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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., McGill U n i v e r s i t y , 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 t h i s 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 requirements  this thesis  f o r an a d v a n c e d  of  British  it  freely available  agree that for  Columbia,  I agree  that  the L i b r a r y  shall  and s t u d y .  I  f o r extensive  p u r p o s e s may  f u l f i l m e n t of the  degree a t the U n i v e r s i t y  f o r reference  permission  scholarly  in partial  for  that  shall  Health Care and Epidemiology  The U n i v e r s i t y o f B r i t i s h 2075 Wesbrook P l a c e V a n c o u v e r , Canada V6T 1W5 Date  October 15, 1981  of this  It is thesis  n o t be a l l o w e d w i t h o u t my  permission.  Department o f  thesis  be g r a n t e d by t h e h e a d o f my  copying or p u b l i c a t i o n  f i n a n c i a l gain  further  copying of t h i s  d e p a r t m e n t o r by h i s o r h e r r e p r e s e n t a t i v e s . understood  make  Columbia  written  ii ABSTRACT C o l l e c t i v e bargaining by nurses in B r i t i s h Columbia began i n the mid 1940's, but the o r i g i n s of concern about the terms and conditions of employment of nurses are i d e n t i f i e d as e x i s t i n g p r i o r to the founding of the Registered Nurses Association of B r i t i s h Columbia. The Board and Annual minutes, 1912-76, of the Association were examined and selected materials such as journals and interviews were reviewed to t r i a n g u l a t e the v a l i d i t y of the data.  Applying  grounded theory (Glaser and Strauss, 1967) to the data, dominant and secondary themes r e f l e c t i n g the A s s o c i a t i o n ' 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 f o r c e , control of work p r a c t i c e and control of the work environment.  That i s , during the period under study, the  Association struggled to exercise control over an uncertain environment. A series of s t r a t e g i e s which the Association pursued are examined. Two groups w i t h i n the Association are i d e n t i f i e d ; cosmopolitans and l o c a l s (Merton, 1957).  Discontent amongst the l o c a l s , the importance  of which was recognized by the cosmopolitans resulted in the e f f o r t s of the Association s h i f t i n g to concentrate on the control of the work environment. This process resulted i n the entry of the Association i n t o c o l l e c t i v e bargaining.  The categories which emerged from the data were compared with selected l i t e r a t u r e on nurses in Canada, England and United States.  The i n t e r p r e t a t i o n of the minutes, and additional sources  appears to be validated by t h i s comparative evidence. Consideration of selected paradigms from the l i t e r a t u r e s of s o c i a l p o l i c y 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 r o l e these ideologies played. Geertz's (1964) i n t e r p r e t a t i o n of the role of ideology i s used to examine the evolution of these i d e o l o g i e s . The evolution of the ideologies of both the cosmop o l i t a n s and l o c a l s i s traced to vocational ism, i n the t r a d i t i o n of Nightingale.  Vocational ism conferred a sense of s a n c t i t y 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 r e s u l t i n g in the l o s s of s a n c t i t y of both the nurse and patient (Williams, 1974). L a t t e r l y an ideology accepting c o l l e c t i v e bargaining as a means of negotiating the q u a l i t y 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 p r i v a t e duty nursing, the development of a hierarchy in nursing, the increased use of technology and the establishment of a t h i r d party payment scheme as well as changes in society such as the recognition of the  iv  inequitable r o l e of women, and discrepancies i n the value of c e r t a i n types of work i n r e l a t i o n to economic reward impeded the entry of nurses i n t o c o l l e c t i v e bargaining.  U l t i m a t e l y , the  s t r a i n (Geertz,  1964) f e l t by the l o c a l s resulted i n confrontations with h o s p i t a l s and government. As a consequence the f i r s t s t r i k e votes (1957, 1959) endorsed  by the Association occurred.  Success in improving the  economic reward of nurses through c o l l e c t i v e 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 t h e i r  interpretations  should provide important basic information f o r health p o l i c y makers in B r i t i s h Columbia.  V  TABLE OF CONTENTS Page  ABSTRACT  ii  TABLE OF CONTENTS  v  LIST OF TABLES  vii  ACKNOWLEDGEMENTS  viii  ABBREVIATIONS CHAPTER 1  CHAPTER 2  ix Introduction The Purpose The Problem The S i g n i f i c a n c e The Data Base ' L i m i t a t i o n s of the Study Methodology A P r o f i l e of the Text of the Study  1 2 2 3 4 4 5  The F a i l u r e of Moral Suasion: 1912-42  7  Introduction: Events, Processes, and Trends The Struggle f o r R e g i s t r a t i o n : 1912-18 Education: The Essential Minimum: 1919-32 D i s p a r i t y : The Rise of M i l i t a n c y : 1933-42 Conclusion: The F a i l u r e of Moral Suasion CHAPTER 3  To Protect the Quality of Nursing: 1943-76 Introduction The Legitimation of C o l l e c t i v e Bargaining: 1943-54 The Legitimation of M i l i t a n c y : 1955-64 . Adjustments to Growth: 1965-76 Conclusion: To Protect the Quality of Nursing: 1943-76  CHAPTER 4  1  Methodology Introduction Problems of Social Research Grounded Theory The A p p l i c a t i o n of Grounded Theory to the Data Conclusion  7 10 16 27 43 44 44 46 66 80 97 99 99 99 102 1*16  vi. Page CHAPTER 5  Analysis and Discussion Introduction The Concept of Control Negotiation with Internal Forces: 'Cosmopolitans and Locals' Negotiation with External Forces Postures of Control Conclusion  CHAPTER 6  L i t e r a t u r e Review Introduction Control of the Work Force Control of Work Practice Control of the Work Environment Conclusion  CHAPTER 7  Explanations: Negotiations with External Forces Introduction Negotiation with External Forces: A Case of Dynamics without Change Negotiation the Importance of Legitimacy Control Contexts, Negotiation and Social Order Negotiation and Societal Process Conclusion  CHAPTER 8  Ideological S h i f t : The Attempt to Resolve Chronic S t r a i n Introduction The Role of Ideology The Orgins and Evolution of Nursing's Ideological Stance Conclusions:Omens f o r the Future  118 118 119 121 126 134 137 139 139 140 144 151 171 173 173 174 179 183 188 190 191 191 191 193 203  REFERENCE LIST  206  REFERENCE NOTES  223  APPENDIX A  APPENDIX B  Correspondence Concerning Access to the Board and Annual Minutes of the Registered Nurses Association of B r i t i s h Columbia  224  Biographical Notes  228  vii LIST OF TABLES TABLE  P a  2.1  Nursing S t a t i s t i c s f o r B r i t i s h Columbia, 1918-38  2.2  Selected Data on the Terms and Conditions of Employment of Nurses in B r i t i s h Columbia and Canada, 1929-43  3.1 3.2  Selected Data from Recommended Personnel Practices of the RNABC, 1946-68  9  e  2 2  39 1 1  The Growth of C e r t i f i e d B a r g a i n i n g Units of Registered Nurses w i t h i n 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 f o r External Negotiation of S p e c i f i c Issues Used by the RNABC, 1912-76  I  2 9  viii ACKNOWLEDGEMENTS I would l i k e to thank the Board of the Registered Nurses' Association of B r i t i s h Columbia f o r allowing 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 c e Wright f o r g r a c i o u s l y agreeing to share t h e i r reminiscences with me.  The assistance of the L i b r a r i a n s of the  Registered Nurses' Association of B r i t i s h Columbia; and the B r i t i s h Columbia Health A s s o c i a t i o n , the L e g i s l a t i v e L i b r a r y , V i c t o r i a , Main and Woodward L i b r a r i e s of the U n i v e r s i t y of B r i t i s h Columbia i s g r a t e f u l l y acknowledged.  Financial assistance from the Graduate  Fellowship (Master's Programme Award), the Suzanne M u l l i n Bursary, U n i v e r s i t y of B r i t i s h Columbia, the Alumnae Association of the Royal V i c t o r i a Hospital Training School f o r Nurses, and the Foster G. McGraw Award of the Association of U n i v e r s i t y Programs i n Health Administration i s also g r a t e f u l l y acknowledged. My thanks are extended to Dr. Anne Crichton f o r d i r e c t i n g the course of t h i s study, and to Drs. Annette Stark and E l v i Whittaker for serving on my committee.  To Celine Gunawardene f o r patience  and speed during the typing of t h i s t h e s i s , my thanks. To my family and friends who gave me encouragement and support throughout my Master's Programme, I extend my thanks.  ix ABBREVIATIONS  BCHA  B r i t i s h Columbia Health. Association (formerly B r i t i s h Columbia H o s p i t a l s ' 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'Association  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 c o l l e c t i v e bargaining by nurses in B r i t i s h Columbia i s the subject of t h i s study.  Nurses have been  viewed as s t r i v i n g to p r o f e s s i o n a l i z e (Katz, 1969;  Krause, 1977;  Wilensky, 1964) and as such, c o l l e c t i v e bargaining has been viewed as the a n t i t h e s i s  of professional behavior (Jacox, 1971). However,  c o l l e c t i v e bargaining by nurses in B r i t i s h Columbia i s now an accepted part of the dynamics of the health care system in B r i t i s h Columbia and i n Canada. The Purpose Professionalism and p a r t i c i p a t i o n in c o l l e c t i v e bargaining may be viewed as opposing i d e o l o g i c a l stances i n which ideology r e f e r s to "a manner or context of thinking c h a r a c t e r i s t i c of an i n d i v i d u a l group or c u l t u r e " (Webster's Third New International D i c t i o n a r y , 1971).  The adoption of c o l l e c t i v e bargaining by nurses  in B r i t i s h Columbia can be viewed as a r e f l e c t i o n of a change i n the thinking of nurses possibly representing a s h i f t i n ideology from professionalism to unionism perhaps as a r e s u l t of changing r e l a t i o n s h i p s w i t h i n society ( E t z i o n i , 1968). Blishen (1969) studying physicians i n Canada has shown that the ideology of physicians in Canada could be analyzed, and t h e i r responses to s t r a i n could be i d e n t i f i e d . S i m i l a r l y ,  it  2 was hoped that a study of the Association representing the nurses of B r i t i s h Columbia could produce data to explain the apparent s h i f t i n ideology of nurses. The Problem The research problem i s stated as a question.  How was i t  that the Registered Nurses'Association of B r i t i s h Columbia, which seemed to have pursued the goal of professional status f o r many years, decided to s h i f t from an ideology of professionalism to an ideology of unionism?  The S i g n i f i c a n c e of the Study It i s intended that t h i s study increase the understanding of the i d e o l o g i c a l basis of nurses i n B r i t i s h Columbia. Since nurses represent a major portion of the work force in health care in B r i t i s h Columbia, an understanding of t h e i r i d e o l o g i c a l p o s i t i o n i s important i n any understanding of the functioning of the health care system. In a d d i t i o n , t h i s study represents a c o n t r i b u t i o n to the w r i t i n g of nursing h i s t o r y , a much neglected a c t i v i t y (Newton, 1965; Nursing Research, 1972; S a f e i r , 1978) and to the w r i t i n g 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. i s a v a i l a b l e from 1948.  The RNABC B u l l e t i n  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 h o s p i t a l s recorded by the Labour D i v i s i o n of the RNABC  i s 1943 (Registered Nurses' Association  of B r i t i s h Columbia, Labour Relations D i v i s i o n , 1977). U l t i m a t e l y , permission to review the Board and Annual Minutes of the Association was requested and granted (Appendix A ) .  These minutes begin in  September 1912 and June 1913 r e s p e c t i v e l y .  1  O r i g i n a l l y , i t was the i n t e n t i o n to review the minutes from 1940-1976 i n d e t a i l doing only a cursory review of the minutes from 1912-39.  However, i t became c l e a r that t h i s material was too  r i c h to be ignored, and would contribute to the strength of t h i s study.  Thus the minutes were reviewed from 1912-76 when the separation  of the professional Association and the Labour Relations D i v i s i o n occurred. The study of the minutes was augmented by using other sources such as the News B u l l e t i n of the RNABC, the published Annual Minutes of the A s s o c i a t i o n , 1946-76, the Annual Minutes of the B r i t i s h Columbia Health Association (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 i s t i n g u i s h between the Executive Council of the Board, the Board and unpublished annual minutes and t h i s i s done where necessary.  4 H o s p i t a l s ' Association) and interviews.  I t i s assumed that issues  reaching the Board and publications represent a degree of importance that grants a c e r t a i n v a l i d i t y to the content.  Limitations of the Study This study i s l i m i t e d in contextual depth by several factors.  There i s an unevenness in the d e t a i l recorded i n the minutes  of the A s s o c i a t i o n .  Further, access to the documents of the Association  was l i m i t e d to the Board and Annual Minutes and thus supporting documents reviewed by board members were not a v a i l a b l e f o r study. As w e l l , there i s a profound and d i s t u r b i n g 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 i n t e r p r e t a t i o n of the events and t h e i r meaning which are presented in t h i s study. Methodology Various methodologies were considered, but a f t e r consideration i t became c l e a r 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 r e l a t e d documents.  Grounded theory i s  defined as "the discovery of theory from data s y s t e m a t i c a l l y obtained and analyzed in s o c i a 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 t h i s study the constant comparative method was the  5  the mode of q u a l i t a t i v e a n a l y s i s . The purpose of the constant comparative method i s the generation of conceptual categories and t h e i r properties from the data. theory i s the g o a l .  The b u i l d i n g of grounded substantive  Substantive theory i s theory that develops a  s p e c i f i c substantive or empirical area of s o c i a l i n q u i r y . study the  In t h i s  focus was the substantive area of a p r o v i n c i a l nursing  o r g a n i z a t i o n , 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 s o c i a l i n q u i r y . There w i l l be no attempt to develop formal theory from the data.  A P r o f i l e of the Study This study i s reported i n eight.chapters.  The f i r s t chapter  presents the i n t r o d u c t i o n to the study in which the problem of the apparent s h i f t i n ideology from professionalism to unionism by nurses in B r i t i s h Columbia i s i d e n t i f i e d . A b r i e f discussion of the purpose, the problem, the data base and the l i m i t a t i o n s and methodology of the study are presented. Chapters Two and Three comprise the n a r r a t i v e . The n a r r a t i v e i s based on the findings in the minutes of the Association and r e l a t e d sources. The narrative i s organized by chronology and by theme.  A natural d i v i s i o n occurred between 1912-42 and 1943-76 and  therefore the n a r r a t i v e i s divided i n t o two chapters.  6 The methodology of grounded theory and i t s a p p l i c a t i o n to study i s presented in Chapter Four.  An analysis of the findings  of t h i s study i s presented in Chapter F i v e .  Chapter Six c o n s t i t u t e s  the l i t e r a t u r e review and considers only selected material that discusses the major themes which emerged from the data. The l i t e r a t u r e review i s directed at i d e n t i f y i n g convergences and s i m i l a r i t i e s with the national and i n t e r n a t i o n a l l i t e r a t u r e as well as forming a comparison group f o r the nurses of B r i t i s h Columbia.  Chapter Seven  presents selected paradigms from the l i t e r a t u r e of s o c i a l  policy  and sociology i n an e f f o r t to explain the events, processes and trends (Smith, 1976) i d e n t i f i e d in t h i s study i n the l a r g e r context of s o c i e t y .  Chapter Eight returns to the theme of the r o l e of  ideology and the i d e o l o g i c a l response of nurses in B r i t i s h Columbia.  7 CHAPTER 2 The F a i l u r e Of Moral Suasion: 1912-42 Introduction: Events, Processes, and Trends As the review of the minutes of the Registered Nurses' Association of B r i t i s h Columbia proceeded, i t became evident that the origins: of c o l l e c t i v e bargaining lay in the roots of the p r a c t i c e of nursing in B r i t i s h Columbia. Following Glaser and Strauss's (1967) suggestion, the themes of importance to the Association were allowed to emerge from the data.  These themes are presented in the form of a  n a r r a t i v e i n segments of approximately 10 years to allow f o r convenient review.  The strategy f o r organizing the themes was suggested by an  analysis of s o c i a l change made by Smith (1976).  The purpose of t h i s  chapter and the f o l l o w i n g chapter, i s to present a n a r r a t i v e of the themes of the a c t i v i t i e s and concerns of the A s s o c i a t i o n .  From the  themes the importance of c e r t a i n events,processes,and trends and t h e i r r e l a t i o n s h i p to the development of c o l l e c t i v e 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 " d e t a i l e d analysis of archival records, to the day to day, or . . . month to month, r e l a t i o n s h i p s between i n d i v i d u a l s and groups which generate and compose p a r t i c u l a r pattern s u b s t i t u t i o n s " (Smith, 1976 pp.17).  Processes are defined as "sequences .of  intermediate d u r a t i o n , such as . . . s o c i a l movements, urbanisation and migration.'Process  1 1  refers to t y p i c a l c l u s t e r s i.n<-sequences: of events and.  8  refers to the ' r u l e s 1976, pp.17).  1  or t y p i c a l sequences of events (Smith,  Smith suggests decades are useful time frames to  study processual change, while trends r e f e r to long term change. The study of processual change i s seen as the c r u c i a l l i n k between 'micro-events' and 'longeval t r e n d s ' ( p p . 1 8 ) . The themes i d e n t i f i e d from the minutes are events and processes which appear to have d i f f e r i n g l e v e l s of importance during the period under study: 1912-1976.  The r e l a t i o n s h i p 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 r e f e r r i n g , motion of s p a t i a l patterns r e s u l t i n g in a clean difference from the preceeding p a t t e r n . . . s o c i a l change i s permanently h i s t o r i c a l in nature,  ...  i s e s s e n t i a 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 c a l r e c o r d " . Thus, Smith (1976 pp.13) defines change as a"succession of events which produce over time a modification or replacement of p a r t i c u l a r patterns or units by other normal o n e s . . . " .  Change i n the c u l t u r a l sphere i s seen as  the most autonomic as well as the most pervasive.. The concept of c u l t u r a l change covers several sets of p a t t e r n s " . . . knowledge and techniques, . . . i d e a s and b e l i e f s . . . c u s t o m a r y behavior and r i t u a l s ' . ' i ^ a l l a r e - l a y e r s of communication and s t y l e " (Smith, 1976 pp.22).  The themes and t h e i r r e l a t i o n s h i p s one to another  9 over time which emerge from the data become the processes which represent.change in the i d e o l o g i c a l stance of the A s s o c i a t i o n . I t i s the understanding of these processes and t h e i r r e l a t i o n s h i p s which contributed to the development and s o r t i n g of categories and properties which, explain the events. The events and processes of the early years of the Association have been described (George, 1969) as occurring in three phases: 1) 1912-1918, the struggle f o r r e g i s t r a t i o n , 2) 1922-1930, the c l o s i n g of substandard schools of nursing, 3) 1933-1944, the problem of working conditions of nurses. The review of the minutes of the RNABC supports t h i s general d i v i s i o n . However, although the RNABC continued to be preoccupied with the problem of the working conditions of nurses up u n t i l 1976 and beyond, the period 1933-1976 i s too complex to be taken as a s i n g l e period. Consequently t h i s period i s divided i n t o four d i s t i n c t segments: 1) 1932-1942, during which time the working conditions of nurses became generally recognized as deplorable and the cause of much i l l n e s s amongst nurses. 2) 1943-1954, during which time c o l l e c t i v e bargaining was l e g i t i m i z e d by the national and p r o v i n c i a l  associations,  3) 1955-1964, during which time there was confrontation with hospitals and government. S t r i k e threats and c o n c i l i a t i o n occurred.  10  4) 1965-1976, during which time change i n the organizational structure of the Association was made to meet the demands of p a r t i c i p a t i o n 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 p r a c t i c e , q u a l i t y assurance, health  and  safety of nurses, s o c i a l s e c u r i t y and the terms and conditions of employment of senior nursing s t a f f .  Throughout the n a r r a t i v e these  themes are presented as; dominant themes of primary i n t e r e s t at any time or as secondary themes.  given  The period 1912-42 i s presented i n t h i s  chapter, while the f o l l o w i n g chapter presents the period 1943-76. The Struggle f o r R e g i s t r a t i o n 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 i n September, 1912 when representatives of the Vancouver Graduate Nurses' A s s o c i a t i o n , the V i c t o r i a Nurses' Club and the New Nurses' Association met.  Their objective was  Westminister Graduate  to form a p r o v i n c i a l  nurses' a s s o c i a t i o n and to engage i n the "preparation and  presentation  to the government of a B i l l providing f o r the r e g i s t r a t i o n of nurses" (September 10, 1912). The Association established a preliminary examining board, a fee structure f o r entrance to the A s s o c i a t i o n , an i n t e r i m  11  form., of r e g i s t r a t i o n and then set about lobbying the government f o r passage of a B i l l to r e g i s t e r nurses b e l i e v i n g that " a l l who work should be r e g i s t e r e d , not in a s p i r i t of m i l i t a n c y , but as a protection f o r the p u b l i c " ( A p r 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 r e g i s t e r e d nurse" (October 11, 1913), there was support to r e g i s t e r two grades of nurses, the graduate and the untrained or household nurse.  The  category o f the household nurse was subsequently dropped, but a grandfather clause was added to l i m i t r e g i s t r a t i o n of the 'experienced nurse' f o r the three years following passage of the Bill. Lobbying f o r r e g i s t r a t i o n began i n 1913, and was conducted by meeting with the Cabinet and Members of the L e g i s l a t i v e Assembly and by the sending of l e t t e r s and postcards to MLA's. Support was s o l i c i t e d from the Local Council of Women, the Medical Associations 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 f o 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 opposition, was approached to sponsor the b i l l .  During debate i n  12  committee, amendments proposed by Dr. H.E.Young (member of the Cabinet, and a "close personal" f r i e n d of the Premier ( Ormsby, 1958, pp.356; 392) put the Association under d i r e c t control of the College of Physicians and Surgeons and made provision f o r the r e g i s t r a t i o n of midwives and maternity nurses.  "Heated and acrimonious debate" i s  reported to have occurred (Doctors to pass upon nurses' r e g u l a t i o n , 1916; Nurses' measure i s cause of contention, 1916; B i l l w i l l meet the s i t u a t i o n , 1918). Debate centered on opposition to "creating a closed corporation and v i r t u a l monopoly to members of (the) a s s o c i a t i o n " (Declare B i l l too arbit ary, 1916) and the "proposed amendment of putting nurses under f  the guardianship of the doctors", and "the f a c t that the B i l l would not l i m 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).  E d i t o r i a l comment suggested that the proposed B i l l  was "more stringent than any of the other enactments of i t s c l a s s . . . was not a r e s u l t of public 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 e g i s l a t i v e prop" (The nursing p r o f e s s i o n , 1916) .  Ultimately 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 e d support of Dr. Wesbrook of the U n i v e r s i t y of B r i t i s h Columbia (December 20, 1917) resulted in a r e v i s i o n of the B i l l .  The Local Council of  13  Women supported the B i l l but wanted to "protect those who practiced midwifery and sick nursing with no t r a i n i n g but who had passed a simple government t e s t " (March 22, 1918). integrated into the r e v i s i o n s . of the 1916 B i l l " .  These proposals were not  Nor were "the objectionable features  The B i l l was presented as "a means whereby a  properly t r a i n e d and q u a l i f i e d nurse may i n d i c a t e to the p u b l i c . . . that she i s an e f f i c i e n t n u r s e . ( h a d ) received t r a i n i n g " and "passed exams", but "allowed graduate nurses and those graduating from proper t r a i n i n g schools to be registered without passing exams f o r the next three years" ( B i l l w i l l meet the s i t u a t i o n , 1918). The B i l l passed A p r i l 23, 1918 and seemed to have brought a sense of s a t i s f a c t i o n and optimism to the A s s o c i a t i o n . Secondary themes. While the R e g i s t r a t i o n B i l l was the dominant issue i n t h i s period, the Association was also engaged in i t s own development as an organization.  Annual meetings were i n i t i a t e d in 1913, dealing with an  agenda which included the working business of the A s s o c i a t i o n , the postgraduate education of i t s members and c u l t u r a l a c t i v i t i e s . The war e f f o r t included volunteering f o r duty, the preparation and packaging of dressings, the c o l l e c t i o n of funds by tag days f o r a home f o r 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 Association of Trained Nurses to overseas duty created an i n t e r n a l f u r o r .  The protest was referred  14  from the f l e d g l i n g association back to the V i c t o 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 P r o v i n c i a l A s s o c i a t i o n . . . s i n c e the appointments had been made i n V i c t o r i a " (September 25, 1914). A cursory review of the early issues of the Canadian Nurse shows that p r a c t i s i n g nurses were concerned about t h e i r working conditions and rates of pay (The Canadian Nurse, 1907, pp.149-150; 645-646; 1908, pp.324-325).  Nurses i n B r i t i s h Columbia were also concerned about the  eight hour day and rates of pay. to have N  The issue of the eight hour day seems  erupted at Vancouver General Hospital in February, 1919.  The  A s s o c i a t i o n ' s minutes report r e c e i p t of a l e t t e r from Dr. MacEachern, Superintendent of VGH, regarding the eight hour day f o r nurses and " r e g r e t t i n g that outside organizations had attempted to i n t e r f e r e with the management i n t h i s regard . . . also expressing the hope that the GNABC would take up t h i s question . . . . Miss Randal (Registrar) . . . urged that nurses take a f i r m and d e f i n i t e stand regarding t h i s .  Miss McKenzie  spoke strongly in favor of the eight hour day but f e l t that t h i s should be arranged by the h o s p i t a l s and nursing organizations and not by Trades and Labor Unions  (February 18, 1919).  Helen Randal was made  convenor f o r a committee to interview Mr. J a r v i s , the Attorney-General Mrs. Ralph Smith, MLA and "any other members that i t seemed n e c e s s a r y ; . . . " . Helen Randal reported that she " f e l t that progress had been made, and i f the hospitals took t h i s up and made provision f o r i t themselves that  15  i n a l l p r o b a b i l i t y the government would take no action 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 A s s o c i a t i o n . The eight hour day committee was formed by the Association as requested by the Canadian Association of Trained Nurses ( A p r i l 29, 1919).  Summary. Despite i n t e r e s t in improving working conditions at the grassroots and with the leadership at p r o v i n c i a l and national  levels,  the major e f f o r t of the Association was directed towards the establishment of the r e g i s t r a t i o n of nurses.  Voluntary r e g i s t r a t i o n  was achieved in 1918 and the A s s o c i a t i o n ' s f i r s t R e g i s t r a r , Helen 2 Randal , was appointed. 1941.  Helen Randal was to hold t h i s p o s i t i o n u n t i l  Under her leadership, the Association s h i f t e d i t s e f f o r t s to  the improvement or closure of substandard schools of nursing. In 1911 the C a l i f o r n i a l e g i s l a t u r e enacted eight hour l e g i s l a t i o n f o r women workers.. In 1915, t h i s was held to be applicable to student (although not graduate) nurses. American nursing was s p l i t on whether t h i s type of l e g i s l a t i o n c l a s s i f i e d nurses as labourers, and whether t h i s was a good thing f o r the profession. Mary Adelaide Nutling of Teachers College, Columbia U n i v e r s i t y supported eight hour l e g i s l a t i o n and labour's intervention to shorten nurses' hours (Ashley, 1976, pp.40-47). See Appendix B f o r biographical note.  16  Education: The Essential Minimum  : 1919-32  Interest i n nursing education began with the formation of a committee to investigate the educational standards of t r a i n i n g 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 r a i n i n g schools were described as being conducted in hospitals with as few as 15 beds with a s t a 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 J o h n s ,  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 sick persons under a roof and c a l l i t a hospital.  Further, they may inaugurate a nursing school. (There  are) no standards ensuring competent i n s t r u c t i o n , (or) proper l i v i n g and working conditions . . . (Johns, 1920, pp.9). Throughout the 20's and 30's the Survey Reports were presented i n o p t i m i s t i c tones: "(There i s ) an improvement i n every department 3 Alberta Creasor, Address of the President, Annual Meetincj, Registered Nurses A s s o c i a t i o n , 1954. 4  See Appendix B f o r biographical note. Margaret S t r e e t ' s biography of Ethel Johns (Watch - f i r e s on the mountains; the l i f e and w r i t i n g s of Ethel Johns. Toronto: U n i v e r s i t y of Toronto Press, 1973) provides an i n s i g h t into the formative years of professional nursing in Canada and the United: States.  17  of the schools, . . . deep i n t e r e s t i n the p r o v i n c i a l exams...... a c l e a r e r consciousness of the r e s p o n s i b i l i t i e s of the Hospital  Boards to the  t r a i n i n g schools ( A p r i l 17, 18, 19, 1922)... better housing, equipment and c l a s s w o r k . . . new nurses' homes (are being) b u i l t ( A p r i l 2 and 3, 1923)... (There i s ) increasing uniformity amongst t r a i n i n g s c h o o l s . . ( A p r i l 18, 1927)... g r a t i f y i n g to report . . . only twelve nursing schools remain (October 1, 1932).^  During t h i s period e f f o r t was directed to  improving the educational process by developing a standard curriculum and by the h i r i n g of a t r a v e l l i n g d i e t i c i a n to teach d i e t e t i c s , notably in the smaller schools. Despite the optimism expressed in the Association minutes, a review of the annual minutes of the B r i t i s h Columbia Hospital Association f o r t h i s period makes a more e x p l i c i t and p e s s i m i s t i c statement about the concerns of the nursing leaders of the day. Helen Randal, i n addressing the 1920 Nursing Session of the BCHA described the 1919 Survey of Schools by s t a t i n g that while she met with the "greatest courtesy and c o n s i d e r a t i o n " , i n "too many of our hospital Board o f f i c i a l s there was p r a c t i c a l l y a t o t a l lack of real understanding that our nurses 5  I t i s not known how many schools of nursing existed i n 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 n a l l y there may have been 23. Non-approved schools (which were unable to meet the standards set by the Association) were known to operate at M e r r i t t in the 1930's (Paulson, 1981) and Grand Forks (Eatson, 1938, pp.57). These graduates could not r e g i s t e r under the Registered Nurses Act.  18  entered the h o s p i t a l s as p u p i l s , or that as a school there was a •'. d e f i n i t e contract entered i n t o between the probationer and the h o s p i t a l , that she was to have a d e f i n i t e course of s t u d y . . . t h a t while the Boards r e a l i z e d , and expressed themselves i n favour of shorter hours, better housing, more i n s t r u c t o r s 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 r e c t appeal must be made tothe P r o v i n c i a l Government f o r a d e f i n i t e sum to be spent on the education of nurses alone.  Cheap  nursing to the advantage of the hospital and to the detriment of the pupils has been gradually taken as something too common to n o t i c e " . Helen Randal concluded with these recommendations: a) presentation of the case to our Legislature of the r i g h t of t r a i n i n g schools i n h o s p i t a l s t o be financed i n part by government money, enforced,  b) standard curriculum and inspection of schools to be  c) t r a i n i n g school hours or accommodation f o r nurses to be sadly d e f i c i e n t - rooms crowded, generally in hospital buildings where no opportunity f o r recreation was provided - no rooms f o r laboratory, d i e t kitchen or study provided • (Randal, 1920, pp.24-26). One year l a t e r , at the BCHA meetings, Ethel Johns r e - i t e r a t e d that "the present shortage of pupils . . . i s a d i r e c t consequence of old methods of e x p l o i t a t i o n . . . "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, i n 1919 and subsequent years c a l l e d f o r the government take-over of public h o s p i t a l s , increased government  19  funding, and d i r e c t government c o n t r i b u t i o n 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 i s more d e t a i l e d than the GNABC minutes, a stronger commitment by the leaders of the profession to improve working and l i v i n g conditions i s i l l u s t r a t e d i n the BCHA minutes.  These same  leaders repeat a commitment to a strategy of "begin(ing) our propaganda f o r better nursing c o n d i t i o n s . . . w i t h the BOards of the schools f o r nurses connected with our h o s p i t a l s . . . " (Randal, 1920, pp.25). Other concerns i n education included the establishment and support of a scholarship fund f o r nurses at McGill U n i v e r s i t y (October 14, 1918), e s t a b l i s h i n g a public health program at the U n i v e r s i t y of B r i t i s h Columbia (January 10, 1920) and the establishment of postgraduate education i n teaching and supervision of nursing (September 12, 1931).  The Weir Report. The problem of "the nurse in her r e l a t i o n s h i p to the h o s p i t a l , the medical profession and the public at large" (Cameron i n Weir, 1932, pp.5) resulted in the s t r i k i n g of a j o i n t committee of the Canadian Nurses Association and the Canadian Medical Association i n 1927.  In 1929, George Weir, then Head of the Department of  Education, U n i v e r s i t y of B r i t i s h Columbia, was charged with the  20  r e s p o n s i b i l i t y of "get(ti.ng) at as many f a c t s regarding the problems of nursing conditions as p o s s i b l e " . . . (Weir, 19.32, pp,7)«  Weir undertook  a q u a n t i t a t i v e survey to i l l u s t r a t e the l i f e of the p r i v a t e duty nurse, the public health nurse and the i n s t i t u t i o n a l and student nurse.  He  found nurses l i v e d an unduly harsh l i f e , with high unemployment and i l l n e s s r a t e s , 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 s o l u t i o n to the complex  of problems facing nurses and the public seeking care he recommended s o c i a l i z e d medicine and that nursing education become an i n t e g r a l part of the state education system.  Weir persisted that ."nursing should be  regarded as a p r o f e s s i o n , however immature in the attainment of professional standards, rather than as a potential member of a trades union" (Weir, 1932, pp.65). The profession responded by promoting p u b l i c i t y of the report by interviewing e d i t o r s of Vancouver, V i c t o r i a and New Westminster papers (November 20, 1931) and by s e t t i n g up study groups throughout the province.  Newspaper coverage was comprehensive and sympathetic  (Health insurance and s o c i a l i z e d nursing are strongly urged, February 20, 1932.pp.1; 10). As early as 1919 discussions within the Association had considered state medicine and state nursing, and the i m p l i c a t i o n s f o r nursing.  —  I n i t i a l l y "the general f e e l i n g seemed to be much  A L e g i s l a t i v e commission of the government of B r i t i s h Columbia was appointed to i n v e s t i g a t e Health Insurance in 1919. No action was taken ( S h i l l i n g t o n , 1972, pp.40).  21  against State Medicine" (January 10, 1919) but with the appointment of a P r o v i n c i a l Royal Commission on State Health Insurance and Maternity Benefits in 1928 and with the p u b l i c a t i o n of the Weir Report strongly endorsing state medicine as a s o l u t i o n to the problems of education and employment of nurses, the p o s i t i o n changed to support. A Committee of the Association worked on health insurance u n t i l the l a t e 1940's.  Secondary themes • The secondary themes of t h i s period include the development of an organizational structure of the A s s o c i a t i o n , the terms and conditions of employment and the health of nurses.  The Association set  up the Private Duty, Public Health and Education Committees as standing committees in 1922.  This r e f l e c t s not only an employment pattern but  areas of i n t e r e s t to nurses.  Private duty within the home or hospital  was the usual form of employment of nurses.  Public Health was gaining  increased recognition e s p e c i a l l y following the influenza epidemics of 1919, but employed r e l a t i v e l y few nurses. by student nurses.  Hospitals were staffed l a r g e l y  Weir (1932, pp.290-291) recommended that an approved  school of nursing have " f u l l time trained i n s t r u c t o r " .  Thus the  composition of the Education Committee, a chairman and " a l l those a c t i v e l y engaged in nursing education" ( A p r i l 17, 18, 19, 1922) i s less s u r p r i s i n g than might be supposed. I t i s possible to reconstruct an approximate d i s t r i b u t i o n  Table Nursing S t a t i s t i c s  Group Current Registered Nurses  2.1  f o r B r i t i s h Columbia,  1918  1919  1921  170°  711'  969  1927  1918-38  1928  1929  1930  2148  1550"  L  Graduates and students  1947  1938  1937 L  c  Non-registered Graduates working i n Hospitals  918'  Students  863'  750  P r i v a t e duty Nurses  4759  222"  P u b l i c Health Nurses  132'  80 1  j  !  Wright, 1958, pp.78 The sudden i n c r e a s e i n Registered Nurses was due to the g r a n d f a t h e r c l a u s e o f Registered Nurses A c t . b c d e f  RNABC, December 21, 1921 Canadian Nurse 1928, pp.488 RNABC, A p r i l 19,1928 Census o f Canada, 1921, pp.32-33 Weir, 1932, pp.279  Note.  g h i j k  RNABC, Latham Eaton, Eaton, Eaton,  162'  the  November 8 , 1929 and Kess, 1980, pp.69 1938, pp.9 1938, pp.65 1938, pp.10.  