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Provincial public health nursing in British Columbia from 1939-1959 : a social history Whyte, Nora Beatrice 1988

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PROVINCIAL PUBLIC HEALTH NURSING IN BRITISH COLUMBIA FROM 1939-1959: A SOCIAL HISTORY By NORA BEATRICE WHYTE B.S.N., The U n i v e r s i t y o f B r i t i s h Columbia, 1973 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n THE FACULTY OF GRADUATE STUDIES (School of Nursing) We accept t h i s t h e s i s as conforming t o the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA October, 1988 © Nora B e a t r i c e Whyte, 1988 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of /v^/ The University of British Columbia Vancouver, Canada Date ^ k - ^ z ^ L ^ DE-6 (2/88) ABSTRACT T h i s s t u d y was d e s i g n e d t o examine the s t a t u s o f p u b l i c h e a l t h n u r s i n g i n B r i t i s h C o l u m b i a ' s P r o v i n c i a l H e a l t h S e r v i c e d u r i n g the p e r i o d from 1939 t o 1959. Based on the s o c i a l h i s t o r y a p p r o a c h , the f o c u s o f the s tudy was p u b l i c h e a l t h n u r s i n g and i n f l u e n c e s on i t s e v o l u t i o n d u r i n g the s e l e c t e d p e r i o d . The h i s t o r i c a l method was used t o c o l l e c t and a n a l y z e d a t a from v a r i o u s p r i m a r y and secondary s o u r c e s ; t h e s e i n c l u d e d annua l r e p o r t s o f p r o v i n c i a l h e a l t h u n i t s , annua l r e p o r t s o f the D i v i s i o n o f P u b l i c H e a l t h N u r s i n g , j o u r n a l a r t i c l e s , and o r a l h i s t o r i e s . Data were s u b j e c t e d t o c o n t e n t a n a l y s i s t o r e v e a l themes r e l e v a n t t o the t o p i c . S e v e r a l impor tan t f a c t o r s were i d e n t i f i e d t h a t had a f f e c t e d the development o f p u b l i c h e a l t h n u r s i n g d u r i n g the s e l e c t e d p e r i o d . Data were c a t e g o r i z e d a c c o r d i n g t o the v a r i o u s i n f l u e n c e s and r e s e a r c h n o t e s were w r i t t e n as a b a s i s f o r the h i s t o r i c a l a c c o u n t . The p r e s e n t a t i o n o f f i n d i n g s i n c l u d e d d e s c r i p t i o n s o f the o r g a n i z a t i o n o f p u b l i c h e a l t h s e r v i c e s i n the p r o v i n c e and the r o l e o f the p u b l i c h e a l t h n u r s e . T h i s was f o l l o w e d by a d i s c u s s i o n o f the f o r c e s and t h e i r impact on p u b l i c h e a l t h n u r s i n g . The s t u d y ' s c o n c l u s i o n s were drawn from the a n a l y s i s o f the h i s t o r i c a l d a t a w i t h i n the s o c i a l c o n t e x t o f the t i m e . D u r i n g the 1939 t o 1959 p e r i o d , some o f the major i i i i n f l u e n c e s on p r o v i n c i a l p u b l i c h e a l t h nursing were b a s i c education f o r p u b l i c h e a l t h nurses, s t a f f development on the job, the demand f o r s e r v i c e s , and the supply of q u a l i f i e d personnel. Other f a c t o r s were the s o c i a l and p o l i t i c a l f o r c e s of the time, the h e a l t h care system, and the r o l e of vo l u n t a r y agencies i n p u b l i c h e a l t h care. Although p u b l i c h e a l t h nursing faced a number of problems, these were overcome t o a l a r g e extent through c r e a t i v e s t r a t e g i e s t h a t promoted c o l l e g i a l i t y among s t a f f and enhanced job s a t i s f a c t i o n . P u b l i c h e a l t h nurses had a strong sense of i d e n t i t y and were respected because t h e i r work c o n t r i b u t e d t o improving the h e a l t h of the communities they served. i v TABLE OF CONTENTS ABSTRACT i i TABLE OF CONTENTS i v LIST OF FIGURES v i ACKNOWLEDGEMENTS v i i CHAPTER ONE: INTRODUCTION 1 Background t o the Problem. . 1 Problem Statement 6 D e f i n i t i o n s 7 Study O b j e c t i v e s 7 L i m i t a t i o n s 8 O r g a n i z a t i o n of T h e s i s 9 CHAPTER TWO: METHODOLOGY 10 Sources 10 H i s t o r i c a l C r i t i c i s m 13 A n a l y s i s and S y n t h e s i s 15 E t h i c a l C o n s i d e r a t i o n s 17 Summary 17 CHAPTER THREE: PUBLIC HEALTH NURSING AND INFLUENCES ON ITS DEVELOPMENT 18 O r g a n i z a t i o n o f P u b l i c H e a l t h S e r v i c e s 18 P r o v i n c i a l H e a l t h S t r u c t u r e 18 H e a l t h U n i t Development 23 P u b l i c H e a l t h Nursing P r a c t i c e 25 B a s i c Programs 25 V School Nursing... 27 Communicable Disease C o n t r o l 31 M a t e r n a l - I n f a n t Care 35 V i s i t i n g N ursing 36 Program Development i n the 1950s 37 P r e n a t a l Programs 39 Mental H e a l t h 40 C i v i l Defence.... 41 The P u b l i c H e a l t h Nurse's Role 42 I n f l u e n c e s on P u b l i c H e a l t h Nursing 43 S o c i a l I n f l u e n c e s 45 Ed u c a t i o n 54 S t a f f Development 72 Supply and Demand i n P u b l i c H e a l t h Nursing 81 I n f l u e n c e of Other Agencies 95 Summary 99 CHAPTER FOUR: SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS FOR FURTHER STUDY 102 Summary 102 Co n c l u s i o n s 103 Recommendations f o r F u r t h e r Study 108 REFERENCES 112 BIBLIOGRAPHY 122 v i LIST OF FIGURES Figure 1 B r i t i s h Columbia Health Units 2 6 2 Public Health Nurses i n Uniform 28 3 Norma Tucker, PHN, en Route to a C l i n i c . . . . 44 4 Graduation Day at the University of B r i t i s h Columbia 57 5 Students i n the Reading Room, University of B r i t i s h Columbia School of Nursing 58 6 F i n a l Year Students Having a Lecture i n Public Health Nursing 60 7 Pr o v i n c i a l PHNs Attending the F i r s t Supervisory Course... 76 8 Public Health Staff 80 9 Norma Tucker, PHN, i n Front of the Port Alberni O f f i c e 101 v i i ACKNOWLEDGEMENTS I w i s h t o acknowledge the p e o p l e who p r o v i d e d s u p p o r t and a s s i s t a n c e d u r i n g t h i s t h e s i s p r o j e c t . I o f f e r my s i n c e r e thanks t o the members o f my t h e s i s commit tee , S h e i l a S t a n t o n (Chairman) and Dr . M a r i l y n Wi l lman f o r t h e i r g u i d a n c e th rough a l l phases o f the s t u d y . T h e i r p r a c t i c a l a d v i c e and t h e i r en thus iasm f o r h i s t o r y made the e x p e r i e n c e e n j o y a b l e . D u r i n g the i n i t i a l s t a g e s o f the s tudy s e v e r a l i n d i v i d u a l s p r o v i d e d u s e f u l i n f o r m a t i o n and took the t ime t o share t h e i r e x p e r t i s e . I ex tend my thanks t o I rene G o l d s t o n e , Mary N i c o l , and Kathryn McPherson f o r t h e i r c o n t r i b u t i o n s i n t h i s r e g a r d . I am g r a t e f u l , a l s o , t o Nan Kennedy and Norma C l a r k f o r t h e i r g e n e r o s i t y i n a l l o w i n g me t o use t h e i r p h o t o g r a g h s . F i n a l l y , I w ish t o thank my f a m i l y f o r the r o l e they p l a y e d i n t h i s t h e s i s . To my r e l a t i v e s and f r i e n d s f o r t h e i r c o n s t a n t encouragement and e x p r e s s i o n s o f i n t e r e s t , I ex tend my t h a n k s . My c h i l d r e n , Ruth and Jeremy, d e s e r v e c r e d i t f o r t h e i r u n d e r s t a n d i n g . I am g r a t e f u l t o my husband , Andy, not o n l y f o r h i s s u p p o r t and p a t i e n c e t h r o u g h o u t my M a s t e r ' s program, but f o r h i s f a i t h i n me. 1 CHAPTER ONE Background t o the Problem Community h e a l t h n u r s i n g i n Canada today has i t s r o o t s i n the p u b l i c h e a l t h movement t h a t began e a r l y i n t h i s c e ntury (Allemang,1985). T h i s l i n k with the p a s t i s o f t e n overlooked i n c u r r e n t d i s c u s s i o n s about the problems a s s o c i a t e d w i t h the changing r o l e of the community h e a l t h nurse i n a complex s o c i e t y . There i s a need f o r a c r i t i c a l examination of the f o r c e s t h a t have shaped t h i s branch of the n u r s i n g p r o f e s s i o n i n v a r i o u s r e g i o n s of the country. The focus o f t h i s study i s the h i s t o r y of p r o v i n c i a l p u b l i c h e a l t h n u r s i n g i n B r i t i s h Columbia d u r i n g the p e r i o d from 1939 t o 1959. Contemporary w r i t i n g s about community h e a l t h n u r s i n g , as i t i s now known i n Canada, p r e s e n t a common theme of a s p e c i a l t y area i n a s t a t e o f c r i s i s (Chavigny & Kroske, 1983; Dreher, 1982; Gebbie, 1986). Problems c i t e d are the l a c k o f a c l e a r l y d e f i n e d r o l e ; fragmentation and c o n f u s i o n about s e r v i c e p r i o r i t i e s ; an u n w i l l i n g n e s s t o take a p r o a c t i v e stance on b e h a l f of c l i e n t groups; and the c o n t i n u i n g focus on the i n d i v i d u a l and f a m i l y r a t h e r than on the community as a whole. Although such a r t i c l e s a re p r o v o c a t i v e , the authors r a r e l y look t o the p a s t f o r e x p l a n a t i o n s t h a t c o u l d i l l u m i n a t e the prese n t . Knowledge of the p a s t i s u s e f u l f o r broadening our p e r s p e c t i v e s on 2 c u r r e n t m a t t e r s o f c o n c e r n t o the p r o f e s s i o n . H i s t o r i c a l r e s e a r c h i n n u r s i n g i s a f i e l d o f i n q u i r y t h a t has r e c e i v e d l i t t l e a t t e n t i o n u n t i l r e c e n t l y ( N o t t e r , 1972; Pa lmer , 1986) . Over twenty y e a r s ago, Newton (1965) wrote o f the need f o r r e s e a r c h i n t o the p r o f e s s i o n ' s p a s t ; she made a c a s e f o r the impor tance o f the s tudy and r e c o r d i n g o f n u r s i n g h i s t o r y . H i s t o r i o g r a p h y i s more than a s i m p l e l i s t i n g o f d a t e s , f a c t s , and s i g n i f i c a n t e v e n t s . A c c o r d i n g t o Newton, r e s e a r c h e r s must l o o k beyond the f a c t s o f the p a s t ; they need t o s e a r c h f o r r e l a t i o n s h i p s among e v e n t s , r e c u r r i n g p a t t e r n s , and i n f l u e n c i n g f o r c e s . What i s impor tan t i s the meaning o f c e r t a i n events w i t h i n the s o c i a l c o n t e x t o f the t i m e . N u r s e s ' p e r s p e c t i v e s on the p r e s e n t and v i s i o n s f o r the f u t u r e a re c o n s t r a i n e d by an i n c o m p l e t e u n d e r s t a n d i n g o f the f a c t o r s t h a t have i n f l u e n c e d the p r o f e s s i o n o v e r t i m e . A change i s o c c u r r i n g i n the way i n which n u r s i n g h i s t o r y i s b e i n g s t u d i e d by a new g e n e r a t i o n o f s c h o l a r s w i t h i n c r e a s i n g e v i d e n c e o f a s h i f t away from the t r a d i t i o n a l approach t o one t h a t embraces the p r i n c i p l e s o f s o c i a l h i s t o r y (James, 1982; Lagemann, 1983) . T r a d i t i o n a l a c c o u n t s o f n u r s i n g h i s t o r y a r e c h a r a c t e r i z e d by an emphasis on t h e " p r o g r e s s " o f n u r s i n g th rough t ime and a l a c k o f a t t e n t i o n t o some o f the c o n t r o v e r s i e s and problems o f the p a s t . C r i t i c s o f t h i s approach ( D a v i e s , 1 9 8 0 ; M e l o s h , 1982; R o s e n b e r g , 1987) d e c r y i t s c o n g r a t u l a t o r y tone and 3 p r e o c c u p a t i o n w i t h n u r s i n g l e a d e r s . Many o f t h e s e h i s t o r i c a l a c c o u n t s c o v e r l a r g e p e r i o d s o f t ime but o f f e r l i t t l e i n t e r p r e t a t i o n o f the p a s t . A l t h o u g h i t i s acknowledged t h a t c h r o n i c l e s o f key f i g u r e s and landmark even ts have m e r i t f o r the p r o f e s s i o n , h i s t o r i c a l s tudy has the p o t e n t i a l t o r e v e a l o t h e r r e a l i t i e s i n n u r s i n g ' s p a s t . The a p p l i c a t i o n o f the s o c i a l h i s t o r y methodology g i v e s r i s e t o c r i t i c a l a n a l y s e s o f s p e c i f i c a s p e c t s o f n u r s i n g w i t h i n r e l a t i v e l y s h o r t t ime p e r i o d s . An example o f t h i s i s found i n the work o f Me losh (1982) who p l a c e s n u r s i n g w i t h i n the c o n t e x t s o f women's h i s t o r y and l a b o u r h i s t o r y . Her emphasis i s on the t r a i n i n g and work c u l t u r e o f o r d i n a r y nurses r a t h e r than on the e l i t e . A growing i n t e r e s t i n the human e x p e r i e n c e o f o r d i n a r y p e o p l e , p r e v i o u s l y i n v i s i b l e i n h i s t o r i c a l a c c o u n t s , i s emerging i n the f i e l d o f s o c i a l h i s t o r y (Rosenberg, 1987) . P u b l i c h e a l t h n u r s i n g has a r i c h and v a r i e d h i s t o r y around the w o r l d y e t p u b l i s h e d a c c o u n t s o f the d a y - t o - d a y e x p e r i e n c e s o f p u b l i c h e a l t h n u r s e s a r e l a c k i n g . There i s e v i d e n c e t h a t t h i s , t o o , i s chang ing as s o c i a l h i s t o r i a n s and n u r s e s a r e becoming i n t e r e s t e d i n the h i s t o r y o f t h i s un ique b r a n c h o f n u r s i n g . H e i n r i c h (1983) found t h a t Amer ican p u b l i c h e a l t h n u r s e s o f the n i n e t e e n t h c e n t u r y were i n v o l v e d i n p r o v i d i n g s e r v i c e s t o immigran ts , f a c t o r y workers and poor f a m i l i e s ; t h i s compe l l ed them t o advocate f o r s o c i a l r e f o r m . G r a d u a l l y , n u r s e s work ing i n p u b l i c 4 h e a l t h n u r s i n g a g e n c i e s s h i f t e d t h e i r emphasis t o h e a l t h t e a c h i n g and p r e v e n t i v e measures and spent l e s s t ime on b e d s i d e n u r s i n g c a r e o f the s i c k . H e i n r i c h s u g g e s t s t h a t problems a r o s e from the e a r l y t w e n t i e t h c e n t u r y t r e n d towards s p e c i a l i z a t i o n w i t h i n p u b l i c h e a l t h n u r s i n g as s c h o o l , home, and m a t e r n a l - i n f a n t n u r s i n g became s e p a r a t e s e r v i c e s . The r e s u l t i n g f r a g m e n t a t i o n o f s e r v i c e d e l i v e r y l e d t o a s t a t e o f d i v i s i v e n e s s i n what c o u l d have been a s t r o n g , c o h e s i v e o c c u p a t i o n a l g r o u p . B u h l e r - W i l k e r s o n ' s (1983) assessment o f e a r l y t w e n t i e t h c e n t u r y p u b l i c h e a l t h n u r s i n g i n the U n i t e d S t a t e s i s congruent w i t h the s i t u a t i o n d e s c r i b e d by H e i n r i c h . A t the t u r n o f the c e n t u r y , i t was a p r o m i s i n g movement t h a t was expanding t o meet h e a l t h needs o f the t i m e . By the l a t e 1920s, however, i t was i n d e c l i n e w i t h the work o f the p u b l i c h e a l t h n u r s e b e i n g " r e l e g a t e d t o an i n c r e a s i n g l y m a r g i n a l r o l e i n the h e a l t h c a r e system" ( B u h l e r - W i l k e r s o n , 1983, p . 9 0 ) . A s i m i l a r s i t u a t i o n i s d e s c r i b e d r e g a r d i n g the d e c l i n i n g prominence o f the work o f the h e a l t h v i s i t o r ( p u b l i c h e a l t h nurse) i n B r i t a i n d u r i n g the f i r s t h a l f o f t h i s c e n t u r y ( L l o y d , 1986; Robson, 1986) . H e a l t h v i s i t i n g ' s f o c u s on the poor and on women and c h i l d r e n c o n t r i b u t e d t o i t b e i n g v iewed as a low s t a t u s a c t i v i t y i n B r i t i s h s o c i e t y . In Canada t h e r e has been a l a c k o f c r i t i c a l i n q u i r y i n t o the h i s t o r y o f p u b l i c h e a l t h n u r s i n g i n t h i s c o u n t r y . 