations: Negotiations with External Forces 173 Introduction 173 Negotiation with External Forces: A Case of Dynamics without Change 174 Negotiation the Importance of Legitimacy 179 Control Contexts, Negotiation and Social Order 183 Negotiation and Societal Process 188 Conclusion 190 CHAPTER 8 Ideological Sh i f t : The Attempt to Resolve Chronic Stra in 191 Introduction 191 The Role of Ideology 191 The Orgins and Evolution of Nursing's Ideological Stance 193 Conclusions:Omens for the Future 203 REFERENCE LIST 206 REFERENCE NOTES 223 APPENDIX A Correspondence Concerning Access to the Board and Annual Minutes of the Registered Nurses Associat ion of B r i t i s h Columbia 224 APPENDIX B Biographical Notes 228 v i i LIST OF TABLES TABLE P a 9 e 2.1 Nursing S t a t i s t i c s for B r i t i s h Columbia, 1918-38 2 2 2.2 Selected Data on the Terms and Conditions of Employment of Nurses in B r i t i sh Columbia and Canada, 1929-43 39 3.1 Selected Data from Recommended Personnel Pract ices of the RNABC, 1946-68 1 1 3.2 The Growth of Cert i f iedBargaining Units of Registered Nurses within the RNABC, 1947-76 8 1 4.1 Categories and Properties Emerging from the Data 115 5.1 Postures of Control Assumed by the RNABC, 1912-76 120 5.2 Strategies for External Negotiation of Spec i f i c Issues Used by the RNABC, 1912-76 I 2 9 v i i i ACKNOWLEDGEMENTS I would l i k e to thank the Board of the Registered Nurses' Associat ion of B r i t i s h Columbia for al lowing me to study the Board and Annual minutes. I would l i k e to express my thanks to Esther Paulson and A l i ce Wright for graciously agreeing to share the i r reminiscences with me. The assistance of the Librar ians of the Registered Nurses' Associat ion of B r i t i s h Columbia; and the B r i t i s h Columbia Health Assoc iat ion, the Leg is la t ive L ibrary, V i c t o r i a , Main and Woodward L ibrar ies of the Univers i ty of B r i t i s h Columbia i s g ra te fu l l y acknowledged. Financial assistance from the Graduate Fellowship (Master's Programme Award), the Suzanne Mul l in Bursary, Univers i ty of B r i t i s h Columbia, the Alumnae Associat ion of the Royal V i c to r i a Hospital Training School for Nurses, and the Foster G. McGraw Award of the Associat ion of Univers i ty Programs in Health Administration i s also gra te fu l l y acknowledged. My thanks are extended to Dr. Anne Crichton for d i rect ing the course of th is study, and to Drs. Annette Stark and E lv i Whittaker for serving on my committee. To Celine Gunawardene for patience and speed during the typing of th is thes i s , my thanks. To my family and fr iends who gave me encouragement and support throughout my Master's Programme, I extend my thanks. i x ABBREVIATIONS BCHA B r i t i s h Columbia Health. Associat ion (formerly B r i t i sh Columbia Hospita ls ' Association) BCHIS B r i t i s h Columbia Health Insurance Scheme BCRNA B r i t i s h Columbia Registered Nurses'Association CNA Canadian Nurses'Associat ion 6NABC Graduate Nurses'Association of B r i t i s h Columbia RNABC Registered Nurses'Association of B r i t i s h Columbia 1 CHAPTER 1 Introduction The development of co l l e c t i ve bargaining by nurses in B r i t i s h Columbia i s the subject of th i s study. Nurses have been viewed as s t r i v i ng to profess ional ize (Katz, 1969; Krause, 1977; Wilensky, 1964) and as such, co l l e c t i ve bargaining has been viewed as the ant i thes is of professional behavior (Jacox, 1971). However, co l l e c t i ve bargaining by nurses in B r i t i s h Columbia is now an accepted part of the dynamics of the health care system in B r i t i s h Columbia and in Canada. The Purpose Professional ism and par t i c ipa t ion in co l l e c t i ve bargaining may be viewed as opposing ideologica l stances in which ideology refers to "a manner or context of thinking charac te r i s t i c of an indiv idual group or cul ture" (Webster's Third New International Dict ionary, 1971). The adoption of co l l e c t i ve bargaining by nurses in B r i t i s h Columbia can be viewed as a re f l ec t i on of a change in the thinking of nurses possibly representing a sh i f t in ideology from professional ism to unionism perhaps as a resu l t of changing re lat ionships with in society (E t z i on i , 1968). Bl ishen (1969) studying physicians in Canada has shown that the ideology of physicians in Canada could be analyzed, and the i r responses to s t ra in could be i den t i f i ed . S im i l a r l y , i t 2 was hoped that a study of the Associat ion representing the nurses of B r i t i s h Columbia could produce data to explain the apparent s h i f t in ideology of nurses. The Problem The research problem is stated as a question. How was i t that the Registered Nurses'Association of B r i t i sh Columbia, which seemed to have pursued the goal of professional status for many years, decided to sh i f t from an ideology of professional ism to an ideology of unionism? The Signi f icance of the Study It i s intended that th is study increase the understanding of the ideologica l basis of nurses in B r i t i s h Columbia. Since nurses represent a major port ion of the work force in health care in B r i t i s h Columbia, an understanding of the i r ideologica l pos i t ion is important in any understanding of the functioning of the health care system. In add i t ion, th i s study represents a contr ibut ion to the wr i t ing of nursing h i s to ry , a much neglected a c t i v i t y (Newton, 1965; Nursing Research, 1972; Sa fe i r , 1978) and to the wr i t ing of one womens' occupation, also a much neglected a c t i v i t y (Marie, 1980). 3 The Data Base Possible sources of data were considered. The RNABC Bu l l e t i n i s ava i lab le from 1948. This did not seem to cover an adequate period of time since the f i r s t union a c t i v i t y in hospita ls recorded by the Labour D iv is ion of the RNABC i s 1943 (Registered Nurses' Associat ion of B r i t i s h Columbia, Labour Relations D iv i s i on , 1977). U l t imate ly , permission to review the Board and Annual Minutes of the Associat ion was requested and granted (Appendix A). These minutes begin in September 1912 and June 1913 respec t i ve ly . 1 Or ig ina l l y , i t was the intent ion to review the minutes from 1940-1976 in deta i l doing only a cursory review of the minutes from 1912-39. However, i t became c lear that th is material was too r i ch to be ignored, and would contribute to the strength of th is study. Thus the minutes were reviewed from 1912-76 when the separation of the professional Associat ion and the Labour Relations Div is ion occurred. The study of the minutes was augmented by using other sources such as the News Bu l l e t i n of the RNABC, the published Annual Minutes of the Assoc iat ion, 1946-76, the Annual Minutes of the B r i t i s h Columbia Health Associat ion (formerly the B r i t i s h Columbia 1 References to the minutes of the Board and the unpublished minutes of annual meetings are by date only. Occassionally i t was necessary to d is t ingu ish between the Executive Council of the Board, the Board and unpublished annual minutes and th is i s done where necessary. 4 Hospi ta ls ' Associat ion) and interviews. It i s assumed that issues reaching the Board and publ icat ions represent a degree of importance that grants a certa in v a l i d i t y to the content. L imitat ions of the Study This study i s l imi ted in contextual depth by several factors . There i s an unevenness in the deta i l recorded in the minutes of the Assoc iat ion. Further, access to the documents of the Associat ion was l im i ted to the Board and Annual Minutes and thus supporting documents reviewed by board members were not ava i lab le for study. As we l l , there i s a profound and disturbing lack of archival material about nursing in B r i t i s h Columbia. A l l of these factors may have contributed to an incomplete or inaccurate interpretat ion of the events and the i r meaning which are presented in th is study. Methodology Various methodologies were considered, but a f ter consideration i t became c lear that while the research question should stand, the approach should be open. Thus grounded theory (Glaser and Strauss, 1967) was the research methodology used to analyze the minutes of the RNABC and related documents. Grounded theory is defined as "the discovery of theory from data systematical ly obtained and analyzed in soc ia l research" (pp.1). Grounded theory promotes the emergence of relevant concepts and hypothesis d i r e c t l y out of the data. In th is study the constant comparative method was the 5 the mode of qua l i ta t i ve ana lys is . The purpose of the constant comparative method i s the generation of conceptual categories and the i r properties from the data. The bui ld ing of grounded substantive theory i s the goal . Substantive theory is theory that develops a spec i f i c substantive or empirical area of soc ia l inquiry. In th i s study the focus was the substantive area of a prov inc ia l nursing organizat ion, with study concentrated on the issues of concern to the members of the organization overtime. This i s contrasted with formal theory developed from a formal or conceptual area of soc ia l inqu i ry . There w i l l be no attempt to develop formal theory from the data. A P ro f i l e of the Study This study is reported in eight.chapters. The f i r s t chapter presents the introduct ion to the study in which the problem of the apparent s h i f t in ideology from professionalism to unionism by nurses in B r i t i s h Columbia i s i den t i f i ed . A br ie f discussion of the purpose, the problem, the data base and the l im i ta t ions and methodology of the study are presented. Chapters Two and Three comprise the narrat ive. The narrat ive i s based on the f indings in the minutes of the Associat ion and re lated sources. The narrat ive is organized by chronology and by theme. A natural d i v i s i on occurred between 1912-42 and 1943-76 and therefore the narrat ive i s divided into two chapters. 6 The methodology of grounded theory and i t s appl icat ion to study i s presented in Chapter Four. An analysis of the f indings of th is study i s presented in Chapter F ive. Chapter Six const i tutes the l i t e r a tu re review and considers only selected material that discusses the major themes which emerged from the data. The l i t e ra tu re review i s directed at ident i fy ing convergences and s im i l a r i t i e s with the national and internat ional l i t e r a tu re as well as forming a comparison group for the nurses of B r i t i s h Columbia. Chapter Seven presents selected paradigms from the l i t e r a tu re of soc ia l po l icy and sociology in an e f fo r t to explain the events, processes and trends (Smith, 1976) i den t i f i ed in th is study in the larger context of soc iety. Chapter Eight returns to the theme of the ro le of ideology and the ideologica l response of nurses in B r i t i s h Columbia. 7 CHAPTER 2 The Fa i lure Of Moral Suasion: 1912-42 Introduction: Events, Processes, and Trends As the review of the minutes of the Registered Nurses' Associat ion of B r i t i s h Columbia proceeded, i t became evident that the origins: of co l l e c t i ve bargaining lay in the roots of the pract ice of nursing in B r i t i s h Columbia. Following Glaser and Strauss's (1967) suggestion, the themes of importance to the Associat ion were allowed to emerge from the data. These themes are presented in the form of a narrat ive in segments of approximately 10 years to al low for convenient review. The strategy for organizing the themes was suggested by an analysis of soc ia l change made by Smith (1976). The purpose of th i s chapter and the fol lowing chapter, i s to present a narrat ive of the themes of the a c t i v i t i e s and concerns of the Assoc iat ion. From the themes the importance of certa in events,processes,and trends and the i r re la t ionsh ip to the development of co l l e c t i ve bargaining became evident. Smith (1976) proposes the use of calendar events, medium term processes and long term trends as a means of organizing temporal sequences. Events are studied by "detai led analysis of archival records, to the day to day, or . . . month to month, re lat ionships between ind iv idua ls and groups which generate and compose par t i cu la r pattern subst i tut ions" (Smith, 1976 pp.17). Processes are defined as "sequences .of intermediate durat ion, such as . . . soc ia l movements, urbanisation and m i g r a t i o n . ' P r o c e s s 1 1 refers to typ ica l c lusters i.n<-sequences: of events and. 8 refers to the ' ru les 1 or typ ica l sequences of events (Smith, 1976, pp.17). Smith suggests decades are useful time frames to study processual change, while trends refer to long term change. The study of processual change i s seen as the cruc ia l l i nk between 'micro-events' and 'longeval trends'(pp.18). The themes i den t i f i ed from the minutes are events and processes which appear to have d i f f e r i ng levels of importance during the period under study: 1912-1976. The re lat ionship of one theme to another suggested a change in the ideology of the nurses of B r i t i s h Columbia. Smith (1976, pp.12) suggests that "change consists of temporal, event re fe r r ing , motion of spat ia l patterns resu l t ing in a clean difference from the preceeding pa t te rn . . . soc ia l change i s permanently h i s t o r i ca l in nature, . . . i s essent ia l l y concerned with sequences of events and movements in space and time; and hence.. .that change cannot be studied apart from the h i s t o r i ca l record" . Thus, Smith (1976 pp.13) defines change as a"succession of events which produce over time a modif icat ion or replacement of par t i cu la r patterns or units by other normal ones. . ." . Change in the cu l tura l sphere i s seen as the most autonomic as wel l as the most pervasive.. The concept of cu l tura l change covers several sets of p a t t e r n s " . . . knowledge and techniques, . . . ideas and bel iefs. . .customary behavior and r i tuals ' . ' i^al l are- layers of communication and s ty le" (Smith, 1976 pp.22). The themes and the i r re lat ionships one to another 9 over time which emerge from the data become the processes which represent.change in the ideological stance of the Assoc iat ion. I t i s the understanding of these processes and the i r re lat ionships which contributed to the development and sort ing of categories and properties which, explain the events. The events and processes of the ear ly years of the Associat ion have been described (George, 1969) as occurring in three phases: 1) 1912-1918, the struggle for r eg i s t r a t i on , 2) 1922-1930, the c los ing of substandard schools of nursing, 3) 1933-1944, the problem of working condit ions of nurses. The review of the minutes of the RNABC supports th i s general d i v i s i on . However, although the RNABC continued to be preoccupied with the problem of the working condit ions of nurses up unt i l 1976 and beyond, the period 1933-1976 i s too complex to be taken as a s ingle period. Conse-quently th i s period i s divided into four d i s t i n c t segments: 1) 1932-1942, during which time the working conditions of nurses became general ly recognized as deplorable and the cause of much i l l ne s s amongst nurses. 2) 1943-1954, during which time co l l e c t i ve bargaining was leg i t imized by the national and provinc ia l assoc iat ions, 3) 1955-1964, during which time there was confrontation with hospitals and government. Str ike threats and conc i l i a t i on occurred. 10 4) 1965-1976, during which time change in the organizational structure of the Association was made to meet the demands of participation in province-wide c o l l e c t i v e bargaining. The themes that run through the chronology, while sometimes major, are at other times secondary. They are r e g i s t r a t i o n , education, terms and conditions of employment, and the organizational structure of the Association. Related themes include private duty, student nurses, subsidiary workers, safety to practice, quality assurance, health and safety of nurses, social security and the terms and conditions of employment of senior nursing s t a f f . Throughout the narrative these themes are presented as; dominant themes of primary interest at any given time or as secondary themes. The period 1912-42 i s presented in this chapter, while the following chapter presents the period 1943-76. The Struggle for Registration 1912-1.8. The Registered Nurses' Association of B r i t i s h Columbia was founded as the Graduate Nurses' Association of B r i t i s h Columbia in September, 1912 when representatives of the Vancouver Graduate Nurses' Association, the V i c t o r i a Nurses' Club and the New Westminister Graduate Nurses' Association met. Their objective was to form a provincial nurses' association and to engage in the "preparation and presentation to the government of a B i l l providing for the registration of nurses" (September 10, 1912). The Association established a preliminary examining board, a fee structure for entrance to the Association, an interim 11 form., of reg is t ra t ion and then set about lobbying the government for passage of a B i l l to reg is ter nurses be l iev ing that "a l l who work should be registered, not in a s p i r i t of mi l i tancy, but as a protect ion for the publ ic" (Apr i l 13, 14, 1914). Because there was concern that "no one was to be prevented from nursing, but would be prevented from claiming to be a registered nurse" (October 11, 1913), there was support to reg is ter two grades of nurses, the graduate and the untrained or household nurse. The category of the household nurse was subsequently dropped, but a grandfather clause was added to l im i t reg is t ra t ion of the 'experienced nurse' for the three years fol lowing passage of the B i l l . Lobbying for reg i s t ra t ion began in 1913, and was conducted by meeting with the Cabinet and Members of the Leg is la t ive Assembly and by the sending of l e t te rs and postcards to MLA's. Support was s o l i c i t e d from the Local Council of Women, the Medical Associat ions and prominent members of the community. Consideration of the B i l l was repeatedly delayed,ostensibly to allow the government to give i t s . f u l l consideration to the war e f f o r t (February 15, 1915),- . In 1916 renewed e f fo r t resulted in-,,.the government refusing to sponsor the b i l l . Mr. H. H. Watson (M..L.A. Vancouver) member of the opposit ion, was approached to sponsor the b i l l . During debate in 12 committee, amendments proposed by Dr. H.E.Young (member of the Cabinet, and a "close personal" f r iend of the Premier ( Ormsby, 1958, pp.356; 392) put the Associat ion under d i rect control of the College of Physicians and Surgeons and made provis ion for the reg i s t ra t ion of midwives and maternity nurses. "Heated and acrimonious debate" i s reported to have occurred (Doctors to pass upon nurses' regulat ion, 1916; Nurses' measure i s cause of contention, 1916; B i l l w i l l meet the s i tua t i on , 1918). Debate centered on opposit ion to "creating a closed corporation and v i r tua l monopoly to members of (the) associat ion" (Declare B i l l too arbit fary, 1916) and the "proposed amendment of putt ing nurses under the guardianship of the doctors", and "the fact that the B i l l would not l im i t charges to be made and i t might be that people of moderate means would be forced to do without the services of a nurse" (Doctors to pass upon 1916). Ed i to r ia l comment suggested that the proposed B i l l was "more str ingent than any of the other enactments of i t s c l a s s . . . was not a resu l t of publ ic demand... and thus was not necessary". It was argued that "nursing i s an honourable and useful profession. It can stand on i t s own merits without any l eg i s l a t i v e prop" (The nursing profess ion, 1916) . Ult imately the B i l l was withdrawn rather than l e t i t pass with the amendments. Renewed lobbying by postcard and the s o l i c i t ed support of Dr. Wesbrook of the Univers i ty of B r i t i s h Columbia (December 20, 1917) resulted in a rev is ion of the B i l l . The Local Council of 13 Women supported the B i l l but wanted to "protect those who pract iced midwifery and sick nursing with no t ra in ing but who had passed a simple government test" (March 22, 1918). These proposals were not integrated into the rev is ions . Nor were "the objectionable features of the 1916 B i l l " . The B i l l was presented as "a means whereby a properly tra ined and qua l i f i ed nurse may indicate to the publ ic . . . that she i s an e f f i c i en t n u r s e . ( h a d ) received t ra in ing" and "passed exams", but "allowed graduate nurses and those graduating from proper t ra in ing schools to be registered without passing exams for the next three years" ( B i l l w i l l meet the s i t ua t i on , 1918). The B i l l passed Apr i l 23, 1918 and seemed to have brought a sense of sa t i s fac t ion and optimism to the Assoc iat ion. Secondary themes. While the Registrat ion B i l l was the dominant issue in th is per iod, the Associat ion was also engaged in i t s own development as an organizat ion. Annual meetings were i n i t i a t ed in 1913, dealing with an agenda which included the working business of the Assoc iat ion, the postgraduate education of i t s members and cu l tura l a c t i v i t i e s . The war e f fo r t included volunteering fo r duty, the preparation and packaging of dressings, the co l l ec t i on of funds by tag days for a home for returning nurses and the sending of Christmas remembrances to nurses overseas. The federal government's action in sending nurses not registered with the Canadian National Associat ion of Trained Nurses to overseas duty created an internal furor . The protest was referred 14 from the f ledg l ing associat ion back to the V i c to r i a Nurses' Club because " i t was f e l t i t would be a mistake to send a protest from the Prov inc ia l Assoc ia t ion . . . s ince the appointments had been made in V i c to r i a " (September 25, 1914). A cursory review of the ear ly issues of the Canadian Nurse shows that pract i s ing nurses were concerned about the i r working condit ions and rates of pay (The Canadian Nurse, 1907, pp.149-150; 645-646; 1908, pp.324-325). Nurses in B r i t i s h Columbia were also concerned about the eight hour day and rates of pay. The issue of the eight hour day seems to Nhave erupted at Vancouver General Hospital in February, 1919. The Assoc iat ion 's minutes report receipt of a l e t t e r from Dr. MacEachern, Superintendent of VGH, regarding the eight hour day for nurses and "regrett ing that outside organizations had attempted to in ter fere with the management in th is regard . . . also expressing the hope that the GNABC would take up th i s question . . . . Miss Randal (Registrar) . . . urged that nurses take a f i rm and de f in i te stand regarding t h i s . Miss McKenzie spoke strongly in favor of the eight hour day but f e l t that th i s should be arranged by the hospita ls and nursing organizations and not by Trades and Labor Unions (February 18, 1919). Helen Randal was made convenor for a committee to interview Mr. Ja r v i s , the Attorney-General Mrs. Ralph Smith, MLA and "any other members that i t seemed necessary;. . ." . Helen Randal reported that she " f e l t that progress had been made, and i f the hospitals took th i s up and made provis ion for i t themselves that 15 in a l l p robab i l i ty the government would take no act ion concerning nurses" (March 7, 1919). This may be a reference to the impact of the Minimum Wage Act of 1919 (BCHA, 1919, pp.164) which affected hospital employees other than nurses and student nurses. 1 I t i s however consistent with a t a c t i c of moral suasion evident throughout the work of the Assoc iat ion. The eight hour day committee was formed by the Associat ion as requested by the Canadian Associat ion of Trained Nurses (Apr i l 29, 1919). Summary. Despite in terest in improving working condit ions at the grassroots and with the leadership at prov inc ia l and national l eve l s , the major e f fo r t of the Associat ion was directed towards the establishment of the reg is t ra t ion of nurses. Voluntary reg i s t ra t ion was achieved in 1918 and the Assoc iat ion 's f i r s t Registrar , Helen 2 Randal , was appointed. Helen Randal was to hold th i s pos i t ion unt i l 1941. Under her leadership, the Associat ion sh i f ted i t s e f for ts to the improvement or closure of substandard schools of nursing. In 1911 the Ca l i f o rn ia leg i s la ture enacted eight hour l eg i s l a t i on for women workers.. In 1915, th i s was held to be appl icable to student (although not graduate) nurses. American nursing was s p l i t on whether th is type of l eg i s l a t i on c l a s s i f i ed nurses as labourers, and whether th is was a good thing for the profession. Mary Adelaide Nutl ing of Teachers Col lege, Columbia Univers i ty supported eight hour l eg i s l a t i on and labour's intervent ion to shorten nurses' hours (Ashley, 1976, pp.40-47). See Appendix B for biographical note. 16 Education: The Essential Minimum : 1919-32 Interest in nursing education began with the formation of a committee to invest igate the educational standards of t ra in ing schools in B r i t i s h Columbia in 1916. In 1919, Helen Randal recognized the need to make a survey of the nursing schools of B r i t i s h Columbia. The annual surveys began in 1921. In 1918 t ra in ing schools were described as being conducted in hospitals with as few as 15 beds with a s ta f f of two registered nurses. Entrance requirements were two years of high school education. In 1921, the two year course was lengthened to three years (Creasor, 1952, pp.60). Ethel Johns, 4 speaking at the BCHA Annual Convention of 1920 i s quoted as saying "In Canada today any person or group of persons may assemble a number of s ick persons under a roof and ca l l i t a hosp i ta l . Further, they may inaugurate a nursing school. (There are) no standards ensuring competent i ns t ruc t i on , (or) proper l i v i ng and working conditions . . . (Johns, 1920, pp.9). Throughout the 20's and 30's the Survey Reports were presented in opt imis t i c tones: "(There i s ) an improvement in every department 3 Alberta Creasor, Address of the President, Annual Meetincj, Registered Nurses Assoc iat ion, 1954. 4 See Appendix B for biographical note. Margaret S t reet ' s biography of Ethel Johns (Watch - f i r e s on the mountains; the l i f e and wr i t ings of Ethel Johns. Toronto: Univers i ty of Toronto Press, 1973) provides an ins ight into the formative years of professional nursing in Canada and the United: States. 17 of the schools, . . . deep interest in the provinc ia l exams...... a c learer consciousness of the respons ib i l i t i e s of the Hospital Boards to the t ra in ing schools (Apr i l 17, 18, 19, 1922)... better housing, equipment and c lasswork.. . new nurses' homes (are being) bu i l t (Apr i l 2 and 3, 1923).. . (There i s ) increasing uniformity amongst t ra in ing schools. . (Apr i l 18, 1927).. . g ra t i fy ing to report . . . only twelve nursing schools remain (October 1, 1932).^ During th i s period e f fo r t was directed to improving the educational process by developing a standard curriculum and by the h i r ing of a t r ave l l i ng d i e t i c i an to teach d i e t e t i c s , notably in the smaller schools. Despite the optimism expressed in the Associat ion minutes, a review of the annual minutes of the B r i t i s h Columbia Hospital Associat ion for th is period makes a more e xp l i c i t and pess imist ic statement about the concerns of the nursing leaders of the day. Helen Randal, in addressing the 1920 Nursing Session of the BCHA described the 1919 Survey of Schools by s tat ing that while she met with the "greatest courtesy and considerat ion", in "too many of our hospital Board o f f i c i a l s there was p rac t i ca l l y a tota l lack of real understanding that our nurses 5 I t i s not known how many schools of nursing existed in B r i t i s h Columbia. Weir (1932, pp.278-9) reports there were 17 in 1930. Paulson (1981) suggests that o r i g i na l l y there may have been 23. Non-approved schools (which were unable to meet the standards set by the Associat ion) were known to operate at Merr i t t in the 1930's (Paulson, 1981) and Grand Forks (Eatson, 1938, pp.57). These graduates could not reg is ter under the Registered Nurses Act. 18 entered the hospita ls as pup i l s , or that as a school there was a •'. de f in i te contract entered into between the probationer and the hosp i t a l , that she was to have a de f in i te course of s tudy. . . that while the Boards rea l i zed , and expressed themselves in favour of shorter hours, better housing, more instructors and better supervision by graduate nurses. There was s t i l l the painful showing on the books of a d e f i c i t . . . (Thus) a d i rec t appeal must be made tothe Prov inc ia l Government for a de f in i te sum to be spent on the education of nurses alone. Cheap nursing to the advantage of the hospital and to the detriment of the pupi ls has been gradually taken as something too common to not ice" . Helen Randal concluded with these recommendations: a) presentation of the case to our Legis lature of the r ight of t ra in ing schools in hospi ta ls to be financed in part by government money, b) standard curriculum and inspection of schools to be enforced, c) t ra in ing school hours or accommodation for nurses to be sadly def i c ient - rooms crowded, general ly in hospital bui ldings where no opportunity for recreation was provided - no rooms for laboratory, d iet kitchen or study provided • (Randal, 1920, pp.24-26). One year l a t e r , at the BCHA meetings, Ethel Johns re- i te ra ted that "the present shortage of pupi ls . . . i s a d i rect consequence of old methods of exp lo i ta t ion . . . "the k i l l i n g of the goose that l a i d the golden eggs" (Johns, 1920, pp.9). Resolutions of the BCHA, in 1919 and subsequent years ca l led for the government take-over of publ ic hosp i ta l s , increased government 19 funding, and d i rec t government contr ibut ion to the education of nurses. (BCHA, 1919, pp 112; 1921, pp.43; 1938, pp.20; 1949, pp.126). Because discussion of the proceedings of the Annual Meetings of the BCHA is more deta i led than the GNABC minutes, a stronger commitment by the leaders of the profession to improve working and l i v i n g condit ions i s i l l u s t r a t ed in the BCHA minutes. These same leaders repeat a commitment to a strategy of "begin(ing) our propaganda for better nursing cond i t ions . . .w i th the BOards of the schools for nurses connected with our ho sp i t a l s . . . " (Randal, 1920, pp.25). Other concerns in education included the establishment and support of a scholarship fund for nurses at McGil l Univers i ty (October 14, 1918), estab l i sh ing a publ ic health program at the Univers i ty of B r i t i s h Columbia (January 10, 1920) and the establishment of post-graduate education in teaching and supervision of nursing (September 12, 1931). The Weir Report. The problem of "the nurse in her re lat ionsh ip to the hosp i ta l , the medical profession and the publ ic at large" (Cameron in Weir, 1932, pp.5) resulted in the s t r i k i ng of a j o i n t committee of the Canadian Nurses Associat ion and the Canadian Medical Associat ion in 1927. In 1929, George Weir, then Head of the Department of Education, Univers i ty of B r i t i s h Columbia, was charged with the 20 respons ib i l i t y of "get(ti.ng) at as many facts regarding the problems of nursing conditions as poss ib l e " . . . (Weir, 19.32, pp,7)« Weir undertook a quant i tat ive survey to i l l u s t r a t e the l i f e of the pr ivate duty nurse, the publ ic health nurse and the i n s t i t u t i ona l and student nurse. He found nurses l i ved an unduly harsh l i f e , with high unemployment and i l l ne s s rates, an educational system which was geared to the running of a hospital not the education of students, and an economic gap between the patient of moderate means and the nurse. As a so lut ion to the complex of problems facing nurses and the publ ic seeking care he recommended soc ia l i zed medicine and that nursing education become an integral part of the state education system. Weir persisted that ."nursing should be regarded as a profession, however immature in the attainment of professional standards, rather than as a potent ia l member of a trades union" (Weir, 1932, pp.65). The profession responded by promoting pub l i c i t y of the report by interviewing editors of Vancouver, V i c to r i a and New Westminster papers (November 20, 1931) and by sett ing up study groups throughout the province. Newspaper coverage was comprehensive and sympathetic (Health insurance and soc ia l i zed nursing are strongly urged, February 20, 1932.pp.1; 10). As ear ly as 1919 discussions within the Associat ion had considered state medicine and state nursing, and the impl icat ions for nursing. I n i t i a l l y "the general fee l ing seemed to be much — A Leg is la t ive commission of the government of B r i t i s h Columbia was appointed to invest igate Health Insurance in 1919. No act ion was taken (Sh i l l i ng ton , 1972, pp.40). 21 against State Medicine" (January 10, 1919) but with the appointment of a Prov inc ia l Royal Commission on State Health Insurance and Maternity Benefits in 1928 and with the publ icat ion of the Weir Report strongly endorsing state medicine as a so lut ion to the problems of education and employment of nurses, the pos i t ion changed to support. A Committee of the Associat ion worked on health insurance unt i l the late 1940's. Secondary themes • The secondary themes of th i s period include the development of an organizational structure of the Assoc iat ion, the terms and conditions of employment and the health of nurses. The Associat ion set up the Pr ivate Duty, Publ ic Health and Education Committees as standing committees in 1922. This re f lec ts not only an employment pattern but areas of in terest to nurses. Pr ivate duty within the home or hospital was the usual form of employment of nurses. Publ ic Health was gaining increased recognit ion espec ia l ly fol lowing the inf luenza epidemics of 1919, but employed r e l a t i v e l y few nurses. Hospitals were staffed large ly by student nurses. Weir (1932, pp.290-291) recommended that an approved school of nursing have " f u l l time trained ins t ruc tor " . Thus the composition of the Education Committee, a chairman and "a l l those ac t ive ly engaged in nursing education" (Apr i l 17, 18, 19, 1922) i s less surpr is ing than might be supposed. It i s possible to reconstruct an approximate d i s t r i bu t i on Table 2.1 Nursing S t a t i s t i c s for B r i t i s h Columbia, 1918-38 Group 1918 1919 1921 1927 1928 1929 1930 1937 1938 Current Registered Nurses Graduates and students 170° 711' 969 L 1550" 1947 c 2148 L Non-registered Graduates working in Hospitals Students Pr ivate duty Nurses 863' 4759 918' 750 j 222" Publ ic Health Nurses 801- 132'! 162' Wright, 1958, pp.78 The sudden increase in Registered Nurses was due to the grandfather clause of the Registered Nurses Act . b RNABC, December 21, 1921 c Canadian Nurse 1928, pp.488 d RNABC, Apr i l 19,1928 e Census of Canada, 1921, pp.32-33 f Weir, 1932, pp.279 g RNABC, November 8, 1929 h Latham and Kess, 1980, pp.69 i Eaton, 1938, pp.9 j Eaton, 1938, pp.65 k Eaton, 1938, pp.10. Note. The census t rac t does not define graduate nurse, and t h i s number probably includes nurses who were not reg is tered . 'Reg is tered nurses' may have been inact ive because they were unemployed, not seeking employment or because they l i v e d outside the province. ' P r i v a t e duty nurses' are probably those who registered with the Associat ion as ava i lab le f o r pr ivate duty or were members of the Pr ivate Duty Sect ion. The number of pr ivate duty nurses stated in t h i s table i s probably f a l s e l y low because only 17% of pr ivate duty nurses were placed by an Assoc iat ion Registry (Weir, 1932, pp.346). 23 of graduate and student nurses, by using several sources, (see Table 2.1) These numbers must not be regarded as absolute. The lack of numerical data ava i lab le in the Assoc iat ion 's minutes made the use of varying sources necessary. Terms and conditions of employment have three aspects: the hours of duty, the organization of care, and the ro le of students. Discussions of the e ight , ten, and eleven hour day occur with increasing frequency towards 1932. The Private Duty Section endorsed the eight hour day (January 18, 1930) but i t i s d i f f i c u l t to estab l i sh how widespread the acceptance of th i s was,since endorsation of the eight hour day repeatedly occurred unt i l the mid 1940's. It must be remembered that an eight hour day meant eight working hours spread over ten or twelve, or more hours. Nurses were working up to twelve or more hours spread over sixteen hours (Eaton, 1938, pp. 36-39).or in the case of pr ivate duty nurses, twenty-four hours (Weir, 1932, pp.89). Pr ivate duty nurses received about 17% of the i r work through the Associat ion Registry and the remainder through pr ivate reg i s t r i e s or physicians (Weir, 1932 pp.386). These nurses were often working in hospita ls where the hours of work were set by the i n s t i t u t i o n . Weir found the employment s i tua t ion of th is group to be woeful. The actual average employment period for pr ivate duty nurses in B r i t i s h Columbia was 29.7 weeks per annum, (with a Canadian average of 14.3 weeks unemployed) 4.5 weeks of i l l n e s s and 3.3 weeks of vacation. These nurses were unable to save any earnings and received ind i rec t subsidy by l i v i n g 24 at home (Weir 19.32 pp.66-96), Fears were expressed at the Depression would encourage nurses to work, twelve hour sh i f t s for addit ional remuneration (January 19, 1934). Thus, although the Associat ion ac t i ve ly supported pr ivate duty nursing by operating a Registry, the Associat ion may not have had s ign i f i can t inf luence over the hours pr ivate duty nurses worked. During th is period there i s no mention, with in the Assoc iat ion, of concern for the terms and conditions of employment of publ ic health nurses. I t i s not possible to reconstruct hours of work or working conditions for publ ic health nurses from the Weir Report (Weir, 1932, pp.118-143). Esther Paulson 7(1981) reca l l s working a 5% day-week in the mid 1930's in the Kootenay d i s t r i c t . Home v i s i t s were done on Sundays as the need ^rose. Weir does show that near f u l l employment of publ ic health nurses ex isted,that very l i t t l e sickness occurred (.9 weeks per annum) and that i t was possible to save a modest amount of the i r earnings (Weir 1932, pp.123-154). Ins t i tu t iona l nurses enjoyed s im i la r employment and i l l n e s s rates as publ ic health nurses, but over hal f were unable to save anything from the i r earnings (Weir, 1932 pp.102-109). Student nurses were c l ea r l y the worst o f f , working twelve hour days, often too fatigued to study, and suffer ing a high i l l n e s s rate (Weir, 1932, pp.168-181). There i s no discussion of the earnings of student nurses in the Weir report. ^See Appendix B for biographical note 25 With hi.gh unemployment rates amongst pr ivate duty nurses, even before the Depression i t i s not surprising that the Associat ion pressed for changes in the organization of the del ivery of care. The Associat ion encouraged hourly nursing and group nursing as a means of increasing the employment of nurses by making nursing care less cost ly to the patient (November 20, 1931, March 15, 1932). Hourly nursing was a method of h i r ing nurses for short in terva ls over a period of time, while in group nursing one private, duty nurse cared for several hosp i ta l i patients at once. E f for t was made to reduce the annual enrollment of student nurses, then approximately 1/2 - 1/3 of the work force (see Table 3.1). I t was argued that h i r i ng graduate nurses was cheaper than the cost of educating students (BCHA, 1931, pp.101). Thus the Associat ion pressed for the reduction in the s ize of schools in order to employ graduate nurses, and further urged that hospita ls consider "very ca re fu l l y the employment of married nurses" (September 26, 1930). These tac t i c s can be assumed to have had considerable impact on the sh i f t of employment of graduates from private duty to i n s t i t u t i ona l nursing. The re lat ionsh ip of the health of nurses and hours of work was understood by the nursing leaders, even though there i s l i t t l e d i rec t reference to th is in the GNABC minutes. The BCHA meetings of 1931 (pp.34) quote the superintendent of Tranqui l le Sanatorium as stat ing that "15-20% of the female pa t i en t s . . . were pupil nurses in t ra in ing in th is province": Weir reports that , in B r i t i s h Columbia of 123 students surveyed, 31.7% had more than f i ve days of f duty through i l l ne s s in the previous 6 months (9.3% had 25 days of i l l n e s s ; among 26 the highest in Canada. 1 (Weir, 1932, pp.173), Helen Randal, in an eloquent statement during a deb_a,te on.the eight hour day "explained that since 1912 she had Been very c lose ly associated with both student and graduate nurses, and had seen the i l l ef fects of long working hours. She could safe ly say that a large proportion of tuberculosis among nurses had Been brought about through the breaking down of the nurses' health due to long hours not only in the wards But in the intensive study they have to make in order to Bring them up to the standard which is expected of them in th i s generation" : (Randal, 1938, pp.'."-53)8,9 Summary. The interva l 1918-1932 represented a period of intense commitment to the reform of nursing through changes in the system of educating nurses. While progress was made in improving or c los ing suBstandard schools, the roots of the problem, inadequate f inancing of health care and nursing education, remained unchanged. Consequently there was no improvement in the working conditions of nurses, whether graduate or student nurses. Unt i l the pressures of World War II were f e l t in the ear ly 1940's, unemployment and working condit ions became the predominant concern of the Assoc iat ion. The high incidence of tuberculosis amongst student nurses was not unique to B r i t i s h Columbia. The "Province of Saskatchewan...records show that the incidence of tuberculosis among nurses...was approximately 10% higher than the normal expectancy for tuberculosis in young women between 19 and 24 years of age" (BCHA, 1939 pp.57). 'Ferguson, (1935, pp.134) states "the!incidence of breakdown among nurses in t ra in ing in general hospita ls during the period 1930-1933 was 12.7 per thousand. This i s twelve times the incidence of tuberculosis morbidity among the general popu la t ion . . . I t i s eight times the incidence found...among normal school students..."The high rate of tuberculosis amongst nurses was at t r ibuted" to the fact that nurses are expos.ed to frequent and larger doses of tuBerculosis in fect ion from unexpected sources". There i s no discussion of working condit ions as a prec ip i ta t ing factor . 27 Dispar i ty: .the Rise of Mil itancy:1933-42 The struggle to improve the terms and condit ions of employment was the dominant theme of th i s period. Secondary themes include mandatory reg i s t ra t i on , education and organizational change within the Assoc iat ion. Background. The po s s i b i l i t y of a prov inc ia l health insurance scheme resolv ing the employment problems of nurses remained unt i l 1937. The Royal Commission on Health Insurance did not d i r e c t l y support the inc lus ion of nursing services in the scheme, but did support adequate hospital funding (Davie, 1932). George Weir entered po l i t i c s in 1933, became Min is ter of Education and l a t e r , Provinc ia l Secretary responsible for health. The Associat ion greeted the news with a l e t t e r of congratulations " rea l i z i ng his inestimable value to a l l professions of his platform of vocational education" (November 24, 1933). As Provinc ia l Secretary, with re spons ib i l i t i e s for health, Weir put forth "A Plan of Health Insurance for B r i t i s h Columbia" in 1935. This was followed by Hearings Committee in the same year (Peebles, 1935). The Associat ion was ac t i ve ly involved in the process (November 30., 1934; February 22, 1935; Apr i l 22, 1935) and repeatedly re i terated the need for the funding of adequate nursing service in home or in the hosp i ta l . Grace Fa i r l ey , Superintendent of Nurses at Vancouver General Hospital sat on the Committee (Peebles, 1932, pp.12). A b i l l was prepared, amended fol lowing demands by the medical profession and 28 the Manufacturers' Assoc iat ion, and passed In March. 