The census t r a c t does not d e f i n e graduate n u r s e , and t h i s number probably i n c l u d e s nurses who were not r e g i s t e r e d . ' R e g i s t e r e d n u r s e s ' may have been i n a c t i v e because they were unemployed, not seeking employment or because they l i v e d o u t s i d e the p r o v i n c e . ' P r i v a t e duty n u r s e s ' are probably those who r e g i s t e r e d with the A s s o c i a t i o n as a v a i l a b l e f o r p r i v a t e duty o r were members o f the P r i v a t e Duty S e c t i o n . The number of p r i v a t e duty nurses s t a t e d i n t h i s t a b l e i s probably f a l s e l y low because only 17% of p r i v a t e duty nurses were placed by an A s s o c i a t i o n R e g i s t r y (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 a v a i l a b l e i n the A s s o c i a t i o n ' 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 r o l e of students. Discussions of the e i g h t , t e n , 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 e s t a b l i s h how widespread the acceptance of t h i s was,since endorsation of the eight hour day repeatedly occurred u n t 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 p r i v a t e duty nurses, twenty-four hours (Weir, 1932, pp.89).  Private  duty nurses received about 17% of t h e i r work through the Association Registry and the remainder through private r e g i s t r i e s or physicians (Weir, 1932 pp.386).  These nurses were often working i n h o s p i t a l s  where the hours of work were set by the i n s t i t u t i o n . employment s i t u a t i o n of t h i s group to be woeful.  Weir found the  The actual average  employment period f o r p r i v a t e 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 i n d i r e c t subsidy by l i v i n g  24  at home (Weir 19.32 pp.66-96), Depression  Fears were expressed at the  would encourage nurses to work, twelve hour s h i f t s  additional remuneration (January 19, 1934).  for  Thus, although the  Association a c t i v e l y supported p r i v a t e duty nursing by operating a Registry, the Association may not have had s i g n i f i c a n t  influence  over the hours private duty nurses worked. During t h i s period there i s no mention, w i t h i n the A s s o c i a t i o n , of concern f o r the terms and conditions of employment of public health nurses.  I t i s not possible to reconstruct hours of work  or working conditions f o r public health nurses from the Weir Report (Weir, 1932, pp.118-143).  Esther Paulson (1981) r e c a l l s working a 5% 7  day-week i n the mid 1930's i n the Kootenay d i s t r i c t . done on Sundays as the need ^rose.  Home v i s i t s were  Weir does show that near f u l l  employment of public health nurses e x i s t e d , t h a t 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 t h e i r earnings (Weir 1932, pp.123-154).  Institutional  nurses  enjoyed s i m i l a r employment and i l l n e s s rates as public health nurses, but over h a l f were unable to save anything from t h e i r earnings (Weir, 1932 pp.102-109). Student nurses were c l e a r l y the worst o f f , working twelve hour days, often too fatigued to study, and s u f f e r i n g 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 f o r biographical note  25  With hi.gh unemployment rates amongst p r i v a t e duty nurses, even before the Depression i t i s not surprising that the Association pressed f o r changes i n the organization of the d e l i v e r y of care. The Association encouraged hourly nursing and group nursing as a means of increasing the employment of nurses by making nursing care less c o s t l y to the patient (November 20, 1931, March 15, 1932).  Hourly nursing  was a method of h i r i n g nurses f o r short i n t e r v a l s over a period of time, while i n group nursing one private, duty nurse cared f o r several patients at once.  hospitali  E f f o r 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 n g graduate nurses was cheaper  than the cost of educating students (BCHA, 1931, pp.101). Association pressed f o r the reduction  Thus the  i n the s i z e of schools in order  to employ graduate nurses, and further urged that h o s p i t a l s consider "very c a r e f u l l y the employment of married nurses" (September 26, 1930). These t a c t i c s can be assumed to have had considerable impact on the s h i f t of employment of graduates from private duty to i n s t i t u t i o n a l nursing. The r e l a t i o n s h i p of the health of nurses and hours of work was understood by the nursing leaders, even though there i s d i r e c t reference to t h i s in the GNABC minutes.  little  The BCHA meetings of  1931 (pp.34) quote the superintendent of T r a n q u i l l e Sanatorium as s t a t i n g that "15-20% of the female p a t i e n t s . . . were pupil nurses in t r a i n i n g in t h i s province": Weir reports t h a t , in B r i t i s h Columbia of 123 students surveyed, 31.7% had more than f i v e days o f f duty through i l l n e 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 l o s e l y associated with both student and graduate nurses, and had seen the i l l e f f e c t s of long working hours. She could s a f e l y 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 i n the wards But i n the intensive study they have to make in order to Bring them up to the standard which i s expected of them in t h i s generation" : (Randal, 1938, pp.'."-53)8,9  Summary. The i n t e r v a 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 l o s i n g  suBstandard schools, the roots of the problem, inadequate financing of health care and nursing education, remained unchanged.  Consequently  there was no improvement i n the working conditions of nurses, whether graduate or student nurses.  U n t i l the pressures of World War II were  f e l t i n the early 1940's, unemployment and working conditions became the predominant concern of the A s s o c i a t i o n . 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 f o r 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 r a i n i n g in general h o s p i t a l s during the period 1930-1933 was 12.7 per thousand. This i s twelve times the incidence of tuberculosis morbidity among the general p o p u l a t i o n . . . I t i s eight times the incidence found...among normal school students..."The high rate of tuberculosis amongst nurses was a t t r i b u t e d " to the f a c t that nurses are expos.ed to frequent and larger doses of tuBerculosis i n f e c t i o n from unexpected sources". There i s no discussion of working conditions as a p r e c i p i t a t i n g f a c t o r .  27  D i s p a r i t y : .the Rise of Militancy:1933-42 The struggle to improve the terms and conditions of employment was the dominant theme of t h i s period. Secondary themes include mandatory r e g i s t r a t i o n , education and organizational change within the A s s o c i a t i o n . Background. The p o s s i b i l i t y of a p r o v i n c i a l health insurance scheme resolving the employment problems of nurses remained u n t i l 1937.  The  Royal Commission on Health Insurance did not d i r e c t l y support the i n c l u s i o n of nursing services i n the scheme, but did support adequate hospital funding (Davie, 1932).  George Weir entered p o l i t i c s in 1933,  became M i n i s t e r of Education and l a t e r , P r o v i n c i a l Secretary responsible f o r health.  The Association greeted the news with a l e t t e r of  congratulations " r e a l i z i n g his inestimable value to a l l professions of his platform of vocational education" (November 24, 1933). As P r o v i n c i a l Secretary, with r e s p o n s i b i l i t i e s f o r health, Weir put f o r t h "A Plan of Health Insurance f o r B r i t i s h Columbia" in 1935.  This was followed by  Hearings Committee in the same year (Peebles, 1935). The Association was a c t i v e l y involved in the process (November 30., 1934; February 22, 1935; A p r i l 22, 1935) and repeatedly r e i t e r a t e d the need f o r the funding of adequate nursing service in home or in the h o s p i t a l .  Grace F a i r l e y , Superintendent of Nurses at Vancouver  General Hospital sat on the Committee (Peebles, 1932, pp.12).  A bill  was prepared, amended f o l l o w i n g demands by the medical profession and  28 the Manufacturers' A s s o c i a t i o n , and passed In March. 1936.  The plan  was to go into e f f e c t March 1937, but despite support from a p l e b i s c i t e held during the e l e c t i o n of that year, the plan was i n d e f i n i t e l y postponed (Taylor, 1978 pp,6).  The doctors supported the p r i n c i p l e  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 c a p i t a t i o n rather than f e e - f o r - s e r v i c e (A B r i e f Analysis:, 1937, pp.97-100). Action by the Association . The Association attempted to exert i t s influence f o r an improvement of working conditions on behalf of p r i v a t e duty, i n s t i t u t i o n a l and student nurses by 1) t r y i n g to persuade private duty nurses to support an eight hour day, 2) attempting to control h i r i n g practices of the Registry, i t s e l f supported f i n a n c i a l l y by the A s s o c i a t i o n , 3) using "moral suasion" with hospital boards and the BCHA on behalf of i n s t i t u t i o n a l and student nurses, and 4) giving support to l e g i s l a t e d change by frequent communication with the appropriate cabinet members.  This a c t i v i t y was most prominent a f t e r completion  of work on health insurance. Thus the minutes read that "..The Registrar (be a u t h o r i z e d ) . . . t o write to various nurses' l o c a l associations and hospital centres endorsing the p r i n c i p l e of the eight hour day ( A p r i l 22, 1 9 3 5 ) . . . h o s p i t a l boards be asked to put an improved time schedule into e f f e c t . . . T h e Council endorses the p o l i c y of allowing s u f f i c i e n t time f o r meals on the eight hour day service without a l t e r a t i o n of  29 the regular f e e . . . " ( A p r i l 3, 1937). The eight hour day f o r 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 o n of the eight hour day in Eastern United States and the consequent migration of nurses.  "Labour trouble i n h o s p i t a l s . . . i n Canada . . . ( w i t h )  "two s t r i k e s of t h e i r employees" was also reported (BCHA, 1937, pp. 71-72).  In 1938, the BCHA , had a protracted debate on the eight hour  day f o r nurses and the costs of implementation. (BCHA, 1938, pp.20-22; 50-59).  A motion of the Canadian Nurses' Association supporting an  eight hour day f o r 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 t a c t i c s in r u l i n g 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 "generally sympathetic" to the 48 hour week f o r nurses, but makes no reference to the r e j e c t i o n of the r e s o l u t i o n supporting the eight hour day by the general assembly of the H o s p i t a l s ' Association (Working time f o r 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 i s s u e . E.E. Winch^, CCF(Burnaby) presented a private members b i l l E.E. Winch i n i t i a t e d debate in the Legislature on the working conditions of nurses i n 1935 (Steeves, 1960, pp.100-101).  to  30  regulate the hours, nurses worked under the Hospital Act.  George Weir,  as P r o v i n c i a 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 Industrial Relations not the H o s p i t a l s A c t . . . " . The Honourable G.S. Pearson, M i n i s t e r of Labour, i s reported as s t a t i n g that "the government i s very sympathetic to the conditions of nurses...(and) had been studying (the problem) f o r two years, . . . improvements had been made in some h o s p i t a l s . the b i l l  With these assurances, E.E. Winch withdrew  (Nurse's b i l l i s withdrawn, 1937).  This debate promoted a  strong rebuttal from "Nurse, Comox" i n the l e t t e r s to the e d i t o r . The nurse w r o t e " . . . , (in) almost every hospital in the province nurses are being s e r i o u s l y overworked, and (are) leaving hospital  service  with ambition crushed and health broken... as a man hired to work in the i n t e r e s t s of the province...some explanation might be in o r d e r . . . Dr. Weir's reply was a c a l c u l a t e d f l a u n t i n g of public opinion" (Overworked nurses, 1937). One year l a t e r the CCF re-introduced the b i l l and p r e c i p i t a t e d "short sharp debate in which, the Opposition pressed the government to supply the eight hour day law and other benefits f o r graduate and students nurses: i n h o s p i t a l s . . . . ( t h e eight hour day) was declared not f e a s i b l e on account of finances" (House K i l l s CCF b i l l , 1938).  H.E.  Winch i n supporting his f a t h e r ' s b i l l i s quoted as saying "the e n t i r e public should bear the burden of the h o s p i t a l s , not j u s t the n u r s e s , . , G.S. Pearson, M i n i s t e r of Labour admitted nurses are the subject of  31 abuse...(but) nurses are generally well looked a f t e r . , most h o s p i t a l s are run by Boards of d i r e c t o r s . , , anything wrong would have been complained ( a b o u t ) . . . we know h o s p i t a l s need more money...(we are) moving f u r t h e r i n B.C. i n the f i e l d of s o c i a l l e g i s l a t i o n than any other province i n Canada...But don't push i t too f a r " ( B i l l  giving  hetter c o n d i t i o n s , 1938). On OctoBer 1, 1937, Mrs. Rex Eaton was appointed to Chair the "Advisory Committee on LaBour Conditions i n H o s p i t a l s " By the P r o v i n c i a l Secretary, G.M. Weir, with the consent of the M i n i s t e r of LaBour, G.S. Pearson.  The Committee was charged with the responsi-  b i l i t y of i n v e s t i g a t i n g and reporting upon "wages, hours of work, conditions of work, and other labour conditions i n h o s p i t a l s " ; recommending "reasonable minimum standards of wages, hours of work, and working c o n d i t i o n s . . . ( s u c h that) working conditions in h o s p i t a l s are not unreasonable, that wages paid are f a i r and that the general labour conditions are such as not to be detrimental  to the health of  the persons employed", and to estimate the increase in the operating costs of h o s p i t a l s should the recommendations be implemented. (Eaton, 1938 pp 1-3). The committee surveyed 49 puBlic and p u b l i c a l l y supported hospitals and s i x private h o s p i t a l s ranging in s i z e from 1374 beds to less than 35 b e d s . 1 1  11  The report of the Advisory Committee was presented  Public hospitals such as the tuBerculosis sanatorium (Tranquille) and , the mental hospital (Riverview) were the d i r e c t administrative and f i n a n c i a l r e s p o n s i b i l i t y of the P r o v i n c i a l Secretary. P u b l i c l y supported h o s p i t a l s received f i n a n c i a l support f o r the costs incurred i n caring f o r c h a r i t y p a t i e n t s . There was no d i r e c t government r e s p o n s i b i l i t y assumed in the administrative or f i n a n c i a l aspects of these h o s p i t a l s . Private h o s p i t a l s were independent of government f i n a n c i a l assistance. In an annual report of the RNABC to the CNA, i t was reported that there were 72 h o s p i t a l s staffed with graduate nurses ( F a i r l y , 1938, pp.444-445).  32 to the P r o v i n c i a l Secretary and the M i n i s t e r of Labour October, 1938. I t would appear from the Association minutes that the Report was not immediately a v a i l a b l e (May 19, 1939);. as " i n t o l e r a b l y long".  The hours of work are described  The nurses are quoted as "understand(ing)" the  pressing need f o r new b u i l d i n g s . . , sympathiz(lng) with the f i n a n c i a l burdens of h o s p i t a l s . . . (but a s ) . . . believe(ing) that very often they form the group which absorbs economies made necessary by other demands and that the very f a c t that they can be depended upon to render service without protest and without d r a s t i c action has kept them working hours of such length that t h e i r health suffers and normal e s s e n t i a l  social  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 h a l f day o f f weekly, while night duty ranged from 48-84 hours per week. Time o f f night duty was extremely l i m i t e d : 29 h o s p i t a l s ( t o t a l 49 reporting) had no evenings or nights o f f duty, while 20 hospitals granted up to one night o f f each week. Night duty lasted f o u r - f i v e weeks at a time occurring one month in every three or four months.  On c a l l and overtime  was recognized as s e r i o u s l y i n t e r f e r i n g with time o f f duty, as was the spread of working hours, often over  15 and even 16 hours a day.. The  s o c i a l i s o l a t i o n of nurses r e s u l t i n g from hours of duty and the requirement by most h o s p i t a l s of l i v i n g i n residence (for both graduate and student nurses), the poor accommodation and the absence of recreational were recognized as a serious problem.  facilities  S a l a r i e s 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 f o r t n i g h t 12 (thus allowing " s p l i t s h i f t s ' to continue),  reduction of o n - c a l l  and overtime, and a s a l a r y of $60.00 monthly plus room, board and laundry expenses as a minimum wage.  Deduction f o r food, lodging and  laundry were s t i p u l a t e d , as was an hourly rate f o r part-time  staff.  I t was recommended that no charge be made f o r breakages of equipment. The nurse was to provide her own uniforms.  No recommendations were  made f o r the amount of vacation time to be granted but the importance of holidays was recognized.  Hours of work recommended f o r students  were s i m i l a r to those of graduates, but with the proviso that c l a s s time be included in "hours of work".  The "average nurse" was seen to be  "working f o r hours which have long since been considered i n t o l e r a b l e both by the average worker and the general p u b l i c . "  The committee  discussed the problem of the health of nurses and "undue f a t i g u e " that was evident.  Nurses were seen as "combin(ing) physical e f f o r t with  grave r e s p o n s i b i l i t i e s and emotional s t r a i n . . . a f f o r d ( i n g ) reason f o r a shorter day than the average w o r k e r . . " . While the committee was u n w i l l i n g to  make "any conclusive statement... concerning the actual percentage  of cases of tuberculosis i n t h i s occupation as compared with percentages found in other occupations" the committee accepted that a person in a state of constant fatigue becomes l i a b l e to the contraction not only of tuberculosis but of other i l l n e s s e s to which a nurse i s  particularly  exposed". Recommendations were made to e s t a b l i s h and maintain health The Committee stated that i t would l i k e to recommend a s t r a i g h t e i g h t hour day as a minimum but since "no occupation has the hours of work confined by l e g i s l a t i o n to less than a 12 hour - spread...(which)has been i n 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 p r a c t i c e preventive measures i n the case, of infected p a t i e n t s , (Eaton, 1938, pp,21-25), The Advisory Committee concluded that there was a general consensus amongst nurses, the A s s o c i a t i o n , the BCHA, and the p u b l i c , that nurses' hours must be shortened.  With the agreement of the  Council of the A s s o c i a t i o n , 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 allow the Association to enforce, regulations concerning students' hours.of work was discussed and discarded.  The r o l e of the Association in regard to students had  been directed to methods of t r a i n i n g , although the Association had encouraged voluntary reduction of students' hours with some success. However, the Executive Council of the Association stated that the success of t h e i r work depended g r e a t l y upon the sympathetic and f r i e n d l y co-operation of hospital boards and administrators. I f at any time such r e l a t i o n s h i p s were destroyed by a disagreeable s i t u a t i o n about the hours of work i t might i n t e r f e r e 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 i n e s and may not be i n a p o s i t i o n to take a completely independent stand without paying a c e r t a i n price f o r firmness. The Council has only one punitive measure to take against the hospital not conforming to the regulations of the Registered Nurses" Act, and that i s to remove the t r a i n i n g school from the approved l i s t . Needless to say, such action would not be taken u n t i l abuses had become f l a g r a n t and u n c o n t r o l l a b l e " . (Eaton, 1938, pp.60-62).  35  Strike action. Within seven months of the submission of the Eaton report, an outburst of m i l i t a n c y culminated in the f i r s t s t r i k e of nurses in 13 B r i t i s h Columbia.  Nine graduates and undergraduates of a s t a f f of  twelve walked out at St. Joseph's H o s p i t a 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 H o s p i t a l , Comox the following requests: - an 8 hour day be adopted - 2 weeks annual vacation, and annual allowance of two weeks' s i c k leave with pay - greater care and s e l e c t i o n of meals - a monthly allowance of $2.50 for laundry. A f t e r several weeks the graduates were conceded 2 weeks' vacation with pay and the $2.50 for laundry only a f t e r a year of s e r v i c e . No allowances were made f o r the undergraduate nurses who have been receiving 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 o f f duty, which would s t i l l leave a minimum 54 hour week day s h i f t and 70 hour week night s h i f t . This request was refused. Nothing was done i n haste or without due consideration. There was ample time given the advisory board to c o r r e c t c o n d i t i o n s . (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 I n d u s t r i a l Disputes Act passed that year. The nurses may not have done so e i t h e r because of ignorance of the Act or because they considered i t to be l e g i s l a t i o n f o r u n i o n i s t s , and thus non-professional ( S t r i k e of nursing s t a f f at Marble Bay H o s p i t a 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 h o s p i t a l s surveyed are reported to have had nurses working s i m i l a r hours f o r day duty, with 27.4% and 23.5% h o s p i t a l s reporting less and more hours worked. Two hospitals reported considerably more hours worked. For night duty, 22% hospitals reported s i m i l a 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 c o n d i t i o n s , caring f o r 50 patients with three nurses, two Interns, nuns and c i t i z e n s who volunteered" (Nurses posts being f i l l e d , 1939). As well " . . . the hospital l a d i e s a u x i l i a r y . . . ( i s ) a s s i s t i n g i n the kitchen and other work."  Two nurses were sent from St. P a u l ' s H o s p i t a l ,  Vancouver to a s s i s t (Nurses' protest i n v e s t i g a t e d , 1939), S i s t e r Walberga, Superior of S i s t e r s of St. Joseph i s quoted as saying "We are very, very sorry t h i s thing has happened., but we are getting along n i c e l y now (Two new nurses a r r i v e , 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 c o n d i t i o n s , we know they deserve them...but, most of our patients are on r e l i e f or too poor to p a y . . . the government grant i s 15 16 i n s u f f i c i e n t " (Nine nurses q u i t , 1939). ' C o l i n 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 f o r the nurses and they stated that i t was impossible f o r them to p a r t i c i p a t e in a public meeting at which the question would be discussed (Two new nurses a r r i v e at Comox, 1939).  An o f f i c i a l of the  Association was quoted as "having no o f f i c i a l report on the matter" and that there had been "no request f o r an investigation"(Nurses  protest  i n v e s t i g a t e d , 1939, p p . 2 ) . . In the minutes of the Association Colin Cameron  _  In 1936, p r o v i n c i a l and municipal funds met more than 40% of the t o t a l cost of operating a l l government aided h o s p i t a l s i n B r i t i s h Columbia." (Ward i n Eaton, 1938, pp.84). Medical indigency was conservatively estimated to be 25% i n 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 k e at St, Joseph's. Comox" ( A p r i l 15, 1939). A f t e r one week the s t r i k e ended with the Board of the hospital agreeing ( to an eight hour day, s i x day week, and two weeks vacation with pay.  "Previously the nurses were on duty up to twelve  hours or more d a i l y , without provision f o r a day-off or vacation" (Nurses at Comox return to duty, 1939). The A s s o c i a t i o n ' s response • Although the Association was in the midst of i t s Annual Meeting during the s t r i k e , there i s no d i r e c t reference to i t in the minutes of the meeting or in newspaper reports of the meeting. The president of the A s s o c i a t i o n , Miss D u f f i e l d , i s quoted as"speaking on the need to improve working conditions f o r nurses...(because)  until  better conditions are obtained, the f u l l benefit of nursing knowledge and t r a i n i n g cannot be made a v a i l a b l e (Nurses urged by president to seek better c o n d i t i o n s , 1939).  The o f f i c i a l Association response may be  intimated from the decision that "(a) l e t t e r be sent to the nurses who l e f t the h o s p i t a l . . . d r a w i n g to t h e i r attention the seriousness of t h e i r action and disapproval of the council and that a copy of t h i s be sent to the S i s t e r s of Comox Hospital  letter  and that (the) l e t t e r be  formulated by the Association lawyer and (the) whole matter be referred to the L e g i s l a t i o n Convenor" (May 19, 1939). made to the s t r i k e .  No f u r t h e r reference i s  However, reference to correspondence with George Weir  on the matter of nurses' hours and students' working conditions was p e r s i s t e n t and lengthy (September 16, 1938, November 22, 1940, A p r i l 19,  38  1940, August 18, 1942, January 31, 19.43). The Association recommended an eight hour day, s i x day week, and a maximum of, 96 hour f o r t n i g h t .  In a d d i t i o n , students were to have  one day o f f a week, lecture periods within the 96 hour f o r t n i g h t ,  on-call  duty l i m i t e d to one eight hour period per week, and not less than three weeks vacation annually.  F i n a l l y "no school of nursing or hospital  s h a l l be permitted to c o l l e c t any fee from any person f o r 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 A s s o c i a t i o n , 1943,pp.40). With the release of the Report on Labour Conditions the Association had more contact with Mrs. Eaton.  She suggested "the  a l t e r n a t i v e s to e f f e c t change in schools of nursing were 1) opening the Registered Nurses' Act to include d e f i n i t e r e g u l a t i o n s , and the assumption of r e s p o n s i b i l i t y of the RNABC f o r enforcement... or . . . 2) bring schools under the Trades' Schools Act with government r e g u l a t i o n . . . ( s h e ) advised the RNABC to r e t a i n control...(September 12, 1940)... (she) i s reported to have made c l e a r the necessity of improvement by voluntary or compulsory means (October 18, 1940). Again, eighteen months l a t e r i t was "noted that Mrs. Eaton f e l t the Council of the RNABC should take a more a c t i v e part in e f f o r t s to bring about the eight h o u r . d a y . ; . . . ( 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 f o r t to e f f e c t  39 Table  2.2  Selected Data on the Terms and C o n d i t i o n s of Employment of Nurses i n B r i t i s h Columbia and Canada, 1 9 2 9 - 4 3  Terms and Conditions of Employment  1929 BC  1938 BC  Canada  1943 Canada  Median range o f hours worked per week h o s p i t a l nurses day duty night duty  50-55% 66.5-76 T  p u b l i c h e a l t h nurses  |  48-55 50  k  o  1  J  Median number of days o f f per week h o s p i t a l nurses day duty night duty p u b l i c h e a l t h nurses  .5  Median number of weeks vacation per year p r i v a t e duty nurses h o s p i t a l nurses p u b l i c h e a l t h nurses Median annual s a l a r y general s t a f f : p r i v a t e duty hospital public health d i r e c t o r of n u r s i n g hospital public health a b c d e f g h i j k 1 m n  e  o gh  3.3 4.2° 4.3c a  565 985  a b  839C  1510  d  3  657 1020 925c  h  a  b  1639  660  1  750 1450-1549 m  n  d  2150-2249  n  Weir, 1932, pp.75 Weir, 1932, pp.102,103 Weir, 1932, pp. 123,124 Weir, 1932, pp.150 Eaton, 1938, pp.13-14 Eaton, 1938, pp.15 Eaton, 1938, pp.16 Eaton, 1938, pp.40; s t a t u t o r y h o l i d a y s were not granted, pp.41 Eaton, 1938, pp.42 CNA, 1943, pp.36-8 CNA, 1943, pp.39 CNA, 1943,pp.22. "Vacations without pay are f a i r l y f r e q u e n t " , CNA, 1943, pp.30 CNA, 1943, pp.32-3  Note: For Sake of comparison w i t h the 1943 d a t a , the cash value of board, l o d g i n g and laundry estimated by Weir and Eaton has been s u b t r a c t e d from the s a l a r i e s as s t a t e d i n the o r i g i n a l material.  40 the eight hour day - thus using "moral suasion" of t h i s Council to bring pressure to bear on t h i s i n s t i t u t i o n " (January 28, 1942),  Mrs, Eaton  p r e d i c t e d , i n an address to the Canadian Nurses Association 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 t h e i r own disadvantage . . . the danger  ...  . was t h a t (during war  time) nurses would be caught up i n a great wave of s e l f - s a c r i f i c e , and would forget t h e i r duty to endeavor to advance t h e i r profession . . . such an a t t i t u d e . . . would be a short - sighted p o l i c y " (Standard of hours and wages f o r nurses poor, Calgary Daily Herald, 1940).  The problem of  working conditions i n hospitals was not unique to B r i t i s h Columbia. A Federal Conference on labour conditions in h o s p i t a l s was c a l l e d in . 1942 (October 21, 22, 1942), but there i s no further reference to t h i s meeting in the minutes.  Table 2.2 summarizes selected data on the terms  and conditions of employment of nurses 1929-43.  Secondary Themes. The secondary themes f o r t h i s period include r e g i s t r a t i o n , the subsidiary worker, education and organizational change. The Weir Report brought i n t e r e s t i n national r e g i s t r a t i o n f o r nurses, but nothing ever came of t h i s ( A p r i l 23, 1937). Renewed consideration was given to mandatory licensure of a l l those who nurse f o r h i r e . This concern was i n i t i a t e d by the CNA (November 2, 1934; January 10, 1939) f o l l o w i n g recommendations from the Weir Report.  With the outbreak of  war, and the predictable shortage of nurses, the question of the r o l e , function and t r a i n i n g 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' Association of B r i t i s h Columbia and to " l e g a l i z e the requirement of Junior M a t r i c u l a t i o n f o r admission to a Training School" (Kerr, 1944, pp 5 ) . Having established that there were s u f f i c i e n t q u a l i f i e d students prepared to e n r o l l in a nursing school the standards f o r entrance were raised as an i n d i r e c t means of improving the educational standing of graduate nurses. In 1938 a committee was struck to examine the organization of l o c a l nursing a s s o c i a t i o n s .  Reorganization into chapters and  d i s t r i c t s along geographic l i n e s was proposed.  The chapters and  d i s t r i c t s were, to function as authorized branches of the A s s o c i a t i o n . The Association responded to a request f o r advice "as to the stand l o c a l (nursing)  organizations should take in discussion and voting  on p o l i t i c a l Issues i n t h e i r l o c a l council of women a f f i l i a t i o n (by suggesting they) not vote . . . u n l e s s authorized by the Nursing Association . . . " (March 24, 1939). The r o l e the Association played in the placement of nurses in employment changed during t h i s period.  Since i t s founding, the  Association had maintained a Registry of private duty nurses. Experiments in hourly and group nursing were conducted with the support of the Association i n the e a r l y 3 0 ' s , but were abandoned by 1935.  In  1941 a Placement Bureau Committee was formed to a s s i s t both nurses and employers (November 28, 1941).  The Registry and Placement Bureau  were combined i n 1943 and a D i r e c t o r 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 r u s t r a t i o n s of the Depression and subsequent years, the Association minutes f o r t h i s period do not have a sense of f u t i l i t y .  The struggle f o r improved employment  practices was the dominant theme.  While the Association was active i n  pressing f o r changes in working conditions through negotiation with the government and BCHA, i t was the nurses of Comox who demanded and received changes in t h e i r working c o n d i t i o n s .  The Association had  l i t t l e concrete success in t h e i r e f f o r t s . Secondary themes include mandatory r e g i s t r a t i o n , education and organizational change within the A s s o c i a t i o n .  The change in  organizational structure both increased the control the Association could exert on i t s members, and created a mechanism to promote a r e s ponsiveness of the Association to i t s membership.  While the Bureau  operated as an employment service i t represented a change i n organizational structure which coincided with a continued s h i f t i n employment of nurses from p r i v a t e duty: to i n s t i t u t i o n a l or wartime service during a period of increasing shortage of nurses.  Thus there developed an organizational  mechanism to deal with the employment problems of nurses.  43  C o n c l u s i o n : The F a i l u r e o f Moral S u a s i o n : 1912-42  In 1912 a s m a l l group o f nurses formed t h e Graduate N u r s e s ' A s s o c i a t i o n o f B r i t i s h Columbia t o p r e s s f o r the r e g i s t r a t i o n nurses.  V o l u n t a r y r e g i s t r a t i o n was a c h i e v e d i n 1918.  of  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 t o e d u c a t i o n and the c l o s u r e o f  substandard  schools of nursing. While the terms and c o n d i t i o n s o f employment were acknowledged t o c o n t r i b u t e t o the i l l  h e a l t h o f n u r s e s , the g r e a t  economic D e p r e s s i o n o f the 1 9 3 0 ' 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 s u r e o f s c h o o l s and the D e p r e s s i o n was t o decrease t h e  proportion  o f s t u d e n t s t o r e g i s t e r e d nurses and t o i n c r e a s e the numbers o f nurses employed by i n s t i t u t i o n s . employment o p t i o n . become a p o l i t i c a l  P r i v a t e duty c o n t i n u e d t o be an i m p o r t a n t  By 1937 the w o r k i n g c o n d i t i o n s o f nurses had i s s u e and a p r o v i n c i a l  survey o f h o s p i t a l  employed  r.urses was conducted by a government a p p o i n t e d committee. In A p r i l , 1939 a s t r i k e o f nurses a t S t . J o s e p h ' s H o s p i t a l , Comox o c c u r r e d .  The  A s s o c i a t i o n responded by sending a l e t t e r d i s a p p r o v i n g o f t h e i r  action.  On the b a s i s o f d a t a i n the Weir Survey ( 1 9 3 2 ) , the Eaton Report and the survey by the Canadian Nurses A s s o c i a t i o n (1943) i t  is  (1938)  apparent  t h a t the terms and c o n d i t i o n s o f employment o f nurses had changed i m p e r c e p t i b l y s i n c e b e f o r e the D e p r e s s i o n a n d , g i v e n the  inflationary  i&^ac'tot" World War I I had i n f a c t dropped below p r e - d e p r e s s i o n  levels.  The f o r m a t i o n o f c h a p t e r s 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 s h o r t a g e o f nurses and e x a c e r b a t i n g the terms and c o n d i t i o n s o f employment o f n u r s e s .  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 l e v e l s to the work force of the nation.  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 s a t i s f a c t i o n f e l t by nurses was known to the Association (October 19, 1946).  A Survey of Nursing  conducted by the CNA under the auspices of the Canadian Medical Procurement and Assignment Board i d e n t i f i e d that "even though there has been an upward trend i n s a l a r i e s paid to nurses since the outbreak of the war, . . . these s a l a r i e s do not compare favourably with those paid to many other professional groups, in normal times.  They are f a r  below wartime salary s c a l e s , even though maintenance i s i n c l u d e d . . . A shortage of nurses i s not s u r p r i s i n g under these conditions" (CNA, 1943, pp.34).  Post-war i n f l a t i o n also contributed to d i s s a t i s f a c t i o n  with s a l a r i e s (RNABC, Labour Relations D i v i s i o n  .1978, pp.4).  A  p e r s i s t a n t c r i t i c a l shortage of nurses lasted u n t i l the early 1950's. Overt pressure f o r action 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 protecting the q u a l i t y of nursing...(May 2, 1951).  46  The secondary themes f o r these three decades, include r e g i s t r a t i o n , education, private duty, subsidiary workers, health and safety of nurses, s o c i a l s e c u r i t y , terms and conditions of employment of senior nursing s t a f f .  The Legitimation of C o l l e c t i v e Bargaining: 1943-54. The shortage of nurses. The shortage of s t a f f p r e c i p i t a t e d by the war exacerbated the problems of the working conditions of nurses.  I n i t i a l l y the shortage  was considered a wartime phenomenon, but when i t continued a f t e r the war, the Association and the public became " t r u l y alarmed" (Wright, A. Report  1947, pp.2; Nursing shortage in Canada described as nearing  national emergency, 1950). During the war the Association 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 r e g i s t e r (November 28, 1941), i s s u i n g temporary permits to nurses who had been e l i g i b l e to r e g i s t e r at the time of graduation but were no longer e l i g i b l e (November 19, 1942), encouraging the employment of p r i v a t e duty nurses as general s t a f f nurses in h o s p i t a l s , a c t i v e l y discouraging private duty nurses from e n r o l l i n g i n the p r i v a t e duty d i r e c t o r y unless "very l e g i t i m a t e reasons" were given (Braund, 1945 pp.19), and f o s t e r i n g the use of subsidiary workers to augment or replace professional nursing s t a f f ( A p r i l 14, 1944).  The a i r l i n e s were  requested not to hire nurses as stewardesses ( A p r i l 24, 1942). The  47  Association requested permission to amend the Act to permit lowering the age f o r entry into schools of nursing ( A p r i l 24  s  1942),  Political  pressure was exerted to shorten the period of t r a i n i n g f o r students. However, these e f f o r t s were r e s i s t e d (January 5, 1944).  Students  were permitted to marry service men and continue t h e i r t r a i n i n g 15, 1943).  (April  F r i c t i o n developed between part-time and f u l l - t i m e nurses  who were " l i a b l e to resent the s a c r i f i c e of a l l the best hours of work which are delegated to the part-time workers" ( A p r 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 figures are 18% and 10%.  The l a r g e s t increase  f o r any f u l l - t i m e group was that of the paid ward aides; t h i s group showed a 52.2% increase" (Canadian Hospital C o u n c i l , 1943, pp.7-8). This i s a national f i g u r e ; no p r o v i n c i a l data are presented. Following the war the shortage was described as due to increases i n population, the increased use of hospital beds, high rates of bed occupancy and new r e s p o n s i b i l i t i e s assigned to nurses ( A p 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 public h e a l t h , tuberculosis c o n t r o l , and i n government-aided and Veterans' h o s p i t a l s were also seen as adding to the shortage.  