5 A s t u d y o f the emergence o f p u b l i c h e a l t h n u r s i n g i n e a r l y t w e n t i e t h - c e n t u r y H a l i f a x i s a r a r e e x c e p t i o n t o the u s u a l c h r o n o l o g i e s (McPherson, 1982) . There a r e , however, s e v e r a l r e f e r e n c e s t h a t p r o v i d e i n f o r m a t i v e a c c o u n t s o f the r o o t s o f Canad ian p u b l i c h e a l t h n u r s i n g (A l lemang, 1985; Emory, 1953; G i b b o n , 1947; Gibbon & Mathewson, 1947) . A h i s t o r y o f the d i s t r i c t n u r s i n g s e r v i c e i n A l b e r t a c o n t a i n s many p e r s o n a l a c c o u n t s o f the e x p e r i e n c e s o f r u r a l p u b l i c h e a l t h n u r s e s o v e r a f i f t y y e a r p e r i o d (Stewar t , 1979) . An h i s t o r i c a l work t h a t i s s p e c i f i c t o B r i t i s h Columbia i s G r e e n ' s book on p r o v i n c i a l p u b l i c h e a l t h n u r s i n g from the t u r n o f the c e n t u r y u n t i l the 1970s. T h i s s t u d y w i l l c o n t r i b u t e t o the e x p l o r a t i o n o f t h i s t o p i c by f o c u s s i n g on the o f f i c i a l p u b l i c h e a l t h n u r s i n g s e r v i c e a d m i n i s t e r e d by the Department o f H e a l t h o f the B r i t i s h Columbia government. To d e l i m i t the t o p i c , the t ime p e r i o d from 1939 t o 1959 has been s e l e c t e d . T h i s c h o i c e i s d e l i b e r a t e : 1939 marked the b e g i n n i n g o f an e r a i n p u b l i c h e a l t h n u r s i n g i n t h i s p r o v i n c e w i t h the e s t a b l i s h m e n t o f the D i v i s i o n o f P u b l i c H e a l t h N u r s i n g w i t h i n the P r o v i n c i a l Board o f H e a l t h (Green, 1984) . Fur thermore , the h i s t o r i c a l s i g n i f i c a n c e o f the date i s notewor thy: the b e g i n n i n g o f the Second World War had a g r e a t impact on the p e o p l e o f t h i s p r o v i n c e (Ormsby, 1958) . The s o c i e t a l change t h a t o c c u r r e d d u r i n g t h i s p e r i o d and i n the immediate p o s t - w a r e r a had an i n f l u e n c e on p u b l i c h e a l t h n u r s e s and t h e i r 6 p r a c t i c e . By examining developments th rough the decade o f the 1950s, i t w i l l be p o s s i b l e t o a s s e s s the impact o f s o c i a l change on p u b l i c h e a l t h n u r s i n g p r a c t i c e . The 1950s were c h a r a c t e r i z e d by improvements i n the domest ic economy and i n i n t e r n a t i o n a l p o l i t i c s . The f i f t i e s were a l s o a t ime o f p o p u l a t i o n growth due t o i n c r e a s e s i n both the b i r t h r a t e and i m m i g r a t i o n ( T o r r a n c e , 1981) . S c i e n t i f i c advances brought changes i n the c o n t r o l o f communicable d i s e a s e s ; mass immuniza t ion programs a g a i n s t p o l i o m y e l i t i s and improved t rea tment f o r t u b e r c u l o s i s had a major impact d u r i n g t h i s p e r i o d (Green,1984) . T h u s , the decade o f the 1950s was a p e r i o d o f change and e x p a n s i o n f o r p u b l i c h e a l t h n u r s i n g . F o r the purposes o f t h i s s t u d y , 1959 i s chosen as the end p o i n t , mark ing the c l o s e o f the decade . T h i s s tudy o f p u b l i c h e a l t h n u r s i n g , t h e r e f o r e , w i l l be c i r c u m s c r i b e d by a t ime frame o f twenty y e a r s . Problem Statement A c r i t i c a l examina t ion o f a s p e c i f i c b r a n c h o f n u r s i n g d u r i n g a l i m i t e d t ime p e r i o d has the p o t e n t i a l t o r e v e a l new i n s i g h t s on the p a s t . Developments i n p u b l i c h e a l t h n u r s i n g a r e r e l a t e d t o v a r i o u s s o c i a l , p o l i t i c a l , and s c i e n t i f i c f o r c e s . The i n t e n t o f the s tudy i s t o examine the ways i n wh ich p u b l i c h e a l t h n u r s i n g was i n f l u e n c e d by s e l e c t e d e x t e r n a l and i n t e r n a l f o r c e s over a p e r i o d o f two d e c a d e s . T h e r e f o r e , t h e c e n t r a l r e s e a r c h q u e s t i o n i s : What was the 7 s t a t u s o f p r o v i n c i a l p u b l i c h e a l t h n u r s i n g i n B r i t i s h Columbia d u r i n g the 1939 t o 1959 p e r i o d ? Some o f the s p e c i f i c q u e s t i o n s e x p l o r e d i n t h i s s tudy a r e as f o l l o w s : -What was the i n f l u e n c e o f n u r s i n g e d u c a t i o n on p u b l i c h e a l t h n u r s i n g p r a c t i c e ? - I n what ways d i d p o l i t i c a l and s o c i a l f a c t o r s a f f e c t p u b l i c h e a l t h n u r s i n g ? -What was the r e l a t i o n s h i p between the o f f i c i a l p u b l i c h e a l t h n u r s i n g s e r v i c e and o t h e r a g e n c i e s (such as the V i c t o r i a n Order o f Nurses) t h a t p r o v i d e d s i m i l a r s e r v i c e s ? - D i d p u b l i c h e a l t h n u r s e s have any i n f o r m a l o r g a n i z a t i o n s d u r i n g the p e r i o d ? D e f i n i t i o n s P u b l i c h e a l t h n u r s i n g - n u r s i n g s e r v i c e concerned w i t h the p r e v e n t i o n o f community h e a l t h problems th rough home v i s i t i n g t o f a m i l i e s , s c h o o l h e a l t h programs, communicable d i s e a s e c o n t r o l , and h e a l t h e d u c a t i o n o f the p u b l i c . P u b l i c h e a l t h nurse - a r e g i s t e r e d nurse employed by the D i v i s i o n o f P u b l i c H e a l t h N u r s i n g , Department o f H e a l t h , o f the B r i t i s h Columbia government. Study O b j e c t i v e s The o b j e c t i v e s o f the s tudy a r e s e t f o r t h as f o l l o w s : 1. To i d e n t i f y the f a c t o r s t h a t shaped the development 8 of p u b l i c h e a l t h n u r s i n g i n B r i t i s h Columbia d u r i n g the s e l e c t e d p e r i o d . 2. To examine the responses o f p u b l i c h e a l t h nurses t o a time o f s o c i a l change. 3. To communicate the f i n d i n g s t o Canadian nurses i n o r d e r t o i n c r e a s e awareness of one aspect o f nu r s i n g ' s h e r i t a g e . L i m i t a t i o n s The nature o f h i s t o r i c a l r e s e a r c h p r e s e n t s s e v e r a l l i m i t a t i o n s . C h i e f among these are p o t e n t i a l d i f f i c u l t i e s w i t h a v a i l a b i l i t y o f source m a t e r i a l , a u t h e n t i c i t y and accuracy, and g e n e r a l i z a b i l i t y . The d i f f i c u l t y i n making g e n e r a l i z a t i o n s from the f i n d i n g s o f h i s t o r i c a l r e s e a r c h must be r e c o g n i z e d . Although many common threads run through n u r s i n g h i s t o r y , i t i s important t o remember t h a t each e r a has i t s unique s e t of circumstances. Thus, the c o n c l u s i o n s o f t h i s study w i l l not n e c e s s a r i l y apply t o othe r p e r i o d s i n h i s t o r y or t o p u b l i c h e a l t h n u r s i n g i n ot h e r p r o v i n c e s . O r g a n i z a t i o n of T h e s i s The o r g a n i z a t i o n of the remaining s e c t i o n s o f t h i s t h e s i s i s as f o l l o w s : Chapter Two c o n t a i n s an o u t l i n e o f the methodology used i n c a r r y i n g out the study. T h i s i s fo l l o w e d , i n Chapter Three, by the p r e s e n t a t i o n and a n a l y s i s 9 of the f i n d i n g s i n r e l a t i o n t o p u b l i c h e a l t h nursing and the i n f l u e n c e s on i t s e v o l u t i o n during the years from 1939 t o 1959. The conclusions and i m p l i c a t i o n s of the study are presented i n the f o u r t h and f i n a l chapter. 10 CHAPTER TWO METHODOLOGY Given the problem chosen f o r i n v e s t i g a t i o n , t h i s study u t i l i z e d the methodology o f h i s t o r i c a l r e s e a r c h . The h i s t o r i c a l approach has s e v e r a l f e a t u r e s which d i s t i n g u i s h i t from o t h e r forms o f r e s e a r c h : the nature o f data sources, p r i n c i p l e s o f h i s t o r i c a l c r i t i c i s m , and methods of a n a l y s i s and s y n t h e s i s ( C h r i s t y , 1975). These f a c t o r s were taken i n t o account i n the de s i g n t h a t was fol l o w e d , as o u t l i n e d below. Sources H i s t o r i c a l documents are c a t e g o r i z e d as e i t h e r primary or secondary m a t e r i a l s . A primary source i s o r i g i n a l m a t e r i a l based on f i r s t - h a n d i n f o r m a t i o n ( P o l i t & Hungler, 1987), whereas a secondary source i s a t l e a s t "once removed" from the o r i g i n a l experience (Kruman, 1985, p.113). M a t e r i a l based on the o b s e r v a t i o n s o f a person who a c t u a l l y w itnessed o r p a r t i c i p a t e d i n an event i s the most d i r e c t l i n k w i t h the f a c t s . T h e r e f o r e , although secondary sources are u s e f u l i n r e s e a r c h , primary sources are c o n s i d e r e d t o be of g r e a t e r v a l u e because the p o s s i b i l i t y o f d i s t o r t i o n of the t r u t h i s minimized. In t h i s study both primary and secondary sources were used. The i n i t i a l phase o f the data c o l l e c t i o n p rocess 11 i n v o l v e d i d e n t i f i c a t i o n of sources and d e t e r m i n a t i o n of t h e i r l o c a t i o n . Primary sources used i n t h i s study are l i s t e d as f o l l o w s : 1. Annual r e p o r t s of p r o v i n c i a l H e a l t h U n i t s 2. Annual r e p o r t s of the D i v i s i o n of P u b l i c H e a l t h Nursing 3. Minutes of the meetings of the P u b l i c H e a l t h Nursing C o u n c i l (1955, 1956) 4. F i l e s of the Personnel P r a c t i c e s Committee, P u b l i c H e a l t h Nursing C o u n c i l (1952-1959) 5. School of Nursing c o l l e c t i o n , U n i v e r s i t y of B r i t i s h Columbia A r c h i v e s 6. O r a l H i s t o r y c o l l e c t i o n , R e g i s t e r e d Nurses A s s o c i a t i o n of B r i t i s h Columbia In a d d i t i o n , s e v e r a l secondary sources were used t o supplement the f i n d i n g s from primary sources. These i n c l u d e d a r t i c l e s p u b l i s h e d i n i s s u e s of two n a t i o n a l j o u r n a l s , the Canadian Nurse and the Canadian J o u r n a l of  P u b l i c H e a l t h (some primary sources were found i n these j o u r n a l s , a l s o ) . S e v e r a l a r t i c l e s and books on the Canadian h e a l t h c a r e system and the h i s t o r y and p o l i t i c s of B r i t i s h Columbia were c o n s u l t e d . I t was not p o s s i b l e t o l o c a t e two s e t s of m a t e r i a l s t h a t might have added other p e r s p e c t i v e s t o the account. In proposing the study, the r e s e a r c h e r a n t i c i p a t e d having access t o c e r t a i n m a t e r i a l s generated by the D i v i s i o n of P u b l i c H e a l t h Nursing d u r i n g the f o r t i e s and 12 f i f t i e s , namely, the minutes o f the P u b l i c H e a l t h N u r s i n g C o u n c i l and t h e monthly n e w s l e t t e r , " P u b l i c H e a l t h N u r s i n g News and V i e w s . " A p a r t from the y e a r s 1955 and 1956, the C o u n c i l minutes were not s a v e d , nor was i t p o s s i b l e t o l o c a t e any c o p i e s o f the n e w s l e t t e r . T h i s drawback was compensated f o r , i n p a r t , by f i n d i n g s e v e r a l u s e f u l s o u r c e s t h a t were u n a n t i c i p a t e d a t the o u t s e t . A l t h o u g h the C o u n c i l minutes were u n a v a i l a b l e , a number o f o t h e r documents (committee r e p o r t s and cor respondence) p e r t a i n i n g t o the C o u n c i l were l o c a t e d . Other u s e f u l s o u r c e s were the t a p e d i n t e r v i e w s w i t h p u b l i c h e a l t h n u r s e s who had p r a c t i s e d d u r i n g the 1939-1959 p e r i o d , a v a i l a b l e th rough the R e g i s t e r e d Nurses A s s o c i a t i o n o f B r i t i s h Columbia L i b r a r y . In c o l l e c t i n g and o r g a n i z i n g the d a t a , many documents were p h o t o c o p i e d from the o r i g i n a l s o u r c e s and a r r a n g e d c h r o n o l o g i c a l l y i n t h r e e - r i n g b i n d e r s f o r f u t u r e r e f e r e n c e . Four such d a t a s e t s c o n s t i t u t e d the main c o n t e n t f o r the s t u d y . These were (a) annual r e p o r t s o f the D i v i s i o n o f P u b l i c H e a l t h N u r s i n g , (b) annual r e p o r t s from e i g h t p r o v i n c i a l h e a l t h u n i t s , (c) a r t i c l e s from the Canadian N u r s e , (d) a r t i c l e s from the Canadian J o u r n a l o f P u b l i c  H e a l t h . The r e p o r t s o f the D i v i s i o n o f P u b l i c H e a l t h N u r s i n g a r e c o n t a i n e d w i t h i n the r e p o r t s o f the P r o v i n c i a l H e a l t h Department and a re a v a i l a b l e f o r a l l the y e a r s o f i n t e r e s t t o t h i s s t u d y . They p r o v i d e c o n s i d e r a b l e i n f o r m a t i o n on 13 programs, s t a f f i n g , c o n t i n u i n g education, and o r g a n i z a t i o n a l changes. Documents t h a t supply r i c h data on p u b l i c h e a l t h n u r s i n g p r a c t i c e are the annual r e p o r t s from the l o c a l h e a l t h u n i t s . These r e p o r t s c o n t a i n d e t a i l about n u r s i n g a c t i v i t i e s and p r o v i d e p r o f i l e s of the communities they served. Many of the p r o v i n c i a l u n i t s were not e s t a b l i s h e d u n t i l the 1950s; t h e r e f o r e , these r e p o r t s are o n l y a v a i l a b l e f o r c e r t a i n y ears w i t h i n the p e r i o d under study. When combined, the r e p o r t s p r o v i d e s u b s t a n t i a l data on p u b l i c h e a l t h n u r s i n g f o r the years from the l a t e f o r t i e s through t o the end o f the f i f t i e s . The s e l e c t i o n of r e l e v a n t m a t e r i a l s i n the j o u r n a l s i n v o l v e d g o ing through each volume f o r the twenty year p e r i o d . I t was necessary, a l s o , t o review the j o u r n a l volumes f o r one t o two years p r e c e d i n g 1939 and f o l l o w i n g 1959 i n order t o g a i n a more comprehensive view of the p e r i o d . J o u r n a l i t e m s — e d i t o r i a l s , o r i g i n a l a r t i c l e s , and news i t e m s — w e r e s e l e c t e d on the b a s i s of r e l e v a n c e t o p u b l i c h e a l t h n u r s i n g . For example, a r t i c l e s t h a t appeared i n the Canadian Nurse i n c l u d e d " M a i n t a i n i n g Standards of P u b l i c H e a l t h N ursing" (Chodat, 1942), "The Use of the V o l u n t e e r i n a P u b l i c H e a l t h Nursing S e r v i c e " (Barr, 1947), and "The P u b l i c H e a l t h Nurse Looks a t C i v i l Defence" (Walker, 1957). In the Canadian J o u r n a l of P u b l i c H e a l t h the f o l l o w i n g a r t i c l e s were r e p r e s e n t a t i v e : " D e s i r a b l e Q u a l i f i c a t i o n s f o r P u b l i c H e a l t h Nursing" (Emory, 1942), 14 " P r o f e s s i o n a l Growth i n P u b l i c H e a l t h N u r s i n g S e r v i c e " ( T a t e , 1946) , "A N a t i o n a l H e a l t h Program f o r Canada" ( M a r t i n , 1948) , and "Newer Trends i n the S c h o o l H e a l t h Program" (Brown, 1956) . The t i t l e s o f the j o u r n a l a r t i c l e s were indexed c h r o n o l o g i c a l l y ; t h e r e were 77 a r t i c l e s from t h e Canad ian Nurse and 46 found i n the Canadian J o u r n a l o f  P u b l i c H e a l t h . H i s t o r i c a l C r i t i c i s m Once d a t a were c o l l e c t e d , they were e v a l u a t e d b e f o r e b e g i n n i n g the a n a l y s i s . As o u t l i n e d by C h r i s t y (1975) , d a t a must be s u b j e c t e d t o two t y p e s o f h i s t o r i c a l c r i t i c i s m t o e s t a b l i s h r e l i a b i l i t y and v a l i d i t y . E x t e r n a l c r i t i c i s m i s concerned w i t h the a u t h e n t i c i t y o f a document. W r i t t e n m a t e r i a l s , such as l e t t e r s and r e p o r t s , must be examined f o r d e t e r m i n a t i o n o f a u t h o r s h i p and the v a l i d i t y o f the s o u r c e i t s e l f . Once a document i s c o n s i d e r e d t o be v a l i d , i t s r e l i a b i l i t y must be a s c e r t a i n e d through the p r o c e s s o f i n t e r n a l c r i t i c i s m . T h i s i n v o l v e s the e v a l u a t i o n o f the a c c u r a c y o f s ta tements w i t h i n the document. As P o l i t and H u n g l e r (1987) p o i n t o u t , the purpose o f i n t e r n a l c r i t i c i s m i s t h e d e t e r m i n a t i o n o f the worth o f a p i e c e o f e v i d e n c e . Conten t must be examined f o r the a u t h o r ' s competence and b i a s e s . C o r r o b o r a t i o n o f e v i d e n c e a s s i s t s i n the e s t a b l i s h m e n t o f r e l i a b i l i t y (Kruman, 1985) . In examin ing the e v i d e n c e assembled f o r t h i s s t u d y , the 15 r e s e a r c h e r was aware o f the p o t e n t i a l f o r b i a s i n many o f the o f f i c i a l r e p o r t s . A u t h o r s o f annua l r e p o r t s had a tendency t o p r o j e c t a p o s i t i v e image o f the department o r h e a l t h u n i t and , t h u s , t h e r e was l i t t l e c r i t i c i s m . O f f i c i a l r e p o r t s o v e r l o o k e d d i f f i c u l t i e s e x p e r i e n c e d by p u b l i c h e a l t h n u r s e s i n t h e i r everyday p r a c t i c e o r work ing c o n d i t i o n s . T h i s b i a s was o f f s e t by more f o r t h r i g h t a c c o u n t s found i n some o f the j o u r n a l a r t i c l e s and the o r a l h i s t o r i e s . T h i s phase o f the h i s t o r i c a l r e s e a r c h p r o c e s s must be w e l l executed b e f o r e embarking on the next s t e p . As C h r i s t y s t a t e s , a l l s o u r c e s "a re not o f equa l v a l u e " (1975, p . 