1936. The plan was to go into ef fect March 1937, but despite support from a p leb i sc i te held during the e lect ion of that year, the plan was i nde f i n i t e l y postponed (Taylor, 1978 pp,6). The doctors supported the pr inc ip le of health insurance but rejected the proposed scheme because i t "omits a l l the very people in the community who most need i t . . . " and because payment was to be by capi tat ion rather than fee- for-serv ice (A Br ie f Analysis:, 1937, pp.97-100). Action by the Associat ion . The Associat ion attempted to exert i t s inf luence for an improvement of working conditions on behalf of pr ivate duty, i n s t i t u t i ona l and student nurses by 1) t ry ing to persuade pr ivate duty nurses to support an eight hour day, 2) attempting to control h i r ing pract ices of the Registry, i t s e l f supported f i nanc i a l l y by the Assoc iat ion, 3) using "moral suasion" with hospital boards and the BCHA on behalf of i n s t i t u t i ona l and student nurses, and 4) giv ing support to leg i s la ted change by frequent communication with the appropriate cabinet members. This a c t i v i t y was most prominent af ter completion of work on health insurance. Thus the minutes read that "..The Registrar (be author i zed) . . . to write to various nurses' local associat ions and hospital centres endorsing the pr inc ip le of the eight hour day (Apr i l 22, 1935).. .hospita l boards be asked to put an improved time schedule into e f fect . . .The Council endorses the pol icy of al lowing su f f i c i en t time for meals on the eight hour day service without a l te ra t ion of 29 the regular f e e . . . " (Apr i l 3, 1937). The eight hour day for nurses was debated at length at the Annual Meetings of the BCHA in 19.37 and 1938. "A serious shortage of nurses in Eastern Canada was reported to be due to the i n s t i t u t i on of the eight hour day in Eastern United States and the consequent migration of nurses. "Labour trouble in ho sp i t a l s . . . i n Canada . . . (w i th ) "two s t r ikes of the i r employees" was also reported (BCHA, 1937, pp. 71-72). In 1938, the BCHA , had a protracted debate on the eight hour day for nurses and the costs of implementation. (BCHA, 1938, pp.20-22; 50-59). A motion of the Canadian Nurses' Associat ion supporting an eight hour day for nurses which was sponsored by a member of the Nursing Section of the BCHA was ruled out of order. The context of the minutes suggests the.exercise of convenient s t a l l i n g tac t i c s in ru l ing the motion out of order (BCHA, 1938, pp.75-77). Newspaper reports of the 1938 meeting record that the Nursing Section of the BCHA was "general ly sympathetic" to the 48 hour week for nurses, but makes no reference to the re jec t ion of the resolut ion supporting the eight hour day by the general assembly of the Hospita ls ' Associat ion (Working time for nurses i s subject of debate, 1938). Action in the p o l i t i c a l arena In the meantime, the hours of nurses had become a p o l i t i c a l issue. E.E. Winch^, CCF(Burnaby) presented a pr ivate members b i l l to E.E. Winch i n i t i a t ed debate in the Legis lature on the working conditions of nurses in 1935 (Steeves, 1960, pp.100-101). 30 regulate the hours, nurses worked under the Hospital Act. George Weir, as Provinc ia l Secretary assured the member that the "problem was, being handled by the government..«(and r e a l l y ) , . . came under the Board of Industr ia l Relations not the H o s p i t a l s A c t . . . " . The Honourable G.S. Pearson, Min ister of Labour, is reported as stat ing that "the government i s very sympathetic to the condit ions of nurses...(and) had been studying (the problem) for two years, . . . improvements had been made in some hosp i ta ls . With these assurances, E.E. Winch withdrew the b i l l (Nurse's b i l l i s withdrawn, 1937). This debate promoted a strong rebuttal from "Nurse, Comox" in the l e t te r s to the ed i to r . The nurse wrote" . . . , ( in) almost every hospital in the province nurses are being ser ious ly overworked, and (are) leaving hospital service with ambition crushed and health broken... as a man hired to work in the interests of the province...some explanation might be in o rder . . . Dr. Weir's reply was a calculated f launt ing of publ ic opinion" (Overworked nurses, 1937). One year l a te r the CCF re-introduced the b i l l and prec ip i tated "short sharp debate in which, the Opposition pressed the government to supply the eight hour day law and other benefits for graduate and students nurses: in hosp i t a l s . . . . ( t he eight hour day) was declared not feas ib le on account of f inances" (House K i l l s CCF b i l l , 1938). H.E. Winch in supporting his fa ther ' s b i l l i s quoted as saying "the ent i re publ ic should bear the burden of the hosp i ta ls , not jus t the nurses, . , G.S. Pearson, Min is ter of Labour admitted nurses are the subject of 31 abuse...(but) nurses are general ly well looked a f te r . , most hospi ta ls are run by Boards of d i r e c t o r s . , , anything wrong would have been complained (about) . . . we know hospita ls need more money...(we are) moving further in B.C. in the f i e l d of soc ia l l eg i s l a t i on than any other province in Canada...But don't push i t too far" ( B i l l g iv ing hetter condit ions, 1938). On OctoBer 1, 1937, Mrs. Rex Eaton was appointed to Chair the "Advisory Committee on LaBour Conditions in Hospita ls" By the Provinc ia l Secretary, G.M. Weir, with the consent of the Min ister of LaBour, G.S. Pearson. The Committee was charged with the responsi-b i l i t y of invest igat ing and reporting upon "wages, hours of work, condit ions of work, and other labour conditions in hosp i ta ls" ; recommending "reasonable minimum standards of wages, hours of work, and working condi t ions. . . (such that) working condit ions in hospita ls are not unreasonable, that wages paid are f a i r and that the general labour condit ions are such as not to be detrimental to the health of the persons employed", and to estimate the increase in the operating costs of hospi ta ls should the recommendations be implemented. (Eaton, 1938 pp 1-3). The committee surveyed 49 puBlic and pub l i ca l l y supported hospitals and s ix pr ivate hospita ls ranging in s ize from 1374 beds to less than 35 beds . 1 1 The report of the Advisory Committee was presented 1 1 Public hospitals such as the tuBerculosis sanatorium (Tranqui l le) and , the mental hospital (Riverview) were the d i rec t administrat ive and f inanc ia l r espons ib i l i t y of the Provinc ia l Secretary. Pub l i c ly supported hospita ls received f inanc ia l support for the costs incurred in caring for char i ty pat ients. There was no d i rect government respons ib i l i t y assumed in the administrat ive or f inanc ia l aspects of these hosp i ta ls . Pr ivate hospita ls were independent of government f inanc ia l assistance. In an annual report of the RNABC to the CNA, i t was reported that there were 72 hospita ls staffed with graduate nurses ( Fa i r l y , 1938, pp.444-445). 32 to the Provinc ia l Secretary and the Minister of Labour October, 1938. I t would appear from the Associat ion minutes that the Report was not immediately ava i lab le (May 19, 1939);. The hours of work are described as " in to le rab ly long". The nurses are quoted as "understand(ing)" the pressing need for new bu i l d ings . . , sympathiz(lng) with the f inanc ia l burdens of hosp i t a l s . . . (but a s ) . . . bel ieve(ing) that very often they form the group which absorbs economies made necessary by other demands and that the very fact that they can be depended upon to render service without protest and without dras t i c action has kept them working hours of such length that the i r health suffers and normal essent ia l soc ia l a c t i v i t i e s are denied to them" (Eaton 1938, pp.12-13). Day duty ranged from 43-65 hours per week with a hal f day of f weekly, while night duty ranged from 48-84 hours per week. Time of f night duty was extremely l im i ted : 29 hospita ls ( tota l 49 report ing) had no evenings or nights of f duty, while 20 hospitals granted up to one night of f each week. Night duty lasted four - f i ve weeks at a time occurring one month in every three or four months. On ca l l and overtime was recognized as ser ious ly in te r fe r ing with time of f duty, as was the spread of working hours, often over 15 and even 16 hours a day.. The socia l i so l a t i on of nurses resu l t ing from hours of duty and the requirement by most hospita ls of l i v i n g in residence (for both graduate and student nurses), the poor accommodation and the absence of recreat ional f a c i l i t i e s were recognized as a serious problem. Salar ies ranged from $30.00 -$80.00/month plus room, board and laundry expenses valued at $25.00/ month (Eaton, 1938, pp.12-37). 33 The Report recommended an eight hour day, 96 hour for tn ight 12 (thus al lowing " sp l i t s h i f t s ' to continue), reduction of on-ca l l and overtime, and a salary of $60.00 monthly plus room, board and laundry expenses as a minimum wage. Deduction for food, lodging and laundry were s t ipu la ted , as was an hourly rate for part-time s ta f f . I t was recommended that no charge be made for breakages of equipment. The nurse was to provide her own uniforms. No recommendations were made for the amount of vacation time to be granted but the importance of holidays was recognized. Hours of work recommended for students were s im i la r to those of graduates, but with the proviso that c lass time be included in "hours of work". The "average nurse" was seen to be "working for hours which have long since been considered in to lerab le both by the average worker and the general pub l i c . " The committee discussed the problem of the health of nurses and "undue fat igue" that was evident. Nurses were seen as "combin(ing) physical e f fo r t with grave respons ib i l i t i e s and emotional s t r a i n . . . afford( ing) reason for a shorter day than the average worker . . " . While the committee was unwi l l ing to make "any conclusive statement... concerning the actual percentage of cases of tuberculosis in th i s occupation as compared with percentages found in other occupations" the committee accepted that a person in a state of constant fat igue becomes l i ab l e to the contract ion not only of tuberculosis but of other i l l nesses to which a nurse i s pa r t i cu l a r l y exposed". Recommendations were made to estab l i sh and maintain health The Committee stated that i t would l i k e to recommend a s t ra ight e ight hour day as a minimum but since "no occupation has the hours of work confined by l eg i s l a t i on to less than a 12 hour - spread...(which)has been in e f f e c t . . . since December, 1937 when the Hours of Work Act was amended to that e f f e c t . . . the Committee considers that i t must hesitate before recommending... a more rigorous requirement concerning the spread of hours than i s now set out in the Hours of Work Act" (Eaton, 1938 pp.37). 34 records of nurses, and to teach and pract ice preventive measures in the case, of infected pat ients, (Eaton, 1938, pp,21-25), The Advisory Committee concluded that there was a general consensus amongst nurses, the Assoc iat ion, the BCHA, and the pub l i c , that nurses' hours must be shortened. With the agreement of the Council of the Assoc iat ion, the Advisory Committee recommended that nurses' hours and wages be regulated under the Female Minimum Wage Act and that the hours of work of students be regulated under the Trades Schools Act (Eaton, 1930,pp.30-31). The option of amending the Registered Nurses' Act to al low the Associat ion to enforce, regulations concerning students' hours.of work was discussed and discarded. The ro le of the Associat ion in regard to students had been directed to methods of t r a i n i ng , although the Associat ion had encouraged voluntary reduction of students' hours with some success. However, the Executive Council of the Associat ion stated that the success of the i r work depended great ly upon the sympathetic and f r i end ly co-operation of hospital boards and administrators. I f at any time such re lat ionships were destroyed by a disagreeable s i tua t ion about the hours of work i t might in ter fere with the progress they wished to make along educational l i n e s . The Members of the Council of Nurses are themselves administrators dealing with Hospital Boards along many l ines and may not be in a pos i t ion to take a completely independent stand without paying a certa in pr ice for firmness. The Council has only one punit ive measure to take against the hospital not conforming to the regulations of the Registered Nurses" Act, and that i s to remove the t ra in ing school from the approved l i s t . Needless to say, such act ion would not be taken unt i l abuses had become f lagrant and uncontro l lable". (Eaton, 1938, pp.60-62). 35 Str ike act ion. Within seven months of the submission of the Eaton report, an outburst of mi l i tancy culminated in the f i r s t s t r i ke of nurses in 13 B r i t i s h Columbia. Nine graduates and undergraduates of a s ta f f of twelve walked out at St. Joseph's Hosp i ta l , Comox. The press report of a statement issued by the nurses declares: "Nearly a month ago there was presented to the advisory board of St. Jospeh's Hosp i ta l , Comox the fol lowing requests: - an 8 hour day be adopted - 2 weeks annual vacat ion, and annual allowance of two weeks' s ick leave with pay - greater care and se lect ion of meals - a monthly allowance of $2.50 for laundry. After several weeks the graduates were conceded 2 weeks' vacation with pay and the $2.50 for laundry only af ter a year of serv ice. No allowances were made for the undergraduate nurses who have been receiv ing less consideration than the maids. Feeling that rest was the most important, i t was decided to forego a l l demands i f we could have one day a week of f duty, which would s t i l l leave a minimum 54 hour week day sh i f t and 70 hour week night s h i f t . This request was refused. Nothing was done in haste or without due considerat ion. There was ample time given the advisory board to correct condit ions. (Nurses walk out at Comox, 1939).14 'Two nurses resigned from a coastal hospital due to inadequate equipment in 1907. Newspaper reports suggested that the nurses should have appealed under the Industr ia l Disputes Act passed that year. The nurses may not have done so e i ther because of ignorance of the Act or because they considered i t to be l eg i s l a t i on for un ion is ts , and thus non-professional (Str ike of nursing s ta f f at Marble Bay Hosp i ta l , 1907). By the way of comparison of the working conditions at St. Joseph's Comox with the data from the Eaton Report, 45% of hospita ls surveyed are reported to have had nurses working s im i la r hours for day duty, with 27.4% and 23.5% hospita ls reporting less and more hours worked. Two hospitals reported considerably more hours worked. For night duty, 22% hospitals reported s im i la r hours while 42% and 36% reported fewer and more hours worked (Eaton, 1938, pp.13-5). 36 The hospital was reported as "working under emergency condit ions, caring for 50 patients with three nurses, two Interns, nuns and c i t i zens who volunteered" (Nurses posts being f i l l e d , 1939). As well " . . . the hospital ladies a u x i l i a r y . . . ( i s ) ass i s t ing in the kitchen and other work." Two nurses were sent from St. Paul 's Hosp i ta l , Vancouver to ass i s t (Nurses' protest invest igated, 1939), S i s ter Walberga, Superior of S i s ters of St. Joseph i s quoted as saying "We are very, very sorry th i s thing has happened., but we are gett ing along n ice ly now (Two new nurses a r r i ve , 1939).. . They were a l l good g i r l s . . . perhaps they were a l i t t l e impulsive and acted imprudently... we are w i l l i n g to give them better condit ions, we know they deserve them...but, most of our patients are on r e l i e f or too poor to pay.. . the government grant i s 15 16 i n su f f i c i en t " (Nine nurses qu i t , 1939). ' Col in Cameron (MLA, CCF, Comox), attempted to interview the "hospital board on the question and succeeded in presenting the nurses' case to two of the members . . . he was assured that the board could do nothing for the nurses and they stated that i t was impossible for them to par t i c ipate in a publ ic meeting at which the question would be discussed (Two new nurses arr ive at Comox, 1939). An o f f i c i a l of the Associat ion was quoted as "having no o f f i c i a l report on the matter" and that there had been "no request for an investigation"(Nurses protest invest igated, 1939, p p . 2 ) . . In the minutes of the Associat ion Col in Cameron _ In 1936, prov inc ia l and municipal funds met more than 40% of the tota l cost of operating a l l government aided hospita ls in B r i t i s h Columbia." (Ward in Eaton, 1938, pp.84). Medical indigency was conservatively estimated to be 25% in Canada in 1936 ( B a i l l i e , 1940). 37 i s noted to have been "refused permission to speak to the (Annual) General meeting (about) the recent s t r i ke at St, Joseph's. Comox" (Apr i l 15, 1939). After one week the s t r i ke ended with the Board of the hospital agreeing ( to an eight hour day, s ix day week, and two weeks vacation with pay. "Previously the nurses were on duty up to twelve hours or more da i l y , without provis ion for a day-off or vacation" (Nurses at Comox return to duty, 1939). The Assoc iat ion 's response • Although the Associat ion was in the midst of i t s Annual Meeting during the s t r i k e , there i s no d i rec t reference to i t in the minutes of the meeting or in newspaper reports of the meeting. The president of the Assoc iat ion, Miss Du f f i e l d , i s quoted as"speaking on the need to improve working conditions for nurses...(because) unt i l better condit ions are obtained, the f u l l benef it of nursing knowledge and t ra in ing cannot be made avai lab le (Nurses urged by president to seek better condit ions, 1939). The o f f i c i a l Associat ion response may be intimated from the decis ion that "(a) l e t t e r be sent to the nurses who l e f t the hospi ta l . . .drawing to the i r attent ion the seriousness of the i r action and disapproval of the council and that a copy of th i s l e t t e r be sent to the S is ters of Comox Hospital and that (the) l e t t e r be formulated by the Associat ion lawyer and (the) whole matter be referred to the Leg is lat ion Convenor" (May 19, 1939). No further reference i s made to the s t r i k e . However, reference to correspondence with George Weir on the matter of nurses' hours and students' working conditions was pers istent and lengthy (September 16, 1938, November 22, 1940, Apr i l 19, 38 1940, August 18, 1942, January 31, 19.43). The Associat ion recommended an eight hour day, s ix day week, and a maximum of, 96 hour for tn ight . In add i t ion, students were to have one day of f a week, lecture periods within the 96 hour for tn ight , on-cal l duty l imi ted to one eight hour period per week, and not less than three weeks vacation annually. F ina l l y "no school of nursing or hospital shal l be permitted to co l l e c t any fee from any person for the work of any student nurse who may have been assigned by the school of nursing or hospital to special duty nursing" (August 18, 1942). These recommendations are consistant with the recommendations of a 1938 ... committee of the CNA (Canadian Nurses Assoc iat ion, 1943,pp.40). With the release of the Report on Labour Conditions the Associat ion had more contact with Mrs. Eaton. She suggested "the a l ternat ives to ef fect change in schools of nursing were 1) opening the Registered Nurses' Act to include de f in i te regulat ions, and the assumption of respons ib i l i t y of the RNABC for enforcement... or . . . 2) bring schools under the Trades' Schools Act with government regulat ion. . . (she) advised the RNABC to reta in control...(September 12, 1940).. . (she) i s reported to have made c lear the necessity of improvement by voluntary or compulsory means (October 18, 1940). Again, eighteen months la te r i t was "noted that Mrs. Eaton f e l t the Council of the RNABC should take a more act ive part in e f for ts to bring about the eight hou r .day . ; . . . ( i t was moved)... that the Registrar send a l e t t e r to the hospital which was not making an honest e f fo r t to ef fect 39 Table 2.2 Selected Data on the Terms and Conditions of Employment of Nurses i n B r i t i s h Columbia and Canada, 1929-43 Terms and Conditions of Employment BC 1929 Canada 1938 BC 1943 Canada Median range of hours worked per week hospital nurses day duty night duty 50-55% 66.5-76 T | 48-55J public health nurses 50 k Median number of days o f f per week hospital nurses day duty night duty public health nurses .5 e o gh Median number of weeks vacation per year private duty nurses hospital nurses public health nurses 3.3 a 4.2° 4.3c 3 h o 1 Median annual salary general s t a f f : private duty hospital public health 565 a 985 b 839C 657 a 1020 b 925c 660 1 750 m 1450-1549n d i r e c t o r of nursing hospital public health 1510 d 1 6 3 9 d 2150-2249n a Weir, 1932, pp.75 b Weir, 1932, pp.102,103 c Weir, 1932, pp. 123,124 d Weir, 1932, pp.150 e Eaton, 1938, pp.13-14 f Eaton, 1938, pp.15 g Eaton, 1938, pp.16 h Eaton, 1938, pp.40; statutory holidays were not granted, pp.41 i Eaton, 1938, pp.42 j CNA, 1943, pp.36-8 k CNA, 1943, pp.39 1 CNA, 1943,pp.22. "Vacations without pay are f a i r l y frequent", m CNA, 1943, pp.30 n CNA, 1943, pp.32-3 Note: For Sake of comparison with the 1943 data, the cash value of board, lodging and laundry estimated by Weir and Eaton has been subtracted from the s a l a r i e s as stated i n the o r i g i n a l m a t e r i a l . 40 the eight hour day - thus using "moral suasion" of th i s Council to bring pressure to bear on th i s i n s t i t u t i on " (January 28, 1942), Mrs, Eaton predicted, in an address to the Canadian Nurses Associat ion Bienm'um 1940, that "there was a s e l f - s a c r i f i c i n g s p i r i t about nurses that might . . . work to the i r own disadvantage . . . the danger . was that (during war time) nurses would be caught up in a great wave of s e l f - s a c r i f i c e , and would forget t he i r duty to endeavor to advance the i r profession . . . such an at t i tude . . . would be a short - sighted pol icy" (Standard of hours and wages for nurses poor, Calgary Dai ly Herald, 1940). The problem of working condit ions in hospitals was not unique to B r i t i s h Columbia. A Federal Conference on labour conditions in hospita ls was ca l led in . 1942 (October 21, 22, 1942), but there i s no further reference to th i s meeting in the minutes. Table 2.2 summarizes selected data on the terms and condit ions of employment of nurses 1929-43. Secondary Themes. The secondary themes for th is period include reg i s t r a t i on , the subsidiary worker, education and organizat ional change. The Weir Report brought interest in national reg i s t ra t ion for nurses, but nothing ever came of th i s (Apr i l 23, 1937). Renewed consideration was given to mandatory l icensure of a l l those who nurse for h i re . This concern was i n i t i a t ed by the CNA (November 2, 1934; January 10, 1939) fo l lowing recommendations from the Weir Report. With the outbreak of war, and the predictable shortage of nurses, the question of the ro l e , function and t ra in ing of subsidiary workers became pressing (November 25, 1941; January 28, 1942; October 21, 1942). In 1935 the Act was opened to 41 re-name the GNABC the Registered Nurses' Associat ion of B r i t i s h Columbia and to " lega l i ze the requirement of Junior Matr icu lat ion for admission to a Training School" (Kerr, 1944, pp 5). Having establ ished that there were su f f i c i en t qua l i f i ed students prepared to enro l l in a nursing school the standards for entrance were raised as an ind i rec t means of improving the educational standing of graduate nurses. In 1938 a committee was struck to examine the organization of local nursing assoc iat ions. Reorganization into chapters and d i s t r i c t s along geographic l ines was proposed. The chapters and d i s t r i c t s were, to function as authorized branches of the Assoc iat ion. The Associat ion responded to a request for advice "as to the stand local (nursing) organizations should take in discussion and voting on p o l i t i c a l Issues in the i r local council of women a f f i l i a t i o n (by suggesting they) not vote . . .un less authorized by the Nursing Associat ion . . . " (March 24, 1939). The ro le the Associat ion played in the placement of nurses in employment changed during th is period. Since i t s founding, the Associat ion had maintained a Registry of pr ivate duty nurses. Experiments in hourly and group nursing were conducted with the support of the Associat ion in the ear ly 30 's , but were abandoned by 1935. In 1941 a Placement Bureau Committee was formed to ass i s t both nurses and employers (November 28, 1941). The Registry and Placement Bureau were combined in 1943 and a Director of Placement Services appointed. 42 The Bureau was. funded hy federal grants, and an increase in membership fees. Summary.. Despite the d i f f i c u l t i e s and f rust rat ions of the Depression and subsequent years, the Associat ion minutes for th i s period do not have a sense of f u t i l i t y . The struggle for improved employment pract ices was the dominant theme. While the Associat ion was act ive in pressing for changes in working conditions through negotiat ion with the government and BCHA, i t was the nurses of Comox who demanded and received changes in the i r working condit ions. The Associat ion had l i t t l e concrete success in the i r e f f o r t s . Secondary themes include mandatory reg i s t r a t i on , education and organizat ional change within the Assoc iat ion. The change in organizat ional structure both increased the control the Associat ion could exert on i t s members, and created a mechanism to promote a res-ponsiveness of the Associat ion to i t s membership. While the Bureau operated as an employment service i t represented a change in organizat ional structure which coincided with a continued sh i f t in employment of nurses from pr ivate duty: to i n s t i t u t i ona l or wartime service during a period of increasing shortage of nurses. Thus there developed an organizat ional mechanism to deal with the employment problems of nurses. 43 Conc lus i on : The F a i l u r e o f Moral Suas ion: 1912-42 In 1912 a smal l group o f nurses formed the Graduate Nurses ' A s so c i a t i o n o f B r i t i s h Columbia to press f o r the r e g i s t r a t i o n o f nurses . Vo luntary r e g i s t r a t i o n was ach ieved i n 1918. The A s s o c i a t i o n then s h i f t e d i t s a t t e n t i o n to educat ion and the c l o su re of substandard schoo ls o f nu r s i ng . Whi le the terms and cond i t i on s o f employment were acknowledged to con t r i bu t e to the i l l hea l th o f nurses , the great economic Depress ion of the 1930's i n h i b i t e d any a c t i o n . The impact o f the c l o su re o f schoo ls and the Depress ion was to decrease the p ropo r t i on o f students to r eg i s t e r ed nurses and to i nc rease the numbers o f nurses employed by i n s t i t u t i o n s . P r i v a t e duty cont inued to be an important employment op t i o n . By 1937 the working cond i t i ons o f nurses had become a p o l i t i c a l i s sue and a p r o v i n c i a l survey o f ho sp i t a l employed r.urses was conducted by a government appointed committee. In A p r i l , 1939 a s t r i k e o f nurses a t S t . Joseph 's H o s p i t a l , Comox occu r red . The A s so c i a t i o n responded by sending a l e t t e r d i sapprov ing o f t h e i r a c t i o n . On the bas i s o f data i n the Weir Survey (1932), the Eaton Report (1938) and the survey by the Canadian Nurses A s s o c i a t i o n (1943) i t i s apparent tha t the terms and cond i t i ons o f employment o f nurses had changed impercept ib ly s i nce before the Depress ion and, g iven the i n f l a t i o n a r y i&^ac'tot" World War I I had i n f a c t dropped below pre -depress ion l e v e l s . The format ion of chapters and d i s t r i c t s w i t h i n the A s s o c i a t i o n f a c i l i t a t e d communication w i t h i n the A s s o c i a t i o n . World War I I began, c r e a t i n g a shortage o f nurses and exacerba t ing the terms and cond i t i on s o f employment o f nurses . 44 CHAPTER 3 To Protect the Quality of Nursing 1943-76 Introduction The Second World War brought f u l l employment and improved income leve ls to the work force of the nat ion. Although wages, hours of work and l i v i n g conditions within hospitals had improved (Agnew, 1943, pp.28-30), the unrest and d i s sa t i s fac t i on f e l t by nurses was known to the Associat ion (October 19, 1946). A Survey of Nursing conducted by the CNA under the auspices of the Canadian Medical Procurement and Assignment Board i den t i f i ed that "even though there has been an upward trend in sa lar ies paid to nurses since the outbreak of the war, . . . these sa lar ies do not compare favourably with those paid to many other professional groups, in normal times. They are far below wartime salary sca les, even though maintenance is inc luded. . . A shortage of nurses i s not surpr is ing under these condit ions" (CNA, 1943, pp.34). Post-war i n f l a t i on also contributed to d i s sa t i s fac t i on with sa lar ies (RNABC, Labour Relations Div is ion .1978, pp.4). A pers istant c r i t i c a l shortage of nurses lasted unt i l the ear ly 1950's. Overt pressure for act ion came from increased unrest amongst nurses and the attempts of labour unions to organize nurses (November 3, 1943). add(a) clause (to printed material concerning Labour Relations) pertaining to protect ing the qua l i ty of nursing...(May 2, 1951). 46 The secondary themes for these three decades, include reg i s t ra t i on , education, pr ivate duty, subsidiary workers, health and safety of nurses, socia l secur i ty , terms and conditions of employment of senior nursing s ta f f . The Legit imation of Co l lec t ive Bargaining: 1943-54. The shortage of nurses. The shortage of s ta f f prec ip i tated by the war exacerbated the problems of the working condit ions of nurses. I n i t i a l l y the shortage was considered a wartime phenomenon, but when i t continued af ter the war, the Associat ion and the publ ic became " t ru l y alarmed" (Wright, A. Report 1947, pp.2; Nursing shortage in Canada described as nearing national emergency, 1950). During the war the Associat ion attempted to ease the shortage by encouraging married nurses to work, ignoring the employment of nurses not e l i g i b l e to reg is ter (November 28, 1941), issuing temporary permits to nurses who had been e l i g i b l e to reg is ter at the time of graduation but were no longer e l i g i b l e (November 19, 1942), encouraging the employment of pr ivate duty nurses as general s ta f f nurses in hosp i ta l s , ac t i ve ly discouraging pr ivate duty nurses from enro l l ing in the pr ivate duty d i rectory unless "very legit imate reasons" were given (Braund, 1945 pp.19), and foster ing the use of subsidiary workers to augment or replace professional nursing s ta f f (Apr i l 14, 1944). The a i r l i n e s were requested not to hire nurses as stewardesses (Apr i l 24, 1942). The 47 Associat ion requested permission to amend the Act to permit lowering the age for entry into schools of nursing (Apr i l 24 s 1942), P o l i t i c a l pressure was exerted to shorten the period of t ra in ing for students. However, these e f for ts were res is ted (January 5, 1944). Students were permitted to marry service men and continue the i r t ra in ing (Apr i l 15, 1943). F r i c t i on developed between part-time and fu l l - t ime nurses who were " l i ab l e to resent the sac r i f i c e of a l l the best hours of work which are delegated to the part-time workers" (Apr i l 14, 1944). The shortage of nurses occurred even though there was a 16.2% increase of general duty nurses and 22.4% increase of supervisors and head nurses. The corresponding national f igures are 18% and 10%. The largest increase for any fu l l - t ime group was that of the paid ward aides; th i s group showed a 52.2% increase" (Canadian Hospital Counci l , 1943, pp.7-8). This i s a national f igure; no provinc ia l data are presented. Following the war the shortage was described as due to increases in population, the increased use of hospital beds, high rates of bed occupancy and new respons ib i l i t i e s assigned to nurses (Ap r i l , 14 1944), The impact of the eight hour day, the return of the married nurses to the home, and an increase in the number of nurses employed in publ ic health, tuberculosis cont ro l , and in government-aided and Veterans' hospita ls were also seen as adding to the shortage. The "stimulus of the glamour of the war" had been los t and "despite an increase in the supply of nurses by 70%" since 1941, the shortage was seen as "a resu l t of long years of inadequate sa lar ies and unsat isfactory working condi t ions"-(Mai lory, 1947, pp.3). Estimates of nurses needed 48 to correct the shortage did not account for the increased number of nurses needed to improve the working conditions of student nurses (Wright, Report. 1947, 2-5). As late as 1947, i t was reported that "the dependence of hospitals upon students for service has not decreased...some-.. students are working 48 hours each, week with classes and study periods added. Seven to seven night duty and 24 hour duty in contagion have not yet been en t i r e l y el iminated (there) has been an ef fect on student recruitment. . .dur ing the war years less than 75% of students who entered schools of nursing remained to complete the course" (Wright, 1947, pp.1). Again in 1948, the Committee on Education made a "plea for (a:) 48 hour week including c lasses, a maximum 44 hour week to decrease to 40 hour week in one year; with night and evening duty res t r i c ted to 12'weeks of each, . . . s ick time and other protect ive measures. . . . I f care ( i s ) exercised to el iminate non-nursing and non-educational dut ies , shortened hours of experience w i l l not be detrimental to the educational program of the schools" (Wright, 1948, pp.6-7). Student nurses bore much of the burden of the shortage of nurses. While indiv idual groups of nurses were improving the i r working condit ions, students were in an unprotected pos i t ion since they were "exempt from regulat ion governing hours and condit ions of work for employees" (Mal lory, 1948, pp.4) Despite the permissive ro le accorded the Lieutenant-Governor in Council in the regulat ion of student nurses' 49 hours by rev is ions to the Act in 1942, as an outcome of the Eaton report, no action was taken (Wright 1948, pp.6-7; May 28, 1948). A Student Nurses'* Associat ion was formed in 1947 and i s remembered as being act ive in working to improve the i r condit ions, (Smith, 1981) although there i s no evidence of th i s in the annual reports for th i s per iod. A par t ia l so lut ion to the con f l i c t between a student's service and education was the block system whereby students were in a period of education or service for blocks of time. (June 23, 1949). The continued shortage of nurses fol lowing the war gave nurses a sense of secur i ty in formulating the i r demands for improved sa lar ies and working condit ions. Over the next three decades the organizational structure that evolved moved from the status of a committee to that of an autonomous organization under the Assoc iat ion. The f i r s t steps towards co l l e c t i ve bargaining. The problem of the a f f i l i a t i o n of nurses with trades and labour unions was f i r s t referred to the executive committee of the CNA by the Registered Nurses' Associat ion of Ontario in June, 1942. The pr inc ip le of co l l e c t i ve bargaining by national and provinc ia l associat ions of nurses was approved by th is committee in November, 1943. A Labour Relations Committee of the CNA was formed at th i s time. The committee studied the question of labour re lat ions and the nursing profession (Beith, 1944, pp.692-693; 693-695). 50 In 1943 the CNA requested information from the prov inc ia l associat ions about nurses in trade unions. "A reply was sent to the ef fect that no unions of nurses existed in BC" (February 25, 1943). This was followed by a request for the convenor of the Leg is la t ive Committee of the CNA asking for "suggestions in giv ing guidance to the provinces" (May 28, 1954). The Associat ion responded with a ser ies of questions about the ro l e , function and re lat ionsh ip of nurses, employers, and Associations: in co l l e c t i ve bargaining (January 19, 1944). In the f a l l of 1943 th\e Associat ion formed a committee to study the question of the membership of nurses in labour organizat ions. For the leaders of the Associat ion the concerns were expressed as " I t i s not better to accept membership in labour organizations and guide the thinking and action of the group for our own protec t ion? . . . Should we not attempt to strengthen our own professional organization so that i t may give nurses the protect ion and support offered by labour organizations to the i r own members "' (October 20, 1943)? As the executive of the Associat ion continued to study the issue, the problems were redefined as l ) " i f nurses were advised not to j o i n trade unions, what assurance of support could come from Provinc ia l or National Assoc-i a t i o n s , 2) what were the mechanics of entering trade union a c t i v i t y 3) what are the potent ia l con f l i c t s to professional standards should nurses jo in trade unions (objection to "punching c locks ," " s t r i ke ac t ion") , 4) i f the Associat ion did not take on the role of co l l e c t i ve bargaining, what would be the re lat ionsh ip between trade unions and the Associat ion" (January 5, 1944; March 1, 1944). 51 The grassroots s.aw the issues, in more pragmatic terms. Meetings amongst "small groups" of the general nursing section i den t i f i ed the problems as" 1) lack of compensation in case of accident while on duty, 2) lack of provis ion for sick time, 3) no uniformity in sa l a r i e s , 4) no graded salary for years of experience" (December 1, 1943), The Executive Council of the Associat ion "endorsed the recommen-dation of the Executive of the CNA . . . that the members . . approve the pr inc ip le of co l l e c t i ve bargaining .. .(and) that co l l e c t i ve bargaining be conducted through the national and prov inc ia l nursing associat ions" (January 5, 1944). This resolut ion was l a te r passed at the 1944 Biennial Meeting of the CNA but was rejected at the annual meeting of the RNABC (Apr i l 14, 1944). The resolut ion read "whereas one of the objects of the Associat ion i s to ra ise the standards of nursing within the province; and whereas in order to do so i t i s necessary to see that i t s members get adequate remuneration for the i r services . . . be i t resolved that the Council . . . take whatever steps that may be necessary to ensure that the Council or i t s nominees . . . be appointed bargaining representatives for any of i t s members or groups of i t s members, in any proceedings under the Industr ia l Arb i t ra t ion and Conc i l i a t ion Act or the Wartime Labour Relations Regulations". The general membership did pass a resolut ion "that the indiv idual nurse, when approached by associations having a f f i l i a t i o n or possible a f f i l i a t i o n with labour unions, be advised that the Council of Registered Nurses of B r i t i s h Columbia strongly recommends that no act ion be taken by the indiv idual nurse at the present time unt i l more 52 information i s ava i lab le" (Apr i l 14, 1944). The 1946 Annual Meeting of the RNABC, on the recommendation of the Labour Relations Committee of the Associat ion reversed i t s re ject ion of the Assoc iat ion 's ro le in co l l e c t i ve bargaining. Stressing "unity of purpose" . . . to achieve progress in the nursing profess ion", the committee reported that " i t i s f e l t that every member of the Asso-c ia t ion should be acquainted with the ro le that the . . . (Association) i s prepared to assume in helping i t s members secure sat i s fac tory working and l i v i n g condit ions with adequate remuneration". The major problem iden t i f i ed in achieving th i s goal was that an organization having both employees and employers as members could not be named as the bargaining agent for a group of employees. However, under wartime Labour Relations Regulations (PCI003) under the Federal Government, an employee group was able to e lect bargaining representatives by majority vote who were not required to be members of that employee group. Thus, the Select Committee on Labour Relations was created to "inform themselves on Labour Relations" and "act as a bargaining agent on behalf of i t s members i f so requested" (Copeland, 1946, pp.1-3; March 5, 1946). The committee was composed of the Registrar, the Director of the Placement Service, the Chairman of the Provinc ia l Leg is lat ion Committee and the Chairman of the Labour Relations Committee (Copeland, 1947, pp.1-4). 2 The passing of the B r i t i s h Columbia Industr ia l Conc i l i a t ion and Arb i t ra t ion Act, 1947 recognized the RNABC as a "Labour organizat ion" and as ..the bargaining author i ty providing that 51 percent of the nurses on the s ta f f were RNABC members (November, 12, 1948; Wright, Select . . . 1949, pp.71). 53 The functions, of the committee were outlined as: (1) to serve on request, in an advisory capacity, individual nurses or groups of nurse employees on matters related to employment conditions, with the objective of assisting nurse employees to prevent or overcome d i f f i cu l t i es by democratic and businesslike procedure. (2) In situations where nurse employees have been unable to effect an agreement with their employer, to arrange conferences with the employer, at which nurse employees would be represented. (3) In situations where a l l other measures have fa i led , and upon the request of a majority of the affected employee group of nurses, to set up a bargaining group (represen-tative of the affected nurse employee group and the Select Committee) which would obtain cert i f icat ion and proceed with negotiations" (Wright, Select 1947, PP. 1-2). The "prevention of d i f f i cu l t i es rather than the correction" as the primary role of the labour relations program of the Association was frequently stressed (Wright, 1949 pp.71; Merrick, 1951, pp.78). The committee's duties included "to study and report on a l l matters affecting employer-employee relations and to serve in an advisory capacity . . . on a l l matters relating to labour relations" (April 22, 1949). This committee later combined with the Placement Service Committee and became known as the Committee on Employment Relations to conform to changes in the CNA committee structure (November 15, 1952). At the 1946 annual meeting of the Association the role of the Labour Relations Committee of the CNA was described by Esther M. Beith (Convenor of Legislation Committee, CNA). "As a committee i t has no authority, i ts primary function being to co-ordinate the thinking of the 54 provinces. I t has concerns with, personnel pract ices , including co l l e c t i ve bargaining, with, a continuing study of the effects, of a f f i l i a t i o n s with trades unions, and with securing information and interpretat ion of labour l eg i s l a t i on (which) af fects or may ef fect nurses". The nursing associat ions were seen to have "secured reg i s t r a t i on , the eight hour day and s ix day week, affected improvements in standards and condit ions of service and approved the pr inc ip le of co l l e c t i ve bargaining" .Esther Bei'th rejected the c r i t i c i sm by some nurses that the Associat ion had f a i l ed them, arguing that the accomplishments in improving working conditions had been made despite ten years of depression and s ix years of war. " I f we stand together, we can write our own labour l e g i s l a t i o n " . She i den t i f i ed interest in co l l e c t i ve bargaining as resu l t ing from "1) the trend towards nurses working in more and larger groups, 2) the fear created by the depression and 3) the convict ion of strength which the shortage has given nurses". Esther Beith acknowledged that, under current l e g i s l a t i o n , d i f f i c u l t i e s , ex is ted, but argued that the national or prov inc ia l associat ions should be the bargaining agents for the i r membership, or i f th i s were not poss ib le, co l l e c t i ve bargaining should be undertaken with the approval of the Assoc iat ion. Any a f f i l i a t i o n with trade unions was rejected: "union methods are not appl icable to nursing . . . . no such thing as s t r i ke action is possible for nurses. Nurses should be interested in trades unions from a publ ic re la t ions and publ ic understanding view-point; not with the motive of gett ing something for ourselves, but because of our in terest in fe l low workers and the benefits they w i l l 55 derive from soc ia l l e g i s l a t i o n " , although she acknowledged the trend toward par t i c ipa t ion by professionals in unions. The fear was expressed that associat ion with trades unions would "lower the prestige and (the) strength, of professional associat ions. This fear was repeatedly expressed throughout th i s period (Apr i l 14, 1944; January 24, 1947; February 13, 1950). In the midst of th is presentation Esther Beith i s quoted as saying: Each nurse entered the profession of her own free w i l l under known condit ions. We know that l i f e may depend upon the service that we can give. Street cars may stop and s ta r t again but i f nursing service i s withdrawn and the patient d ies , there is no second chance. This point i s i l l u s t r a t ed by a story of Dr. Fleming who, while on vacat ion, was cont inual ly ca l led upon to attend pat ients. When Mrs. Fleming remonstrated - argued that he has the same r ight to a vacation as other workers, Dr. Fleming rep l ied: "I should have thought of that before I went into medicine" (Bei th, 1946, pp.1-4). In concluding her remarks,Miss Beith stated "the State Nurses' Associat ion of Ca l i fo rn ia i s the bargaining agent for i t s members and has obtained the best condit ions of work that nurses have anywhere" CBeith, 1946, pp .1-4) 3 . In 1937 the American Nurses' Associat ion recommended "that nurses not j o i n unions" but suggested that in the i r professional associat ions nurses have the instruments best f i t t e d and equipped to improve every phase of the i r working and professional l i ve s " (Anderson c i ted in Metzger, pp.34-35 in 1946 co l l e c t i ve bargaining by d i s t r i c t and state chapters was in 1946. Co l lec t i ve bargaining by d i s t r i c t and state chapters was accepted in 1946. (BuTlough, 1971, pp.273-288). 