The  "stimulus of the glamour of the war" had been l o s t and "despite an increase in the supply of nurses by 70%" since 1941, the shortage was seen as "a r e s u l t of long years of inadequate s a l a r i e s and unsatisfactory working c o n d i t i o n s " - ( M a i l o r y , 1947, pp.3).  Estimates of nurses needed  48 to correct the shortage did not account f o r the increased number of nurses needed to improve the working conditions of student nurses (Wright, Report. 1947, 2-5). As l a t e as 1947, i t was reported that "the dependence of hospitals upon students f o r 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 i n contagion have  not yet been e n t i r e l y eliminated  (there) has been an e f f e c t on  student r e c r u i t m e n t . . . d u r i n g the war years less than 75% of students who entered schools of nursing remained to complete the course" (Wright, 1947, pp.1).  Again i n 1948, the Committee on Education made a  "plea f o r (a:) 48 hour week including c l a s s e s , a maximum 44 hour week to decrease to 40 hour week in one year; with night and evening duty r e s t r i c t e d to 12'weeks of each, . . . sick time and other protective measures. . . . I f care ( i s ) exercised to eliminate non-nursing and non-educational d u t i e s , 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 i n d i v i d u a l groups of nurses were improving t h e i r  working c o n d i t i o n s , students were i n an unprotected p o s i t i o n since they were "exempt from regulation governing hours and conditions of work f o r employees" (Mallory, 1948, pp.4)  Despite the permissive r o l e accorded  the Lieutenant-Governor in Council in the regulation of student nurses'  49  hours by r e v i s i o n s 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'* Association was formed in 1947 and i s remembered as being active in working to improve t h e i r c o n d i t i o n s , (Smith, 1981) although there i s no evidence of t h i s in the annual reports f o r t h i s period. A p a r t i a l s o l u t i o n to the c o n 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 f o r blocks of time. (June 23, 1949). The continued shortage of nurses following the war gave nurses a sense of s e c u r i t y in formulating t h e i r demands f o r improved s a l a r i e s and working conditions.  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 A s s o c i a t i o n . The f i r s t steps towards c o l l e c t i v e 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' Association of Ontario in June, 1942. The p r i n c i p l e of c o l l e c t i v e bargaining by national and p r o v i n c i a l associations of nurses was approved by t h i s committee in November, 1943. A Labour Relations Committee of the CNA was formed at t h i s time. The committee studied the question of labour r e l a t i o n s and the nursing profession ( B e i t h , 1944, pp.692-693; 693-695).  50  In 1943 the CNA requested information from the p r o v i n c i a l associations about nurses in trade unions. "A reply was sent to the e f f e c t that no unions of nurses existed in BC" (February 25, 1943). This was followed by a request f o r the convenor of the L e g i s l a t i v e Committee of the CNA asking f o r "suggestions in g i v i n g guidance to the provinces" (May 28, 1954).  The Association responded with a series of  questions about the r o l e , function and r e l a t i o n s h i p of nurses, employers, and Associations: in c o l l e c t i v e bargaining (January 19, 1944).  In the  f a l l of 1943 th\e Association formed a committee to study the question of the membership of nurses in labour organizations. For the leaders of the Association 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 f o r our own p r o t e c t i o n ? . . . Should we not attempt to strengthen our own professional  organization  so that i t may give nurses the protection and support offered by labour organizations to t h e i r own members "' (October 20, 1943)?  As the  executive of the Association 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 P r o v i n c i a l or National Associ 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 potential c o n f l i c t s to professional standards should nurses j o i n trade unions (objection to "punching c l o c k s , " " s t r i k e a c t i o n " ) , 4) i f the Association did not take on the role of c o l l e c t i v e bargaining, what would be the r e l a t i o n s h i p between trade unions and the A s s o c i a t i o n " (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 d e n t i f i e d the problems as" 1) lack of compensation  i n case of  accident while on duty, 2) lack of provision f o r sick time, 3) no uniformity in s a l a r i e s , 4) no graded salary f o r years of experience" (December 1, 1943), The Executive Council of the Association "endorsed the recommendation of the Executive of the CNA . . . that the members . . approve the p r i n c i p l e of c o l l e c t i v e bargaining ...(and) that c o l l e c t i v e bargaining be conducted through the national and p r o v i n c i a l nursing a s s o c i a t i o n s " (January 5, 1944). This r e s o l u t i o n was l a t e r passed at the 1944 Biennial Meeting of the CNA but was rejected at the annual meeting of the RNABC ( A p r i l 14, 1944).  The r e s o l u t i o n read "whereas one of the objects of the  Association i s to r a i s e the standards of nursing w i t h i n the province; and whereas i n order to do so i t i s necessary to see that i t s members get adequate remuneration f o r t h e 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 f o r any of i t s members or groups of i t s members, in any proceedings under the I n d u s t r i a l A r b i t r a t i o n and C o n c i l i a t i o n Act or the Wartime Labour Relations Regulations".  The general membership did pass a r e s o l u t i o n "that the  i n d i v i d u a l 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 action be taken by the i n d i v i d u a l nurse at the present time u n t i l more  52  information i s a v a i l a b l e " ( A p r i l 14, 1944). The 1946 Annual Meeting of the RNABC, on the recommendation of the Labour Relations Committee of the Association reversed i t s r e j e c t i o n of the A s s o c i a t i o n ' s r o l e in c o l l e c t i v e bargaining. Stressing "unity of purpose" . . . to achieve progress in the nursing p r o f e s s i o n " , the committee reported that " i t i s f e l t that every member of the Assoc i a t i o n should be acquainted with the r o l e that the . . .  (Association)  i s prepared to assume i n helping i t s members secure s a t i s f a c t o r y working and l i v i n g conditions with adequate remuneration".  The major problem  i d e n t i f i e d in achieving t h i s goal was that an organization having both employees and employers as members could not be named as the bargaining agent f o r a group of employees.  However, under wartime Labour Relations  Regulations (PCI003) under the Federal Government, an employee group was able to e l e c t 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 R e g i s t r a r , the Director of the Placement Service, the Chairman of the P r o v i n c i a l L e g i s l a t i o n 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 Industrial C o n c i l i a t i o n and A r b i t r a t i o n Act, 1947 recognized the RNABC as a "Labour organization" and as ..the bargaining authority providing that 51 percent of the nurses on the s t a 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 a s s i s t i n g nurse employees to prevent or overcome d i f f i c u l t i e s by democratic and businesslike procedure. (2) In situations where nurse employees have been unable to effect an agreement with t h e i r employer, to arrange conferences with the employer, at which nurse employees would be represented. (3) In situations where a l l other measures have f a i l e d , and upon the request of a majority of the affected employee group of nurses, to set up a bargaining group (representative of the affected nurse employee group and the Select Committee) which would obtain c e r t i f i c a t i o n and proceed with negotiations" (Wright, Select 1947, PP. 1-2). The "prevention of d i f f i c u l t i e s  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 l a t e r 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 t s primary function being to co-ordinate the thinking of the  54  provinces.  I t has concerns with, personnel p r a c t i c e s ,  including  c o l l e c t i v e 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 i n t e r p r e t a t i o n of labour l e g i s l a t i o n (which) a f f e c t s or may e f f e c t nurses".  The nursing associations were seen to have "secured r e g i s t r a t i o n ,  the eight hour day and s i x day week, affected improvements in standards and conditions of service and approved the p r i n c i p l e of c o l l e c t i v e bargaining" .Esther Bei'th rejected the c r i t i c i s m by some nurses that the Association had f a i l e d them, arguing that the accomplishments i n improving working conditions had been made despite ten years of depression and s i x 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 d e n t i f i e d i n t e r e s t in c o l l e c t i v e bargaining as r e s u l t i n g from "1) the trend towards nurses working i n more and l a r g e r groups, 2) the fear created by the depression and 3) the conviction of strength which the shortage has given nurses". Beith acknowledged t h a t , under current l e g i s l a t i o n ,  Esther  difficulties,  e x i s t e d , but argued that the national or p r o v i n c i a l associations should be the bargaining agents f o r t h e i r membership, or i f t h i s were not p o s s i b l e , c o l l e c t i v e bargaining should be undertaken with the approval of the A s s o c i a t i o n . "union methods are  Any a f f i l i a t i o n with trade unions was r e j e c t e d : not applicable to nursing . . . . no such thing  s t r i k e action i s possible f o r nurses.  as  Nurses should be interested in  trades unions from a p u b l i c r e l a t i o n s and p u b l i c understanding viewpoint; not with the motive of getting something f o r ourselves, but because of our i n t e r e s t in f e l l o w workers and the benefits they w i l l  55  derive from s o c i a l l e g i s l a t i o n " , although she acknowledged the trend toward p a r t i c i p a t i o n by professionals in unions.  The fear was expressed  that association with trades unions would "lower the prestige and (the) strength, of professional a s s o c i a t i o n s .  This fear was repeatedly  expressed throughout t h i s period ( A p r i l 14, 1944; January 24, 1947; February 13, 1950).  In the midst of t h i s presentation Esther Beith i s  quoted as saying: Each nurse entered the profession of her own free w i l l under known conditions. We know that l i f e may depend upon the service that we can g i v e . Street cars may stop and s t a r t again but i f nursing service i s withdrawn and the patient d i e s , there i s no second chance. This point i s i l l u s t r a t e d by a story of Dr. Fleming who, while on vacation, was c o n t i n u a l l y c a l l e d upon to attend p a t i e n t s . When Mrs. Fleming remonstrated - argued that he has the same r i g h t to a vacation as other workers, Dr. Fleming r e p l i e d : "I should have thought of that before I went into medicine" ( B e i t h , 1946, pp.1-4). In concluding her remarks,Miss Beith stated "the State Nurses' Association of C a l i f o r n i a i s the bargaining agent f o r i t s members and has obtained the best conditions of work that nurses have anywhere" CBeith, 1946, p p . 1 - 4 ) . 3  In 1937 the American Nurses' Association recommended "that nurses not j o i n unions" but suggested that i n t h e i r professional associations nurses have the instruments best f i t t e d and equipped to improve every phase of t h e i r working and professional l i v e s " (Anderson c i t e d in Metzger, pp.34-35 in 1946 c o l l e c t i v e bargaining by d i s t r i c t and state chapters was in 1946. C o l l e c t i v e bargaining by d i s t r i c t and state chapters was accepted in 1946. (BuTlough, 1971, pp.273-288).  56 The S e t t i n g o f Standards f o r the Terms and c o n d i t i o n s o f Employment. The Annual Meeting o f 1946 heard one o t h e r r e p o r t to t h i s study.  important  The E x e c u t i v e S e c r e t a r y ( A l i c e Wright)^ p r e s e n t e d 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 b a s i s o f  bargaining  on the terms and c o n d i t i o n s o f employment. S i n c e the f o r m a t i o n o f the A s s o c i a t i o n ,  fee schedules of  duty nurses had from time t o time been r e v i s e d by committee,  private  presented  t o the p r i v a t e duty s e c t i o n and voted upon and accepted as the c u r r e n t fee schedule.  The Placement S e r v i c e Committee took on t h i s r o l e when  the s e c t i o n s were d i s s o l v e d and the Placement Bureau was formed i n 1941. While the committee c o n t i n u e d t o put f o r t h a p r i v a t e duty f e e s c h e d u l e until  1966, i t expanded i t s r o l e t o study "employment problems . . .  and  t o c o o r d i n a t e the e f f o r t s o f . . . those . . . concerned w i t h the employment of nurses" ( A p r i l  15, 1943).^ P r i o r t o t h i s , a p r o v i n c e - w i d e survey o f  employment and l i v i n g c o n d i t i o n s was a u t h o r i z e d by the E x e c u t i v e and the D i r e c t o r o f the Placement S e r v i c e ( A p r i l 24, 1942). formed the b a s i s o f r e v i s i o n s o f the Recommended Personnel  Secretary  This  survey  Practices  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 t o the  c o n s t i t u e n c y o f each o r g a n i z a t i o n ( A p r i l 26, 1946). The p a t t e r n o f j o i n t a p p r o v a l o f Recommended Personnel P r a c t i c e s c o n t i n u e d u n t i l (April  1956.  5, 1944; B e c k e t t , 1964) On the b a s i s o f the i n f o r m a t i o n 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  5  See Appendix B f o r a b i o g r a p h i c a l  note.  I t i s t h i s committee t h a t i s r e f e r r e d t o as a Labour R e l a t i o n s Committee i n C r e a s o r , (1954, pp.4)and B e c k e t t , ( 1 9 6 4 ) , s i n c e t h e r e i s no r e f e r e n c e t o a Labour R e l a t i o n s Committee i n the minutes o f 1942.  57  (representing) . . . the thinking and wishes of the great majority of our members" were presented. ( A p r i l 5, 1944).  The philosophy which underlies the p r i n c i p l e s and recommendations now presented i s that nurses and t h e i r employers have a mutual i n t e r e s t in and r e s p o n s i b i l i t y f o r f u l f i l l i n g the purposes f o r which health i n s t i t u t i o n s and agencies e x i s t ; these are (1) to care f o r the sick and (2) to promote the health of a l l c i t i z e n s . With t h i s in mind, the p r i n c i p l e s upon which d e s i r a b l e , and reasonable p o l i c i e s of personnel practices f o r nurses may be developed can be outlined as f o l l o w s : 1.  Nurses, l i k e a l l other human beings, need opportunities f o r s a t i s f a c t i o n i n service and f o r self-development.  2.  Acceptable l i v i n g and working conditions., with recognition of good s e r v i c e , r e s u l t i n a more e f f i c i e n t and interested worker, with consequent improvement in service.  3.  The hours of work should not exceed those of other s a l a r i e d , professional workers; should be considered in r e l a t i o n . t o the p h y s i c a l , i n t e l l e c t u a l and psychological s t r a i n s under which nurses work; should be.such that e f f i c i e n c y i s not impaired and should make possible p a r t i c i p a t i o n in the s o c i a l and c u l t u r a l l i f e of the community.  4.  The length of vacation should be such as would permit the b u i l d i n g up of physical reserve and resistance to i n f e c t i o n and should compensate f o r the i r r e g u l a r i t y of hours and free time.  5.  A d e f i n i t e p o l i c y of continuance of salary during time l o s t through i l l n e s s i s p r o t e c t i v e of the health of the nurse, her patients and her co-workers.  5.  A nurse i s e n t i t l e d to the r i g h t accorded other workers of choosing where she l i v e s and has her meals.  7.  When i t i s necessary f o r 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 f o r normal s o c i a l l i v i n g .  58  An employee health program i s economically sound and operates to increase e f f i c i e n c y . Deductions f o r room and board should be in r e l a t i o n 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 differences i n the q u a l i t y of the accommodation provided. 10.  The cost of laundering uniforms should be borne by the employing i n s t i t u t i o n , i n keeping with the p r a c t i c e i n other occupations where the wearing of a uniform i s required.  11. Salary schedules f o r nurses should be based on the value of the s e r v i c e rendered, i r r e s p e c t i v e of the c h a r i t a b l e functions of the employing i n s t i t u t i o n . 12. The basic minimum s a l a r y should ensure a standard of l i v i n g i n keeping with the nurse's professional status and make i t possible f o r nurses to take advantage of educational opportunities and to provide f o r retirement. 13. A contributory pension plan r e s u l t s i n increased l o y a l t y 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 a b i l i z i n g e f f e c t .  14. Married nurses should have equal opportunities f o r employment. 15. Stated terms of employment tend to eliminate d i s s a t i s f a c t i o n and unrest. 16. S t a f f r e l a t i o n s h i p s should be such that the nurse w i l l feel free to take her problems and grievances to the member of the administrative s t a f f to whom she i s responsible. 17. A s t a f f education programme aids i n the more rapid and e f f e c t i v e o r i e n t a t i o n of new employees, tends to increase the i n t e r e s t i n and understanding of the functions of the employing i n s t i t u t i o n and promotes unity of s t a f f and improved employee-employer r e l a t i o n s h i p s . ( W r i g h t and Braund, 1946, pp.1-3).  59  The Recommendations were organized under the following  headings:  Hours of Work Vacation Sick Leave Residence Salaries Marital Status Permanancy Temporary General Duty S t a f f S t a f 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 p r a c t i c e s , the RNABC had outlined a set of standards that would be the f i r s t step in educating the employer group and the p u b l i c , as well as the nurses themselves, to the need f o r improved conditions and would give a l l p a r t i e s a f a i r basis on which to judge e x i s t i n g c o n d i t i o n s " . 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 t h e i r f e l l o w workers to obtain better economic s e c u r i t y through the channels i n operation with the RNA.  Some nurses were apparently unaware of or i n d i f f e r e n t  to such means and were w i l l i n g to turn to outside sources such as organized labour unions f o r assistance"(Copeland, 1947, pp.1-4). The introduction of compulsory hospital insurance by the province did not ease the f i n a n c i a l d i f f i c u l t i e s of the h o s p i t a l s .  60  Indeed Evelyn Mallory foresaw that the impact of hospital  insurance  would prevent hospitals from m a t e r i a l l y increasing the s i z e of the nursing budget without approval of the Hospital Commission and that s a l a r i e s to nurses would probably be subjected to some degree of control by the Hospital Commission "although nurses were urged to cooperate" in the introduction of hospital insurance (Mallory, 1949, pp.9-10). During t h 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 f o r room and board were both issues f o r c o l l e c t i v e bargaining.  Nurses were charged  increased rates f o r room and board as s a l a r i e s increased or were charged f o r room and board they did not use.  This remained an issue u n t i l  1956. The issue of marital status i n t e r f e r i n g with permanent employment was contested as early as 1946, but f o r some groups employment practices prevented the f u l l time employment of married nurses u n t i l 1955 ( C i t y w i l l hire married nurses, 1955). In a discussion of the problem of statutory holidays  falling  i n a vacation period, i t was recommended that extra days not be requested "as (there i s ) . . . evidence of f e e l i n g on the part of employers that nurses' longer vacation i s perhaps not j u s t i f i e d " ' . 1  At the same meeting, "threats of mass resignation were seen as " v i o l a t i o n s of professional s e r v i c e , and in the opinion of the public constitute(d) s t r i k e action . . . (and thus were) disapproved of" ( A p r 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 resolutions from the f l o o r were challenging the Recommended Personnel Practices to increase basic rates of pay (May 21, 1954).  In an e f f o r t to obtain a  44 hour week f o r students the Association approached the M i n i s t e r of Health to request provision f o r a budget s u f f i c i e n t to allow improved working conditions f o r students (October 11, 1951). The i d e o l o g i c a l  shift.  In reviewing the P r e s i d e n t i a l Addresses of the Association i t  is  evident that the leadership were well aware of the s h i f t i n ideology of the A s s o c i a t i o n .  Evelyn Mai l o r y , 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 s a t i s f a c t o r y s o l u t i o n . . . i s a democratic and sane procedure . . . That the thinking and action of nursing associations have undergone marked change i n regard to employer-employee r e l a t i o n s h i p s i s 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 i n the minds of the people. It i s one of respect, even of a f f e c t i o n a t e respect. To our people the nurse i s e s s e n t i a l l y a giver — a giver of comfort. This fundamental concept p s y c h o l o g i c a l l y i s at war with the need of the i n d i v i d u a l nurse f o r reasonable working conditions and f o r economic s e c u r i t y . I t i s also at war with the methods of unions. Compare that with the following quotation from the March 1949 number of "The Trained Nurse and Hospital Review" (in which a meeting of representatives of the American Nurses" Association i s reported): . . . n e i t h e r as an i n d i v i d u a l nor as an a s s o c i a t i o n does the nurse compromise the e t h i c a l standards of her  62  profession when she a t t a i n s economic benefits, by means, of c o l l e c t i v e bargaining. C o l l e c t i v e bargaining Is not only a means of s e t t l i n g employment terms but can be a means of improving r e l a t i o n 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 t a l k through d i f f i c u l t i e s with a view to reaching a mutually s a t i s f a c t o r y s o l u t i o n that process i s a democratic and a sane procedure, and one that we approve of very much [Mallory, 1949, pp.8). In 1953, Esther Paulson described the objectives and a c t i v i t i e s of the Association as:  (1)  to implement and protect standards in nursing education and p r a c t i c e to meet p r e v a i l i n g community needs  (2)  by providing two r e g i s t r i e s f o r p r i v a t e duty nursing in two of the three l a r g e s t c i t i e s in the province and a placement service f o r other types of nursing positions throughout the province. While the primary purpose of these resources i s to serve our registered members, the public i s also served through the placement of nurses, p r i v a t e duty, i n s t i t u t i o n a l and public h e a l t h , where needed in the communities through-out B.C.  (3)  By providing a labour r e l a t i o n s programme to obtain and safeguard s u i t a b l e working conditions and acceptable personnel practices f o r our members through d i r e c t conferences with employees.6  Esther Paulson closed her address by s t r e s s i n g the challenge of meeting "the public i n t e r e s t " inherent in a " p r i v i l e g e d profession" such as nursing and by urging nurses to work f o r and l i v e f o r t h e 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 f o r t h i s study.  63  Secondary themes.  The secondary themes f o r t h i s period are the issue of pensions f o r nurses,the increased d i f f i c u l t y of employment of private duty nurses, and the education and l i c e n s u r e of. subsidiary workers, and r e g i s t r a t i o n . The issue of pensions f o r nurses had been of concern to the Association for a number of years.  As e a r l y as 1932, nurses were being urged to  make t h e i r own arrangements f o r insurance (May 27, 1932).  In the face  of high unemployment and low income c l e a r l y t h 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 h o s p i t a l s public i n s t i t u t i o n s , pressure by the Association on the Hospital Services Commission continued, but to no a v a i l (May 25, 1950; June 22, 1951). The Association had increasing d i f f i c u l t y keeping the Vancouver and V i c t o r i a d i r e c t o r i e s operating even with the d i r e c t f i n a n c i a l assistance of the A s s o c i a t i o n .  By 1956 private duty represented  7%&>f the membership but required 25% of the Association budget to operate the Directory.. (Stewart, 1956, pp.58). Under pressure of shortage of nurses during wartime, p r a c t i c a l nurses were in e f f e c t doing private duty (November 3, 1943).  This p r a c t i c e was condemned (November 16, 1950).  The d i f f i c u l t y of f i n d i n g employment f o r private duty nurses was i n part due to a less pressing shortage of nurses, but also due to "changes occurring in medical p r a c t i c e and in (the) organization w i t h i n hospitals e f f e c t ( i n g ) the use of private duty nurses"(December 9, 1948), and the f a c t that the Social Assistance Department would not pay f o r  64  p r i v a t e duty nursing when patients required constant care (December 19» 1953; January 23, 1954],  (Recovery rooms f o r 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 t o r i a and Vancouver D i r e c t o r i e s had been  closed; the function being taken over by the private 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 n g  courses f o r o r d e r l i e s and p r a c t i c a l nurses (Wright, 1951, pp.42), and l i c e n s u r e of p r a c t i c a l nurses.  The College of Physicians and  Surgeons endorsed the p r i n c i p l e of " p r a c t i c a l nurses administering such treatments as are necessary in the sick room under the d i r e c t i o n of the attending physicians" which included the administration of drugs (October 18, 1952).  This was opposed by the Association and  the BCHA (December 13, 1952). The Association continued to be concerned about the number of nurses who were not r e g i s t e r e d .  The Act l i c e n s i n g  p r a c t i c a l nurses was described as 'permissive' and not a f f e c t i n g non-registered graduate nurses (June 23, 1951),  Non-registered  nurses were refused access to the A s s o c i a t i o n ' s private duty d i r e c t o r y (November 1, 1947) and not permitted to p a r t i c i p a t e in the a f f a i r s of the A s s o c i a t i o n .  Nurses were encouraged to  r e g i s t e r by d i r e c t pressure from the Association and by i n d i r e c t  65  pressure through, the h o s p i t a l s .  "Letters were sent to a l l  hospitals,  and the Hospital Association urging that a l l nurses he encouraged to r e g i s t e r . . . and that a salary d i f f e r e n t i a l of $10/month be i n s t i t u t e d f o r non-registered nurses"(January 13, 1949).  Summary . The f i r s t few years of experience in c o l l e c t i v e bargaining can be seen as t e n t a t i v e explorations in the exercise of power. An awareness of the response of employers, the public and the government led the Association to hold the l i n e on nurses' demands in several instances.  While discussions between the Association and the BCHA on  Recommended Personnel Practices and d i r e c t negotiation with  employers  resulted in improvements i n the terms and conditions of employment, the gains were not s u f f i c i e n t to s a t i s f y the grassroots workforce. The evidence presented in the n a r r a t i v e suggests that although the Association took a new r o l e in undertaking c o l l e c t i v e bargaining, there was a residual r e l i a n c e on paternalism, the mutual r o l e of the nurse and the employer, and on professionalism to m o l l i f y demands. Pressure from the grassroots, because of the increased recognition of economic d i s p a r i t y forced the Association to take stronger action in the l a t e 1950's.  66  The Legitimation of M i l i t a n c y : 1955-64  Introduction. The period 1954-64 brought increased confidence to the A s s o c i a t i o n ' s a c t i v i t i e s in c o l l e c t i v e bargaining. C o l l e c t i v e bargaining expanded such that i n 1951, a f u l l time labour r e l a t i o n s o f f i c e r , Evelyn Hood, was h i r e d . Nora Patton succeeded Evelyn Hood in 1970.  Other personnel were hired-incrementaly throughout the next 20  years.  By the l a t e 1950's the process of c o l l e c t i v e bargaining had  become i n c r e a s i n g l y p r o f e s s i o n a l i z e d with h o s p i t a l s h i r i n g negotiators and with experiments in regional and p r o v i n c i a l bargaining.  Contract  issues were concerned l a r g e l y with s a l a r i e s , hours of work, sick time and pensions.  The 40 hour week was widespread in public h o s p i t a l s ,  and universal in p r o v i n c i a l and federal h o s p i t a l s in B r i t i s h Columbia by 1955 (Hood, 1955, pp.49-50). Contract settlements during t h i s period often required c o n c i l i a t i o n procedures. The r e j e c t i o n of a c o n c i l i a t i o n report by several h o s p i t a l s led to s t r i k e action in 1957.  The f i r s t grievance  that went to a r b i t r a t i o n was i n 1959 (Hood, 1960, pp.69). The outcome of c o l l e c t i v e bargaining was f r u s t r a t e d by hospital budget freezes ordered by the p r o v i n c i a l government. As a r e s u 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 r e s t r a i n t adopted by the  67 hospitals led to increased concern about the standards of nursing care. This become a dominant theme of the Association by the 1970's. The f i r s t instances of c o n f l i c t between professional role of the Association and outcomes of a c t i v i t y i n labour r e l a t i o n s occurred in t h i s period. Secondary themes f o r t h i s period include education, r e g i s t r a t i o n , terms and conditions of employment f o r senior nursing s t a f f and the health and safety of nurses.  Background . Ormsby. (1958, pp.486-489) describes the climate of 9  B r i t i s h Columbia p r i o r to the introduction of hospital insurance in 1949, as a "class divided society in which "probably one-third of i t s population hoped to see . . . the introduction of a. s o c i a l i s t system . . . which the majority of the voters favoured a free enterprise system. Paradoxically . . . t h e y expected the government to provide more s o c i a l assistance" ( pp.486). The demand became so i n s i s t e n t that the Johnson-Anscomb (Liberal-Conservation) c o a l i t i o n 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 administrative nightmare that resulted from "the combination of lack of advanced planning, inadequate time f o r t r a i n i n g of new s t a f f , and two complicated c o l l e c t i o n s 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 r o p o r t i o n o f the u n i n s u r e d were h o s p i t a l i z e d and unable  t o pay t h e i r b i l l s ; h o s p i t a l s '  c o s t s i n c r e a s e d , as d i d t h e i r  deficits'  (pp. 1 6 7 - 8 ) . C r i t i c i s m from the p u b l i c , the p r e s s , and a c r i m o n i o u s debate i n t h e l e g i s l a t u r e l e d t o formal i n q u i r i e s , r e s i g n a t i o n s  of  t h e m i n i s t e r r e s p o n s i b l e and t h e t r a n s f e r o f t h e e x e c u t i v e d i r e c t o r BCHIS.  Under a new m i n i s t e r , L l o y d D e t w i l l e r from the  provincial  Finance Department was a p p o i n t e d commissioner o f BCHIS. payments were i n t r o d u c e d . were i n s u r e d a c c o u n t s .  The i m p o s i t i o n o f c o - i n s u r a n c e ,  o f the i n s u r a n c e scheme and rumors o f a s p l i t C a b i n e t o v e r the scheme made h o s p i t a l emotional and c o n t r o v e r s i a l  Co-insurance  A p p r o x i m a t e l y 85% o f h o s p i t a l  i n c r e a s e s i n 1950 and 1951, charges o f i n e f f i c i e n c y  accounts premium  i n the  i n the  of  administration  Liberal-Conservative  i n s u r a n c e the most  bitterly  i s s u e i n the 1952 e l e c t i o n campaign"  (pp.168).  The new S o c i a l C r e d i t p a r t y l e d by W.A.C. Bennett won the  election.  A number o f changes were made t o the p l a n , and by e a r l y 1954,  " t h e system was w o r k i n g t o l e r a b l y w e l l " ( p p . 1 6 8 ) . d e c i s i o n t o a b o l i s h premiums f o r h o s p i t a l social  services r e t a i l  However, a p o l i t i c a l  i n s u r a n c e and i n c r e a s e  t a x from t h r e e t o f i v e p e r c e n t was made.  e f f o r t s were now d i r e c t e d t o the development o f the h o s p i t a l s  the "All  system,  improvement o f s t a n d a r d s , and the r e f i n e m e n t o f the system o f paying hospitals for insured services"  (pp.169).  In T a y l o r ' s terms B r i t i s h C o l u m b i a " p a i d p a r t o f the c o s t s i n e d u c a t i n g Canadian governments i n the f o r m u l a t i o n o f  tuition effective  p o l i c i e s and a d m i n i s t r a t i v e procedures i n t h i s most complex o f the insurances" (pp.169).  social  The c o l l e c t i o n o f premiums as w e 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 r e s i s t a n t to government interference in the budgetary arena.  The Hospital s" Association was not strong in its. a b i l i t y to  represent the i n t e r e s t s of the hospital to the government.  Pressure  from unionized hospital employees, under the leadership of B i l l  Black  was developing,the introduction of hospital insurance removed the i d e o l o g i c a l c o n s t r a i n t of " c h a r i t a b l e ' work from the employees of these institutions. limited.  At the same time, f i n a n c i a l support f o r h o s p i t a l s was  Competition f o r a v a i l a b l e revenue came from W.A.C. Bennett's  commit'ment to the development of the natural resources of the province and in his desire f o r a balanced budget.  Freezes on hospital budgets  were l e v i e d 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 i n the face of the e l e c t i o n of 1956 ( D e t w i l l e r , 1981). With the introduction of the Hospital Insurance and Diagnostic Services Act in 1957, the federal government entered the funding of health care, a p r o v i n c i a l r e s p o n s i b i l i t y under the B r i t i s h North America Act. In exchange f o r meeting c e r t a i n federal standards to q u a l i f y the federal government provided funds f o r hospital and diagnostic services within hospitals on a cost shared b a s i s .  The p o l i c y  of cost sharing (the 50<t d o l l a r ) was extended to cover medical services under the Medical Care Act of 1966 ( inaugurated i n J u l y , 1968).  Cost  sharing as a formula f o r federal support of health care was discontinued when block funding and more l a t i t u d e in p r o v i n c i a l government personal and corporate income tax r i g h t s was granted to the provinces in 1977.  70 This was done to decrease federal f i n a n c i a l commit ments to increasing health care costs (Sod.erstr.om, 1978; Taylor, 19.78, Van Loon, 1978).  The growth of c o l l e c t i v e bargaining. An assessment of the rate of growth of c o l l e c t i v e bargaining by nurses i n 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 t h i s period. Only the t o t a 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 c o l l e c t i v e bargaining consumed much of the time and energy of the Executive Secretary and s t a f f of Personnel Services.  By 1961 the Select Committee  on Labour Relations had given up i t s function of preparing Recommended Personnel Practices to the Director of Personnel Services (Hood, 1961 pp.1064-1065). S t a f f representatives from each bargaining unit contributed to the development of the Recommended Practices through regional meetings with the D i r e c t o r of Personnel Services.  The  Executive Committee of the Association continued to review the Recommended Practices before presenting them to the Annual Meeting f o r endorsation. It was not uncommon f o r chapters to communicate t h e i r concerns about the Recommended Practices 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  N e i t h e r the RNABC nor the Labour Arm of the Association i s able to provide t h i s information (Patton, N. Personal Communication, January 1980; Grice H. Personal Communication, J u l y 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 r e l a t i o n s consultants to do t h e i r bargaining.  The Association saw d i r e c t negotiation with  members of the hospital or public 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 . . . r e s u l t (ing) in better understanding and respect on both sides . . . . A professional negotiator t h r i v e s on disagreement and cannot p o s s i b l y know the varying s i t u a t i o n s that e x i s t in d i f f e r e n t i n s t i t u t i o n s " (Hood, 1955, pp.49-50). Regional bargaining was seen as making "working conditions and s a l a r i e s more u n i f o r m . . . " but had the disadvantage of "loss of personal contact with the i n d i v i d u a l boards (that denies us the opportunity to i n t e r p r e t nursing and nurses' problems to them)"(Hood, 1958, pp.70). The Executive Council of the Association rejected provincewide bargaining in 1958 (March 29, 1958) but a year l a t e r was " w i l l i n g to recommend...that . . . the Association p a r t i c i p a t e in a plan f o r province wide bargaining on a t r i a l basis and with the understanding that bargaining w i l l not be handed over to a professional negotiator" (October 17, 1959). to be s u c c e s s f u l .  "Province-wide bargaining . . . proved  Many nurses . . . expressed s a t i s f a c t i o n with t h i s  method of negotiating agreements.  With uniform s a l a r i e s nurses are  able to make t h e i r choice of employment on factors such as type of community, interpersonal r e l a t i o n s h i p s w i t h i n the hospital and working conditions that permit reasonable job s a t i s f a c t i o n " pp.62).  (Hood, 1961,  With s i m i l a r misgivings the Association agreed to standardize  Tdble 3.1 Selected Data from Recommended Personnel Practices of the RNABC, 1946 - 68  1946  1947  1948  1952  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  37i 2 16  Vacation Days paid/annually Statutory holidays paid  28 9  28 9  28 10  10  11  20 11  20 11  a  Sick Leave Days paid/monthly  l«s  Salaries-Basic Monthly Rate Hospitals staff nurse head nurse supervisor(A) instructor (university preparation)  $125 $150 $150  Public HealthStaff nurse (university preparation) Private Duty - Rate per shift (for care duty in hospital)  $6.50  Increments - monthly Bachelor's Degree Master's Degree  $10 $10  b  l'i  C  d  | K ) r t  f  r ( i v i s i ( , n  o  f  1964  f  1968  9  a  l'i  l'i  l'i  l'i  $140 $150 $170 $160  $150 $160 $180 $170  $220 $235 $255 $245  $250 $265 $285 $265  $340 $374 $292 $424  $500 $604 $634 $664  $160  $170  $290  $424  $664  $17.00 $10 $10  $10 $10  $10 $10  Wright and Braund, 1946, pp. 3-5 RNABC, Personnel practices, 1947,pp.3-5. RNABC Suggested revision of RNABC recommendations on personnel practices, 1948 Mckenna, Revision of personnel practices, 1952, pp.6ii ' 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 <  e  l'i  Experience 6 levels  a b c d f  1956  $25 $25  $60 $85  73 c o n t r a c t s a c r o s s the p r o v i n c e ( A p r i l 7, 1962). Contract  Issues.  