1 9 0 ) . T h i s was t a k e n i n t o account as v a r i o u s s o u r c e s were l o c a t e d and e v a l u a t e d . A n a l y s i s and S y n t h e s i s The c r i t i c a l a s p e c t i n the a n a l y s i s o f h i s t o r i c a l d a t a i s the s y s t e m a t i c s e a r c h f o r meaning i n the a v a i l a b l e e v i d e n c e . T h i s c a l l s f o r s e l e c t i v i t y r e g a r d i n g which d a t a t o i n c l u d e i n the a n a l y s i s , b e i n g c e r t a i n t o c o n s i d e r a l l m a t e r i a l r e l e v a n t t o the problem (Fox, 1982) . The p r o c e s s o f s e l e c t i o n o f d a t a , a l r e a d y r e f e r r e d t o i n the p r e v i o u s s e c t i o n , i n v o l v e d s e v e r a l rev iews o f a l l the a v a i l a b l e d a t a i n o r d e r t o be c l e a r about what t o i n c l u d e and what t o d i s r e g a r d . On s e v e r a l o c c a s i o n s , m a t e r i a l s u r f a c e d t h a t was o f i n t e r e s t t o the r e s e a r c h e r ; however, f u r t h e r examina t ion showed t h a t i t was not p e r t i n e n t t o the s tudy t o p i c so i t 16 was not used. The p r o c e s s used t o analyze the evidence began wi t h review of a l l the assembled data s e t s . In p a r t i c u l a r , the h e a l t h u n i t r e p o r t s and the annual r e p o r t s of the D i v i s i o n o f P u b l i c H e a l t h Nursing were s u b j e c t e d t o d e t a i l e d content a n a l y s i s . Key words and c o l o u r coding were used t o i d e n t i f y the v a r i o u s c a t e g o r i e s . Some of the c a t e g o r i e s s e l e c t e d were educa t i o n , s o c i a l and p o l i t i c a l f o r c e s , supply o f PHNs, funding, and v o l u n t e e r s . T h i s p a r t of the process enabled the r e s e a r c h e r t o review the data i n a s y s t e m a t i c f a s h i o n and develop thematic c a t e g o r i e s f o r f u r t h e r a n a l y s i s . I t was then p o s s i b l e t o w r i t e r e s e a r c h notes on i n d i v i d u a l t o p i c s , drawing upon the f o u r main data s e t s and o t h e r secondary sources as necessary. A n a l y s i s gave r i s e t o the s y n t h e t i c p a r t o f the process as the r e s e a r c h notes were org a n i z e d i n t o an h i s t o r i c a l account. D i r e c t i o n f o r t h i s stage came from the themes t h a t emerged and the r e s e a r c h e r ' s judgment about t h e i r r e l a t i v e importance. S e v e r a l guides t o h i s t o r i c a l thought and w r i t i n g were c o n s u l t e d i n t h i s r e g ard (Barzun & G r a f f , 1977; Shafer, 1974). At t h i s p o i n t i t was necessary t o pay c l o s e a t t e n t i o n t o the a r t of h i s t o r i c a l w r i t i n g (Allemang, 1973). I t i s important t o p r e s e n t the f i n d i n g s i n a l o g i c a l sequence w i t h e x p l a n a t o r y comments i n c o r p o r a t e d i n the t e x t . As S hafer notes, the arrangement of h i s t o r i c a l evidence i s an important p a r t of the f i n a l s y n t h e s i s . In t h i s t h e s i s 17 t h e major l e v e l o f arrangement i s by t o p i c w i t h the a c c o u n t s p r e s e n t e d c h r o n o l o g i c a l l y . E t h i c a l C o n s i d e r a t i o n s The e t h i c a l " a s p e c t s o f the s tudy were rev iewed and approved by the U n i v e r s i t y o f B r i t i s h Columbia B e h a v i o u r a l S c i e n c e s S c r e e n i n g Committee f o r Research and Other S t u d i e s I n v o l v i n g Human S u b j e c t s . Throughout the s tudy t h e r e s e a r c h e r was g u i d e d by i s s u e s o f c o n f i d e n t i a l i t y r e g a r d i n g documents i n a r c h i v a l f i l e s and d a t a r e l a t e d t h r ough p e r s o n a l communica t ion . C o p i e s o f the completed s tudy w i l l be made a v a i l a b l e t o the n u r s i n g p r o f e s s i o n t h r ough the l i b r a r i e s o f the R e g i s t e r e d Nurses A s s o c i a t i o n o f B r i t i s h Columbia and the Canadian Nurses A s s o c i a t i o n (CNA). Summary In t h i s c h a p t e r the s t e p s i n the h i s t o r i c a l r e s e a r c h p r o c e s s were o u t l i n e d . The way i n which the p r o c e s s was a p p l i e d i n t h i s s tudy was d e s c r i b e d : d a t a s o u r c e s were l o c a t e d and s e l e c t e d , t h e s e were s u b j e c t e d t o h i s t o r i c a l c r i t i c i s m , and c o n t e n t was a n a l y z e d . F i n a l l y , the f i n d i n g s were i n t e g r a t e d i n t o an h i s t o r i c a l account from which c o n c l u s i o n s were drawn. T h i s account i s p r e s e n t e d i n the f o l l o w i n g c h a p t e r . 18 CHAPTER THREE PUBLIC HEALTH NURSING AND INFLUENCES ON ITS DEVELOPMENT A d e s c r i p t i o n o f p u b l i c h e a l t h n u r s i n g p r a c t i c e i n B r i t i s h Columbia and some of the i n f l u e n c e s on i t s e v o l u t i o n d u r i n g the 1939 t o 1959 p e r i o d are the t o p i c s f o r d i s c u s s i o n i n t h i s chapter. An overview of the o r g a n i z a t i o n a l s t r u c t u r e w i t h i n which the p u b l i c h e a l t h nurse (PHN) worked i s p resented as background t o t h i s d i s c u s s i o n . The l a t t e r p a r t o f the chapter c o n t a i n s an a n a l y s i s o f c e r t a i n f o r c e s t h a t i n f l u e n c e d the s t a t u s of p r o v i n c i a l p u b l i c h e a l t h n u r s i n g . O r g a n i z a t i o n o f P u b l i c H e a l t h S e r v i c e s P r o v i n c i a l H e a l t h S t r u c t u r e The h i s t o r y o f the o r g a n i z a t i o n of p u b l i c h e a l t h s e r v i c e s dates back t o the P u b l i c H e a l t h A c t of 1893 and the subsequent es t a b l i s h m e n t o f the P r o v i n c i a l Board of H e a l t h . From 1907 t o 1946, the Board of Hea l t h f e l l under the au s p i c e s o f the P r o v i n c i a l S e c r e t a r y ' s Department. I t gained departmental s t a t u s i n 1946 when the Department of H e a l t h and Welfare A c t was passed. In 1959 another change o c c u r r e d w i t h the s e p a r a t i o n o f the H e a l t h and Welfare branches i n t o two m i n i s t r i e s , the former becoming the Department of H e a l t h S e r v i c e s and H o s p i t a l Insurance. The j u r i s d i c t i o n o f the P r o v i n c i a l H e a l t h Department was the 19 e n t i r e p r o v i n c e a p a r t from the c i t i e s o f V i c t o r i a and Vancouver where p u b l i c h e a l t h s e r v i c e s were a d m i n i s t e r e d by t h e c i v i c a u t h o r i t i e s . N u r s i n g s e r v i c e s were d e l i v e r e d i n the e a r l y y e a r s by n u r s e s o p e r a t i n g w i t h i n p u b l i c h e a l t h n u r s i n g d i s t r i c t s and r e p o r t i n g t o l o c a l boards o f h e a l t h . A t the P r o v i n c i a l Board o f H e a l t h l e v e l t h e r e was no s e n i o r n u r s i n g o f f i c i a l , a c i r c u m s t a n c e t h a t c r e a t e d problems f o r the n u r s e s who f e l t the need f o r an a d v i s o r ( K i l p a t r i c k , 1938; M c M i l l a n & Law, 1938) . The growth o f the n u r s i n g s e r v i c e a t t h a t t ime a l s o c r e a t e d the need f o r an a d m i n i s t r a t i v e s t r u c t u r e f o r n u r s i n g . T h i s need was met i n 1939 w i t h the e s t a b l i s h m e n t o f the D i v i s i o n o f P u b l i c H e a l t h N u r s i n g and the appointment o f i t s f i r s t d i r e c t o r the f o l l o w i n g y e a r (Board o f H e a l t h , 1940) . S e v e r a l i n d i v i d u a l s h e l p e d t o shape the p r o v i n c e ' s p u b l i c h e a l t h system d u r i n g i t s deve lopmenta l p e r i o d . Dr . Henry E s s o n Young was P r o v i n c i a l H e a l t h O f f i c e r from 1916 t o 1939; under h i s d i r e c t i o n p u b l i c h e a l t h n u r s i n g s e r v i c e s and the f i r s t h e a l t h u n i t s were o r g a n i z e d (Board o f H e a l t h , 1939) . D r . Y o u n g ' s e a r l y c a r e e r i n c l u d e d m e d i c a l p r a c t i c e i n n o r t h e r n B r i t i s h Columbia b e f o r e he e n t e r e d p o l i t i c a l l i f e as t h e e l e c t e d r e p r e s e n t a t i v e o f the A t l i n c o n s t i t u e n c y i n 1903. He s e r v e d twe lve y e a r s i n the P r o v i n c i a l L e g i s l a t u r e : from 1907 t o 1915 he h e l d the p o r t f o l i o s o f P r o v i n c i a l S e c r e t a r y and E d u c a t i o n . H i s knowledge o f the 20 c o n d i t i o n s i n the o u t l y i n g a reas c o n t r i b u t e d t o h i s v i s i o n f o r the d i s t r i b u t i o n o f h e a l t h s e r v i c e s th roughout the p r o v i n c e . Wide ly r e s p e c t e d as a p u b l i c h e a l t h a u t h o r i t y , he h e l d o f f i c e i n a number o f Canadian and Amer ican p r o f e s s i o n a l o r g a n i z a t i o n s and r e c e i v e d many honours f o r h i s ach ievements i n the f i e l d . H i s s u c c e s s o r was Dr . G r e g o i r e Amyot, a p u b l i c h e a l t h p h y s i c i a n who had worked i n Saskatchewan and B r i t i s h Columbia p r i o r t o an appointment a t the U n i v e r s i t y o f M i n n e s o t a (Board o f H e a l t h , 1940) . As P r o v i n c i a l H e a l t h O f f i c e r from 1940 t o 1962, he oversaw the r e s t r u c t u r i n g o f the Board o f H e a l t h i n t o a f u l l government department i n 1946, a t which p o i n t he became Deputy M i n i s t e r o f H e a l t h (Department o f H e a l t h and W e l f a r e , 1946) . A c c o r d i n g t o Monica Green (1984), who worked c l o s e l y w i t h h im, Dr . Amyot b e l i e v e d i n the impor tance o f l o c a l h e a l t h s e r v i c e s and , as a s t r o n g promoter o f p u b l i c h e a l t h n u r s i n g , was i n s t r u m e n t a l i n o b t a i n i n g funds f o r p r e v e n t i v e s e r v i c e s . In summariz ing h i s c o n t r i b u t i o n , Green noted t h a t " h i s c o n t i n u e d s u p p o r t and encouragement kept the mora le o f the p u b l i c h e a l t h n u r s e s h i g h " (p. 125) . D u r i n g Dr . Amyot 's t e n u r e i n the H e a l t h Department , l e a d e r s h i p w i t h i n the D i v i s i o n o f P u b l i c H e a l t h N u r s i n g was p r o v i d e d by the t h r e e women who s e r v e d as D i r e c t o r s . The f i r s t t o h o l d the p o s i t i o n was Heather K i l p a t r i c k , a g radua te o f the U n i v e r s i t y o f B r i t i s h C o l u m b i a , who had 21 worked as a PHN i n Duncan (Board o f H e a l t h , 1940) . In p r e p a r a t i o n f o r h e r appointment , she had been s e n t t o the U n i v e r s i t y o f T o r o n t o t o s tudy p u b l i c h e a l t h s u p e r v i s i o n . She p r o v i d e d " c a p a b l e " l e a d e r s h i p (Green, 1984, p . 53) and opened t e n n u r s i n g d i s t r i c t s from 1940 t o 1944. In o r d e r t o improve communica t ion , Heather K i l p a t r i c k s t a r t e d a monthly n e w s l e t t e r f o r PHNs and a l s o i n i t i a t e d r e g u l a r n u r s e s ' m e e t i n g s . F o l l o w i n g h e r r e s i g n a t i o n i n 1944 ( to work f o r an o v e r s e a s r e l i e f a g e n c y ) , another member o f the D i v i s i o n was a p p o i n t e d as h e r rep lacement : Dorothy T a t e , a l s o a U n i v e r s i t y o f B r i t i s h Columbia alumna, s e r v e d as D i r e c t o r u n t i l 1948 (Department o f H e a l t h and W e l f a r e , 1948) . She had a b r o a d background i n p u b l i c h e a l t h and knew the p r o v i n c e w e l l because o f s e v e r a l y e a r s spent w i t h the t r a v e l l i n g T u b e r c u l o s i s C l i n i c ( S l a u g h t e r , 1988) . She i s remembered f o r h e r accompl ishments i n b r i n g i n g i n a u n i f o r m s a l a r y s c a l e f o r PHNs, d e v e l o p i n g i n - s e r v i c e e d u c a t i o n , and p r o d u c i n g the f i r s t p rocedure manuals (Green, 1984) . The t h i r d D i r e c t o r was Monica F r i t h ( l a t e r , Green) who s e r v e d from 1948 t o 1975. Her c a r e e r w i t h the P r o v i n c i a l S e r v i c e spanned 35 y e a r s , b e g i n n i n g w i t h r u r a l p u b l i c h e a l t h p lacements i n the Okanagan and the Kootenays i n the e a r l y f o r t i e s (Board o f H e a l t h , 1944) . As D i r e c t o r , she g u i d e d the D i v i s i o n th rough many changes i n c l u d i n g i t s e x p a n s i o n d u r i n g the f i f t i e s . Her c o n t r i b u t i o n t o p u b l i c h e a l t h was r e c o g n i z e d w i t h honours p r e s e n t e d by bo th the Amer ican 22 P u b l i c H e a l t h A s s o c i a t i o n and Canadian P u b l i c H e a l t h A s s o c i a t i o n . A f t e r she r e t i r e d , Monica Green au thored the f i r s t book t o c h r o n i c l e the h i s t o r y o f p u b l i c h e a l t h n u r s i n g i n B r i t i s h Co lumbia : Through the Years w i t h P u b l i c H e a l t h  N u r s i n g was p u b l i s h e d i n 1984. When the D i v i s i o n o f P u b l i c H e a l t h N u r s i n g was c r e a t e d i n 1939, the s t a f f c o n s i s t e d o f 44 n u r s e s i n v a r i o u s p a r t s o f the p r o v i n c e . In the e a r l y f o r t i e s two a d d i t i o n a l s e n i o r s t a f f were h i r e d t o p r o v i d e s u p e r v i s i o n t o the f i e l d s t a f f and t o a s s i s t w i t h a d m i n i s t r a t i v e f u n c t i o n s . Based i n V i c t o r i a , t h e c o n s u l t a n t s (as they were known) made r e g u l a r f i e l d v i s i t s , but were not a v a i l a b l e t o d e a l w i t h d a i l y p r o b l e m s . As the D i v i s i o n grew from a s t a f f o f 44 t o 111 o v e r the p e r i o d from 1939 t o 1949, a g r e a t need a r o s e f o r s u p e r v i s o r s and s e n i o r n u r s e s a t the l o c a l l e v e l . As the D i r e c t o r o f P u b l i c H e a l t h N u r s i n g s t a t e d i n h e r Annual Repor t f o r 1949, " s u p e r v i s i o n i s n e c e s s a r y t o ensure a q u a l i t y o f s e r v i c e which w i l l meet a c c e p t a b l e s t a n d a r d s " (Department o f H e a l t h and W e l f a r e , 1949, p . 53 ) . The f i r s t such appointment was made i n 1947 and o t h e r s f o l l o w e d as the budget and a v a i l a b i l i t y o f s u i t a b l e c a n d i d a t e s p e r m i t t e d . By t h e end o f t h e f i f t i e s , 13 h e a l t h u n i t s had s u p e r v i s o r s ; each s u p e r v i s o r had r e s p o n s i b i l i t y f o r a s t a f f o f from 15 t o 20 PHNs, depending on the l o c a t i o n . On Vancouver I s l a n d , f o r i n s t a n c e , the s u p e r v i s o r i n Nanaimo had r e s p o n s i b i l i t y f o r 17 PHNs i n the s u b - o f f i c e s o f Lake Cowichan, Duncan, 23 L a d y s m i t h , P a r k s v i l l e , P o r t A l b e r n i and Nanaimo ( C e n t r a l Vancouver I s l a n d H e a l t h U n i t , 1959) . A l t h o u g h s t a f f numbers were s m a l l , i t i s apparent t h a t t h i s t y p e o f s u p e r v i s i o n r e q u i r e d c o n s i d e r a b l e t r a v e l and a good u n d e r s t a n d i n g o f the needs o f the v a r i o u s communi t ies . In 1959 the D i v i s i o n had a complement o f 191 n u r s e s , i n c l u d i n g the a d m i n i s t r a t o r s i n V i c t o r i a , l o c a l s u p e r v i s o r s , and s t a f f PHNs. H e a l t h U n i t Development The h e a l t h u n i t concept came i n t o b e i n g i n B r i t i s h Columbia as the most e f f i c i e n t means o f o r g a n i z i n g the d e l i v e r y o f p u b l i c h e a l t h s e r v i c e s w i t h i n a g e o g r a p h i c r e g i o n . A l t h o u g h p a r t o f the p r o v i n c i a l h e a l t h s t r u c t u r e , each h e a l t h u n i t had " r e g i o n a l autonomy, a u t h o r i t y , and r e s p o n s i b i l i t y " (Department o f H e a l t h and W e l f a r e , 1952b, p . 4 4 ) . A h e a l t h u n i t ' s h e a d q u a r t e r s was d e s i g n e d t o s e r v e t h e l a r g e s t p o p u l a t i o n c e n t r e i n a r e g i o n and s u b - o f f i c e s were e s t a b l i s h e d i n s e v e r a l o t h e r r u r a l d i s t r i c t s and m u n i c i p a l i t i e s . In the E a s t Kootenay a r e a , f o r example, the h e a l t h u n i t had i t s main o f f i c e i n Cranbrook w i t h s m a l l e r o f f i c e s i n C r e s t o n , F e r n i e , K i m b e r l e y , and Invermere s e r v i n g t h e s e communi t ies and t h e i r s u r r o u n d i n g r u r a l d i s t r i c t s (Eas t Kootenay H e a l t h U n i t , 1954) . Each s u b - o f f i c e was s t a f f e d by one o r two PHNs and a p a r t - t i m e c l e r k ; s u p e r v i s i o n was p r o v i d e d by the s e n i o r PHN i n Cranbrook . When h e a l t h u n i t s were d e v e l o p i n g i n the f o r t i e s , the p e r s o n n e l c o n s i s t e d o f a m e d i c a l o f f i c e r o f h e a l t h , a 24 s a n i t a r y i n s p e c t o r , the PHNs, and c l e r i c a l s t a f f . L a t e r , s p e c i a l i s t s such as d e n t a l c o n s u l t a n t s and n u t r i t i o n i s t s were added as s e r v i c e s expanded i n t h e s e a r e a s . The 1950s were a t ime o f tremendous growth i n the development o f l o c a l h e a l t h f a c i l i t i e s and s e r v i c e s . U n t i l t h a t t ime s t a f f o c c u p i e d o f f i c e space i n m u n i c i p a l b u i l d i n g s w i t h the r e s u l t t h a t the h e a l t h department l a c k e d a d i s t i n c t p h y s i c a l p r e s e n c e i n the community. The a v a i l a b i l i t y o f f e d e r a l f u n d i n g , th rough the N a t i o n a l H e a l t h G r a n t s , a c t e d as a c a t a l y s t t o a major b u i l d i n g program under which l o c a l h e a l t h c e n t r e s were c o n s t r u c t e d (Department o f H e a l t h and W e l f a r e , 1952a) . These new b u i l d i n g s , known as community h e a l t h c e n t r e s , were d e s i g n e d t o meet the p a r t i c u l a r needs o f p u b l i c h e a l t h programs. A t y p i c a l h e a l t h c e n t r e b u i l t i n the 1950s was a f r e e s t a n d i n g , o n e - s t o r e y b u i l d i n g c o n s i s t i n g o f a r e c e p t i o n a r e a , s t a f f o f f i c e s , s t o r a g e a r e a , l i b r a r y , and c l i n i c rooms. Some o f the l a r g e r c e n t r e s had meet ing rooms f o r use by community groups and a u d i t o r i u m s f o r h e a l t h e d u c a t i o n s e s s i o n s (Green, 1984) . In l o o k i n g back a t the impact t h a t t h e s e h e a l t h c e n t r e s had a t the t i m e , Monica Green n o t e d : A t l o n g l a s t , p u b l i c h e a l t h n u r s e s had s u i t a b l e work ing q u a r t e r s o f which they c o u l d be p r o u d . . . . I t was a j o y t o have adequate space f o r c h i l d h e a l t h c o n f e r e n c e s where c o u n s e l l i n g c o u l d be p r i v a t e and space f o r m o t h e r s ' c l a s s e s i n c l u d i n g room f o r e x e r c i s e c l a s s e s . . . . The h e a l t h c e n t r e s were a t l a s t v i s i b l e and a t t r a c t i v e and h e l p e d r a i s e t h e mora le o f the s t a f f and the p r e s t i g e o f the s e r v i c e i n the community. (1984, p . 