56 The Se t t i ng o f Standards f o r the Terms  and cond i t i ons o f Employment. The Annual Meet ing o f 1946 heard one o ther r epo r t important to t h i s s tudy . The Execut ive Sec re ta ry ( A l i c e Wright)^ presented the p r i n c i p l e s o f personnel p r a c t i c e s which formed the bas i s o f ba rga in ing on the terms and cond i t i ons o f employment. S ince the format ion o f the A s s o c i a t i o n , fee schedules o f p r i v a t e duty nurses had from time to time been rev i sed by committee, presented to the p r i v a t e duty s e c t i o n and voted upon and accepted as the cu r ren t fee schedu le . The Placement Se rv i ce Committee took on t h i s r o l e when the sec t i ons were d i s s o l v ed and the Placement Bureau was formed i n 1941. Whi le the committee cont inued to put f o r t h a p r i v a t e duty fee schedule u n t i l 1966, i t expanded i t s r o l e to study "employment problems . . . and to coord ina te the e f f o r t s o f . . . those . . . concerned w i th the employment of nurses" ( Ap r i l 15, 1943).^ P r i o r to t h i s , a prov ince-wide survey of employment and l i v i n g cond i t i on s was au tho r i zed by the Execut ive Sec re ta ry and the D i r e c t o r o f the Placement Se rv i ce ( A p r i l 24, 1942). Th is survey formed the bas i s o f r e v i s i o n s o f the Recommended Personnel P r a c t i c e s drawn up i n 1944 and approved by the BCHA annual meeting and the RNABC. The Recommended Personnel P r a c t i c e s were then d i s t r i b u t e d to the cons t i t uency o f each o r gan i z a t i on ( Ap r i l 26, 1946). The pa t te rn o f j o i n t approval o f Recommended Personnel P r a c t i c e s cont inued u n t i l 1956. ( Ap r i l 5, 1944; Becke t t , 1964) On the bas i s o f the in fo rmat ion i n the survey (not a v a i l a b l e ) the " p r i n c i p l e s o f personnel p r a c t i c e s . . . 4 See Appendix B f o r a b i og raph i c a l no te . 5 I t i s t h i s committee tha t i s r e f e r r ed to as a Labour Re l a t i ons Committee i n Creasor , (1954, pp.4)and Becke t t , ( 1964 ) , s i n ce there i s no re fe rence to a Labour Re l a t i ons Committee i n the minutes o f 1942. 57 (representing) . . . the thinking and wishes of the great majority of our members" were presented. (Apr i l 5, 1944). The philosophy which underl ies the pr inc ip les and recommendations now presented i s that nurses and the i r employers have a mutual interest in and respons ib i l i t y for f u l f i l l i n g the purposes for which health i ns t i tu t i ons and agencies ex i s t ; these are (1) to care for the sick and (2) to promote the health of a l l c i t i z ens . With th i s in mind, the pr inc ip les upon which des i rab le , and reasonable po l i c i es of personnel pract ices for nurses may be developed can be out l ined as fo l lows: 1. Nurses, l i k e a l l other human beings, need opportunit ies for sa t i s fac t ion in service and for self-development. 2. Acceptable l i v i n g and working conditions., with recognit ion of good serv ice , resu l t in a more e f f i c i e n t and interested worker, with consequent improvement in serv ice. 3. The hours of work should not exceed those of other sa l a r i ed , professional workers; should be considered in re l a t i on . to the phys i ca l , i n te l l e c tua l and psychological s t ra ins under which nurses work; should be.such that e f f i c i ency is not impaired and should make possible par t i c ipa t ion in the soc ia l and cu l tu ra l l i f e of the community. 4. The length of vacation should be such as would permit the bui ld ing up of physical reserve and resistance to in fect ion and should compensate for the i r r egu l a r i t y of hours and free time. 5. A de f in i te po l i cy of continuance of salary during time los t through i l l n e s s i s protect ive of the health of the nurse, her patients and her co-workers. 5. A nurse i s en t i t l ed to the r ight accorded other workers of choosing where she l i ves and has her meals. 7. When i t i s necessary for nurses to accept accommodation provided by the employing i n s t i t u t i o n , such accommodation should ensure privacy and comfort and should provide for normal soc ia l l i v i n g . 58 10. An employee health program i s economically sound and operates to increase e f f i c i ency . Deductions fo r room and board should be in re la t ion to the cost to the i n s t i t u t i o n and should r e f l e c t the dif ferences in the qua l i ty of the accommodation provided. The cost of laundering uniforms should be borne by the employing i n s t i t u t i o n , in keeping with the pract ice in other occupations where the wearing of a uniform i s required. 11. Salary schedules for nurses should be based on the value of the service rendered, i r respect ive of the char i tab le functions of the employing i n s t i t u t i o n . 12. The basic minimum salary should ensure a standard of l i v i n g in keeping with the nurse's professional status and make i t possible for nurses to take advantage of educational opportunit ies and to provide for retirement. 13. A contr ibutory pension plan resu l ts i n increased loya l ty to the employing i n s t i t u t i o n , l i f t s and maintains morale and has a s t ab i l i z i n g e f fec t . 14. Married nurses should have equal opportunit ies for employment. 15. Stated terms of employment tend to el iminate d i s s a t i s -fact ion and unrest. 16. Staf f re lat ionsh ips should be such that the nurse w i l l feel free to take her problems and grievances to the member of the administrat ive s ta f f to whom she i s responsible. 17. A s ta f f education programme aids in the more rapid and ef fect ive or ientat ion of new employees, tends to increase the in teres t i n and understanding of the functions of the employing i n s t i t u t i on and promotes unity of s ta f f and improved employee-employer re lat ionships.(Wright and Braund, 1946, pp.1-3). 59 The Recommendations were organized under the fol lowing headings: Hours of Work Vacation Sick Leave Residence Salar ies Marital Status Permanancy Temporary General Duty Staf f Staf f Health Program Pension.Plans Terms of Employment (Wright and Braund, 1946, pp.1-5). The outcomes. In 1947 the Labour Relations Committee reported that "with the adoption of the recommendations on personnel pract ices , the RNABC had out l ined a set of standards that would be the f i r s t step in educating the employer group and the pub l i c , as well as the nurses themselves, to the need for improved conditions and would give a l l part ies a f a i r basis on which to judge ex is t ing condit ions". The major task of the committee was described as "acquaint(ing) the members . . . of the ways in which they might become more informed of means and methods whereby they might help themselves and the i r fe l low workers to obtain better economic secur i ty through the channels in operation with the RNA. Some nurses were apparently unaware of or ind i f fe rent to such means and were w i l l i n g to turn to outside sources such as organized labour unions for assistance"(Copeland, 1947, pp.1-4). The introduct ion of compulsory hospital insurance by the province did not ease the f inanc ia l d i f f i c u l t i e s of the hosp i ta ls . 60 Indeed Evelyn Mallory foresaw that the impact of hospital insurance would prevent hospitals from mater ia l ly increasing the s ize of the nursing budget without approval of the Hospital Commission and that sa lar ies to nurses would probably be subjected to some degree of control by the Hospital Commission "although nurses were urged to cooperate" in the introduct ion of hospital insurance (Mal lory, 1949, pp.9-10). During th i s period nurses tended to l i v e in residence, and, i t i s implied that some were required to l i v e in residence. The f a c i l i t i e s within the residence and the rate charged for room and board were both issues for co l l e c t i ve bargaining. Nurses were charged increased rates for room and board as sa lar ies increased or were charged for room and board they did not use. This remained an issue unt i l 1956. The issue of marital status in ter fe r ing with permanent employment was contested as ear ly as 1946, but for some groups employment pract ices prevented the f u l l time employment of married nurses unt i l 1955 (C i ty w i l l h ire married nurses, 1955). In a discussion of the problem of statutory holidays f a l l i n g in a vacation per iod, i t was recommended that extra days not be requested "as (there i s ) . . . evidence of fee l ing on the part of employers that nurses' longer vacation is perhaps not jus t i f i ed" ' 1 . At the same meeting, "threats of mass resignation were seen as "v io la t ions of professional serv ice, and in the opinion of the publ ic const i tute(d) s t r i ke act ion . . . (and thus were) disapproved of" (Apr i l 3, 1948). 61 Wage demands did not change between 1952-55, although, the hours of work were recommended to be reduced from 44 to 40 per week (McKenna, 1952, pp.68; Hood, 1955, pp.82). By 1954, the resolut ions from the f l oo r were challenging the Recommended Personnel Pract ices to increase basic rates of pay (May 21, 1954). In an e f fo r t to obtain a 44 hour week for students the Associat ion approached the Min ister of Health to request provis ion for a budget su f f i c i en t to allow improved working conditions for students (October 11, 1951). The ideologica l s h i f t . In reviewing the Pres ident ia l Addresses of the Associat ion i t i s evident that the leadership were well aware of the sh i f t in ideology of the Assoc iat ion. Evelyn Mai l o ry , addressing the 1949 Annual meeting acknowledged that while some were "not too happy about the use of the term 'bargaining' . . . the process (of) reaching a mutually sat i s fac tory so lut ion . . . i s a democratic and sane procedure . . . That the thinking and action of nursing associat ions have undergone marked change in regard to employer-employee re lat ionships is evidenced by a comparison of a r t i c l e s appearing in nursing journals about ten years ago with those appearing to-day. For example,here i s a quotation from the May 1938 issue of "The American Journal of Nursing". Nursing occupies a unique place in the minds of the people. It i s one of respect, even of af fect ionate respect. To our people the nurse i s essent ia l l y a giver — a giver of comfort. This fundamental concept psychological ly i s at war with the need of the indiv idual nurse for reasonable working conditions and for economic secur i ty . I t i s also at war with the methods of unions. Compare that with the fol lowing quotation from the March 1949 number of "The Trained Nurse and Hospital Review" ( in which a meeting of representatives of the American Nurses" Associat ion i s reported): . . .ne i ther as an indiv idual nor as an associat ion does the nurse compromise the eth ica l standards of her 62 profession when she atta ins economic benefits, by means, of co l l e c t i ve bargaining. Co l lec t ive bargaining Is not only a means of se t t l i ng employment terms but can be a means of improving r e l a t i on -ships in general, between employers and nurses, so that they may work together to provide optimal nursing care. Some of us may not even yet be any too happy about the use of the term 'bargaining' but the process, that of gathering around a table to ta lk through d i f f i c u l t i e s with a view to reaching a mutually sat i s fac tory so lut ion that process i s a democratic and a sane procedure, and one that we approve of very much [Mal lory, 1949, pp.8). In 1953, Esther Paulson described the objectives and a c t i v i t i e s of the Associat ion as: (1) to implement and protect standards in nursing education and pract ice to meet preva i l ing community needs (2) by providing two reg i s t r i e s for pr ivate duty nursing in two of the three largest c i t i e s in the province and a placement service for other types of nursing posit ions throughout the province. While the primary purpose of these resources i s to serve our registered members, the publ ic i s also served through the placement of nurses, pr ivate duty, i n s t i t u t i ona l and publ ic health, where needed in the communities through-out B.C. (3) By providing a labour re lat ions programme to obtain and safeguard su i tab le working condit ions and acceptable personnel pract ices for our members through d i rec t conferences with employees.6 Esther Paulson closed her address by stress ing the challenge of meeting "the publ ic in terest" inherent in a " pr iv i leged profession" such as nursing and by urging nurses to work for and l i v e for the i r profession" (Paulson, 1953,.pp.3-6). Employee was changed to "employer" by E. Mallory former owner of the copy of the Annual Meeting Minutes, June 5-6, 1953 used for th i s study. 63 Secondary themes. The secondary themes for th is period are the issue of pensions for nurses,the increased d i f f i c u l t y of employment of pr ivate duty nurses, and the education and l icensure of. subsidiary workers, and reg i s t ra t i on . The issue of pensions for nurses had been of concern to the Associat ion for a number of years. As ear ly as 1932, nurses were being urged to make the i r own arrangements for insurance (May 27, 1932). In the face of high unemployment and low income c lea r l y th i s was d i f f i c u l t . With the advent of the Municipal Superannuation Act and the Hospital Insurance Act, making v i r t u a l l y a l l hospita ls publ ic i n s t i t u t i on s , pressure by the Associat ion on the Hospital Services Commission continued, but to no avai l (May 25, 1950; June 22, 1951). The Associat ion had increasing d i f f i c u l t y keeping the Vancouver and V i c to r i a d i rec tor ies operating even with the d i rec t f inanc ia l assistance of the Assoc iat ion. By 1956 pr ivate duty represented 7%&>f the membership but required 25% of the Associat ion budget to operate the Directory.. (Stewart, 1956, pp.58). Under pressure of shortage of nurses during wartime, pract i ca l nurses were in e f fect doing pr ivate duty (November 3, 1943). This pract ice was condemned (November 16, 1950). The d i f f i c u l t y of f ind ing employment for pr ivate duty nurses was in part due to a less pressing shortage of nurses, but also due to "changes occurring in medical pract ice and in (the) organization within hospitals e f fect( ing) the use of pr ivate duty nurses"(December 9, 1948), and the fact that the Social Assistance Department would not pay for 64 pr ivate duty nursing when patients required constant care (December 19» 1953; January 23, 1954], (Recovery rooms for post-anaesthetic care were not in general use at that time and intensive care units were yet to come). By 1967 both V i c to r i a and Vancouver Director ies had been closed; the function being taken over by the pr ivate duty nurses themselves. (December 16, 1966). Concern, over the role and function of subsidiary workers resulted in the formation of a Government Committee on Nursing chaired by Mrs. Rex Eaton. This a c t i v i t y resulted in i n s t i t u t i ng courses for order l ies and pract ica l nurses (Wright, 1951, pp.42), and l icensure of pract ica l nurses. The College of Physicians and Surgeons endorsed the pr inc ip le of "pract ica l nurses administering such treatments as are necessary in the s ick room under the d i rec t ion of the attending physicians" which included the administrat ion of drugs (October 18, 1952). This was opposed by the Associat ion and the BCHA (December 13, 1952). The Associat ion continued to be concerned about the number of nurses who were not reg istered. The Act l i cens ing pract ica l nurses was described as 'permissive' and not af fect ing non-registered graduate nurses (June 23, 1951), Non-registered nurses were refused access to the Assoc iat ion 's pr ivate duty d i rectory (November 1, 1947) and not permitted to par t i c ipate in the a f f a i r s of the Assoc iat ion. Nurses were encouraged to reg is ter by d i rect pressure from the Associat ion and by i nd i r e c t 65 pressure through, the hosp i ta ls . "Letters were sent to a l l hospitals, and the Hospital Associat ion urging that a l l nurses he encouraged to r eg i s t e r . . . and that a salary d i f f e ren t i a l of $10/month be ins t i tu ted for non-registered nurses"(January 13, 1949). Summary . The f i r s t few years of experience in co l l e c t i ve bargaining can be seen as tentat ive explorations in the exercise of power. An awareness of the response of employers, the publ ic and the government led the Associat ion to hold the l i ne on nurses' demands in several instances. While discussions between the Associat ion and the BCHA on Recommended Personnel Pract ices and d i rec t negotiat ion with employers resulted in improvements in the terms and conditions of employment, the gains were not su f f i c i en t to sa t i s fy the grassroots workforce. The evidence presented in the narrat ive suggests that although the Associat ion took a new role in undertaking co l l e c t i ve bargaining, there was a residual re l iance on paternal ism, the mutual ro le of the nurse and the employer, and on professional ism to mo l l i f y demands. Pressure from the grassroots, because of the increased recognit ion of economic d i spar i ty forced the Associat ion to take stronger act ion in the la te 1950's. 66 The Legit imation of Mi l i tancy: 1955-64  Introduct ion. The period 1954-64 brought increased confidence to the Assoc iat ion 's a c t i v i t i e s in co l l e c t i ve bargaining. Co l lec t ive bargaining expanded such that in 1951, a f u l l time labour re la t ions o f f i c e r , Evelyn Hood, was h i red. Nora Patton succeeded Evelyn Hood in 1970. Other personnel were hired-incrementaly throughout the next 20 years. By the late 1950's the process of co l l e c t i ve bargaining had become increasingly profess ional ized with hospita ls h i r ing negotiators and with experiments in regional and prov inc ia l bargaining. Contract issues were concerned largely with sa l a r i e s , hours of work, s ick time and pensions. The 40 hour week was widespread in publ ic hosp i ta l s , and universal in prov inc ia l and federal hospita ls in B r i t i s h Columbia by 1955 (Hood, 1955, pp.49-50). Contract settlements during th is period often required conc i l i a t i on procedures. The re ject ion of a conc i l i a t i on report by several hospita ls led to s t r i ke act ion in 1957. The f i r s t grievance that went to a rb i t ra t i on was in 1959 (Hood, 1960, pp.69). The outcome of co l l e c t i ve bargaining was f rustrated by hospital budget freezes ordered by the provinc ia l government. As a r e su l t ; o f hospital budget freezes there was no guarantee that hospital d e f i c i t s , in part due to contract settlements, would be financed by the government. Budgetary res t ra in t adopted by the 67 hospitals led to increased concern about the standards of nursing care. This become a dominant theme of the Associat ion by the 1970's. The f i r s t instances of c on f l i c t between professional role of the Associat ion and outcomes of a c t i v i t y in labour re lat ions occurred in th i s per iod. Secondary themes for th i s period include education, r eg i s t r a t i on , terms and condit ions of employment for senior nursing s ta f f and the health and safety of nurses. Background . Ormsby.9 (1958, pp.486-489) describes the climate of B r i t i s h Columbia pr io r to the introduct ion of hospital insurance in 1949, as a "class divided society in which "probably one-third of i t s population hoped to see . . . the introduct ion of a. s o c i a l i s t system . . . which the majority of the voters favoured a free enterprise system. Paradoxical ly . . . they expected the government to provide more soc ia l assistance" ( pp.486). The demand became so ins i s tent that the Johnson-Anscomb (Liberal-Conservation) coa l i t i on was compelled to introduce hospital insurance in 1948. Taylor (.1978, pp.167-169) describes the establishment of the B r i t i s h Columbia Hospital Insurance Service and the administrat ive nightmare that resulted from "the combination of lack of advanced planning, inadequate time for t ra in ing of new s ta f f , and two complicated co l lec t ions systems". "Many were uninsured. Many who had paid premiums received no entitlement card; some who had not paid, did receive them; the 68 change - o f - employer and change - o f - address procedures bogged down . . . A p ropo r t i on o f the uninsured were h o s p i t a l i z e d and unable to pay t h e i r b i l l s ; h o s p i t a l s ' cos t s i n c r ea sed , as d i d t h e i r d e f i c i t s ' (pp. 167-8) . C r i t i c i s m from the p u b l i c , the p re s s , and acr imonious debate i n the l e g i s l a t u r e l e d to formal i n q u i r i e s , r e s i gna t i on s o f the m i n i s t e r r e spons i b l e and the t r a n s f e r o f the execu t i ve d i r e c t o r o f BCHIS. Under a new m i n i s t e r , L loyd D e t w i l l e r from the p r o v i n c i a l Finance Department was appointed commissioner of BCHIS. Co- insurance payments were i n t roduced . Approx imate ly 85% of ho sp i t a l accounts were insured accounts . The impos i t i on o f co - i n su rance , premium increases i n 1950 and 1951, charges o f i n e f f i c i e n c y i n the adm in i s t r a t i o n o f the insurance scheme and rumors o f a s p l i t i n the L i b e r a l - Conse r va t i v e Cabinet over the scheme made ho sp i t a l insurance the most b i t t e r l y emotional and c on t r o v e r s i a l i s sue i n the 1952 e l e c t i o n campaign" (pp.168) . The new Soc i a l C r ed i t par ty l ed by W.A.C. Bennett won the e l e c t i o n . A number o f changes were made to the p l a n , and by e a r l y 1954, "the system was working t o l e r a b l y w e l l " (pp .168) . However, a p o l i t i c a l de c i s i on to a bo l i s h premiums f o r ho sp i t a l insurance and inc rease the s o c i a l s e r v i c e s r e t a i l tax from three to f i v e percent was made. " A l l e f f o r t s were now d i r e c t ed to the development of the h o sp i t a l s system, improvement o f s tandards , and the ref inement of the system o f paying ho sp i t a l s f o r insured s e r v i c e s " (pp.169) . In T a y l o r ' s terms B r i t i s h Columbia"paid pa r t o f the t u i t i o n cos ts i n educat ing Canadian governments i n the fo rmu la t i on o f e f f e c t i v e p o l i c i e s and adm i n i s t r a t i v e procedures i n t h i s most complex of the s o c i a l insurances" (pp.169) . The c o l l e c t i o n o f premiums as we l l as the reimbursement o f h o s p i t a l s , and t h e i r budgetary systems were problems. 69 Hospitals were res i s tant to government interference in the budgetary arena. The Hospital s" Associat ion was not strong in its. a b i l i t y to represent the interests of the hospital to the government. Pressure from unionized hospital employees, under the leadership of B i l l Black was developing,the introduct ion of hospital insurance removed the ideological constra int of "char i tab le ' work from the employees of these i n s t i t u t i ons . At the same time, f inanc ia l support for hospita ls was l im i ted . Competition for ava i lab le revenue came from W.A.C. Bennett's commit'ment to the development of the natural resources of the province and in his desire for a balanced budget. Freezes on hospital budgets were lev ied in 1956 and 1959 and only l i f t e d when outstanding payments •to local businesses resulted in the business community applying pressure to the government, not^ably in the face of the e lect ion of 1956 (Detwi l ler , 1981). With the introduct ion of the Hospital Insurance and Diagnostic Services Act in 1957, the federal government entered the funding of health care, a prov inc ia l respons ib i l i t y under the B r i t i s h North America Act. In exchange for meeting certa in federal standards to qua l i fy the federal government provided funds for hospital and diagnostic services within hospitals on a cost shared basis. The po l icy of cost sharing (the 50<t do l l a r ) was extended to cover medical services under the Medical Care Act of 1966 ( inaugurated in Ju ly , 1968). Cost sharing as a formula for federal support of health care was discontinued when block funding and more la t i tude in prov inc ia l government personal and corporate income tax r ights was granted to the provinces in 1977. 70 This was done to decrease federal f inanc ia l commit ments to increasing health care costs (Sod.erstr.om, 1978; Taylor, 19.78, Van Loon, 1978). The growth of co l l e c t i ve bargaining. An assessment of the rate of growth of co l l e c t i ve bargaining by nurses in the province i s d i f f i c u l t . Table 3.1 represents an amalgamation of information from annual reports of th is period. Only the tota l numbers of registered nurses and the number of groups of nurses who became c e r t i f i e d are known.^ I t i s evident from the minutes that the process of co l l e c t i ve bargaining consumed much of the time and energy of the Executive Secretary and s ta f f of Personnel Services. By 1961 the Select Committee on Labour Relations had given up i t s function of preparing Recommended Personnel Pract ices to the Director of Personnel Services (Hood, 1961 pp.1064-1065). Staf f representatives from each bargaining unit contributed to the development of the Recommended Pract ices through regional meetings with the Director of Personnel Services. The Executive Committee of the Associat ion continued to review the Recommended Pract ices before presenting them to the Annual Meeting for endorsation. It was not uncommon for chapters to communicate the i r concerns about the Recommended Pract ices d i r e c t l y to the Executive Committee (January 2, 1957; March 30, 1957; May 31, 1961; November 4, 1961; June 22, 1963; November 21, 1964). 7 Neither the RNABC nor the Labour Arm of the Associat ion i s able to provide th i s information (Patton, N. Personal Communication, January 1980; Grice H. Personal Communication, July 1980). 71 Negotiations were f i r s t spread over four months, and then nine months of the year (Hood, 1955, pp.49-50). Concern, was expressed over the tendency of the hospitals employing labour re lat ions consultants to do the i r bargaining. The Associat ion saw d i rec t negotiat ion with members of the hospital or publ ic health board as an opportunity to iron out "misunderstandings and points of f r i c t i o n " as well as a chance to "hear management's problems and points of view . . . resu l t (ing) in better understanding and respect on both sides . . . .A professional negotiator thr ives on disagreement and cannot possib ly know the varying s i tuat ions that ex i s t in d i f fe rent i n s t i t u t i ons " (Hood, 1955, pp.49-50). Regional bargaining was seen as making "working condit ions and sa lar ies more un i form. . . " but had the disadvantage of " loss of personal contact with the indiv idual boards (that denies us the opportunity to interpret nursing and nurses' problems to them)"(Hood, 1958, pp.70). The Executive Council of the Associat ion rejected province-wide bargaining in 1958 (March 29, 1958) but a year l a te r was "w i l l i ng to recommend...that . . . the Associat ion par t i c ipate in a plan for province wide bargaining on a t r i a l basis and with the under-standing that bargaining w i l l not be handed over to a professional negotiator" (October 17, 1959). "Province-wide bargaining . . . proved to be successfu l . Many nurses . . . expressed sa t i s fac t ion with th i s method of negotiat ing agreements. With uniform sa lar ies nurses are able to make the i r choice of employment on factors such as type of community, interpersonal re lat ionships within the hospital and working condit ions that permit reasonable job sa t i s f a c t i on " (Hood, 1961, pp.62). With s im i la r misgivings the Associat ion agreed to standardize Tdble 3.1 Selected Data from Recommended Personnel Practices of the RNABC, 1946 - 68 1946a 1947b 1948C 1952d 1956e 1964f 19689 Hours Weekly Days off/week Hours between shifts 48 1 16 44 l'i 16 44 l'i 16 44 l'i 16 40 2 16 40 2 16 37ia 2 16 Vacation Days paid/annually Statutory holidays paid 28 9 28 9 28 10 10 11 20 11 20 11 Sick Leave Days paid/monthly l«s l'i l'i l'i l'i l'i l'i Salaries-Basic Monthly Rate Hospitals staff nurse head nurse supervisor(A) instructor (university preparation) $125 $150 $150 $140 $150 $170 $160 $150 $160 $180 $170 $220 $235 $255 $245 $250 $265 $285 $265 $340 $374 $292 $424 $500 $604 $634 $664 Public Health-Staff nurse (university preparation) $160 $170 $290 $424 $664 Private Duty - Rate per shift (for care duty in hospital) Increments - monthly Bachelor's Degree Master's Degree $6.50 $10 $10 $10 $10 $10 $10 $10 $10 $25 $25 $17.00 $60 $85 Experience 6 levels a Wright and Braund, 1946, pp. 3-5 b RNABC, Personnel practices, 1947,pp.3-5. c RNABC Suggested revision of RNABC recommendations on personnel practices, 1948 d Mckenna, Revision of personnel practices, 1952, pp.6ii f ' < f | K ) r t ° f r ( i v i s i ( , n o f recomiiienda Moris on personnel practices, 1956, pp 78 K N A b L , Proposed recommended personnel practices, 1964, pamphlet g RNABC Proposed recoiimended personnel practices, 1968, pamphlet 73 con t rac t s across the prov ince ( Ap r i l 7, 1962). Cont rac t I s sues . The con t r a c t i s sue tha t c reated the g rea tes t debate was s a l a r i e s . Concern was r a i s ed by the North Car iboo Chapter tha t "barga in ing to i n c rease nurses ' s a l a r i e s should cease f o r the t ime being i n B . C . . o therwise nurses w i l l be t a l k i n g themselves out o f those jobs and be rep laced by nurs ing a i d s " (September 15, 1954). There i s no record o f t h i s i s sue coming to an Annual Meet ing , however no inc rease i n s a l a r i e s was requested i n 1955. The on l y request was f o r a change i n the increment s t r u c t u r e f o r years o f s e r v i c e . Th is was not accepted by many h o s p i t a l s , and the i s sue d i d not go to c o n c i l i a t i o n because i t was not cons idered important enough. The B r i t i s h Columbia Hosp i t a l Insurance S e r v i c e , which had become the government funding agency f o r the h o sp i t a l s o f the prov ince : ordered a f reeze on a l l h o sp i t a l s a l a r i e s thus n u l l i f y i n g the increments b u i l t i n t o the prev ious y e a r ' s c on t r a c t . In o r de r to honour the c on t r a c t , many h o s p i t a l s had l a r ge d e f i c i t s . Th is d e f i c i t was a l l e v i a t e d when the government agreed to accept 1/3 o f the d e f i c i t i n c u r r e d . The ho sp i t a l s were permi t ted to recogn ize 1956 s a l a r i e s i n 1957 i f agreements were i n e f f e c t . Nurses were desc r i bed as most sympathet ic to the f i n a n c i a l d i f f i c u l t i e s tha t the h o s p i t a l s have been expe r i enc ing but have been very concerned when budget cu ts have an adverse e f f e c t on nu r s ing ca re . Many h o s p i t a l s have d r a s t i c a l l y cu t nu r s ing s t a f f s , sometimes a t the i n s i s t e n c e o f the Government and at o ther t imes , i n an e f f o r t to balance the budget. The nurses are unhappy about t h e i r i n a b i l i t y to g ive good nurs ing and f ee l the care t ha t p a t i e n t s are r e c e i v i n g i s not always even safe nu r s i ng . They f i n d i t d i f f i c u l t t o de r i v e s a t i s f a c t i o n i n doing a j ob t h a t i s l e s s than adequate and f r u s t r a t i o n 74 resul ts when work i s never f in ished (Hood, 1956, pp.75). This i s contrasted with the requests from Port Alberni nurses " in excess of Recommended Personnel Pract i ces" . There i s no record of how th i s was handled (January 27, 1957). However the minutes of the Executive Council record that "whereas basic pay has been $235.00 since 1953, and has not kept pace with other leve ls of work or profess ions . . . that basic pay be raised to $275 or $300 (a month)". A proposal to carry increments from one job to another was rejected as jeopardiz ing the older nurse (March 30, 1957). The recommended basic salary was set at $250/month (Hood, 1957, pp.83.) Negotiation Breaks Down. On the basis of these recommendations, negotiations were again undertaken. Events led to a reject ion of the conc i l i a t i on board's report by several hosp i ta ls . The Executive Counci l , with the assistance of a labour lawyer, i den t i f i ed four courses of act ion: pub l i c i t y , mass res ignat ion, s t r i k e , and do nothing. Because a "united e f fo r t " was seen as "most important" and because "s t r ike action presented a de f in i te framework within which to work," s t r i ke act ion was supported by the Associat ion (Rossi ter, 1957, pp.799; June 1, 1957). However th i s was not an easy decis ion for the Executive Counci l . Or ig ina l l y a motion supporting s t r i ke action or resignation was ca r r i ed , while a motion stat ing a preference for s t r i ke action was withdrawn; in e f fect leaving the course of act ion open to the nurses themselves (June 1, 1957). U l t imate ly , s t r i ke 75 votes were taken in three hospita ls and the Associat ion supported th i s action on the basis of "supporting the request for a rb i t ra t i on rather than for an increase in the i r own sa la r ies" (July 9, 1957). The Executive Secretary met with the local chapters of the BCMA to "inform them of the s i tuat ion . . . not to seek the i r support". The s t r i ke vote was supported on the grounds that the recommendations were f a i r and ju s t . The doctors objected to the inadequate f inancing of hospita ls and deplored the government's po l i c ies of hospital f inanc ing. Following the s t r i ke votes plans were made to s ta f f the hospita ls for emergency care only and directed a l l of fers of help to representatives of the nurses (July 9, 1957). A s im i la r s i tuat ion arose in 1959 when a conc i l i a t i on board report was rejected by eight hospita ls (January 22, 1959). A meeting with the Cabinet was sought. " I t was the consensus that there was no hope for an ear ly hear ing. . . a l l possible means of avert ing (the) threat of a s t r i ke or s t r i ke action were exp lo red . . . ( i t was) agreed that neither the hospita ls nor the government would consider rev is ing the i r stand un t i l the nurses had shown that they are prepared to invoke the f u l l strength of labour l eg i s l a t i on . . . . ( I t was agreed) that the Executive Committee stand behind the nurses in whatever ac t ion , with in the provisions of labour l e g i s l a t i o n , i s found to be necessary in forc ing acceptance of the Conc i l i a t ion Board Report. . . . I t was agreed that ( in a l e t t e r to the Cabinet) i t be stated that the at t i tude of the nurses involved prohib i ts further delay on the part of the Execut ive. . . (also that) l e t t e r s be sent to a l l hospital boards involved, point ing 76 out the resentment the Executive feels in the fact that nurses are being used by the hospita ls as a tool to f ight f inanc ia l d i f f i c u l t i e s " . The f i na l motion was passed when the President of the Executive Council cast the deciding vote in favour (January 22, 1959), Both c r i ses were resolved when, short ly before the s t r i ke was to take e f fec t , the government provided increased funds to the hospita ls (Hood, 1959, pp.58). Again, in 1962 the Associat ion supported the nurses of VGH in s t r i ke act ion. Throughout th i s period the Associat ion pressed the government for binding a rb i t ra t i on for nurses, without success. Outcomes. While co l l e c t i ve bargaining improved the incomes of nurses, nurses were confronted with the budgeted shortage of s ta f f and the growing recognit ion of c on f l i c t between the professional and labour re lat ions roles of the Assoc iat ion. Although nurses' sa lar ies were touted as the best in Canada (Nurses' sa lar ies best in Canada,1 1957) concern was raised within the Associat ion and in publ ic about the supply of nurses and the adequacy of patient care due to the "arb i t rary way in which BCHIS set down regulations in l im i t i ng s ize of s ta f f in a l l hospita ls in B.C , many patients are not receiv ing adequate nursing care and, in sp i te of t h i s , nurses are working many hours overt ime.. ." (March 3., 1956). This concern resulted in the formation of a committee on Standards of Hospital Nursing Care. The committee was to " inquire into safe 77 nursing pract ices and indicate safe standards of nursing care (March 4, 1961; Small, 1962, pp.49-50). Later, the RNABC and BCHA formed a j o i n t committee to examine standards of care and "define' 1 the extent and l im i ta t ions of nursing pract ice" (F isher, 1964, pp.57-58). The budgeted shortage of nurses was recognized as a contr ibut ing problem (November 21, 1964). The problem of standards of care re-emerges as 'safety to pract i ce ' and becomes a dominant theme of the Associat ion in the 1970's. Conf l i c t between the professional and labour re lat ions roles of the Associat ion f i r s t surfaced when a representative of the Associat ion was "sought for the professional nursing group, not for nurses as employees of hosp i ta ls" to s i t on a committee of BCHIS (February 19, 1949). The Executive of the Associat ion recognized that chapters of the Associat ion were having " d i f f i c u l t y d is t inguish ing between Chapter business and matters for negot ia t i on . . . " (November 4, 1961). These types of con f l i c t s u l t imately led to the d i v i s i on of the organizat ion into Professional A f f a i r s and Labour Relations by which functioning and f inancing were separated. Secondary themes. The secondary themes for th i s period include education, r eg i s t r a t i on , terms and conditions of employment for senior nursing s ta f f and the health and safety of nurses. The theme of the education of nurses was quiesc ent during th i s period except to introduce refresher courses for nurses who had not practiced for ten or more 78 yea r s (May 26-27, 1960). R e g i s t r a t i o n remained an i s sue and was d e a l t w i t h i n two ways. Ways and means o f s t i m u l a t i n g i n t e r e s t i n employers r e qu i r i n g r e g i s t r a t i o n f o r employment were cons idered (May 15, 1956). At the same t ime , s a l a r y d i f f e r e n t i a l s f o r r eg i s t e r ed and non-r eg i s t e r ed nurses were negot ia ted (Hood,1957, pp .83) . The terms and cond i t i ons o f employment f o r s en i o r nurs ing s t a f f had been o f i n t e r m i t t e n t concern f o r many y e a r s . Concern i s f i r s t recorded when d i r e c t o r s of nurs ing were f i r e d wi thout due no t i c e (June 3, 1920; January 29, 1927). The t e n t a t i v e p o s i t i o n o f d i r e c t o r s o f nurs ing i s suggested i n the Eaton Report (1938, pp. 61-62) . Concern over the du t i e s and r e s p o n s i b i l i t i e s o f d i r e c t o r s o f nurs ing r e su l t e d i n the c i r c u l a t i o n of a statement to d i r e c t o r s , ho sp i t a l adm in i s t r a t o r s and chairman o f ho sp i t a l and pub l i c hea l th boards. The i s sue of s a l a r i e s f o r s en i o r nurs ing personnel r e s u l t e d i n the format ion of a committee to g i ve adv ice to nurses o r employers f o r s p e c i f i c s en i o r p o s i t i o n s i n h o sp i t a l s (March 10, 1962; October 24, 1964). A long s tand ing observer o f the nurs ing adm in i s t r a t i o n group a t t e s t s to the general v u l n e r a b i l i t y o f d i r e c t o r s o f nu r s i ng , the h igh a t t r i t i o n ra te o f ho lders o f the p o s i t i o n and the i n c r ea s i ng i s o l a t i o n o f t h i s group from a s s o c i a t i o n a c t i v i t i e s (McCann, 1981). From the i n cep t i on o f organ ized p ro f e s s i ona l nu r s i ng , the ra te o f t u be r cu l o s i s amongst nurses was the main focus o f concern f o r the hea l th and sa fe t y o f nurses . The advent of vo lun ta ry group insurance prompted many h o s p i t a l s to g i ve up ca r i ng f o r s i c k nurses 79 at minimal or no cost to nurses (October 18, 1940). Unt i l the advent of compulsory hospital insurance, 1949, nurses were in a d i f f i c u l t pos i t ion because they had no provinc ia l employee group through which to j o i n voluntary insurance schemes. Under co l l e c t i ve bargaining, nurses were "expected to carry hospital insurance and where poss ib le , complete medical insurance" through the provinc ia l hospital insurance scheme and through pr ivate insurance agencies (Hood, 1953, pp.82). The Associat ion directed i t s e f for ts to the establishment and maintenance of health records of students and the coverage of various diseases by the Workmen's Compensation Board: tuberculosis (September 6, 1950), staphlococcal infect ions (January 21, 1956), salmonella (February 2, 1957) and infect ious hepat i t i s (March 9, 1957). The RNABC agreed with WCB that compensation for mental i l l n e s s should not be recognized by WCB (February 13, 1960). Summary. The period 1955-1964 saw an evolution on the part of the Associat ion on the subject of s t r i kes . The Associat ion moved from the approval of a s t r i ke on the grounds of supporting the pr inc ip le of conc i l i a t i on by both part ies to the acceptance of s t r i k i ng for economic benef i t . It would appear that th is change was prec ip i tated by pressure from grassroots nurses, although i t i s c lear that nurses were not un i f ied in the i r response to the issues of the terms and conditions of employment. Coincident with th i s change in ideology was the beginning of a con f l i c t in professional and union roles of the Assoc iat ion. 80 Adjustments, to Growth: 1965- 7,6 . Introduction . The period 1965-76 i s dominated by structural/changes in the organization of the Associat ion and by influences external to the Associat ion that affected the process of co l l e c t i ve bargaining. The growth of co l l e c t i ve bargaining amongst nurses affected the Associat ion by increasing the volume and complexity of work re lated to co l l e c t i ve bargaining. Although province-wide bargaining establ ished a uniformity in the major components of the contract, secondary issues were negotiated with each i n s t i t u t i on . The organizat ional changes were a d i rec t resu l t of the growing complexity of the business of the Associat ion and a growing awareness of the potent ia l of con f l i c t between the labour re lat ions role of the Associat ion and the t rad i t iona l roles of the Assoc iat ion. Secondary themes for th is period include education, r eg i s t r a t i on , safety to pract ice , d i s c i p l i n e , socia l secur i ty and subsid iary workers. Changes in the preparation for bargaining. The preparation of Recommended Personnel Pract ices went through, several changes between 1942/43-1971. I n i t i a l l y Recommended Personnel Pract ices were prepared by the Executive Secretary. From 1946-50 the contract demands were prepared by the Committee on Labour Relations and la te r by the Director of the Personnel Service 81 TABLE .3,2 The Growth of Ce r t i f i ed Bargaining Units of Registered Nurses Within the RNABC 1946-76"! 