The c o n t r a c t i s s u e t h a t c r e a t e d the g r e a t e s t debate was s a l a r i e s . Concern was r a i s e d by t h e North C a r i b o o Chapter t h a t " b a r g a i n i n g t o i n c r e a s e n u r s e s ' s a l a r i e s s h o u l d cease f o r the time being i n B . C . .  o t h e r w i s e nurses w i l l  be t a l k i n g themselves o u t o f  those j o b s and be r e p l a c e d by n u r s i n g a i d s " (September 15, 1954). There i s no r e c o r d o f t h i s i s s u e coming t o an Annual M e e t i n g , however no i n c r e a s e  i n s a l a r i e s was r e q u e s t e d i n 1955.  The o n l y r e q u e s t was  f o r a change i n the increment s t r u c t u r e f o r y e a r s o f s e r v i c e .  This  was not a c c e p t e d by many h o s p i t a l s , and t h e i s s u e d i d not go t o  conciliation  because i t was not c o n s i d e r e d i m p o r t a n t enough.  The B r i t i s h Columbia H o s p i t a l  Insurance S e r v i c e , which had become  the government f u n d i n g agency f o r the h o s p i t a l s o f the p r o v i n c e : o r d e r e d a f r e e z e on a l l  h o s p i t a l s a l a r i e s thus n u l l i f y i n g t h e i n c r e m e n t s  b u i l t i n t o the p r e v i o u s y e a r ' s c o n t r a c t .  In o r d e r t o honour the  c o n t r a c t , many h o s p i t a l s had l a r g e d e f i c i t s .  T h i s d e f i c i t was a l l e v i a t e d  when the government agreed t o a c c e p t 1/3 o f t h e d e f i c i t i n c u r r e d . The h o s p i t a l s were p e r m i t t e d t o r e c o g n i z e 1956 s a l a r i e s i n 1957 i f were i n e f f e c t .  agreements  Nurses were d e s c r i b e d as  most s y m p a t h e t i c t o the f i n a n c i a l d i f f i c u l t i e s t h a t the h o s p i t a l s have been e x p e r i e n c i n g but have been v e r y concerned when budget c u t s have an adverse e f f e c t on n u r s i n g c a r e . Many h o s p i t a l s have d r a s t i c a l l y c u t n u r s i n g 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 t h e r t i m e s , i n an e f f o r t t o b a l a n c e the budget. The nurses are unhappy about t h e i r i n a b i l i t y t o g i v e good n u r s i n g and f e e l the c a r e t h a t p a t i e n t s a r e r e c e i v i n g i s not always even s a f e n u r s i n g . They f i n d i t d i f f i c u l t t o d e r i v e s a t i s f a c t i o n i n d o i n g a j o b 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 r e s u l t s when work i s never f i n i s h e d  (Hood, 1956, pp.75).  This i s contrasted with the requests from Port Alberni nurses " i n excess of Recommended Personnel P r a c t i c e s " . record of how t h i s was handled (January 27, 1957).  There i s no  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 l e v e l s of work or p r o f e s s i o n s . . . that basic pay be raised to $275 or $300 (a month)".  A proposal to carry increments from one job to another  was rejected as jeopardizing 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 r e j e c t i o n of the c o n c i l i a t i o n  board's report by several h o s p i t a l s .  The Executive C o u n c i l , with the  assistance of a labour lawyer, i d e n t i f i e d four courses of a c t i o n : p u b l i c i t y , mass r e s i g n a t i o n , s t r i k e , and do nothing. Because a "united e f f o r t " was seen as "most important" and because " s t r i k e action presented a d e f i n i t e framework within which to work," s t r i k e action was supported by the Association ( R o s s i t e r , 1957, pp.799; June 1, 1957).  However t h i s was not an easy decision f o r the  Executive C o u n c i l .  O r i g i n a l l y a motion supporting s t r i k e action or  resignation was c a r r i e d , while a motion s t a t i n g a preference f o r s t r i k e action was withdrawn; in e f f e c t leaving the course of action open to the nurses themselves (June 1, 1957).  Ultimately,  strike  75 votes were taken i n three h o s p i t a l s and the Association supported t h i s action on the basis of "supporting the request f o r a r b i t r a t i o n rather than f o r an increase in t h e i r own s a l a r i e s " (July 9, 1957). The Executive Secretary met with the l o c a l chapters of the BCMA to "inform them of the s i t u a t i o n . . . not to seek t h e i r support". The s t r i k e vote was supported on the grounds that the recommendations were f a i r and j u s t .  The doctors objected to the inadequate financing  of h o s p i t a l s and deplored the government's p o l i c i e s of hospital f i n a n c i n g . Following the s t r i k e votes plans were made to s t a f f the h o s p i t a l s f o r emergency care only and directed a l l o f f e r s of help to representatives of the nurses (July 9, 1957). A s i m i l a r s i t u a t i o n arose in 1959 when a c o n c i l i a t i o n board report was rejected by eight h o s p i t a l s (January 22, 1959).  A meeting  with the Cabinet was sought. " I t was the consensus that there was no hope f o r an e a r l y h e a r i n g . . . a l l possible means of averting (the) threat of a s t r i k e or s t r i k e action were e x p l o r e d . . . ( i t was) agreed that neither the h o s p i t a l s nor the government would consider r e v i s i n g t h e i r stand u n t i l the nurses had shown that they are prepared to invoke the f u l l strength of labour l e g i s l a t i o n . . . . ( I t was agreed) that the Executive Committee stand behind the nurses in whatever a c t i o n , w i t h i n the provisions of labour l e g i s l a t i o n , i s found to be necessary in f o r c i n g acceptance of the C o n c i l i a t i o n Board Report. . . . I t was agreed that ( i n a l e t t e r t o the Cabinet) i t be stated that the a t t i t u d e of the nurses involved p r o h i b i t s f u r t h e r delay on the part of the E x e c u t i v e . . . (also that) l e t t e r s be sent to a l l hospital boards involved, pointing  76 out the resentment the Executive f e e l s i n the f a c t that nurses are being used by the h o s p i t a l s as a tool to f i g h t f i n a n c i a l  difficulties".  The f i n a l motion was passed when the President of the Executive Council cast the deciding vote in favour (January 22, 1959), Both c r i s e s were resolved when, s h o r t l y before the s t r i k e was to take e f f e c t , the government provided increased funds to the h o s p i t a l s (Hood, 1959, pp.58).  Again, in 1962 the Association supported  the nurses of VGH i n s t r i k e a c t i o n .  Throughout t h i s period the  Association pressed the government f o r binding a r b i t r a t i o n f o r nurses, without success. Outcomes. While c o l l e c t i v e bargaining improved the incomes of nurses, nurses were confronted with the budgeted shortage of s t a f f and the growing recognition of c o n f l i c t between the professional and labour r e l a t i o n s roles of the A s s o c i a t i o n . Although nurses' s a l a r i e s were touted as the best i n Canada (Nurses' s a l a r i e s best in Canada,  1  1957) concern was raised w i t h i n the  Association and i n public about the supply of nurses and the adequacy of patient care due to the " a r b i t r a r y way i n which BCHIS set down regulations in l i m i t i n g s i z e of s t a f f in a l l h o s p i t a l s i n B.C  ,  many patients are not receiving adequate nursing care and, in s p i t e of t h i s , nurses are working many hours o v e r t i m e . . . " (March 3., 1956). This concern resulted Hospital Nursing Care.  i n the formation of a committee on Standards of The committee was to "inquire into safe  77  nursing practices and i n d i c a t e 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 i m i t a t i o n s of nursing p r a c t i c e " ( F i s h e r , 1964, pp.57-58). The budgeted shortage of nurses was recognized as a c o n t r i b u t i n g problem (November 21, 1964).  The problem of standards of care re-emerges  as ' s a f e t y to p r a c t i c e ' and becomes a dominant theme of the Association in the 1970's. C o n f l i c t between the professional and labour r e l a t i o n s roles of the Association f i r s t surfaced when a representative of the Association was "sought f o r the professional nursing group, not f o r nurses as employees of h o s p i t a l s " to s i t on a committee of BCHIS (February 19, 1949).  The Executive of the Association recognized that  chapters of the Association were having " d i f f i c u l t y  distinguishing  between Chapter business and matters f o r n e g o t i a t i o n . . . " (November 4, 1961).  These types of c o n f l i c t s u l t i m a t e l y led to the d i v i s i o n of the  organization into Professional A f f a i r s and Labour Relations by which functioning and financing were separated.  Secondary themes. The secondary themes f o r t h i s period include education, r e g i s t r a t i o n , terms and conditions of employment f o r senior nursing s t a f f and the health and safety of nurses.  The theme of the education  of nurses was quiesc ent during t h i s period except to introduce refresher courses f o r nurses who had not practiced f o r ten or more  78 y e a r s (May 2 6 - 2 7 , 1960).  R e g i s t r a t i o n remained an i s s u e and was d e a l t w i t h two ways.  in  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 q u i r i n g r e g i s t r a t i o n f o r employment were c o n s i d e r e d (May 1 5 , 1 9 5 6 ) . At the same t i m e , s a l a r y d i f f e r e n t i a l s f o r r e g i s t e r e d and nonr e g i s t e r e d nurses were n e g o t i a t e d (Hood,1957, p p . 8 3 ) . The terms and c o n d i t i o n s o f employment f o r s e n i o r 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 .  nursing  Concern i s  f i r s t r e c o r d e d when d i r e c t o r s o f n u r s i n g were f i r e d w i t h o u t due n o t i c e (June 3 , 1920; J a n u a r y 2 9 , 1 9 2 7 ) . of directors 61-62).  The t e n t a t i v e  position  o f n u r s i n g i s suggested i n the Eaton Report (1938, pp.  Concern o v e r the d u 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  of  n u r s i n g r e s u l t e d i n the c i r c u l a t i o n o f a statement t o d i r e c t o r s , h o s p i t a l a d m i n i s t r a t o r s and chairman o f h o s p i t a l and p u b l i c  health  boards.  resulted  The i s s u e o f s a l a r i e s f o r s e n i o r n u r s i n g p e r s o n n e l  i n the f o r m a t i o n o f a committee t o g i v e a d v i c e t o nurses o r employers f o r s p e c i f i c s e n i o r p o s i t i o n s October 24, 1964).  in hospitals  A l o n g s t a n d i n g o b s e r v e r o f the  (March 1 0 , 1962; nursing  a d m i n i s t r a t i o n group a t t e s t s t o the g e n e r a l v u l n e r a b i l i t y o f  directors  o f n u r s i n g , the h i g h a t t r i t i o n r a t e o f h o l d e r s o f the p o s i t i o n and the i n c r e a s i n g 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  activities  (McCann, 1981). From the i n c e p t i o n o f o r g a n i z e d p r o f e s s i o n a l  n u r s i n g , the  r a t e o f t u b e r c u l o s i s amongst nurses was the main f o c u s o f concern f o r the h e a l t h and s a f e t y o f n u r s e s .  The advent o f v o l u n t a r y group  i n s u r a n c e prompted many h o s p i t a l s t o g i v e up c a r i n g f o r s i c k  nurses  79  at minimal or no cost to nurses (October 18, 1940).  U n t i l the  advent of compulsory hospital insurance, 1949, nurses were i n a d i f f i c u l t p o s i t i o n because they had no p r o v i n c i a l employee group through which to j o i n voluntary insurance schemes.  Under c o l l e c t i v e  bargaining, nurses were "expected to carry hospital insurance and where p o s s i b l e , complete medical insurance" through the p r o v i n c i a l hospital insurance scheme and through private insurance agencies (Hood, 1953, pp.82).  The Association directed i t s e f f o r t s 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 i n f e c t i o n s  21, 1956), salmonella (February 2, 1957) and i n f e c t i o u s (March 9, 1957).  (January  hepatitis  The RNABC agreed with WCB that compensation f o r  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 Association on the subject of s t r i k e s .  The Association moved from  the approval of a s t r i k e on the grounds of supporting the p r i n c i p l e of c o n c i l i a t i o n by both p a r t i e s to the acceptance of s t r i k i n g f o r economic b e n e f i t .  It would appear that t h i s change was p r e c i p i t a t e d  by pressure from grassroots nurses, although i t i s c l e a r that nurses were not u n i f i e d in t h e i r response to the issues of the terms and conditions of employment.  Coincident with t h i s change i n ideology  was the beginning of a c o n f l i c t in professional and union roles of the A s s o c i a t i o n .  80  Adjustments, to Growth: 1965- 7,6 . Introduction . The period 1965-76 i s dominated by structural/changes  in  the organization of the Association and by influences external to the Association that affected the process of c o l l e c t i v e bargaining. The growth of c o l l e c t i v e bargaining amongst nurses affected the Association by increasing the volume and complexity of work r e l a t e d to c o l l e c t i v e bargaining.  Although province-wide bargaining  established a uniformity in the major components of the c o n t r a c t , secondary issues were negotiated with each i n s t i t u t i o n . The organizational changes were a d i r e c t r e s u l t of the growing complexity of the business of the Association and a growing awareness of the potential of c o n f l i c t between the labour r e l a t i o n s role of the Association and the t r a d i t i o n a l roles of the A s s o c i a t i o n . Secondary themes f o r t h i s period include education, r e g i s t r a t i o n , safety to p r a c t i c e , d i s c i p l i n e , s o c i a l s e c u r i t y and s u b s i d i a r y workers.  Changes in the preparation f o r bargaining. The preparation of Recommended Personnel Practices went through, several changes between 1942/43-1971.  I n i t i a l l y Recommended  Personnel Practices were prepared by the Executive Secretary. From 1946-50  the contract demands were prepared by the Committee on  Labour Relations and l a t e r by the Director of the Personnel Service  81  TABLE .3,2  The Growth of C e r t i f i e d Bargaining Units of Registered Nurses Within the RNABC 1946-76"!  1946 Certified Bargaining  1956  1966  1976  56  63  76  Unit*  RNABC Labour Relations D i v i s i o n , Present C e r t i f i c a t i o n s , 1981. Note:  I t i s not possible to c a l c u l a t e the percentage of Registered nurses who were w i t h i n bargaining u n i t s . 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 p r e c i s e l y with the data derived from the RNABC Annual Minutes, 1946-76.  82 w i t h the support of an advisory committee on Employment R e l a t i o n s . This committee l a t e r became a standing committee to co-inci.de with changes i n the CNA structure (Capelle, 1956, pp.60-61).  In 1964  t h 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 t u d i e s , p r a c t i c e s , 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 s o c i a l and economic welfare of members. The second clause became the sole respons i b i l i t y of the Committee on Social and Economic Welfare. This committee's r o l e was defined as: "to recommend to the Council  policies  which w i l l promote the s o c i a l and economic welfare of the members, and which w i l l a s s i s t the Association to meet personnel problems of members whenever they e x i s t "(October 24, 1964, March 20, 1965)., Subcommittees under the committee on Social and Economic Welfare included Personnel Practices (formerly, Employment R e l a t i o n s ) , Referral and Review (formerly Ethics  and Welfare Services f o r Members  (Wadsworth, 1966, pp.57). Input from the membership i n the development of contract demands was a long standing problem f o r the A s s o c i a t i o n .  Earlier  attempts to separate Chapter (professional) business and business concerning labour r e l a t i o n s had been unsuccessful, and i n 1964 i t was decided that "bargaining representatives (would be) elected from each regional group of s t a f f because i t was agreed (that i t was) improper  83 f o r a c o u n c i l l o r to be involved i n the bargaining procedure" (November 21, 1964).  The method of developing conditions of  employment was revised to establish, a Committee on Contract Terms. The members were the P r o v i n c i a l Bargaining Committee, with the addition of s t a f f representatives from public 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 S t a f f Representatives' Conference (February 23, 1968).  Thus the Annual Meeting of 1968  was the l a s t year in which Revisions of Recommended Personnel Practices were submitted to the membership of the Association f o r discussion and approval.  This decision was disputed but not revised i n 1968  (May 29-31, 1968).  Selected date from Recommended Personnel  of the RNABC, 1946-1968 i s presented in Table 3.  Practices  The guidelines f o r 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 s a l a r i e s f o r nurses should be commensurate with education, q u a l i f i c a t i o n s and past experience" (November 22-23, 1968). These changes, and the formation of the p r o v i n c i a l Committee on Social and Economic Welfare were a d i r e c t outcome of changes within the CNA.  The national committee, formally established in  A p r i l 1965, described i t s terms of reference as: 1.  To i n t e r p r e t the philosophy of s o c i a l and economic welfare f o r nurses in Canada.  2.  To provide guidance, i n t e r p r e t a t i o n and moral support to p r o v i n c i a l nurses' associations in the development of s o c i a l and economic welfare programmes.  84  3. To promote research e s s e n t i a l to the advancement of s o c i a l and economic welfare programmes f o r nurses (CNA, 1966, pp.7). and i t s philosophy as: The Canadian Nurses' Association believes that one r e s p o n s i b i l i t y of the organized profession i s to safeguard the welfare of i t s members. The Association believes that the profession has the r i g h t and r e s p o n s i b i l i t y to define i t s functions. It recognizes that basic to the provision of a high q u a l i t y of nursing care i s the adequacy of the nursing s t a f f , conditions of work and an environment conducive to e f f i c i e n c y and individual satisfaction. The Canadian Nurses' Association approves the p r i n c i p l e of c o l l e c t i v e bargaining f o r nurses and believes that the bargaining authority f o r i t s members should be vested i n the professional nurses' a s s o c i a t i o n in each province. The Canadian Nurses' Association recognizes that the r e l a t i o n s h i p of nurses to the p u b l i c i s a major asset in promoting the s o c i a l and economic welfare of i t s members. The q u a l i t y of t h e i r work and t h e i r i n t e r p r e t a t i o n of i t s character, content and r e s p o n s i b i l i t y w i l l serve to b u i l d up a genuine understanding of the c o n t r i bution of nurses i n the community. The acceptance of the p r i n c i p l e s and r e s p o n s i b i l i t i e s of c o l l e c t i v e bargaining f o r 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 p o 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 i n d i v i d u a l to function outside of a larger group was emphasized.  85  The i d e o l o g i c a l  shift.  In 1968 a committee to revise the structure of the RNABC was struck.  The r a t i o n a l e f o r the r e v i s i o n 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) administration of the Act, 2) f u r t h e r i n g the p r o f e s s i o n , 3) promotion of employee-employers' r e l a t i o n s under which placement and counselling services as well as c o l l e c t i v e bargaining f e l l , and 4) "performance of such other lawful things as are i n c i d e n t a l or conducive to the welfare of the public 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 o b j e c t i v e s , r e - s t r u c t u r i n g the Board, the standing committees and the functioning of the professional s t a f f of the A s s o c i a t i o n .  The r o l e and functioning of the President  of the Association became an i s s u e .  I t was suggested that the President  be reimbursed f o r loss of salary r e s u l t i n g from the r e s p o n s i b i l i t i e s of her o f f i c e and t h i s was defeated.  Later the issue was re-considered  in terms of the P r e s i d e n t ' s r o l e being a f u l l time paid p o s i t i o n . This was defeated because i t created leave of absence problems although i t was recognized that the P r e s i d e n t ' s role demanded a considerable investment of time (February 19, 1972). voluntary, unpaid p o s i t i o n .  The role was l e f t as a  This i s consistent with the A s s o c i a t i o n ' s  p o s i t i o n that s t a f f nurses or t h e i r i n s t i t u t i o n were to be reimbursed f o r loss of salary only i f the nurse was unable to arrange days o f f to  86  perform o f f i c i a l Association business (November 20, 1965, March 17-19, 1977). In view of the s t r u c t u r a l changes that occurred, and i n view also of the evolving a t t i t u d e of the role of c o l l e c t i v e bargaining w i t h i n the A s s o c i a t i o n , a consideration of the A s s o c i a t i o n ' s statement of objectives between 1950-1971 i s u s e f u l . In 1953, the President of the Association stated the objectives as: (1)  to implement and protect standards i n nursing education and p r a c t i c e to meet p r e v a i l i n g community needs and  (2)  to serve the membership through safeguarding the professional status of nurses and improving t h e i r economic s e c u r i t y ,  to be achieved (!)  By s e t t i n g and safeguarding the standards f o r nursing education and p r a c t i c e i n t h i s province and evaluating and l i c e n s i n g the graduates of B.C. Schools and graduates from other centres according to those.standards in the i n t e r e s t of safe nursing care f o r the public and protection of our professional s t a t u s .  (2)  By providing two r e g i s t r i e s f o r p r i v a t e duty nursing i n two of the three l a r g e s t c i t i e s in the province and a placement service f o r other types of nursing positions throughout the province. While the primary purpose of these resources i s to serve our registered members, the public i s also served through the placement of nurses, p r i v a t e duty, i n s t i t u t i o n a l and public h e a l t h , where needed, in the communities throughout B.C.  (3)  By providing a labour r e l a t i o n s programme to obtain and safeguard s u i t a b l e working conditions and acceptable personnel practices f o r our members through d i r e c t conferences with employees? (Paulson, 1953 pp.4-5).  'Employee' was changed to 'employer' by E. Mallory, former owner of the Annual Meeting Minutes, June 5-6, 1953 used f o r t h 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 i n nursing. 3. To elevate the standard of nursing p r a c t i c e in order to render e f f i c i e n t service in the i n t e r e s t of the p u b l i c . 4. To promote and regulate sound employee-employer r e l a t i o n s in the nursing profession. ( R o s s i t e r , I960, pp.5) These were u l t i m a t e l y revised during the l a t e 1960's to read: The object of the Association i s to f u r t h e r the standard of nursing p r a c t i c e 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 f e c t i n g the provisions of the Registered Nurses' Act,  5..  promoting improvement in nursing education and nursing practice,  c.  regulating r e l a t i o n s between employers and employees through c o l l e c t i v e 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 public 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 r e v i s i o n of the C o n s t i t u t i o n and Bylaws and the re-organization of the structure of the Association did not solve the problem of a s i n g l e organization representing s t a t u t o r y ,  professional  and economic i n t e r e s t s of the membership of the A s s o c i a t i o n .  Concern  about the r o l e , function and structure of the Association led to the commissioning of the Baumgart study on Nursing L e g i s l a t i o n . (November 17, 1972).  The purpose of the study was to expand under-  standing of some of the fundamental i s s u e s . . . ( i n nursing l e g i s l a t i o n )  88  and to provide a basis f o r discussion and debate"(Baumgart, 1973). Baumgart i d e n t i f i e d three roles of the A s s o c i a t i o n , 1) the corporate r o l e delegated by the State concerned with educational and e t h i c a l regulation f o r the protection of the p u b l i c , 2) the a s s o c i a t i o n - o r profession-centered r o l e f o r the influence of the form, range, and q u a l i t y of services f o r the p u b l i c , and 3) the union r o l e f o r the protection and improvement of the s o c i a l and economic s i t u a t i o n of the membership (Baumgart, 1973 pp.1).  Baumgart  (1973, pp.8) i d e n t i f i e d the key issue as how to achieve greater public responsiveness and a c c o u n t a b i l i t y without s a c r i f i c i n g the values of voluntary professional i n i t i a t i v e " /  Baumgart saw an " i n e x t r i c a b l e  i n t e r t w i n i n g of i n t e r e s t of the public and the nursing profession The b e l i e f i s that the benefits to the public coming from the harmonizing and i n t e g r a t i n g of these i n t e r e s t s outweigh the potential dangers of c o n f l i c t . The important organizational consideration i s to ensure that checks e x i s t and are applied to prevent sustained departures of a professional a s s o c i a t i o n from, i t s declared public purposes. P a r t i c u l a r reference i s often made here to the r e l a t i o n s h i p between socio-economic i n t e r e s t s - the union r o l e , and conditions f o r patient care - the public i n t e r e s t r o l e . The great d i s t i n c t i o n seen between a professional a s s o c i a t i o n ' s negotiating i n t e r e s t s and a trade union's i s the almost c e r t a i n preoccupation of professional people with o f f e r i n g an i n c r e a s i n g l y superior level of s e r v i c e . To have the professional association act as bargaining agent f o r i t s memberships i s f e l t to give greater assurance that working conditions secured f o r nurses w i l l be d i r e c t l y r e l a t e d to public welfare considerations. (Baumgart, 1973, pp.4). At the same time, the CNA commissioned "A Discussion Paper on the Three Major Roles of P r o v i n c i a l Nurses' Organizations"  89 (Bachard, 1973).  Bachard i d e n t i f i e d three legal e n t i t i e s which may  comprise a professional organization: 1) a professional  corporation  responsible f o r regulatory and d i s c i p l i n a r y f u n c t i o n s , 2) a professional a s s o c i a t i o n interested in promoting the profession and 3) the professional syndicate or union interested i n the socioeconomic welfare of i t s members.  Bachard examined the nursing organizations  of the provinces and i d e n t i f i e d four versions of organizational structures dealing with the three r o l e s .  She then presented a model  structure in which the three roles were separated but incorporated under a Council of the p r o v i n c i a l nurses' a s s o c i a t i o n . In the proposed model, the three roles i d e n t i f i e d were to be performed by separate structures w i t h i n ••the Association 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 Association would be required in order to  p r a c t i c e 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' Association could not engage i n c o l l e c t i v e bargaining on behalf of i t s members because of the r o l e management nurses played in the Associaton. The RNABC recognized the s i g n i f i c a n c e of the Supreme Court decision (November 17, 1973). The Labour r e l a t i o n s and professional a c t i v i t i e s of the Association  90  were (now to he) separated such that the Association s h a l l not be e n t i t l e d to make or amend anything in the Constitution or Bylaws, the e f f e c t of which would give the Association any control over the bargaining functions of the Labour Relations D i v i s i o n " (January 9-10, 1976).  This was refined i n 1978 to read "the Labour Relations  D i v i s i o n s h a l l be governed by a Labour Relations Council to be elected amongst members of bargaining units..(RNABC, Constitution and Bylaws, May 10, 1978).  The Professional and Labour Relations D i v i s i o n  continued to operate under the umbrella of the RNABC u n t i l complete separation was established in 1981. Unrest in the hospital i n d u s t r y , which included s t r i k e 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 c o l l e c t i v e bargaining process i n the hospital industry and make recommendations f o r an improved and a more viable c o l l e c t i v e bargaining s y s t e m . . . " (January 17, 18, 1975).  The report recommended the separation  The objectives were revised to read: The object of the Association i s to further the standard of nursing p r a c t i c e 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 f e c t i n g the provisions of the Registered Nurses Act; b. promoting improvement in nursing education and nursing p r a c t i c e ; c. r e g u l a t i n g , through a Labour Relations D i v i s i o n , r e l a t i o n s between employers and employees through c o l l e c t i v e bargaining onbehalf of nurses f o r whom the RNABC holds c e r t i f i c a t i o n and bargaining authority; 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 p u b l i c and the welfare of the nursing and a l l i e d professions. (RNABC, Constitution and Bylaws, 1978).  91 of the Health Labour Relations D i v i s i o n as a separate e n t i t y from BCHA but employers' p a r t i c i p a t i o n in the new. Health. Labour Relations Association was conditional on membership i n the BCHA ( B l a i r , 1974). The separation of labour r e l a t i o n s a c t i v i t y from the BCHA was analogous to the separation of labour r e l a t i o n s from the RNABC.  The RNABC  response to the B l a i r report and was " p o s i t i v e " (February 14, 1975).  Secondary themes. The secondary themes f o r t h i s period are: education, r e g i s t r a t i o n , safety to p r a c t i c e , d i s c i p l i n e , s o c i a l s e c u r i t y and subsidiary workers. Two major events in nursing education occurred during t h i s period: 1) the submissions to the Royal Commission on Health services i n Canada i n 1964 (Hall Commission) and 2) the introduction of 2 year community college programs. CNA and RNABC submission to the Hall Commission stressed the need f o r increased funding f o r nursing education, the need to remove nursing schools from h o s p i t a l s , and the need to increase the a v a i l a b i l i t y of u n i v e r s i t y education f o r nurses. Provision f o r f l e x i b i l i t y i n the structure of nursing education had been made in r e v i s i o n s to the Registered Nurses Act (May 26-27, 1966).  Establishment of two year community college  programs had started in the S i x t i e s and the consequent, c l o s i n g of hospital schools: of nursing  fegan.  In 1967 the student nurses'  92  Association i s recorded as requesting that the Association send " l e t t e r s to Boards of four (of a t o t a l of seven) hospital schools of nursing with 44 hour weeks, requesting a 40 hour week and two free days per week f o r student nurses"- The Boards in question "endorsed in p r i n c i p l e the i n t e n t of the recommendation and (were) hoping to implement a gradual t r a n s i t i o n to a 40 hour week" (Cunningham, 1967, pp.61). Contract demands f o r 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  p o l i c i e s f o r schools of nursing were stated as-a 40 hour week one,year l a t e r (Cunningham, 1968, pp.18). With the growth of community college programs, concern over the performance of new graduates prompted the Association to study the functioning of new graduates and to "define and v a l i d a t e e s s e n t i a 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 e n t i a l s f o r nurses (May 11 , 1963).., The need f o r funds f o r o r i e n t a t i o n programs f o r new s t a f f and f o r continuing education was presented to the government (May 31, June 1, 2, 1967) (September 19, 20, 1969).  The need f o r additional s p e c i a l i z e d t r a i n i n g  f o r nurses, l a r g e l y as a r e s u 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  p a r t i c i p a t i o n had been variable..  The r o l e of examiners disappeared  with the use of m u l t i p l e choice exams i n the 60.'s,  The College  relinquished i t s examining r o l e i n 1969 at i t s own request (December 12, 1969). Registration of nurses continued to be a v i s i b l e i s s u e . A motion "to i n v e s t i g a t e the question of mandatory r e g i s t r a t i o n arose at the 1965 Annual Meeting,  There are two aspects to t h i s issue:  1) to protect the q u a l i t y of nursing care and 2) to protect the employment of nurses.  Mandatory r e g i s t r a t i o n was studied at length and rejected  because "1)'mandatory r e g i s t r a t i o n would increase the shortage of s t a f f . . . ( a n d ) probably be met by an increase i n the u t i l i z a t i o n of a u x i l i a r y nursing personnel, 2) mandatory r e g i s t r a t i o n would preclude employment as a graduate nurse: a) preparatory to re-instatement as a registered nurse f o l l o w i n g d i s c i p l i n a r y a c t i o n , or b) following 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 i n salary schedules to become r e g i s t e r e d i f employed continuously i n B.C. (Campbell, 1966, pp.46).  Again i n 1970,  1974 and 1976, motions f o r mandatory r e g i s t r a t i o n were discussed. In the context of budgetary c o n s t r a i n t and the r e s u l t i n g h i r i n g of other than r e g i s t e r e d nurses, mandatory r e g i s t r a t i o n was seen as a means of protecting the public (May 27-29, 1970).  In 1976, discussion  of mandatory r e g i s t r a t i o n was i n terms of r e - r e g i s t r a t i o n on the basis  94 of demonstrated competence (November 18, 19, 20, 1976).  Concern about  safety to p r a c t i c e nursing resulted in a p o s i t i o n paper on nursing p r a c t i c e (May 25, 1973), a study on safety to p r a c t i c e (November 13, 14, 1975) and the development of a q u a l i t y assurance program (September 23-25, 1976). D i s c i p l i n a r y action i s another facet of the r e g i s t r a t i o n i s s u e . U n t i l the 70's d i s c i p l i n a r y action was an informal procedure w i t h i n the realm of the Board.  A formalized procedure was developed with the stated  p o l i c y that when "tak(ing) d i s c i p l i n a r y a c t i o n , t h i s  action  should provide the members with the greatest possible opportunity to r e - e s t a b l i s h professional competence that i s consistent with public safety" (November 18-20, 1976). Throughout the minutes there i s only occas: ional discussion of d i s c i p l i n a r y matters. Although the Association was aware of the need f o r s o c i a l s e c u r i t y f o r i t s members from i t s i n c e p t i o n , l i t t l e concrete action was taken u n t i l government plans f o r unemployment insurance and pension plans become a v a i l a b l e .  U n t i l the i n t r o d u c t i o n of unemployment  insurance by the federal government, the BCHA stood alone amongst hospital associations i n Canada i n support of unemployment insurance f o r hospital employees and nurses (BCHA, 1940, pp 28 9).The RNABC supported 7  unemployment insurance f o r nurses as e a r l y as 1950 (March  3, 1950),  but l a t e r revised t h i s decision (November 18, 1967). With the p u b l i c a t i o n of the Federal government paper on unemployment insurance both the CNA and RNABC supported the i n c l u s i o n of nurses in such a plan (November 13, 1970).  U n t i l t h i s time, fears had been expressed that nurses would  95 receive l i t t l e benefit from the plan; because of t h e i r low unemployment rates. With the s h i f t of employment of nurses from private duty to p u b l i c l y funded h o s p i t a l s and the enactment of the Municipal Superannuation Act, the Association urged BCHIS to provide a superannuation plan f o r employees of p u b l i c l y funded h o s p i t a l s (May 25, 1950). H o s p i t a l s , as employers,could p a r t i c i p a t e i n 1957 (May 3-4, 1957), but generally did not u n t i l the early 1960's. Interest then s h i f t e d to the i n c l u s i o n of medical insurance premiums, income protection plans, and the r e v i s i o n of superannuation plans to end d i s c r i m i n a t i o n against dependants and spouses of women (September 19-20, 1969; A p r i l 28, 1973). Subsidiary workers concerned the RNABC in terms of t h e i r r o l e , function and p r o l i f e r a t i o n .  The A s s o c i a t i o n ' s concern that  p r a c t i c a l nurses be used only i n an a u x i l i a r y capacity was expressed to Directors of Nursing, BCHIS and BCHA (February 24, 1968; May 2-23, 1969).  The Association (with the BCHA) rejected Canada  Manpower i n i t i a t i v e s i n developing a program f o r nurses' aides, (December 12, 1969) and a l t e r n a t e l y urged that operating room technicians be phased out ( A p r i l 17, 1971).and expressed concern about i n s u f f i c i e n t numbers of t h i s group (June 17, 1972).  The p r o l i f e r a t i o n  of health care workers was studied ( A p r i l 15, 1972) as was the p o s s i b i l i t y of bringing together registered nurses, p s y c h i a t r i c and p r a c t i c a l nurses under one piece of l e g i s l a t i o n .  96 Summary.  The period 1964-76 represents the end of r e l i a n c e on paternalism.  The emphasis of commitment to service in the face of  d i v e r s i t y (shortages of nurses, patient need e t c . ) i n which economic needs were put in second place had ended. In considering the objectives of the Association 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 s e c u r i t y for nurses i s now stated in terms of 'employee-employer" acknowledging the completion of the t r a n s i t i o n from the major form of employment as p r i v a t e duty nurses to employment as an employee w i t h i n an institutional  structure;  3) acknowledgement of c o l l e c t i v e bargaining as the mechanism f o r dealing with economic matters i s f i r s t stated in the 1972 statement of o b j e c t i v e s ; 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 p a r t i c i p a t i o n in " a c t i v i t i e s conducive to the health and welfare of the p u b l i c " i s made, although the Association had been a c t i v e in health p o l i c y matters since i t s inception eg: the p r a c t i c e of midwifery  (April  26, 1917; A p r i l 21, 1924; A p r i l 22, 1935); p r o v i n c i a l and  97 national health p o l i c y (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 i n t e r e s t i n g omission i s the lack of expressed i n t e r e s t 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  itself.  A l t e r n a t i v e l y t h i s omission may represent an acceptance of r i s k or a b e l i e f that the 'good' p r a c t i c e of nursing eliminates any r i s k to health.  This had been implied i n the discussion of tuberculosis  in  the Eaton Report (1938, pp.21-23). On the secondary themes education was the most important. The s o l u t i o n to the problem of hours of work f o r student nurses was the end of a system based on service in exchange f o r education.  While the  Association had exerted pressure f o r change, the s o l u t i o n came as a r e s u l t of changes external to the A s s o c i a t i o n .  Nursing education  became apart of the general education system.  