109) 25 As d e p i c t e d above, the advent of community h e a l t h f a c i l i t i e s p r o v i d e d improved working environments f o r the nurses and enhanced program d e l i v e r y a t the l o c a l l e v e l . In t o t a l , 43 new community h e a l t h c e n t r e s were c o n s t r u c t e d d u r i n g the p e r i o d from 1951 t o 1959; funding was based on a three-way c o s t s h a r i n g scheme ( f e d e r a l , p r o v i n c i a l , and municipal) w i t h a d d i t i o n a l a s s i s t a n c e from the v o l u n t a r y s e c t o r i n some cases (Department of H e a l t h and Welfare, 1953; Department of H e a l t h S e r v i c e s and H o s p i t a l Insurance, 1959). Throughout t h i s p e r i o d s t a f f i n g a l s o i n c r e a s e d t o meet the demands of a growing p o p u l a t i o n . By 1959 t h e r e were 16 p r o v i n c i a l h e a l t h u n i t s t h a t , along w i t h the two m e t r o p o l i t a n u n i t s (Greater Vancouver and V i c t o r i a ) , p r o v i d e d p u b l i c h e a l t h s e r v i c e s t o the people of B r i t i s h Columbia (see F i g u r e 1). Funding f o r the p r o v i n c i a l u n i t s was based on an annual l e v y of 30 cents per c a p i t a a t the l o c a l l e v e l (paid i n c o n j u n c t i o n w i t h the s c h o o l taxes) and was supplemented by o p e r a t i n g g r a n t s from the Department of H e a l t h and Welfare. P u b l i c H e a l t h Nursing P r a c t i c e B a s i c Programs The p u b l i c h e a l t h nurse had a v a r i e t y of r e s p o n s i b i l i t i e s r e g a r d i n g the h e a l t h of the community d u r i n g the 1939 t o 1959 p e r i o d ; the predominant aspects of the r o l e were s c h o o l n u r s i n g , communicable d i s e a s e c o n t r o l , m a t e r n a l - i n f a n t care, and v i s i t i n g n u r s i n g (Board of Health, 26 F i g u r e 1. B r i t i s h Columbia Health U n i t s i n 1959. From T a y l o r , J . A. (1962). The Health Branch of the B r i t i s h Columbia Department of H e a l t h S e r v i c e s and H o s p i t a l Insurance. In Canadian P u b l i c H e a l t h A s s o c i a t i o n (Ed.), The  f e d e r a l and p r o v i n c i a l h e a l t h s e r v i c e s i n Canada. Toronto: Author. Note. Gibson-Howe Sound became a h e a l t h u n i t (Coast G a r i b a l d i ) i n 1964. 27 1944). During the e a r l y years o f p u b l i c h e a l t h n u r s i n g , s e r v i c e s had been s p e c i a l i z e d so t h a t a nurse c a r r i e d out d u t i e s r e l a t e d t o one program area o n l y (e.g., s c h o o l n u r s i n g and t u b e r c u l o s i s n u r s i n g ) . By the 1930s the Board o f H e a l t h had moved t o a g e n e r a l i z e d n u r s i n g program i n which each PHN c a r r i e d out a l l p a r t s o f the r o l e (Board of Hea l t h , 1940). Beginning i n 1944, a l l p r o v i n c i a l p u b l i c h e a l t h nurses wore a d i s t i n c t i v e u n i f o r m — a t a i l o r e d navy b l u e s u i t over a white blouse w i t h a hat and coat f o r o u t s i d e wear (see F i g u r e 2). T y p i c a l l y , a PHN served a p o p u l a t i o n o f 5,000, c o v e r i n g a geographic area w i t h i n 20 t o 50 m i l e s from the h e a l t h u n i t (Department of H e a l t h and Welfare, 1948). School Nursing As p a r t o f the g e n e r a l i z e d program, PHNs p r o v i d e d h e a l t h s u p e r v i s i o n t o a l l the sch o o l c h i l d r e n i n t h e i r d i s t r i c t s . S c h o o l - r e l a t e d d u t i e s c e n t r e d around immunizing, s c r e e n i n g f o r h e a l t h problems, and c o n t r o l l i n g the spread o f communicable d i s e a s e s . In a d d i t i o n , the nurse acted as a res o u r c e f o r the te a c h e r s r e g a r d i n g h e a l t h o r b e h a v i o u r a l problems observed i n students. PHNs p a r t i c i p a t e d i n the annual r o u t i n e examinations c a r r i e d out by p h y s i c i a n s i n the s c h o o l s . P r o v i n c i a l l e g i s l a t i o n , the School M e d i c a l I n s p e c t i o n A c t of 1911, made p r o v i s i o n f o r every s c h o o l c h i l d i n the p r o v i n c e t o have a medical examination once a year. By the 1940s t h i s was m o d i f i e d t o the extent t h a t a l l 28 F i g u r e 2. P u b l i c h e a l t h nurses i n uniform, 1950. C h i l l i w a c k o f f i c e , Upper F r a s e r V a l l e y H e a l t h U n i t . Photo c o u r t e s y of Nan Kennedy. Used wi t h p e r m i s s i o n . 29 c h i l d r e n i n s p e c i f i e d grades were seen by a p h y s i c i a n , whereas the remainder were s c r e e n e d by the PHN (Board o f H e a l t h , 1942) . L a v i n i a C r a n e , who began as a P r o v i n c i a l PHN i n 1951, d e s c r i b e s the b e n e f i t o f the examina t ions i n the e r a b e f o r e u n i v e r s a l m e d i c a r e : We used t o do m e d i c a l examina t ions on every c h i l d , e v e r y y e a r . There w e r e n ' t the r e s o u r c e s ; p e o p l e d i d n ' t have m e d i c a l p l a n s and so o n , so t h a t even i f they perhaps wanted t o , i t was d i f f i c u l t f o r them t o g e t the money t o ge t c a r e . (Crane, 1987) Sometimes a c h i l d l i v i n g i n a remote a r e a had t o go away f o r extended t rea tment i n a major c e n t r e . L a v i n i a Crane r e c a l l s t h a t the n u r s e made arrangements f o r any n e c e s s a r y f i n a n c i a l a s s i s t a n c e and a l s o s u p p o r t e d the f a m i l y i n c o p i n g w i t h the s e p a r a t i o n . The n u r s e s d i d much o f the o r g a n i z i n g f o r the m e d i c a l i n s p e c t i o n s and the n e c e s s a r y f o l l o w - u p o f s t u d e n t s ' h e a l t h problems (Board o f H e a l t h , 1942; 1944) . The 1944 Board o f H e a l t h Repor t s p e c i f i e d the n u r s e ' s r e s p o n s i b i l i t i e s i n t h i s r e g a r d : C o n t a c t w i t h the home— To f o l l o w up and e x p l a i n d e f e c t s d i s c o v e r e d th rough p h y s i c a l examina t ion o f p u p i l s . To a s s i s t i n the c o n t r o l o f communicable d i s e a s e and t o g i v e a d v i c e c o n c e r n i n g o t h e r p u b l i c h e a l t h problems i n the home. (pp. 28-29) The PHN's s c h o o l r o l e extended i n t o the home; she p r o v i d e d i n f o r m a t i o n and e x p l a n a t i o n about h e a l t h m a t t e r s and was c o n c e r n e d w i t h the h e a l t h o f the whole f a m i l y . S c h o o l n u r s i n g a l s o i n v o l v e d e f f o r t s t o improve the poor n u t r i t i o n a l s t a t u s o f the s c h o o l p o p u l a t i o n as r e v e a l e d by t h e p h y s i c a l examina t ions (Department o f H e a l t h and 30 Welfare, 1946). To o f f s e t t h i s problem, some d i s t r i c t s o r g a n i z e d s c h o o l lunch programs. A c c o r d i n g t o an account by Margaret L i t t l e , PHN, i n the 1938 P u b l i c H e a l t h Nurses' B u l l e t i n , the s c h o o l lunch program f u l f i l l e d a d e f i n i t e need i n s c h o o l s i n Revelstoke. In t h a t community, a s c h o o l m i l k program was s u b s i d i z e d by a l o c a l s e r v i c e c l u b ; c h i l d r e n were charged a nominal fee of 50 cents per month f o r h a l f a p i n t o f m i l k a t lunc h time, but no c h i l d was excluded: Those who cannot a f f o r d t o pay r e c e i v e t h i s s e r v i c e f r e e . . . . T h i s s e r v i c e has proven a boon t o the poorer c h i l d r e n . I l i k e t o t h i n k t h a t the added s p a r k l e i n t h e i r eyes and a s l i g h t bloom on the cheek i s due t o the d a i l y m i l k s e r v i c e a t s c h o o l . ( L i t t l e , 1938, p. 21) H e a l t h t e a c h i n g about d i e t a r y needs was seen as another way o f b r i n g i n g about improvements i n n u t r i t i o n a l s t a t u s . In 1951 the N u t r i t i o n S e r v i c e o f the Department of H e a l t h conducted a d i e t a r y survey o f 4,000 sch o o l c h i l d r e n . The PHNs c o l l e c t e d data i n t h e i r s c h o o l s ; r e s u l t s showed t h a t the m a j o r i t y o f c h i l d r e n had d i e t s t h a t were d e f i c i e n t i n c i t r u s f r u i t s and oth e r sources o f v i t a m i n C, milk, and v i t a m i n D; moreover, many c h i l d r e n were consuming l a r g e q u a n t i t i e s o f sugar i n the form of candy and s o f t d r i n k s (Department of Health, 1951). As a r e s u l t of these f i n d i n g s , the H e a l t h Department i n i t i a t e d a novel method of demonstrating the p r i n c i p l e s o f good n u t r i t i o n through " r a t -f e e d i n g experiments" (Department of H e a l t h and Welfare, 1951, p. 58). Schools r e c e i v e d l a b o r a t o r y r a t s t h a t were p l a c e d i n classrooms and f e d by the stu d e n t s . The 31 experiment i n v o l v e d f e e d i n g one group of r a t s a c c o r d i n g t o Canada's food r u l e s , w h i l e the oth e r group consumed a d i e t of sweet foods. The dramatic d i f f e r e n c e s between the groups o f r a t s i n terms of growth, a c t i v i t y , and stamina served t o r e i n f o r c e the message of the b e n e f i t s o f a balanced d i e t . T h i s was a c r e a t i v e way t o make h e a l t h e d u c a t i o n come a l i v e i n the classroom and was, undoubtedly, one of the few times when p u b l i c h e a l t h personnel looked f a v o u r a b l y upon the r a t ! Communicable Disease C o n t r o l Communicable d i s e a s e c o n t r o l i n the ge n e r a l p o p u l a t i o n o u t s i d e the s c h o o l was a l s o a f u n c t i o n o f the PHN. I t i n v o l v e d p r e v e n t i o n of d i s e a s e through immunization and h e a l t h e d u c a t i o n . T u b e r c u l o s i s was "a major p u b l i c h e a l t h problem" t h a t demanded a t t e n t i o n a t the l o c a l l e v e l t o b r i n g i t under c o n t r o l (Department of H e a l t h and Welfare, 1948, p.48). Throughout the f o r t i e s , t u b e r c u l o s i s took i t s t o l l : i n 1946, i t ranked f o u r t h as a cause of death i n a l l age groups and was the l e a d i n g cause of death among young a d u l t s (aged 20-39); t h a t year t h e r e were over 2,500 cases of t u b e r c u l o s i s and treatment s e r v i c e s were s e v e r e l y s t r a i n e d (Department of H e a l t h and Welfare, 1946). During t h i s p e r i o d , PHNs were i n v o l v e d i n t u b e r c u l o s i s c o n t r o l and s u p e r v i s i o n o f p a t i e n t s and t h e i r f a m i l i e s ; t h i s i n c l u d e d t u b e r c u l i n t e s t i n g , follow-up v i s i t s , and c o n t a c t t r a c i n g . An important aspect o f t h e i r work i n v o l v e d t e a c h i n g p a t i e n t s and f a m i l i e s p r e c a u t i o n s a g a i n s t the spread o f i n f e c t i o n 32 (Department of Health and Welfare, 1946). After the war, the advent of chemotherapy brought a major change in treatment: patients could be treated at home rather than in sanatoria and the PHN served an important function by administering streptomycin injections to patients in the community. In the late forties each PHN had approximately 20 tuberculosis patients receiving regular v i s i t s for follow-up care (Department of Health and Welfare, 1948). Although tuberculosis was responsible for deaths of nurses in previous decades, Health Department documents for the forties and f i f t i e s did not mention i t as a major threat to the health of PHNs during this period. Another health concern was venereal disease; in 194 6 there were 4,618 cases of gonorrhea and 2,126 cases of syphilis, making the incidence the highest of a l l reportable diseases in the province (Department of Health and Welfare, 1946). Public health nursing duties in this regard centred around case finding and community education to prevent the spread of infection. Nurses received guidance for this aspect of their work from the Health Department's Division of Venereal Disease Control (Department of Health and Welfare, 1950). A number of other communicable diseases posed a threat to the population of British Columbia during the forties and f i f t i e s . Statistics for 1946, for instance, showed that there were 63 cases of diphtheria, 17 cases of typhoid 33 f e v e r , 597 cases o f s c a r l e t f e v e r , and 167 cases o f whooping-cough, a l l p r e v e n t a b l e d i s e a s e s a t the time (Department of H e a l t h and Welfare, 1946). B u i l d i n g up a h i g h l e v e l o f immunity i n the ge n e r a l p o p u l a t i o n was the be s t way t o prevent t h e i r spread. The shortage o f p h y s i c i a n s d u r i n g the war c r e a t e d a need f o r immunizations t o be done by another group of workers and t h a t a u t h o r i t y was g i v e n t o PHNs by the P r o v i n c i a l Board o f H e a l t h (Board of H e a l t h , 1941). The importance of m a i n t a i n i n g a p r o v i n c e -wide immunization program d u r i n g the war i s shown i n the Board of Hea l t h ' s 1943 Report: An e x t e n s i v e i n c r e a s e has taken p l a c e i n the immunization o f persons i n B r i t i s h Columbia, p a r t i c u l a r l y c h i l d r e n . By t h i s method of p r o t e c t i n g c h i l d r e n a g a i n s t d i p h t h e r i a , s c a r l e t f e v e r , whooping-cough, smallpox, t y p h o i d f e v e r , and tetanus i t i s p o s s i b l e t o prevent widespread epidemics of these d i s e a s e s which would s e r i o u s l y tax and d i s r u p t a l r e a d y overloaded h o s p i t a l , medical, and n u r s i n g s e r v i c e s i n a p e r i o d o f war. Such immunization procedures, though always of g r e a t importance i n peace-time, are a r e a l war measure a t the pr e s e n t time. (p. 14) C a r r y i n g out a g e n e r a l i z e d immunization program i n v o l v e d more than the t a s k of a d m i n i s t e r i n g the i n j e c t i o n ; i t r e q u i r e d c o n s i d e r a b l e o r g a n i z a t i o n by the nurses t o s e t up c l i n i c s and keep ac c u r a t e r e c o r d s . F u r t h e r , nurses had t o prepare t h e i r own s u p p l i e s , o f t e n s t e r i l i z i n g s y r i n g e s and needles over a hot p l a t e i n a community h a l l o r a s c h o o l . PHNs had t o have c u r r e n t knowledge about dosages and spa c i n g of immunizing agents and were r e q u i r e d t o e x e r c i s e independent judgment i n conducting these programs. I t i s 34 noteworthy t h a t B r i t i s h Columbia's p r o v i n c i a l PHNs were the f i r s t i n Canada t o take r e s p o n s i b i l i t y f o r a l l a s p e c t s of these programs as opposed t o a c t i n g as a s s i s t a n t s t o p h y s i c i a n s d o ing immunizations (Green, 1984). Born out of wartime n e c e s s i t y , p u b l i c immunization programs remained as p a r t o f the PHN's r o l e a f t e r the war. As a r e s u l t o f the d i s t r i b u t i o n o f PHNs throughout B r i t i s h Columbia and t h e i r a b i l i t y t o t r a v e l t o the s m a l l e r communities t o h o l d immunization c l i n i c s , the l e v e l o f coverage i n c r e a s e d and i n c i d e n c e r a t e s d e c l i n e d over time. By 1956, 70% of the sc h o o l p o p u l a t i o n had been immunized a g a i n s t d i p h t h e r i a ; i n t h a t year t h e r e was o n l y one r e p o r t e d case i n the p r o v i n c e (Department o f H e a l t h and Welfare, 1956). A major e f f o r t on the p a r t o f the nurses concerned the f i g h t a g a i n s t p o l i o i n the 1950s. P o l i o outbreaks o c c u r r e d i n t he e a r l y f i f t i e s , c a u s i n g p a n i c i n l o c a l communities because o f the s e r i o u s consequences (Department of H e a l t h and Welfare, 1952). The i n c i d e n c e o f the d i s e a s e rose from 6.4 t o 49.6 per 100,000 between 1950 and 1952 (Department of H e a l t h and Welfare, 1952). With the a v a i l a b i l i t y of the S a l k v a c c i n e , b e g i n n i n g i n 1955, the H e a l t h Department undertook a major immunization campaign t h a t l a s t e d f o r s e v e r a l y e a r s . P r o t e c t i o n was achieved through a s e r i e s of t h r e e i n j e c t i o n s ; t h e r e f o r e , i t was a massive t a s k t o c r e a t e a h i g h l e v e l of immunity throughout the p r o v i n c e . H e a l t h u n i t r e p o r t s f o r t h i s time showed t h a t the PHNs put f o r t h a 35 tremendous e f f o r t t o conduct the immunization program; the f o l l o w i n g e x c e r p t from a 1956 r e p o r t p r e s e n t s a t y p i c a l s i t u a t i o n : The S a l k v a c c i n e program was very time-consuming. Besides the work of a c t u a l l y g i v i n g the i n j e c t i o n s i t was necessary f o r our nurses t o devote much time t o the c l e a n i n g and s t e r i l i z i n g of s y r i n g e s and keeping c a r e f u l r e c o r d s which are r e q u i r e d f o r a s t a t i s t i c a l e v a l u a t i o n o f the v a c c i n e . I t has been necessary f o r us t o c u t back on some of our r e g u l a r work t o accomplish the p o l i o v a c c i n e program but we have been v e r y g l a d t o do t h i s i n view of the encouraging evidence of the h i g h degree of p r o t e c t i o n a f f o r d e d a g a i n s t the dread d i s e a s e of p o l i o m y e l i t i s . (South C e n t r a l H e a l t h U n i t , 1956, p. 9) F i g u r e s f o r the 1958/59 sc h o o l year showed t h