1946 1956 1966 1976 Cer t i f i ed Bargaining Unit* 56 63 76 RNABC Labour Relations D iv i s ion , Present Ce r t i f i c a t i ons , 1981. Note: It i s not possible to ca lcu late the percentage of Registered nurses who were within bargaining un i ts . By 1956, the nurses of the major hospitals of the province were c e r t i f i e d . The data presented here does not coincide prec ise ly with the data derived from the RNABC Annual Minutes, 1946-76. 82 wi th the support of an advisory committee on Employment Relat ions. This committee l a te r became a standing committee to co-inci.de with changes in the CNA structure (Capel le, 1956, pp.60-61). In 1964 th i s committee became a sub-committee of the Committee on Social and Economic Welfare, which was i t s e l f a subcommittee of Nursing Service. The functions of the Nursing Service Committee were to 1) recommend to the Council s tudies, pract ices , and project s which w i l l help promote a high standard of nursing, and 2) serve in an adviso capacity to the Council on a l l matters concerning the soc ia l and economic welfare of members. The second clause became the sole respon-s i b i l i t y of the Committee on Social and Economic Welfare. This committee's ro le was defined as: "to recommend to the Council po l i c i es which w i l l promote the soc ia l and economic welfare of the members, and which w i l l ass i s t the Associat ion to meet personnel problems of members whenever they ex i s t "(October 24, 1964, March 20, 1965)., Subcommittees under the committee on Social and Economic Welfare included Personnel Pract ices (formerly, Employment Re lat ions) , Referral and Review (formerly Ethics and Welfare Services for Members (Wadsworth, 1966, pp.57). Input from the membership in the development of contract demands was a long standing problem for the Assoc iat ion. Ea r l i e r attempts to separate Chapter (professional) business and business concerning labour re lat ions had been unsuccessful, and in 1964 i t was decided that "bargaining representatives (would be) elected from each regional group of s ta f f because i t was agreed (that i t was) improper 83 for a counc i l lo r to be involved in the bargaining procedure" (November 21, 1964). The method of developing conditions of employment was revised to establ ish, a Committee on Contract Terms. The members were the Provinc ia l Bargaining Committee, with the addit ion of s ta f f representatives from publ ic health groups. A l l s t a f f groups were to submit proposed changes to the contract which the Committee would then present to the Staf f Representatives' Conference (February 23, 1968). Thus the Annual Meeting of 1968 was the l as t year in which Revisions of Recommended Personnel Pract ices were submitted to the membership of the Associat ion for discussion and approval. This decis ion was disputed but not revised in 1968 (May 29-31, 1968). Selected date from Recommended Personnel Pract ices of the RNABC, 1946-1968 i s presented in Table 3. The guidel ines for the Committee on Employment Relations contains the statement that "remuneration should r e f l e c t the value of service to society and therefore sa lar ies for nurses should be commensurate with education, qua l i f i ca t i ons and past experience" (November 22-23, 1968). These changes, and the formation of the provinc ia l Committee on Social and Economic Welfare were a d i rect outcome of changes within the CNA. The national committee, formally establ ished in Apr i l 1965, described i t s terms of reference as: 1. To interpret the philosophy of soc ia l and economic welfare for nurses in Canada. 2. To provide guidance, interpretat ion and moral support to prov inc ia l nurses' associat ions in the development of soc ia l and economic welfare programmes. 84 3. To promote research essent ia l to the advancement of socia l and economic welfare programmes for nurses (CNA, 1966, pp.7). and i t s philosophy as: The Canadian Nurses' Associat ion bel ieves that one respons ib i l i t y of the organized profession i s to safeguard the welfare of i t s members. The Associat ion believes that the profession has the r ight and respons ib i l i t y to define i t s funct ions. It recognizes that basic to the provis ion of a high qua l i ty of nursing care i s the adequacy of the nursing s t a f f , condit ions of work and an environment conducive to e f f i c i ency and indiv idual sa t i s f a c t i on . The Canadian Nurses' Associat ion approves the pr inc ip le of co l l e c t i ve bargaining for nurses and believes that the bargaining author i ty for i t s members should be vested in the professional nurses' associat ion in each province. The Canadian Nurses' Associat ion recognizes that the re lat ionsh ip of nurses to the publ ic i s a major asset in promoting the socia l and economic welfare of i t s members. The qua l i ty of the i r work and the i r interpre-tat ion of i t s character, content and respons ib i l i t y w i l l serve to bui ld up a genuine understanding of the con t r i -bution of nurses in the community. The acceptance of the pr inc ip les and respons ib i l i t i e s of co l l e c t i ve bargaining for the members of the nursing profession has the f u l l o f f i c i a l approval and support of the profession throughout Canada (CNA, 1966, pp.8). In the preamble to these statements to CNA described the s o c i a l , economic and po l i t i c a l changes taking place in Canada. The growing i n a b i l i t y of the indiv idual to function outside of a larger group was emphasized. 85 The ideological s h i f t . In 1968 a committee to revise the structure of the RNABC was struck. The rat ionale for the rev is ion was the increased complexity of the roles and functions of the organization (George, 1969, pp.24-26). The functions of the RNABC were seen to be: 1) administrat ion of the Act, 2) further ing the profession, 3) promotion of employee-employers' re lat ions under which placement and counsel l ing services as well as co l l e c t i ve bargaining f e l l , and 4) "performance of such other lawful things as are inc idental or conducive to the welfare of the publ ic and of the nursing and a l l i e d professions"(George, 1965 pp. 10-15). The implementation of the recommendations resulted in revised object ives, re-s t ructur ing the Board, the standing committees and the functioning of the professional s ta f f of the Assoc iat ion. The ro le and funct ioning of the President of the Associat ion became an issue. I t was suggested that the President be reimbursed for loss of salary resu l t ing from the respons ib i l i t i e s of her o f f i ce and th is was defeated. Later the issue was re-considered in terms of the President 's ro le being a f u l l time paid pos i t ion . This was defeated because i t created leave of absence problems although i t was recognized that the President 's role demanded a considerable investment of time (February 19, 1972). The role was l e f t as a voluntary, unpaid pos i t ion . This i s consistent with the Assoc iat ion 's pos i t ion that s ta f f nurses or the i r i n s t i t u t i on were to be reimbursed for loss of salary only i f the nurse was unable to arrange days of f to 86 perform o f f i c i a l Associat ion business (November 20, 1965, March 17-19, 1977). In view of the structura l changes that occurred, and in view also of the evolving at t i tude of the role of co l l e c t i ve bargaining within the Assoc iat ion, a consideration of the Assoc iat ion 's statement of objectives between 1950-1971 i s usefu l . In 1953, the President of the Associat ion stated the objectives as: (1) to implement and protect standards in nursing education and pract ice to meet preva i l ing community needs and (2) to serve the membership through safeguarding the professional status of nurses and improving the i r economic secur i ty , to be achieved (!) By sett ing and safeguarding the standards for nursing education and pract ice in th is province and evaluating and l i cens ing the graduates of B.C. Schools and graduates from other centres according to those.standards in the interest of safe nursing care for the publ ic and protect ion of our professional status. (2) By providing two reg i s t r i e s for pr ivate duty nursing in two of the three largest c i t i e s in the province and a placement service for other types of nursing posit ions throughout the province. While the primary purpose of these resources i s to serve our registered members, the publ ic i s also served through the placement of nurses, pr ivate duty, i n s t i t u t i ona l and publ ic health, where needed, in the communities through-out B.C. (3) By providing a labour re lat ions programme to obtain and safeguard su i tab le working conditions and acceptable personnel pract ices for our members through d i rec t conferences with employees? (Paulson, 1953 pp.4-5). 'Employee' was changed to 'employer' by E. Mal lory, former owner of the Annual Meeting Minutes, June 5-6, 1953 used for th i s study. 87 In I960, the objectives were stated as; 1. To maintain the honour and status of the nursing profession. 2. To advance the educational standards in nursing. 3. To elevate the standard of nursing pract ice in order to render e f f i c i en t service in the interest of the publ ic . 4. To promote and regulate sound employee-employer re lat ions in the nursing profession. (Rossi ter, I960, pp.5) These were ult imately revised during the late 1960's to read: The object of the Associat ion i s to further the standard of nursing pract ice in order to ensure e f f i c i en t service to the people of B r i t i s h Columbia by: a. e f fect ing the provisions of the Registered Nurses' Act, 5.. promoting improvement in nursing education and nursing pract i ce , c. regulat ing re lat ions between employers and employees through co l l e c t i ve bargaining on behalf of members. d. engaging in such other a c t i v i t i e s as are conducive to the health and welfare of the publ ic and the welfare of the nursing and a l l i e d professions. (RNABC~ News, 1971, 7 pp.32). To change the structure of the Association? The rev is ion of the Const i tut ion and Bylaws and the re-organizat ion of the structure of the Associat ion did not solve the problem of a s ingle organization representing statutory, professional and economic interests of the membership of the Assoc iat ion. Concern about the ro le , function and structure of the Associat ion led to the commissioning of the Baumgart study on Nursing Leg i s la t ion . (November 17, 1972). The purpose of the study was to expand under-standing of some of the fundamental i s sues . . . ( i n nursing l eg i s l a t i on ) 88 and to provide a basis for discussion and debate"(Baumgart, 1973). Baumgart i den t i f i ed three roles of the Assoc iat ion, 1) the corporate ro le delegated by the State concerned with educational and eth ica l regulat ion for the protect ion of the pub l i c , 2) the associat ion-or profession-centered ro le for the inf luence of the form, range, and qua l i ty of services for the pub l i c , and 3) the union ro le for the protection and improvement of the soc ia l and economic s i tuat ion of the membership (Baumgart, 1973 pp.1). Baumgart (1973, pp.8) i den t i f i ed the key issue as how to achieve greater publ ic responsiveness and accountabi l i ty without s a c r i f i c i ng the values of voluntary professional i n i t i a t i v e " / Baumgart saw an " inext r i cab le intertwin ing of in terest of the publ ic and the nursing profession The be l i e f i s that the benefits to the publ ic coming from the harmonizing and integrat ing of these interests outweigh the potent ia l dangers of c on f l i c t . The important organizational consideration i s to ensure that checks ex i s t and are applied to prevent sustained departures of a professional associat ion from, i t s declared publ ic purposes. Par t i cu la r reference i s often made here to the re lat ionsh ip between socio-economic interests - the union ro le , and conditions for patient care - the publ ic interest ro le . The great d i s t i n c t i on seen between a professional assoc iat ion 's negotiat ing interests and a trade union's i s the almost certa in preoccupation of professional people with of fer ing an increas ingly superior level of serv ice. To have the professional associat ion act as bargaining agent for i t s memberships i s f e l t to give greater assurance that working conditions secured for nurses w i l l be d i r e c t l y re lated to publ ic welfare considerat ions. (Baumgart, 1973, pp.4). At the same time, the CNA commissioned "A Discussion Paper on the Three Major Roles of Prov inc ia l Nurses' Organizations" 89 (Bachard, 1973). Bachard i den t i f i ed three legal en t i t i e s which may comprise a professional organizat ion: 1) a professional corporation responsible for regulatory and d i s c i p l i na ry funct ions, 2) a professional associat ion interested in promoting the profession and 3) the professional syndicate or union interested in the socioeconomic welfare of i t s members. Bachard examined the nursing organizations of the provinces and iden t i f i ed four versions of organizat ional structures dealing with the three ro les . She then presented a model structure in which the three roles were separated but incorporated under a Council of the provinc ia l nurses' assoc iat ion. In the proposed model, the three roles i den t i f i ed were to be performed by separate structures within ••the Associat ion which was to be governed by a Council formed of representatives of government, the chairman of the professional union sections and representatives elected from the membership. Membership in the Associat ion would be required in order to pract ice nursing. External influences oh the structure and process  of col 1ecti ve bargaining_.. In 1973, the Supreme Court of Canada ruled that the Saskatchewan Registered Nurses' Associat ion could not engage in co l l e c t i ve bargaining on behalf of i t s members because of the ro le management nurses played in the Associaton. The RNABC recognized the s ign i f i cance of the Supreme Court decis ion (November 17, 1973). The Labour re lat ions and professional a c t i v i t i e s of the Associat ion 90 were (now to he) separated such that the Associat ion shal l not be en t i t l ed to make or amend anything in the Const i tut ion or Bylaws, the ef fect of which would give the Associat ion any control over the bargaining functions of the Labour Relations D iv is ion" (January 9-10, 1976). This was ref ined in 1978 to read "the Labour Relations Div is ion shal l be governed by a Labour Relations Council to be elected amongst members of bargaining units..(RNABC, Const i tut ion and Bylaws, May 10, 1978). The Professional and Labour Relations Div is ion continued to operate under the umbrella of the RNABC unt i l complete separation was establ ished in 1981. Unrest in the hospital industry, which included s t r i ke votes amongst nurses in 1968 and 1974 led to the government's commissioning of the B l a i r Report. Its purpose was "to examine the experience of the co l l e c t i ve bargaining process in the hospital industry and make recommendations for an improved and a more viable co l l e c t i ve bargaining system.. ." (January 17, 18, 1975). The report recommended the separation The object ives were revised to read: The object of the Associat ion i s to further the standard of nursing pract ice in order to ensure e f f i c i e n t service to the people of B r i t i s h Columbia by: a. e f fect ing the provisions of the Registered Nurses Act; b. promoting improvement in nursing education and nursing pract ice; c. regulat ing, through a Labour Relations D iv i s ion , re lat ions between employers and employees through co l l e c t i ve bargaining onbehalf of nurses for whom the RNABC holds c e r t i f i c a t i on and bargaining author i ty; d. engaging in such other a c t i v i t i e s as are conducive to the health and welfare of the publ ic and the welfare of the nursing and a l l i e d professions. (RNABC, Const i tut ion and Bylaws, 1978). 91 of the Health Labour Relations Div is ion as a separate ent i ty from BCHA but employers' par t i c ipa t ion in the new. Health. Labour Relations Associat ion was condit ional on membership in the BCHA (B l a i r , 1974). The separation of labour re lat ions a c t i v i t y from the BCHA was analogous to the separation of labour re lat ions from the RNABC. The RNABC response to the B l a i r report and was "pos i t ive" (February 14, 1975). Secondary themes. The secondary themes for th i s period are: education, reg i s t ra t i on , safety to pract i ce , d i s c i p l i n e , soc ia l secur i ty and subsidiary workers. Two major events in nursing education occurred during th i s period: 1) the submissions to the Royal Commission on Health services in Canada in 1964 (Hall Commission) and 2) the introduct ion of 2 year community col lege programs. CNA and RNABC submission to the Hall Commission stressed the need for increased funding for nursing education, the need to remove nursing schools from hosp i ta l s , and the need to increase the a v a i l a b i l i t y of un ivers i ty education for nurses. Provis ion for f l e x i b i l i t y in the structure of nursing education had been made in revis ions to the Registered Nurses Act (May 26-27, 1966). Establishment of two year community col lege programs had started in the S ix t i es and the consequent, c los ing of hospital schools: of nursing fegan. In 1967 the student nurses' 92 Associat ion i s recorded as requesting that the Associat ion send " le t te rs to Boards of four (of a to ta l of seven) hospital schools of nursing with 44 hour weeks, requesting a 40 hour week and two free days per week for student nurses"- The Boards in question "endorsed in pr inc ip le the i n ten t of the recommendation and (were) hoping to imple-ment a gradual t rans i t i on to a 40 hour week" (Cunningham, 1967, pp.61). Contract demands for graduate nurses changed from a maximum 40 hour week in 1966 to a maximum 37% hour week in 1968 (RNABC, proposed , 1966; RNABC, proposed...T968). Recommended admission requirements and po l i c i es for schools of nursing were stated as-a 40 hour week one,year l a te r (Cunningham, 1968, pp.18). With the growth of community col lege programs, concern over the performance of new graduates prompted the Associat ion to study the functioning of new graduates and to "define and val idate essent ia l s k i l l s required of new graduates" (May 10, 1977). In the early T960's continuing education was an issue in determining salary d i f f e r en t i a l s for nurses (May 11 , 1963).., The need for funds for or ientat ion programs for new s ta f f and for continuing education was presented to the government (May 31, June 1, 2, 1967) (September 19, 20, 1969). The need for addit ional spec ia l i zed t ra in ing for nurses, large ly as a resu l t of advanced technology, was also recognized (November 21-22, 1969). Although a representative from the College of Physicians and Surgeons had been a part of the Examining Board since 1918, 93 par t i c ipa t ion had been variable.. The ro le of examiners disappeared with the use of mult ip le choice exams in the 60.'s, The College relinquished i t s examining ro le in 1969 at i t s own request (December 12, 1969). Registrat ion of nurses continued to be a v i s i b l e issue. A motion "to invest igate the question of mandatory reg i s t ra t ion arose at the 1965 Annual Meeting, There are two aspects to th i s issue: 1) to protect the qua l i ty of nursing care and 2) to protect the employment of nurses. Mandatory reg is t ra t ion was studied at length and rejected because "1)'mandatory reg i s t ra t ion would increase the shortage of s ta f f . . . (and) probably be met by an increase in the u t i l i z a t i o n of aux i l i a r y nursing personnel, 2) mandatory reg is t ra t ion would preclude employment as a graduate nurse: a) preparatory to re-instatement as a registered nurse fol lowing d i s c i p l i na ry ac t ion , or b) fol lowing i l l n e s s preventing work as a registered nurse, or c) preparatory to instatement as a registered nurse when nursing education had been obtained outside the province" (Campbell, 1967, pp.44). This committee recognized that "there i s strong incentive in salary schedules to become registered i f employed continuously in B.C. (Campbell, 1966, pp.46). Again in 1970, 1974 and 1976, motions for mandatory reg i s t ra t ion were discussed. In the context of budgetary constraint and the resu l t ing h i r ing of other than registered nurses, mandatory reg i s t ra t ion was seen as a means of protect ing the publ ic (May 27-29, 1970). In 1976, discussion of mandatory reg i s t ra t ion was in terms of re - reg i s t ra t ion on the basis 94 of demonstrated competence (November 18, 19, 20, 1976). Concern about safety to pract ice nursing resulted in a pos i t ion paper on nursing pract ice (May 25, 1973), a study on safety to pract ice (November 13, 14, 1975) and the development of a qua l i ty assurance program (September 23-25, 1976). D i sc ip l ina ry action i s another facet of the reg i s t ra t ion issue. Unt i l the 70's d i s c i p l i na ry action was an informal procedure within the realm of the Board. A formalized procedure was developed with the stated pol icy that when "tak(ing) d i s c i p l i na ry act ion, th i s action should provide the members with the greatest possible opportunity to re-estab l i sh professional competence that i s consistent with publ ic safety" (November 18-20, 1976). Throughout the minutes there i s only occas: ional discussion of d i s c i p l i na ry matters. Although the Associat ion was aware of the need for socia l secur i ty for i t s members from i t s incept ion, l i t t l e concrete action was taken unt i l government plans for unemployment insurance and pension plans become ava i lab le . Unt i l the introduct ion of unemployment insurance by the federal government, the BCHA stood alone amongst hospital associat ions in Canada in support of unemployment insurance for hospital employees and nurses (BCHA, 1940, pp 28 79).The RNABC supported unemployment insurance for nurses as ear ly as 1950 (March 3, 1950), but l a te r revised th i s decision (November 18, 1967). With the publ icat ion of the Federal government paper on unemployment insurance both the CNA and RNABC supported the inc lus ion of nurses in such a plan (November 13, 1970). Unt i l th is time, fears had been expressed that nurses would 95 receive l i t t l e benefit from the plan; because of the i r low unemployment rates. With the sh i f t of employment of nurses from private duty to pub l i c l y funded hospita ls and the enactment of the Municipal Superannuation Act, the Associat ion urged BCHIS to provide a super-annuation plan for employees of pub l i c l y funded hospita ls (May 25, 1950). Hospita ls , as employers,could par t i c ipate in 1957 (May 3-4, 1957), but general ly did not unt i l the ear ly 1960's. Interest then shi f ted to the inc lus ion of medical insurance premiums, income protect ion plans, and the rev is ion of superannuation plans to end d iscr iminat ion against dependants and spouses of women (September 19-20, 1969; Apr i l 28, 1973). Subsidiary workers concerned the RNABC in terms of the i r ro le , function and p ro l i f e r a t i on . The Assoc iat ion 's concern that pract ica l nurses be used only in an aux i l i a ry capacity was expressed to Directors of Nursing, BCHIS and BCHA (February 24, 1968; May 2-23, 1969). The Associat ion (with the BCHA) rejected Canada Manpower i n i t i a t i v e s in developing a program for nurses' a ides, (December 12, 1969) and a l ternate ly urged that operating room technicians be phased out (Apr i l 17, 1971).and expressed concern about i n su f f i c i en t numbers of th i s group (June 17, 1972). The p ro l i f e ra t i on of health care workers was studied (Apr i l 15, 1972) as was the po s s i b i l i t y of bringing together registered nurses, psych iat r ic and pract i ca l nurses under one piece of l e g i s l a t i on . Summary. 96 The period 1964-76 represents the end of re l iance on paternalism. The emphasis of commitment to service in the face of d ive rs i t y (shortages of nurses, pat ient need etc . ) in which economic needs were put in second place had ended. In considering the objectives of the Associat ion o v e r t h i s pen several points are noteworthy. 1) statements about the professional status of nurses had changed from "safeguarding" and "maintaining" to a statement of nursing as a profession; 2) economic secur i ty for nurses i s now stated in terms of 'employee-employer" acknowledging the completion of the t rans i t i on from the major form of employment as pr ivate duty nurses to employment as an employee within an i n s t i t u t i ona l st ructure; 3) acknowledgement of co l l e c t i ve bargaining as the mechanism for dealing with economic matters i s f i r s t stated in the 1972 statement of object ives; 4) the objectives of 1953 have a sense of s t a t i c steadfastness while a sense of motion or advancement i s noted in the objectives of 1960 and 1970; and f i n a l l y , 5) an acknowledgement of par t i c ipa t ion in " a c t i v i t i e s conducive to the health and welfare of the publ ic" i s made, although the Associat ion had been act ive in health pol icy matters since i t s inception eg: the pract ice of midwifery (Apr i l 26, 1917; Apr i l 21, 1924; Apr i l 22, 1935); prov inc ia l and 97 national health po l i cy (January 10, 1919; November 30, 1934; March 25, 1938; December 1, 1942; August 5, 1943 e t c . ) ; and women's issues (September 6, 1927; December 3, 1960; October 17, 1970 e t c . ) . An in terest ing omission i s the lack of expressed interest in the health as well as the welfare of nurses. This i s perhaps because the health hazards to nurses were seen only as a consequence of the terms of employment rather than as consequence of the work i t s e l f . A l te rnat i ve ly th i s omission may represent an acceptance of r i sk or a be l i e f that the 'good' pract ice of nursing el iminates any r i sk to health. This had been implied in the discussion of tuberculosis in the Eaton Report (1938, pp.21-23). On the secondary themes education was the most important. The solut ion to the problem of hours of work for student nurses was the end of a system based on service in exchange for education. While the Associat ion had exerted pressure for change, the so lut ion came as a resu l t of changes external to the Assoc iat ion. Nursing education became apart of the general education system. Conclusion: To Protect the Qual i ty of Nursing; 1943-76 Confronted with increased economic and soc ia l d i spa r i t y , reinforced by the strength of a shortage of nurses during and fo l lowing World War I I , nurses in B r i t i s h Columbia voted to support co l l e c t i v e bargaining in 1946. This act ion was seen to be taken ' to protect 98 the qua l i ty of nursing' (May 2, 1951), Restraint on wage demands during the f i r s t years of co l l e c t i ve bargaining resulted in the eruption of s t r i ke votes in 1957 and 1959, The decis ion by the Supreme Court of Canada in 1973, that the Saskatchewan Registered Nurses' Associat ion could not represent nurses in co l l e c t i ve bargaining because of the ro le of managerial nurses on the Assoc iat ion 's board, and concern within the Assoc iat ion 's membership about the appropriate ro le and funct ioning of the Associat ion led to the separation of professional and labour re lat ions roles and functions in 1976. 99 CHAPTER 4 Methodology Introduction The purpose of th i s chapter i s to present the methodology used to analyze the material presented in Chapters two and three. The methodology chosen was grounded theory (Glaser and Strauss, 1967). This chapter begins with a br ie f consideration of some of the problems of doing soc ia l research and continues with a discussion of the theoret ica l aspects of grounded theory. A discussion of the appl icat ion of grounded theory in th is study i s then presented. A b r i e f discussion of the c r e d i b i l i t y of grounded theory i s presented in the conclusion. Some Problems of Social Research This research had two major problems, the se lect ion of 1) the data base, and 2) the methodology. The main source of data, the Board and Annual Minutes of the RNABC, were chosen because these represented the only continuing source of documentary evidence from the inception of the organization to the present. As such, the minutes represented a mass of data organized only by chronology. This data base was supplemented when questions arose or d i rec t reference was made or i n tu i t i on prompted, by such sources as The Canadian Nurse, The Bu l l e t i n of the Registered Nurses' Associat ion of B r i t i s h Columbia, the Annual Minutes of the B r i t i s h Columbia Health Associat ion and selected interviews. Interviews were l imi ted to 100 persons who were considered to be key persona l i t i es , and who were known to be receptive to the study of issues in health care. The interviews were open-ended and, because of the nature of the p a r t i -c ipants, were reminiscences. No tape recordings were made. Some background understanding was developed in the course of soc ia l i n te r -act ion with people who had l i ved through some of the issues presented. Their perspectives were found to substantiate the sort ing of the data, and the i r comments were included to enhance the richness of the mater ia l . These contr ibut ions were spontaneous, and given with enthusiasm and interest in the study. The question of the method of analysis of the material presented two po s s i b i l i t i e s - quant i tat ive or qua l i t a t i ve . Cole (1976) has suggested that qua l i t a t i ve research i s most appl icable for descr ip t ion , formulation of hypotheses, and understanding of the causal process. Cole states that qua l i t a t i ve research r i sks the d i s to r t i on of r e a l i t y , (1976; pp.186) but he points out that th i s can be countered by ' t r i angu l a t i on ' , that i s , other documentary sources and interviews can be used to see what elements can be agreed or disagreed upon. A l te rna t i ve l y , preceptions of r e a l i t y can be viewed as in te res t ing , and what ' r e a l l y ' happened as not so important. Quantitat ive methodology, "a means Of co l l ec t ing data which can be converted into numbers" (Cole, 1976, pp.77) provides the rat iona le for a technique of content analysis in which s c i e n t i f i c methods are applied to documentary evidence (Holst i 1969 pp.5). 101 Hoist i (1969, pp.14) defines content analysis as "any technique for making references by object ive ly and systematical ly ident i fy ing charac ter i s t i cs of messages". A l t e rna t i ve l y , content analysis can be done as qua l i t a t i ve analys is of documents. There are several arguments against using quant i tat ive content analys is i n th i s study. ' S c i e n t i f i c method' i s a reference to the borrowing and adapting of the methods of natural science to sociology (F i l s tead , 1970, pp.2-5). As appealing as th i s may be, F i l s tead contends that th i s i s not necessar i ly an appropriate method for the study of behavior. He argues the case for qua l i ta t i ve methodology, "as a legi t imate source of e i ther data co l l e c t i on or theory cons-t ruc t i on , " and supports the use of Glaser and Strauss's methodology of grounded theory (F i l s tead , 1970, pp.5-8). Advice was sought from two sources. Neither supported the use of quant i tat ive content ana lys is . I t was suggested that the subt lety of the material would be l os t (Whittaker, 1980). I t was also suggested that quant i tat ive content analysis had proven to be less useful than hoped in the study of the messages of adver t i s ing . (Po l la rd , 1980). Thus, the methodology of grounded theory was chosen as the means to study the data. The remainder of th i s chapter draws heavi ly on the work of Glaser and Strauss (1965, 1967, 1968). 102 Grounded theory Glaser and Strauss (1967, pp.1) define grounded theory as "the discovery of theory systematical ly obtained and analyzed from the data of soc ia l research". Theory i s generated by the process of theoret ica l sampling whereby the researcher j o i n t l y c o l l e c t s , codes and analyses data. While the researcher begins with an idea which i den t i f i e s the basic features of the study, the process of data co l l ec t i on i s contro l led by the emerging theory d i rec t ing the researcher to new sources of data. Thus, while E t z i on i ' s (1968) concept of a soc ieta l s h i f t from normative to u t i l i t a r i a n behavior suggested the d i rec t ion th i s study might take, i t did not inf luence the data co l l e c t i on nor the f indings in the data. In th i s study, a prel iminary step of organizing events, processes and trends under thematic headings, by decade (Smith, 1976) was taken to f a c i l i t a t e the organization of the mater ia l . Grounded theory i s an inductive method of research which i s contrasted with theory generated by deductive methods based on a p r i o r i assumptions. Grounded theory i s contrasted with research in which empirical examples are chosen to support theoret ica l fo r -mulations. While the research area is entered into with certa in ideas or models, 'the development of co l l e c t i ve bargaining as a s h i f t in ideology from professional ism to unionism' the methodology of grounded theory represents a sh i f t from the ve r i f i c a t i on of borrowed theory to the preceding step of discovering what concepts and 103 hypotheses are relevant for the area under study. In the case of th i s study, the research was an examination of the data, the Board and Annual Minutes of the RNABC and selected mater ia l , to estab l i sh relevant concepts and emergent hypotheses a r i s ing d i r e c t l y out of the data base. Grounded theory may y i e l d substantive or formal theory. Substantive theory is defined as theory developed from "substantive or empirical areas of soc io log ica l inqui ry , such as patient care, race r e l a t i o n s . . . " . Formal theory i s "developed from a formal or conceptual area of soc ia l inquiry such as stigma, deviant behav ior . . . " Glaser and Strauss (1967; pp.32). Glaser and Strauss (1967, pp.33) state that substantive and formal theories ex i s t on dist inguishable leve ls of genera l i ty , " and thus "can shade at points into the other"'. They state that the researcher should focus c l ea r l y on one or other leve l or on a spec i f i c combination because the strategies vary for a r r i v ing at each. There was no attempt to develop formal theory from the data studied. In th i s instance the focus was the substantive area of a prov inc ia l nursing organizat ion, with study concentrated on the entry into co l l e c t i ve bargaining on behalf of the membership. 104 The Development of Theory. . v The systematic study of multiple comparison groups is used to generate theory. Glaser and Strauss state that the elements of theory that are generated by comparative analysis are 1) conceptual categories and their conceptual properties, and 2) hypotheses or generalized relations among the categories and their properties. Comparative analysis allows the validation of facts, the development of conceptual categories from the facts, the specification of concepts (ie: the development of the properties of conceptual categories), the generation of theory, and the verification of theory. Glaser and Strauss recommend researchers immerse them-selves in the data, and allow concepts and categories to emerge. These concepts and categories are then organized into groups for comparison. This is the process of theoretical sampling. Initially hypotheses are suggested relations amongst categories, not tested relationships. As the data collection continues the researcher is able to generate and verify hypotheses through the comparison of groups. The first hypotheses tend to become integrated to form the basis of the central analytic framework of the research. It is sufficient to generate hypotheses on the basis of suggestion, not on evidence piled up to establish proof. Only i f an underlying hypothesis is disproved are the relevant relationships stated in the theory discarded. Out of this activity grounded theory emerges. Grounded theory is presented either as a well codified set of 105 proposit ions or as a running theoret ica l discussion using the conceptual categories and properties generated from the research. Theoretical sampling. The ro le of comparison groups is to promote the comparison of diverse or s im i la r evidence ind icat ing the same conceptual categories and propert ies. Evidence i s not compared for i t s own sake. The researcher begins with no preplanned set of groups, and no rules for the comparison of groups. The only c r i t e r i on i s that the material be relevant. I t is necessary to be c lear on the basic types of groups in order to control the ef fect of the groups on the general i ty of the population studied and the conceptual level of the theory. The d i f f i c u l t i e s of se lect ing groups for study may be decreased by studying only one group or the sub-groups of a selected group during a s ingle research period. The scope of substantive theory can be ca re fu l l y increased and contro l led by the conscious choice of groups. In substantive theory only s im i la r groups are studied. In the development of formal theory the comparison of d i s s im i l a r substantive groups of conceptual s im i l a r i t y i s used. Categories and properties are dist inguished in order to indicate a systematic re lat ionsh ip between the two elements of theory. A category i s a concept about the problem, not i t s s i t ua t i on . A category stands by i t s e l f as a conceptual element of the theory, while a property i s a conceptual aspect or element of a category. 106 The f i r s t stage in the development of categories i s the i den t i f i c a t i on of themes that have recurred and seem to have some bearing on the problem at hand. These themes are l a te r sorted into categories and propert ies. Glaser and Strauss advise against borrowing categories from the l i t e ra tu re in order to f a c i l i t a t e the development of new categories and to avoid se lect ing data that forces a ' f i t ' . Ignoring establ ished categories allows the emergence of new categories that are most relevant and suited to the data. An attempt is made to aim for d i ve r s i t y in emergent categor ies. The l i t e r a tu re i s examined for s im i l a r i t i e s and convergences only a f ter the ana lyt ic core of the categories has been establ ished, and therefore the l i t e r a tu re review fol lows the analysis of the data. Glaser and Strauss (1967, pp.65-69) use the concept of a ' s l i c e of data 1 to promote the use of d i f fe rent kinds and sources of data in the development of a category and i t s propert ies. Theory generated from mult ip le sources of data promotes a richness and a ve r i f i c a t i on of data, as well as a propor-tioned view of the evidence. The systematic analysis of data allows the development of conceptual categories from the data. While spec i f i c facts may change, the concept does not, and thus the process of developing a conceptual framework i s not dependent on factual events but rather the concepts these events represent. 107 Categories reach theoretical saturation when no additional data can be found to continue the development of the properties of a category. Saturation is determined by a combination of the empirical limits of the data, the integration and density of the theory, and the researcher's theoretical sensitivity, ie: the researcher becomes empirically confident that a category is saturated. The adequacy of a theoretical sample is judged on the basis of how widely and diversely the researcher chose the groups for saturation according to the type of theory to be developed. The adequacy of a statistical sample is judged on the basis of techniques of random and stratified sampling used in relation to the social structure of a group or groups sampled. The inadequate theoretical sample is usually thin, poorly integrated and has many obvious unexplained exceptions. The inadequate statistical sample may be accepted uncritically by all those untrained in statistical methods. Glaser and Strauss do not feel theoretical sampling and statistical sampling need be combined. Should i t be desirable to express the magnitude of a relationship within a particular group, statistical sampling or a highly systematic observation procedure over time is necessary. Theoretical sampling is concluded when the researcher judges that saturation has occurred, that is the theory is approaching stable integration and dense development of properties. The concepts that are generated must have two essential features: the capacity to be 1) analytic, that is the general characteristic of the entity should be evident, not the entity itself, and 2) sensitizing, 108 that i s the ent i ty should suggest a meaningful picture to the reader. Glaser and Strauss state that theoret ica l s en s i t i v i t y i s developed with pract ice by the researcher and may be a re f l ec t i on of the researcher's personal and temperamental bent as wel l as the researcher's a b i l i t y to have ins ight or borrow the ins ight of others. Once a category or a property i s establ ished, only strong evidence, usual ly from a d i f fe rent substantive area in addit ion to the creat ion of a better category, i s su f f i c i en t to change a category. To avoid forced in tegrat ion, there i s no attempt to apply a model of a formal theory unt i l one i s sure i t w i l l f i t . There w i l l be no attempt to apply a model of a formal theory to th i s study. Depth of theoret ica l sampling refers to the amount of data co l lected on a group and on a category. Theoretical sampling requires the f u l l e s t possible sampling of the group at the beginning of the research when the main categories are emerging. Core theoret ica l categories need to be as f u l l y saturated as poss ib le. In pract i ce , Glaser and Strauss have found that the researcher saturates a l l categories un t i l i t i s c lear which are the most important. Through-out th i s process, systematic, simultaneous co l l e c t i on , coding and analysis take place. As the work progresses, the researcher looks for emergent categor ies, reformulates categories as new properties emerge and prunes and adds unt i l a theoret ica l framework emerges understandable to both layman and soc io log i s t . 