Conclusion:  To Protect the Quality of Nursing; 1943-76  Confronted with increased economic and s o c i a l  disparity,  reinforced by the strength of a shortage of nurses during and f o l l o w i n g World War I I , nurses i n B r i t i s h Columbia voted to support c o l l e c t i v e bargaining i n  1946.  This action was seen to be taken ' t o protect  98  the q u a l i t y of nursing' (May 2, 1951),  Restraint on wage demands  during the f i r s t years of c o l l e c t i v e bargaining resulted in the eruption of s t r i k e votes i n 1957 and 1959,  The d e c i s i o n by the  Supreme Court of Canada in 1973, that the Saskatchewan Registered Nurses' Association could not represent nurses i n c o l l e c t i v e bargaining because of the r o l e of managerial nurses on the A s s o c i a t i o n ' s board, and concern within the A s s o c i a t i o n ' s membership about the appropriate r o l e and functioning of the Association led to the separation of professional and labour r e l a t i o n s roles and functions in 1976.  99 CHAPTER 4 Methodology Introduction The purpose of t h 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 b r i e f consideration of some of the problems of doing s o c i a l research and continues with a discussion of the t h e o r e t i c a l aspects of grounded theory.  A discussion of the a p p l i c a t i o n  of grounded theory i n t h i s 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 i n the conclusion.  Some Problems of Social Research This research had two major problems, the s e l e c t i o n 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 r e c t reference was made or i n t u i t i o n prompted, by such sources as The Canadian Nurse, The B u l l e t i n of the Registered Nurses' Association of B r i t i s h Columbia, the Annual Minutes of the B r i t i s h Columbia Health Association and selected interviews.  Interviews were l i m i t e d to  100 persons who were considered to be key p e r s o n a l i t i e s , and who were known to be receptive to the study of issues i n health care.  The  interviews were open-ended and, because of the nature of the p a r t i c i p a n t s , were reminiscences. No tape recordings were made.  Some  background understanding was developed in the course of s o c i a l  inter-  action with people who had l i v e d through some of the issues presented. Their perspectives were found to substantiate the s o r t i n g of the data, and t h e i r comments were included to enhance the richness of the material.  These contributions were spontaneous, and given with  enthusiasm and i n t e r e s t i n the study. The question of the method of analysis of the material presented two p o s s i b i l i t i e s - q u a n t i t a t i v e or q u a l i t a t i v e . Cole (1976) has suggested that q u a l i t a t i v e research i s most applicable f o r d e s c r i p t i o n , formulation of hypotheses, and understanding of the causal process. Cole states that q u a l i t a t i v e research r i s k s the d i s t o r t i o n of r e a l i t y , (1976; pp.186) but he points out that t h i s can be countered by ' t r i a n g u l a t i o n ' , that i s , other documentary sources and interviews can be used to see what elements can be agreed or disagreed upon. A l t e r n a t i v e l y , preceptions of r e a l i t y can be viewed as i n t e r e s t i n g , and what ' r e a l l y ' happened as not so important. Quantitative methodology, "a means O f c o l l e c t i n g data which can be converted into numbers" (Cole, 1976, pp.77) provides the r a t i o n a l e for a technique of content analysis i n which s c i e n t i f i c methods are applied to documentary evidence ( H o l s t i 1969 pp.5).  101 H o i s t i (1969, pp.14) defines content analysis as "any technique f o r making references by o b j e c t i v e l y and s y s t e m a t i c a l l y c h a r a c t e r i s t i c s of messages".  identifying  A l t e r n a t i v e l y , content analysis can  be done as q u a l i t a t i v e a n a l y s i s of documents. There are several arguments against using q u a n t i t a t i v e content a n a l y s i s i n t h 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 t e a d , 1970, pp.2-5).  As appealing as t h i s may be, F i l s t e a d  contends that t h i s i s not n e c e s s a r i l y an appropriate method f o r the study of behavior.  He argues the case f o r q u a l i t a t i v e methodology,  "as a l e g i t i m a t e source of e i t h e r data c o l l e c t i o n or theory const r u c t i o n , " and supports the use of Glaser and Strauss's methodology of grounded theory ( F i l s t e a d , 1970, pp.5-8). Advice was sought from two sources. use of q u a n t i t a t i v e content a n a l y s i s .  Neither supported the  I t was suggested that the  subtlety of the material would be l o s t (Whittaker, 1980).  I t was  also suggested that q u a n t i t a t i v e content analysis had proven to be l e s s useful than hoped i n the study of the messages of a d v e r t i s i n g . ( P o l l a r d , 1980).  Thus, the methodology of grounded theory was chosen  as the means to study the data. The remainder of t h i s chapter draws heavily 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 s y s t e m a t i c a l l y obtained and analyzed from the data of s o c i a l research".  Theory i s generated by the process of  t h e o r e t i c a 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 d e n t i f i e s the basic features of the study, the process of data c o l l e c t i o n i s c o n t r o l l e d by the emerging theory d i r e c t i n g the researcher to new sources of data.  Thus, while E t z i o n i ' s  (1968)  concept of a s o c i e t a 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 r e c t i o n t h i s study might take, i t did not influence the data c o l l e c t i o n nor the findings i n the data.  In t h i s study, a  preliminary 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 m a t e r i a 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  i n which empirical examples are chosen to support t h e o r e t i c a l mulations.  for-  While the research area i s entered into with c e r t a i n ideas  or models, 'the development of c o l l e c t i v e bargaining as a s h i f t i n ideology from professionalism to unionism' the methodology of grounded theory represents a s h i f t from the v e r i f i c a t i o n of borrowed theory to the preceding step of discovering what concepts and  103 hypotheses are relevant f o r the area under study. study, the research was an examination of the  In the case of t h i s  data, the Board and  Annual Minutes of the RNABC and selected m a t e r i a l , to e s t a b l i s h relevant concepts and emergent hypotheses a r i s i n g 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 i s defined as theory developed from "substantive or empirical areas of s o c i o l o g i c a l i n q u i r y , 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 s o c i a l inquiry such as stigma, deviant b e h a v i o r . . . " Glaser and Strauss (1967; pp.32).  Glaser and Strauss (1967, pp.33)  state that substantive and formal theories e x i s t on d i s t i n g u i s h a b l e l e v e l s of g e n e r a l i t y , " and thus "can shade at points into the other"'. They state that the researcher should focus c l e a r l y on one or other l e v e l or on a s p e c i f i c combination because the s t r a t e g i e s vary f o r a r r i v i n g at each.  There was no attempt to develop formal theory  from the data studied.  In t h i s instance the focus was the  substantive area of a p r o v i n c i a l nursing o r g a n i z a t i o n , with study concentrated on the entry into c o l l e c t i v e 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 themselves 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 f i r s t 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  propositions or as a running t h e o r e t i c a l discussion using  the  conceptual categories and properties generated from the research.  Theoretical sampling. The r o l e of comparison groups i s to promote the comparison of diverse or s i m i l a r evidence i n d i c a t i n g the same conceptual categories and p r o p e r t i e s . sake.  Evidence i s not compared f o r i t s own  The researcher begins with no preplanned set of groups, and  no rules f o r the comparison of groups. the material be relevant.  The only c r i t e r i o n i s that  I t i s necessary to be c l e a r on the basic  types of groups i n order to control the e f f e c t of the groups on the g e n e r a l i t y 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 s e l e c t i n g groups f o r study may be  decreased by studying only one group or the sub-groups of a selected group during a s i n g l e research period.  The scope of substantive  theory can be c a r e f u l l y increased and c o n t r o l l e d by the conscious choice of groups. studied.  In substantive theory only s i m i l a r groups are  In the development of formal theory the comparison of  d i s s i m i l a r substantive groups of conceptual s i m i l a r i t y i s used. Categories and properties are distinguished in order to i n d i c a t e a systematic r e l a t i o n s h i p between the two elements of theory. A category i s a concept about the problem, not i t s s i t u a t i o n . 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 i n the development of categories i s the i d e n t i f i c a t i o n of themes that have recurred and seem to have some bearing on the problem at hand.  These themes are l a t e r sorted into categories and  properties. Glaser and Strauss advise against borrowing categories from the l i t e r a t u r e in order to f a c i l i t a t e the development of new categories and to avoid s e l e c t i n g data that forces a ' f i t ' .  Ignoring  established categories allows the emergence of new categories that are most relevant and suited to the data. f o r d i v e r s i t y i n emergent c a t e g o r i e s .  An attempt i s  made to aim  The l i t e r a t u r e i s examined f o r  s i m i l a r i t i e s and convergences only a f t e r the a n a l y t i c core of the categories has been e s t a b l i s h e d , and therefore the l i t e r a t u r e review follows the analysis of the data.  Glaser and Strauss (1967, pp.65-69)  use the concept of a ' s l i c e of data kinds and sources properties.  1  to promote the use of d i f f e r e n t  of data in the development of a category and i t s  Theory generated from m u l t i p l e sources of data  promotes a richness and a v e r i f i c a t i o n of data, as well as a proportioned view of the evidence. The systematic analysis of data allows the development of conceptual categories from the data.  While s p e c i f i c f a c t s 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 i t s e l f , and 2) sensitizing,  108 that i s the e n t i t y should suggest a meaningful picture to the reader. Glaser and Strauss state that t h e o r e t i c a l s e n s i t i v i t y i s developed with p r a c t i c e by the researcher and may be a r e f l e c t i o n of the researcher's personal and temperamental bent as well as the researcher's a b i l i t y to have i n s i g h t or borrow the i n s i g h t of others. Once a category or a property i s e s t a b l i s h e d , only strong evidence, u s u a l l y from a d i f f e r e n t substantive area in addition to the creation of a better category, i s s u f f i c i e n t to change a category. To avoid forced i n t e g r a t i o n , there i s no attempt to apply a model of a formal theory u n t 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 t h i s study. Depth of t h e o r e t i c a l sampling refers to the amount of data c o l l e c t e d 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 t h e o r e t i c a l  categories need to be as f u l l y saturated as p o s s i b l e . In p r a c t i c e , Glaser and Strauss have found that the researcher saturates a l l categories u n t i l i t i s c l e a r which are the most important.  Through-  out t h i s process, systematic, simultaneous c o l l e c t i o n , coding and analysis take  place.  As the work progresses, the researcher looks  f o r emergent c a t e g o r i e s , reformulates categories as new properties emerge and prunes and adds u n t i l a t h e o r e t i c a l framework emerges understandable to both layman and s o c i o l o g i s t .  109 The Constant Comparative Method of Q u a l i t a t i v e A n a l y s i s . The constant comparative method of analysis i s concerned with generating and suggesting, but not t e s t i n g categories, properties and hypotheses about the general problem under study.  Glaser and  Strauss suggest that the properties may be causes, c o n d i t i o n s , consequences, dimensions, types, processes e t c .  There i s no attempt  to e s t a b l i s h the u n i v e r s a l i t y or proof of suggested causes or r e l a t i o n s h i p s . Since no proof i s needed, i t i s necessary only to saturate the categories; thus not a l l data need be considered. There are four stages i n the constant comparative method: 1) comparing incidents applicable to each category, 2) i n t e g r a t i n g categories and t h e i r p r o p e r t i e s , 3) d e l i m i t i n g the theory and 4) w r i t i n g the theory.  There w i l l be no attempt in t h i s study to  d e l i m i t or write theory. In phase one, each incident i s coded into as many categories of analysis as p o s s i b l e . f i e l d notes. vis  recorded.  Headings were noted on the margin of the  The comparison group in which each incident occurred While coding an incident f o r a category, comparison*  are made with previous incidents i n the same and d i f f e r e n t groups coded i n the same category.  This process generated the t h e o r e t i c a l  properties of the category.  Glaser and Strauss state that the  researcher w i l l notice that the concepts abstracted from the substantive s i t u a t i o n tend to be l a b e l s c u r r e n t l y i n use f o r the actual process and behaviors that are being explained: 'the s t r u g g l e '  110 f o r the eight hour day, while the concepts constructed by the researcher tend to be the explanations, 'the attempt to c o n t r o l ' the working environment. The i n t e g r a t i o n of categories and t h e 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 i n c i d e n t s . The u n i t of comparison has changed to a more complex l e v e l .  Ultimately,  diverse properties become i n t e g r a t e d ; the i n t e g r a t i o n of theory occurs. Delimiting theory occurs at two l e v e l s , 1) the theory s o l i d i f i e s , i e . modifications of the theory become fewer, and 2) the o r i g i n a l l i s t of categories f o r 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 e f f e c t of reduction and t h e o r e t i c a l saturation moves  the a n a l y t i c framework  to the l e v e l of theory.  The f i n a l stage of w r i t i n g 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 d e s c r i p t i v e content behind the categories.  Glaser and  Strauss state that the presentation of theory can be made i n the forms of a discussion which i s s u f f i c i e n t f o r the exploratory stage of theory development or i n the form of p r o p o s i t i o n s . This study w i l l be confined to the level of an exploratory statement.  The A p p l i c a t i o n of Grounded Theory to the Data_._ The generation of categories and properties began with a review of the minutes of the A s s o c i a t i o n .  The minutes are contained  i n notebooks and bound volumes dating from 1912 to the present. They are  hand w r i t t e n from 1912-1923 and typed t h e r e a f t e r . The format,  depth and s t y l e varies over the 64 years that were reviewed. The minutes include the minutes of the Executive C o u n c i l , the C o u n c i l , l a t e r c a l l e d the Board, and the Annual Minutes. Executive Council meetings  Minutes of the  1923-27 do not appear to e x i s t . Published  annual minutes e x i s t from 1945. Reports of annual meetings appeared both i n B r i t i s h Columbia newspapers and i n the Canadian Nurse. The minutes of standing or ad hoc committees of the Association were not made a v a i l a b l e f o r t h i s research.  Contextual depth i s a problem  on some i s s u e s . For example, the t r a n s i t i o n of the organizational structure and objectives of the Association 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 r y 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 d e t a i l e d summary of the minutes, with d i r e c t quotes as  were  felt  to be u s e f u l , was recorded i n 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 applicable to the content of the minutes was recorded.  These headings were both  substantive and t h e o r e t i c a l words or phrases. Examples of substantive  112 headings included the themes presented i n the n a r r a t i v e of Chapters Two and Three, and words or phrases used by the p a r t i c i p a n t s themselves; thus the chapter heading 'to protect the q u a l i t y of n u r s i n g ' . The headings that appeared in the f i e l d notes u l t i m a t e l y numbered 25. made.  A summary of the content r e l a t e d to these headings was  Themes emerged and t h i s material was grouped under the  consolidated headings of r e g i s t r a t i o n , education, terms and conditions of employment and the organizational structure of the A s s o c i a t i o n . These themes were considered to be the major themes of the A s s o c i a t i o n . It was recognized that these themes s h i f t e d between positions of primary and secondary importance as the i n t e r e s t s of the Association s h i f t e d . The r e l a t e d themes of the subsidiary worker, health and safety of nurses, s o c i a l s e c u r i t y , terms and conditions of employment of senior nursing s t a f f while important in themselves, are d i r e c t l y r e l a t e d but subsidiary to the major themes.  In the n a r r a t i v e , these headings have  been presented as dominant themes, that  i s those themes of primary  i n t e r e s t at any given time, or as secondary themes.  Suggested  r e l a t i o n s h i p s amongst the themes and headings were noted i n a t h i r d 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 r e l a t i o n s h i p s were repeatedly re-examined  as the comparison of groups began. Early i n the research process the comparison of groups presented a problem.  I t was never the i n t e n t i o n to compare nurses  i n B r i t i s h Columbia with another occupational group that has  113 s i m i l a r i t i e s with nursing, i n , f o r example, the preponderance of women, and i n c l u s i o n i n the debate over professional status ( E t z i o n i , 1969). Anything other than a comparative study using a s i m i l a r data base would be t h e o r e t i c a l l y unsound and to repeat the research methodology undertaken f o r t h i s study was beyond the scope of the researcher's resources. Thus the comparison of groups was l i m i t e d to groups w i t h i n the data and the l i t e r a t u r e . The comparison of public h e a l t h , p r i v a t e duty and education nursing groups was considered because these are d i s t i n c t groups that emerged early i n the A s s o c i a t i o n ' s h i s t o r y .  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 e v e l s . The f i r s t level of comparison i s a comparison of the A s s o c i a t i o n ' s response to the themes which emerged from the data. The second level i s a comparison of the o r i g i n a l data c o l l e c t e d i n B r i t i s h Columbia compared with data i n the literature.  The f i r s t level of comparison represents the a n a l y s i s  of the data (Chapter Five) while the second l e v e l i s the l i t e r a t u r e review (Chapter S i x ) . Comparison of the A s s o c i a t i o n ' s response to the themes which emerged from the data resulted i n the emergence of the i n t e g r a t i n g concept of c o n t r o l .  The f i r s t i n d i c a t i o n that control  may be the underlying and unifying concept arose from discussions i n the minutes on the control of subsidiary workers (March 21, 22, 1969).  114 Using the concept of c o n t r o l , the categories that emerged are 1) the control of the work f o r c e , 2) the control of work p r a c t i c e , 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 Association which varied over time. or themes are the properties of the categories.  Thus the headings  Control of the work  force represents the attempt of the Association to control the numbers of nurses and the q u a l i t y of the i n d i v i d u a l entering the work f o r c e . The category of control of the work force has the properties of r e g i s t r a t i o n , education, and private duty nurses, student nurses, and subsidiary workers.  The category of work p r a c t i c e represents the  attempts of the Association to control the q u a l i t y of the p r a c t i c e of nursing and i s c l o s e l y associated with control of the work f o r c e . The category of control of work p r a c t i c e has the properties of education, r e g i s t r a t i o n , student nurses, d i s c i p l i n e , safety to p r a c t i c e , q u a l i t y assurance, and the r o l e and function of subsidiary workers. The category of control of the work environment represents the attempt of the Association to control the terms and conditions of employment.  The category of control over the work environment  represents the attempt of the Association to control the terms and conditions of employment. The category of control over the work environment has the properties of the terms and conditions of employment, education, student nurses, the health and safety of nurses and s o c i a l s e c u r i t y .  The major theme of the organizational  structure of the Association became a property of each of the  TABLE 4.1 Categories and Properties Emerging from the Data  Category  Property  Control over the work force  Control over work practice  Control over the work environment  registration  education  education  registration  terms and conditions of employment  private duty  student nurses  student nurses  disci piine  subsidiary workers  safety to practice  organizational structure  quality assurance role and function of subsidiary workers organizational structure  education student nurses health and safety of nurses social security organizational structure  116  three categories of control because changes in the organizational structure were a response to e f f o r t s to exert control over each of these areas. The v a l i d i t y of the i n t e g r a t i v e concept was confirmed by thinking through the themes and t h e i r r e l a t i o n s h i p s to the suggested categories and p r o p e r t i e s .  The concept of control and the A s s o c i a t i o n ' s  attempt to control the work f o r c e , work p r a c t i c e , and the work environment seemed the most complete explanation f o r what had occurred during the A s s o c i a t i o n ' s  history.  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  q u a l i t a t i v e research i s often considered 'unsystematic' or ' e x p l o r a t o r y ' .  'impressionistic',  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 i s that which the  researcher knows " s y s t e m a t i c a l l y " .  The researcher has combined the  e f f e c t of becoming immersed i n the data as well as r e t a i n i n g informed detachment.  Glaser and Strauss argue that t h i s represents the  conversion of a "normal strategy of r e f l e c t i v e persons to a strategy of research" (1967, pp.227).  Those, having gone through the experience  of doing substantive f i e l d - w o r k , who do not believe the theory that emerges; out of t h e i r research are considered to be "tempted toward compulsive scientism" (1967, pp.227).  117 Glaser and Strauss i d e n t i f y two problems, associated with, conveying the c r e d l h i ! i t y of the grounded theory.  These are  1) conveying the t h e o r e t i c a l framework in an understandable fashion and 2] presenting the data in a s u f f i c i e n t l y v i v i d manner as to convey r e a l i t y while s t i l l within the t h e o r e t i c a l framework. The f i r s t problem i s dealt with by presenting the t h e o r e t i c a l framework and associated t h e o r e t i c a 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 c h a r a c t e r i s t i c i l l u s t r a t i o n s ( d i r e c t quotes, t e l l - t a l e phrases, dramatic segments e t c . ]  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  if  s u f f i c i e n t l y caught up in the material as well as by analyzing the research m a t e r i a l . Both the researcher and the reader have r e s p o n s i b i l i t i e s in the assessment of m a t e r i a l . The former f o r the content and presentation, 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 n a r r a t i v e presented in Chapters Two and Three i s found in t h i s Chapter.  On the basis of  t h e o r e t i c a l sampling conducted according to the tenets of grounded theory and a comparison of groups w i t h i n the data (Glaser and Strauss, 1967) categories and properties emerged from the data. The i n t e g r a t i n g concept of control emerged to form the categories of control of the work f o r c e , control of work p r a c t i c e , and control of the work environment.  From these categories of c o n t r o l , three  pastures of control assumed by the Association are i d e n t i f i e d . These are 1) compromised c o n t r o l , 2) co-ordinated c o n t r o l , and 3) bargained c o n t r o l .  These postures of control were assumed i n  response to the need to achieve what was possible i n negotiation with forces external to the A s s o c i a t i o n .  External forces include  the p o l i t i c a l processes inherent in negotiation with the government, hospital a d m i n i s t r a t i o n s , the H o s p i t a l s ' A s s o c i a t i o n , the medical profession and consumers.  According to the A s s o c i a t i o n ' s  negotiating power, the strategy was one of lobbying, moral suasion, or bargaining. Association.  Negotiation also took place amongst groups within the These groups include private duty, public h e a l t h ,  education and hospital nurses as well as the A s s o c i a t i o n s '  elected  119  leaders, professional s t a f f and grassroots membership. There i s no c l e a r pattern of negotiation i n t h i s s e t t i n g but the emergence of 'cosmopolitan' and ' l o c a l ' groups i s i d e n t i f i e d and recognized as i n f l u e n c i n g the pattern of negotiation with external forces. This chapter begins with a b r i e f discussion of the concept of control as i t i s used in t h i s study and i s followed by a discussion of negotiation w i t h i n and external to the A s s o c i a t i o n . Following t h i s , examples of compromised c o n t r o l , co-ordinated control and bargained control are discussed. The Concept of Control Control i s defined as "the power of d i r e c t i n g and r e s t r a i n i n g the course of a c t i o n " (Pocket Oxford D i c t i o n a r y , 1959). The concept of control used i n t h i s study i s thus the power of d i r e c t i n g and r e s t r a i n i n g the course of action of the members ( i n d i v i d u a l s ) and the membership (the whole) i n the p r a c t i c e of nursing.  Thus, the categories of control which emerged are  1) control of the work f o r c e , 2) control of work p r a c t i c e , and 3) control of the work environment.  A comparison of the categories  of control led to the i d e n t i f i c a t i o n of three postures of control assumed by the Association in i t s negotiation with external f o r c e s . These are compromised c o n t r o l , coordinated control and bargained control.  Compromised control i s characterized by taking a  "middle or mixed course" (Pocket Oxford D i c t i o n a r y , 1959),  120  These postures; of control existed both, s e q u e n t i a l l y and simultaneously.  Thus compromised control predominanted (1912-43),  coordinated c o n t r o 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 Association directed i t s l e g i s l a t i v e sponsor to withdraw the ammended r e g i s t r a t i o n B i l l of 1916.  Compromised control has  persisted on the issue of r e g i s t r a t i o n .  The Association has never been  prepared to r e s t r i c t the care of the sick to registered nurses. The Association has responded to the need to care f o r the sick by the expansion or contraction of the work force according to need l a r g e l y defined by external f o r c e s .  Compromised control of education and  working conditions of student nurses existed u n t i l the education of student nurses was removed from the d e l i v e r y s e t t i n g h o s p i t a l s . The most prevalent pattern has been compromised c o n t r o l . Table 5.1 Postures of Control Assumed by the RNABC: 1912-76  Postures Compromised control Coordinated control Bargained control  1912  1 928  1943  1959  1976  Control of the work force Control of work p r a c t i c e Control of the work environment Control of work environment  Control of work practice  Control of the work environment  121  Negotiation with Internal Forces: 'CosmOpoli.tails  and Locals '  The nurses who i n i t i a t e d the struggle for registration in B r i t i s h Columbia may be seen as setting out to establish nursing as an organized professional group in an e f f o r t 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 B r i t i s h 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 d i s t i n c t i o n between "orientation toward local and larger social structures" in which the ' l o c a l ' is parochial  in interest and the cosmopolitan i s orientated to the  world, or i s ecumenical i n interest" (pp.392-93). Helen Randal, Ethel Johns, Grace FairleyJ A l i c e Wright, Esther Paulson and others aptly qualify as cosmopolitans.  By the nature of cosmopolitans and l o c a l s , and by the nature of the Association, the locals rarely appear in the minutes as i n d i v i d u a l s , but t h e i r 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 r e g i s t r a t i o n , usually because of inadequate secondary school education.  The separation of  cosmopolitans and locals is most graphically i l l u s t r a t e d by the events of the s t r i k e , 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 p a r t i c i p a t i n g in Association  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 organizational structure that did not f a c i l i t a t e communication w i t h i n the A s s o c i a t i o n , and 5) the absence of p a r t i c i p a t i o n in Association a f f a i r s by student nurses u n t i l 1946. The long hours of work by nurses have been discussed at length in e a r l i e r chapters.  Nonetheless a group of nurses  p a r t i c i p a t e d a c t i v e l y in Association a f f a i r s with considerable commitment, e f f o r t and with a major loss of t h e i r l e i s u r e time. Executive Council and Council meetings were held a f t e r the normal working day, usually Friday evenings, and l a t e r , a l l day Saturday. Attendance at p r o v i n c i a l , national or i n t e r n a t i o n a l meetings was often done on holiday time (Paulson, 1981).  The minutes of the  Association record repeated requests to the BCHA and hospital boards to allow nurses time to p a r t i c i p a t e in Association a f f a i r s . There was nonetheless the f e e l i n g amongst cosmopolitans that more nurses could have p a r t i c i p a t e d i f they had wished (Paulson, 1981). The development of a hierarchy amongst nurses, was the r e s u l t of a s h i f t in employment pattern from the independent p r a c t i c e of p r i v a t e duty nurses to i n s t i t u t i o n a l employment.  This was  reinforced by the shortage of nurses during World War II in which p r a c t i c a l nurses became a substantial part of the work force and a  123 heirachy of supervision developed.  Eaton has made c l e a r that  d i r e c t o r s of nursing were in a p o s i t i o n of c o n f l i c t between getting the job of caring f o r the s i c k done and improving working c o n d i t i o n s . This c o n f l i c t separated nurses. The leaders by employment were also the leaders of the Association (Eaton, 1938, pp.61). This means that u n t i l a h i e r a r c h i c a l structure of i n s t i t u t i o n a l nursing had developed by the mid 1940's, most nurses were peers of one another and as such there was less c o n f l i c t of i n t e r e s t amongst nurses i n the 1920's and 1930's than  developed l a t e 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 p a r t i c i p a t i o n , although there were mechanisms within the Association to allow non-active nurses to p a r t i c i p a t e in Association a f f a i r s .  The outcome of l i m i t e d p a r t i c i p a t i o n by the  general membership contributes to a general unawareness of Association a f f a i r s amongst the membership.  Recognition of t h i s led to the formation  of Chapters and D i s t r i c t s w i t h i n the Association on the basis of the proposals of 1938.  Student nurses who formed 50% of the registered  nursing work force u n t i l the early 1940's were excluded from p a r t i c i p a t i n g in Association a c t i v i t i e s u n t i l 1946 when a Student Nurses' Association within the RNABC was formed. This background provides an explanation f o r the ascendancy of a cosmopolitan group within the Association and some explanation of the 'need to educate' nurses on what the Association could o f f e r when control of the work environment become a dominant theme of the  124 Association's a c t i v i t i e s .  Also explained i s the potential f o r con-  f l i c t of i n t e r e s t over the means of getting the job of caring f o r the sick done, and the potential a b i l i t y of the leaders of the Association to control the extent of s o c i a l and economic demands of the l o c a l s once c o l l e c t i v e bargaining had been l e g i t i m i z e d . The minutes of the Association provide l i t t l e data on negotiation amongst occupational i n t e r e s t groups w i t h i n the Association.  Private duty, public health and education i n t e r e s t  groups were the f i r s t groups formed w i t h i n the A s s o c i a t i o n . The p r i v a t e duty r e g i s t r y as a separate e n t i t y w i t h i n the Association ceased to e x i s t i n the l a t e 1960's a f t e r protracted negotiation w i t h i n the A s s o c i a t i o n .  The end of Association support f o r t h i s  group represents the ascendancy of the i n s t i t u t i o n a l l y employed nurse, and i s part of the A s s o c i a t i o n ' s attempt to control the work force.  With the exception of the e l i m i n a t i o n of support f o r the  private duty r e g i s t r y , changes i n the structure of the Association a f f e c t i n g occupational groups were usually i n response to changes i n structure of the CNA, and consequently do not seem to have been negotiated w i t h i n the A s s o c i a t i o n . On the basis of t h i s discussion i t would appear that the A s s o c i a t i o n ' s leaders were i n a p o s i t i o n to represent nursing's best i n t e r e s t s as defined by the cosmopolitans u n t i l 1957.  The strongest  evidence supporting t h i s view i s the lengthy discussion at the executive council level on r e g i s t r a t i o n , the formulation of a p o l i c y on the A s s o c i a t i o n ' s r o l e i n c o l l e c t i v e bargaining, and the  125  A s s o c i a t i o n ' s response to the s t r i k e vote of 1957. (Ross.Iter, 1957, pp.799) strength.  This i s not to s ay that the membership was without The membership e f f e c t i v e l y forced the Association executive  to take a strong stand with the government in the negotiations of 1959. I t 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 negotiation of the terms and conditions of employment when the postures of compromised control and coordinated control dominated, reinforced the separation between the cosmopolitans and the l o c a l s and decreased the power base of the Association in external relationships.  The v i s i b l e struggle to improve working conditions  p r i o r to 1946 was l e f t to the CCF, the nurses themselves (the Comox s t r i k e ) 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 k e votes of 1957, 1959) the r e s u l t s improved.  In the period of coordinated control (1943-1957) the  balance of power was not n e c e s s a r i l y favourable to the leadership who took on negotiation with employers on behalf of the nurses. Esther Paulson, as a member of the executive of the RNABC, while employed by the P r o v i n c i a l Government presented the economic concerns of nurses employed in P r o v i n c i a l Government h o s p i t a l s . She described negative repercussions i n her own work and economic s e c u r i t y (Paulson, 1981).  The r e l i a n c e on moral suasion and the  t r u s t in paternalism evident in t h i s period provides an explanation f o r f a l l i n g to p r e d i c t t h i s outcome.  126  A f t e r 1959, there i s i n s u f f i c i e n t data to assess the balance of power between the cosmopolitans and l o c a l s . The lack of data dealing with labour r e l a t i o n s a c t i v i t i e s in the Association minutes a f t e r 1959 i s a r e f l e c t i o n of the growth of t h i s a c t i v i t y as a separate function of the A s s o c i a t i o n .  The formation of a Nursing  Administrators' Association in the l a t e 1960's suggests a loss of power by the cosmopolitans in t h e i r capacity to respond to the pressures exerted by the l o c a l s w i t h i n the Association and i n the work s e t t i n g and i s a statement of appreciation of t h e i r increased vulnerability.  Negotiation with External Forces Hospitals i n B r i t i s h Columbia were established by r e l i g i o u s orders, c h a r i t a b l e groups, e n t e r p r i s e s , whether medical, nursing or p r i v a t e i n t e r e s t s and i n the case of mental disease and t u b e r c u l o s i s , the p r o v i n c i a l government. Administrators of these h o s p i t a l s organized themselves to form the B r i t i s h Columbia Hospital Association tn 1918.  Nursing administrators p a r t i c i p a t e d through  the nursing section or as i n v i t e d guests. I t i s apparent from the minutes of the BCHA annual meetings that inadequate funding of h o s p i t a l s was i d e n t i f i e d as an issue of major concern as e a r l y as 1919. Revenue f o r h o s p i t a l s was generated from p a t i e n t s ' fees, c h a r i t a b l e sources and municipal and p r o v i n c i a l revenue tn proportions of approximatley 1/3 u n t i l 1949 when the p r o v i n c i a l government took over the funding of h o s p i t a l s . This event  127  had the e f f e c t of transforming an amorphous body responsible f o r hospital funding into a concrete e n t i t y .  However, c o l l e c t i v e  bargaining by nurses remained at the l o c a l hospital level u n t i l the mid 1950's.  Since then, the BCHA and l a t e r the HLRA has buffered  the government from d i r e c t negotiations with nurses on the issue of the terms and conditions of employment.  Nonetheless,the creation of  a s i n g l e funding source has created a s i n g l e body u l t i m a t e l y responsible f o r the funding of h o s p i t a l s .  However, the funding of h o s p i t a l s and  the terms and conditions of employment of nurses are not the f i r s t or the only Issues about which the Association has negotiated.  The  issues involved i n control of the work f o r c e , work p r a c t i c e and work environment are interwined such that one negotiation affected another over the course of the A s s o c i a t i o n ' s h i s t o r y .  The r e a l i z a t i o n of  these i n t e r r e l a t i o n s h i p has influenced the s t r a t e g i e s the Association has chosen.  The s t r a t e g i e s chosen were lobbying, moral suasion and  bargaining. These r e f l e c t the balance of power and the nature of the r e l a t i v e stakes involved. Lobbying i s defined as "the frequenting of parliament  ...  