a t over 86% of a l l s c h o o l c h i l d r e n had been immunized a g a i n s t p o l i o ; the i n c i d e n c e r a t e d e c l i n e d a c c o r d i n g l y t o 0.8 per 100,000 i n 1958 (Department of H e a l t h and Welfare, 1958). M a t e r n a l - I n f a n t Care The p r o v i s i o n of p r e v e n t i v e h e a l t h s e r v i c e s t o mothers and i n f a n t s was another major focus of the p u b l i c h e a l t h n u r s i n g program. During the f o r t i e s , p r e n a t a l t e a c h i n g took p l a c e i n the woman's home and i n c l u d e d i n s t r u c t i o n about n u t r i t i o n , hygiene, the p h y s i o l o g y of pregnancy, as w e l l as p r e p a r a t i o n f o r the baby. A f t e r a baby's a r r i v a l , s e v e r a l v i s i t s were made t o demonstrate i n f a n t care techniques and t o monitor the new mother's h e a l t h . F o l l o w i n g the postpartum p e r i o d , the home v i s i t i n g u s u a l l y ended and the mother was encouraged t o a t t e n d the c h i l d h e a l t h conference i n her neighbourhood. C h i l d h e a l t h conferences ( a l s o known as w e l l baby 36 c l i n i c s ) were adopted i n the pr o v i n c e , b e g i n n i n g around 1928, as the primary mode of d e l i v e r y o f p u b l i c h e a l t h s e r v i c e s t o the i n f a n t and p r e s c h o o l p o p u l a t i o n (Board o f He a l t h , 1928). They were h e l d a t r e g u l a r i n t e r v a l s i n s t r a t e g i c community l o c a t i o n s : church h a l l s , community c e n t r e s , and h e a l t h u n i t o f f i c e s . A t y p i c a l s e t up i n v o l v e d an a f t e r n o o n c l i n i c t o which women would b r i n g t h e i r i n f a n t s and young c h i l d r e n (Boundary He a l t h U n i t , 1952; Skeena H e a l t h U n i t , 1953). The PHN monitored growth, c o u n s e l l e d mothers, gave immunizations, and made r e f e r r a l s t o p h y s i c i a n s when h e a l t h problems were presented. At these s e s s i o n s the nurse p r o v i d e d a d v i c e about common concerns o f mothers i n r e s p e c t t o c h i l d development, s k i n c a r e , and b e h a v i o u r a l problems. V i s i t i n g N u rsing The p r o v i s i o n o f a bedside n u r s i n g s e r v i c e i n the home was o f f e r e d on a l i m i t e d b a s i s d u r i n g t h i s p e r i o d . In the g e n e r a l i z e d n u r s i n g program f o l l o w e d by the P r o v i n c i a l P u b l i c H e a l t h S e r v i c e , each nurse had a l i m i t e d amount of time a v a i l a b l e t o g i v e bedside care t o i n d i v i d u a l s who were i l l a t home. In s i t u a t i o n s where home care was r e q u i r e d , the PHN made s e v e r a l v i s i t s i n order t o demonstrate home n u r s i n g techniques t o f a m i l y c a r e g i v e r s . In t h i s way the p a t i e n t ' s d a i l y c a r e was handled by the f a m i l y and the nurse v i s i t e d as needed t o monitor progress o r t o c a r r y out c e r t a i n procedures such as i n j e c t i o n s and d r e s s i n g s 37 (Department of H e a l t h and Welfare, 1957). Some communities, i n c l u d i n g T r a i l , Surrey, Gibsons, and O l i v e r had a more e x t e n s i v e v i s i t i n g n u r s i n g s e r v i c e p r o v i d e d through the V i c t o r i a n Order of Nurses (Board of Health, 1943; Boundary H e a l t h U n i t , 1957). During the f i f t i e s s e v e r a l experimental home ca r e programs were launched and s t u d i e d by p r o v i n c i a l h e a l t h a u t h o r i t i e s p r e p a r a t o r y t o e s t a b l i s h i n g an o f f i c i a l home care program (Department of H e a l t h and Welfare, 1951, 1958). The p r o v i n c i a l Home Care Program was not implemented u n t i l 1974 (Green, 1984). Program Development i n the 1950s As d e s c r i b e d above, the p u b l i c h e a l t h n u r s i n g program r e v o l v e d around work with s c h o o l c h i l d r e n , mothers and i n f a n t s , communicable d i s e a s e c o n t r o l , and v i s i t i n g n u r s i n g . There was c o n s i d e r a b l e o v e r l a p among these program elements and, i n a l l work, the f a m i l y was the focus of s e r v i c e . In the f i f t i e s p u b l i c h e a l t h n u r s i n g added new programs t o meet the needs of the time. Around 1950 a t t e n t i o n was focussed on the s t a t e of p u b l i c h e a l t h p r a c t i c e i n Canada wi t h the r e l e a s e of a major r e p o r t commissioned by the Canadian P u b l i c H e a l t h A s s o c i a t i o n : Report of the Study Committee on P u b l i c H e a l t h  P r a c t i c e i n Canada (Canadian P u b l i c H e a l t h A s s o c i a t i o n , 1950). Members of the committee were prominent nurses and p h y s i c i a n s i n p u b l i c h e a l t h ; the f i e l d s t a f f and authors of the r e p o r t were Dr. J . H. B a i l l i e , E x e c u t i v e D i r e c t o r of the 38 A s s o c i a t i o n , and L y l e Creelman, who was on le a v e from her p o s i t i o n as D i r e c t o r o f P u b l i c H e a l t h Nursing i n the M e t r o p o l i t a n H e a l t h S e r v i c e o f Vancouver. The B a i l l i e -Creelman Report, as i t was known, was based on an e x t e n s i v e study o f o f f i c i a l and v o l u n t a r y agencies from c o a s t t o c o a s t . The authors found c o n s i d e r a b l e v a r i a t i o n i n programs around the country and noted s e r i o u s d e f i c i t s i n some areas. They found t h a t many agencies p r o v i d e d r o u t i n e s e r v i c e s year a f t e r y e a r without ever examining t h e i r e f f e c t i v e n e s s . In reg a r d t o s c h o o l s e r v i c e s , they recommended t h a t n u r s i n g time c o u l d be b e t t e r spent on h e a l t h e d u c a t i o n programs r a t h e r than on r o u t i n e work of q u e s t i o n a b l e m e r i t (such as v i s i t i n g a l l absentees). The B a i l l i e - C r e e l m a n Report advocated a move toward more group work i n h e a l t h education; f o r example, i t suggested t h a t one-to-one p r e n a t a l i n s t r u c t i o n be r e p l a c e d by group p r e n a t a l c l a s s e s . The r e p o r t was important because i t presented, f o r the f i r s t time, a d e t a i l e d account of a c t u a l p u b l i c h e a l t h o r g a n i z a t i o n and p r a c t i c e i n Canada and gave c o n s t r u c t i v e s u g g e s t i o n s f o r ways t o improve s e r v i c e d e l i v e r y . C e r t a i n program m o d i f i c a t i o n s suggested i n the B a i l l i e - C r e e l m a n Report were a l r e a d y i n p l a c e i n B r i t i s h Columbia. N e v e r t h e l e s s , a c c o r d i n g t o Monica Green who was D i r e c t o r o f P r o v i n c i a l P u b l i c H e a l t h Nursing a t t h a t time, the g u i d e l i n e s had a " p o s i t i v e e f f e c t " on p u b l i c h e a l t h n u r s i n g (1984, p. 98). Much of the program development t h a t took 39 p l a c e i n the 1950s was guided by the p r o g r e s s i v e d i r e c t i o n o f the r e p o r t . P r e n a t a l Programs The 1950s brought the i n t r o d u c t i o n and g e n e r a l acceptance o f p r e n a t a l c l a s s e s i n the p r o v i n c i a l p u b l i c h e a l t h program. In some areas i t was necessary t o i n t r o d u c e t h i s i d e a c a u t i o u s l y t o g a i n p h y s i c i a n support. The f o l l o w i n g e x c e r p t from the East Kootenay H e a l t h U n i t Annual Report f o r 1954 i n d i c a t e s the r a t i o n a l e f o r p r e n a t a l e d u c a t i o n and shows t h a t the nurses were aware of p o t e n t i a l sources o f r e s i s t a n c e t o t h i s new program: T h i s f a l l the f i r s t s e r i e s o f P r e n a t a l C l a s s e s was h e l d i n Cranbrook , adding t o a s e r v i c e t h a t had been c o n f i n e d t o home v i s i t i n g . We f e e l t h a t expectant mothers should be under the care and guidance o f t h e i r f a m i l y d o c t o r s throughout t h e i r pregnancy. However, busy d o c t o r s cannot d i s c o v e r and answer each mother's unspoken qu e s t i o n s and doubts and we hope, through these c l a s s e s , t o l e n d our a s s i s t a n c e . We f e e l t h a t more understanding and knowledge i n c r e a s e s the mother's sense o f co n f i d e n c e and makes the whole experience h a p p i e r and more s a t i s f y i n g t o the mother. The s e r i e s o f c l a s s e s i n c l u d e s i n f o r m a t i o n about the growth of the baby, good n u t r i t i o n , p r e n a t a l care, labour and c h i l d b i r t h , as w e l l as i n s t r u c t i o n on b a t h i n g the baby and the baby's care a f t e r he i s home from the h o s p i t a l , (p. 8) The f o l l o w i n g year the r e p o r t from t h i s h e a l t h u n i t i n d i c a t e d t h a t the c l a s s e s were g a i n i n g p o p u l a r i t y and were bei n g o f f e r e d throughout the d i s t r i c t . Consumer support seems t o have been a c r i t i c a l f a c t o r i n t h e i r acceptance. A f t e r the f i r s t c l a s s e s , the p a r t i c i p a n t s were asked t o complete an e v a l u a t i o n q u e s t i o n n a i r e ; 100% of the women found t h e c l a s s e s o f v a l u e t o them and t h e i r recommendations 40 f o r content were i n c o r p o r a t e d i n t o subsequent c l a s s e s . For i n s t a n c e , p a r t i c i p a n t s suggested t h a t g r e a t e r emphasis sho u l d be g i v e n t o b r e a t h i n g e x e r c i s e s f o r l a b o u r and d e l i v e r y and the importance of d a i l y e x e r c i s e . The Annual Report f o r the f o l l o w i n g year s t a t e s t h a t the nurses " r e v i s e d the l e c t u r e s i n p r e p a r a t i o n f o r the p r e - n a t a l programme i n 1955, p u t t i n g more emphasis on the p o i n t s which the p a r t i c i p a n t s i n former c l a s s e s found of g r e a t e s t v a l u e " (East Kootenay H e a l t h U n i t , 1955, p.8). Furthermore, the h e a l t h u n i t s t a f f c o n s u l t e d the m a t e r n i t y ward nurses a t the l o c a l h o s p i t a l and r e c e i v e d a f a v o u r a b l e response. By the l a t e f i f t i e s , a l l h e a l t h u n i t s were p r o v i d i n g p r e n a t a l c l a s s e s as the primary mode of p r e n a t a l e d u c a t i o n (Department o f H e a l t h and Welfare, 1957). Although the PHN was concerned w i t h expectant mothers, some u n i t s o f f e r e d one or two evening s e s s i o n s f o r f a t h e r s - t o - b e ( C e n t r a l Vancouver I s l a n d H e a l t h U n i t , 1952). Mental H e a l t h Annual r e p o r t s f o r the e a r l y f i f t i e s i n d i c a t e t h a t mental h e a l t h or mental hygiene, as i t was c a l l e d a t the time, was becoming a t o p i c of concern. In the 1951 Annual Report of the D i v i s i o n of P u b l i c H e a l t h Nursing i t was announced t h a t a new mental hygiene program was b e i n g i n t r o d u c e d , the purpose was "to promote mental w e l l - b e i n g i n a l l age-groups and t o h e l p prevent mental d i s o r d e r s and emotional d i s t u r b a n c e s " (p. 52). Mental hygiene p r i n c i p l e s 41 were i n t r o d u c e d t o the s t a f f through i n - s e r v i c e e d u c a t i o n programs a t both the l o c a l and p r o v i n c i a l l e v e l s . In 1953 a l l the s e n i o r nurses were sent on a two-week course a t the U n i v e r s i t y of Washington where the t o p i c was covered i n d e t a i l (Department of H e a l t h and Welfare, 1953). Rather than d e v e l o p i n g t h i s as a s p e c i a l i z e d s e r v i c e , the D i v i s i o n ' s p h i l o s o p h y was the i n t e g r a t i o n of mental hygiene i n t o the g e n e r a l i z e d p u b l i c h e a l t h n u r s i n g program. T h i s was c o n s i s t e n t w i t h the recommendations of the B a i l l i e -Creelman Report t h a t the g e n e r a l i s t PHN was the a p p r o p r i a t e f i e l d worker t o c a r r y out p r e v e n t i v e mental h e a l t h work. The PHN's work wit h young f a m i l i e s was seen as h i g h l y conducive t o promoting mental h e a l t h : By r e l i e v i n g a n x i e t y and b u i l d i n g up the mother's mental s e c u r i t y , the p u b l i c h e a l t h worker i n c o n t a c t w i t h the mother and c h i l d a t the c h i l d h e a l t h conference has an o p p o r t u n i t y t o do more f o r the mental h e a l t h of the community than i n any o t h e r way. (Canadian P u b l i c H e a l t h A s s o c i a t i o n , 1950, p. 47) T h i s b a s i c approach t o the p r e v e n t i o n of mental h e a l t h problems had m e r i t w i t h i n the context of the time and i l l u s t r a t e s one way i n which the PHN's r o l e was broadened i n the f i f t i e s . C i v i l Defence Another phenomenon of t h i s decade was the concern over c i v i l defence, c l e a r l y a r e a c t i o n t o the h o r r o r s of the atomic bomb and the development of b i o l o g i c a l warfare t e c h n i q u e s . P u b l i c knowledge about t h e i r e f f e c t s l e d t o a movement t o prepare Canada f o r the aftermath of p o s s i b l e 42 a t t a c k s . A f e d e r a l department of C i v i l Defence was c r e a t e d t o c o o r d i n a t e l o c a l e f f o r t s i n d i s a s t e r p l a n n i n g ; t h i s i n c l u d e d p l a n s f o r emergency h o s p i t a l s , f a l l o u t s h e l t e r s , and m o b i l i z a t i o n o f v o l u n t e e r s . P u b l i c h e a l t h nurses were i n v o l v e d w i t h e d u c a t i o n a l programs focussed on n u r s i n g and c i v i l defence and many nurses added t h e i r e x p e r t i s e t o l o c a l p l a n n i n g endeavours. In 1951 the P u b l i c H e a l t h Nursing S e c t i o n of the Canadian P u b l i c H e a l t h A s s o c i a t i o n (CPHA) devoted i t s e n t i r e meeting t o the s u b j e c t . By the l a t e f i f t i e s , however, i n t e r e s t had waned because the " t h r e a t of imminent d i s a s t e r " had decreased and i t was i m p o s s i b l e f o r the c i v i l defence movement t o m a i n t a i n i t s l e g i t i m a c y ( N i k i t i u k , 1978, p. 47). The P u b l i c H e a l t h Nurse's Role As d e s c r i b e d above, the r o l e of the PHN i n the P r o v i n c i a l S e r v i c e was v a r i e d : the work r e q u i r e d a s o l i d background i n n u r s i n g as w e l l as knowledge of epidemiology, n u t r i t i o n , growth and development, and i n f e c t i o n c o n t r o l i n the home and community. The r o l e i n c l u d e d h e a l t h t e a c h i n g and c o u n s e l l i n g of i n d i v i d u a l s and f a m i l i e s from a l l backgrounds (Creelman, 1941). PHNs were a source of i n f o r m a t i o n t o members of the p u b l i c i n an era when l a y people d i d not have easy access t o h e a l t h m a t e r i a l (McArthur, 1952). As g e n e r a l i s t s , the nurses p r o v i d e d a broad p u b l i c h e a l t h program i n t h e i r communities; t h i s r e q u i r e d e x c e l l e n t o r g a n i z a t i o n a l a b i l i t i e s i n o r d e r t o 43 d e l i v e r an e f f i c i e n t and e f f e c t i v e s e r v i c e . Although t h e r e was a c e n t r a l a d m i n i s t r a t i o n , PHNs a t the l o c a l l e v e l f u n c t i o n e d q u i t e autonomously. The nurses planned t h e i r own d a i l y schedules and spent many hours t r a v e l l i n g around t h e i r d i s t r i c t s (see F i g u r e 3). S e v e r a l PHNs who p r a c t i s e d d u r i n g t h i s p e r i o d r e c a l l t h a t one of the c h i e f a t t r a c t i o n s of the P r o v i n c i a l P u b l i c H e a l t h Nursing S e r v i c e was the independence i t allowed (George, 1987; Kennedy, 1987; S l a u g h t e r , 1988). P u b l i c h e a l t h n u r s i n g was demanding i n the f o r t i e s and f i f t i e s , but i t was worthwhile because the nurses knew t h a t t h e i r work was important and "made a d i f f e r e n c e " t o the h e a l t h of the community (Norma C l a r k , p e r s o n a l communication, J u l y 12, 1988). The nurses themselves and the p u b l i c they served r e c o g n i z e d the v a l u e of p u b l i c h e a l t h n u r s i n g . I n f l u e n c e s on P u b l i c H e a l t h Nursing A number of f a c t o r s shaped the d i r e c t i o n of the P r o v i n c i a l P u b l i c H e a l t h Nursing S e r v i c e d u r i n g t h i s p e r i o d ; some of the i n f l u e n c e s t h a t were of p a r t i c u l a r s i g n i f i c a n c e are d e s c r i b e d i n the remainder of t h i s chapter. They i n c l u d e the impact of s o c i a l and p o l i t i c a l f o r c e s on the development of p r o v i n c i a l h e a l t h s e r v i c e s and on n u r s i n g p r a c t i c e . B a s i c e d u c a t i o n f o r p u b l i c h e a l t h nurses and s t a f f development on the job a f f e c t e d the s t a t u s of p u b l i c h e a l t h n u r s i n g . Other important f a c t o r s , d u r i n g the p e r i o d 44 F i g u r e 3. Norma Tucker ( C l a r k ) , PHN, on the o l d Hope-P r i n c e t o n Road en route t o a c l i n i c . 1948. Photo c o u r t e s y o f Norma C l a r k . Used wi t h p e r m i s s i o n . 