109 The Constant Comparative Method of Qual i tat ive Analys is . The constant comparative method of analysis is concerned with generating and suggesting, but not test ing categories, properties and hypotheses about the general problem under study. Glaser and Strauss suggest that the properties may be causes, condit ions, consequences, dimensions, types, processes e tc . There i s no attempt to estab l i sh the un iversa l i t y or proof of suggested causes or re la t ionsh ips . Since no proof is needed, i t i s necessary only to saturate the categories; thus not a l l data need be considered. There are four stages in the constant comparative method: 1) comparing incidents appl icable to each category, 2) integrat ing categories and the i r propert ies, 3) de l imi t ing the theory and 4) wr i t ing the theory. There w i l l be no attempt in th i s study to de l imi t or write theory. In phase one, each incident i s coded into as many categories of analysis as poss ib le. Headings were noted on the margin of the f i e l d notes. The comparison group in which each incident occurred vis recorded. While coding an incident for a category, comparison* are made with previous incidents in the same and d i f ferent groups coded in the same category. This process generated the theoret ica l propert ies of the category. Glaser and Strauss state that the researcher w i l l notice that the concepts abstracted from the substantive s i tua t ion tend to be labels current ly i n use for the actual process and behaviors that are being explained: 'the struggle ' 110 for the eight hour day, while the concepts constructed by the researcher tend to be the explanations, 'the attempt to cont ro l ' the working environment. The integrat ion of categories and the i r properties (phase two) occurs as coding develops from the constant comparison of incidents to the comparison of an incident with the properties of the category that resulted from the i n i t i a l comparison of inc idents. The unit of comparison has changed to a more complex l e ve l . U l t imate ly , diverse properties become integrated; the integrat ion of theory occurs. Del imit ing theory occurs at two l eve l s , 1) the theory s o l i d i f i e s , i e . modif icat ions of the theory become fewer, and 2) the or ig ina l l i s t of categories for coding becomes reduced. This occurs because some categories are shown not to have relevance or because what seemed to be a category became a property of another category. The ef fect of reduction and theoret ica l saturat ion moves the ana lyt ic framework to the leve l of theory. The f i na l stage of wr i t ing theory occurs when the researcher i s reasonably convinced that an accurate statement of the subject matter studied can be made. The categories become the major themes of the theory with the coded data and the researcher's notes become the descr ipt ive content behind the categories. Glaser and Strauss state that the presentation of theory can be made in the forms of a discussion which i s su f f i c i en t for the exploratory stage of theory development or in the form of proposit ions. This study w i l l be confined to the level of an exploratory statement. The Appl icat ion of Grounded Theory to the Data_._ The generation of categories and properties began with a review of the minutes of the Assoc iat ion. The minutes are contained in notebooks and bound volumes dating from 1912 to the present. They are hand wr i t ten from 1912-1923 and typed thereafter. The format, depth and s ty le varies over the 64 years that were reviewed. The minutes include the minutes of the Executive Counci l , the Counci l , l a t e r ca l led the Board, and the Annual Minutes. Minutes of the Executive Council meetings 1923-27 do not appear to ex i s t . Published annual minutes ex i s t from 1945. Reports of annual meetings appeared both in B r i t i s h Columbia newspapers and in the Canadian Nurse. The minutes of standing or ad hoc committees of the Associat ion were not made avai lab le for th is research. Contextual depth i s a problem on some issues. For example, the t rans i t i on of the organizational structure and objectives of the Associat ion i s unclear and d i f f i c u l t to reconstruct. Supplementary sources such as newspapers, discussion papers, journal a r t i c l e s and interviews were used to t ry to overcome these d i f f i c u l t i e s . Because of the length and complexity of the data base a deta i led summary of the minutes, with d i rec t quotes as were f e l t to be use fu l , was recorded in f i e l d notes t o t a l l i n g 300 pages. In a separate column adjacent to the notes, a heading appl icable to the content of the minutes was recorded. These headings were both substantive and theoret ica l words or phrases. Examples of substantive 112 headings included the themes presented i n the narrat ive of Chapters Two and Three, and words or phrases used by the part ic ipants themselves; thus the chapter heading ' to protect the qua l i ty of nurs ing ' . The headings that appeared in the f i e l d notes u l t imate ly numbered 25. A summary of the content re lated to these headings was made. Themes emerged and th i s material was grouped under the consolidated headings of r eg i s t r a t i on , education, terms and condit ions of employment and the organizational structure of the Assoc iat ion. These themes were considered to be the major themes of the Assoc iat ion. It was recognized that these themes sh i f ted between posit ions of primary and secondary importance as the interests of the Associat ion sh i f ted . The re lated themes of the subsidiary worker, health and safety of nurses, soc ia l secur i ty , terms and condit ions of employment of senior nursing s ta f f while important in themselves, are d i r e c t l y re lated but subsidiary to the major themes. In the narrat ive , these headings have been presented as dominant themes, that i s those themes of primary in teres t at any given time, or as secondary themes. Suggested re lat ionships amongst the themes and headings were noted in a th i rd column on the f i e l d notes, as well as on separate sheets headed with the relevant t i t l e . These re lat ionships were repeatedly re-examined as the comparison of groups began. Early in the research process the comparison of groups presented a problem. It was never the intent ion to compare nurses in B r i t i s h Columbia with another occupational group that has 113 s im i l a r i t i e s with nursing, i n , for example, the preponderance of women, and inc lus ion in the debate over professional status (E t z i on i , 1969). Anything other than a comparative study using a s im i la r data base would be theore t i ca l l y unsound and to repeat the research methodology undertaken for th i s study was beyond the scope of the researcher's resources. Thus the comparison of groups was l imi ted to groups within the data and the l i t e r a tu r e . The comparison of publ ic heal th, pr ivate duty and education nursing groups was considered because these are d i s t i n c t groups that emerged ear ly in the Assoc iat ion 's h i s tory . However, the data did not provide adequate information to form comparative groups. As the review of the minutes continued, i t became apparent that a comparison of groups could be done on two l eve l s . The f i r s t level of comparison i s a comparison of the Assoc iat ion 's response to the themes which emerged from the data. The second level i s a comparison of the o r ig ina l data co l lected in B r i t i s h Columbia compared with data in the l i t e r a t u r e . The f i r s t level of comparison represents the analys is of the data (Chapter Five) while the second level i s the l i t e ra tu re review (Chapter S i x ) . Comparison of the Assoc iat ion 's response to the themes which emerged from the data resulted in the emergence of the integrat ing concept of cont ro l . The f i r s t ind icat ion that control may be the underlying and unify ing concept arose from discussions in the minutes on the control of subsidiary workers (March 21, 22, 1969). 114 Using the concept of cont ro l , the categories that emerged are 1) the control of the work force, 2) the control of work prac t i ce , and 3) the control of the work environment. The headings of the themes, both major and secondary, represent more than data; they represent responses of the Associat ion which varied over time. Thus the headings or themes are the properties of the categories. Control of the work force represents the attempt of the Associat ion to control the numbers of nurses and the qua l i ty of the indiv idual entering the work force. The category of control of the work force has the properties of r eg i s t r a t i on , education, and pr ivate duty nurses, student nurses, and subsidiary workers. The category of work pract ice represents the attempts of the Associat ion to control the qua l i ty of the pract ice of nursing and is c lose ly associated with control of the work force. The category of control of work pract ice has the properties of education, r eg i s t r a t i on , student nurses, d i s c i p l i n e , safety to pract i ce , qua l i ty assurance, and the ro le and function of subsidiary workers. The category of control of the work environment represents the attempt of the Associat ion to control the terms and condit ions of employment. The category of control over the work environment represents the attempt of the Associat ion to control the terms and condit ions of employment. The category of control over the work environment has the properties of the terms and condit ions of employment, education, student nurses, the health and safety of nurses and soc ia l secur i ty . The major theme of the organizat ional structure of the Associat ion became a property of each of the TABLE 4.1 Categories and Properties Emerging from the Data Category Control over the work force Control over work practice Control over the work environment Property registration education private duty student nurses subsidiary workers organizational structure education registration student nurses disci piine safety to practice quality assurance role and function of subsidiary workers organizational structure terms and conditions of employment education student nurses health and safety of nurses social security organizational structure 116 three categories of control because changes in the organizat ional structure were a response to e f fo r ts to exert control over each of these areas. The v a l i d i t y of the integrat ive concept was confirmed by thinking through the themes and the i r re lat ionships to the suggested categories and propert ies. The concept of control and the Assoc iat ion 's attempt to control the work force, work pract i ce , and the work environment seemed the most complete explanation for what had occurred during the Assoc iat ion 's h i s tory . Conclusion. By way of conclusion, b r i e f consideration w i l l be given to the c r e d i b i l i t y of grounded theory. Glaser and Strauss point out that qua l i ta t i ve research i s often considered 'unsystematic' ' impress i on i s t i c ' , or 'exp loratory ' . The research i s concluded only when the researcher is. convinced that a 'reasonably accurate' statement of the subject matter can be made. Thus, what i s presented is that which the researcher knows "systemat ica l ly" . The researcher has combined the ef fect of becoming immersed in the data as well as reta in ing informed detachment. Glaser and Strauss argue that th i s represents the conversion of a "normal strategy of r e f l e c t i ve persons to a strategy of research" (1967, pp.227). Those, having gone through the experience of doing substantive f i e l d -wo r k , who do not bel ieve the theory that emerges; out of the i r research are considered to be "tempted toward compulsive scientism" (1967, pp.227). 117 Glaser and Strauss ident i fy two problems, associated with, conveying the c red lh i ! i t y of the grounded theory. These are 1) conveying the theoret ica l framework in an understandable fashion and 2] presenting the data in a su f f i c i en t l y v i v id manner as to convey r ea l i t y while s t i l l within the theoret ica l framework. The f i r s t problem is dealt with by presenting the theoret ica l framework and associated theoret ica l statements in terms of the emergent concepts of the fleldwork and in terms of the concepts and language of sociology. The second i s dealt with by presenting charac te r i s t i c i l l u s t r a t i on s (d i rect quotes, t e l l - t a l e phrases, dramatic segments e tc . ] and by the use of the constant comparative method. Readers: w i l l be convinced of the c r e d i b i l i t y of the researcher i f s u f f i c i en t l y caught up in the material as well as by analyzing the research mater ia l . Both the researcher and the reader have respons ib i l i t i e s in the assessment of mater ia l . The former for the content and presentat ion, the l a t t e r for c r i t i c a l assessment of the material presented. 118 CHAPTER 5  Analysis arid Discussion. Introduction An analysis and discussion of the narrat ive presented in Chapters Two and Three i s found in th i s Chapter. On the basis of theoret ica l sampling conducted according to the tenets of grounded theory and a comparison of groups within the data (Glaser and Strauss, 1967) categories and properties emerged from the data. The integrat ing concept of control emerged to form the categories of control of the work force, control of work pract i ce , and control of the work environment. From these categories of cont ro l , three pastures of control assumed by the Associat ion are i den t i f i ed . These are 1) compromised cont ro l , 2) co-ordinated cont ro l , and 3) bargained cont ro l . These postures of control were assumed in response to the need to achieve what was possible in negotiation with forces external to the Assoc iat ion. External forces include the p o l i t i c a l processes inherent in negotiation with the government, hospital administrat ions, the Hospita ls ' Assoc iat ion, the medical profession and consumers. According to the Assoc iat ion 's negotiat ing power, the strategy was one of lobbying, moral suasion, or bargaining. Negotiation also took place amongst groups within the Assoc iat ion. These groups include pr ivate duty, publ ic health, education and hospital nurses as well as the Associat ions ' elected 119 leaders, professional s ta f f and grassroots membership. There i s no c lear pattern of negotiation in th i s set t ing but the emergence of 'cosmopolitan' and ' l o c a l ' groups i s i den t i f i ed and recognized as inf luencing the pattern of negotiation with external forces. This chapter begins with a br ie f discussion of the concept of control as i t i s used in th i s study and i s followed by a discussion of negotiation within and external to the Assoc iat ion. Following t h i s , examples of compromised cont ro l , co-ordinated control and bargained control are discussed. The Concept of Control Control i s defined as "the power of d i rec t ing and rest ra in ing the course of act ion" (Pocket Oxford Dict ionary, 1959). The concept of control used in th i s study i s thus the power of d i rec t ing and rest ra in ing the course of action of the members ( ind iv idua ls) and the membership (the whole) in the pract ice of nursing. Thus, the categories of control which emerged are 1) control of the work force, 2) control of work pract i ce , and 3) control of the work environment. A comparison of the categories of control led to the i den t i f i c a t i on of three postures of control assumed by the Associat ion in i t s negotiation with external forces. These are compromised cont ro l , coordinated control and bargained cont ro l . Compromised control i s characterized by taking a "middle or mixed course" (Pocket Oxford Dict ionary, 1959), 120 These postures; of control existed both, sequent ia l ly and simultaneously. Thus compromised control predominanted (1912-43), coordinated cont ro l , 1944-57, and bargained control from 1957 to the present date. Elements of each type of control can be found in other time periods. For example, an episode of bargained control existed when the Associat ion directed i t s l eg i s l a t i v e sponsor to withdraw the ammended reg is t ra t ion B i l l of 1916. Compromised control has persisted on the issue of reg i s t ra t i on . The Associat ion has never been prepared to r e s t r i c t the care of the s ick to registered nurses. The Associat ion has responded to the need to care for the s ick by the expansion or contraction of the work force according to need large ly defined by external forces. Compromised control of education and working conditions of student nurses existed unt i l the education of student nurses was removed from the de l ivery set t ing hosp i ta ls . The most prevalent pattern has been compromised cont ro l . Table 5.1 Postures of Control Assumed by the RNABC: 1912-76 Postures 1912 1 928 1943 1959 1976 Compromised control Control of the work force Control of work pract ice Control of the work environment Coordinated control environment Control of work work pract ice Control of Bargained control Control of the work environment 121 Negotiation with Internal Forces: 'CosmOpoli.tails and Locals ' The nurses who init iated the struggle for registration in Brit ish Columbia may be seen as setting out to establish nursing as an organized professional group in an effort to supersede other types of nursing available. Out of the struggle for registration emerged a group of leaders who were to become the leaders of nursing in Br it ish Columbia, and indeed who were part of the cosmopolitan nursing guild of Canada and the International Congress of Nurses. Merton (1957, pp.392-402) uses the dist inction between "orientation toward local and larger social structures" in which the ' loca l ' is parochial in interest and the cosmopolitan is orientated to the world, or is ecumenical in interest" (pp.392-93). Helen Randal, Ethel Johns, Grace FairleyJ Alice Wright, Esther Paulson and others aptly qualify as cosmopolitans. By the nature of cosmopolitans and locals , and by the nature of the Association, the locals rarely appear in the minutes as individuals, but their concerns . especially between 1942-68 appear-V These concerns are expressed as issues in the terms and conditions of employment, and the struggle by private duty nurses to maintain a registry within the Association. Occasionally^ individuals appealed the refusal of registration, usually because of inadequate secondary school education. The separation of cosmopolitans and locals is most graphically i l lustrated by the events of the str ike, in 1939, by the Comox nurses, and the Association's response. 1 See Appendix B for biographical note 122 Several factors reinforced the formation of a cosmopolitan group. These are 1) the d i f f i c u l t y of par t i c ipa t ing in Associat ion a f f a i r s due to the long hours of work, 2) the development of a hierarchy amongst nurses, 3) the impact of short term career commit ment, 4) an organizat ional structure that did not f a c i l i t a t e communication within the Assoc iat ion, and 5) the absence of par t i c ipa t ion in Associat ion a f f a i r s by student nurses unt i l 1946. The long hours of work by nurses have been discussed at length in ea r l i e r chapters. Nonetheless a group of nurses part ic ipated ac t i ve ly in Associat ion a f f a i r s with considerable commitment, e f fo r t and with a major loss of the i r le i sure time. Executive Council and Council meetings were held af ter the normal working day, usual ly Friday evenings, and l a t e r , a l l day Saturday. Attendance at p rov inc i a l , national or internat ional meetings was often done on holiday time (Paulson, 1981). The minutes of the Associat ion record repeated requests to the BCHA and hospital boards to allow nurses time to par t i c ipate in Associat ion a f f a i r s . There was nonetheless the fee l ing amongst cosmopolitans that more nurses could have part ic ipated i f they had wished (Paulson, 1981). The development of a hierarchy amongst nurses, was the resu l t of a sh i f t in employment pattern from the independent pract ice of pr ivate duty nurses to i n s t i t u t i ona l employment. This was reinforced by the shortage of nurses during World War II in which pract ica l nurses became a substantial part of the work force and a 123 heirachy of supervision developed. Eaton has made c lear that d i rectors of nursing were in a pos i t ion of con f l i c t between gett ing the job of caring for the s ick done and improving working condit ions. This c on f l i c t separated nurses. The leaders by employment were also the leaders of the Associat ion (Eaton, 1938, pp.61). This means that unt i l a h ierarch ica l structure of i n s t i t u t i ona l nursing had developed by the mid 1940's, most nurses were peers of one another and as such there was less con f l i c t of in terest amongst nurses in the 1920's and 1930's than developed l a te r . The a t t r i t i o n of nurses to marriage compounded the problems of the d i f f i c u l t y of pa r t i c i pa t i on , although there were mechanisms within the Associat ion to al low non-active nurses to par t i c ipate in Associat ion a f f a i r s . The outcome of l imi ted par t i c ipa t ion by the general membership contributes to a general unawareness of Associat ion a f f a i r s amongst the membership. Recognition of th is led to the formation of Chapters and D i s t r i c t s with in the Associat ion on the basis of the proposals of 1938. Student nurses who formed 50% of the registered nursing work force unt i l the ear ly 1940's were excluded from par t i c ipa t ing in Associat ion a c t i v i t i e s un t i l 1946 when a Student Nurses' Associat ion within the RNABC was formed. This background provides an explanation for the ascendancy of a cosmopolitan group within the Associat ion and some explanation of the 'need to educate' nurses on what the Associat ion could o f fer when control of the work environment become a dominant theme of the 124 Assoc iat ion 's a c t i v i t i e s . Also explained i s the potent ia l for con-f l i c t of in terest over the means of gett ing the job of caring for the s ick done, and the potent ia l a b i l i t y of the leaders of the Associat ion to control the extent of soc ia l and economic demands of the loca ls once co l l e c t i ve bargaining had been leg i t im ized . The minutes of the Associat ion provide l i t t l e data on negotiat ion amongst occupational in terest groups within the Assoc iat ion. Pr ivate duty, publ ic health and education interest groups were the f i r s t groups formed with in the Assoc iat ion. The pr ivate duty reg is t ry as a separate ent i ty within the Associat ion ceased to ex i s t in the late 1960's af ter protracted negotiation within the Assoc iat ion. The end of Associat ion support for th i s group represents the ascendancy of the i n s t i t u t i o na l l y employed nurse, and i s part of the Assoc iat ion 's attempt to control the work force. With the exception of the e l iminat ion of support for the pr ivate duty reg i s t r y , changes in the structure of the Associat ion af fect ing occupational groups were usual ly in response to changes in structure of the CNA, and consequently do not seem to have been negotiated with in the Assoc iat ion. On the basis of th i s discussion i t would appear that the Assoc iat ion 's leaders were in a pos i t ion to represent nursing's best interests as defined by the cosmopolitans unt i l 1957. The strongest evidence supporting th is view i s the lengthy discussion at the executive council level on reg i s t r a t i on , the formulation of a po l i cy on the Assoc iat ion 's ro le in co l l e c t i ve bargaining, and the 125 Assoc iat ion 's response to the s t r i ke vote of 1957. (Ross.Iter, 1957, pp.799) This i s not to s ay that the membership was without strength. The membership e f fec t i ve l y forced the Associat ion executive to take a strong stand with the government in the negotiations of 1959. It would also appear that the r e l a t i v e l y low v i s i b i l i t y of the process of negotiat ion of the terms and condit ions of employment when the postures of compromised control and coordinated control dominated, reinforced the separation between the cosmopolitans and the loca ls and decreased the power base of the Associat ion in external re la t ionsh ips . The v i s i b l e struggle to improve working conditions pr io r to 1946 was l e f t to the CCF, the nurses themselves (the Comox s t r i ke) and a p o l i t i c a l mediator, Mrs. Eaton. When v i s i b i l i t y increased (s t r i ke votes of 1957, 1959) the resu l ts improved. In the period of coordinated control (1943-1957) the balance of power was not necessar i ly favourable to the leadership who took on negotiat ion with employers on behalf of the nurses. Esther Paulson, as a member of the executive of the RNABC, while employed by the Provinc ia l Government presented the economic concerns of nurses employed in Provinc ia l Government hosp i ta ls . She described negative repercussions in her own work and economic secur i ty (Paulson, 1981). The re l iance on moral suasion and the t rust in paternalism evident in th i s period provides an explanation for f a l l i n g to predict th is outcome. 126 After 1959, there i s i n su f f i c i en t data to assess the balance of power between the cosmopolitans and l o ca l s . The lack of data dealing with labour re lat ions a c t i v i t i e s in the Associat ion minutes af ter 1959 i s a re f l ec t i on of the growth of th i s a c t i v i t y as a separate function of the Assoc iat ion. The formation of a Nursing Administrators ' Associat ion in the late 1960's suggests a loss of power by the cosmopolitans in the i r capacity to respond to the pressures exerted by the loca ls with in the Associat ion and in the work set t ing and i s a statement of appreciation of the i r increased vu lne rab i l i t y . Negotiation with External Forces Hospitals in B r i t i s h Columbia were establ ished by re l ig ious orders, char i table groups, enterpr ises, whether medical, nursing or pr ivate interests and in the case of mental disease and tubercu los is , the provinc ia l government. Administrators of these hospita ls organized themselves to form the B r i t i s h Columbia Hospital Associat ion tn 1918. Nursing administrators part ic ipated through the nursing section or as inv i ted guests. I t i s apparent from the minutes of the BCHA annual meetings that inadequate funding of hospita ls was i den t i f i ed as an issue of major concern as ear ly as 1919. Revenue for hospita ls was generated from pat ients ' fees, char i table sources and municipal and prov inc ia l revenue tn proportions of approximatley 1/3 unt i l 1949 when the prov inc ia l government took over the funding of hosp i ta ls . This event 127 had the ef fect of transforming an amorphous body responsible for hospital funding into a concrete en t i t y . However, co l l e c t i ve bargaining by nurses remained at the local hospital level un t i l the mid 1950's. Since then, the BCHA and la te r the HLRA has buffered the government from d i rect negotiations with nurses on the issue of the terms and conditions of employment. Nonetheless,the creation of a s ingle funding source has created a s ingle body u l t imate ly responsible for the funding of hosp i ta ls . However, the funding of hospita ls and the terms and condit ions of employment of nurses are not the f i r s t or the only Issues about which the Associat ion has negotiated. The issues involved in control of the work force, work pract ice and work environment are interwined such that one negotiat ion affected another over the course of the Assoc iat ion 's h is tory . The rea l i za t i on of these in ter re la t ionsh ip has influenced the strategies the Associat ion has chosen. The strategies chosen were lobbying, moral suasion and bargaining. These re f l e c t the balance of power and the nature of the re la t i ve stakes involved. Lobbying i s defined as "the frequenting of parliament . . . to s o l i c i t votes" (Pocket Oxford Dict ionary, 1959), moral suasion as "reasoning or advice as incentive"(Pocket Oxford Dict ionary, 1959), and bargaining as "haggl(ing) or dispute"(Pocket Oxford Dict ionary, 1959). Overt lobbying occurred only during the struggle for reg i s t ra t ion - there was nothing to lose, the Associat ion had no power to inf luence the course of nursing pract ice without reg i s t ra t i on . 128 Moral suasion was used between 1919 and 1957, In the face of an abundance of nurses. (19.19 - 39) the poor f inanc ia l pos i t ion of hospitals and a decl ine in number of pr ivate patients during the depression, the Associat ion had no ef fec t ive power to negotiate the terms and condit ions of employment, but was able to promote the c los ing of substandard schools and i nd i r ec t l y promote the employment, i f not improve the terms and condit ions, of nurses. The curriculum of students was the d i rec t respons ib i l i t y of the Associat ion under the Registered Nurses Act, but working, classroom, and l i v i n g conditions were not. Thus the strategy of moral suasion in an attempt to improve the l o t of students. The shortage of nurses during and af ter World War II changed the dynamics of the balance of power, and thus the strategies in the negotiat ion process. Bargaining as a strategy began only when the balance of power was favourable to the membership at large. The membership had to be prepared to play for high stakes (s t r i ke) before the f u l l exercise of the Assoc iat ion 's power could be tested. Because of the vu lne rab i l i t y of the Assoc iat ion 's leadership in the i r own employment, the leadership had a stake in containing the memberships' demands to what was thought to be acceptable to the BCHA and the government. 129 Table 5.2 Strategies for External Negotiation of Spec i f i c Issues Used by the RNABC : 1912-76 Strategy 1'912 1928 1943 1959 1976 Lobbying reg i s t ra t ion Moral Suasion education terms and condit ions of employment Bargaining terms and conditions of employment. In every instance of negotiat ion the options were l im i ted because of the underlying commitment' to providing care for the s ick and because of the interrelatedness of the issues. Negotiations on one issue had the potent ia l of af fect ing negotiations on other issues. Mandatory reg i s t ra t ion was not sought because, while there was a desire to protect the publ ic , there was no desire to prevent anyone from nursing, but only from "claiming to be a registered nurse" (October, 11, 1913). It has.been made c lear that a l l . the. issues surrounding the education of student nurses were compromised by the need to provide service to patients in hosp i ta l , and that th is compromise ended only af ter the education of nurses was establ ished outside of hosp i ta ls . Bargaining over the terms and condit ions of employment occurred only af ter the membership was prepared to s t r i k e . The strategies of negotiat ion were chosen to achieve what was 130 thought to be poss ib le. Postures of Contro l . Compromised Control. Compromised control i s defined as a "middle or mixed course" (Pocket Oxford Dict ionary, 1959). The Assoc iat ion 's attempt to control the work force and work pract ice has been dominated by the issues of reg i s t ra t ion and education. In the struggle for r eg i s t r a t i on , the f ledg l ing Associat ion acted in apparent unity to estab l i sh a new order of nursing. But reg i s t ra t ion was not achieved without compromise with the external arena. The Associat ion recognized the Provinc ia l Leg is la ture 's resistance to mandatory reg i s t r a t i on , and the need of the publ ic for various leve ls of nursing care. I t would appear that in exchange for voluntary reg i s t r a t i on , midwifery was not recognized. This had the support of the medical profession who could now count on a more re l i ab l e workforce and control over maternal care. The major outcome of th is compromise was that the tota l nursing work force has never been under the control of the Assoc iat ion. Consequently, over the years, the forces of supply and demand have forced the Associat ion to modify i t s pos i t ion on ro le and function of student nurses, pr ivate duty married nurses, and subsidiary workers. The Associat ion has never been able to control the volume of the work force or to inf luence the 131 patterns of demand for nursing care, as for example has the medical profession (Cooper,' 1973, pp.93; Evans,1973,pp, 162). Thus a posture of compromise has dominated the Assoc iat ion 's attempt to control the work force and consequently work pract ice. Discussions of mandatory reg i s t ra t ion have occurred throughout the h is tory of the Assoc iat ion, but have remained internal to the Assoc iat ion. Another example of compromised control was the pos i t ion of the Associat ion v is a v i s educational standards and the l i v i n g , studying and working condit ions of student nurses. Educational standards were improved i nd i r e c t l y by increasing the educational entrance requirements in the 1930's. Helen Randal, representing the Assoc iat ion, used moral suasion as a strategy to close substandard schools of nursing and in an attempt to improve conditions for student nurses in. the 1920s and 1930s. Substandard schools of nursing were closed due to the e f for ts of Helen Randal and due to the adoption of the be l i e f by the Hospital Associat ion and hospital boards, that graduate nurses could be hired more cheaply than students could be t ra ined. This was espec ia l ly true during the Depression when unemployment amongst nurses was very high, and nurses, espec ia l ly those from the p r a i r i e s , could be hired very cheaply (Randal, 1938; Eaton, 1938, pp.11). The Associat ion had the power (by statute) to approve schools of nursing but could not actua l ly force the closure of schools. The graduates of non-approved schools were denied reg i s t ra t ion as a 132 means of exert ing pressure upon non-approved schools of nursing. Conditions improved for students because of the Assoc iat ion 's e f fo r t s and poss ib ly , also because of the impact of the Hospital Construction Act of 1949 providing f inancing for hospital construction which included nurses' residences and classrooms. This i s not certa in because Esther Paulson reca l l s that one school received a new residence and classroomsj in the ear ly 19501s only because of the pr ivate donation of funds (Paulson, 1981). Although the government had the regulatory power to control the working condit ions of student nurses from the ear ly 1940's no action was taken, and the Associat ion had no power to force act ion. The improvement of working condit ions of students and graduate nurses was compromised by the pos i t ion of the leaders of the Assoc iat ion, who were also the d i rectors of nursing of the hospita ls and schools, which were the subject of concern, and by the desire of the Associat ion to improve the education of nurses before the issue of the working conditions was addressed (Eaton, 1938, pp.60-62). The fact that the Assoc iat ion 's leaders were themselves compromised well before co l l e c t i ve bargaining began, lends credence to the viewing of d i rectors of nursing as vulnerable. This vu lne rab i l i t y u l t imately led to the formation of a nursing administrators ' group which separated from the Associat ion in the mid 1970s. This also i l l u s t r a t e s the importance of the roles played by Helen Randal, as Registrar (1918-1941) and A l i ce Wright as Registrar, and l a te r as 133 Executive Secretary (1943-60). as. employees of the Assoc iat ion, as well as explaining the use of the strategy of moral suasion. Coordinated Control• Coordinated control represents a state in which the part ies are "equal in status" (Pocket Oxford Dict ionary, 1959). With the Second World War came a shortage of nurses, a h ierarch ica l structure of the nursing work force, improved sa lar ies and working conditions for the general population, the growth of unionizat ion and, postwar, rapid i n f l a t i o n . Nurses were characterized as " res t l ess " . I t i s d i f f i c u l t to assess the extent of the rest lessness of nurses. B r i t i s h Columbia was a province whose work force was ac t i ve ly engaged in unionizat ion (Jamieson, 1968). Nurses must have been aware of the economic gains achieved by unionized workers. Since reg i s t ra t ion was not mandatory for pract i ce , the Associat ion could have l os t a portion of i t s membership i f act ion were not taken. This was recognized when the Associat ion discussed the potent ia l re la t ionsh ip between the Associat ion and trades unions (January 5, 1944; March 1, 1944). This i s an example of compromised control of forces with in the Associat ion and serves to explain the e f fo r t to educate nurses about the gains the Associat ion had made in improving the terms and condit ions of employment. However, there was s t i l l the problem of the ' l o c a l s ' who did not par t i c ipate in Associat ion a c t i v i t i e s and thus would not hear the message, and the fact that those 134 who were informed may not have seen the e f for ts of the Associat ion as su f f i c i en t . The option of jo in ing a union was thus appealing. However, the fact that i t took two votes, 1944 and 1946, to endorse the ro le of the Associat ion in co l l e c t i ve bargaining speaks to the general confusion of the membership. The formation of chapters and d i s t r i c t s of the Associat ion in the ear ly 1940's may have contributed to increased communication between the cosmopolitans and l oca l s . In 1942 a committee under the Placement Service had begun a survey of working condit ions and sa la r i e s . A l i ce Wright, a r r i v ing as new Registrar of the Assoc iat ion, recognized the seriousness of the rest lessness of nurses, and under her leadership, began a fresh attempt to exercise some control on the work environment. Out of the work of th i s committee a base-l ine of Recommended Personnel Pract ices was developed by A l i ce Wright and El izabeth Braund, and was rev ised, usual ly annually. Negotiation with BCHA took place; both part ies were in e f fect s e l l i ng the i r agreement to the Recommended Personnel Pract ices to the i r respective const i tuencies. This occurred before co l l e c t i ve bargaining was approved nat iona l ly or p rov inc i a l l y . To the extent that both part ies met vo lunta r i l y and contracted to ' s e l l an agreement to the i r const i tuencies ' a state of co-ordinated control ex is ted. Undoubtedly the BCHA had a vested interest in a quiet labour scene, espec ia l ly during the period of the war years when pressure on hospita ls was very great. The shortage of nurses, which pers isted unt i l the mid-late 1950's 135 strengthened the posi t ion of the Associat ion. Once the 'glamour of the war' had worn o f f , both part ies could afford more la t i tude in the i r t a c t i c s . By 1950, Harvey Agnew of the Canadian Hospitals Associat ion was wr i t ing in support of better sa lar ies and working condit ions for nurses even i f i t meant a higher b i l l for pat ients (Agnew, 1950, pp.27-28). The pract ice of co-ordinated control exercised by the RNABC and BCHA continued af ter nurses became c e r t i f i e d and engaged in co l l e c t i ve bargaining for the benef it of non-unionized nurses. The Associat ion continues to th i s day to represent the interests of non-unionized nurses to employers, on the nurses' request. An element of co-ordinated control i s present in the current system of education of student nurses. While the pattern of approval of schools based on the curriculum continues as an internal mechanism, the existance,funding and operation of schools i s now a matter.for un i ve r s i t i e s , community col leges and the Ministry, of Education. The use of hospita ls and publ ic health d i s t r i c t s for prac t i ca l experience i s negotiated by nurse educators with the Associat ion playing a f a c i l i t a t i n g role but not actua l ly inf luencing the construct ion or use of c l i n i c a l un i ts . This pattern developed in the mid 19601s with the beginning of the closure of hospital schools of nursing .. 136 Bargained Control . The period of bargained cont ro l , characterized by 'haggl ing' and 'd ispute ' (Pocket Oxford Dict ionary, 1959) was i n i t i a t ed by the Assoc iat ion 's support of s t r i ke action in 1957. To the extent that Recommended Personnel Pract ices were prepared by the o f f i ce r s of the Assoc iat ion, with input from s ta f f representatives of employee groups, and approved by the Executive Council before being presented to the general membership for debate at the annual meetings unt i l 1968, the Associat ion was able to inf luence the demands of the membership and the power of bargained control was mit igated. As the labour re lat ions function of the Associat ion grew to dominate the Assoc iat ion 's a c t i v i t i e s , the power of those associated with th i s aspect of the Assoc iat ion 's a c t i v i t i e s grew. Coincident with t h i s , the process of bargaining became rat iona l i zed and the government, who had become the sole funder of hosp i ta l s , was forced to become more responsive to the demands of nurses because s t r i ke votes were exercised as leverage. As sa lar ies and soc ia l secur i ty measures for nurses improved,the Associat ion turned inwardly to re-examine i t s ro le and funct ion. The discussion papers Baumgart (1973) and Bachard (1973) can be seen as attempts to evaluate and re-estab l i sh the alignment of the nursing assoc iat ions ' ro les . The separation of labour re la t ions functions from the Assoc iat ion, although prec ip i tated by an external force (the ru l ing by the Supreme Court of Canada, 1973, in 137 which the Saskatchewan Registered Nurses Associat ion los t i t s r ight to engage in co l l e c t i ve bargaining for nurses because of the ro le of management nurses in the Associat ion) forced th i s realignment. Bargained control of the work environment w i l l no longer be mit igated by the internal resolut ion of professional and labour in te res ts . Conclusion This chapter has presented an analys is of the data based on the Assoc iat ion 's attempt to control the work force, work pract ice and work environment. Comparison of these categories led to the i den t i f i c a t i on of three postures of control assumed by the Assoc iat ion: Compromised cont ro l , co-ordinated control and bargained cont ro l . A consideration of negotiat ion within the Associat ion led to the i den t i f i c a t i on of 'cosmopolitan' and ' l o c a l ' const i tuencies. Negotiation with external forces was considered. The strategies used were i den t i f i ed as lobbying, moral suasion and bargaining. The changing postures of control were i den t i f i ed as a response to internal and external forces and the need to achieve what was poss ib le. For terms and condit ions of employment the 'poss ib le ' was defined by the cosmopolitans un t i l 1959, and thereafter by the l o ca l s . The sh i f t from compromised control to coordinated control of the work force was re f lec ted by the introduct ion of the negotiat ion of Recommended Personnel Pract ices with the BCHA, and by the introduct ion of co l l e c t i ve bargaining in ind iv idual hospital s as the loca ls 138 demanded. The push to coordinated control was the resu l t of the recognit ion of the increased economic and soc ia l d i spar i ty of nurses, and the fear of a loss of membership to unions organizing hospital workers reinforced by a profound shortage of nurses. The bargained control of the work environment began in 1959 with the Assoc iat ion 's support of the nurses s t r i ke votes for economic gain. The Assoc iat ion 's sh i f t to accept the postures of bargained control of the work environment i s a re f l ec t i on of the Assoc iat ion 's attempt to reta in control of the work force. While i t has not been the intent ion to examine the re la t i ve economic gains made during the evolution of the Assoc iat ion 's a c t i v i t i e s , i t i s nonetheless argued that only af ter nurses were prepared to s t r i ke could compromised and coordinated control be exchanged for bargained control on the issue of the terms and condit ions of employment. 139 CHAPTER 6 L i terature Review Introduction Glaser and Strauss (1967, pp.37) suggest that the purpose of the l i t e r a tu re review in grounded theory i s to compare the analyt ic core of the categories which emerged from the data with the s imi -l a r i t i e s and convergences with the l i t e r a t u r e . In th is study, the l i t e r a tu re review has the addit ional funct ion of providing compara-t i ve groups for the groups which emerged from the data. Glaser and Strauss (1967, pp.37) suggest that the l i t e r a tu re review be done af ter the emergence of these categories in order to avoid contaminating the development of the ana ly t i c core. Thus the l i t e r a tu re review fol lows the presentation of the narrat ive, a discussion of the methodology, and the presentation and d i s -cussion of the ana ly t i c core. The comparison groups which emerged from the data were 1) 'cosmopolitans and l o ca l s ' who were functioning within the RNABC, and 2) the Assoc iat ion 's responses to the themes found in the data. The major themes which emerged from the data were r eg i s t r a t i on , education and the terms and condit ions of employment. Secondary themes included student nurses, pr ivate duty nurses, 140 health and safety of nurses, subsidiary workers and soc ia l secur i ty . Repeated review of these themes resulted in the emergence of the integrat ing concept of cont ro l . Using the concept of cont ro l , the categories that emerged are 1) control of the work force, 2) control of work pract ice and 3) control of the work environment. The l i t e r a tu re w i l l be reviewed under these headings, using the properties of the categories, or what were the major and secondary themes of the narrat ive as i s appropriate. A discussion of the groups comparable "to cosmopolitans and loca ls i s integrated under these headings. The l i t e ra tu re review i s l im i ted to l i t e r a tu re analyzing the h istory and a c t i v i t i e s of nurses and nursing associat ion s; in Canada, England and United States. L i t t l e of the l i t e r a tu re reviewed had the focus of th i s study, and thus i t was necessary to review selected portions of ind iv idual pieces of l i t e r a t u r e . Control of the Work Force  Regis t rat ion. The control of the work force has been defined in th is study as the attempt of the nursing associat ion to control the numbers of nurses and the qua l i ty of the individuals entering the nursing work force. Registrat ion has become the common standard by which to d is t ingu ish leve ls of nurses(trained and untrained). Registrat ion as a goal of nursing associat ions or ig inated in 141 England before the turn of the century (Abel-Smith, 1960). In England, the batt le for the reg i s t ra t ion of nurses was b i t t e r , s p l i t the ranks of nurses and generated controversy in the Houses of Parliament, but was ul t imately passed by a M in i s te r ' s b i l l , in December, 1919 (Abel-Smith, 1966, pp.61-98). Midwives had achieved reg is t ra t ion in 1902 (Abel-Smith, 1960, pp.77). Abel-Smith (1960) and Bellaby and Oribar (1980) consider the movement for the reg i s t ra t ion of trained nurses as the outcome of the reformist zeal of the second generation of Night ingale 's nurses. Bellaby and Oribar see these nurses as part of a soc ia l and technical e l i t e who were responding to the threat" that untrained and voluntary labor posed to i t s hegemony over nursing" (pp.298). As we l l , Bellaby and Oribar see reg i s t ra t ion as an attempt to wrest from hospital and state author i t ies the recognit ion of the "d i s t i n c t " and "unsubstituable s k i l l s of untrained hospital nurses" (pp.298). Bellaby and Oribar (1980, pp.298) argue that although reg i s t ra t ion was a pr ize the reformers won, i t was a compromise because i t granted the new General Nursing Council j u r i s d i c t i on over the standards of nurse t ra in ing (and i nd i rec t l y over pract ice) but did not grant nurses legal control over entry to the profession. The 'dominance of medicine1' was not challenged, and the recruitment of labour for hospital work could continue without reference to the GNC (pp.298). 