to s o l i c i t votes" (Pocket Oxford D i c t i o n a r y , 1959), moral suasion as "reasoning or advice as incentive"(Pocket Oxford D i c t i o n a r y , 1959), and bargaining as "haggl(ing) or dispute"(Pocket Oxford D i c t i o n a r y , 1959).  Overt lobbying occurred only during the struggle f o r  r e g i s t r a t i o n - there was nothing to l o s e , the Association had no power to influence the course of nursing p r a c t i c e without r e g i s t r a t i o n .  128  Moral suasion was used between 1919 and 1957, abundance of nurses. (19.19 - 39)  In the face of an  the poor f i n a n c i a l p o s i t i o n of  hospitals and a decline in number of private patients during the depression, the Association had no e f f e c t i v e power to negotiate the terms and conditions of employment, but was able to promote the c l o s i n g of substandard schools and i n d i r e c t l y promote the employment, i f not improve  the terms and c o n d i t i o n s , of nurses. The curriculum of  students was the d i r e c t r e s p o n s i b i l i t y of the Association under the Registered Nurses A c t , but working, classroom, and l i v i n g conditions were not.  Thus the strategy of moral suasion i n an attempt to improve  the l o t of students.  The shortage of nurses during and a f t e r World  War II changed the dynamics of the balance of power, and thus the s t r a t e g i e s i n the negotiation process.  Bargaining as a strategy  began only when the balance of power was favourable to the membership at l a r g e .  The membership had to be prepared to play f o r high stakes  ( s t r i k e ) before the f u l l exercise of the A s s o c i a t i o n ' s power could be tested.  Because of the v u l n e r a b i l i t y of the A s s o c i a t i o n ' s  leadership  in t h e 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 f o r External Negotiation of S p e c i f i c Issues Used by the RNABC : 1912-76  Strategy  1'912  Lobbying  registration  Moral Suasion  1928  1943  1959  1976  education terms and conditions of employment terms and conditions of employment.  Bargaining  In every instance of negotiation the options were l i m i t e d because of the underlying commitment' to providing care f o r the sick and because of the interrelatedness of the issues.  Negotiations on  one issue had the potential of a f f e c t i n g negotiations on other issues. Mandatory r e g i s t r a t i o n was not sought because, while there was a desire to protect the p u b l i c , 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 l e a r that a l l . the. issues surrounding the education of student nurses were compromised by the need to provide service to patients i n h o s p i t a l , and that t h i s compromise ended only a f t e r the education of nurses was established outside of h o s p i t a l s .  Bargaining over the terms and conditions of  employment occurred only a f t e r the membership was prepared to s t r i k e . The s t r a t e g i e s of negotiation were chosen to achieve what was  130  thought to be p o s s i b l e .  Postures of C o n t r o l . Compromised Control. Compromised control i s defined as a "middle or mixed course" (Pocket Oxford D i c t i o n a r y , 1959).  The A s s o c i a t i o n ' s attempt  to control the work force and work p r a c t i c e has been dominated by the issues of r e g i s t r a t i o n and education. In the struggle f o r r e g i s t r a t i o n , the f l e d g l i n g Association acted i n apparent unity to e s t a b l i s h a new order of nursing. But r e g i s t r a t i o n was not achieved without compromise with the external arena.  The Association recognized the P r o v i n c i a l  Legislature's  resistance to mandatory r e g i s t r a t i o n , and the need of the public f o r various l e v e l s of nursing care.  I t would appear that i n exchange  f o r voluntary r e g i s t r a t i o n , midwifery was not recognized.  This had  the support of the medical profession who could now count on a more r e l i a b l e workforce and control over maternal care. The major outcome of t h i s compromise was that the t o t a l nursing work force has never been under the control of the A s s o c i a t i o n .  Consequently, over the  years, the forces of supply and demand have forced the Association to modify i t s p o s i t i o n on r o l e and function of student nurses, p r i v a t e duty married nurses, and subsidiary workers. The Association has never been able to control the volume of the work force or to influence the  131  patterns of demand f o r nursing care, as f o r example has the medical profession (Cooper,' 1973, pp.93; Evans,1973,pp, 162).  Thus a posture  of compromise has dominated the A s s o c i a t i o n ' s attempt to control the work force and consequently work p r a c t i c e .  Discussions of mandatory  r e g i s t r a t i o n have occurred throughout the h i s t o r y of the A s s o c i a t i o n , but have remained i n t e r n a l to the A s s o c i a t i o n . Another example of compromised control was the p o s i t i o n of the A s s o c i a t i o n v i s a v i s educational standards and the l i v i n g , studying and working conditions of student nurses.  Educational  standards were improved i n d i r e c t l y by increasing the educational entrance requirements in the 1930's.  Helen Randal, representing the  A s s o c i a t i o n , used moral suasion as a strategy to close substandard schools of nursing and i n an attempt to improve conditions f o r student nurses i n . t h e 1920s and 1930s.  Substandard schools of nursing were  closed due to the e f f o r t s of Helen Randal and due to the adoption of the b e l i e f by the Hospital Association and hospital boards, that graduate nurses could be hired more cheaply than students could be trained.  This was e s p e c i a l l y true during the Depression when  unemployment amongst nurses was very high, and nurses, e s p e c i a l l y those from the p r a i r i e s , could be hired very cheaply (Randal, 1938; Eaton, 1938, pp.11). The Association had the power (by statute) to approve schools of nursing but could not a c t u a l l y force the closure of schools. The graduates of non-approved schools were denied r e g i s t r a t i o n as a  132  means of exerting pressure upon non-approved schools of nursing. Conditions improved f o r students because of the A s s o c i a t i o n ' s and p o s s i b l y , also because of the impact of the Hospital  efforts  Construction  Act of 1949 providing financing f o r hospital construction which included nurses' residences and classrooms. This i s not c e r t a i n because Esther Paulson r e c a l l s that one school received a new residence and classroomsj in the e a r l y 1950 s only because of the private donation 1  of funds (Paulson, 1981). Although the government had the regulatory power to control the working conditions of student nurses from the e a r l y 1940's no action was taken, and the Association had no power to force a c t i o n . The improvement of working conditions of students and graduate nurses was compromised by the p o s i t i o n of the leaders of the A s s o c i a t i o n , who were also the d i r e c t o r s of nursing of the h o s p i t a l s and schools, which were the subject of concern, and by the desire of the Association to improve the education of nurses before the issue of the working conditions was addressed (Eaton, 1938, pp.60-62).  The f a c t that the A s s o c i a t i o n ' s leaders were themselves  compromised well before c o l l e c t i v e bargaining began, lends credence to the viewing of d i r e c t o r s of nursing as vulnerable.  This v u l n e r a b i l i t y  u l t i m a t e l y led to the formation of a nursing a d m i n i s t r a t o r s ' group which separated from the Association 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 c e Wright as R e g i s t r a r , and l a t e r as  133  Executive Secretary (1943-60).  as. employees of the A s s o c i a t i o n ,  as well as explaining the use of the strategy of moral suasion.  Coordinated Control• Coordinated control represents a state in which the p a r t i e s are "equal i n status" (Pocket Oxford D i c t i o n a r y , 1959).  With the Second  World War came a shortage of nurses, a h i e r a r c h i c a l structure of the nursing work f o r c e , improved s a l a r i e s and working conditions f o r the general population, the growth of unionization and, postwar, rapid inflation.  Nurses were characterized as " r e s t l e s s " .  I t i s d i f f i c u l t to assess the extent of the restlessness of nurses.  B r i t i s h Columbia was a province whose work force was  a c t i v e l y engaged in unionization (Jamieson, 1968).  Nurses must have  been aware of the economic gains achieved by unionized workers. Since r e g i s t r a t i o n was not mandatory f o r p r a c t i c e , the Association could have l o s t a portion of i t s membership i f action were not taken. This was recognized when the Association discussed the potential r e l a t i o n s h i p between the Association and trades unions (January 5, 1944; March 1, 1944).  This i s an example of compromised control of  forces w i t h i n the Association and serves to explain the e f f o r t to educate nurses about the gains the Association had made in improving the terms and conditions of employment.  However, there was s t i l l  the  problem of the ' l o c a l s ' who did not p a r t i c i p a t e i n Association a c t i v i t i e s and thus would not hear the message, and the f a c t that those  134 who were informed may not have seen the e f f o r t s of the Association as s u f f i c i e n t .  The option of j o i n i n g a union was thus appealing.  However, the f a c t that i t took two votes, 1944 and 1946, to endorse the r o l e of the Association i n c o l l e c t i v e 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 Association i n the e a r l y 1940's may have contributed to increased communication between the cosmopolitans and l o c a l s . In 1942 a committee under the Placement Service had begun a survey of working conditions and s a l a r i e s .  A l i c e Wright, a r r i v i n g as  new Registrar of the A s s o c i a t i o n , recognized the seriousness of the restlessness of nurses, and under her leadership, began a fresh attempt to exercise some control on the work environment.  Out of  the work of t h i s committee a base-line of Recommended Personnel Practices was developed by A l i c e Wright and Elizabeth Braund, and was r e v i s e d , usually annually.  Negotiation with BCHA took place;  both p a r t i e s were in e f f e c t s e l l i n g t h e i r agreement to the Recommended Personnel Practices to t h e i r respective c o n s t i t u e n c i e s . This occurred before c o l l e c t i v e bargaining was approved n a t i o n a l l y or p r o v i n c i a l l y .  To the extent that both p a r t i e s met v o l u n t a r i l y  and contracted to ' s e l l an agreement to t h e i r c o n s t i t u e n c i e s ' a state of co-ordinated control e x i s t e d .  Undoubtedly the BCHA had  a vested i n t e r e s t i n a quiet labour scene, e s p e c i a l l y during the period of the war years when pressure on h o s p i t a l s was very great. The shortage of nurses, which p e r s i s t e d u n t i l the mid-late 1950's  135  strengthened the p o s i t i o n of the A s s o c i a t i o n . Once the 'glamour of the war' had worn o f f , both p a r t i e s could a f f o r d more l a t i t u d e i n their tactics.  By 1950, Harvey Agnew of the Canadian Hospitals  Association was w r i t i n g in support of better s a l a r i e s and working conditions f o r nurses even i f i t meant a higher b i l l f o r patients (Agnew, 1950, pp.27-28).  The p r a c t i c e of co-ordinated control  exercised by the RNABC and BCHA continued a f t e r nurses became c e r t i f i e d and engaged i n c o l l e c t i v e bargaining f o r the benefit of non-unionized nurses. The  Association continues to t h i s day to  represent the i n t e r e s t s 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 i n t e r n a l mechanism, the existance,funding and operation of schools i s now a matter.for u n i v e r s i t i e s , community colleges and the Ministry, of Education.  The use of h o s p i t a l s and public health d i s t r i c t s  for  p r a c t i c a l experience i s negotiated by nurse educators with the Association playing a f a c i l i t a t i n g role but not a c t u a l l y i n f l u e n c i n g the construction or use of c l i n i c a l u n i t s .  This pattern developed  i n the mid 1960 s with the beginning of the closure of hospital 1  schools of nursing ..  136  Bargained Control. The period of bargained c o n t r o l , characterized by 'haggling' and ' d i s p u t e ' (Pocket Oxford D i c t i o n a r y , 1959) was i n i t i a t e d by the A s s o c i a t i o n ' s support of s t r i k e action i n 1957.  To the extent that  Recommended Personnel Practices were prepared by the o f f i c e r s of the A s s o c i a t i o n , with input from s t a f f representatives of employee groups, and approved by the Executive Council before being presented to the general membership f o r debate at the annual meetings u n t i l 1968, the Association was able to influence the demands of the membership and the power of bargained control was m i t i g a t e d .  As the labour  r e l a t i o n s function of the Association grew to dominate the A s s o c i a t i o n ' s a c t i v i t i e s , the power of those associated with t h i s aspect of the A s s o c i a t i o n ' s a c t i v i t i e s grew. Coincident with t h i s , the process of bargaining became r a t i o n a l i z e d and the government, who had become the sole funder of h o s p i t a l s , was forced to become more responsive to the demands of nurses because s t r i k e votes were exercised as leverage. As s a l a r i e s and s o c i a l s e c u r i t y measures f o r nurses improved,the Association turned inwardly to re-examine i t s r o l e and f u n c t i o n . The discussion papers Baumgart (1973) and Bachard (1973) can be seen as attempts to evaluate and r e - e s t a b l i s h the alignment of the nursing a s s o c i a t i o n s ' r o l e s .  The separation of labour  r e l a t i o n s functions from the A s s o c i a t i o n , although p r e c i p i t a t e d by an external force (the r u l i n g by the Supreme Court of Canada, 1973, in  137 which the Saskatchewan Registered Nurses Association l o s t i t s  right  to engage i n c o l l e c t i v e bargaining f o r nurses because of the r o l e of management nurses i n the Association) forced t h i s realignment. Bargained control of the work environment w i l l no longer be mitigated by the i n t e r n a l r e s o l u t i o n of professional and labour i n t e r e s t s .  Conclusion This chapter has presented an a n a l y s i s of the data based on the A s s o c i a t i o n ' s attempt to control the work force, work p r a c t i c e and work environment.  Comparison of these categories led to the  i d e n t i f i c a t i o n of three postures of control assumed by the A s s o c i a t i o n : Compromised c o n t r o l , co-ordinated control and bargained control.  A consideration of negotiation w i t h i n the Association led  to the i d e n t i f i c a t i o n of 'cosmopolitan' and ' l o c a l ' Negotiation with external forces was considered.  constituencies.  The s t r a t e g i e s  used were i d e n t i f i e d as lobbying, moral suasion and bargaining. The changing postures of control were i d e n t i f i e d as a response to i n t e r n a l and external forces and the need to achieve what was possible.  For terms and conditions of employment the ' p o s s i b l e ' was  defined by the cosmopolitans u n t i l 1959, and thereafter by the l o c a l s . The s h i f t from compromised control to coordinated control of the work force was r e f l e c t e d by the introduction of the negotiation of Recommended Personnel Practices with the BCHA, and by the i n t r o d u c t i o n of c o l l e c t i v e bargaining in i n d i v i d u a l hospital s as the l o c a l s  138 demanded.  The push to coordinated control was the r e s u l t of the  recognition of the increased economic and s o c i a l d i s p a r i t y 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 A s s o c i a t i o n ' s support of the nurses s t r i k e votes f o r economic gain. s h i f t to accept the postures  The A s s o c i a t i o n ' s  of bargained control of the work  environment i s a r e f l e c t i o n of the A s s o c i a t i o n ' s attempt to r e t a i n control of the work f o r c e . While i t has not been the i n t e n t i o n to examine the r e l a t i v e economic gains made during the evolution of the A s s o c i a t i o n ' s a c t i v i t i e s , i t i s nonetheless argued that only a f t e r nurses were prepared to s t r i k e could compromised and coordinated control be exchanged f o r bargained control on the issue of the terms and conditions of employment.  139  CHAPTER 6 L i t e r a t u r e Review  Introduction Glaser and Strauss (1967, pp.37) suggest that the purpose of the l i t e r a t u r e review i n grounded theory i s to compare the a n a l y t i c core of the categories which emerged from the data with the s i m i l a r i t i e s and convergences with the l i t e r a t u r e .  In t h i s study, the  l i t e r a t u r e review has the a d d i t i o n a l function of providing comparat i v e groups f o r the groups which emerged from the data.  Glaser  and Strauss (1967, pp.37) suggest that the l i t e r a t u r e review be done a f t e r the emergence of these categories i n order to avoid contaminating the development of the a n a l y t i c core.  Thus the  l i t e r a t u r e review follows the presentation of the n a r r a t i v e , a discussion of the methodology, and the presentation and d i s cussion of the a n a l y t i c core. The comparison groups which emerged from the data were 1) 'cosmopolitans and l o c a l s ' who were functioning w i t h i n the RNABC, and 2) the A s s o c i a t i o n ' s responses to the themes found i n the data. The major themes which emerged from the data were r e g i s t r a t i o n , education and the terms and conditions of employment. Secondary themes included student nurses, private duty nurses,  140  health and safety of nurses, subsidiary workers and s o c i a l security.  Repeated review of these themes resulted i n the  emergence of the i n t e g r a t i n g concept of c o n t r o l . Using the concept of c o n t r o l , the categories that emerged are 1) control of the work f o r c e , 2) control of work p r a c t i c e and 3) control of the work environment.  The l i t e r a t u r e 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  narrative as i s appropriate.  A  discussion of the groups comparable "to cosmopolitans and l o c a l s  is  integrated under these headings. The l i t e r a t u r e review i s l i m i t e d to l i t e r a t u r e analyzing the h i s t o r y and a c t i v i t i e s of nurses and nursing association s; in Canada, England and United States.  L i t t l e of the l i t e r a t u r e  reviewed had the focus of t h i s study, and thus i t was necessary to review selected portions of i n d i v i d u a l pieces of l i t e r a t u r e . Control of the Work Force Registration. The control of the work force has been defined i n t h i s study as the attempt of the nursing association to control the numbers of nurses and the q u a l i t y of the individuals entering the nursing work f o r c e .  R e g i s t r a t i o n has become the common standard  by which to d i s t i n g u i s h l e v e l s of nurses(trained and untrained). R e g i s t r a t i o n as a goal of nursing associations o r i g i n a t e d i n  141  England before the turn of the century (Abel-Smith, 1960). In England, the b a t t l e f o r the r e g i s t r a t i o n 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 u l t i m a t e l y passed by a M i n i s t e r ' s b i l l , i n December, 1919 (Abel-Smith, 1966, pp.61-98).  Midwives  had achieved r e g i s t r a t i o n i n 1902 (Abel-Smith, 1960, pp.77). Abel-Smith (1960) and Bellaby and Oribar (1980) consider the movement f o r the r e g i s t r a t i o n of trained nurses as the outcome of the reformist zeal of the second generation of N i g h t i n g a l e ' s nurses.  Bellaby and Oribar see these nurses as part of a s o c i a 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 w e l l , Bellaby and Oribar see r e g i s t r a t i o n as an  attempt to wrest from hospital and state a u t h o r i t i e s the recognition 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 r e g i s t r a t i o n was a p r i z e the reformers won, i t was a compromise because i t granted the new General Nursing Council  jurisdiction  over the standards of nurse t r a i n i n g (and i n d i r e c t l y over p r a c t i c e ) but did not grant nurses legal control over entry to the profession. The 'dominance of medicine ' was not challenged, and the recruitment 1  of labour f o r hospital work could continue without reference to the GNC (pp.298).  142  White (1976, pp.209-217) suggests that r e g i s t r a t i o n i n Great B r i t a i n was delayed u n t i l 1919 not only because there was 1) lack of agreement i n the profession over the d e t a i l s of r e g i s t r a t i o n , 2) disagreement over the p r i n c i p l e of r e g i s t r a t i o n and 3) the p r a c t i c a l problems o f defining a nurse, but 4) because the Government feared the system of educating nurses which provided "the l e a s t expensive means of  obtaining and employing nurses"  (pp.216) would break down. In the United. States the struggle f o r r e g i s t r a t i o n was conducted on a state by state b a s i s .  The e a r l i e s t b i l l  for  r e g i s t r a t i o n was passed i n North Carolina i n January, 1903 ( K a l i s c h and K a l i s c h , 1977, pp.259).  Krause (1977, pp.46) points  out that i n the United States, nurses are the only subsidary work force i n health care that has achieved r e g i s t r a t i o n without dominance and control by physicians. In Canada, the struggle f o r r e g i s t r a t i o n i s described by Gibbon and Mathewson (1947, pp.352-358).  There were three  unsuccessful attempts to secure Dominion r e g i s t r a t i o n f o r nurses p r i o r to 1909.  A l l the provinces w i t h i n Confederation had achieved  voluntary or mandatory r e g i s t r a t i o n by 1922.  Coburn (1974, pp.152)  points out that i n the struggle f o r r e g i s t r a t i o n i n Canada, "nurses were arguing from a powerless p o s i t i o n f o r protection against " p r a c t i c a l " nurses who were forced to accept even lower pay and the broadest range of domestic duties i n order to s u r v i v e . Unfortunately,  143  as was the case with many unions, nurses did not combat the problem by including these unorganized women w i t h i n a r e g i s t r a t i o n scheme which could have recognized d i f f e r e n t l e v e l s of nursing.  As i t was,  the e x p l o i t a t i o n of t h i s cheap source of labour continued to plague the nursing associations  into the 1940's and even l a t e r " (pp.152).  Summary. The goal of r e g i s t r a t i o n , and the r o l e of a nursing e l i t e , as well as the outcomes  described by Bellaby and Oribar are  consistent with events i n 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 i n England over  the issue of r e g i s t r a t i o n . (Abel-Smith, 1960, pp.65-80) there i s no discussion of t h i s occurring i n Canada or the United States. There i s no discussion of the response to r e g i s t r a t i o n by grassroots or ' l e s s e r trained n u r s e s ' .  In the l i t e r a t u r e on American  nursing, an e l i t e and p r o l e t e r i a t have been i d e n t i f i e d as a r i s i n g from the t r a n s i t i o n of p r i v a t e duty nursing to i n s t i t u t i o n a l l y employed nursing (Wagner, 1980, pp.271-290).  Ashby (1976)  describes a s p l i t i n American nursing leaders over eight hour laws, and the r o l e of education and service of students. It i s evident t h a t , as Coburn (1974) suggests, the f a i l u r e to include the ranks of l e s s e r trained nurses, or to close the ranks of nursing by mandatory r e g i s t r a t i o n or, as Bellaby and Oribar (1980) suggest, the f a i l u r e to grant nursing associations the legal  144  control over the entry to nursing has resulted in an i n a b i l i t y of nursing associations to control the work force. This led to the continued e x p l o i t a t i o n of student and graduate nurses as was described i n the n a r r a t i v e . Thus, the presence of the category of control of the work force with the property of r e g i s t r a t i o n i s confirmed i n the l i t e r a t u r e as i s a s p l i t i n the ranks between the leaders of the nursing a s s o c i ations and the grassroots.  The recognition and r e g i s t r a t i o n of  midwives and t h e i r subsequent r o l e in the d e l i v e r y of health care i n England i s at odds with events in Canada and the United States. This would make an i n t e r e s t i n g comparative study, since there was support f o r the p r a c t i c e of midwifery by Local Councils of Women i n B r i t i s h Columbia, but none in the ranks of nurses and doctors.  Control of Work P r a c t i c e In t h i s study, control of work p r a c t i c e represents the attempt of the p r o v i n c i a l nursing association to control the q u a l i t y of the p r a c t i c e of nursing by means of c o n t r o l l i n g the education of student nurses.  In the context of the n a r r a t i v e of t h i s study,  control of the p r a c t i c e of nursing has been considered as nursing was known and practiced during the 20th century.  The context of t h i s  i s l o s t without r e c a l l i n g that women were once considered the healers of western s o c i e t y .  Ehreneich and English describe the persecution  145  of wise women as witches, supression of the knowledge of h e a l i n g , the banning of midwifery and the subsequent dominance of the medical profession and the subservience of women in health care.  The  appearance of N i g h t i n g a l e ' s v i s i o n of nursing i n the 19th century can be seen as an attempt to r e - e s t a b l i s h control over the care of the s i c k i n the context of V i c t o r i a n times.  In the 20th century  r e g i s t r a t i o n and education as a means to p r o f e s s i o n a l i z e have been the main s t r a t e g i e s to gain control over the p r a c t i c e of nursing. In Canada, Coburn (1974) and in the United States Ashley(19.76), Strauss(1966), and Wagner(1980) describe the rapid p r o l i f e r a t i o n of nursing schools designed l a r g e l y to provide cheap labour.  As l a t e as 1958 Saskatchewan hospitals with teaching  programs reported a d i r e c t p r o f i t to the hospital as a consequence of the value of the labour of the students (Royal Commission on Health S e r v i c e s , 1, 1964 pp.274 c i t e d , by A l l e n t u c k , 1978, pp.45). In England, White (1977) describes the c r i t i c a l r o l e which poor.law nurses, who were well established before the advent of Nightingale, played i n forming "an a l t e r n a t i v e group of nurses who cared f o r the poor, the long-term sick and the aged-infirm" (pp.23), these patients represented 75% of the h o s p i t a l i z e d sick of the country, consequently nurses trained i n the t r a d i t i o n of Nightingale i n the voluntary hospitals cared only f o r a small portion of patients.  institutionalized  146  In the United States the response to the d i l u t i o n of the p r a c t i c e of nursing, as defined by the leaders of the nursing profession, was the development of an ideology of reform by s p e c i a l l y trained nursing educators (Strauss, 1966, pp.72-81).  Because of  the close a l l i a n c e of American and Canadian nursing leaders o r i g i n a l l y established through the Nurses' Associated Alumnae Associations of the United States and Canada (1896-1907) (Gibbon and Mathewson, 1947, pp.356) t h i s ideology i s evident i n 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 r a d i t i o n 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 u n i v e r s i t y school of nursing in Canada at the U n i v e r s i t y of B r i t i s h Columbia. In England Nightingalism, a t r a d i t i o n of reform with an ideology of vocational ism, a commitment to s a c r i f i c e and subservience to male doctors in the care of the sick (Williams, 1974), and ah ideology of s a n i t a t i o n (Davies  c i t e d 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 associations and the struggle f o r r e g i s t r a t i o n .  This ideology seems  to have p e r s i s t e d u n t i l the P i a t t report (1964) because the education  147  of nurses i n Great B r i t a i n was considered by the Royal College of Nurses i n 1943 "as to (be to) a c e r t a i n extent an apprenticeship" and l a t e r , . i n 1964, (the P i a t t Report) as "an education rather than an apprenticeship" (Davies, 1978).  Thus the ideologies of reform i n  North America and Great B r i t a i n d i f f e r e d .  This was due i n part to the  role of education i n North American society where education i s seen as a means of achieving class m o b i l i t y . .  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 p r a c t i c e by p r o f e s s i o n a l i z i n g nursing.  Nurses' struggle to be acknowledged  as a professional occupational group represents the struggle to achieve status and recognition in the context of s o c i e t y , and thus the control of work p r a c t i c e . The l i t e r a t u r e on occupations has devoted much energy to the study of those occupations referred to as  'professions'.  Volltner and M i l l s (1966) distinguished between the concepts of profession and p r o f e s s i o n a l i z a t i o n .  The term profession has been  used to describe abstract models of occupational  characteristics  while the concept of p r o f e s s i o n a l i z a t i o n refers to "a dynamic process whereby many occupations can be observed to change c r u c i a l c h a r a c t e r i s t i c s i n the d i r e c t i o n of ' p r o f e s s i o n ' " ( p p . 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  o r g a n i z a t i o n , r e g i s t r a t i o n , a code of e t h i c s , the s h i f t to u n i v e r s i t y education and the attempt to control work p r a c t i c e 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 t h e i r careers are interspersed with other commitments. nurses have a d i s c r e e t knowledge base.  He r e j e c t s the idea that The lack of d i f f e r e n t i a t i o n  in the ranges of tasks and r e s p o n s i b 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 s p e c i a l i z e d task. Krause (1977) and Wilensky (1964) see the s h i f t of nursing education to a u n i v e r s i t y s e t t i n g as one of the key s t r a t e g i e s in the process of p r o f e s s i o n a l i z a t i o n .  While a u n i v e r s i t y education provides s t a t u s ,  Krause considers the move to u n i v e r s i t i e s a f a i l u r e , because nursing does not control the means of nursing work. Nonetheless Wilensky's (1964) sequence of p r o f e s s i o n a l i z a t i o n defining work as a f u l l time s p e c i a l i z e d task, e s t a b l i s h i n g a t r a i n i n g school preferably at a u n i v e r s i t y , the establishment of a l i c e n s i n g mechanism, and creating a code of e t h i c s based on p u r i t y and service has been achieved with varying degrees of success.  149  Krause (1977, pp. 52-55) takes the analysis of the attempt to p r o f e s s i o n a l i z e a step f u r t h e r by arguing that t h i s has been one of a series of s t r a t e g i e s in an attempt to gain autonomy i n the work place.  He describes the sequence as the "shift to u n i v e r s i t y t r a i n i n g "  and 'take-over of physicians' d i r t y work," the "adoption of a managerial ideology,"the'butside mover approach," the'"s*ize the technology s t r a t e g y " and'linionization"fo.r greater control over work as well as f o r higher wage l e v e l s .  Basing nursing education i n a u n i v e r s i t y s e t t i n g i s seen  as an attempt to gain upward occupational m o b i l i t y .  This has f a i l e d  because nursing does not control the s e t t i n g of health care d e l i v e r y . The takeover of physicians' d i r t y work i s seen as an attempt to gain authority i n the work s e t t i n g but i s d i l u t e d by the p h y s i c i a n s ' c l a i m of legal r e s p o n s i b i l i t y and ultimate r e s p o n s i b i l i t y .  Public health was  seen i n the 1900's as an avenue f o r greater occupational autonomy. This f a i l e d due to the legal subservience of nurses to physicians. The seize the technology strategy has f a i l e d because other occupational groups have moved i n more q u i c k l y than nurses, and because u l t i m a t e l y the technology i s c o n t r o l l e d by physicians.  The use of c o l l e c t i v e  bargaining has f a i l e d , i n Krause's view, because increased wages have been used as a bribe by employers to d i v e r t a t t e n t i o n from the demands of nurses to control t h e i r work. Nurses and nursing a s s o c i a t i o n s , by emphasizing r e g i s t r a t i o n and improved standards of education, have vested importance i n  150  p r o f e s s i o n a l i z i n g by the achieving lism.  of the a t t r i b u t e s of professiona-  As Strauss (1966) points out, nurses have succeeded i n  convincing the public of t h e i r professional s t a t u s . This has created a dilemma, since e f f o r t s to improve the terms and conditions of employment by professional means f a i l e d , the a l t e r n a t i v e was c o l l e c t i v e bargaining, considered u n t i l recently a non-professional strategy.  Changes in the organization of nursing work and the  entry of government i n t o health care changed these dynamics.  Summary . The l i t e r a t u r e recognizes that nurses used a v a r i e t y of s t r a t e g i e s in an attempt to control work p r a c t i c e . The primary e f f o r t s were directed to the establishment of r e g i s t r a t i o n and the control of the education of students.  The role of students as cheap  labour impeded educational reform in Canada, England.  the United States and  In the l i t e r a t u r e these e f f o r t s to bring about reform have been  characterized as p r o f e s s i o n a l i z i n g s t r a t e g i e s , 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 p r a c t i c e . The l i t e r a t u r e does not a s s i s t in supporting or r e j e c t i n g the postures, or the s t r a t e g i e s of control ;  suggested i n . t h e analysis of t h i s study.  Although the approach and  the d e f i n i t i o n s vary, the l i t e r a t u r e supports the category of control of work p r a c t i c e with the properties of r e g i s t r a t i o n and education.  151  Control, of the work .environment In t h i s study the control of the work environment represents the nursing a s s o c i a t i o n ' s attempt to control the terms and conditions of employment.  The l i t e r a t u r e i d e n t i f i e s 1) the development of  s c i e n t i f i c medicine, 2) changes i n the organization of the work, 3) the development of a hierarchy within nursing and 4) the socio-economic concerns of nurses as factors i n the development of c o l l e c t i v e bargaining by nurses in Canada, England and United States.  Depending on the i d e o l o g i c a l stance the emphasis on these  factors v a r i e s . Concurrent with the urbanization and i n d u s t r i a l i z a t i o n 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 p r a c t i c e . The development of s c i e n t i f i c medicine and the increased use of technology i n the care of the sick meant that by the 1930 s i t was no longer possible 1  to be i l l and receive good care at home. in h o s p i t a l s had a r r i v e d .  The age of technology  Hospitals were no longer reserved f o r  the s i c k 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 p r i v a t e duty nurses in the United States to become i n s t i t u t i o n a l employees and t h e i r vigorous p r o t e s t .  There i s no Canadian or  152  English l i t e r a t u r e describing t h i s phenomenon. Abel-Smith (1960) describes p r i v a t e duty nurses as f u l l y employed u n t i l the Depression, but as not n e c e s s a r i l y , in the eyes of the College of Nursing, giving s a t i s f a c t o r y s e r v i c e s .  The l i t e r a t u r e does acknowledge the  development of a hierarchy w i t h i n 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 o n a l employment i n Canada as entering a " s o c i a l system that had been designed and f o r many years had operated according to the s o c i a l norm of the n a t i v e , submissive student who was subjected to c l o s e r control and d i s c i p l i n e in her work"  (pp 3).  Baumgart states that nurses were forced to t r a n s f e r t h e i r respons 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 physician and the p a t i e n t .  .the i n s t i t u t i o n , the  White (1977, pp.24) i l l u s t r a t e s that  a hierarchy was well established in poor law nursing i n England in the 19th century. Carpenter (1977) describes the r i s e of a managerial c l a s s of nurses in Great B r i t a i n and ascribes the development of c o l l e c t i v e bargaining to t h i s d i v i s i o n w i t h i n the profession. Carpenter argues that t h i s occurred because of "profound changes in job content" (pp.174)'. He i d e n t i f i e s three areas of change 1) the increase i n numbers of c l i n i c a l r e s p o n s i b i l i t i e s being delegated to nurses from doctors as a r e s u 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 i n t e r m i t t e n t contact with p a t i e n t s , and 3) the increased number.of care.  c h r o n i c a l l y i l l patients who require long term  Carpenter argues that as the proportion of c h r o n i c a l l y s i c k  patients increased, "job s a t i s f a c t i o n i n carrying out basic nursing tasks d e c l i n e d .  The nursing e l i t e began to look more towards  c l i n i c a l and managerial aspects of t h e i r work" (pp.174).  D i r t y work  or routine work was delegated, and t h i s meant an increased abandonment of t r a d i t i o n a l nursing values. Katz (1966) ,Krause (1977),Mauksch (1966) and Williams(1974) support t h i s general argument, but Williams (1974) describes the issue not as a loss i n job s a t i s f a c t i o n but as a. s h i f t i n ideology from vocational ism to professionalism. Vocationalism i s the expression of t r a d i t i o n a l nursing values i n which the sancity of both the nurse and patient are preserved.  Professionalism i s an ideology i n which prestige  and reward to nurses i s associated with c l i n i c a l tasks delegated by medicine and managerial  activities.  This l i t e r a t u r e pays l i t t l e attention to socio-economic concerns of nurses.  Badgley (1975, pp.9-17) w r i t i n g from a  Canadian experience, i d e n t i f i e s growing unionization and wage discrepancies triggered by monetary i n f l a t i o n as r e s u l t i n g i n labour unrest and s t r i k e s by health workers. The consequence has been the  154  gradual erosion of professional autonomy, the emergence of s o c i a l pressures stemming from job status i n c o n s i s t e n c i e s , and the , increased importance of r e l a t i v e income l e v e 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 associations to trade unions and argues that c o l l e c t i v e bargaining w i l l r e s u l t in more d i r e c t s o c i a l responsib i l i t y on the part of these occupations than was previously evident. With s p e c i f i c reference to nurses, Badgley suggests that status symbolism, e s p e c i a l l y v i s i b l e in nursing, has been stressed i n l i e u of job remuneration or job b e n e f i t s .  He views t h i s middle  l e v e l work force as having a short term career commitment  and a  high job turnover which has l i m i t e d the growth of strong a s s o c i ations and constrained the sense of m i l i t a n c y among workers. A slow b u i l d up of job f r u s t r a t i o n f i l l e d by an awareness of women's r i g h t s , the impact of i n f l a t i o n , and by disenchantment with t r a d i t i o n a l prestige symbols has resulted in an awareness of income l e v e l s equaled or excelled by workers with less formal t r a i n i n g and in a sense of job a l i e n a t i o n .  