45 under c o n s i d e r a t i o n , were the demand f o r s e r v i c e s and the supply of q u a l i f i e d PHNs t o meet t h a t demand. A l s o , the involvement of v o l u n t a r y agencies i n p u b l i c h e a l t h work had an impact on p u b l i c h e a l t h n u r s i n g s e r v i c e s . S o c i a l I n f l u e n c e s The e v o l u t i o n of p u b l i c h e a l t h n u r s i n g d u r i n g the f o r t i e s and f i f t i e s was i n f l u e n c e d , t o a c e r t a i n extent, by the s o c i a l c l i m a t e of B r i t i s h Columbia at the time. Many f a c t o r s , i n c l u d i n g p o p u l a t i o n c h a r a c t e r i s t i c s , p o l i t i c s , economics, l i v i n g c o n d i t i o n s , and s o c i e t a l a t t i t u d e s acted as i n f l u e n c e s on aspects of p u b l i c h e a l t h n u r s i n g . During the 1939 t o 1959 p e r i o d , B r i t i s h Columbia experienced a p o p u l a t i o n boom: i n one decade (from 1941 t o 1951) the p o p u l a t i o n expanded by 42%. A c c o r d i n g t o census f i g u r e s the p o p u l a t i o n grew from 817,861 i n 1941 t o 1,165,210 t e n years l a t e r ; by the 1961 census i t had reached 1,629,082 (Urquhart, 1965). T h i s growth was c o n s i d e r a b l y above the n a t i o n a l average f o r the p e r i o d . As p o i n t e d out by J . T. M a r s h a l l (1958), A s s i s t a n t Dominion S t a t i s t i c i a n a t the time, B r i t i s h Columbia's r a t e of n a t u r a l i n c r e a s e had always been low compared t o other p r o v i n c e s , a phenomenon a t t r i b u t e d t o the excess of males i n the resource-based economy. F o l l o w i n g the Depression, however, the s i t u a t i o n began t o change as the b i r t h r a t e i n c r e a s e d . The b i r t h r a t e f o r the 1950-1954 p e r i o d was t h r e e times g r e a t e r than f o r the 1935-1939 p e r i o d . T h i s change a l s o had an impact on the 46 age s t r u c t u r e o f the p o p u l a t i o n : the under 15 age group doubled between 1941 and 1956. F a c t o r s thought t o have been r e s p o n s i b l e f o r t h i s s i t u a t i o n were h i g h e r marriage r a t e s and a t r e n d toward e a r l i e r marriages and c h i l d b e a r i n g , as w e l l as the s o c i a l a c c e p t a b i l i t y o f l a r g e r f a m i l i e s ( M a r s h a l l , 1958). M i g r a t i o n continued t o make a s i g n i f i c a n t c o n t r i b u t i o n t o p o p u l a t i o n growth as the economic a c t i v i t y of the f o r t i e s and f i f t i e s a t t r a c t e d a l a r g e l a b o u r f o r c e (Ormsby, 1958). Adding t o the m i g r a t i o n f i g u r e s was the steady i n f l u x o f r e t i r e e s from the p r a i r i e s and elsewhere due t o the f a v o u r a b l e c l i m a t e t h a t made B r i t i s h Columbia "a haven f o r e l d e r l y people" ( M a r s h a l l , 1958, p. 66). While the demography of the p r o v i n c e was changing, B r i t i s h Columbia a l s o experienced a p e r i o d o f p o l i t i c a l change. The L i b e r a l government of T. D. P a t t u l l o dominated the p o l i t i c a l scene i n the 1930s (Jackman, 1969). Although P a t t u l l o had p l a n s f o r grand schemes such as h e a l t h i n s u r a n c e and major p u b l i c works p r o j e c t s , they were not r e a l i z e d i n h i s p o l i t i c a l l i f e t i m e due t o the c o n t i n u i n g depressed economy. A key member of the P a t t u l l o c a b i n e t was Dr. G. M. Weir, P r o v i n c i a l S e c r e t a r y and M i n i s t e r o f Educ a t i o n , who gained a r e p u t a t i o n as a reformer (Ormsby, 1958). Formerly the Head of the Department o f Educat i o n a t the U n i v e r s i t y of B r i t i s h Columbia, he authored the 1932 Survey o f Nursing E d u c a t i o n i n Canada (the Weir Report), which was w i d e l y c i r c u l a t e d and formed the b a s i s f o r many 47 subsequent changes i n n u r s i n g e d u c a t i o n . Weir advocated the upgrading of n u r s i n g education and wider use of p u b l i c h e a l t h nurses. P a t t u l l o ' s l e a d e r s h i p of the L i b e r a l p a r t y was c o n t e s t e d and won i n 1941 by h i s former M i n i s t e r of Finance, John Hart. A f t e r the Premier's r e s i g n a t i o n , Hart formed a c o a l i t i o n w i t h the C o n s e r v a t i v e s and l e d the p r o v i n c e through the remainder of the war and i n t o the p o s t -war p e r i o d . H a r t ' s background i n f i n a n c e served the p r o v i n c e w e l l ; h i s p o l i c i e s c o n t r i b u t e d t o r e d u c i n g the government's f i n a n c i a l d i f f i c u l t i e s (Jackman, 1969). As a wartime Premier he i s remembered f o r h i s p a r t i n the internment o f the Japanese Canadians, "a blemish on the good name of Canada, B r i t i s h Columbia and John Hart" (Jackman, 1969, p. 239). The L i b e r a l - C o n s e r v a t i v e c o a l i t i o n c o ntinued through t o 1952 w i t h B. I. Johnson succeeding Hart as Premier from 1947 t o 1952. Johnson brought i n " p r o g r e s s i v e and c o n s t r u c t i v e l e g i s l a t i o n " (Ormsby, 1958, p. 489), but p a r t y p o l i t i c s became t u r b u l e n t i n the e a r l y 1950s. D i v i s i v e n e s s w i t h i n the c o a l i t i o n c l e a r e d the way f o r the e n t r y of a new p o l i t i c a l p a r t y : the S o c i a l C r e d i t p a r t y spearheaded by W. A. C. Bennett. F i r s t e l e c t e d t o power i n 1952, Bennett appealed t o the e l e c t o r a t e w i t h the promise of "middle of the road f r e e e n t e r p r i s e government" (Ormsby, 1958, p. 489). Bennett took advantage of the improved economic c l i m a t e t o embark on major undertakings such as highway c o n s t r u c t i o n 48 and h y d r o e l e c t r i c p r o j e c t s . Bennett's 1956 budget was, t o use h i s d e s c r i p t i o n , a "great p r o s p e r i t y budget" ( M i t c h e l l , 1983, p. 233) i n which c i v i l s e r v i c e s a l a r i e s were r a i s e d , a d d i t i o n a l g r a n t s were earmarked f o r m u n i c i p a l i t i e s , and a major road c o n s t r u c t i o n p r o j e c t was f i n a n c e d . S o c i a l spending, however, was kept under f i r m c o n t r o l . The government's stance on s o c i a l p o l i c y was r u l e d by i t s o p p o s i t i o n t o the concept of the w e l f a r e s t a t e ; t h i s was supported by the v o t e r s who urged p o l i t i c i a n s t o c u r t a i l w e l f a r e spending. The Bennett government's a t t i t u d e t o h e a l t h and w e l f a r e was summarized as f o l l o w s : "the S o c i a l C r e d i t government p r o v i d e d the b a s i c s e r v i c e s f o r a r e l a t i v e l y e n l i g h t e n e d s o c i a l p o l i c y , but the f i n a n c i a l c o n t r o l s Bennett e x e r c i s e d as m i n i s t e r of f i n a n c e ensured t h a t f r i l l s and government-sponsored s o c i a l experiments were almost n o n e x i s t e n t " ( M i t c h e l l , 1983, pp. 356-357). In s p i t e of t h i s , p u b l i c h e a l t h made c e r t a i n advances d u r i n g the f i f t i e s , p r obably due t o the i n f l u e n c e of the Deputy M i n i s t e r of H e a l t h , Dr. Amyot, and the r i s i n g e x p e c t a t i o n s o f the p u b l i c f o r h e a l t h s e r v i c e s i n t h e i r own communities. As the 1950s came t o an end, the government of W. A. C. Bennett was w e l l e s t a b l i s h e d and had begun t o put i t s mark on the p r o v i n c e ' s p o l i t i c a l h i s t o r y . The p o l i t i c a l and demographic changes of the p e r i o d were c l o s e l y connected t o the p r o v i n c e ' s economy. The Second World War marked the beginning of a growth phase i n 49 the B r i t i s h Columbia economy (Ormsby, 1958). By 1941 the s h i p b u i l d i n g i n d u s t r y i n V i c t o r i a and Vancouver was i n f u l l p r o d u c t i o n as were other i n d u s t r i e s t h a t manufactured items f o r use i n the war. The west c o a s t a t t r a c t e d workers from a c r o s s Canada; a t one p o i n t 30,000 workers were employed i n the s h i p y a r d s alone (Ormsby). The needs of the war i n d u s t r i e s s t i m u l a t e d o t h e r aspects of the economy throughout the p r o v i n c e . On the n o r t h e r n c o a s t , f o r i n s t a n c e , P r i n c e Rupert became a supply base f o r the American f o r c e s s t a t i o n e d i n A l a s k a and i t s p o p u l a t i o n doubled. The p r o v i n c e ' s n a t u r a l r e s o u r c e s were i n demand: spruce t r e e s were used i n the manufacture of l i g h t w e i g h t p l a n e s and m i n e r a l s were needed f o r m i l i t a r y purposes. Furthermore, the world-wide demand f o r a g r i c u l t u r a l products i n c r e a s e d the v a l u e of c a t t l e ranches, farms, and orchards. The economic a c t i v i t y was not c o n f i n e d t o the urban areas but, r a t h e r , touched most p a r t s of the p r o v i n c e . B r i t i s h Columbia was f o r t u n a t e t o s u s t a i n t h i s growth a f t e r the war. C a p i t a l from E a s t e r n Canada, the U n i t e d S t a t e s , and overseas was i n v e s t e d i n f o r e s t r y and mining. Large company towns were c r e a t e d around new pulp and paper m i l l s , aluminum sm e l t e r s , and energy p r o j e c t s (Ralston,1982). In t u r n , s e r v i c e i n d u s t r i e s developed t o meet the needs of an expanding p o p u l a t i o n base throughout the p r o v i n c e . The new p r o s p e r i t y of the e r a , however, d i d not cause l i v i n g c o n d i t i o n s t o improve o v e r n i g h t . Communities faced 50 problems w i t h inadequate s a n i t a t i o n , housing shortages, and l a c k of p u b l i c h e a l t h s e r v i c e s ( S e l k i r k H e a l t h U n i t , 1956; Skeena H e a l t h U n i t , 1953). P u b l i c h e a l t h workers were w e l l aware t h a t l i v i n g standards a f f e c t e d h e a l t h and t h a t o v e r a l l improvements i n the community's h e a l t h depended on adequate environments ( P r o v i n c i a l Board of Health, 1941, 1942). T h i s was r e c o g n i z e d by Paul M a r t i n , the M i n i s t e r of N a t i o n a l H e a l t h and Welfare, i n a speech t o the Canadian P u b l i c H e a l t h A s s o c i a t i o n i n 1948: Canada i s among those c o u n t r i e s where p u b l i c h e a l t h i s s h i f t i n g i t s emphasis and broadening i t s o u t l o o k t o embrace a l l t h a t a f f e c t s human l i f e . . . . In those wider a p p l i c a t i o n s of p u b l i c h e a l t h , f u l l weight i s now b e i n g g i v e n t o environmental hygiene. N u t r i t i o n , housing, s a n i t a t i o n , r e c r e a t i o n , economic and working c o n d i t i o n s — a l l are now p a r t of our ever-widening f i e l d o f p u b l i c h e a l t h i n t e r e s t . (1948, p. 225) One of the c h a l l e n g e s of post-war reform was the improvement i n g e n e r a l l i v i n g c o n d i t i o n s i n order t o decrease i l l -h e a l t h . A c t i o n on the causes of poor h e a l t h and s o c i a l problems was needed a t the n a t i o n a l , p r o v i n c i a l , and m u n i c i p a l l e v e l s . At the n a t i o n a l l e v e l , a number of steps were taken toward the development of a p u b l i c h e a l t h insurance scheme. During the 1940s, the f e d e r a l government sought t o come t o an agreement wi t h the p r o v i n c e s t o adopt a p u b l i c l y a d m i n i s t e r e d h e a l t h insurance p l a n (Torrance, 1981). The L i b e r a l government of Mackenzie King e n v i s i o n e d t h a t the p l a n would be f i n a n c e d by a 50-50 c o s t shared arrangement w i t h the p r o v i n c e s ; however, a major f e d e r a l - p r o v i n c i a l 51 conference i n 1945 f a i l e d t o come t o an agreement on r e s t r u c t u r i n g the tax system ( T a y l o r , 1978). I t was not u n t i l 1957 t h a t a n a t i o n a l h e a l t h insurance scheme became a r e a l i t y but, i n the meantime, the f e d e r a l government was under p r e s s u r e t o f i n a n c e h e a l t h and s o c i a l programs. In 1948 the N a t i o n a l H e a l t h Grants Program was launched t o p r o v i d e funding f o r s p e c i f i c needs i n h e a l t h s e r v i c e s . T h i s program had a major impact on p u b l i c h e a l t h around the country: p u b l i c h e a l t h agencies were a b l e t o draw on grant funds f o r programs, f a c i l i t i e s , and p r o f e s s i o n a l t r a i n i n g (Martin, 1948). The a v a i l a b i l i t y of the t r a i n i n g funds, which were a v a i l a b l e from the l a t e f o r t i e s through t o the s i x t i e s , boosted the ranks of p u b l i c h e a l t h nurses by e n a b l i n g nurses t o o b t a i n p u b l i c h e a l t h t r a i n i n g (Department of H e a l t h S e r v i c e s and H o s p i t a l Insurance, 1960). Thus, f e d e r a l c o n t r i b u t i o n s t o p r o v i n c i a l h e a l t h d e l i v e r y systems a i d e d the development of p u b l i c h e a l t h n u r s i n g i n the p o s t -war p e r i o d . The i n t e r r e l a t e d f o r c e s of economics and p o l i t i c s i n f l u e n c e d a l l aspects of l i f e and p u b l i c h e a l t h n u r s i n g was a f f e c t e d by the c o n d i t i o n s of the time. C l o s e l y r e l a t e d t o these f a c t o r s i s another v a r i a b l e t h a t must be c o n s i d e r e d i n t h i s d i s c u s s i o n : the r o l e of s o c i e t a l v a l u e s of the f o r t i e s and f i f t i e s . S o c i e t a l a t t i t u d e s were i n f l u e n c e d by and, i n t u r n , had an i n f l u e n c e on the circumstances of the p e r i o d . The new p r o s p e r i t y l e d t o an o p t i m i s t i c atmosphere around the 52 p r o v i n c e as new housing and p u b l i c f a c i l i t i e s were being c o n s t r u c t e d i n r e c o r d numbers (Ralston, 1982). The r e t u r n t o peace c r e a t e d a f e e l i n g o f s t a b i l i t y t h a t s e t the stage f o r the "baby boom" of the post-war y e a r s . In s t u d y i n g B r i t i s h Columbia census data, M a r s h a l l (1958) a t t r i b u t e d i n c r e a s e d f e r t i l i t y i n the f o r t i e s and f i f t i e s t o changed a t t i t u d e s r e g a r d i n g f a s h i o n a b l e f a m i l y s i z e and a r e t u r n t o f a m i l y v a l u e s . In d i s c u s s i n g the c h a r a c t e r i s t i c s o f Canadian s o c i e t y i n the post-war years, h i s t o r i a n Donald C r e i g h t o n (1976) noted t h a t , although economic r e s t r a i n t s had been l i f t e d , Canadians d i d not in d u l g e themselves: "The work e t h i c s t i l l s t u r d i l y c o n f r o n t e d the p l e a s u r e p r i n c i p l e " (p.247). L e i s u r e time, a c c o r d i n g t o Creighton, had a ne g a t i v e c o n n o t a t i o n and s o c i a l l i f e r e v o l v e d around f a m i l y l i f e , church, and s e r v i c e c l u b s r a t h e r than p l e a s u r e p u r s u i t s . W r i t i n g about American s o c i e t y o f the 1950s, M i l l e r and Nowak (1977) o f f e r a c r i t i c a l examination o f the decade t h a t d i f f e r s from the g l a m o r i z a t i o n o f the "fabulous f i f t i e s " (p. 3) as p o r t r a y e d i n popul a r c u l t u r e of the s e v e n t i e s and e i g h t i e s . Viewed with a c e r t a i n amount of n o s t a l g i a , the f i f t i e s r e p r e s e n t e d "a golden age of innocence and s i m p l i c i t y " ( M i l l e r & Nowak, p. 5) and marked the begin n i n g of a h i g h e r standard o f l i v i n g and the promise of a b e t t e r l i f e i n the suburbs. These authors p o i n t out t h a t beneath the s u r f a c e a l l was not w e l l : the c o n f o r m i s t m e n t a l i t y , 53 w h i c h p r e v a i l e d i n s o c i a l l i f e , p o l i t i c s , a n d e d u c a t i o n , m a s k e d s e r i o u s p r o b l e m s a n d i n h i b i t e d c r e a t i v e s o l u t i o n s . The d r e a m d i d n o t m a t e r i a l i z e a s e x p e c t e d ; t h e e m p t i n e s s o f s u b u r b a n l i f e , e s p e c i a l l y f o r women, l e d t o a d i s c o n t e n t t h a t was e x p r e s s e d o p e n l y i n t h e 19 6 0 s ( F r i e d a n , 1 9 6 3 , 1 9 8 1 ) . T h i s a n a l y s i s c a n a l s o b e a p p l i e d t o B r i t i s h C o l u m b i a b e c a u s e o f i t s c o n n e c t i o n t o A m e r i c a n c u l t u r e . S u b u r b a n g r o w t h , f o r i n s t a n c e , was a n o t i c e a b l e f e a t u r e o f t h e f i f t i e s — b y t h e e n d o f t h e d e c a d e 68% o f t h e p o p u l a t i o n l i v e d i n u r b a n a r e a s a n d "bedroom c o m m u n i t i e s " h a d s p r u n g up a r o u n d V a n c o u v e r ( T a y l o r , 1 9 6 2 ) . P u b l i c h e a l t h n u r s i n g , a s a p r o f e s s i o n d o m i n a t e d b y women, was s u r e l y i n f l u e n c e d b y s o c i e t a l a t t i t u d e s r e g a r d i n g t h e s t a t u s o f women. A l t h o u g h women made g a i n s i n t h e f i r s t h a l f o f t h e t w e n t i e t h c e n t u r y , i t was s t i l l "a man's w o r l d " i n p o l i t i c s a n d t h e economy. The S e c o n d W o r l d War p r e c i p i t a t e d c h a n g e s i n women's i n v o l v e m e n t o u t s i d e t h e home: t h e p a r t i c i p a t i o n o f C a n a d i a n women i n t h e w o r k f o r c e r o s e f r o m 2 4 . 4 % i n 1939 t o 3 3 . 