142 White (1976, pp.209-217) suggests that reg i s t ra t ion in Great B r i t a i n was delayed unt i l 1919 not only because there was 1) lack of agreement in the profession over the deta i l s of r eg i s t r a t i on , 2) disagreement over the pr inc ip le of reg i s t ra t ion and 3) the pract i ca l problems of def ining a nurse, but 4) because the Government feared the system of educating nurses which provided "the least expensive means of obtaining and employing nurses" (pp.216) would break down. In the United. States the struggle for reg i s t ra t ion was conducted on a state by state bas is . The ea r l i e s t b i l l for reg i s t ra t ion was passed in North Carol ina in January, 1903 (Kal isch and Ka l i sch , 1977, pp.259). Krause (1977, pp.46) points out that in the United States, nurses are the only subsidary work force in health care that has achieved reg i s t ra t ion without dominance and control by physic ians. In Canada, the struggle for reg i s t ra t ion i s described by Gibbon and Mathewson (1947, pp.352-358). There were three unsuccessful attempts to secure Dominion reg i s t ra t ion for nurses pr io r to 1909. A l l the provinces within Confederation had achieved voluntary or mandatory reg i s t ra t ion by 1922. Coburn (1974, pp.152) points out that in the struggle for reg i s t ra t ion in Canada, "nurses were arguing from a powerless posi t ion for protect ion against "p rac t i ca l " nurses who were forced to accept even lower pay and the broadest range of domestic duties in order to surv ive. Unfortunately, 143 as was the case with many unions, nurses did not combat the problem by including these unorganized women within a reg i s t ra t ion scheme which could have recognized d i f fe rent leve ls of nursing. As i t was, the exp lo i ta t ion of th i s cheap source of labour continued to plague the nursing associations into the 1940's and even la te r " (pp.152). Summary. The goal of r eg i s t r a t i on , and the ro le of a nursing e l i t e , as well as the outcomes described by Bellaby and Oribar are consistent with events in B r i t i s h Columbia and the analysis in the preceeding chapter. While the e l i t e were s p l i t in England over the issue of r eg i s t ra t i on . (Abel-Smith, 1960, pp.65-80) there i s no discussion of th i s occurring in Canada or the United States. There i s no discussion of the response to reg i s t ra t ion by grass-roots or ' l esser trained nurses ' . In the l i t e r a tu re on American nursing, an e l i t e and pro le te r i a t have been iden t i f i ed as ar i s ing from the t rans i t i on of pr ivate duty nursing to i n s t i t u t i o na l l y employed nursing (Wagner, 1980, pp.271-290). Ashby (1976) describes a s p l i t in American nursing leaders over eight hour laws, and the ro le of education and service of students. It i s evident that , as Coburn (1974) suggests, the f a i l u r e to include the ranks of lesser trained nurses, or to close the ranks of nursing by mandatory reg i s t ra t ion or, as Bellaby and Oribar (1980) suggest, the f a i l u re to grant nursing associat ions the legal 144 control over the entry to nursing has resulted in an i n a b i l i t y of nursing associat ions to control the work force. This led to the continued exp lo i ta t ion of student and graduate nurses as was described in the narrat ive. Thus, the presence of the category of control of the work force with the property of reg i s t ra t ion i s confirmed in the l i t e ra tu re as i s a s p l i t in the ranks between the leaders of the nursing assoc i -ations and the grassroots. The recognit ion and reg is t ra t ion of midwives and the i r subsequent ro le in the del ivery of health care in England i s at odds with events in Canada and the United States. This would make an interest ing comparative study, since there was support for the pract ice of midwifery by Local Councils of Women in B r i t i s h Columbia, but none in the ranks of nurses and doctors. Control of Work Pract ice In th is study, control of work pract ice represents the attempt of the provinc ia l nursing associat ion to control the qua l i ty of the pract ice of nursing by means of cont ro l l i ng the education of student nurses. In the context of the narrat ive of th i s study, control of the pract ice of nursing has been considered as nursing was known and pract iced during the 20th century. The context of th i s i s l os t without reca l l i ng that women were once considered the healers of western soc iety. Ehreneich and English describe the persecution 145 of wise women as witches, supression of the knowledge of heal ing, the banning of midwifery and the subsequent dominance of the medical profession and the subservience of women in health care. The appearance of Night ingale 's v i s ion of nursing in the 19th century can be seen as an attempt to re-estab l i sh control over the care of the s ick in the context of V ic tor ian times. In the 20th century reg i s t ra t ion and education as a means to profess ional ize have been the main strategies to gain control over the pract ice of nursing. In Canada, Coburn (1974) and in the United States Ashley(19.76), Strauss(1966), and Wagner(1980) describe the rapid p ro l i f e ra t i on of nursing schools designed large ly to provide cheap labour. As late as 1958 Saskatchewan hospitals with teaching programs reported a d i rec t p ro f i t to the hospital as a consequence of the value of the labour of the students (Royal Commission on Health Services, 1, 1964 pp.274 c i t ed , by Al lentuck, 1978, pp.45). In England, White (1977) describes the c r i t i c a l ro le which poor.law nurses, who were well establ ished before the advent of Night ingale, played in forming "an a l ternat ive group of nurses who cared for the poor, the long-term sick and the aged-infirm" (pp.23), these patients represented 75% of the hospi ta l i zed s ick of the country, consequently nurses trained in the t rad i t i on of Nightingale in the voluntary hospitals cared only for a small portion of i n s t i t u t i ona l i z ed pat ients. 146 In the United States the response to the d i l u t i on of the pract ice of nursing, as defined by the leaders of the nursing profession, was the development of an ideology of reform by spec ia l l y trained nursing educators (Strauss, 1966, pp.72-81). Because of the close a l l i ance of American and Canadian nursing leaders o r i g i na l l y establ ished through the Nurses' Associated Alumnae Associat ions of the United States and Canada (1896-1907) (Gibbon and Mathewson, 1947, pp.356) th i s ideology i s evident in Canada. Thus, the importance of the Goldmark report of 1923 studying nursing education in the United States, and the Weir Report of 1932 in Canada i s explained. Also explained i s the importance of the t rad i t i on of Columbia Teachers College in nursing education (Strauss, 1966, pp.72-81), as i s the importance of the establishment of the f i r s t un ivers i ty school of nursing in Canada at the Univers i ty of B r i t i s h Columbia. In England Nightingal ism, a t r ad i t i on of reform with an ideology of vocational ism, a commitment to sac r i f i c e and subservience to male doctors in the care of the s ick (Wil l iams, 1974), and ah ideology of sani tat ion (Davies c i ted by Carpenter, 1977, pp.166), had been adopted as a response to poor law nursing and was part of the f i r s t wave of reform which led to the formation of nursing associat ions and the struggle for reg i s t ra t i on . This ideology seems to have pers isted un t i l the P ia t t report (1964) because the education 147 of nurses in Great B r i t a i n was considered by the Royal College of Nurses in 1943 "as to (be to) a certa in extent an apprenticeship" and l a t e r , . i n 1964, (the P ia t t Report) as "an education rather than an apprenticeship" (Davies, 1978). Thus the ideologies of reform in North America and Great B r i t a in d i f f e red . This was due in part to the role of education in North American society where education i s seen as a means of achieving class mobi l i ty . . The Push to Professionalize.,. The importance of the educational ideology in North America i s that i t i s part of the struggle to control work pract ice by profess iona l i z ing nursing. Nurses' struggle to be acknowledged as a professional occupational group represents the struggle to achieve status and recognit ion in the context of soc iety, and thus the control of work pract ice . The l i t e ra tu re on occupations has devoted much energy to the study of those occupations referred to as 'p ro fess ions ' . Volltner and M i l l s (1966) dist inguished between the concepts of profession and profess iona l i za t ion . The term profession has been used to describe abstract models of occupational charac ter i s t i cs while the concept of profess iona l i zat ion refers to "a dynamic process whereby many occupations can be observed to change cruc ia l charac ter i s t i cs in the d i rec t ion of 'p ro fess ion ' " ( pp . v i i , v i i i ) . 148 The question of whether or not nursing i s a profession has been debated at length. The establishment of a professional organizat ion, r eg i s t r a t i on , a code of e th i cs , the s h i f t to un ivers i ty education and the attempt to control work pract ice a l l represent the attempt by nurses to achieve the c r i t e r i a of professional status (Wilensky, 1964). Katz (1969)views nurses as a semi-profession because nurses are predominantly women, employed by organizations in which close supervision i s an inherent - feature, and because the i r careers are interspersed with other commitments. He rejects the idea that nurses have a d iscreet knowledge base. The lack of d i f f e ren t i a t i on in the ranges of tasks and respons ib i l i t i e s amongst grades of nurses clouds the degree to which nursing i s a f u l l , time spec ia l i zed task. Krause (1977) and Wilensky (1964) see the sh i f t of nursing education to a un ivers i ty set t ing as one of the key strategies in the process of p ro fess iona l i za t ion . While a univers i ty education provides status, Krause considers the move to un ivers i t i es a f a i l u r e , because nursing does not control the means of nursing work. Nonetheless Wilensky's (1964) sequence of profess iona l i zat ion def ining work as a f u l l time spec ia l i zed task, estab l ish ing a t ra in ing school preferably at a un ivers i t y , the establishment of a l i cens ing mechanism, and creat ing a code of ethics based on pur i ty and service has been achieved with varying degrees of success. 149 Krause (1977, pp. 52-55) takes the analysis of the attempt to profess ional ize a step further by arguing that th i s has been one of a ser ies of strategies in an attempt to gain autonomy in the work place. He describes the sequence as the "shift to un ivers i ty t r a i n i ng " and 'take-over of physicians' d i r t y work," the "adoption of a managerial ideology,"the'buts ide mover approach," the'"s*ize the technology s t rategy" and'l inionization"fo.r greater control over work as well as for higher wage l eve l s . Basing nursing education in a univers i ty set t ing i s seen as an attempt to gain upward occupational mobi l i ty . This has f a i l ed because nursing does not control the sett ing of health care de l ivery . The takeover of physic ians' d i r t y work i s seen as an attempt to gain author i ty in the work set t ing but i s d i lu ted by the phys ic ians 'c la im of legal respons ib i l i t y and ult imate respons ib i l i t y . Publ ic health was seen in the 1900's as an avenue for greater occupational autonomy. This f a i l ed due to the legal subservience of nurses to physic ians. The seize the technology strategy has f a i l ed because other occupational groups have moved in more quick ly than nurses, and because u l t imate ly the technology i s contro l led by physic ians. The use of co l l e c t i ve bargaining has f a i l e d , in Krause's view, because increased wages have been used as a bribe by employers to d iver t attent ion from the demands of nurses to control the i r work. Nurses and nursing assoc iat ions, by emphasizing reg i s t ra t ion and improved standards of education, have vested importance in 150 profess iona l i z ing by the achieving of the at t r ibutes of professiona-l i sm. As Strauss (1966) points out, nurses have succeeded in convincing the publ ic of the i r professional status. This has created a dilemma, since e f fo r ts to improve the terms and condit ions of employment by professional means f a i l e d , the a l ternat ive was co l l e c t i ve bargaining, considered unt i l recently a non-professional strategy. Changes in the organization of nursing work and the entry of government into health care changed these dynamics. Summary . The l i t e r a tu re recognizes that nurses used a var iety of strategies in an attempt to control work pract ice. The primary e f for ts were directed to the establishment of reg i s t ra t ion and the control of the education of students. The role of students as cheap labour impeded educational reform in Canada, the United States and England. In the l i t e r a tu re these e f for ts to bring about reform have been characterized as profess iona l i z ing s t ra teg ies , and are viewed as a f a i l u r e in the attempt to gain professional status and as a consequence, to control work pract ice. The l i t e ra tu re does not ass i s t in supporting or ; re ject ing the postures, or the strategies of control suggested in. the analysis of th i s study. Although the approach and the de f in i t i ons vary, the l i t e r a tu re supports the category of control of work pract ice with the properties of reg i s t ra t ion and education. 151 Control, of the work .environment In th i s study the control of the work environment represents the nursing assoc iat ion 's attempt to control the terms and condit ions of employment. The l i t e r a tu re i den t i f i e s 1) the development of s c i e n t i f i c medicine, 2) changes in the organization of the work, 3) the development of a hierarchy within nursing and 4) the socio-economic concerns of nurses as factors in the development of co l l e c t i ve bargaining by nurses in Canada, England and United States. Depending on the ideologica l stance the emphasis on these factors var ies . Concurrent with the urbanization and i ndus t r i a l i z a t i on of Europe, Eastern United States and Canada was the development of s c i e n t i f i c a l l y based medical pract i ce . The development of s c i e n t i f i c medicine and the increased use of technology in the care of the s ick meant that by the 19301s i t was no longer possible to be i l l and receive good care at home. The age of technology in hospita ls had ar r ived. Hospitals were no longer reserved for the s ick poor (Somers, 1971). With changes in the technology of health care, the organization of nursing work changed. Wagner (1980, pp.278-284) Bullough and Bui lough,(1965, pp.84-85) describe the pressures exerted on pr ivate duty nurses in the United States to become i n s t i t u t i ona l employees and the i r vigorous protest. There i s no Canadian or 152 English l i t e ra tu re describing th i s phenomenon. Abel-Smith (1960) describes pr ivate duty nurses as f u l l y employed unt i l the Depression, but as not necessar i ly , in the eyes of the College of Nursing, giv ing sa t i s fac tory serv ices. The l i t e ra tu re does acknowledge the development of a hierarchy within nursing service and i t s consequences. Baumgart (1980) describes the entry of the graduate nurse into i n s t i t u t i ona l employment in Canada as entering a "socia l system that had been designed and for many years had operated according to the soc ia l norm of the nat ive, submissive student who was subjected to c loser control and d i s c i p l i ne in her work" (pp 3). Baumgart states that nurses were forced to transfer the i r respon-s i b i l i t i e s from the emphasis on the care of patients and the healing act to balancing l o y a l i t i e s among .the i n s t i t u t i o n , the physician and the pat ient. White (1977, pp.24) i l l u s t r a t e s that a hierarchy was well establ ished in poor law nursing in England in the 19th century. Carpenter (1977) describes the r i se of a managerial c lass of nurses in Great B r i t a in and ascribes the development of co l l e c t i ve bargaining to th i s d i v i s i on within the profession. Carpenter argues that th i s occurred because of "profound changes in job content" (pp.174)'. He i den t i f i e s three areas of change 1) the increase in numbers of c l i n i c a l r e spons ib i l i t i e s being delegated to nurses from doctors as a resu l t of the growth of s c i e n t i f i c medicine; 153 2) the increased importance of the nurse as coordinator of a c t i v i t i e s at the ward level due to the emergence of paramedical occupations who have intermittent contact with pat ients , and 3) the increased number.of chron ica l ly i l l patients who require long term care. Carpenter argues that as the proportion of chron ica l ly s ick patients increased, "job sa t i s fac t ion in carrying out basic nursing tasks decl ined. The nursing e l i t e began to look more towards c l i n i c a l and managerial aspects of the i r work" (pp.174). Dirty work or routine work was delegated, and th i s meant an increased abandonment of t rad i t i ona l nursing values. Katz (1966) ,Krause (1977),Mauksch (1966) and Williams(1974) support th i s general argument, but Will iams (1974) describes the issue not as a loss in job sa t i s fac t i on but as a. sh i f t in ideology from vocational ism to professional ism. Vocationalism i s the expression of t rad i t i ona l nursing values in which the sancity of both the nurse and patient are preserved. Professional ism i s an ideology in which prest ige and reward to nurses i s associated with c l i n i c a l tasks delegated by medicine and managerial a c t i v i t i e s . This l i t e ra tu re pays l i t t l e attent ion to socio-economic concerns of nurses. Badgley (1975, pp.9-17) wr i t ing from a Canadian experience, i den t i f i e s growing unionizat ion and wage discrepancies tr iggered by monetary i n f l a t i on as resu l t ing in labour unrest and s t r i kes by health workers. The consequence has been the 154 gradual erosion of professional autonomy, the emergence of soc ia l pressures stemming from job status incons istenc ies, and the , increased importance of re la t i ve income l eve l s . In Badgley's view professional autonomy has been challenged when national health insurance plans have been introduced. Badg;ley sees the resemblance of professional associat ions to trade unions and argues that co l l e c t i ve bargaining w i l l resu l t in more d i rec t soc ia l responsi-b i l i t y on the part of these occupations than was previously evident. With spec i f i c reference to nurses, Badgley suggests that status symbolism, espec ia l ly v i s i b l e in nursing, has been stressed in l i eu of job remuneration or job benef i ts . He views th i s middle level work force as having a short term career commitment and a high job turnover which has l imi ted the growth of strong assoc i -ations and constrained the sense of mi l i tancy among workers. A slow bui ld up of job f rus t ra t ion f i l l e d by an awareness of women's r i gh t s , the impact of i n f l a t i o n , and by disenchantment with t rad i t i ona l prest ige symbols has resulted in an awareness of income leve ls equaled or excelled by workers with less formal t ra in ing and in a sense of job a l i enat ion . Badgely predicts sharper con f l i c t in the future i f the health system remains r i g i d and author i tar ian in the face of current soc ia l forces. As an example, Badg.ley points out that sanctions against s t r i k i ng doctors have not occurred, but professional hospital employees 155 and nurses have been subject to sanctions Badgley i den t i f i e s the moral issue to be solved as whether con f l i c t w i l l be "ant ic ipated and s t ruc tua l l y channelled to increase the sa t i s fac t i on of health workers and in turn achieve the target of good health for the publ ic" (pp.16). Issues in co l l e c t i ve bargaining by nurses in  England, United States and Canada. Engl and. Regardless of the emphasis on the factors p rec ip i ta t ing co l l e c t i ve bargaining by nurses, the l i t e ra tu re supports the pos i t ion that the nursing work force entered co l l e c t i ve bargaining as a response to the f a i l u re of nursing associat ions to control the work environment. In England the f i r s t union a c t i v i t y amongst health care workers i s traced to the Asylum Workers' Union formed in 1896 as a response to the exclusion of asylum nurses and attendants from reg i s t ra t i on . The f i r s t s t r i ke occurred in 1918, when a 60 hour week was sought (Green, 1975, Ross, 1979). Lewis (1976) describes the re lat ionsh ip between nurses, trade unions, professional organizations and the government since the formation of the National Health Service in 1948. The representatives of the professional bodies are viewed as being drawn from a se lect group 156 from the ru l ing class and the i r a l l i e s who are cont ro l l i ng the soc ia l order of nursing in B r i t a i n . The organizations representing nurses are argued to have f a i l ed to enable nurses to keep pace with the cost of l i v i n g and achieve a wage increase of any note. This has resulted in work to ru le , demonstrations and s t r i kes by nurses. McKay (1974) has described the al legiances and att i tudes of B r i t i s h hospital nurses in response to th i s s t r a i n . Bellaby and Oribar (1980, pp.291-309) in a Marxist analysis of strategies adopted by B r i t i s h hospital nurses do not bel ieve that developments in medical technology are the prime explanation for a l l the changes in the mode of control and de l ivery of health care. The dominance of medicine over health care workers, the inf luence of technology and i t s suppl iers , and government intervent ion are seen as promoting the erosion of nurses' control over the means of treatment. Consequently nurses have responded by equivocating between the strategies of professional ism and unionism. The issue of the r ight to s t r i ke and the dilemma of professional ism and union a c t i v i t y in B r i t i s h nursing i s debated by Clark (1979), Ferguson (1976) and Will iams (1979). The North American model of professional associat ions engaging in co l l e c t i ve bargaining with the r ight to s t r i ke i s not suggested in the B r i t i s h l i t e r a t u r e . The models suggested are, a professional 157 organization with a commitment to no s t r i ke act ion or, a f f i l i a t i o n with a union with an in terest in patient care and l inks with trade unions or the Labour party (Ferguson, 1976). United States Co l lec t ive bargaining by nurses in the United States i s important in th i s study for two reasons: 1) because of the general ly acknowledged inf luence of American union a c t i v i t y on the Canadian scene (Woods, 1973, pp.65-94) and 2) because A l i ce Wright was aware of and supported the a c t i v i t i e s of the Ca l i f o rn ia Nurses' Associat ion before she returned to B r i t i s h Columbia in 1943. Swanberg (1970, pp.54-56) i den t i f i e s three phases of a c t i v i t y amongst hospital workers in the United States: 1) 1896 to the entry of the US into World War I I , characterized by i na c t i v i t y and passiveness, 2) World War II to 1965, characterized by growing awareness and organizat ion, 3.) 1965, characterized by intense act ion and mi l i tancy. In 1935 the Wagner Act permitted hospital employees to engage in co l l e c t i ve bargaining, but attempts to organize were large ly unsuccessful. This act was amended in 1947 (Taft-Hart ley) and hospital workers in nonprofit hospita ls were exempted co l l e c t i ve bargaining r i gh t s . In 1962 employees of federal health care ins t i tu t ions were permitted to engage in co l l e c t i ve bargaining. In 1967 Cathol ic hospita ls in the 158 United States were influenced by the Vatican II "Pastoral Const i tut ion on the church in the Modern World" which stated "among the basic r ights of the human person. . . ( i s ) the r ight of f ree ly founding labour unions" (Brown, 1967, pp.57-60) M i l l e r and Shorte l l (1969) show that unionizat ion in non-federal hospitals doubled between 1961-69. In 1974 an amendment to the; Taft-Hart ly Act extended co l l e c t i ve bargaining to non-prof i t hosp i ta ls . This was opposed by the American Hospitals' Associat ion (Rasaco, 1974, pp.79-80). The f i r s t union a c t i v i t y in hospita ls in the U.S. occurred in San Francisco in 1919. The pr inc ipa l demands were shorter hours and better working condit ions. There was r e l a t i v e l y l i t t l e a c t i v i t y unt i l 1936 when the American Federation of Labour orga-nized the engineers and i n s t i t u t i ona l workers of three large San Francisco hosp i ta ls . The Toledo Plan of 1956 occurred af ter an extended hospital workers' s t r i ke in that c i t y and resulted in an agreement that unions would not bargain co l l e c t i v e l y or s t r i k e ; and that hospita ls would not discr iminate against union members (Bruner, 1959). A b i t t e r s t r i ke in New York C i t y , was preceeded by the establishment of a union at Montefiore hospital (Cruickshank, 1959). The administrat ion of th i s par t i cu la r hospital supported the entry of the union (Cherkasky, 1959). Increased union a c t i v i t y of hospital workers in the US i s seen as associated with the C i v i l Rights movement because of the 159 composition of the hospital work force (Davis and Foner, 1975). Bullough (1971, pp.276-278) describes the growth of mi l i tancy amongst nurses in Ca l i f o rn ia during World War II as due to an intense recruitment for workers in a booming economy in which "nursing's economics did not benefit" (pp.277). The American Nurses'Association did not estab l i sh a committee on economic a f f a i r s unt i l 1946. The e f for ts of Sh i r ley T i tus , then executive d i rector of the Ca l i f o rn ia Nurses'Association, persuaded the ANA to study employment condit ions of nurses in 1945. Bullough describes Titus as "an enthusiast ic supporter of co l l e c t i ve bargaining" (1971, pp.278). The ANA approved the ro le of state nursing associat ions in co l l e c t i ve bargaining in 1946. The ANA l i f t e d a ban on s t r i kes by nurses in 1968 (M i l l e r , 1975). T i tus , wr i t ing in The Modern Hosp i ta l , 1944 (pp.71-74) in an a r t i c l e ca l led "Economic Security i s not too much to ask" at t r ibuted the "awakening of nurses. . . to a f u l l appreciation of the i r economic pos i t ion" to 1) the development of a system of general s ta f f nursing in which there was a marked increase in the number of general s ta f f nurses subjected to hospital exp lo i ta t i on , 2) a sharp reduction of nurses sa lar ies and prerequis i tes (laundry services) during the depression, which for many nurses had never returned to the i r pre-depression l e v e l , 3) the advancement of medicine and s c i e n t i f i c knowledge... which has elevated the status 160 of nursing from a c ra f t to a profess ion, and the lack of professional status, 4) the passing of the Social Security Act in which workers, but few nurses, received protect ion against old age, i l l n e s s and lack of employment opportunit ies, 5) i n f l a t i on which increased the cost of l i v i n g but not nurses ' sa la r ies . Titus recognized the desire of s ta f f nurses to organize, and the pressure s ta f f nurses and pr ivate duty nurses were prepared to exert on the i r leaders "to do something about sa la r ies" (pp.73). She argued that bargaining f ree ly and independently re la t i ve to the conditions of employment was a democratic r i gh t , and that professional status offered no protect ion to employed persons. This a r t i c l e i s important not only for i t s t iming, and leg i t im i z ing of co l l e c t i ve bargaining but also because reference i s made to th is a r t i c l e in the Executive minutes of the RNABC (December, 1943) to "acquire copies". The l i t e r a tu re on co l l e c t i ve bargaining and nurses in the American nursing journals concentrates on 1) whether or not co l l e c t i ve bargaining i s appropriate for professionals (Conta, 1972; Er ickson, 1971; Gi l l ingham, 1950; Hopping, 1976; Mahony and Conlan,1966); 2) the ef fect of co l l e c t i ve bargaining on the structure and funct ioning of professional ism (Bloom, 1979; 1980; Cle land, 1974; Conta, 1972; Copp, 1973; Denton, 1976; Hott, 1976; Schutt, 1973; Zimmerman, 1971); 3) the ambiguous ro le of the d i rector of nursing: i s she to a l l y hersel f with the nursing s t a f f , management, or act as a go-between (American Nurses' Assoc iat ion, 1970; D r i s c o l l , 1974; 161 Hospi ta ls , 1974; Rosasco, 1974); 4) the ro le of middle nursing management, espec ia l ly in labour disputes (Bloom, 1980; Cle land, 1974); 5) the ro le of co l l e c t i ve bargaining in def ining patient care (Jacox, 1971; Krav i t , 1973); 6) the r ight of nurses to s t r i ke (Mauksch, 1971; M i l l e r , 1975; Schutt, 1968). Jacox (1971) has suggested that the emphasis on the "professional behavior" of nurses was used by hospita ls and nursing administrators as a means of soc ia l control because of the i r vested interests in a quiescent workforce. The issues are not resolved. Grand (1971, pp.289-299) describes the con f l i c t as re f l e c t i ng three d i s t i n c t ideologica l posit ions of nurses. Nightingalism i s an ideology of service which i s interpreted as precluding concern with economic and working condit ions. Employeeism represents a set of be l ie fs that lead nurses, as employees, to bel ieve that the i r employer had the i r best interests at heart. Grand argues that the employeeism i s reciprocal of paternalism and that the Depression contributed to the growth of employeeism. Professional co l l ec t i v i sm i s based on the assumption that working condit ions are inherently and pos i t i ve l y re lated to the qua l i ty of nursing care. Grand argues that the service ideology and the r e a l i t y of the low economic status of nurses were recounci l led by viewing the qua l i ty of care given by nurses as dependent upon sat i s fac tory economic status and working condit ions. While the narrat ive c l ea r l y i l l u s t r a t e s 162 that both grassroots nurses and the leaders of the RNABC recognized the problems of the terms and conditions of employment from the ea r l i e s t days- ofthe Assoc iat ion, th is pos i t ion was not ennunciated unt i l the middle of late 1940's. Nightingalism in a pure form as described by Grand did not ex i s t amongst nurses in B r i t i s h Columbia. Given the char i tab le nature of hosp i ta l s , and the l imi ted publ ic funding of hospita ls unt i l 1949 in B r i t i s h Columbia the use of moral suasion from the formation of the Associat ion unt i l the f i r s t s t r i ke votes of 1957 and 1959, employeeism may best describe the dominant ideology of nurses in B r i t i s h Columbia unt i l 1957. Two c r i t iGs • outside of nursing have examined the ro le of the ANA and state nursing associat ions (Dolan, 1980; Lev i , 1980). Dolan argues that the professional nursing associat ion serves the e l i t e and because of the f a i l u re of co l l e c t i ve bargaining by nursing associat ions to make s ign i f i can t economic gains unionizat ion outside of professional associat ions w i l l occur (Dolan, 1980). Levi (1980) argues that nursing associat ions have been unable to control the nursing labour supply and have f a i l ed to monopolize a d i s t i n c t set of tasks and thus are unable to achieve upward soc ia l and economic mobi l i ty on behalf of nurses. While acknow-ledging an oversupply of beds and the a v a i l a b i l i t y of unemployed nurses, Levi suggests that the Seatt le nurses s t r i ke of 1976 was broken by the hospita ls because of the f a i l u re of the professional 163 associat ion 1) to control nurses w i l l i n g to work as scab labour 2) the absence of "powerful a l l i e s " or "c lout" 3) the f a i l u r e of nurses to secure a monopoly over any set of " soc i a l l y s i gn i -f i c an t , or even i n s i gn i f i c an t , ro les" (pp.347). What Levi does not address i s the in tegra t ion i s t role of middle nursing management (Jones, N. and Jones, W., 1979) who were prohibited from s t r i k i ng in th i s s i tuat ion and the amount of medical care given in hospital which i s may or not be an essent ia l service (Ha l l , 1967). In Canada two review a r t i c l e s consider the issue of co l l e c t i ve act ion by nurses to improve the i r sa lar ies and working condit ions. A federal study for the Women's Bureau, Department of Labour (Beckett, 1964) i den t i f i ed the publ ic and professional view that co l l e c t i ve act ion on the part of nurses to improve the i r working condit ions was uneth ica l . Low sa lar ies and unsat isfactory working condit ions are i den t i f i ed as contr ibut ing to an i n su f f i c i en t supply of nurses and a high rate of wastage. Because the majority of nurses in Canada were not covered by labour re lat ions l eg i s -l a t i on co l l e c t i ve bargaining was a voluntary act without the protect ion of labour l e g i s l a t i on . The evolut ion of recommended minimum standards for personnel po l i c i es for nurses by a committee on employment re lat ions with in the professional associat ion to co l l e c t i ve bargaining by professional associat ions i s described province by province. The ' s i tua t i on in B.C.'was as described in the narrat ive except that no evidence of the formation of a Labour 164 Relations Committee formed in 1942 was found in the minutes of the Assoc iat ion. Beckett concludes that the growth of co l l e c t i ve bargaining by nurses depends on 1) the amount of publ ic support given, 2) the importance of health services in the community and the demand for health personnel, 3) the awareness by nurses that dedication to service does not obviate the r ight to sa lar ies and working condit ions consistent with the importance of the i r con t r i -bution to the community, and 4) the a c t i v i t y of trades unions amongst non-professional employees of hospitals as a spur to nurses. Beckett remarks that "except in the province of Quebec, the labour movement in Canada has not been act ive in rec ru i t ing nurses to i t s ranks" (pp.12). Beckett has overlooked the ef fect of the Hospital Employees Union to unionize the nurses of VGH on the a c t i v i t i e s of the RNABC. Cormick (1969, pp.667-682) views nurses as professionals who are part of the publ ic sector because the government i s the ultimate employer. and because "the essent ia l nature of the i r task decrees that the i r employment i s a matter of publ ic concern" (pp.667). Cormick recognizes that the con f l i c t between professional ism and unionism with in nursing, l eg i s l a t i v e impediments and the lack of s k i l l e d bargainers within nursing associat ions have impeded progress towards co l l e c t i ve bargaining by nurses. Health care, because of the high cost, and undes i rab i l i t y of dupl icat ion and i t s non-prof i t status, i s considered to be a monopoly s i tuat ion 165 with the nursing profession cont ro l l i ng entrance to the profession through reg i s t ra t ion procedures. Cormick does not acknowledge the p ro l i f e ra t i on of health care workers including the establishment of a subsidiary nursing work force, evident in the late 1960's, and the consequent d i f f i c u l t y in ident i fy ing work unique to nurses, nor the ef fect of subsidiary and para l l e l workers d i l u t i ng nurses' monopoly (Krause, 1977; ,,Levi, 1980). Cormick suggests that hospital administrators have been opposed to co l l e c t i ve bargaining by nurses because "wage increases would have to be passed on to consumers who are in no posi t ion to f i gh t the r i s i ng costs of an essent ia l serv ice: (Hawley c i ted by^ Cormick pp.679). This view has been noted to be prevalent in the American l i t e r a t u r e , and indeed was the crux of debate in rev is ion of laws proh ib i t ing employees of non-prof i t hospita ls from entering into co l l e c t i v e bargaining in the US (Match, Goldstein and L ight, 1975, pp.27-36). but i s not general ly consistent with the Canadian pos i t ion . As ear ly as 1950, Harvey Agnew, long time Executive Director of the Canadian Hospi ta ls 'Assoc iat ion supported the entry of Ontario nurses into co l l e c t i ve bargaining by arguing that "the publ ic cannot expect to get hospital care at prices which can only be maintained by holding sa lar ies and wages at less than current levels" (Agnew, 1950, pp.27-28). This view i s supported by J.D.Bradford (1981) former executive d i rector of the BCHA and Steeves (1960, pp.100-101). 166 On the basis of ava i lab le data,Cormick suggests that i t i s d i f f i c u l t to estab l i sh a c lear re lat ionship 'between bargaining strength' and 'salary or salary gains' but suggests that prov inc ia l associat ions with "high" bargaining strength (eg. B.C.) do better on basic salary rates and salary gains. He.also i den t i f i e s a " re lat ionsh ip between general per capita income rank and nursing salary rank. . . which suggests that the general economic environment i s an important factor" (pp.681-682). Cormick predicts that organizing for co l l e c t i ve bargaining w i l l increase the general strength of nursing associat ions in areas where they are able to act as bargaining agents and that nursing associat ions w i l l be able to exert increased influence over t ra in ing standards and methods, even though the basic avenue of change w i l l s t i l l be through the l eg i s l a t i v e process. Foucher (1980) ,in addressing the Canadian Nurses Asso-c i a t i on Biennal^discusses the question of nurses and the i r member-ship in professional associat ions and trade unions. He suggests that a change in values of. nurses has come about due to increased government intervent ion in health care, resu l t ing in administrat ion based on bureaucratic values. He argues that "whereas formerly i t was reasonable to expect open discussion and free r a t i f i c a t i o n of agreements between professional associat ions and hospital adminis-t ra t ion which shared cer ta in values, the use of such a process of estab l i sh ing nurses' working condit ions became less sat i s fac tory when 167 administrative, values began to change" (pp.2). While nurses have sought "protect ion from management decisions by means of hureau-c r a t i c a l l y - oriented rather than profess ional ly-or iented contract pos i t i ons . . . " (pp.2) nurses have expressed ideological con f l i c t by a reluctance to s t r i k e . In the case of B r i t i s h Columbia, working condit ions of nurses did not improve a great deal or uniformly as a re f l ec t i on of the 'sharing of certa in values' but rather as a resu l t of 1) the shortage of nurses beginning in 1939-40, 2) the beginning of co l l e c t i ve bargaining by non-professional hospital workers, and 3) the beginning of co l l e c t i ve action by nurses in 1946. Rather i t would seem that bureaucratic administrat ion has reinforced the pressure nurses feel to maintain act ive unionism. Foucher discusses nurses' claim to be professional and suggests that the problem nurses have belonging to a professional organization w i l l increase in proportion to the lack of c l a r i t y in the way they perceive the act of nursing. The ro le the professional associat ion takes in c l a r i f y i ng and promoting the act of nursing w i l l a f fect the commitment to the assoc iat ion. In considering trade unions, Foucher uses Torraine's (.1965) typology to describe three types. Unions may be based on 1) c lass , and "dominated by the struggle against c lass power", 2) negot iat ion, with the aim to improve member's working condi t ions", or 3) in tegrat ion, with the aim "to contribute to the smooth operation of society and i t s structures" (pp.6-7). The object ive of unionism based on negotiat ion may be u t i l i t a r i a n i sm , control or co-management. It i t s purpose i s u t i l i t a r i a n , the union i s 168 committed to the defence of workers' interests and the i r co l l e c t i ve p r i v i l eges , without challenging the employer or attempting to involve i t s e l f in the management process. I f i t s purpose i s cont ro l , the union endeavours to take on management r ights and to inf luence dec is ion-making. I t may adopt a cooperative or an adversary stance within the ex i s t ing i n s t i t u t i ona l framework. I f i t s purpose i s co-management, the union wishes a share of the power and to use that power to i t s own advantage". (Durand, 1971 c i ted by Foucher, pp.6-7). On the basis of the narrat ive presented in Chapters 2 and 3, the object ive of co l l e c t i ve bargaining a c t i v i t y of the RNABC could be characterized as u t i l i t a r i a n between 1943-76. Foucher points out that the interests and demands of nursing unions and professional associat ions overlap or are in ter re la ted and that the organizations can e lect to adopt opposing or j o i n t strategies for deal ing with these demands. Fa i l i ng t h i s , unions and professional associat ions may integrate, with one or the other los ing membership i f membership i s voluntary, or los ing power. In the case of the RNABC, with voluntary membership in law, but mandatory membership enforced by h i r ing i n s t i t u t i on s , the professional associat ion may lose out to the union. To ensure the maintenance and development of professional assoc iat ion, Foucher suggests that these organizations should 169 1) "display an interest in member's concerns.. . and provide through open structures the opportunity for membership input" 2)"put forward professional models in the f i e l d of nursing...