Badgely predicts  sharper c o n f l i c t i n the future i f the health system remains r i g i d and a u t h o r i t a r i a n in the face of current s o c i a l  forces.  As an example, Badg.ley points out that sanctions against s t r i k i n g doctors have not occurred, but professional hospital employees  155  and nurses have been subject to sanctions Badgley i d e n t i f i e s the moral issue to be solved as whether c o n f l i c t w i l l be " a n t i c i p a t e d and s t r u c t u a l l y channelled to increase the s a t i s f a c t i o n of health workers and in turn achieve the target of good health f o r the p u b l i c " (pp.16).  Issues i n c o l l e c t i v e bargaining by nurses in England, United States and Canada. Engl and. Regardless of the emphasis on the factors  precipitating  c o l l e c t i v e bargaining by nurses, the l i t e r a t u r e supports the p o s i t i o n that the nursing work force entered c o l l e c t i v e bargaining as a response to the f a i l u r e of nursing associations 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 r e g i s t r a t i o n .  The f i r s t s t r i k e occurred in 1918,  when a 60 hour week was sought (Green, 1975, Ross, 1979). Lewis (1976) describes the r e l a t i o n s h i p 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 s e l e c t group  156  from the r u l i n g class and t h e i r  a l l i e s who are c o n t r o l l i n g the  s o c i a l order of nursing in B r i t a i n .  The organizations  representing  nurses are argued to have f a i l e d 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 i n work to r u l e , demonstrations and s t r i k e s by nurses.  McKay (1974) has described the allegiances and a t t i t u d e s of  B r i t i s h hospital nurses in response to t h i s s t r a i n . Bellaby and Oribar (1980, pp.291-309) in a Marxist analysis of s t r a t e g i e s adopted by B r i t i s h hospital nurses do not believe that developments in medical technology are the prime explanation f o r a l l the changes in the mode of control and d e l i v e r y of health care. The dominance of medicine over health care workers, the influence of technology and i t s s u p p l i e r s , and government i n t e r v e n t i o n are seen as promoting the erosion of nurses' control over the means of treatment.  Consequently nurses have responded by equivocating  between the s t r a t e g i e s of professionalism and unionism. The issue of the r i g h t to s t r i k e and the dilemma of professionalism and union a c t i v i t y i n B r i t i s h nursing i s debated by Clark (1979), Ferguson (1976) and Williams (1979). The North American model of professional associations engaging i n c o l l e c t i v e bargaining with the r i g h t to s t r i k e i s not suggested i n 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 k e action o r ,  affiliation  with a union with an i n t e r e s t i n patient care and l i n k s with trade unions or the Labour party (Ferguson, 1976).  United States C o l l e c t i v e bargaining by nurses in the United States i s important i n t h i s study f o r two reasons: 1) because of the generally acknowledged influence 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 c e Wright was aware of and supported the a c t i v i t i e s of the C a l i f o r n i a Nurses' Association before she returned to B r i t i s h Columbia i n 1943. Swanberg (1970, pp.54-56) i d e n t i f i e s three phases of a c t i v i t y amongst hospital workers i n the United States: 1) 1896 to the entry of the US i n t o World War I I , characterized by i n a c t i v i t y and passiveness, 2) World War II to 1965, characterized by growing awareness and o r g a n i z a t i o n , 3.) 1965, characterized by intense action and m i l i t a n c y . In 1935 the Wagner Act permitted hospital employees to engage i n c o l l e c t i v e bargaining, but attempts to organize were l a r g e l y unsuccessful.  This act was  amended i n 1947 (Taft-Hartley) and hospital workers i n nonprofit h o s p i t a l s were exempted c o l l e c t i v e bargaining r i g h t s .  In 1962  employees of federal health care i n s t i t u t i o n s were permitted to engage in c o l l e c t i v e bargaining.  In 1967 Catholic h o s p i t a l s i n the  158  United States were influenced by the Vatican II "Pastoral C o n s t i t u t i o n on the church i n the Modern World" which stated "among the basic r i g h t s of the human p e r s o n . . . ( i s ) the r i g h t of f r e e l y founding labour unions" (Brown, 1967, pp.57-60) M i l l e r and S h o r t e l l (1969) show that unionization i n non-federal hospitals doubled between 1961-69.  In 1974 an amendment to the;  T a f t - H a r t l y Act extended c o l l e c t i v e bargaining to non-profit hospitals.  This was opposed by the American Hospitals' Association  (Rasaco, 1974, pp.79-80). The f i r s t union a c t i v i t y i n h o s p i t a l s in the U.S. occurred i n San Francisco i n 1919.  The p r i n c i p a l demands were shorter  hours and better working c o n d i t i o n s .  There was r e l a t i v e l y  little  a c t i v i t y u n t i l 1936 when the American Federation of Labour organized the engineers and i n s t i t u t i o n a l workers of three large San Francisco h o s p i t a l s .  The Toledo Plan of 1956 occurred a f t e r an  extended hospital workers' s t r i k e i n that c i t y and resulted in an agreement that unions would not bargain c o l l e c t i v e l y or s t r i k e ; and that h o s p i t a l s would not discriminate against union members (Bruner, 1959).  A b i t t e r s t r i k e i n New York C i t y , was preceeded  by the establishment of a union at Montefiore hospital (Cruickshank, 1959).  The administration of t h i s  particular  hospital supported the entry of the union (Cherkasky, 1959). Increased union a c t i v i t y of hospital workers i n 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 m i l i t a n c y amongst nurses in C a l i f o r n i a during World War II as due to an intense recruitment f o r workers i n a booming economy i n which "nursing's economics did not benefit" (pp.277).  The American  Nurses'Association did not e s t a b l i s h a committee on economic a f f a i r s u n t i l 1946.  The e f f o r t s of S h i r l e y T i t u s , then executive d i r e c t o r  of the C a l i f o r n i a Nurses'Association, persuaded the ANA to study employment conditions of nurses i n 1945.  Bullough describes Titus  as "an e n t h u s i a s t i c supporter of c o l l e c t i v e bargaining" (1971, pp.278).  The ANA approved the r o l e of state nursing associations  i n c o l l e c t i v e bargaining in 1946.  The ANA l i f t e d a ban on s t r i k e s  by nurses in 1968 ( M i l l e r , 1975). T i t u s , w r i t i n g in The Modern H o s p i t a l , 1944 (pp.71-74) in an a r t i c l e c a l l e d "Economic Security i s not too much to ask" a t t r i b u t e d the "awakening of n u r s e s . . . to a f u l l appreciation of t h e i r economic p o s i t i o n " to 1) the development of a system of general s t a f f nursing in which there was a marked increase i n the number of general s t a f f nurses subjected to hospital e x p l o i t a t i o n , 2) a sharp reduction of nurses s a l a r i e s and p r e r e q u i s i t e s (laundry services) during the depression, which f o r many nurses had never returned to t h e 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 r a f t to a p r o f e s s i o n , and the lack of professional s t a t u s , 4) the passing of the Social Security Act in which workers, but few nurses, received protection against old age, i l l n e s s and lack of employment o p p o r t u n i t i e s , 5) i n f l a t i o n which increased the cost of l i v i n g but not n u r s e s ' s a l a r i e s .  Titus recognized the  desire of s t a f f nurses to organize, and the pressure s t a f f nurses and p r i v a t e duty nurses were prepared to exert on t h e i r leaders "to do something about s a l a r i e s " (pp.73).  She argued that bargaining  f r e e l y and independently r e l a t i v e to the conditions of employment was a democratic r i g h t , and that professional status offered no protection to employed persons.  This a r t i c l e i s important not only  f o r i t s t i m i n g , and l e g i t i m i z i n g of c o l l e c t i v e bargaining but also because reference i s made to t h i s a r t i c l e i n the Executive minutes of the RNABC (December, 1943) to "acquire copies". The l i t e r a t u r e on c o l l e c t i v e bargaining and nurses in the American nursing journals concentrates on 1) whether or not c o l l e c t i v e bargaining i s appropriate f o r professionals (Conta, 1972; Erickson, 1971; Gillingham, 1950; Hopping, 1976; Mahony and Conlan,1966); 2) the e f f e c t of c o l l e c t i v e bargaining on the structure and functioning of professionalism (Bloom, 1979; 1980; C l e l a n d , 1974; Conta, 1972; Copp, 1973; Denton, 1976; Hott, 1976; Schutt, 1973; Zimmerman, 1971); 3) the ambiguous r o l e of the d i r e c t o r of nursing: i s she to a l l y  h e r s e l f with the nursing s t a f f , management, or act as  a go-between (American Nurses' A s s o c i a t i o n , 1970; D r i s c o l l , 1974;  161  H o s p i t a l s , 1974; Rosasco, 1974);  4) the r o l e of middle nursing  management, e s p e c i a l l y in labour disputes (Bloom, 1980; Cleland, 1974);  5) the r o l e of c o l l e c t i v e bargaining i n defining  patient care (Jacox, 1971; K r a v i t , 1973);  6) the r i g h t of nurses  to s t r i k e (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 h o s p i t a l s and nursing administrators as a means of s o c i a l control because of t h e i r vested i n t e r e s t s in a quiescent workforce. The issues are  not resolved.  Grand (1971, pp.289-299)  describes the c o n f l i c t as r e f l e c t i n g three d i s t i n c t p o s i t i o n s of nurses.  ideological  Nightingalism i s an ideology of service which  i s interpreted as precluding concern with economic and working c o n d i t i o n s . Employeeism represents a set of b e l i e f s that lead nurses, as employees, to believe that t h e i r employer had t h e i r best i n t e r e s t s at heart.  Grand argues that the employeeism i s  reciprocal of paternalism and that the Depression contributed to the growth of employeeism.  Professional c o l l e c t i v i s m i s based  on the assumption that working conditions are inherently and p o s i t i v e l y r e l a t e d to the q u a l i t y of nursing care.  Grand argues  that the s e r v i c e ideology and the r e a l i t y of the low economic status of nurses were r e c o u n c i l l e d by viewing the q u a l i t y of care given by nurses as dependent upon s a t i s f a c t o r y economic status and working c o n d i t i o n s .  While the narrative c l e a r l y  illustrates  162  that both grassroots nurses and the recognized the problems of the  leaders of the RNABC  terms and conditions of employment  from the e a r l i e s t days- ofthe A s s o c i a t i o n , t h i s p o s i t i o n was not ennunciated u n t i l the middle of l a t e 1940's.  Nightingalism i n a  pure form as described by Grand did not e x i s t amongst nurses in B r i t i s h Columbia.  Given the c h a r i t a b l e nature of h o s p i t a l s , and  the l i m i t e d public funding of h o s p i t a l s u n t i l 1949 i n B r i t i s h Columbia the use of moral suasion from the formation of the Association u n t i l the f i r s t s t r i k e votes of 1957 and 1959, employeeism may best describe the dominant ideology of nurses in B r i t i s h Columbia u n t i l 1957. Two c r i t i G s • outside of nursing have examined the r o l e of the ANA and state nursing associations (Dolan, 1980; L e v i , 1980). Dolan argues that the professional nursing a s s o c i a t i o n serves the e l i t e and because of the f a i l u r e of c o l l e c t i v e bargaining by nursing associations to make s i g n i f i c a n t economic gains unionization outside of professional associations w i l l occur (Dolan, 1980). Levi (1980) argues that nursing associations have been unable to control the nursing labour supply and have f a i l e d to monopolize a d i s t i n c t set of tasks and thus are unable to achieve upward s o c i a l and economic m o b i l i t y 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 Seattle nurses s t r i k e of 1976 was broken by the h o s p i t a l s because of the f a i l u r e of the professional  163  a s s o c i a t i o n 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 l o u t " 3) the f a i l u r e of nurses to secure a monopoly over any set of " s o c i a l l y s i g n i f i c a n t , or even i n s i g n i f i c a n t , r o l e s " (pp.347).  What Levi does  not address i s the i n t e g r a t i o n i s t role of middle nursing management (Jones, N. and Jones, W., 1979) who were prohibited from s t r i k i n g i n t h i s s i t u a t i o n and the amount of medical care given in hospital which i s may or not be an e s s e n t i a l service ( H a l l , 1967). In Canada two review a r t i c l e s consider the issue of c o l l e c t i v e action by nurses to improve t h e i r s a l a r i e s and working c o n d i t i o n s . A federal study f o r the Women's Bureau, Department of Labour (Beckett, 1964) i d e n t i f i e d the public and professional view that c o l l e c t i v e action on the part of nurses to improve t h e i r working conditions was u n e t h i c a l .  Low s a l a r i e s and unsatisfactory  working conditions are i d e n t i f i e d as c o n t r i b u t i n g to an i n s u f f i c i e n t supply of nurses and a high rate of wastage.  Because the majority  of nurses in Canada were not covered by labour r e l a t i o n s l e g i s l a t i o n c o l l e c t i v e bargaining was a voluntary act without the p r o t e c t i o n of labour l e g i s l a t i o n .  The evolution of recommended  minimum standards for personnel p o l i c i e s f o r nurses by a committee on employment r e l a t i o n s w i t h i n the professional a s s o c i a t i o n to c o l l e c t i v e bargaining by professional associations i s described province by province.  The ' s i t u a t i o n in B.C.'was as described i n  the narrative except that no evidence of the formation of a Labour  164  Relations Committee formed i n 1942 was found i n the minutes of the Association.  Beckett concludes that the growth of c o l l e c t i v e  bargaining by nurses depends on 1) the amount of public support given, 2) the importance of health services i n the community and the demand f o r health personnel, dedication to service does not  3) the awareness by nurses that obviate the r i g h t to s a l a r i e s and  working conditions consistent with the importance of t h e i r c o n 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 i n the province of Quebec, the labour movement i n Canada has not been a c t i v e i n r e c r u i t i n g nurses to i t s ranks" (pp.12).  Beckett has overlooked the e f f e c t  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 p u b l i c sector because the government i s the ultimate employer.  and because "the e s s e n t i a l nature of t h e i r task  decrees that t h e i r employment i s a matter of p u b l i c concern" (pp.667). Cormick recognizes that the c o n f l i c t between professionalism and unionism w i t h i n nursing, l e g i s l a t i v e impediments and the lack of s k i l l e d bargainers w i t h i n nursing associations have impeded progress towards c o l l e c t i v e bargaining by nurses. because of the high cost, and u n d e s i r a b i l i t y  Health care,  of d u p l i c a t i o n and  i t s non-profit s t a t u s , i s considered to be a monopoly s i t u a t i o n  165  with the nursing profession c o n t r o l l i n g entrance to the profession through r e g i s t r a t i o n procedures.  Cormick does not acknowledge the  p r o l i f e r a t i o n of health care workers including the establishment of a subsidiary nursing work f o r c e , evident i n the l a t e 1960's, and the consequent d i f f i c u l t y i n i d e n t i f y i n g work unique to nurses, nor the e f f e c t of subsidiary and p a r a l l e l workers d i l u t i n g nurses' monopoly (Krause, 1977; ,,Levi, 1980). Cormick suggests that hospital administrators have been opposed to c o l l e c t i v e bargaining by nurses because "wage increases would have to be passed on to consumers who are in no p o s i t i o n to f i g h t the r i s i n g costs of an e s s e n t i a l s e r v i c e : (Hawley c i t e d by^ Cormick pp.679).  This view has been noted to be prevalent i n the  American l i t e r a t u r e , and indeed was the crux of debate in r e v i s i o n of laws p r o h i b i t i n g employees  of  non-profit h o s p i t a l s from entering  i n t o c o l l e c t i v e bargaining i n the US (Match, Goldstein and L i g h t , 1975, pp.27-36). but i s not generally consistent with the Canadian position.  As e a r l y as 1950, Harvey Agnew, long time Executive  Director of the Canadian H o s p i t a l s ' A s s o c i a t i o n supported the entry of Ontario nurses into c o l l e c t i v e bargaining by arguing that "the public cannot expect to get hospital care at prices which can only be maintained by holding s a l a r i e s levels" (Agnew, 1950, pp.27-28).  and wages at less than current This view i s supported by J.D.Bradford  (1981) former executive d i r e c t o r of the BCHA and Steeves (1960, pp.100-101).  166  On the basis of a v a i l a b l e data,Cormick suggests that i t i s d i f f i c u l t to e s t a b l i s h a c l e a r r e l a t i o n s h i p  'between bargaining  strength' and 'salary or salary gains' but suggests that p r o v i n c i a l associations with "high" bargaining strength (eg. B.C.) do better on basic salary rates and salary gains.  He.also i d e n t i f i e s a  " r e l a t i o n s h i p between general per capita income rank and nursing salary r a n k . . . which suggests that the general economic environment i s an important f a c t o r " (pp.681-682).  Cormick predicts that  organizing f o r c o l l e c t i v e bargaining w i l l increase the general strength of nursing associations i n areas where they are able to act as bargaining agents and that nursing associations w i l l be able to exert increased influence over t r a i n i n g standards and methods, even though the basic avenue of change w i l l s t i l l be through the l e g i s l a t i v e process. Foucher (1980) ,in addressing the Canadian Nurses Assoc i a t i o n Biennal^discusses the question of nurses and t h e i r membership in professional associations and trade unions. that a change in values  He suggests  of. nurses has come about due to increased  government intervention in health c a r e , r e s u l t i n g i n administration 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 associations and hospital administ r a t i o n which shared c e r t a i n values, the use of such a process of e s t a b l i s h i n g nurses' working conditions became less s a t i s f a c t o r y when  167 administrative, values began to change" (pp.2).  While nurses have  sought "protection from management decisions by means of hureauc r a t i c a l l y - oriented rather than p r o f e s s i o n a l l y - o r i e n t e d contract p o s i t i o n s . . . " (pp.2) nurses have expressed i d e o l o g i c a l c o n 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 conditions of nurses did not improve a great deal or uniformly as a r e f l e c t i o n of the 'sharing of c e r t a i n values' but rather as a r e s u l t of 1) the shortage of nurses beginning i n 1939-40, 2) the beginning of c o l l e c t i v e bargaining by nonprofessional hospital workers, and 3) the beginning of c o l l e c t i v e action by nurses in 1946.  Rather i t would seem that bureaucratic administration  has reinforced the pressure nurses feel to maintain a c t i v e 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 r o l e the professional association takes in c l a r i f y i n g  and promoting the act of nursing w i l l a f f e c t the commitment to the a s s o c i a t i o n . In considering trade unions, Foucher uses Torraine's (.1965) typology to describe three types.  Unions may be based on 1) c l a s s , and "dominated by  the struggle against c l a s s power", 2) n e g o t i a t i o n , with the aim to improve member's working c o n d i t i o n s " , or 3) i n t e g r a t i o n , with the aim "to contribute to the smooth operation of society and i t s structures" (pp.6-7). The o b j e c t i v e of unionism based on negotiation may be u t i l i t a r i a n i s m , 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' i n t e r e s t s and t h e i r c o l l e c t i v e p r i v i l e g e s , 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 c o n t r o l , the union endeavours to take on management r i g h t s and to influence d e c i s i o n making.  I t may adopt a cooperative or an adversary stance within the  e x i s t i n g i n s t i t u t i o n a 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 t e d by Foucher, pp.6-7).  On the basis of the n a r r a t i v e presented i n Chapters 2 and 3, the objective of c o l l e c t i v e 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 i n t e r e s t s and demands of nursing unions and professional associations overlap or are i n t e r r e l a t e d and that the organizations can e l e c t to adopt opposing or j o i n t s t r a t e g i e s f o r dealing with these demands.  F a i l i n g t h i s , unions and professional  associations may i n t e g r a t e , with one or the other l o s i n g membership i f membership i s voluntary, or l o s i n g power.  In the case of the  RNABC, with voluntary membership in law, but mandatory membership enforced by h i r i n g i n s t i t u t i o n s , the professional a s s o c i a t i o n may lose out to the union. To ensure the maintenance and development of professional a s s o c i a t i o n , Foucher suggests that these organizations should  169  1) "display an i n t e r e s t i n member's concerns... and provide through open structures the opportunity f o r membership input" 2)"put forward professional models in the f i e l d of nursing...(and) " i f warranted f o r the p r a c t i c e of nursing, a bachelor's degree as a requirement f o r admission into the p r o f e s s i o n . " 3) " c a l l f o r more f o r c e f u l persuasive s t r a t e g i e s in the i n s t i t u t i o n a l framework" (pp.9-10). In t h i s 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 i n t e r e s t i n g  omission from Foucher's paper i s any  discussion on the role of nursing management i n the professional a s s o c i a t i o n and the nursing union or the need for a separate union f o r middle management nurses. With the separation of the professional and union structures in Canada, the question of managerial nurses p a r t i c i p a t i n g i n the professional a s s o c i a t i o n i s less acute than in the United S t a t e s .  In due course the B.C. nursing adminis-  t r a t o r s group may come back under the wing of the  professional  a s s o c i a t i o n see p 31 and union a s p e c i f i c issues-does not challenge, but r  rather supports t h i s group.  With increasing budgetary c o n s t r a i n t  in health care, and theinherent tension between hospital administration and the nursing department, because of the  large  consumption of the t o t a l budget by the nursing department, the d i r e c t o r of nursing i s i n an i n c r e a s i n g l y tenuous p o s i t i o n , and challenges to the system by the professional association and/or  170  the union may not be interpreted as supportive. Baumgart (1980) i n Professional O b l i g a t i o n s , Employment R e s p o n s i b i l i t i e s and C o l l e c t i v e Bargaining: A New Agenda f o r the 1980's i n an address given to the RNABC Labour Relations D i v i s i o n , 4th Annual Convention argues f o r the coexistence of the professional a s s o c i a t i o n and union.  She states that both have s p e c i f i c and  complementary r o l e s . Baumgart predicts the "emergence of c o l l e c t i v e bargaining as a means of harmonizing professional i n t e r e s t s and r e s p o n s i b i l i t i e s with employment o b l i g a t i o n s " (pp.1) Baumgart expresses the concern that because of the lack of value attached to nurses' work, and the i n h i b i t i o n of the development of s p e c i a l i z a t i o n amongst nurses, both to the advantage of hospital a d m i n i s t r a t i o n , nurses w i l l have d i f f i c u l t y gaining greater autonomy and control over t h e i r work.  Summary. The l i t e r a t u r e reviewed supports the category of the control of the work environment with the major properties of the terms and conditions of employment, although, c l e a r l y and education played important r o l e s .  registration  The l i t e r a t u r e acknowledges  that c o l l e c t i v e bargaining i s a well established response i n Canada, England and United States. The s t r a t e g i e s of nurses were seen to equivocate between  171  professionalism and unionism.  The form of union a c t i v i t y and i t s  e f f e c t on the professional organization was discussed by several authors.  The issues remain unresolved.  As with control of work  p r a c t i c e , the l i t e r a t u r e does not a s s i s t i n supporting or negating the postures or s t r a t e g i e s of control suggested in the analysis of t h i s study.  Conclusion This chapter has presented a review of selected l i t e r a t u r e relevant to t h i s study.  The purpose of the l i t e r a t u r e review was to  compare the a n a l y t i c core of the categories which emerged from the data with the s i m i l a r i t i e s and convergences of the l i t e r a t u r e .  In  addition t h i s l i t e r a t u r e review had the function of providing comparisons for the groups which emerged from the data of t h i s study. C o l l e c t i v e bargaining as a response to the terms and conditions of employment of nurses i s well, established in Canada, England and United States.  C o l l e c t i v e bargaining as a strategy was  contrasted with the f a i l u r e of so c a l l e d professional  strategies.  The r o l e of cosmopolitans and l o c a l s , or e l i t e and p r o l e t e r i a t was confirmed by several authors.  The concepts of control of the  work f o r c e , control of work p r a c t i c e and control of work environment were also confirmed i n the l i t e r a t u r e .  Strategies of nurses were  seen as equivocating between professionalism and unionism.  172  No l i t e r a t u r e studied showed nurses or nursing associations, using the strategy of lobbying and moral suasion to emerge, although the pattern of bargaining emerged.  S i m i l a r l y the postures of the  RNABC, compromised c o n t r o l , co-ordinated control and bargained control could not be found in the l i t e r a t u r e . This i s more l i k e l y due to the c h a r a c t e r i s t i c s of the data base of t h i s study rather than to the Tack of s i m i l a r i t y of the RNABC with other nursing associations.  173 CHAPTER 7  Explanatjons: Negotiations with External Forces.  Introduction The purpose of t h i s chapter i s to consider selected paradigms from the l i t e r a t u r e on s o c i a l p o l i c y and from the l i t e r a t u r e of sociology i n an attempt to explain the events, processes and trends (Smith, 1976) of the negotiation process. A l f o r d ' 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 i m 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 r a t u r e a paradigm of  l e g i t i m a c y , f e a s i b i l i t y and support ( H a l l , Land, Parker and Webb, 1975) can explain the f a i l u r e of the issue of the terms and conditions of nurses to be recognized and acted upon. A b r i e f discussion of the r e l a t i o n s h i p of control contexts, s o c i a l order and negotiation and the professions i s presented by considering Johnson's typology of professions.  The chapter  concludes with b r i e f comments on E t z l o n i ' s (.1968) concept of s o c i e t a l processes and the entry of nurses in B r i t i s h Columbia to c o l l e c t i v e bargaining.  174  Negotiation with External Forces,: A Case of Dynamics without Change  1  A l f o r d (.1972, pp. 127-64) proposes a paradigm f o r 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 d e t a i l applicable to the American scene, t h i s paradigm becomes a useful tool f o r analyzing issues in the B r i t i s h Columbia health care scene that are r e l a t e d to the terms and conditions of employment of nurses. The American health care system which i s c o n t r o l l e d by p r i v a t e enterprise i s  analogous to the health care system i n B r i t i s h  Columbia p r i o r to the introduction by the p r o v i n c i a l government, of hospital insurance i n 1949, and medical insurance i n 1968.  Alford  proposes that there are two groups of reformers, market reformers and bureaucratic reformers, and three i n t e r e s t groups, corporate r a t i o n a l i z e r s , professional monopolists and the community.  Market  reformers "would expand the d i v e r s i t y of f a c i l i t i e s a v a i l a b l e , t h e . number of physicians, the competition between health f a c i l i t i e s , and the quantity and q u a l i t y of private insurance" (pp.128).  Market reformers are  those, who believe that h o s p i t a l s should serve as the organizational framework f o r health care d e l i v e r y , 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 public insurance only f o r the poor. Bureaucratic reformers "stress the importance of the hospital...... and wish to put i n d i v i d u a l doctors under the control of hospital medical boards and administrators"(pp.129). 1  Bureaucratic  A l f o r d , R. The P o l i t i c a l Economy of Health Care: Dynamics Without Change. P o l i t i c s and Science. Winter, 1972, pp.127-164.  175 reformers are concerned p r i m a r i l y with coordinating fragmented services and i n s t i t u t i n g planning and public funding while keeping the hospital as the centre of a network of health s e r v i c e s .  The  community population i s seen as an external constituency of health providers to be organized to represent i t s i n t e r e s t f o r the maintenance of the system.  The reforms concerning the r o l e and organization of the  professions are i n s t i g a t e d by bureaucratic reformers.  Alford  describes corporate r a t i o n a l i z e r s as being composed of hospital administrators, medical school d i r e c t o r s and government health o f f i c i a l s , with an ideology of r a t i o n a l , e f f i c i e n t , cost conscious coordinated health care d e l i v e r y .  The professional monopolists are seen as  supporting those bureaucratic reforms which protect t h e i r own i n t e r e s t s . In A l f o r d ' s paradigm they accuse the corporate r a t i o n a l i z e r s of not being concerned with personalized care.  In turn professional mono-  p o l i s t s are accused of s e t t i n g up a screen of legitimacy to protect t h e i r own i n t e r e s t s .  Community i n t e r e s t s 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 o n s and thus are free to demand more and better health care.  However, A l f o r d  points out that t h i s group does not have the necessary information to lobby e f f e c t i v e l y , nor does i t know the levers of power, the i n t e r e s t s at stake or the actual nature of the (health care d e l i v e r y )  institution  and thus i t s members are e i t h e r coopted into the system or excluded from successful lobbying due to ignorance.  A l f o r d argues that the  s t r a t e g i e s of reform based on e i t h e r 'market' or bureaucratic reform are u n l i k e l y to work because each type of reform stresses c e r t a i n  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 i n t e r e s t groups because the major c h a r a c t e r i s t i c s of the health system are due to private c o n t r o l . A l f o r d concludes by arguing that "change i s not l i k e l y without the presence of a s o c i a l and p o l i t i c a l movement which r e j e c t s the legitimacy of the economic and s o c i a l base of p l u r a l i s t p o l i t i c s " (pp.164). In applying t h i s paradigm to B r i t i s h Columbia of the l a t e 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 f o r the 1936 Health Insurance l e g i s l a t i o n which was passed but never proclaimed.  Had t h i s  l e g i s l a t i o n been proclaimed the unemployment and economic s i t u a t i o n of nurses might have improved incremental.y. Hospital would have ceased to be c h a r i t a b l e i n s t i t u t i o n s and thus nurses would have been freed from that p a r t i c u l a r i d e o l o g i c a l burden.  As an academic  George Weir prepared the survey of Nursing, 1932, and made s p e c i f i c recommendation to s o c i a l i z e medical and nursing care and to take nursing education out of the h o s p i t a l s (Weir, 1932).  On entry into  p o l i t i c s he became P r o v i n c i a l Secretary and as such was responsible f o r the mental and tuberculosis hospitals of the province and f o r the province's support of c h a r i t a b l e h o s p i t a l s .  When the question of  the working conditions of nurses became p o 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 conditions in hospitals i n 1938.  Steeves d e s c r i p t i o n 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 f o r the Report of the R o w e l l - S i r o i s Commission on dominion - p r o v i n c i a l r e l a t i o n s to see whether something hopeful would come out of i t " (pp.121).  The  dynamics of party and f e d e r a l - p r o v i n c i a l p o l i t i c s stagnated the impetus f o r change. I f the broad base of support f o r health insurance given by the plebiscite, of 1937, was i n s u f f i c i e n t to prompt the government to a c t , l i t t l e could be expected f o r nurses. When hospital insurance did come to the province in 1949, working conditions f o r nurses improved only g r a d u a l l y , and through the e f f o r t s of nurses, not those responsible f o r the health care system. The work week f o r graduate nurses was reduced from 48 to 40 hours by 1955. nurses continued to work longer hours.  Student  With the support of the  A s s o c i a t i o n , there was r e s t r a i n t i n demand f o r improvement i n s a l a r i e s , u n t i l increased pressure from the grassroots supported by s t r i k e threats i n 1957 and 1959 resulted i n wage adjustments. Of the i n t e r e s t groups, the corporate r a t i o n a l i z e 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 f a s t 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 t h i s group acknowledging a need f o r improvement in working conditions but f i n d i n g reasons, l a r g e l y f i n a n c i a l , not to implement change. The doctors as professional  178 monopolists, supported voluntary r e g i s t r a t i o n f o r nurses,  They were  assured some control over the Association by. p a r t i c i p a t i n g in the annual examination of graduating students. The doctors l o s t i n t e r e s t i n t h i s a c t i v i t y and relinquished t h e i r r o l e v o l u n t a r i l y , but exercised a more pervasive control i n the work s e t t i n g . In t h i s study, the community i n t e r e s t s are the public at large and the Women's I n s t i t u t e 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 e a r l y no organized support, other than that offered by the CCF in the l e g i s l a t u r e , e x i s t e d .  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 e s t a b l i s h health, centres throughout the province. "By 1930, 132 public health nurses had been appointed as a r e s u l t of women's representation" (Douglas, c i t e d by Zacharias 1980, pp.69). The r o l e of the W:I.B.C. i n supporting public health i s acknowledged in the 1921 Report of the P r o v i n c i a l Health Department. What the community i n t e r e s t s , a s represented by the Local Council of Women,could not Influence was the medical monopoly over maternal care. The LCW lobbied to r e g i s t e r midwives and l a t e r to permit the p r a c t i c e of midwifery " i n scattered d i s t r i c t s of Canada"  ( A p r i l 26, 1917). I t i s an  i n t e r e s t i n g question whether the growth of public health nursing was a bureaucratic response to protect the medical dominance of maternal care. The nursing Association f i r s t opposed . and l a t e r supported "advanced o b s t e r i c a l t r a i n i n g under medical  179  supervision"(Apri1 22, 1935).  The nursing profession supported medical  dominance of t h i s a c t i v i t y e i t h e r because of a lack of confidence i n nurses' t r a i n i n g and knowledge, under the influence of the m e d i c a l i z a t i o n of natural processes or because of a lack of t r a i n i n g 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 i n f a n t m o r t a l i t y r a t e s . 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 f o r d ' s terms the nursing Association represented a weak professional monopolist because i t could not control the work force g i v i n g nursing care and because i t could not define work p r a c t i c e independently of the medical profession. Despite the presence of i n f l u e n t i a l leaders, such as Grace F a i r l y , on the Health Insurance Committee of 1932, there i s no evidence that the p r o f e s s i o n ' s opinion influenced the course of events u n t i l a s t r i k e vote was a r e a l i t y .  Negotiation: The Importance of Legitimacy A l f o r d ' s paradigm i s about the system, which i f a l t e r e d might have had a r e d i s t r i b u t o r y e f f e c t (Marchak, 1975) for nurses.Thi-s paradigm leaves unanswered the question of why the issue of the terms and conditions of employment of nurses was not dealt with d i r e c t l y as a  180  s i n g l e i s s u e , or as part of l e g i s l a t i o n regulating .general working c o n d i t i o n s . An a l t e r n a t i v e approach f o r examining the lack of change in the terms and conditions of employment of nurses in B r i t i s h Columbia H a l l , Land, Parker and Webb's model (1975) of legitimacy, 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 should be concerned.  it  Those issues which are considered l e g i t i m a t e  may or may not be given p r i o r i t y . F e a s i b i l i t y i s considered important because the p o 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 a t t e n t i o n .  F e a s i b i l i t y i s determined  by 1) the p r e v a i l i n g structure and d i s t r i b u t i o n of t h e o r e t i c a l and technical knowledge, 2) who (bearing i n mind t h e i r i d e o l o g i e s , i n t e r e s t s , prejudices and information) does the judging, and 3) the outcome of (government) t e s t i n g f o r f e a s i b i l i t y in r e l a t i o n to the use of resources, c o l l a b o r a t i o n , and administrative f e a s i b i l i t y .  Support  f o r 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 public opinion i s more important than an empirical e v a l u a t i o n . This paradigm i s most useful  in explaining  negotiation with external f o r c e s , but i n passing i t should be noted that negotiation within the Association on the means to deal with the issue of the terms and conditions of employment of nurses also took place within the framework of legitimacy, f e a s i b i l i t y and support. C o l l e c t i v e bargaining was a l e g i t i m a t e and f e a s i b l e method-of dealing with the  181 new r e g i s t r a r , A l i c e Wright (Wright, 1981).  The legitimacy granted  c o l l e c t i v e bargaining by the CNA i n 1944 was probably i n f l u e n t i a l  in  l e g i t i m i z i n g c o l l e c t i v e bargaining f o r the general membership. Support f o r c o l l e c t i v e bargaining was denied by the general membership i n 1944 but granted i n 1946.  