5 % i n 1944 ( P i e r s o n , 1 9 8 6 ) . I n a d d i t i o n , a l m o s t 50,000 women s e r v e d i n t h e C a n a d i a n armed f o r c e s . The u r g e n t n e e d f o r women a s w o r k e r s i n t h e w a r i n d u s t r i e s l e d t o a r e m a r k a b l e s e t o f s u p p o r t s a n d f a v o u r a b l e w o r k i n g c o n d i t i o n s f o r f e m a l e e m p l o y e e s . T h e s e i n c l u d e d g o v e r n m e n t - s u p p o r t e d c h i l d c a r e f a c i l i t i e s ( o p e n 12 h o u r s / d a y ) , a f t e r - s c h o o l p r o g r a m s , p a r t - t i m e w o r k , a n d " h o u s e w i f e s h i f t s " ( e v e n i n g h o u r s ) a t f a c t o r i e s ( P i e r s o n ) . 54 Another i n c e n t i v e took the form o f changes i n the income tax l e g i s l a t i o n t o encourage married women t o e n t e r the workforce. P i e r s o n p o i n t s out t h a t these c o n c e s s i o n s were removed a b r u p t l y as soon as the war ended; the gai n s d i m i n i s h e d as r a p i d l y as they had oc c u r r e d . The v i t a l c o n t r i b u t i o n o f women t o the war e f f o r t , a t home and overseas, was re c o g n i z e d but " d i d not t r a n s l a t e i n t o an equal p l a c e f o r women on the post-war c o u n c i l s o f the n a t i o n " ( P i e r s o n , p. 61). Women were expected t o r e t u r n t o the home t o le a v e room f o r the (male) vet e r a n s t o r e - e n t e r the workforce. Although some women s t r u g g l e d t o r e t a i n the wartime b e n e f i t s (such as the day n u r s e r i e s ) , a t t i t u d e s toward working women undermined these attempts. The immediate post-war p e r i o d saw the m a j o r i t y o f women r e t u r n t o home d u t i e s ; i t took another twenty years f o r t h e i r p a r t i c i p a t i o n i n the p a i d workforce t o equal t h a t o f the wartime peak ( P i e r s o n ) . S o c i e t a l a t t i t u d e s r e g a r d i n g working women had a d e f i n i t e impact on the supply o f p u b l i c h e a l t h nurses. During the f o r t i e s and e a r l y f i f t i e s , marriage was the c h i e f reason f o r p u b l i c h e a l t h n u r s i n g r e s i g n a t i o n s from the B r i t i s h Columbia H e a l t h Department (Department o f He a l t h and Welfare, 1946, 1950, 1952). Educat i o n From i t s beginnings p u b l i c h e a l t h n u r s i n g r e q u i r e d s p e c i a l i z e d knowledge and s k i l l s beyond what was a c q u i r e d through diploma n u r s i n g education i n h o s p i t a l s c h o o l s . T h i s 55 need was r e c o g n i z e d p r i o r t o 1920 and l e d t o the e s t a b l i s h m e n t o f s p e c i a l c o u r s e s a t s e v e r a l Canadian u n i v e r s i t i e s t o p r e p a r e q u a l i f i e d p u b l i c h e a l t h n u r s e s . The impetus f o r t h e s e programs i s thought t o have come from i n c r e a s e d awareness about the c r i t i c a l l a c k o f p u b l i c h e a l t h measures i n Canada i n the wake o f s e r i o u s i n f l u e n z a e p i d e m i c s i n 1918 and 1919 and the need t o b r i n g about improvements i n the h e a l t h o f the p o p u l a t i o n (Gray, 1932) . The most e x p e d i t i o u s method o f p r o d u c i n g the t y p e o f p e r s o n needed f o r g e n e r a l i z e d p u b l i c h e a l t h work was t o p r o v i d e p u b l i c h e a l t h t r a i n i n g f o r g raduate n u r s e s th rough s h o r t -term c o u r s e s . E a r l y p u b l i c h e a l t h n u r s i n g c o u r s e s , l a s t i n g from f o u r t e e n weeks t o s i x months, were i n i t i a t e d a t D a l h o u s i e U n i v e r s i t y , M c G i l l U n i v e r s i t y , and the U n i v e r s i t i e s o f T o r o n t o , Western O n t a r i o and B r i t i s h Columbia around 1920 (Gibbon & Mathewson,1947; G r a y , 1932) . D r . H. E s s o n Young was the d r i v i n g f o r c e b e h i n d the i n a u g u r a t i o n o f the p u b l i c h e a l t h c o u r s e f o r n u r s e s i n B r i t i s h C o l u m b i a ; d u r i n g the 1919-20 academic y e a r i t l a s t e d f o u r t e e n weeks and expanded t o n i n e months the f o l l o w i n g y e a r (Gray, 1942) . I n i t i a l f u n d i n g f o r t h i s c o u r s e and t h o s e o f f e r e d i n o t h e r p r o v i n c e s came from the Canadian Red C r o s s ( P o r t e r , 1960) . A t t h e same t i m e , another i n f l u e n c e on the development o f p u b l i c h e a l t h n u r s i n g was the e s t a b l i s h m e n t , i n 1919, o f a degree program i n n u r s i n g a t the U n i v e r s i t y o f B r i t i s h 56 Columbia. The Department of Nursing and Health offered a combined un i v e r s i t y and hospital t r a i n i n g course leading to the degree of Bachelor of Applied Science (in Nursing), as depicted i n Figure 4 (Gray,1932). The purpose of the u n i v e r s i t y course as explicated i n the 1944-45 calendar was: The University o f f e r s courses i n Nursing to students who desire to receive a broader education than can be secured i n a hospital school of nursing alone, and who wish, at the same time, to prepare themselves for teaching or supervisory positions i n schools of nursing or f o r Public Health Nursing service. (University of B r i t i s h Columbia, 1944, p. 241) Students enrolled i n the degree program spent two academic years at the University where they took arts and science courses along with other undergraduates. They then embarked on a 28-month period of nursing t r a i n i n g at the Vancouver General Hospital from which they emerged as graduate nurses. A f i n a l year was spent back at the University (see Figure 5) where the students had two options for t h e i r course of study: teaching and supervision i n schools of nursing or public health nursing. Starting i n 1954 these options were merged into a generalized f i n a l year for the degree students. During the f o r t i e s and f i f t i e s these courses were also available as c e r t i f i c a t e programs for graduate nurses meeting u n i v e r s i t y entrance c r i t e r i a (Gray, 1942). The public health nursing c e r t i f i c a t e course took ten months to complete and included p r a c t i c a l experience i n public health agencies. The u n i v e r s i t y calendar for the 1944-45 session 57 F i g u r e 4. Graduation Day a t the U n i v e r s i t y o f B r i t i s h Columbia, 1950. From l e f t t o r i g h t , E l i n o r P a l l i s e r , D i r e c t o r o f Nursing, Vancouver General H o s p i t a l ; S h e i l a g h Wheeler, Head of the Nursing g r a d u a t i n g c l a s s ; Ruth Mo r r i s o n , A s s i s t a n t P r o f e s s o r , U n i v e r s i t y o f B r i t i s h Columbia School of Nursing. Photo c o u r t e s y o f UBC A r c h i v e s . Figure 5. Students i n the Reading Room, University of B r i t i s h Columbia School of Nursing (Wesbrook Building) 1953. Photo courtesy of UBC Archives. 59 provides information on the public health nursing curriculum at that time; courses covered were preventive medicine, mental hygiene, infant and child health, sanitation, v i t a l s t a t i s t i c s , public health organization, principles of public health nursing, methods in health teaching, current nursing problems, principles of teaching, social case work, and sociology. This varied program shows that public health nursing knowledge was derived from a blend of public health science, education, sociology, and nursing. The calendar for 1944-45 offers a glimpse into the content of these courses. For instance, the course in sanitation was described as "a study of community sanitation and of relevant legislative measures" (p. 284). It involved one hour of instruction weekly and included f i e l d v i s i t s . Two hours per week were devoted to methods of health teaching which covered "the application of the principles of teaching to health instruction as carried out in the home, the school, and the community" (p. 285). Although preventive medicine was given the greatest emphasis (four hours per week), the students also spent much of their time on the social and health aspects of public health nursing (see Figure 6). During the forties and f i f t i e s nurses taking the certificate course outnumbered the degree students. In the early 1940s, for instance, there were about eight degree graduates per year who specialized in public health nursing 60 Figure 6. F i n a l year students having a l e c t u r e i n p u b l i c h e a l t h n u r s i n g , 1953. Photo courtesy of UBC A r c h i v e s 61 i n c o n t r a s t t o the 15 t o 25 nurses who completed the c e r t i f i c a t e course. By the 1950s, the u n i v e r s i t y program was a t t r a c t i n g more students so t h a t t h e r e were 25 degree graduates and 28 p u b l i c h e a l t h c e r t i f i c a t e r e c i p i e n t s per year on average (School o f Nursing Report, 1961). Fieldwork was an important component of p u b l i c h e a l t h t r a i n i n g and was pr o v i d e d i n b l o c k s o f two t o s i x weeks a t s e l e c t e d times d u r i n g the year. I t i s apparent t h a t p u b l i c h e a l t h placements i n v o l v e d students i n a d i f f e r e n t work environment from t h a t o f a h o s p i t a l . One such d i f f e r e n c e i s h i g h l i g h t e d by the advic e g i v e n i n the c a l e n d a r t h a t "candidates f o r admission t o Nursing B [the P u b l i c H e a l t h N u r s i n g c e r t i f i c a t e course] are urged t o o b t a i n i n s t r u c t i o n i n d r i v i n g a motor c a r and t o secure t h e i r d r i v e r ' s l i c e n c e " ( U n i v e r s i t y o f B r i t i s h Columbia, 1944, p.248). Norma C l a r k , a graduate o f the degree course i n 1947, r e c a l l s having a t o t a l o f t h r e e months of p u b l i c h e a l t h f i e l d w o r k d u r i n g her f i n a l y ear (personal communication, J u l y 11, 1988). She spent one month each with the V i c t o r i a n Order o f Nurses, M e t r o p o l i t a n H e a l t h o f Vancouver, and the P r o v i n c i a l H e a l t h Department; i n a l l cases s t a f f nurses p r o v i d e d o r i e n t a t i o n and f i e l d s u p e r v i s i o n . Students were g i v e n c o n s i d e r a b l e independence and freedom; f o r example, they made home v i s i t s on t h e i r own and c o u n s e l l e d mothers a t c h i l d h e a l t h c o n f e r e n c e s . O p p o r t u n i t i e s f o r f i e l d experience were p r o v i d e d by the f o l l o w i n g agencies: C h i l d r e n ' s A i d S o c i e t y 62 of Vancouver, P r o v i n c i a l H e a l t h Department, M e t r o p o l i t a n H e a l t h o f G r e a t e r Vancouver, Family Welfare Bureau of G r e a t e r Vancouver, P r o v i n c i a l Mental H o s p i t a l , P r o v i n c i a l D i v i s i o n of T u b e r c u l o s i s C o n t r o l , and the V i c t o r i a n Order of Nurses. The f o l l o w i n g passage d e s c r i b e s the r o l e of the P r o v i n c i a l H e a l t h Department i n t h i s r e gard: Student f i e l d experience i s p r o v i d e d f o r students from the U n i v e r s i t y of B r i t i s h Columbia i n s e l e c t e d areas throughout the P r o v i n c e t o p r o v i d e a p e r i o d of o r i e n t a t i o n t o the p u b l i c h e a l t h n u r s i n g program i n r u r a l communities, and t o p r o v i d e d e f i n i t e experience i n the v a r i o u s phases of g e n e r a l i z e d s e r v i c e . (Department of H e a l t h and Welfare, 1946, p. 41) Reports from i n d i v i d u a l h e a l t h u n i t s i n d i c a t e d a s u p p o r t i v e a t t i t u d e toward the student program, although t h e r e are no accounts found of what the students a c t u a l l y d i d . T h i s e x c e r p t from the 1957 Annual Report of the S e l k i r k H e a l t h U n i t i s t y p i c a l : We were p r i v i l e g e d t o have t h r e e students i n P u b l i c H e a l t h Nursing from the U n i v e r s i t y of B r i t i s h Columbia v i s i t us f o r a p e r i o d of one month f o r the purpose of having f i e l d - w o r k experience, (p.23) At p r o v i n c i a l h e a l t h u n i t s the students were s u p e r v i s e d by experienced p u b l i c h e a l t h nurses who i n t r o d u c e d them t o r u r a l p u b l i c h e a l t h . The 1956 Report of the D i v i s i o n of P u b l i c H e a l t h Nursing r e v e a l s t h a t 29 students were assig n e d t o v a r i o u s communities f o r f i e l d w o r k ; these i n c l u d e d Vernon, Kamloops, Kelowna, C h i l l i w a c k , Nakusp, New Denver, and P o r t A l b e r n i (Department of H e a l t h and Welfare, 1956, p. 51). The P r o v i n c i a l H e a l t h Department s u b s i d i z e d the s t u d e n t s 7 t r a n s p o r t a t i o n t o f i e l d w o r k l o c a t i o n s ; t h i s was of 63 c o n s i d e r a b l e b e n e f i t because of the d i s t a n c e s i n v o l v e d . During t h a t year the Cariboo H e a l t h U n i t p r o v i d e d placements f o r two students from the U n i v e r s i t y o f Saskatchewan. The d i v e r s i t y o f f i e l d experiences a v a i l a b l e t o the students gave o p p o r t u n i t i e s t o apply content from t h e i r classroom l e a r n i n g t o the p r a c t i c e s i t u a t i o n . From the p r e c e d i n g account, i t can be seen t h a t the t h e o r e t i c a l and c l i n i c a l a s pects of the u n i v e r s i t y program c o n t r i b u t e d t o a comprehensive n u r s i n g e d u c a t i o n . There i s , however, a q u e s t i o n t h a t m e r i t s f u r t h e r c o n s i d e r a t i o n i n t h i s r e g a r d : Did the n u r s i n g e d u c a t i o n of the time p r o v i d e a p p r o p r i a t e p r e p a r a t i o n f o r a c a r e e r i n p u b l i c h e a l t h nursing? As d i s c u s s e d above, t h e r e were two e d u c a t i o n a l paths t o becoming a q u a l i f i e d PHN: a one-year c e r t i f i c a t e course f o l l o w i n g nurses t r a i n i n g and a degree program t h a t i n c l u d e d p u b l i c h e a l t h courses. On f i r s t g l ance these o p t i o n s appear d i s s i m i l a r , but on c l o s e r examination i t i s apparent t h a t the same amount of p u b l i c h e a l t h content was i n c l u d e d i n both programs. For the degree students, the p u b l i c h e a l t h content was not covered u n t i l the f i n a l year a t which p o i n t they took the same courses as the nurses e n r o l l e d i n the c e r t i f i c a t e course. Thus, f o r both groups o f s t u d e n t s , p u b l i c h e a l t h concepts were added on t o a b a s i c n u r s i n g e d u c a t i o n ; the students had t o s h i f t t h e i r t h i n k i n g from the s i c k n e s s and c u r a t i v e o r i e n t a t i o n of the h o s p i t a l t o the w e l l n e s s and p r e v e n t i v e outlook of p u b l i c h e a l t h . 64 I t can be argued, however, t h a t the degree r o u t e t o p u b l i c h e a l t h n u r s i n g gave students the advantage o f knowledge and academic s k i l l s t h a t would prove b e n e f i c i a l i n t h e i r p r o f e s s i o n a l c a r e e r s . Moreover, the f i r s t two years o f u n i v e r s i t y study (and involvement i n u n i v e r s i t y l i f e ) may have served t o broaden the st u d e n t s ' outlooks on l i f e , c l e a r l y an a s s e t i n p u b l i c h e a l t h work. N e v e r t h e l e s s , the f a c t remains t h a t h o s p i t a l t r a i n i n g had a s i g n i f i c a n t s o c i a l i z i n g e f f e c t on these women; i n no way was i t conducive t o p r e p a r i n g nurses f o r work t h a t r e q u i r e d independence i n thought and judgment (Kennedy, 1987; R u s s e l l , 1933; Wallace, 1946). T h i s was a fundamental weakness i n the approach t o educating p u b l i c h e a l t h nurses. At the time c e r t a i n l e a d e r s i n Canadian p u b l i c h e a l t h n u r s i n g questioned the adequacy of t h i s type o f t r a i n i n g . One o f these was F l o r e n c e Emory, P r e s i d e n t o f CNA from 1930-1934 and the A s s o c i a t e D i r e c t o r o f the School o f Nursing a t the U n i v e r s i t y o f Toronto. In an e d i t o r i a l i n the Canadian  J o u r n a l o f P u b l i c Health, she s t r e s s e d the importance o f sound q u a l i f i c a t i o n s f o r p u b l i c h e a l t h n u r s i n g and the need t o a t t r a c t "young women of i n t e l l i g e n c e " (1942, p. 525) t o f i l l l e a d e r s h i p p o s i t i o n s i n an expanding f i e l d . Emory b e l i e v e d t h a t PHNs had a s i g n i f i c a n t r o l e as p r o f e s s i o n a l s i n t he community and, as such, r e q u i r e d a p r o f e s s i o n a l e d u c a t i o n o f a h i g h standard (1946). In her a u t h o r i t a t i v e textbook, P u b l i c H e a l t h Nursing i n Canada (1953), she 65 devoted a c h a p t e r t o the i s s u e o f p u b l i c h e a l t h p r e p a r a t i o n about which she wro te : The v a l i d i t y o f add ing one academic y e a r o f s p e c i a l i z e d work t o a b a s i c t r a i n i n g i n n u r s i n g and c a l l i n g the p r o d u c t a q u a l i f i e d p u b l i c h e a l t h nurse i s g r a v e l y q u e s t i o n e d . However, f o r f i n a n c i a l and o t h e r reasons t h i s t y p e o f p r e p a r a t i o n i s l i k e l y t o c o n t i n u e t o be t h e c h i e f s o u r c e f o r p r o v i d i n g s t a f f workers f o r the f i e l d . T h i s b e i n g so the c e r t i f i c a t e c o u r s e s h o u l d be made as r i c h as p o s s i b l e w i t h i n the l i m i t a t i o n s imposed, (p. 83-84) An a l t e r n a t i v e method o f e d u c a t i o n t h a t i n t e g r a t e d p r e v e n t i v e and c u r a t i v e a s p