(and) " i f warranted for the pract ice of nursing, a bachelor's degree as a requirement for admission into the profess ion." 3) "ca l l for more forcefu l persuasive strategies in the i n s t i t u t i ona l framework" (pp.9-10). In th is l a s t respect the RNABC's a c t i v i t i e s during the 1976 c r i s i s at V6H were supportive to the membership. An interest ing omission from Foucher's paper i s any discussion on the role of nursing management in the professional associat ion and the nursing union or the need for a separate union for middle management nurses. With the separation of the professional and union structures in Canada, the question of managerial nurses par t i c ipa t ing in the professional associat ion i s less acute than in the United States. In due course the B.C. nursing adminis-t rators group may come back under the wing of the professional associat ion see p r31 and union a spec i f i c issues-does not challenge, but rather supports th is group. With increasing budgetary constra int in health care, and theinherent tension between hospital administrat ion and the nursing department, because of the large consumption of the tota l budget by the nursing department, the d i rec tor of nursing i s in an increas ingly tenuous pos i t i on , and challenges to the system by the professional associat ion and/or 170 the union may not be interpreted as supportive. Baumgart (1980) in Professional Obl igat ions, Employment Respons ib i l i t i es and Co l lec t ive Bargaining: A New Agenda for the 1980's in an address given to the RNABC Labour Relations D iv i s i on , 4th Annual Convention argues fo r the coexistence of the professional associat ion and union. She states that both have spec i f i c and complementary ro les . Baumgart predicts the "emergence of co l l e c t i ve bargaining as a means of harmonizing professional interests and respons ib i l i t i e s with employment ob l igat ions" (pp.1) Baumgart expresses the concern that because of the lack of value attached to nurses' work, and the i nh ib i t i on of the development of spec ia l i za t ion amongst nurses, both to the advantage of hospital administrat ion, nurses w i l l have d i f f i c u l t y gaining greater autonomy and control over the i r work. Summary. The l i t e ra tu re reviewed supports the category of the control of the work environment with the major properties of the terms and condit ions of employment, although, c l ea r l y reg i s t ra t ion and education played important ro les . The l i t e ra tu re acknowledges that co l l e c t i ve bargaining i s a well establ ished response in Canada, England and United States. The strategies of nurses were seen to equivocate between 171 professional ism and unionism. The form of union a c t i v i t y and i t s e f fect on the professional organization was discussed by several authors. The issues remain unresolved. As with control of work pract i ce , the l i t e r a tu re does not ass i s t in supporting or negating the postures or strategies of control suggested in the analysis of th i s study. Conclusion This chapter has presented a review of selected l i t e ra tu re relevant to th i s study. The purpose of the l i t e r a tu re review was to compare the ana lyt ic core of the categories which emerged from the data with the s im i l a r i t i e s and convergences of the l i t e r a t u r e . In addit ion th i s l i t e ra tu re review had the funct ion of providing comparisons for the groups which emerged from the data of th is study. Co l lec t i ve bargaining as a response to the terms and condit ions of employment of nurses i s well, establ ished in Canada, England and United States. Co l lec t ive bargaining as a strategy was contrasted with the f a i l u r e of so ca l led professional s t ra teg ies . The ro le of cosmopolitans and l o ca l s , or e l i t e and pro le te r i a t was confirmed by several authors. The concepts of control of the work force, control of work pract ice and control of work environment were also confirmed in the l i t e r a t u r e . Strategies of nurses were seen as equivocating between professional ism and unionism. 172 No l i t e ra tu re studied showed nurses or nursing associations, using the strategy of lobbying and moral suasion to emerge, although the pattern of bargaining emerged. S imi la r l y the postures of the RNABC, compromised cont ro l , co-ordinated control and bargained control could not be found in the l i t e r a tu r e . This i s more l i k e l y due to the character i s t i cs of the data base of th is study rather than to the Tack of s im i l a r i t y of the RNABC with other nursing associat ions. 173 CHAPTER 7 Explanatjons: Negotiations with External Forces.  Introduction The purpose of th i s chapter i s to consider selected paradigms from the l i t e r a tu re on socia l po l icy and from the l i t e ra tu re of sociology in an attempt to explain the events, processes and trends (Smith, 1976) of the negotiation process. A l fo rd ' s (1972), "A Case of Dynamics without Change" can be used to explain the f a i l u r e of the reformers, 1918-43. S im i l a r i t i e s between the current American scene and the scene in B r i t i s h Columbia 1912-43 are described. From the English l i t e ra tu re a paradigm of legit imacy, f e a s i b i l i t y and support (Ha l l , Land, Parker and Webb, 1975) can explain the f a i l u re of the issue of the terms and conditions of nurses to be recognized and acted upon. A br ie f discussion of the re lat ionship of control contexts, soc ia l order and negotiat ion and the professions i s presented by considering Johnson's typology of professions. The chapter concludes with br ie f comments on E t z l on i ' s (.1968) concept of soc ieta l processes and the entry of nurses in B r i t i s h Columbia to co l l e c t i ve bargaining. 174 Negotiation with External Forces,: A Case of Dynamics without Change1 Al ford (.1972, pp. 127-64) proposes a paradigm for examining the debate on the reform of the American health care system and the lack of change over the past 40 years. Using the concepts and discarding the deta i l appl icable to the American scene, th i s paradigm becomes a useful tool for analyzing issues in the B r i t i s h Columbia health care scene that are re lated to the terms and condit ions of employment of nurses. The American health care system which i s contro l led by pr ivate enterprise i s analogous to the health care system in B r i t i s h Columbia pr io r to the introduct ion by the provinc ia l government, of hospital insurance in 1949, and medical insurance in 1968. A l ford proposes that there are two groups of reformers, market reformers and bureaucratic reformers, and three interest groups, corporate r a t i ona l i z e r s , professional monopolists and the community. Market reformers "would expand the d i ve r s i t y of f a c i l i t i e s ava i l ab le , the. number of physic ians, the competition between health f a c i l i t i e s , and the quantity and qua l i ty of pr ivate insurance" (pp.128). Market reformers are those, who bel ieve that hospita ls should serve as the organizational framework for health care de l i very , and that problems of access should be resolved by increasing the numbers of physicians and f a c i l i t i e s , and providing publ ic insurance only for the poor. Bureaucratic reformers "stress the importance of the hospital...... and wish to put indiv idual doctors under the control of hospital medical boards and administrators"(pp.129). Bureaucratic 1 A l f o r d , R. The Po l i t i c a l Economy of Health Care: Dynamics Without Change. Po l i t i c s and Science. Winter, 1972, pp.127-164. 175 reformers are concerned pr imar i ly with coordinating fragmented services and i n s t i t u t i ng planning and publ ic funding while keeping the hospital as the centre of a network of health serv ices. The community population i s seen as an external constituency of health providers to be organized to represent i t s in terest for the maintenance of the system. The reforms concerning the ro le and organization of the professions are inst igated by bureaucratic reformers. A l ford describes corporate ra t iona l i ze rs as being composed of hospital administrators, medical school d i rectors and government health o f f i c i a l s , with an ideology of r a t i ona l , e f f i c i e n t , cost conscious coordinated health care de l ivery . The professional monopolists are seen as supporting those bureaucratic reforms which protect the i r own in te res ts . In A l fo rd ' s paradigm they accuse the corporate ra t iona l i ze rs of not being concerned with personalized care. In turn professional mono-po l i s t s are accused of sett ing up a screen of legit imacy to protect the i r own in te res ts . Community in terests are characterized as a group of people who are not part of a network of health i n s t i t u t i ons and thus are free to demand more and better health care. However, A l ford points out that th is group does not have the necessary information to lobby e f f e c t i ve l y , nor does i t know the levers of power, the interests at stake or the actual nature of the (health care de l ivery) i n s t i t u t i on and thus i t s members are e i ther coopted into the system or excluded from successful lobbying due to ignorance. A l ford argues that the strategies of reform based on e i ther 'market' or bureaucratic reform are un l ike ly to work because each type of reform stresses certa in 176 core functions of the health system and regards the others as secondary. Government i s not seen as an independent power standing above and beyond the competing in terest groups because the major character i s t i cs of the health system are due to pr ivate cont ro l . A l ford concludes by arguing that "change i s not l i k e l y without the presence of a socia l and po l i t i c a l movement which rejects the legit imacy of the economic and soc ia l base of p l u r a l i s t p o l i t i c s " (pp.164). In applying th i s paradigm to B r i t i s h Columbia of the late 1920's and 1930's,George Pearson and George Weir can be characterized as bureaucratic reformers. Pearson chaired the hearings on Health Insurance in 1932 and was responsible for the 1936 Health Insurance l eg i s l a t i on which was passed but never proclaimed. Had th i s l eg i s l a t i on been proclaimed the unemployment and economic s i tuat ion of nurses might have improved incremental.y. Hospital would have ceased to be char i table i n s t i t u t i ons and thus nurses would have been freed from that par t i cu lar ideologica l burden. As an academic George Weir prepared the survey of Nursing, 1932, and made spec i f i c recommendation to soc ia l i ze medical and nursing care and to take nursing education out of the hospita ls (Weir, 1932). On entry into po l i t i c s he became Provinc ia l Secretary and as such was responsible for the mental and tuberculosis hospitals of the province and for the province's support of char i tab le hosp i ta ls . When the question of the working condit ions of nurses became po l i t i c a l fodder (Steeves, pp. 100-101) the response was to i n i t i a t e the Eaton survey or working condit ions in hospitals in 1938. Steeves descr ipt ion of these events 177 suggests that Weir "had waited so long he could wait a b i t longer", while the Premier i s described as, "waiting for the Report of the Rowel l -S iro is Commission on dominion - prov inc ia l re lat ions to see whether something hopeful would come out of i t " (pp.121). The dynamics of party and federa l -prov inc ia l p o l i t i c s stagnated the impetus for change. I f the broad base of support for health insurance given by the plebiscite, of 1937, was i n su f f i c i en t to prompt the government to act , l i t t l e could be expected for nurses. When hospital insurance did come to the province in 1949, working condit ions for nurses improved only gradual ly, and through the e f for ts of nurses, not those responsible for the health care system. The work week for graduate nurses was reduced from 48 to 40 hours by 1955. Student nurses continued to work longer hours. With the support of the Assoc iat ion, there was res t ra in t in demand for improvement in sa l a r i e s , unt i l increased pressure from the grassroots supported by s t r i ke threats in 1957 and 1959 resulted in wage adjustments. Of the in terest groups, the corporate ra t i ona l i ze r s represented by the hospital administrators and government o f f i c i a l s could do nothing but gain by holding fast on the terms and conditions of employment of nurses. The debate on the "Amendments to Hospital Act and Hospital Regulations" at the BCHA annual meeting of 1938 (pp.20-21; 50-59; 76-77) i s i l l u s t r a t i v e of th i s group acknowledging a need for improvement in working conditions but f ind ing reasons, l a rge ly f i n an c i a l , not to implement change. The doctors as professional 178 monopolists, supported voluntary reg is t ra t ion for nurses, They were assured some control over the Associat ion by. par t i c ipa t ing in the annual examination of graduating students. The doctors los t in terest in th is a c t i v i t y and rel inquished the i r ro le vo lun ta r i l y , but exercised a more pervasive control in the work se t t ing . In th i s study, the community interests are the publ ic at large and the Women's Ins t i tu te of B r i t i s h Columbia and the Local Councils of Women. Eaton described the general community as being very concerned about the working conditions of nurses (1938, pp.30), but c l ea r l y no organized support, other than that offered by the CCF in the l eg i s l a tu re , ex is ted. The W.I.B.C. i s described by Zacharias (1980, pp.69) as being instrumental in working with the BC Department of Health to estab l i sh health, centres throughout the province. "By 1930, 132 publ ic health nurses had been appointed as a resu l t of women's representation" (Douglas, c i ted by Zacharias 1980, pp.69). The ro le of the W:I.B.C. in supporting publ ic health i s acknowledged in the 1921 Report of the Prov inc ia l Health Department. What the community interests ,as represented by the Local Council of Women,could not Influence was the medical monopoly over maternal care. The LCW lobbied to reg is ter midwives and l a te r to permit the pract ice of midwifery " in scattered d i s t r i c t s of Canada" (Apr i l 26, 1917). I t i s an interest ing question whether the growth of publ ic health nursing was a bureaucratic response to protect the medical dominance of maternal care. The nursing Associat ion f i r s t opposed . and l a te r supported "advanced obster ica l t ra in ing under medical 179 supervision"(Apri1 22, 1935). The nursing profession supported medical dominance of th i s a c t i v i t y e i ther because of a lack of confidence in nurses' t ra in ing and knowledge, under the inf luence of the medical izat ion of natural processes or because of a lack of t ra in ing and knowledge due to medical dominance. The issue of midwifery i s an example of the dominance of professional monopolists at the expense of improving maternal and infant morta l i ty rates. The issue of medical dominance arose again as technology expanded and the role of the nurse was questioned (January 5, 1950; November 14, 1953). Summary. In A l fo rd ' s terms the nursing Associat ion represented a weak professional monopolist because i t could not control the work force giv ing nursing care and because i t could not define work pract ice independently of the medical profession. Despite the presence of i n f l uen t i a l leaders, such as Grace Fa i r l y , on the Health Insurance Committee of 1932, there i s no evidence that the profess ion's opinion influenced the course of events unt i l a s t r i ke vote was a r e a l i t y . Negotiat ion: The Importance of Legitimacy A l fo rd ' s paradigm is about the system, which i f a l tered might have had a red is t r ibutory ef fect (Marchak, 1975) for nurses.Thi-s paradigm leaves unanswered the question of why the issue of the terms and condit ions of employment of nurses was not dealt with d i r e c t l y as a 180 s ingle i ssue, or as part of l eg i s l a t i on regulat ing .general working condit ions. An a l ternat ive approach for examining the lack of change in the terms and conditions of employment of nurses in B r i t i s h Columbia Ha l l , Land, Parker and Webb's model (1975) of legit imacy, f e a s i b i l i t y and support. Hal 1 et a l . suggest there are three general c r i t e r i a against which the claims of an issue may be measured. Legitimacy i s determined by asking i f i t ' i s an issue with which the government considers i t should be concerned. Those issues which are considered legit imate may or may not be given p r i o r i t y . F ea s i b i l i t y i s considered important because the po s s i b i l i t y of taking steps to deal with a problem may determine i t s chances of gaining at tent ion. F ea s i b i l i t y i s determined by 1) the preva i l ing structure and d i s t r i bu t i on of theoret ica l and technical knowledge, 2) who (bearing in mind the i r ideologies, in te res ts , prejudices and information) does the judging, and 3) the outcome of (government) test ing for f e a s i b i l i t y in re la t ion to the use of resources, co l laborat ion, and administrat ive f e a s i b i l i t y . Support for an issue i s recognized to be d i f f i c u l t to measure. In the short term what i s thought to be publ ic opinion i s more important than an empirical evaluat ion. This paradigm i s most useful in explaining negotiat ion with external forces, but in passing i t should be noted that negotiation within the Associat ion on the means to deal with the issue of the terms and condit ions of employment of nurses also took place within the framework of legit imacy, f e a s i b i l i t y and support. Co l lec t ive bargaining was a legit imate and feas ib le method-of dealing with the 181 new reg i s t ra r , A l i ce Wright (Wright, 1981). The legit imacy granted co l l e c t i ve bargaining by the CNA in 1944 was probably i n f l uen t i a l in l eg i t im i z ing co l l e c t i ve bargaining for the general membership. Support for co l l e c t i ve bargaining was denied by the general membership in 1944 but granted in 1946. The entry of the HEU into the scene may be viewed as forc ing the legit imacy of co l l e c t i ve bargaining for some of the membership. The inter im period of negotiating recommended Personnel Pract ices with the BCHA may be seen as a version of co l l e c t i ve bargaining viewed as feas ib le by the leadership. This i s also true of the l im i ted contract demands made unt i l 1969. Some loca ls were d i s sa t i s f i ed with the leadership given during th is period (Crawford, 1981). In the case of external negot iat ions, the respons ib i l i t y for the de l ivery of hospital care large ly through char i table i n s t i t u t i ons unt i l 1949, buffered the government from d i rect respons ib i l i t y for the working condit ions in hosp i ta ls . In the governments' view the issue of the terms and condit ions of nurses did not have legit imacy. The f e a s i b i l i t y of improving the terms and conditions of employment of nurses was large ly a do l l a rs and cents issue. The government rejected the po s s i b i l i t y of granting increased funds for the sa lar ies of nurses during the 1930's (Steeves, 1960, pp.100-102; 120-121). Percy Ward, as hospital inspector for the government, submitted a report on "economic Aspects" to the Eaton Report (1938, pp. 82-104). He was unable to predict the expected increased costs of granting nurses in government aided hospitals a basic salary of $60.00 per month with room and board because of varied administrat ive procedures in the 182 hospitals, surveyed (pp.80-90). Thus the technical knowledge was too l imi ted to produce concrete data to promote act ion. There i s also the case of the working conditions of student nurses, for whom the government had the regulatory power of control fo l lowing the release of the Eaton Report in 1939. The argument that the ef fect of the Depression on the province and on Vancouer, the p o l i t i c a l chaos of the Liberal party, and i ts defeat ( including George Weir) in 1941 as well as World War II (Ormsby, 1968, pp.469-479) was to place the problems of the nurses' too low on the agenda for the attainment of the p o l i t i c a l support necessary for change can be made. However, a minimum Wage Act which did not af fect nurses, but did af fect other hospital workers had passed in 1938. It would appear that the lack of legit imacy, at the p o l i t i c a l level and the lack of support at the bureaucratic l e v e l , exacerbated by a view of nurses as "form(ing) a group which absorbs economics made necessary by other demands and that the very fact that they can be depended upon to render service without protest and without drast i c action has kept them working hours of such length that the i r health suffers and normal, essent ia l soc ia l a c t i v i t i e s are denied to them" (Eaton, 1938, pp.12-13). Connelly (1978), E ich ler (1973) and Smith (1973), discuss women at work in Canada which supports th i s general pos i t ion . The struggle by women to achieve a ' l eg i t imate ' ro le in B r i t i s h Columbia i s described in "In Her Own Right' (Latham and Kess, 1980). 183 Summary . The terms and conditions of employment of nurses f a i l ed to gain the attent ion and action of the government because the issue f a i l ed to have the legit imacy, f e a s i b i l i t y and support of the p o l i t i c a l and bureaucratic powers of government. Post-war, gains were made in the hours of work, and modestly, in sa l a r i e s . The confrontation with the government expressed in the s t r i ke votes of 1957 and 1959, i l l u s t r a t e that the legit imacy, f e a s i b i l i t y and support to improve the terms and conditions of employment of nurses did not a l t e r unt i l nurses forced the issue by ca l l i ng a s t r i ke vote. Conditions for students improved incrementally on the wake of improvements for graduates. Marked improvement of conditions for students improved only when nursing education was removed from hospital schools. Control Contexts, Negotiation and Social Order With the comparison of the responses of the . Associat ion to attempt to control the work force, work pract ice , and •. work environment, three postures of control contexts were i den t i f i ed . These were compromised cont ro l , coordinated control and bargained cont ro l . The concept of the exercise of-control i s about negotiation as a means of maintaining soc ia l order (Strauss,1977, pp.4-7; 234-239). The study of soc ia l order has been described as the central problem of sociology, Watkins (1975)writes that "the c l a ss i ca l formation of the problem was provided by Thomas Hobbes, the 17th" century 184 philosopher. The essence of i.t is. given in the question. How, i,f human beings are fundamentally egoti.sti.cial and se l f -seek ing, is. society possible? How is the indiv idual to be restrained from simply grabbing a l l he can for himself without consideration for his fel lows? How are ind iv idua ls to be obliged to l i v e together in reasonable harmony?" (1975, pp.2-3). There are however, two socia l orders in th i s study; an internal soc ia l order within the membership of the Assoc iat ion, and an external soc ia l order in the re lat ionsh ip of nurses as ind iv idua l s , and as an Associat ion in soc iety. Johnson (1972) suggests a model for studying occupational groups which rejects the usual approach of t r a i t s and functional ism to suggest that "various soc ia l mechanisms have ar isen to 'manage' areas of soc ia l tension which present problems of soc ia l contro l" (pp.44). "Those occupations which are associated with pecu l ia r ly acute tensions . . . have given r i se to a number of i n s t i t u t i ona l i s ed forms of cont ro l , 'profess ional ism' being one. Professional ism, then, becomes redefined as a pecul iar type of occupational control rather than an expression of the inher ient nature of occupations" (pp.45). Johnsons' typology of profession i s 1) co l leg ia te cont ro l , in which the "producer defines the needs of the consumer and the manner in which these needs are catered for" (pp.45). Law and medicine exemplify th i s pattern. 2) patronage in which the "consumer defines his own needs and the manner in which they are to be met" (pp.46), and i s 185 expressed as o l igarch ic or corporate forms of patronage. Communal control expressed as consumer po l i t i c s Is also present, 3) mediative in which "a th i rd party mediates the re lat ionsh ip between the producer and consumer, def ining both the needs and manner in which the needs are met" (pp.46). Cap i ta l i s t s and state mediative types are i den t i f i ed . In the state mediative type the state mediates between the producer and consumer. Thus th i s typology suggests three d i f fe rent ways in which professionals become bureaucratized, each "having varying consequences for occupational pract ice" and each being "the product of d i f fe rent i n s t i t u t i ona l i z ed forms of contro l " (pp.85). In the case of nurses, doctors mediate the re lat ionsh ip of the nurse with the patient (Bellaby and Oribar, 1980) by cont ro l l i ng the entry of the patient into the system (Watkins, 1975) while the state mediates the organization d i s t r i bu t i on and funding of the means of care. The entry into co l l e c t i ve bargaining with the acceptance of the po s s i b i l i t y of s t r i ke action represents the pa r t i -c ipat ion of the nursing associat ion into th i s mechanism of socia l cont ro l . The ' f i r s t round' has been the negotiat ion of the terms and conditions of employment but the 'second round' i s l i k e l y to deal with "the needs and the manner in which needs are met" as the disputes at Vancouver General Hospital and the ro le of the health Min is t ry exemplify (Bellyache at VGH, 1978). The states 'entry into the mediative process in health care represents the states' concern for the "provis ion of soc ia l services in a general rather than a 186 personal service or ientat ion of professional ism (pp.84). I t may be that the disruptions at VGH represents the Ideological response of the personal service or ientat ion of nurses. Summary The concept of professions and the state as agents of socia l control has been suggested. Co l lec t ive bargaining by nurses has been proposed as a response to the state mediation of health care. Negotiation and Societal Processes This study began with an awareness of E t z i on i ' s concept of the s h i f t . i n . re lat ionships within society from normativism to u t i l i t a r i an i sm . During the research process there was no attempt to look for data which, would confirm or disprove th i s concept. I t would seem appropriate, at the end of th is study, to examine E t z i on i ' s concept in l i gh t of the f indings of th i s study. Etz ioni (1968 pp.104) suggests that both, ind iv idual and organizat ional re lat ionships with in society may be characterized as normative, u t i l i t a r i a n or coercive. "A normative re la t ionsh ip enta i l s shared values and norms; the re la t ing actors t reat each other as goals and the i r mutual commitments are non-rat ional . U t i l i t a r i a n re la t ions enta i l a complementary in teres t ; the actors t reat each other as means and commitments are r a t i ona l . Coercion enta i l s the use or the threatened use, of means of violence by one actor 187 against one or more other actors.. Actors, t reat each other as objects, and the commitment may Be e i ther rat ional or non-rat ional . Concrete re lat ions are frequently a mixture of the three kinds. However, one tends to dominate.... each, of the three basic re lat ionships serves as a base of both integrat ion and cleavage, and that the very act of binding i s also an act of set t ing a boundary.." (pp.96). He writes that cooperation i s more l i k e l y to occur within the f i r s t , contained con f l i c t with in the second, and uncontained con f l i c t with in the t h i r d . " (pp.96) Within th i s concept of re lat ionships Etz ioni (pp.357) i den t i f i e s three leve ls of power:persuasive power (eg. propaganda) i s associated with normative re la t ionsh ips , u t i l i t a r i a n power i s power expressed in economic terms and in terms of control over technical and administrat ive capab i l i t i e s . F i na l l y , coercive power i s expressed with the use of weapons,and m i l i t a ry force etc. Professional ism represents the normative re lat ionsh ip between the nurse and the patient which developed as a natural extension of the vocational ism of nursing in the 19th c. (Wil l iams, 1974). Will iams notes that th i s vocational ism elevated the status of both, the nurse and the pat ient. The sanct i ty of caring for a help-less adult human being establ ished the meaning of the work of nursing in the soc ia l context in which i t was performed. In th is set t ing power was expressed in symbolic fashion by persuasion. The in teg r i t y of the nurse and patient remained in tac t . 188 Efforts to profess ional ize nursing began late in the 19th C (Abel-Smith., I960] and in B r i t i s h Columbia resulted in the passing of the Registered Nurses'Act of 1918. Because nursing i s seen to have achieved many of the character i s t i cs associated with profess iona l i zat ion (Wilensky, 1964) and because nurses are seen to have a strong commitment to the service ideal i e : pat ient care, the RNABC i s characterized as havi a commitment to professional ism. Thus, the term 'profess ional ism' as i t was interpreted in the f i r s t three quarters of the twentieth century, w i l l be used to represent the normative stance of both the indiv idual nurse and the assoc iat ion. While normative re lat ionships continued to dominate, a number of forces moved nursing towards u t i l i t a r i an i sm . With the end of the F i r s t World War there was concerted e f fo r t to standardize and improve the education of student nurses, and improve the working con-d i t ions of graduate nurses. The end of pr ivate nursing duty as a major employment group in nursing changed the status of the majority of nurses from re l a t i v e l y independent practioners to employees of i n s t i t u t i on s . This change in employment status and the r i se of technology and the subsequent necessity for hosp i ta l i za t ion i n s t i t u t i ona l i z ed the re lat ionships involved in the care of the s ick . During th i s period, the value of nursing and the "proper conduct" of nurses and of the nursing society were dominant themes of the professional be l i e f system (Jacox, 1971). 189 As nursing struggled to become complementary to the physic ian, took on increas ingly sophist icated technical tasks and delegated d i rec t human care to the ass istant to the professional nurse, nursing attempted to declare i t s e l f an autonomous profession (Katz, 1969). Patients became both the means of work and the meaning of work. The helpless adult had become a c l i n i c a l categor izat ion, both nurse and the patient had los t the i r sanct i ty (Wil l iams, 1974). In B r i t i s h Columbia, u t i l i t a r i an i sm amongst nurses has been expressed as unionism since the ear ly 1940's (Registered Nurses Associat ion of B r i t i s h Columbia, Labour Relations D iv i s ion , 1977). While unionism in nursing has continued to espouse a commitment to high standards of pat ient care, the dominant value i s a "rat ional commitment" (Etz ioni 1968, pp.96) to the i n s t i t u t i on of employment. This rat ional commitment was i n i t i a l l y negotiated in economic terms and more recently in demands for d i rec t par t i c ipa t ion in the decisions af fect ing the working environment. The recent demands (Unhappy VGH nurses, 1978) for increased par t i c ipa t ion in the decisions af fect ing the work environment may be part of the rat ional commitment to the i n s t i t u t i on of employment, or i t may be a ' l a s t f l i n g ' at negotiat ing normative re lat ionships in patient care. Summary. This study would appear to conf i rm:Etz ion i ' s contention that re lat ionships with in society are moving from the normative to u t i l i t a r i a n . The pr i ce , for nurses, in th i s sh i f t has been the loss of 190 sanct i ty for both the patient and the nurse. Co l lec t ive bargaining by nurses, in B r i t i sh . Columbia has represented the move to u t i l i t a r i an i sm But co l l e c t i ve bargaining has also represented an attempt to regain los t sanct i ty , f i r s t l y by estab l ish ing a competitive economic status and secondly by attempting to negotiate the context of the nurse-patient re la t ionsh ip . Conclusion This chapter has considered selected paradigms' from the l i t e r a tu re on soc ia l po l icy and the l i t e ra tu re of sociology in an attempt to explain the f a i l u re of the terms and condit ions of employment of nurses to improve, and the subsequent entry of nurses in B r i t i s h Columbia into co l l e c t i ve bargaining. 191 CHAPTER Ideological Sh i f t 8 : The Attempt To Resolve Chronic Stra in Introduction This study began with the notion that the minutes of the Registered Nurses'Associat ion of B r i t i s h Columbia would provi<kan explanation for the ear ly development of co l l e c t i ve bargaining by nurses in B r i t i s h Columbia. On one level the explanation can be reduced to the understanding that nurses in B r i t i s h Columbia were no longer w i l l i n g to to lerate the i r perceived economic and socia l d i spa r i t y . On another l e v e l , the data i s a study of a sh i f t in ideology of a spec i f i c group with in soc iety. As was noted e a r l i e r , Bl ishen has wr i t ten of the ideological response of doctors in Canada to soc ia l change, in par t i cu la r to changes in the f inancing of health care. S im i l a r l y , th is study i s about the response of nurses in B r i t i s h Columbia, as ref lected by the data in the i r Assoc iat ion 's minutes, to changes in soc iety. This chapter examines the ideologica l sh i f t of nurses beginning with a discussion of the ro le of ideology and continuing with a discussion of the or ig ins and evolut ion of nursing's ideologica l stance. This chapter concludes with some comment on the impl icat ions to the health care system of the sh i f t of ideology of nurses. The Role of Ideology The ro le of ideology in the study of society has a long h is tory (Geertz 1964, pp.47-52). Geertz writes that "there are 192 current ly two main approaches to the study of the socia l determinants of ideology: i n te res t theory-and s t ra in theory (pp.52). Interest theory is considered to be rooted in the ' cu l tura l idea systems' of soc ia l systems. Ideological statements are seen "against the background of a universal struggle for advantage, (pp.52). While s t ra in theory takes cognizance of soc ia l systems and personal i ty systems, s t ra in theory d i f f e r s from interest theory in the acceptance of the idea that no soc ia l structure i s completely successful in coping with con f l i c t i ng values. Thus s t ra in theory adopts the notion of the "chronic malintegration of society" (pp.54). Interest theory's concentration on indiv idual or group quest for advantage i s considered to be too simple an explanation. Thus Geertz quotes Sutton's de f i n i t i on of ideology as "a patterned reaction to the patterned st ra ins of soc ia l ro le" (pp.52). The concept of s t ra in i s not viewed so much as "an expla-nation of ideologica l patterns but (as) a general ized label for the kinds of factors to look for in working out an explanation" (Sutton quoted by Geertz pp.54). Geertz has i den t i f i ed four main classes of explanation for the use of ideology. These are l ) " the cathart ic expla-nation" that i s , "the safety-valve" or scapegoat theory. . . . 2)"the morale explanation" that i s , "the a b i l i t y of ideology to. sustain ind iv iduals (or groups) in the face of chronic s t r a i n . . . 3) the so l i da r i t y exp lanat ion. . . the power of ideology to kni t a soc ia l group or c lass together . . . " and 4) the advocacy explanation " in which the ideologists state the problems for the larger soc i e t y . . . " (pp.55). Geertz 193 acknowledges the l im i ta t ions of the concept of ideology and points out that the ro le of the symbolic out le t is more eas i l y understood than the complex process of the symbolic formulation of ideology. The Origins and Evolution of Nursing's Ideological Stance To understand the or ig ins and evolut ion of nursing's ideological stance, i t i s necessary to examine nursing's commitment to the care of the s ick . The or ig ins of the vocationalism of nursing, a ca l l i ng which "involved the tota l submission and eradicat ion of se l f " (Wil l iams, 1974) i s found in the po r t ra i t of nursing heroines and prac t i t i oners . In the eyes of nursing h i s to r ians , Fabiola , an ear ly Chr is t ian saint, characterized the work of nursing s i s te r s of both Roman Cathol ic and Protestant orders through whom nursing i s said to have survived.(Goodnow, 1916) Florence Nightingale represented the 19th century expression of th is c a l l i n g . Will iams (1974) writes of the ideologica l resolut ion of the ' ca l l i ng ' to nursing and the r e a l i t y of the soc ia l status and economic pos i t ion of women of the 19th and 20th century, in re l a t i on -ship to the care of the helpless adul t . The status of nurses was low, they had no legal r ight to wealth or property, except through men's dispensat ion, and male control was further sustained through the value of 'obedience'. "The re la t ionsh ip between doctors and nurses ref lected the same structura l and moral condit ions of male dominance. 194 Then, as now, doctors have a monopoly of the knowledge re la t ing to disease and i t s treatment, and nurses' work i s regarded as being in service to th i s knowledge...".Obedience became the ideological reso lu-t ion to the r e a l i t y of soc ia l status and job s i tuat ion of the 19th century nurse. Embodied in an ideology of vocational ism, "the se rv i l e ro le of nursing and the submission that i t required of i t s incumbents, was consolidated and adjusted to psychologica l ly . For, being ca l l ed , a nurse could see her s e r v i l i t y , not as her r igh t fu l place and her r i gh t fu l work, but as her tota l s a c r i f i c e " . This ideologica l stance was consistent with 19th century values, ( re l i g i ous , soc ia l and economic) and with Night ingale 's e f f o r t to disabuse nursing of i t s image of Sairey Gamp. The performance of nursing acts for the s ick adult were thus part of a s a c r i f i c a l performance regarded by the nurse as her p r i v i l ege and through which she found her sa t i s fac t ion and f u l f i l lmen t . Defining the care of the s ick as a s a c r i f i c a l performance elevated both the patient and nurse and conferred a sense of d ign i ty on both (Wil l iams, 1974). Florence Nightingale adopted th is s p i r i t of vocational ism from Kaiserwerth (Goodnow, 1916, pp.49) and promoted i t in England by establ ish ing St. Thomas's school for lady pupils in 1860. The graduates were sought by North American schools of nursing (Gibbon and Mathewson, 1947, pp.146; Kal isch and Ka l i sch, 1978, pp.88-91) in an e f fo r t to reform lay nursing pract ice . The ear ly nursing leaders did not envisage reg i s t ra t i on . Because of open recruitment and the spread of schools of nursing of varying qua l i t y , reg i s t ra t ion 195 represented a means of i n s t i t u t i ona l i z i ng the reform of nursing. Nightingale did not support reg i s t ra t ion (Abel-Smith, 1960, pp.65) but the f l e x i b i l i t y of the Nightingale legend (Whittaker and Olesen, 1967, pp.30-46) allowed ear ly reformers to ignore t h i s , although Abel-Smith (1960, pp.65) suggests tha t , in Br i ta in ,her views on reg i s t ra t ion may have been ignored for other reasons. Strauss (1966, pp.65-84) describes the adoption of the Nightingale model by nursing leaders in the United States. This model f a i l ed because of the p ro l i f e ra t i on of schools of poor qua l i t y . Subsequently an educational ideology (Strauss, 1966, pp.72) of reform through un ivers i ty education was adopted. I t was the intent ion of those programs to change nursing by providing better qua l i f i ed teachers who would teach nursing students bet ter , and who would work towards decreasing students working hours and improving standards of care. Nursing leaders in Canada and the United States have been c lose ly associated since the f i r s t attempts to organize professional nursing associat ions in North America. The Nurses'Associated Alumnae Associat ion of the United States and Canada was founded in 1896. The objects of the Associat ion were to "establ ish and maintain a code of e th i cs , to elevate the standard of nursing education, to promote the usefulness and honor, the f inanc ia l and other interests of the nursing profess ion" . This Associat ion l a te r became the American Nurses' Associat ion while the Canadian branch ul t imately became the Canadian Nurses' Associat ion in 1930. (Gibbon and Mathewson, 1947, pp.356-358). The influence of the educational models crossed the 196 49th p a r a l l e l . B r i t i s h Columbia's nursing leaders part ic ipated in th is process, i n i t i a t i n g the opening of the f i r s t Canadian un ivers i ty school of nursing in 1920. The out come of th is a c t i v i t y was to re inforce the idea of nursing as a profession in the minds of nurses and the publ ic (Strauss, 1966, pp.71-72). This too was accomplished in B r i t i s h Columbia. During the l eg i s l a t i v e debates on reg i s t r a t i on , nursing was referred to as "an honourable and useful profession" (The nursing profess ion, 1916). Strauss points out that during th is period a concept of a 'profess ion ' had hardly been developed in North America. F lexner 's report on medical education had enunciated the charac ter i s t i cs of a profession and the reform of medical education began. Although Canada was never faced with the diploma m i l l s of the United States medical schools, Flexner did have an impact on Canadian medical education (MacNabb, 1970, pp.33). Becuase of the re lat ionsh ip between nurses and doctors, nurses looked up to physic ians, and leaders such as Isabel l Hampton-Robb re- inforced th i s : "Medicine has made us a profession: now we must l i v e up to i t " . (Robb. 1907), c i ted by Strauss, 1966, pp.72). From the points of view of soc io log i s t s , i t was considered that , by 1933, nursing in England was becoming profess ional ized (Carr-Saunders and Wilson, 1933, pp.1.17-121). In North America, the debate has been lengthy with many considering nursing a semi-profession. Katz (1969) t yp i f i e s th is pos i t i on . 197 Professional ism, as an ideology was adopted by nurses and became a source of c on f l i c t with the ideology of vocational ism. The value system of medicine and nursing sh i f ted to a respect for the expert use of hospital based technology. The task of nursing sh i f ted from intimate tasks 'performed s a c r i f i c a l l y ' such that the task, the nurse and the patient were ' sanc t i f i ed and consecrated', to actions and judgements which were based on...mainly c l i n i c a l de f in i t i ons of i l l n e s s and he lp lessness. . . . An ideology of vocation becomes dysfunctional or obsolete where s k i l l e d tasks require independent judgement rather than obedience, and since the acqu is i t ion of s k i l l s has to be paid fo r , the task to which they re late cannot then be regarded by soc iety, doctors or nurses as menial. Since they are not seen as menial then they do not require a sac r i f i c e of s e l f , but seen as s k i l l e d they require, rather, an assert ion of s e l f in creat ive and innovative act ion. These newer at t r ibutes of nursing are embodied in the ideology of Profession. When analysed in a spec i f i c context of usage i t i s seen as a claim for equal i ty between nurses and doctors, and here the re la t ion between men and women of the cul ture i s again re f l ec ted . It asserts that nursing is a profess ion, and that as such ' i t i s not anc i l l a r y to medicine, but complementary to i t . The claim to be a profession thus importantly involves the break of the t rad i t i ona l re la t ionsh ip between doctors and nurses, and we have been that th is re lat ionsh ip i s one dimension of the image of the bedside nurse. . . 'P ro fess iona l ' imagery attends the bedside nurse performing tasks that are highly s k i l l e d . This i s in contrast to the t rad i t i ona l bedside nurse whose work we have seen centred importantly on helplessness and was performed through notions of humanitarian service and newly const i tuted routines that preserved the person and adult-hood of the s i ck . Where a 'p ro fess iona l ' nurse's work focuses on c l i n i c a l procedures and observations, then helplessness as a condit ion of an adult human being may become categorised, and even lose i t s e l f as a human condi t ion, through the emphasised use of c l i n i c a l terms and c l i n i c a l l y oriented judgements and behaviours of the nurse. (Wil l iams, 1974). 