The entry of the HEU i n t o the scene may be  viewed as f o r c i n g the legitimacy of c o l l e c t i v e bargaining f o r some of the membership.  The interim period of negotiating recommended  Personnel Practices with the BCHA may be seen as a version of c o l l e c t i v e bargaining viewed as f e a s i b l e by the leadership. the l i m i t e d contract demands made u n t i l 1969.  This i s also true of  Some l o c a l s were  d i s s a t i s f i e d with the leadership given during t h i s period (Crawford, 1981). In the case of external n e g o t i a t i o n s , the r e s p o n s i b i l i t y f o r the d e l i v e r y of hospital care l a r g e l y through c h a r i t a b l e  institutions  u n t i l 1949, buffered the government from d i r e c t r e s p o n s i b i l i t y f o r the working conditions in h o s p i t a l s . In the governments' view the issue of the terms and conditions of nurses did not have legitimacy. The f e a s i b i l i t y of improving the terms and conditions of employment of nurses was l a r g e l y a d o l l a r s and cents i s s u e .  The government rejected  the p o s s i b i l i t y of granting increased funds f o r the s a l a r i e s of nurses during the 1930's (Steeves, 1960, pp.100-102; 120-121). Percy Ward, as hospital inspector f o r the government, submitted a report on "economic Aspects" to the Eaton Report (1938, pp. 82-104).  He was unable  to p r e d i c t the expected increased costs of granting nurses i n government aided hospitals a basic salary of $60.00 per month with room and board because of varied administrative procedures i n the  182 hospitals, surveyed (pp.80-90). Thus the technical knowledge was too l i m i t e d to produce concrete data to promote a c t i o n . There i s also the case of the working conditions of student nurses, f o r whom the government had the regulatory power of control f o l l o w i n g the release of the Eaton Report in 1939.  The argument that  the e f f e c t 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 t s 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 f o r the attainment of the p o l i t i c a l support necessary f o r change can be made. However, a minimum Wage Act which did not a f f e c t nurses, but did a f f e c t other hospital workers had passed i n 1938.  I t would appear that the lack  of l e g i t i m a c y , 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 f a c t that they can be depended upon to render service without protest and without d r a s t i c action has kept them working hours of such length that t h e i r health suffers and normal, e s s e n t i a l  social  a c t i v i t i e s are denied to them" (Eaton, 1938, pp.12-13). Connelly (1978), E i c h l e r (1973) and Smith (1973), discuss women at work i n Canada which supports t h i s general p o s i t i o n .  The struggle by women to achieve  a ' l e g i t i m a t e ' r o l e in B r i t i s h Columbia i s described i n "In Her Own Right'  (Latham and Kess, 1980).  183  Summary . The terms and conditions of employment of nurses f a i l e d to gain the attention and action of the government because the issue f a i l e d to have the l e g i t i m a c y , 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, i n s a l a r i e s . The confrontation with the government expressed in the s t r i k e votes of 1957 and 1959, i l l u s t r a t e that the legitimacy, 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 u n t i l nurses forced the issue by c a l l i n g a s t r i k e vote. Conditions f o r students improved incrementally on the wake of improvements f o r graduates.  Marked improvement of conditions f o r 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 . Association to attempt to control the work f o r c e , work p r a c t i c e , and •. work environment, three postures of control contexts were i d e n t i f i e d . These were compromised c o n t r o l , coordinated control and bargained control. The concept of the exercise of-control i s about negotiation as a means of maintaining s o c i a l order (Strauss,1977, pp.4-7; 234-239). The study of s o c i a l order has been described as the central problem of sociology, Watkins (1975)writes that "the c l a s s i c a l formation of the problem was provided by Thomas Hobbes, the 17th" century  184  philosopher.  The essence of i.t is. given i n the question. How, i,f  human beings are fundamentally egoti.sti.cial and s e l f - s e e k i n g , is. society possible?  How i s the i n d i v i d u a l to be restrained from  simply grabbing a l l he can f o r himself without consideration f o r his fellows?  How are i n d i v i d u a l s to be obliged to l i v e together i n reasonable  harmony?" (1975, pp.2-3).  There are however, two s o c i a l orders i n  t h i s study; an i n t e r n a l s o c i a l order within the membership of the A s s o c i a t i o n , and an external s o c i a l order i n the r e l a t i o n s h i p of nurses as i n d i v i d u a l s , and as an Association in  society.  Johnson (1972) suggests a model f o r studying occupational groups which r e j e c t s the usual approach of t r a i t s and functional ism to suggest that "various s o c i a l mechanisms have arisen to 'manage' areas of s o c i a l tension which present problems of s o c i a l c o n t r o l " (pp.44).  "Those occupations which are associated with p e c u l i a r l y  acute tensions . . . have given r i s e to a number of i n s t i t u t i o n a l i s e d forms of c o n t r o l , ' p r o f e s s i o n a l i s m ' being one.  Professionalism, then,  becomes redefined as a p e c u l i a r type of occupational control  rather  than an expression of the i n h e r i e n t nature of occupations" (pp.45). Johnsons' typology of profession i s 1) c o l l e g i a t e c o n t r o l , i n which the "producer defines the needs of the consumer and the manner in which these needs are catered f o r " (pp.45).  Law and medicine exemplify t h 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 i g a r c h i c or corporate forms of patronage. Communal control expressed as consumer p o l i t i c s Is also present, 3) mediative in which "a t h i r d party mediates the r e l a t i o n s h i p between the producer and consumer, defining both the needs and manner i n which the needs are met" (pp.46). C a p i t a l i s t s and state mediative types are i d e n t i f i e d . In the state mediative type the state mediates between the producer and consumer.  Thus t h i s typology  suggests three d i f f e r e n t ways in which professionals become bureaucratized, each "having varying consequences f o r occupational p r a c t i c e " and each being "the product of d i f f e r e n t  institutionalized  forms of c o n t r o l " (pp.85). In the case of nurses, doctors mediate the r e l a t i o n s h i p of the nurse with the patient (Bellaby and Oribar, 1980) by c o n t r o l l i n g the entry of the patient into the system (Watkins, 1975) while the state mediates the organization d i s t r i b u t i o n and funding of the means of care.  The entry into c o l l e c t i v e bargaining with the  acceptance of the p o s s i b i l i t y of s t r i k e action represents the p a r t i c i p a t i o n of the nursing association into t h i s mechanism of s o c i a l control.  The ' f i r s t round' has been the negotiation 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 r o l e of the health M i n i s t r y exemplify (Bellyache at VGH, 1978).  The s t a t e s ' e n t r y into  the mediative process i n health care represents the states' concern f o r the "provision of s o c i a l services in a general rather than a  186  personal service o r i e n t a t i o n of professionalism (pp.84).  I t may be that the  disruptions at VGH represents the Ideological response of the personal service o r i e n t a t i o n of nurses. Summary The concept of professions and the state as agents of s o c i a l control has been suggested.  C o l l e c t i v e 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 o n i ' s concept of the s h i f t . i n . r e l a t i o n s h i p s w i t h i n society from normativism to u t i l i t a r i a n i s m . During the research process there was no attempt to look f o r data which, would confirm or disprove t h i s concept.  I t would seem  appropriate, at the end of t h i s study, to examine E t z i o n i ' s concept i n l i g h t of the findings of t h i s study. E t z i o n i (1968 pp.104) suggests that both, i n d i v i d u a l and organizational r e l a t i o n s h i p s w i t h i n society may be characterized as normative, u t i l i t a r i a n or coercive. "A normative r e l a t i o n s h i p e n t a i l s shared values and norms; the r e l a t i n g actors t r e a t each other as goals and t h e i r mutual commitments are n o n - r a t i o n a l . U t i l i t a r i a n r e l a t i o n s e n t a i l a complementary i n t e r e s t ; the actors t r e a t each other as means and commitments are r a t i o n a l . Coercion e n t a 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 r e a t each other as o b j e c t s , and the commitment may Be e i t h e r r a t i o n a l or n o n - r a t i o n a l . Concrete r e l a t i o n s are frequently a mixture of the three kinds. However, one tends to dominate.... each, of the three basic r e l a t i o n s h i p s serves as a base of both i n t e g r a t i o n and cleavage, and that the very act of binding i s also an act of s e t t i n g a boundary.." (pp.96). He writes that cooperation i s more l i k e l y to occur w i t h i n the f i r s t , contained c o n f l i c t w i t h i n the second, and uncontained c o n f l i c t w i t h i n the t h i r d . " (pp.96) Within t h i s concept of r e l a t i o n s h i p s E t z i o n i  (pp.357)  i d e n t i f i e s three l e v e l s of power:persuasive power (eg. propaganda) i s associated with normative r e l a t i o n s h i p s , u t i l i t a r i a n power i s power expressed i n economic terms  and in terms of control over technical  and administrative c a p a b i l i t i e s .  F i n a l l y , coercive power i s  expressed with the use of weapons,and m i l i t a r y force e t c . Professionalism represents the normative r e l a t i o n s h i p between the nurse and the patient which developed as a natural extension of the vocational ism of nursing i n the 19th c. 1974).  (Williams,  Williams notes that t h i s vocational ism elevated the status  of both, the nurse and the p a t i e n t .  The s a n c t i t y of caring f o r a help-  less adult human being established the meaning of the work of nursing i n the s o c i a l context i n which i t was performed.  In t h i s  power was expressed in symbolic fashion by persuasion. of the nurse and patient remained i n t a c t .  setting  The i n t e g r i t y  188 E f f o r t s to p r o f e s s i o n a l i z e nursing began l a t e i n 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 c h a r a c t e r i s t i c s associated with p r o f e s s i o n a l i z a t i o n (Wilensky, 1964) and because nurses are seen to have a strong commitment to the service ideal i e : patient care, the RNABC i s characterized as havi a commitment to professionalism. Thus, the term ' p r o f e s s i o n a l i s m ' 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 i n d i v i d u a l nurse and the a s s o c i a t i o n . While normative r e l a t i o n s h i p s continued to dominate, a number of forces moved nursing towards u t i l i t a r i a n i s m .  With the end  of the F i r s t World War there was concerted e f f o r t to standardize and improve the education of student nurses, and improve the working cond i t i o n s of graduate nurses.  The end of private nursing duty as a major  employment group in nursing changed the status of the majority of nurses from r e l a t i v e l y independent practioners to employees of institutions.  This change in employment status and the r i s e of  technology and the subsequent necessity f o r h o s p i t a l i z a t i o n i n s t i t u t i o n a l i z e d the r e l a t i o n s h i p s involved i n the care of the s i c k . During t h i s period, the value of nursing and the "proper conduct" of nurses and of the nursing society were dominant themes of the professional b e l i e f system (Jacox, 1971).  189 As nursing struggled to become complementary to the p h y s i c i a n , took on i n c r e a s i n g l y sophisticated technical tasks and delegated d i r e c t human care to the a s s i s t a n t to the professional nurse, nursing attempted to declare i t s e l f an autonomous profession (Katz, 1969). of work.  Patients became both the means of work and the meaning  The helpless adult had become a c l i n i c a l  categorization,  both nurse and the patient had l o s t t h e i r s a n c t i t y (Williams, 1974). In B r i t i s h Columbia, u t i l i t a r i a n i s m amongst nurses has been expressed as unionism since the early 1940's (Registered Nurses Association of B r i t i s h Columbia, Labour Relations D i v i s i o n , 1977).  While unionism  i n nursing has continued to espouse a commitment to high standards of patient care, the dominant value i s a " r a t i o n a l commitment" ( E t z i o n i 1968, pp.96) to the i n s t i t u t i o n of employment.  This r a t i o n a l  commitment was i n i t i a l l y negotiated in economic terms and more recently i n demands f o r d i r e c t p a r t i c i p a t i o n i n the decisions  affecting  the working environment. The recent demands (Unhappy VGH nurses, 1978) f o r increased p a r t i c i p a t i o n in the decisions a f f e c t i n g the work environment may be part of the r a t i o n a l commitment to the i n s t i t u t i o n of employment, or i t may be a ' l a s t f l i n g ' at negotiating normative r e l a t i o n s h i p s in patient care.  Summary. This study would appear to c o n f i r m : E t z i o n i ' s  contention  that r e l a t i o n s h i p s w i t h i n society are moving from the normative to u t i l i t a r i a n . The p r i c e , f o r nurses, in t h i s s h i f t has been the loss of  190 s a n c t i t y f o r both the patient and the nurse.  C o l l e c t i v e bargaining  by nurses, i n B r i t i s h . Columbia has represented the move to u t i l i t a r i a n i s m But c o l l e c t i v e bargaining has also represented an attempt to regain l o s t s a n c t i t y , f i r s t l y by e s t a b l i s h i n g a competitive economic status and secondly by attempting to negotiate the context of the nursepatient r e l a t i o n s h i p .  Conclusion  This chapter has considered selected paradigms' from the l i t e r a t u r e on s o c i a l p o l i c y and the l i t e r a t u r e of sociology in an attempt to explain the f a i l u r e of the terms and conditions of employment of nurses to improve, and the subsequent entry of nurses in B r i t i s h Columbia into c o l l e c t i v e bargaining.  191 CHAPTER 8 Ideological  S h i f t : The Attempt  To Resolve Chronic S t r a i n  Introduction This study began with the notion that the minutes of the Registered Nurses'Association of B r i t i s h Columbia would provi<kan explanation f o r the early development of c o l l e c t i v e bargaining by nurses in B r i t i s h Columbia.  On one l e v e l 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 t o l e r a t e t h e i r perceived economic and s o c i a l  disparity.  On another l e v e l , the data i s a study of a s h i f t in ideology of a s p e c i f i c group w i t h i n s o c i e t y . As was noted e a r l i e r , Blishen has w r i t t e n of the i d e o l o g i c a l response of doctors i n Canada to s o c i a l change, in p a r t i c u l a r to changes i n the financing of health care.  S i m i l a r l y , t h i s study i s about the  response of nurses in B r i t i s h Columbia, as r e f l e c t e d by the data in t h e i r A s s o c i a t i o n ' s minutes, to changes i n s o c i e t y .  This chapter  examines the i d e o l o g i c a l s h i f t of nurses beginning with a discussion of the r o l e of ideology and continuing with a discussion of the o r i g i n s and evolution of nursing's i d e o l o g i c a l stance. This chapter concludes with some comment on the implications to the health care system of the s h i f t of ideology of nurses. The Role of Ideology The r o l e of ideology i n the study of society has a long h i s t o r y (Geertz 1964, pp.47-52).  Geertz writes that "there are  192 c u r r e n t l y two main approaches to the study of the s o c i a l determinants of ideology: i n t e r e s t theory-and s t r a i n theory (pp.52). Interest theory i s considered to be rooted in the ' c u l t u r a l  idea  systems' of s o c i a l systems. Ideological statements are seen "against the background of a universal struggle f o r advantage, (pp.52).  While s t r a i n theory takes cognizance of s o c i a l systems and  p e r s o n a l i t y systems, s t r a i n theory d i f f e r s from i n t e r e s t theory i n the acceptance of the idea that no s o c i a l structure i s completely successful in coping with c o n f l i c t i n g values.  Thus s t r a i n theory  adopts the notion of the "chronic malintegration of society" (pp.54). Interest theory's concentration on i n d i v i d u a l or group quest for advantage i s considered to be too simple an explanation.  Thus  Geertz quotes Sutton's d e f i n i t i o n of ideology as "a patterned reaction to the patterned s t r a i n s of s o c i a l r o l e " (pp.52). The concept of s t r a i n i s not viewed so much as "an explanation of i d e o l o g i c a l patterns but (as) a generalized label f o r the kinds of factors to look f o r i n working out an explanation" (Sutton quoted by Geertz pp.54).  Geertz has i d e n t i f i e d four main classes of  explanation f o r the use of ideology. These are l ) " t h e c a t h a r t i c explanation" that i s , "the s a f e t y - v a l v e " or scapegoat t h e o r y . . . . 2)"the morale explanation" that i s , "the a b i l i t y of ideology to. sustain i n d i v i d u a l s (or groups) i n the face of chronic s t r a i n . . . 3) the s o l i d a r i t y e x p l a n a t i o n . . . the power of ideology to k n i t a s o c i a l group or c l a s s t o g e t h e r . . . " and 4) the advocacy explanation " i n which the i d e o l o g i s t s state the problems f o r the larger s o c i e t y . . . " (pp.55).  Geertz  193  acknowledges the l i m i t a t i o n s of the concept of ideology and points out that the r o l e of the symbolic o u t l e t i s more e a s 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 o r i g i n s and evolution of nursing's i d e o l o g i c a l stance, i t i s necessary to examine nursing's commitment to the care of the s i c k .  The o r i g i n s of the vocationalism of nursing,  a c a l l i n g which "involved the t o t a l submission and eradication of s e l f " (Williams, 1974) i s found in the p o r t r a i t of nursing heroines and practitioners. In the eyes of nursing h i s t o r i a n s , Fabiola , an early C h r i s t i a n saint, characterized the work of nursing s i s t e r s of both Roman Catholic and Protestant orders through whom nursing i s said to have survived.(Goodnow, 1916)  Florence Nightingale represented the  19th century expression of t h i s c a l l i n g . Williams (1974) writes of the i d e o l o g i c a l r e s o l u t i o n of the ' c a l l i n g ' t o nursing and the r e a l i t y of the s o c i a l status and economic p o s i t i o n of women of the 19th and 20th c e n t u r y , i n r e l a t i o n ship to the care of the helpless a d u l t .  The status of nurses was low,  they had no legal r i g h t to wealth or property, except through men's dispensation, and male control was further sustained through the value of 'obedience'.  "The r e l a t i o n s h i p between doctors and nurses  r e f l e c t e d the same s t r u c t u r a l and moral conditions of male dominance.  194 Then, as now, doctors have a monopoly of the knowledge r e l a t i n g to disease and i t s treatment, and nurses' work i s regarded as being in service to t h i s knowledge...".Obedience became the i d e o l o g i c a l r e s o l u t i o n to the r e a l i t y of s o c i a l status and job s i t u a t i o n of the 19th century nurse.  Embodied i n an ideology of vocational ism, "the s e r v i l e r o l e  of nursing and the submission that i t required of i t s incumbents, was consolidated and adjusted to p s y c h o l o g i c a l l y .  For, being c a l l e d ,  a nurse could see her s e r v i l i t y , not as her r i g h t f u l place and her r i g h t f u l work, but as her t o t a l s a c r i f i c e " .  This i d e o l o g i c a l stance  was consistent with 19th century values, ( r e l i g i o u s , s o c i a l and economic) and with N i g h t i n g a l e ' s e f f o r t to disabuse nursing of i t s image of Sairey Gamp.  The performance of nursing acts f o r the sick  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 e g e and through which she found her s a t i s f a c t i o n and f u l f i l l m e n t .  Defining the care of the sick 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 i g n i t y on both (Williams, 1974). Florence Nightingale adopted t h i s s p i r i t of vocational ism from Kaiserwerth (Goodnow, 1916, pp.49) and promoted i t in England by e s t a b l i s h i n g 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; Kalisch and K a l i s c h , 1978, pp.88-91) i n an e f f o r t to reform lay nursing p r a c t i c e . did not envisage r e g i s t r a t i o n .  The e a r l y nursing leaders  Because of open recruitment and the  spread of schools of nursing of varying q u a l i t y ,  registration  195  represented a means of i n s t i t u t i o n a l i z i n g the reform of nursing. Nightingale did not support r e g i s t r a t i o n (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 early reformers to ignore t h i s , although Abel-Smith (1960, pp.65) suggests t h a t , i n B r i t a i n , h e r views on r e g i s t r a t i o n may have been ignored f o r other reasons.  Strauss  (1966, pp.65-84) describes the adoption of the Nightingale model by nursing leaders i n the United States.  This model f a i l e d because of  the p r o l i f e r a t i o n of schools of poor q u a l i t y .  Subsequently an  educational ideology (Strauss, 1966, pp.72) of reform through u n i v e r s i t y education was adopted.  I t was the i n t e n t i o n of those programs to change  nursing by providing better q u a l i f i e d teachers who would teach nursing students b e t t e r , and who would work towards decreasing students working hours and improving standards of care. Nursing leaders i n Canada and the United States have been c l o s e l y associated since the f i r s t attempts to organize professional nursing associations in North America.  The Nurses'Associated Alumnae  Association of the United States and Canada was founded i n 1896.  The  objects of the Association were to " e s t a b l i s h and maintain a code of e t h i c s , to elevate the standard of nursing education, to promote the usefulness and honor, the f i n a n c i a l and other i n t e r e s t s of the nursing p r o f e s s i o n " . This Association l a t e r became the American Nurses' Association while the Canadian branch u l t i m a t e l y became the Canadian Nurses' Association i n 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 p a r t i c i p a t e d i n t h i s  process, i n i t i a t i n g the opening of the f i r s t Canadian u n i v e r s i t y school of nursing i n 1920. The out come of t h i s a c t i v i t y was to r e i n f o r c e the idea of nursing as a profession i n the minds of nurses and the public (Strauss, 1966, pp.71-72). Columbia.  This too was accomplished in B r i t i s h  During the l e g i s l a t i v e debates on r e g i s t r a t i o n , nursing  was referred to as "an honourable and useful profession" (The nursing p r o f e s s i o n , 1916).  Strauss points out that during t h i s period  a concept of a ' p r o f e s s i o n ' had hardly been developed in North America.  Flexner's report on medical education had enunciated the  c h a r a c t e r i s t i c s 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 r e l a t i o n s h i p  between nurses and doctors, nurses looked up to physicians, and leaders such as Isabell Hampton-Robb r e - i n f o r c e d t h i s : "Medicine has made us a profession: now we must l i v e up to i t " . c i t e d by Strauss, 1966, pp.72).  (Robb. 1907),  From the points of view of s o c i o l o g i s t s ,  i t was considered t h a t , by 1933, nursing in England was becoming p r o f e s s i o n a l i z e d (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 y p i f i e s t h i s p o s i t i o n .  197 Professionalism, as an ideology was adopted by nurses and became a source of c o n f l i c t with the ideology of vocational ism.  The  value system of medicine and nursing s h i f t e d to a respect f o r the expert use of hospital based technology.  The task of nursing s h i f t e d  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 ' s a n c t i f i e d and consecrated', to actions and judgements which were based on...mainly c l i n i c a l d e f i n i t i o n s of i l l n e s s and h e l p l e s s n e s s . . . . 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 a c q u i s i t i o n of s k i l l s has to be paid f o r , the task to which they r e l a t e cannot then be regarded by s o c i e t y , doctors or nurses as menial. Since they are not seen as menial then they do not require a s a c r i f i c e of s e l f , but seen as s k i l l e d they r e q u i r e , r a t h e r , an assertion of s e l f i n c r e a t i v e and innovative action. These newer a t t r i b u t e s of nursing are embodied i n the ideology of Profession. When analysed i n a s p e c i f i c context of usage i t i s seen as a claim f o r e q u a l i t y between nurses and doctors, and here the r e l a t i o n between men and women of the c u l t u r e i s again r e f l e c t e d . It asserts that nursing i s a p r o f e s s i o n , and that as such ' i t i s not a n c 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 r a d i t i o n a l r e l a t i o n s h i p between doctors and nurses, and we have been that t h i s r e l a t i o n s h i p i s one dimension of the image of the bedside n u r s e . . . ' P r o f e s s i o n a l ' imagery attends the bedside nurse performing tasks that are highly s k i l l e d . This i s i n contrast to the t r a d i t i o n a l bedside nurse whose work we have seen centred importantly on helplessness and was performed through notions of humanitarian service and newly constituted routines that preserved the person and adult-hood of the s i c k . Where a ' p r o f e s s i o n a l ' nurse's work focuses on c l i n i c a l procedures and observations, then helplessness as a condition of an adult human being may become categorised, and even lose i t s e l f as a human c o n d i t i o n , 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. (Williams, 1974).  198 As Williams s t a t e s , the r i s e of a professional resulted in a claim by nurses to control t h e i r own work.  ideology But before  t h i s claim was made, a comparison of the economic reward of the work of nurses to reward f o r the work of other workers was made by nurses. Canadian nurses were voicing a sense of economic d i s p a r i t y 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 i n working c o n d i t i o n s , and a succession of advocates challenged the system.  Thus Weir can be i d e n t i f i e d as an external  advocate who made a very c l e a r statement of the problems of nursing. The promise of health insurance sustained nurses f o r a period of time but not i n d e f i n i t e l y . as did Mrs. Eaton.  The CCF played an advocacy r o l e i n the l a t e 1930 s 1  Internal advocates include the nurses who struck  at Comox i n 1939 and A l i c e Wright.  While A l i c e Wright was hired by the  A s s o c i a t i o n because of her expertise i n nursing education, with the expectation  of acting as an educational consultant and managing the  A s s o c i a t i o n , she was confronted with ' r e s t l e s s n e s s amongst the n u r s e s ' . A l i c e Wright's successors i n c o l l e c t i v e bargaining, Evelyn Hood and Nora Patton played roles t h a t , although new, had been l e g i t i m i z e d by the RNABC and CNA membership.  A l i c e Wright would then, i n Watkins'  (1975) terms, have played a c r i t i c a l l e g i t i m i z i n g r o l e by v i r t u e of her p o s i t i o n in the s o c i a l structure of nursing i n B r i t i s h Columbia.  199  Underlying the ideologies of vocational ism, professionalism and reform through r e g i s t r a t i o n and improved education i s a commitment to the care of the s i c k .  The most c l e a r l y stated example of t h i s  commitment in t h i s study i s found in the interviews with p r a c t i c i n g nurses quoted by the Eaton Report.  The nurses are quoted a s " b e l i e v i n g  that the very f a c t that they can be depended upon to render service without protest and without d r a s t i c action has kept them working hours of such length that t h e i r health suffers and  normal e s s e n t i a l  a c t i v i t i e s are denied to them" (Eaton 1938, pp.12-13).  social  The commitment  to t h i s ideology, by both the leaders and the grassroots nurses insured the performance of roles "that otherwise might have  been  abandoned i n  despair or apathy" (Geertz, 1964, pp.55) Geertz has c a l l e d t h i s the 'morale explanation' of ideology, that i s 'the a b i l i t y of ideology to sustain i n d i v i d u a l s or groups in the face of chronic s t r a i n " (Geertz, 1964, pp.55).  The commitment to the care of the s i c k 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 s o c i a l group or c l a s s together.  But as the  n a r r a t i v e has shown, the i d e o l o g i c a l commitment of nurses, while never g i v i n g up a commitment to patient care, s h i f t e d i n expression. This i s the advocacy explanation of ideology (pp.55).  The chronic s t r a i n of nurses. The chronic s t r a i n of nurses has three r e a d i l y  identifiable  sources, 1) the nature of the work i t s e l f , 2) the terms and conditions under which the work i s undertaken, and 3) the r e l a t i o n s h i p of the  200  work and!'i; ts rewards to the work and rewards of others. ;  Thus f a r , in t h i s  study l i t t l e a t t e n t i o n 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 i n the care of the sick and the p r o l i f e r a t i o n 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 t h e i r own d i r t y work.  In a d d i t i o n to Hughes' concept of  d i r t y work, there i s the d i r t y work that a r i s e s out of the care of patients that i s not delegated.  Williams (1974) has defined bedside  nursing as "a complex compound of actions and  tasks performed i n . a  context of s o c i a l r e l a t i o n s , the evaluation of these tasks . . . e n t a i l s an evaluation of persons ( s p e c i f i c a l l y . . . doctors, nurses and s i c k people)  and t h e i r status r e l a t i v e to one another".  Henderson has  defined the function of the nurse as " a s s i s t ( i n g ) the i n d i v i d u a l or w e l l , i n the performance  sick  of those a c t i v i t i e s c o n t r i b u t i n g 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. i n such a way as to help him (Henderson, 1964, pp.63).  And to do t h i s  gain independence as r a p i d l y as p o s s i b l e "  Thus f a r two types of d i r t y work have been  i d e n t i f i e d , 1) those tasks delegated by medicine to nursing, and 2) those tasks r e l a t e d to the intimate care of p a t i e n t s .  But there i s a t h i r d  type of d i r t y work not usually acknowledged beyond a l l u s i o n s to bedpans.  201 Esther Paulson describes how she, as the only nurse on a tuberculosis ward at the Royal Columbian Hospital i n 1929 had to clean a l l the l i n e n of blood and excreta before i t went to the laundry i n order to protect the laundry s t a f f from possible i n f e c t i o n .  !:  Helen Shore describes a s i m i l a r a c t i v i t y as a student at VGH i n the 1940's.  While nurses are no longer required to prepare l i n e n f o r the  laundry, and h o s p i t a l s are s t a f f e d with personnel assigned to clean the hospital premises nurses do continue to p a r t i c i p a t e i n modern versions of t h i s type of work.  But more importantly,  technological  advances have resulted in the p o s s i b i l i t y of salvaging patients devastated by trauma or s u r g i c a l procedure, thus i n t e n s i f y i n g the nature of the intimate care of p a t i e n t s .  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 distasteful.  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 t h i r d i s often forgotten or ignored and thus i t i s important to r e c a l l them to e s t a b l i s h 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 i g n i t y and s a n c t i t y of both the patient and the nurse i s i n t e n s i f i e d . The f a c t that nurses continue to care f o r  the sick  illustrates  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 s o c i a l group o r . c l a s s together.  Greenwood (1966)  has i d e n t i f i e d the existenceof a professional c u l t u r e as a c h a r a c t e r i s t i c of professional groups.  Watkins (1976, pp.111-113)  202 takes t h i s notion, and discusses i t in terms of "something that may be meaningful and s i g n i f i c a n t because c e r t a i n i n d i v i d u a l s or groups have come to adopt i t " .  He notes also that "the extent of t h e i r adoption  of the ' i d e a l ' , the degree to which t h i s i n p r a c t i c e e f f e c t s  their  behaviour, what they regard as circumstances which r e l i e v e them of various of the self-imposed o b l i g a t i o n s , are a l l matters of empirical f a c t and have to be discovered by i n v e s t i g a t i o n .  I t i s also useful  to recognize the existence of c e r t a i n ' p o s i t i o n s ' in the s o c i a l  structure  where persons may be located i n an important ' c o n t r o l l i n g ' way.  In  the case of the nurses in B r i t i s h Columbia, the o b l i g a t i o n s which developed out of the vocational ism of 19th century nursing and which were seen as the normative r e l a t i o n s h i p between nurses and society changed over time.  The change occurred because of changes i n the  technology of health care, changes i n the p r a c t i c e of nursing and because of changes i n the values and norms of s o c i e t y .  These changes  created a discrepancy which could not longer be accommodated. Advocates, w i t h i n and external to nursing, attempted to accommodate the c o n f l i c t i n g forces of the old ideologies and the  new pressures.  Geertz defines  the advocacy explanation "of ideologies (and i d e o l o g i s t s ) as a r t i c u l a t i n g , however p a r t i a l l y and i n d i s t i n c t l y , the s t r a i n s that impel them, thus f o r c i n g them into the p u b l i c n o t i c e .  Ideologists  state the problems f o r the l a r g e r s o c i e t y , take sides on the issues involved and 'present them i n the court' of the i d e o l o g i c a l . market place" (White, c i t e d by Geertz).  Although i d e o l o g i c a l advocates  (not altogether unlike t h e 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 l e a s t c a l l a t t e n t i o n to t h e i r existence and, by p o l a r i z i n g issues, make continued neglect more d i f f i c u l t "  (pp.55).  Conclusion: Omens f o r the Future The move towards acceptance of c o l l e c t i v e bargaining by nurses was influenced by the s h i f t from an ideology of vocationalism to professionalism.  The f a i l u r e of these  ideologies to r e l i e v e the  chronic s t r a i n of nurses, exacerbated by the recognition of the discrepancy i n economic value between the nurse and subsidary health workers and others in s o c i e t y , resulted i n the adoption of c o l l e c t i v e bargaining.  A f a c t o r in the development of m i l i t a n c y was that h o s p i t a l s  had ceased to be c h a r i t a b l e i n s t i t u t i o n s .  While P r o v i n c i a l funding of  h o s p i t a l s ( i n 1948) did not r e l i e v e h o s p i t a l s of economic pressures, nurses no longer had to view themselves as part of a c h a r i t a b l e system. The demand f o r increased wages by nurses was restrained between 1948-56 but the r e j e c t i o n of the c o n c i l i a t i o n report by the hospitals in 1957 p r e c i p i t a t e d a new m i l i t a n c y .  In 1959 a s t r i k e vote was taken to  support increased wage settlements.  The support of these actions by  the Association represented an escalated level of m i l i t a n c y . While nurses i n B r i t i s h Columbia have been i n the f o r e f r o n t of c o l l e c t i v e bargaining by Canadian nurses, there has been increased use of c o l l e c t i v e bargaining by employed professionals generally (Goldenberg, 1975) and t h i s has, no doubt, been an important  204 l e g i t i m i z i n g f a c t o r f o r nurses.  Only i n 1976 was s t r i k e action  taken by nurses i n B r i t i s h Columbia, (since the 1939 s t r i k e of the nurses of S t . Joseph's H o s p i t a l , Comox)  In other provinces, both  nurses and doctors, had established precedents, (St. J u s t i n e ' s nurses s t r i k e , 1963; doctors' s t r i k e s in Saskatchewan, 1962, and i n Quebec, 1967 and 1970).  These s t r i k e s have been c a l l e d to "protect  the public i n t e r e s t " (Goldenberg, 1975, pp.286-288).  Hall's  p r e d i c t i o n of c o n f l i c t because of a "gross i n e q u a l i t y in d i s t r i b u t i o n of b e n e f i t s " ( H a l l , 1967, pp.5) had m a t e r i a l i z e d .  However,  negotiations on behavioural issues ( E t z i o n i , 1968) have proved more d i f f i c u l t to solve f o r a l l professional groups (Goldenberg, 1975, pp.288). The entry of the Association into c o l l e c t i v e bargaining has a l l e v i a t e d but not r e l i e v e d nurses of t h e i r sense of economic disparity.  Twenty years a f t e r nurses entered c o l l e c t i v e  bargaining  i n B r i t i s h Columbia, Noel H a l l , addressing the 50th Annual Conference of the BCHA i n 1967, spoke of the vlaue system of society which endorsed  these d i s p a r i t i e s by v i r t u e of the wage s t r u c t u r e . He  p r e d i c t e d , with p a r t i c u l a r reference to nursing, that c o n f l i c t would r e s u l t from a s i t u a t i o n i n which education, t r a i n i n g and s k i l l were valued but not rewarded. The c o n f l i c t has been defined only in economic terms u n t i l recently.  The dispute at VGH i n which several nursing administrators  were summarily f i r e d because of t h e i r attempts to deal with the lack  yu.1 un-  205 of grassroots  nursing p a r t i c i p a t i o n i n the decisions that e f f e c t nurses  work (Bellyache at VGH, September 2, 1978) represents an extension of the c o n f l i c t i n which education, t r a i n i n g and s k i l l are valued but not rewarded.  Indeed, i n W i l l i a m s ' terms, "the a s s e r t i o n of s e l f i n  c r e a t i v e and innovative a c t i o n " so valued in the professional nurse i s thwarted. Negotiaton on the issue of the p a r t i c i p a t i o n of nurses i n the decisions that a f f e c t t h e i r work, that i s , the terms and conditions under which employment f o r the p r a c t i c e of nursing i s undertaken, i s l i k e l y to be the next phase i n the attempts by nurses to r e l i e v e t h e i r chronic s t r a i n .  Because the underlying commitment to patient care seems  to c o - e x i s t with W i l l i a m s ' concept of nurses' professional  ideology,  nurses w i l l attempt to regain the d i g n i t y and s a n c t i t y of t h e i r work by bargaining on normative issues. t h i s i n d e f i n i t e l y (Krauss, 1977).  Improved s a l a r i e s cannot f o r e s t a l l This w i l l challenge the present  s t r u c t u r e and organization of health at a l l l e v e l s of the d e l i v e r y system.  Since there are strong vested i n t e r e s t s i n the status quo  the challenge w i l l be  met with a c t i v e r e s i s t a n c e .  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