198 As Will iams states, the r i se of a professional ideology resulted in a claim by nurses to control the i r own work. But before th i s claim was made, a comparison of the economic reward of the work of nurses to reward for the work of other workers was made by nurses. Canadian nurses were voic ing a sense of economic d i spar i ty in the f i r s t issues of the Canadian Nurse (Canadian Nurse 1907; 1908). Early advocates such as Helen Randal, thinking change would come with improved education of nurses and with the education of society to the needs of nurses, used moral suasion to achieve the closure of numerous substandard schools in the Province. But improved education did not bring a change in working condit ions, and a succession of advocates challenged the system. Thus Weir can be i den t i f i ed as an external advocate who made a very c lear statement of the problems of nursing. The promise of health insurance sustained nurses for a period of time but not i nde f i n i t e l y . The CCF played an advocacy ro le in the late 19301s as did Mrs. Eaton. Internal advocates include the nurses who struck at Comox in 1939 and A l i ce Wright. While A l i ce Wright was hired by the Associat ion because of her expert ise in nursing education, with the expectation of acting as an educational consultant and managing the Assoc iat ion, she was confronted with ' rest lessness amongst the nurses ' . A l i ce Wright's successors in co l l e c t i ve bargaining, Evelyn Hood and Nora Patton played roles that , although new, had been leg i t imized by the RNABC and CNA membership. A l i ce Wright would then, in Watkins' (1975) terms, have played a c r i t i c a l l eg i t im iz ing ro le by v i r tue of her pos i t ion in the socia l structure of nursing in B r i t i s h Columbia. 199 Underlying the ideologies of vocational ism, professional ism and reform through reg i s t ra t ion and improved education i s a commitment to the care of the s ick . The most c l ea r l y stated example of th i s commitment in th i s study i s found in the interviews with pract ic ing nurses quoted by the Eaton Report. The nurses are quoted as"bel ieving that the very fact that they can be depended upon to render service without protest and without drast i c act ion has kept them working hours of such length that the i r health suffers and normal essent ia l soc ia l a c t i v i t i e s are denied to them" (Eaton 1938, pp.12-13). The commitment to th is ideology, by both the leaders and the grassroots nurses insured the performance of roles "that otherwise might have been abandoned in despair or apathy" (Geertz, 1964, pp.55) Geertz has ca l led th is the 'morale explanation' of ideology, that i s 'the a b i l i t y of ideology to sustain ind iv idua ls or groups in the face of chronic s t ra in " (Geertz, 1964, pp.55). The commitment to the care of the s ick also represents Geertz's s o l i d a r i t y explanation of ideology: that i s , the power of ideology to bind a socia l group or c lass together. But as the narrat ive has shown, the ideologica l commitment of nurses, while never giv ing up a commitment to pat ient care, sh i f ted in expression. This i s the advocacy explanation of ideology (pp.55). The chronic s t ra in of nurses. The chronic s t ra in of nurses has three read i ly i den t i f i ab l e sources, 1) the nature of the work i t s e l f , 2) the terms and condit ions under which the work i s undertaken, and 3) the re lat ionsh ip of the 200 work and!'i;;ts rewards to the work and rewards of others. Thus f a r , in th is study l i t t l e attent ion has been given to the nature of the work i t s e l f . The work of nursing has been influenced by the development of technology in the care of the s ick and the p ro l i f e ra t i on of a l l i e d health workers. As a consequence of the development of technology, medicine has passed to nursing i t s ' d i r t y work' (Hughes, 1958, pp.49-52) and a subsidiary work force has been introduced into nursing which allows nurses to delegate the i r own d i r t y work. In addit ion to Hughes' concept of d i r t y work, there i s the d i r t y work that ar ises out of the care of patients that i s not delegated. Will iams (1974) has defined bedside nursing as "a complex compound of actions and tasks performed in .a context of soc ia l re l a t i ons , the evaluation of these tasks . . . en ta i l s an evaluation of persons ( spec i f i c a l l y . . . doctors, nurses and s ick people) and the i r status re l a t i ve to one another". Henderson has defined the function of the nurse as "ass is t ( ing) the ind iv idual s ick or we l l , in the performance of those a c t i v i t i e s contr ibut ing to health or i t s recovery (or a peaceful death) that he would perform unaided i f he had the necessary strength, w i l l or knowledge. And to do th is in such a way as to help him gain independence as rap id ly as possib le" (Henderson, 1964, pp.63). Thus far two types of d i r t y work have been i d en t i f i e d , 1) those tasks delegated by medicine to nursing, and 2) those tasks re lated to the intimate care of pat ients. But there i s a th i rd type of d i r t y work not usual ly acknowledged beyond a l lus ions to bedpans. 201 Esther Paulson describes how she, as the only nurse on a tuberculosis ward at the Royal Columbian Hospital in 1929 had to clean a l l the l inen of blood and excreta before i t went to the laundry in order to protect the laundry s ta f f from possible i n fec t i on . !: Helen Shore describes a s im i la r a c t i v i t y as a student at VGH in the 1940's. While nurses are no longer required to prepare l inen for the laundry, and hospita ls are staffed with personnel assigned to clean the hospital premises nurses do continue to par t i c ipate in modern versions of th i s type of work. But more importantly, technological advances have resulted in the po s s i b i l i t y of salvaging patients devastated by trauma or surgical procedure, thus intens i fy ing the nature of the intimate care of pat ients. Consequently nurses perform the tasks of the f i r s t two types of d i r t y work which may be profoundly d i s t a s t e f u l . While these tasks have been accepted and performed as a part of nursing care, the r e a l i t y of the second and th i rd i s often forgotten or ignored and thus i t i s important to reca l l them to estab l i sh the r e a l i t y of nursing work. The difference between the performance of ' d i r t y work* with an ideology of vocational ism and the current ideology i s that the loss of d ign i ty and sanct i ty of both the patient and the nurse i s i n t ens i f i ed . The fact that nurses continue to care for the s ick i l l u s t r a t e s Geertz 's s o l i d a r i t y explanation of ideology, that i s the power of ideology to bind a soc ia l group or .c lass together. Greenwood (1966) has i den t i f i ed the existenceof a professional culture as a charac te r i s t i c of professional groups. Watkins (1976, pp.111-113) 202 takes th is not ion, and discusses i t in terms of "something that may be meaningful and s ign i f i can t because certa in ind iv iduals or groups have come to adopt i t " . He notes also that "the extent of the i r adoption of the ' i d e a l ' , the degree to which th i s in pract ice effects the i r behaviour, what they regard as circumstances which re l ieve them of various of the self-imposed ob l igat ions , are a l l matters of empirical fac t and have to be discovered by invest igat ion . I t i s also useful to recognize the existence of cer ta in 'pos i t ions ' in the soc ia l structure where persons may be located in an important ' con t ro l l i ng ' way. In the case of the nurses in B r i t i s h Columbia, the obl igat ions which developed out of the vocational ism of 19th century nursing and which were seen as the normative re la t ionsh ip between nurses and society changed over time. The change occurred because of changes in the technology of health care, changes in the pract ice of nursing and because of changes in the values and norms of soc iety. These changes created a discrepancy which could not longer be accommodated. Advocates, with in and external to nursing, attempted to accommodate the con f l i c t i ng forces of the old ideologies and the new pressures. Geertz defines the advocacy explanation "of ideologies (and ideo log is ts) as a r t i c u l a t i ng , however p a r t i a l l y and i n d i s t i n c t l y , the st ra ins that impel them, thus forc ing them into the publ ic not ice. Ideologists state the problems for the larger soc ie ty , take sides on the issues involved and 'present them in the court ' of the ideo log ica l . market place" (White, c i ted by Geertz). Although ideological advocates (not altogether unl ike the i r legal counterparts) tend as much to ; 203 obscure as to c l a r i f y the true nature of the problems involved, they at least ca l l attent ion to the i r existence and, by po lar i z ing issues, make continued neglect more d i f f i c u l t " (pp.55). Conclusion: Omens for the Future The move towards acceptance of co l l e c t i ve bargaining by nurses was influenced by the sh i f t from an ideology of vocationalism to professional ism. The f a i l u re of these ideologies to re l ieve the chronic s t ra in of nurses, exacerbated by the recognit ion of the discrepancy in economic value between the nurse and subsidary health workers and others in soc iety, resulted in the adoption of co l l e c t i ve bargaining. A factor in the development of mi l i tancy was that hospita ls had ceased to be char i table i n s t i t u t i on s . While Prov inc ia l funding of hospita ls ( in 1948) did not re l ieve hospi ta ls of economic pressures, nurses no longer had to view themselves as part of a char i table system. The demand for increased wages by nurses was restrained between 1948-56 but the re ject ion of the conc i l i a t i on report by the hospitals in 1957 prec ip i tated a new mi l i tancy. In 1959 a s t r i ke vote was taken to support increased wage settlements. The support of these actions by the Associat ion represented an escalated level of mi l i tancy. While nurses in B r i t i s h Columbia have been in the forefront of co l l e c t i ve bargaining by Canadian nurses, there has been increased use of co l l e c t i ve bargaining by employed professionals general ly (Goldenberg, 1975) and th is has, no doubt, been an important 204 leg i t im iz ing factor for nurses. Only in 1976 was s t r i ke act ion taken by nurses in B r i t i s h Columbia, (since the 1939 s t r i ke of the nurses of St . Joseph's Hosp i ta l , Comox) In other provinces, both nurses and doctors, had establ ished precedents, (St. Jus t ine ' s nurses s t r i k e , 1963; doctors' s t r ikes in Saskatchewan, 1962, and in Quebec, 1967 and 1970). These s t r i kes have been ca l led to "protect the publ ic in terest" (Goldenberg, 1975, pp.286-288). Ha l l ' s predict ion of c on f l i c t because of a "gross inequal i ty in d i s t r i bu t i on of benef i ts" (Ha l l , 1967, pp.5) had mater ia l i zed. However, negotiat ions on behavioural issues (E t z i on i , 1968) have proved more d i f f i c u l t to solve for a l l professional groups (Goldenberg, 1975, pp.288). The entry of the Associat ion into co l l e c t i ve bargaining has a l l ev ia ted but not re l ieved nurses of the i r sense of economic d i spa r i t y . Twenty years a f ter nurses entered co l l e c t i ve bargaining in B r i t i s h Columbia, Noel H a l l , addressing the 50th Annual Conference of the BCHA in 1967, spoke of the vlaue system of society which yu.1 un-endorsed these d i spa r i t i e s by v i r tue of the wage structure. He predicted, with par t i cu la r reference to nursing, that c on f l i c t would resu l t from a s i tuat ion in which education, t ra in ing and s k i l l were valued but not rewarded. The con f l i c t has been defined only in economic terms unt i l recent ly. The dispute at VGH in which several nursing administrators were summarily f i r ed because of the i r attempts to deal with the lack 205 of grassroots nursing par t i c ipa t ion in the decisions that e f fect nurses work (Bellyache at VGH, September 2, 1978) represents an extension of the con f l i c t in which education, t ra in ing and s k i l l are valued but not rewarded. Indeed, in Wi l l iams' terms, "the assert ion of s e l f i n creat ive and innovative act ion" so valued in the professional nurse i s thwarted. Negotiaton on the issue of the par t i c ipa t ion of nurses in the decis ions that a f fec t the i r work, that i s , the terms and condit ions under which employment for the pract ice of nursing i s undertaken, i s l i k e l y to be the next phase in the attempts by nurses to re l ieve the i r chronic s t r a i n . Because the underlying commitment to patient care seems to co-ex is t with Wi l l iams' concept of nurses' professional ideology, nurses w i l l attempt to regain the d ign i ty and sanct i ty of the i r work by bargaining on normative issues. Improved sa lar ies cannot f o res ta l l th i s i nde f i n i t e l y (Krauss, 1977). This w i l l challenge the present structure and organization of health at a l l leve ls of the de l ivery system. Since there are strong vested interests in the status quo the challenge w i l l be met with act ive res istance. Turbulence more complex than that generated by the demand for improved sa lar ies can be ant i c ipated. 206 R E F E R E N C E L I S T ABEL-SMITH, B. A h is tory of the nursing profession. London: Heinemann, 1960. AGNEW, G.H. The nurses' labour code in Ontario. Canadian Hosp i ta l , 1950, 27, 6, 27-28. AGNEW, G.H. Report of the Proceedings of the 26th Annual Convention  of the B r i t i s h Columbia-Hospital Assoc iat ion, 1943, 28-30. ALFORD, R. The p o l i t i c a l economy of health care: dynamics without change. Po l i t i c s and Society, 1972, Winter, 127-64. ALLENTUCK, A. Who speaks for the patients? Don M i l l s , Ontario: Burns and MacEachern, L t d . , 1978. AMERICAN NURSES ASSOCIATION. The ro le of the d i rector of an organized nursing service in co l l e c t i ve bargaining. American Journal  of Nursing. 1970, 70, 3, 551-6. AMERICAN PSYCHOLOGICAL ASSOCIATION. Publ icat ion manual (2nd ed. ) . Baltimore: Garamond/Pridemark Press, Inc. , 1979. ASHLEY, J.A. Hospi ta ls , paternal ism, and the ro le of the nurse. New York: Teacher's College Press, 1976. BACHARD, M. A discussion paper on the three major roles of prov inc ia l  nurses' organizat ions. Ottawa: Canadian Nurses Assoc iat ion, 1973. BADGLEY, R.F. Health workers s t r i kes : soc ia l and economic bases of c on f l i c t . International Journal of Health Serv ices. 1975, 5_, 1, 9-17. BADGLEY, R.F. and Wolfe, S. Doctor's S t r i ke . Toronto, MacMillan of Canada, 1967. BAILLIE, D.M. The whole "set-up" i s wrong. Bu l l e t i n of the Vancouver  Medical Assoc iat ion, 1940, j_6, 242-46. BAUMGART, A . J . Nursing l eg i s l a t i on : a discussion paper prepared for  the Registered Nurses' Associat ion of B r i t i s h Columbia, Vancouver, 1973. BAUMGART, A . J . Professional ob l igat ions , employment r e spons i b i l i t i e s , and co l l e c t i ve bargaining: a new agenda for the 1980's. Address to the 4th Annual RNABC. Labour Relations D iv i s i on , 1980. 207 BECKETT, A. Co l lec t i ve act ion by nurses to improve the i r sa la r ies and working condit ions. (Women's Bureau, Department of Labour.) Ottawa: Queen's Pr inter and Contro l ler of Stat ionary, 1964. BEITH, E. Registered Nurses Associat ion of B r i t i s h Columbia,  Annual Meeting, 1946, 1-4. BEITH, E. Report of the labour re la t ions committee. Canadian Nurse, 1944, 40, 693-695. BEITH, E. Reports of the l eg i s l a t i v e committee. Canadian Nurse, 1944, 40, 692-693. BELLABY P. and Oribabor P. Determinants of the occupational strategies adopted by B r i t i s h hospital nurses. International Journal of  Health Sciences, 1980, 1_0_, 2, 292-309. BELLYACHE at V6H. The Vancouver Province, September 2, 1978 pp.14. B i l l g iv ing better condit ions. Dai ly Province, December 8, 1938 pp.9. B i l l w i l l meet the s i t ua t i on . Dai ly Co lon is t , Apr i l 16, 1918, pp.7 BLAIR, W. Special o f f i c e r report: hospital industry co l l e c t i ve bargaining  system. V i c t o r i a , Min ister of Labour, 1974. BLISHEN, B.R. Doctors and doctr ines: The ideology of medical care in  Canada. Toronto: Univers i ty of Toronto Press, 1969. BLOOM, J .R . , O 'Re i l l y , C.A. and Par le t te , G.N. Changing images of professional ism: the case of publ ic health nurses. American  Journal of Publ ic Health. 1979, 69, 1, 43-6. BLOOM, J .R . , O 'Re i l l y , C.A. and Par lette. . G.N. Co l lec t ive bargaining by nurses: a comparative analys is of management and employee perceptions. Health Care Management Review, 1980, Winter, 25-33. BRADFORD, J.D. B r i t i s h Columbia hospita ls learn to l i v e with labor. Canadian Hosp i ta l , 1965, 42, 33-5. BRAUND, E. Second annual report of the d i rec tor of prov inc ia l placement serv ice . Registered Nurses Associat ion of B r i t i s h Columbia, Annual Meeting, 1945, 19. A b r i e f analysis of the tentat ive plan suggested by the health insurance committee. Bu l l e t i n of the Vancouver Medical Assoc iat ion, 1937, 13, 5, 97-100. 208 BRITISH COLUMBIA, 25th. Report of the Provinc ia l Board of Health, V i t a l ~ S t a t i s t i c s , V i c t o r i a , Br i t i sh - Columbia:Pr in ter to the King-s Most Excel lent Majesty, 1921. : Br i t i s h Columbia Hospi ta ls ' Assoc iat ion. Report of the Proceedings of the  2nd Annual Convention, 1919, pp.112; 164. B r i t i s h Columbia.Hospitals' Assoc iat ion. Report of the Proceedings of  the 4th Annual Convention, 1921 , 43. B r i t i s h Columbia Hospita ls ' Assoc iat ion. Report of the Proceedings of  the 14th Annual Convention, 1931, pp.34; 101. B r i t i s h Columbia Hospi ta ls ' Assoc iat ion. Report of the Proceedings of the  20th Annual Convention of the B r i t i s h Columbia Hospi ta ls '  Assoc iat ion, 1937, 71-72. B r i t i s h Columbia Hospi ta ls ' Assoc iat ion. Report of the Proceedings of the  21st Annual Convention of the B r i t i s h Columbia Hospi ta ls ' Assoc iat ion, 1938, 20-22; 50-59; 75-77. B r i t i s h Columbia Hospita ls ' Assoc iat ion. Report of the Proceedings of the  22nd Annual Convention of the B r i t i s h Columbia Hospi ta ls ' Assoc iat ion, 1939, 57. B r i t i s h Columbia Hospita ls ' Assoc iat ion. Report of the 23rd Annual  Convention of the B r i t i s h Columbia Hospi ta ls ' Assoc iat ion, 1940, pp.28-9. B r i t i s h Columbia Hospi ta ls ' Assoc iat ion. Report of the 32nd Annual  Convention of the B r i t i s h Columbia Hospi ta ls ' Assoc iat ion, 1949, 126. BROWN, L.C. (S.J .) The Cathol ic hospital and unionizat ion of i t s employees. Hospital Progress, 1967, 48, 57-60. BRUNER, R. "Toledo Plan" supported by hospital and labor. Modern  Hosp i ta l , 1959, 93, 1 , 76-77. BULLOUGH, B. The new mi l i tancy in nursing. Nursing Forum, 1971, JfJ, 3, 273-288. BULLOUGH, V.L. and Bullough, B. The problem of goal changes. Nursing Forum, 1965, 4, 2, 80-92. CAMERON, G.S. Foreward to Weir, G.M. Survey of Nursing Education  in Canada, Toronto: Univers i ty of Toronto Press, 1932. 209 CAMPBELL, M.A. Committee on l e g i s l a t i o n , const i tut ion and by-laws. Registered Nurses' Associat ion of B r i t i s h Columbia, 1966, 46. CAMPBELL, M.A. Committee on l e g i s l a t i o n , cons t i tu t ion , and by-laws. Registered Nurses' Associat ion of B r i t i sh Columbia, 1967, 44. Canadian Hospital Counci l . Survey of hospital personnel and f a c i l i t i e s . Canadian Hospital Council in conjunction with the Canadian Medical Procurement and Assignment Board. Ottawa, Canadian Hospital Counci l , 1943, 46, 7-8. Canadian Nurse, Good food for nurses. The Canadian Nurse, 1907, 3_, 3, 149-50. Canadian Nurse. The nurse's day. The Canadian Nurse, 1908, 4, 3, 324-25. Canadian Nurse, The overworked nurse. The Canadian Nurse, 1907, 3_, 12, 645-646. Canadian Nurse, the Graduate Nurses'Association of B r i t i s h Columbia. The Canadian Nurse, 1928, 24, 587-8. Canadian Nurses' Assoc iat ion. Co l lec t i ve bargaining for nurses. Ottawa; Canadian Nurses'Associat ion, 1966. Canadian Nurses' Assoc iat ion. Co l lec t ive bargaining l eg i s l a t i on of fers so lu t ion . Canadian Nurses' Associat ion Bu l l e t i n , 1968, 64. Canadian Nurses' Assoc iat ion. Survey of nursing. Canadian Nurses' Associat ion under the auspices of the Canadian Medical Procurement and Assignment Board. Ottawa: Canadian Nurses' Assoc iat ions, 1943. Canadian Nurses' Assoc iat ion. Why do nurses need co l l e c t i ve bargaining l eg i s l a t i on? Canadian Nurses'Associat ion Bu l l e t i n , 1968, 64, 3. Canadian Nurses'Associat ion. Withdrawal of se r v i ce . . . a dilemma for nursing. Canadian Nurse, 1968, 64, 29. CAPELLE, E. Committee on Leg i s la t ion . Registered Nurses' Associat ion  of B r i t i s h Columbia, Annual Meeting, 1956, 60-61. CARPENTER, M. The new managerial ism and professional ism in nursing. In M. Stacey, and M. Reid, (eds.) Health and the Div is ion of  Labour. London: Croom Helm, 1977. 210 CARR-SAUNDERS, A.M., Wilson P.A. The professions. Oxford: At the Clarendon Press, 1933. Cavers, A.S. Our school of nursing: 1899-1949. Vancouver: Vancouver General Hosp i ta l . Census of Canada. Occupation of the population 10 years of age and over, c l a s s i f i e d by sex, for provinces, 1921, 32-3. Ottawa: King's P r in te r . CHERKASKY, M. Why we signed a union agreement. Modern Hosp i ta l , 1959, 33, 1 , 64-70. C i ty w i l l h i re married nurses. Vancouver Sun, Apr i l 13, 1955, pp.1 CLARK, J . The r ight to s t r i k e . Nursing mir ror , 1979, 149, 8, 20-21. CLELAND, V.S. The supervisor in co l l e c t i ve bargaining. Journal of  Nursing Administrat ion, 1974, 4, 5. 33-5. COBURN, J . , "I see and am s i l en t " : a short h is tory of Nursing in Ontario. In Acton, J , Goldsmith, P. and Shepard, B. (Eds.)A  Women at work, Ontario, 1850-1930. Toronto: Canadian Women's Educational Press, 1974. COLE, S. The soc io log ica l method. Chicago: Rand McNally College Publ ishing Company, 1976. CONTA, A.L. Bargaining by profess ionals . American Journal of Nursing. 1972, 72, 2, 309-12. CONNELLY, P. Last h i red, f i r s t f i r e d . Toronto: The Women's Press, 1978. COOPER, M. Economics of need: the experience of the B r i t i s h Health Service. In.M.PerTman (Ed:.), Conference on the economics of  health and medical care. Proceedings of a conference held at the International Economics Associat ion at Tokyo, 1973. New York: John Wiley and Sons L td . , 1974. COPELAND, E. The annual report of the labour re lat ions committee of the BCRNA for 1945-46. Registered Nurses'Association of B r i t i s h  Columbia, Annual Meeting, 1946, 1-4. COPELAND, E. Annual report of the labour re la t ions committee. Registered Nurses'Association of B r i t i s h Columbia, Annual  Meeting, 1947, 1-4. COPP, L.A. Professional change: which trends w i l l nurses endorse. International Journal of Nursing Studies, 1978, ]0_, 55-63. 211 CORMICK, G.W. Co l lec t ive bargaining experience of Canadian nurses. Labor Law Journal , 1969 October, 667-682. CREASOR, A. Address of the president. Registered Nurses' Associat ion,  of B r i t i s h Columbia, Annual Meeting, 1954. CRUICKSHANK, N.A. The case for unionizat ion of hospital workers, Modern Hosp i ta l , 1959, 93, 1, 71-2. CUNNINGHAM, R.J. Committee on nursing educaton. Registered Nurses' Associat ion of B r i t i s h Columbia, Annual Meeting, 1967, 61. CUNNINGHAM, R.J. Committee on nursing education. Registered Nurses' Associat ion of B r i t i s h Columbia, Annual Meeting, 1968, 16-19. DAVIE, C.F. Final report of the Royal Commission on state health  insurance and maternity benef i ts . V i c t o r i a , 1932. DAVIES, C. Four events in nursing h is tory: a new look - 2. Nursing Times, 1978, 74, 18, 9-17. Declare b i l l too a rb i ta ry , Dai ly Co lon is t , Apr i l 17, 1916, pp.3. DENTON, J.A. Att i tudes toward a l ternat ive models of unions and professional assoc iat ions, Nursing Research, 1976, 25_, 3, 178-80. Doctors to pass upon nurses' regulat ion. Dai ly Colonist Apr i l 28, 1916, pp.7. DOLAN, A.K. The l ega l i t y of nursing associat ions serving as co l l e c t i ve bargaining agents: the Arundel case. Journal of Health P o l i t i c s , Po l icy and Law. 1980, 5, 1, 26.54. DRISCOLL, V.M. The myth of two hats. Supervisor Nurse, 1974, 5_, 6, 24-7. EATON, R. Report of the advisory committee on labour conditions in  hosp i ta l s . V i c t o r i a : Provinc ia l Secretary, and Min ist ry of Labour, 1938. EHRENREICH, B. English D. Witches, midwives, and nurses, a h istory of women healers. OstyerBay, N.Y.: Glass Mountain Pamphlets. 212 EICHLER, M. Wpmen as. personal dependants. In M. Stephenson (Ed.) , Women in Canada. Toronto; newpress, 1973. ETZIONI, A. The act iye society. New York.: The Free Press, 1968. ETZIONI, A. (Ed). The semi-professions and the i r organization-., New York: The Free Press, 1969. ERICKSON, E.H. Co l lec t ive Bargaining: an inappropriate technique for profess ionals. Nursing Foriim, 1971 , 10, 3, 301-11. EVANS, R.G. Supplier - induced demand: some empirical evidence and impl icat ions. In M. Perlman (Ed.) Conference on the  economics of health and medical careT Proceedings of a Conference held at the International Economics Associat ion at Tokyo, 1973. New: York: John Wiley and Sons L td . , 1974.' Ex-reg is t rar of nurses dies at 91. Vancouver Province, August 21, 1963, pp.44 FAIRLEY, G. Annual Report of the President of the RNABC to the CNA. Canadian Nurse, 1938, 34, 444-45. FERGUSON, R.C. A c t i v i t i e s in a province-wide programme for the control of tuBerculos is . Canadian Journal of PuBlic Health, 1935, 26, 130-137. FERGUSON, M. The dilemma of professional ism and nursing organizat ion. Nursing Minor, 1976, 143, 25, 61-4. FILSTEAD, W.J. (Ed.) Qual i tat ive methodology: f i rsthand involvement  with the soc ia l world. Chicago: Markham PuBlishing Company, 1970. FISHER, N.H. BCHA/RNABC Jo int committee. Registered Nurses'Association  of B r i t i s h ColumBia Annual Meeting, 1964, 57-8. FOUCHER, R. Some thoughts on Canadian nurses and memBership in professional associat ions or trade unions. Canadian Nurses'  Associat ion Biannual Meeting and Convention, Vancouver, July 24, 1980. GEERTZ, C. Ideology as a cu l tura l system. In D.E. Apter (Ed.) Ideology and discontent. New York: The Free Press, 1964, 46-76. GEORGE, A. Address of president. Registered Nurses' Associat ion of  B r i t i s h Columbia, Annual Meeting, 1965, 10-15. 213 GEORGE, A. Committee on structure study. Registered Nurses' Associat ion of B r i t i s h Columhja News; 1969, 24-7. GIBBON, J . M. and Mat'hewson, M.S. Three centuries of Canadian nursing. Toronto: The Macmlllan Company of Canada Limited, 1947. GILLINGHAM, J .B. Co l lec t ive bargaining and professional e th ics . American Journal of Nursing, 1950, 50, 4, 214-16. GLASER, B.G., and Strauss, A.L. Awareness of dying.Chicago: Aldine Publ ishing Company, 1965. GLASER B.G., and Strauss, A.L. The discovery of grounded theory: strategies for qua! i ta t ive research. New York: Aldine Publ ishing Company, 1967. GLASER, B.G. and Strauss, A.L. Time for dying. Chicago: Aldine Publ ishing Company, 1968. GOLDENBERG, S.B. Professional workers and co l l e c t i ve bargaining. In H.C. Jain (Ed.) Canadian labour and indust r ia l re la t ions: publ ic and pr ivate sectors. Toronto: McGraw H i l l Rycrson L td . , 1975. GOLDMARK, J . Nursing and Nursing Education in the Uhited States, (Report of the Committee for the Study of Nursing Education). New York: The MacMillan Company, 1923. G00DN0W, M. Outl ines of Nursing h is tory . Ph i lade lph ia: W.B. Saunders Co., 1916. GRAND, N.K. Nightingal ism, employism, and professional co l l ec t i v i sm. Nursing Forum, 1971, 10_, 3, 289-99. Green, B. The r i se and f a l l of the Asylum Workers'Association. Nursing Minor, 1975, 141, 26, 53-5: GRICE, H. Personal Communication, Ju ly 10, 1980. HALL, N. Address to the 50th Annual Convention of the Bri t i sh Columbia Hosp i ta ls 'Assoc ia t ion, 1967. HALL, P., Land, H. Parker, P.. and Webb, A. Change, choice and conf1 l e t in socia l po l i cy . London: Heinemann, 1975, 475-509. Health insurance and soc ia l i zed nursing are strongly urged. Vancouver Dai ly Province, February 20, 1930, pp. 1,10. 214 HENDERSON, V. The nature of nursing. American Journal of Nursing, 1966 6 4 , 8 , 6 2 - 6 8 . HOLSTI, 0.R. Content analysis for the socia l sciences and humanities. Don M i l l s , Ontario: Addison-Wesley Publ ishing Company, 1969. HOOD, E. Province-wide bargaining for nurses. Canadian Nurse, 1961, 57 ,11 ,1064-65/ HOOD, E. Report of d i rector of personnel serv ices. Registered Nurses' Associat ion of B r i t i s h Columbia, Annual Meeting, 1953, 45-6. HOOD, E. Report of revis ions of personnel pract ice . Registered  Nurses' Associat ion of B r i t i s h Columbia, Annual Meeting, 1953, 82": HOOD, E. Report of the d i rector of personnel serv ices. Registered  Nurses' Associat ion of B r i t i s h Columbia, Annual Meeting, 1955, 49-50. : HOOD, E. Report of the d i rector of personnel serv ices. Registered Nurses' Associat ion of B r i t i s h Columbia Annual Meeting, 1956, 75^67 HOOD, E. Report of d i rector of personnel serv ices . . Registered Nurses' . Associat ion of B r i t i s h Columbia, Annual Meeting, 1958, 70. HOOD, E. Report of d i rector of personnel serv ices. Registered Nurses' Associat ion of B r i t i s h Columbia, Annual Meeting, 1959, 58. HOOD, E. Report of d i rector of personnel serv ices. Registered Nurses'  Associat ion of B r i t i s h Columbia, Annual Meeting, 1960, 68-9. HOOD, E. Report of d i rector of personnel serv ices. Registered Nurses'  Associat ion of B r i t i s h Columbia, Annual Meeting, 1961, 62 HOOD, E. Report of d i rector of personnel serv ices. Registered Nurses' Associat ion of B r i t i s h Columbia, Annual Meeting, 1962, 62. HOOD, E. Report of d i rector of personnel serv ices. Registered Nurses'  Associat ion of B r i t i s h Columbia, Annual Meeting, 1964, 59. HOOD, E. Report of d i rector of personnel serv ices. Registered Nurses' Associat ion of B r i t i s h Columbia, Annual Meeting, 1966, 71. HOOD, E. Report of rev is ion of personnel pract ices. Registered Nurses'  Associat ion of Bri t i sh Col urhbia, Annual Meeti ng, 1955, 82. HOOD. E. Report of rev is ion of recommendations on personnel pract ices. Registered Nurses' Associat ion of B r i t i s h Columbia, Annual  Meeting, 1956, 78. 215 HOOD, E. Report of rev is ion of recommendations and personnel pract ices . Registered Nurses' Associat ion of B r i t i s h  Columbia, Annual Meeting, 1957, 83. HOPPING, B. Professional ism and unionism: con f l i c t i ng ideologies. Nursing Forum, 1976, 15, 4, 372-82. Hospitals must show d e f i c i t s , V i c to r i a Dai ly Times, November 4, 1937, pp.8. HOLT, J.R. The struggle ins ide nursing's body p o l i t i c . Nursing Forum, 1976, 15_, 4, 325-340. House k i l l s CCF b i l l . Dai ly Co lon is t , December 8, 1938, pp.1. JACOX, A. Co l lec t ive act ion and control of pract ice by profess ionals. Nursing Forum, 1971, 10_, 3, 239-57. JAMIESON, S.M. Times of trouble: labour unrest and indust r ia l c on f l i c t  in Canada, 1900-66. (Study No.22, Task Force on Labour Relations (under the Privy Counci l ) : Ottawa: Information Canada, 1968. JOHNS E. Third Annual Convention of the Hospitals of B r i t i s h Columbia,  1920, 9. JOHNSON, T . J . Professions and power. London: The Macmillan Press L td . , 1972. KALISCH, P. A. , Kal i sen., B.J. The advance of American nursing. Bos ton: L i t t l e , Brown and Company, 1978. KATZ, F.E. Nurses. In A. E t z i on i , (Ed .) The semi-professions and, the i r organization.- New York: Free Press,'1969.' KERR, M. Br ie f h is tory of the Registered Nurses' Associat ion of B r i t i s h Columbia, Vancouver: Registered Nurses' Associat ion of B r i t i s h Columbia, 1944. KRAUSE, E.A. Power and i l l n e s s : the p o l i t i c a l sociology of health  and medical care. New York: E l sev ie r , 1977. KRAVIT, S. Co l lec t i ve bargaining for profess ionals. Supervisor  Nurse, 1973, 4, 7, 46-51. LATHAM, B. and KESS, C. (Eds.) In her own r igh t . V i c t o r i a : Camosun Col lege, 1980. 216 LEVI, M. Functional redundancy and the process of pro fess iona l i za t ion: the case of registered nurses in the United States. Journal  of Health, P o l i t i c s , Po l icy and Law. 1980, 5, 2, 333-53. LEWIS, S.S. Nurses and trade unions in B r i t a i n . International  Journal of Health Services, 1976, 6, 4, 641-49. MCKAY, H. Membership patterns and att i tudes of hospital nurses. Nursing Times, 1974, 70, 1547-9. MCKENNA, M. Revision of personel pract ices . Registered Nurses' Associat ion of B r i t i s h Columbia, Annual Meeting, 1952, 68. MCNAB, E. A legal h is tory of health professionals in Ontario. A study for the committee on the Healing Ar ts . Toronto: Queen's P r in te r , 1970. MCKENNA, M. Revisions of recommended personnel pract ices . Registered  Nurses' Associat ion of B r i t i s h Columbia, Annual Meeting, 1952, 68. MAHONEY, A.B. and Conlan, A.Y. Convincing the membership; convincing the leg i s la ture - bargaining r ights for nurses. American  Journal of Nursing, 1966, 66_, 3, 544-48. MALLORY, E. Pres ident ia l address. Registered Nurses' Associat ion  of B r i t i s h Columbia, Annual Meeting, 1947, 3. MALLORY, E. Remarks of the president Registered Nurses' Associat ion  of B r i t i s h Columbia, Annual Meeting, 1948, 4. MALLORY, E. Pres ident ia l address. Registered Nurses' Associat ion  of B r i t i s h Columbia, Annual Meeting, 1949, 8, 9-10. MARCHAK, M.P. Ideological perspectives on Canada. Toronto: McGraw H i l l Ryerson, 1975. MARIE, G. Writ ing women into B r i t i s h Columbia's h i s tory . In B. Latham and C. Kess (Eds.) In her own r i gh t . V i c to r i a Camosun Col lege, 1980. MATCH, R.K., Goldste in, A.H. and L ight, H.L. Unionizat ion, s t r i k e s , threatened s t r i kes and hosp i ta l s . The view from hospital management. International Journal of Health Services, 1975. 5, 1 , 27-36. MAUKSCH, H.O. The organizat ional context of nursing pract i ce . In F. Davis (Ed.) The Nursing Profession: Five Socio logica l  Essays. New York: John Wiley and Sons, Inc. 1966. 217 MAUKSCH, I.C. How did i t come to pass? Nursing Forum, 1971, 10, 258-72. MERRICK, E. Committee on labour re la t ions . Registered Nurses  Associat ion of B r i t i s h Columbia. Annual Meeting. 1951, 78. MERTON, R.K. Patterns of inf luence: local and cosmopolitan i n f l u e n t i a l . Glencoe, 111: The Free Press, 1957. METZGER, N. and Pointer, D. Labour management re lat ions in the health services industry: theory and pract ice. Washington, D .C : Science and Health Publ icat ions Inc. , 1972, 34-35. MILLER, J.D. and Shorte. l l , S.M. Hospital unionizat ion: a study of trends. Hospita ls , 1969, 43, 67-72. MILLER, M.H. Nurses' r ight to s t r i k e . Journal of Nursing Adminis- t r a t i on , 1975, 5_, 2, 35-9. NEWTON, M.E. The case for h i s t o r i c a l research. Nursing Research, 1965, 14, 1 , 20-26. Nine nurses quit Comox hosp i ta l . V i c to r i a Dai ly Times, Apr i l 13, 1939, pp.2. Nurse, Comox ( l e t t e r to Editor) overworked nurses, Vancouver Dai ly  Province, December 14, 1937, pp.4. Nurses at Comox return to duty. Dai ly Co lon is t , Apr i l 19, 1939, pp.2 Nurses 'b i l l i s withdrawn. V i c to r i a Dai ly Times, December 4, 1937, pp.17. Nurses'measure i s cause of contention. Dai ly Colonist , May 11, 1916, pp.7. Nurses' posts being f i l i e d . Dai ly Co lon is t , Apr i l 14, 1939, pp.3. Nurses' protest invest igated. V i c to r i a Dai ly Times, Apr i l 15, 1939, pp.2. Nurses' sa la r ies 'best in Canada', Dai ly Co lon is t , March 2, 1957, pp.17. Nurses urged by president to seek better condit ions. Vancouver  Sun, Apr i l 17, 1939, pp.6 Nurses walkout at Comox. Vancouver Sun, Apr i l 13, 1939, pp.1. 218 The Nursing profession. Dai ly Colonist , Apr i l 8, 1916,pp.4 Nursing Research, (ed i to r i a l ) The case for h i s to r i ca l research in nursing, 1972, 2j_, 483 Nursing shortage in Canada described as fast nearing national emergency. News Herald, June 27, 1950, pp.8 ORMSBY, M. B r i t i s h Columbia: a h is tory . Toronto: The Macmillan Company of Canada, 1958. PAULSON, E. Address of the president. Registered Nurses' Associat ion of B r i t i s h Col uttibi a, Annual Meeti ng, 1953, pp.3-6. PEEBLES, A. Report of the Hearings Committee on Health Insurance V i c t o r i a : B r i t i s h Columbia: Department of Provinc ia l Secretary, November, 1935. Pocket Oxford d ict ionary of current Engl ish. Oxford: At the Clarendon Press, 1959. RANDAL, H. Report of the Proceedings of the Third Annual Convention of the Hospitals of B r i t i s h Columbia, 1920, 24-26. RANDAL, H. Report of the Proceedings of the 21st Annual Convention of  the Bri t i sh Columbia Hospi t a l ' s Assocrati on, 1938, 53. Registered Nurses' Associat ion of B r i t i s h Columbia, Const i tut ion  and Bylaws. 1978. Registered Nurses' Associat ion of B r i t i s h Columbia. Proposal Recommended Personnel Pract ices, Ef fect ive January 1 , 1964; January 1, 1968. pamphlet. Registered Nurses' Associat ion of B r i t i s h Columbia. Suggested revis ions of RNABC recommendations on personnel pract i ces. Registered Nurses Associat ion of B r i t i s h Columbia, Annual Meeting, 1948. Registered Nurses' Associat ion of B r i t i s h Columbia, Labour Relations D iv i s ion . Manual for Staf f Representatives, 1978, pp.4. RNABC News. Proposed Revised RNABC Const i tut ion and Bylaws, 1971, 7± 2, pp.32. R0SACC0, L.C. Co l lec t ive bargaining: what's a\director of nursing to do? Hospita ls, 1974, 48, 79-80. 219 ROSS, T. 69 years of struggle. Nursing Minor. 1979, 148, 23, 16-18. ROSSITER, E.A. Statement regarding labour re la t ions . Registered Nurses Associat ion df B r i t i s h COlumbia, News Bu l l e t i r i , 1957, 53, 9, pp.799. ROSSITER, E. Address of the president. Registered Nurses' Associat ion  of B r i t i s h Columbia, Annual Meeting, 1960. SAFEIR, G. Leaders among contemporary nurses: an oral h is tory. In N.L. Chaska (Ed.) The Nursing Profession. New York: McGraw H i l l Book Company, 1978. SCHUTT, B.G. Co l lec t ive action for professional secur i ty , American  Journal of Nursing, 1973, 73, 1946-51 SCHUTT, B.G. The r ight to s t r i ke (an e d i t o r i a l ) . American Journal of  Nursing, 1968, 68, 1455. SHILLINGTON, C H . The road to medicare in Canada. Toronto: Del Graphics Publ ishing Department, 1972. SMALL, M.E. Committee on Nursing Service. Registered Nurses' Associat ion of B r i t i s h Columbia, Annual Meetirig, 1962, 4-5. SMITH, A.D. Social change: socia l theory and h i s to r i ca l change. London: Longman Group Limited, 1976. SMITH, D.E. Women, the family and corporate cap i ta l i sm, In M. Stephenson (Ed.) Women in Canada. Toronto: new press, 1973. SODERSTROM, L. The Canadian health Care system. London: Croom Helm, 1978. SOMERS, A.R. Health care in t r ans i t i on : d i rect ions for the future. Chicago: Hospital Research and Education Trust, 1971. Standard of hours and wages for nurses poor in Canada. Calgary Dai ly  Herald, June 26, 1948, pp.14). STEWART, H. Report of the committee on f inance. Registered Nurses' Associat ion of B r i t i s h Columbia Annual Meeting, 1956, 58. STRAUSS, A. Negotiations: Var i e t i es , contexts, processes, and soc ia l  order. San Francisco: Jossey-Bass, Inc. , 1978. STRAUSS, A. The structure and ideology of American nursing: an in te r -pretat ion. In F. Davis, The nursing profession, f i ve  soc io log ica l essays. New York: John Wiley & Sons, Inc. 1966. 220 STREET, M. Watch f i r e s on the mountains: the l i f e and wr i t ings of Ethel  Johns-. Toronto: Univers i ty of Toronto Press, 1973. St r ike at Marble Bay Hospital of nursing s ta f f . Vancouver Dai ly Province, June 4, 1907, pp.1. SWANBERG, G. Labour negot iat ions, Hospita ls , Journal of the American Hospital Assoc iat ion, 1970, 44, 1, 54-56. TAYLOR, M.G. Health insurance and Canadian publ ic po l i cy . Montreal McGi11-Queen's Univers i ty Press, 1978. TITUS, S.C. Economic secur i ty i s not too much to ask. The Modern  Hosp i ta l , 1943, 6J_, 3, 71-4. Two new nurses arr ive at Comox. Vancouver Sun, Apr i l 14, 1939, pp.1. Unhappy VGH nurses agree to work through committee. Vancouver Sun, May 16, 1978. VAN LOON, R.J. From shared cost to block funding and beyond. Journal of Health P o l i t i c s , Pol icy and Law, 1978, 4, 2, 454-78. VOLLMER, H.M..Mi l l s , D.L. Profess iona l i zat ion Englewood C l i f f s , N.J . , 1966. WADSWORTH, P. Committee on soc ia l and economic welfare. Registered  Nurses' Associat ion of B r i t i s h Columbia, Annual Meeting, 1966, 57. WAGNER, D. The pro le tar ian izat ion of nursing in the United States, 1932-46. internat ional Journal of Health Services, 1980, 10, 2, 271-90. WARD, P. Economic aspect in Report of the advisory committee on  labour condit ions in hosp i ta ls . V i c t o r i a : Prov inc ia l Secretary and Min ist ry of Labour, 1938. WATKINS, K.C. Social cont ro l . London and New York: Langman, 1975. WEBSTER'S Third New International Dict ionary. Spr ingf ie ld Massachusetts: G & C. Merrian Company Publ ish ing, 1971. WEIR, G.M. Survey of nursing, education in Canada. Toronto: The Univers i ty of Toronto Press, 1932. WEIR, G.M. A plan of health insurance for B r i t i s h Columbia. V i c t o r i a : Department of the Prov inc ia l Secretary, 1935. 221 WHITE, R. The development of the poor law nurs ing s e r v i c e 1848-1948. A d i s cu s s i on of h i s t o r i c a l method and a summary of some o f the f i n d i n g s . I n t e rna t i ona l Journa l o f Nurs ing S t ud i e s , 1977, 14, 1, 19-27. WHITE, R. Some p o l i t i c a l i n f l uences surrounding the Nurses R eg i s t r a t i o n Act 1919 i n the Un i ted Kingdom. Journa l o f Advanced Nur s i ng , 1976, 1, 209-217. WHITTAKER, E . , OLESEN, V. Faces o f F lo rence N i gh t i nga l e : f unc t i on o f the legend i n an occupat iona l sub - cu l t u re i n M. Abrahamson ( Ed . ) , The p ro f e s s i ona l i n the o r g an i z a t i o n . Chicago: Rond McNal ly and Company, 1967. WILENSKY, H.L. The p r o f e s s i o n a l i z a t i o n of everyone? American Journa l  o f Soc i o l ogy , 1964, 14-, 137-8. WILLIAMS, D. The r i g h t to s t r i k e . Nurs ing M i r r o r , 1979, 149, 7, 16. WILLIAMS, K. Ideo log ies o f nu r s i ng : t h e i r meanings and i m p l i c a t i o n s . Nurs ing Times, 1974, 70, 32. WOODS, H.D. Os t r y , S . , and Mahmod, A .Z . Labour p o l i c y i n Canada (2nd ed . ) Toronto: Macmi l lan o f Canada, 1973. Working time f o r nurses i s sub jec t to debate. Da i l y C o l o n i s t , November 10, 1938, pp .8 . WRIGHT, A. R e g i s t r a r ' s r epo r t . Reg i s te red Nurses ' A s s o c i a t i o n of  B r i t i s h Columbia, Annual Meet ing, 1948, 1; 6-7 . WRIGHT, A. Report o f execu t i ve sec re ta r y and r e g i s t r a r . Reg i s te red Nurses A s so c i a t i o n of B r i t i s h Columbia, Annual Meet ing , 1958, 78. WRIGHT, A. Report o f the Reg i s t r a r . Reg i s te red Nurses o f B r i t i s h  Columbia, Annual Meet ing , 1942, 1-5. WRIGHT, A. Report o f r e g i s t r a r . Reg i s te red Nurses ' A s s o c i a t i o n  o f B r i t i s h Columbia, Annual Meet ing, 1951, 42. WRIGHT, A. Se l e c t committee on labour r e l a t i o n s . Reg i s te red Nurses ' A s s o c i a t i o n o f B r i t i s h Columbia, Annual Meet ing , 1947, 1-2. WRIGHT, A. Se l e c t committee on labour r e l a t i o n s . Reg i s te red Nurses '  A s s o c i a t i o n of B r i t i s h Columbia, Annual Meet ing , 1949. WRIGHT, A. Se l e c t committee on labour r e l a t i o n s . Reg i s te red Nurses ' A s s o c i a t i o n of B r i t i s h Columbia, Annual Meet ing , 1950. 57-8. 222 WRIGHT, A. and Braund, E. Report of working conditions and salaries,. Registered Nurses Assoc iat ion, Annual Meeting, 1946, 1-5. ZIMMERMAN, A. The ANA economic secur i ty program in retrospect. Nursing Forum, 1971,'TO, 3, 312-21. ZACHARIAS, A. B r i t i s h Columbia Women's Inst i tu te in the ear ly years: time to remember. In B. Latham and C. Kess (Eds.), In her own r ight . V i c t o r i a : Camosun Col lege, 1980. 223 R E F E R E N C E N P T E S BRADFORD, J.D. Personal Communication, January 21, 1981. CRAWFORD, R. Personal Communication, July 9, 1981. DETWILLER, L. Personal Communication, July 23, 1981. GRICE, H. Personal Communication, July 10, 1980. MCCANN, E. Personal Communication, Apr i l 29, 1981. PATTON, N. Personal Communication, January 29, 1980. PAULSON. E. Personal Communication, Apr i l 13, 1981; June 29, 1981. POLLARD, R. Personal Communication, Apr i l 5, 1980. RANDAL, H. Correspondence to E. Paulson, May 25, 1937. Registered Nurses' Associat ion of B r i t i s h Columbia. Minutes of the Executive Council ( t i t l e var ies) Vancouver: Unpublished, 1912-23; 1927-76. Registered Nurses' Associat ion of B r i t i s h Columbia. Minutes of Annual Meetings ( t i t l e var ies) Vancouver:Unpublished, 1913-76. SHORE, H. Personal Communication, Apr i l 29, 1981. SMITH, S. Personal Communication, Apr i l 21, 1981. WHITTAKER, E. Personal Communication, January,1980. WRIGHT, A. Personal Communication, June 5, 1981. 224: APPENDIX A CORRESPONDENCE CONCERNING ACCESS TO THE BOARD AND ANNUAL MINUTES OF THE REGISTERED NURSES ASSOCIATION OF BRITISH COLUMBIA 

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