e c t s o f n u r s i n g i n an independent n u r s i n g s c h o o l was c o n s i d e r e d by some as a more a p p r o p r i a t e way o f p r e p a r i n g PHNs. In Canada the f i r s t u n i v e r s i t y program o f t h i s n a t u r e was i n i t i a t e d i n 1933 under the d i r e c t i o n o f E . K a t h l e e n R u s s e l l a t the U n i v e r s i t y o f T o r o n t o ( R u s s e l l , 1933, 1938) . The program grew from R u s s e l l ' s c o n v i c t i o n t h a t the p r e p a r a t i o n o f n u r s e s s h o u l d be based on sound e d u c a t i o n a l p r i n c i p l e s and a c u r r i c u l u m t h a t had h e a l t h as i t s f o c u s . An impor tan t f e a t u r e o f the U n i v e r s i t y o f T o r o n t o program was i t s independence from any one h o s p i t a l ; s t u d e n t s r e c e i v e d c l i n i c a l e x p e r i e n c e i n a v a r i e t y o f community and i n s t i t u t i o n a l s e t t i n g s . In 1942 a f o u r - y e a r c o u r s e , l e a d i n g t o the B a c h e l o r o f S c i e n c e i n N u r s i n g d e g r e e , was e s t a b l i s h e d t o r e p l a c e the t h r e e - y e a r program. I t p r o v i d e d g e n e r a l i z e d p r e p a r a t i o n f o r p u b l i c h e a l t h , h o s p i t a l , and home n u r s i n g th rough the i n t e g r a t i o n o f r e l e v a n t t h e o r y and c l i n i c a l p r a c t i c e th roughout the f o u r y e a r s . The U n i v e r s i t y o f T o r o n t o program s e r v e d as the 66 p r o t o t y p e f o r " g e n e r i c b a c c a l a u r e a t e n u r s i n g e d u c a t i o n " (Allemang, 1985, p. 25) i n Canada. Notwithstanding the advantages of t h i s method, the predominant approach t o p r e p a r a t i o n o f PHNs d u r i n g the f o r t i e s and f i f t i e s was the one y e a r c e r t i f i c a t e course (Canadian P u b l i c H e a l t h A s s o c i a t i o n , 1950; U n i v e r s i t y o f B r i t i s h Columbia School o f Nursing, 1961). Another matter c l o s e l y a s s o c i a t e d w i t h b a s i c e d u c a t i o n f o r those e n t e r i n g the p u b l i c h e a l t h n u r s i n g f i e l d was funding. Grants t o u n i v e r s i t i e s from o r g a n i z a t i o n s such as the R o c k e f e l l e r and K e l l o g g Foundations made i t p o s s i b l e f o r courses t o be o f f e r e d i n a l l aspects o f p u b l i c h e a l t h (Canadian P u b l i c H e a l t h A s s o c i a t i o n , 1942). S c h o l a r s h i p s t o nurses u n d e r t a k i n g p u b l i c h e a l t h courses were a l s o p r o v i d e d by these p h i l a n t h r o p i e s . The need f o r t r a i n i n g funds was a common theme i n a r t i c l e s and e d i t o r i a l s t h a t appeared i n the f o r t i e s . In 1942, f o r i n s t a n c e , a r t i c l e s p u b l i s h e d i n the Canadian Nurse f c o n t r i b u t e d by the P u b l i c H e a l t h Nursing S e c t i o n o f the CNA, c a l l e d f o r g r e a t e r funding f o r s c h o o l s of n u r s i n g (Chodat, 1942) and s t r e s s e d the need f o r s c h o l a r s h i p s and loans t o encourage nurses t o take p u b l i c h e a l t h t r a i n i n g (Kerr, 1942). At t h a t time Margaret Kerr (from the Department of Nursing and H e a l t h a t the U n i v e r s i t y of B r i t i s h Columbia and, subsequently, E d i t o r o f the Canadian Nurse) was the chairman o f the P u b l i c H e a l t h S e c t i o n . Under her guidance an e x t e n s i v e s e t of 67 recommendations f o r minimum q u a l i f i c a t i o n s was drawn up and p r e s e n t e d t o CNA. A c c o r d i n g t o the Report o f S t u d i e s  Regarding Minimum Requirements f o r Employment i n the F i e l d  o f P u b l i c H e a l t h Nursing (Kerr, 1942), an i n t e g r a l p a r t of any p l a n t o r a i s e standards was the a v a i l a b i l i t y o f funding. In 1948, the f e d e r a l government embarked on the N a t i o n a l H e a l t h Program t o combat some of the major h e a l t h problems i n Canada; one p a r t of t h i s scheme i n v o l v e d the a l l o c a t i o n of funds f o r p r o f e s s i o n a l t r a i n i n g (Martin, 1948). Each year approximately 10 t o 15 nurses working f o r the P r o v i n c i a l H e a l t h Department i n B r i t i s h Columbia were awarded these g r a n t s t o take the one year p u b l i c h e a l t h course a f t e r p r o m i s i n g t o serve f o r two years as p r o v i n c i a l p u b l i c h e a l t h nurses upon completion of the program. The terms of these g r a n t s were c o n s i d e r e d "most generous," a c c o r d i n g t o the 1955 Annual Report of the D i v i s i o n of P u b l i c H e a l t h Nursing (p. 51); b u r s a r i e s covered t u i t i o n f e e s ($240 f o r the c e r t i f i c a t e course a t the U n i v e r s i t y of B r i t i s h Columbia), books, and p r o v i d e d $100 per month f o r l i v i n g expenses. At t h a t time t h e r e was a s c a r c i t y of housing on campus, but room and board were a v a i l a b l e i n the a d j a c e n t r e s i d e n t i a l d i s t r i c t f o r a monthly r a t e of $55-$60 w i t h l i g h t housekeeping rooms i n the $25-$30 range ( U n i v e r s i t y of B r i t i s h Columbia, 1955). Grant r e c i p i e n t s had the freedom t o a t t e n d the u n i v e r s i t y of t h e i r c h o i c e ; some chose the programs a t M c G i l l , U n i v e r s i t y o f Western 68 O n t a r i o , and U n i v e r s i t y o f Saskatchewan w h i l e o t h e r s remained i n the p r o v i n c e a t the U n i v e r s i t y o f B r i t i s h Columbia. There i s no mention i n the departmental r e p o r t s about fun d i n g f o r t r a v e l t o o u t - o f - p r o v i n c e u n i v e r s i t i e s ; presumably t h i s expense was the r e s p o n s i b i l i t y o f the i n d i v i d u a l . Over time, these g r a n t s were r e c e i v e d by nurses who made a s u b s t a n t i a l c o n t r i b u t i o n t o i n c r e a s i n g the number of q u a l i f i e d p u b l i c h e a l t h nurses i n the p r o v i n c i a l n u r s i n g s e r v i c e . During the twelve year p e r i o d from the i n c e p t i o n o f the N a t i o n a l H e a l t h Grant bu r s a r y program i n 1948 t o 1960, 91 nurses r e c e i v e d p u b l i c h e a l t h t r a i n i n g ; over 80% remained w i t h the H e a l t h Department f o r t h r e e years o r l o n g e r (Department of Hea l t h S e r v i c e s and H o s p i t a l Insurance, 1960). I t i s e v i d e n t t h a t the a v a i l a b i l i t y o f both shor t - t e r m courses i n p u b l i c h e a l t h and t r a i n i n g b u r s a r i e s g r e a t l y expanded the supply of PHNs. T h i s was an e f f i c i e n t and e f f e c t i v e way of p r e p a r i n g a l a r g e number of p u b l i c h e a l t h workers f o r the H e a l t h Department's purposes. I t should be p o i n t e d out t h a t , although these women h e l d a c e r t i f i c a t e from a u n i v e r s i t y , they had not r e c e i v e d a u n i v e r s i t y degree; t h i s c o n s t r a i n e d t h e i r o p p o r t u n i t i e s f o r advancement w i t h i n the H e a l t h Department and elsewhere. Thus, the bu r s a r y program can be viewed p r i m a r i l y as one t h a t b e n e f i t e d the employer wi t h a secondary b e n e f i t t o the 69 employee. I t i s p o s s i b l e t h a t c o n t i n u i n g support f o r s h o r t -term t r a i n i n g f o r PHNs hindered the advancement of p u b l i c h e a l t h n u r s i n g as a p r o f e s s i o n a l e n t i t y because i t delayed making the b a c c a l a u r e a t e degree a requirement f o r p r a c t i c e . As the p u b l i c h e a l t h s e r v i c e expanded, the need arose f o r q u a l i f i e d people t o take on s u p e r v i s o r y and a d m i n i s t r a t i v e f u n c t i o n s . By p r o v i d i n g study l e a v e s and p r o c u r i n g funding, the D i v i s i o n was a b l e t o send p o t e n t i a l l e a d e r s f o r advanced education. In the 1940s s e v e r a l nurses were r e c i p i e n t s o f R o c k e f e l l e r and Commonwealth s c h o l a r s h i p s ; they used these t o study a t i n s t i t u t i o n s such as the Johns Hopkins School of P u b l i c H e a l t h and the U n i v e r s i t y o f Michigan. A number of the D i v i s i o n ' s l e a d e r s r e c e i v e d t h e i r p r e p a r a t i o n i n t h i s way. For example, i n the e a r l y f o r t i e s Dorothy Tate was a s t a f f member who was awarded a R o c k e f e l l e r F e l l o w s h i p t o at t e n d Columbia U n i v e r s i t y from which she earned a Master of A r t s degree i n p u b l i c h e a l t h n u r s i n g a d m i n i s t r a t i o n . By 1944 she was appointed as D i r e c t o r o f the P u b l i c H e a l t h Nursing D i v i s i o n . Her s u c c e s s o r i n 1948, Monica F r i t h , was another PHN who had been sent f o r graduate s t u d i e s a t an American u n i v e r s i t y . She was a r e c i p i e n t o f a Commonwealth F e l l o w s h i p which f i n a n c e d her s t u d i e s a t the U n i v e r s i t y o f Michigan and a K e l l o g g F e l l o w s h i p which gave her the o p p o r t u n i t y t o have f i e l d e x p e r i e n c e i n f i v e s t a t e s b e f o r e r e t u r n i n g t o B r i t i s h Columbia ( P r o v i n c i a l Board o f Health, 1944). Other s e n i o r 70 s t a f f attended the U n i v e r s i t y of Toronto and M c G i l l where postgraduate programs i n s u p e r v i s i o n and a d m i n i s t r a t i o n were o f f e r e d . In examining the outcomes of these e f f o r t s t o prepare s p e c i a l i s t s and a d m i n i s t r a t o r s , i t i s noteworthy t h a t s e v e r a l p o t e n t i a l l e a d e r s who were sent t o E a s t e r n Canada or the U n i t e d S t a t e s f o r advanced educ a t i o n d i d not remain i n the p r o v i n c e f o r t h e i r e n t i r e c a r e e r s . I t may be t h a t t h e i r exposure t o people and p l a c e s o u t s i d e t h e i r home p r o v i n c e i n s t i l l e d i n them the d e s i r e f o r g r e a t e r c h a l l e n g e s o r a more cosmopolitan l i f e . Margaret Cammaert and L u c i l l e Giovando were two Consultant PHNs i n the H e a l t h Department who l e f t t o j o i n the World H e a l t h O r g a n i z a t i o n (WHO) i n the m i d - f i f t i e s . In a d d i t i o n , s e v e r a l l e a d e r s who h e l d s e n i o r p o s i t i o n s i n p r o v i n c i a l and m e t r o p o l i t a n p u b l i c h e a l t h n u r s i n g were p a r t of t h i s exodus. They i n c l u d e d L y l e Creelman who l e f t her p o s i t i o n as D i r e c t o r of P u b l i c H e a l t h Nursing i n Vancouver t o work f o r a war r e l i e f agency, U n i t e d Nations R e l i e f and R e h a b i l i t a t i o n A d m i n i s t r a t i o n (UNRRA) and, l a t e r , t o become C h i e f of the Nursing D i v i s i o n of WHO); Heather K i l p a t r i c k , the f i r s t D i r e c t o r of PHN f o r the P r o v i n c i a l Board of H e a l t h who r e s i g n e d i n 1944 t o do UNRRA work overseas; and Nan Kennedy, S e n i o r Nurse i n the Upper F r a s e r V a l l e y H e a l t h U n i t , who became a nurse t u t o r i n P a k i s t a n and I r a n w i t h WHO. Although p u b l i c h e a l t h n u r s i n g i n B r i t i s h Columbia l o s t some of i t s l e a d e r s h i p , these 71 i n d i v i d u a l s made an important c o n t r i b u t i o n i n t e r n a t i o n a l l y . In some i n s t a n c e s , a f t e r s e v e r a l years overseas, they r e t u r n e d t o t h e i r home p r o v i n c e w i t h a world view t h a t undoubtedly enhanced t h e i r p r a c t i c e . Likewise, B r i t i s h Columbia b e n e f i t e d by importing t a l e n t from o t h e r p r o v i n c e s and c o u n t r i e s d u r i n g t h i s p e r i o d . In 1948, f o r example, the P r o v i n c i a l H e a l t h Department h i r e d PHNs from Manitoba, O n t a r i o , Oregon, M i s s o u r i , and England (Canadian Nurses A s s o c i a t i o n , 1948). O v e r a l l , funding f o r l e a d e r s h i p development was u s e f u l because i t f a c i l i t a t e d the p r e p a r a t i o n o f a c o l l e c t i v e r e source from which the P r o v i n c i a l H e a l t h Department was abl e t o draw c e r t a i n i n d i v i d u a l s f o r e x e c u t i v e p o s i t i o n s . To summarize t h i s s e c t i o n : the scope and nature o f p u b l i c h e a l t h n u r s i n g r e q u i r e d e d u c a t i o n a l p r e p a r a t i o n beyond t h a t o f a graduate nurse. In B r i t i s h Columbia t h i s need was r e c o g n i z e d i n the 1920s and every e f f o r t was made by the Department o f Hea l t h t o secure and r e t a i n w e l l -q u a l i f i e d s t a f f members (Board of Hea l t h , 1941; Department o f H e a l t h and Welfare, 1950). Beginning i n 1928, the B r i t i s h Columbia H e a l t h Department r e q u i r e d a p u b l i c h e a l t h n u r s i n g c e r t i f i c a t e o r a n u r s i n g degree f o r permanent appointments t o the P u b l i c H e a l t h Nursing S e r v i c e (Department of H e a l t h and Welfare, 1950). The access o f p r o v i n c i a l nurses t o the degree and c e r t i f i c a t e programs a t the U n i v e r s i t y o f B r i t i s h Columbia f a c i l i t a t e d t h i s p rocess 72 as d i d the a v a i l a b i l i t y of s c h o l a r s h i p s . In 1951, 38% of new appointees t o PHN p o s i t i o n s l a c k e d the d e s i r e d q u a l i f i c a t i o n s (Department of H e a l t h and Welfare, 1951); by 1959, however, 94% of the n u r s i n g s t a f f were q u a l i f i e d PHNs (Department of H e a l t h S e r v i c e s and H o s p i t a l Insurance, 1959). During t h i s p e r i o d t h e r e was c o n t r o v e r s y over what c o n s t i t u t e d a s u i t a b l e e d u c a t i o n a l background f o r p u b l i c h e a l t h n u r s i n g p r a c t i c e ; although some l e a d e r s c a l l e d f o r h i g h e r standards and a movement i n t o i n t e g r a t e d u n i v e r s i t y programs, the one year c e r t i f i c a t e courses f o r graduate nurses a t t r a c t e d the most can d i d a t e s . During the 1939 t o 1959 p e r i o d t h e r e was an i n c r e a s e i n the number of nurses prepared f o r both s t a f f and a d m i n i s t r a t i v e p o s i t i o n s . As shown i n the p r e c e d i n g paragraphs, e d u c a t i o n was a major i n f l u e n c e on the development of p u b l i c h e a l t h n u r s i n g d u r i n g the f o r t i e s and f i f t i e s . S t a f f Development Once on the job, PHNs were ab l e t o a v a i l themselves of o p p o r t u n i t i e s f o r c o n t i n u i n g e d u c a t i o n . The P r o v i n c i a l H e a l t h Department p r o v i d e d s t a f f development, the scope of which ranged from l o c a l study groups t o p r o v i n c i a l meetings and n a t i o n a l conferences (Department of H e a l t h and Welfare, 1956). The most b a s i c p a r t of the s t a f f development program took p l a c e a t the l o c a l l e v e l and began wi t h the o r i e n t a t i o n of new s t a f f t o the h e a l t h u n i t . The amount of o r i e n t a t i o n 73 and i n i t i a l s u p e r v i s i o n r e q u i r e d depended on the background o f the new employee. The shortage of q u a l i f i e d PHNs n e c e s s i t a t e d the h i r i n g of temporary nurses who l a c k e d p u b l i c h e a l t h p r e p a r a t i o n ; these nurses needed an e x t e n s i v e o r i e n t a t i o n t o d i s t r i c t n u r s i n g . A c c o r d i n g t o the D i r e c t o r ' s Report f o r 1949, the s e n i o r nurses were r e s p o n s i b l e f o r a r r a n g i n g t h i s "time-consuming" (p. 53) o r i e n t a t i o n . In cases of q u a l i f i e d PHNs, o r i e n t a t i o n was l e s s p r o b l e m a t i c ; i t u s u a l l y i n v o l v e d f a m i l i a r i z a t i o n w i t h the d i s t r i c t w h i l e the outgoing PHN was s t i l l p r e s e n t . New employees from other p r o v i n c e s r e c e i v e d an o r i e n t a t i o n t o the o r g a n i z a t i o n a l s t r u c t u r e of the H e a l t h Department (Department of H e a l t h and Welfare, 1949). In a paper presented a t the 194 6 Conference o f the Canadian P u b l i c H e a l t h A s s o c i a t i o n , Dorothy Tate ( D i r e c t o r o f the D i v i s i o n of P u b l i c H e a l t h Nursing a t the time) d e s c r i b e d the v a r i o u s o p p o r t u n i t i e s f o r p r o f e s s i o n a l growth a v a i l a b l e t o P r o v i n c i a l PHNs. She p o i n t e d out t h a t the p r o v i s i o n of a v a r i e t y of experiences was an important aspect o f the s t a f f development program: To a s s i s t the nurse t o m a i n t a i n an ' a l i v e ' i n t e r e s t , she i s g i v e n the o p p o r t u n i t y of a t r a n s f e r t o a d i f f e r e n t type of d i s t r i c t where she may have more r e s p o n s i b i l i t y . I t i s our p o l i c y t o o f f e r inducements t o p u b l i c h e a l t h nurses t o t r a n s f e r every two, t h r e e o r f o u r y e a r s . (Tate, 1946, p. 497) H e a l t h u n i t r e p o r t s f o r t h i s time c e r t a i n l y r e f l e c t t h i s p o l i c y — t h e r e were frequent t r a n s f e r s of s t a f f from one u n i t t o another, sometimes a f t e r o n l y one year. For example, the 74 r e p o r t s from the South C e n t r a l H e a l t h U n i t (1952, 1953, 1954, 1955) show frequent t u r n o v e r from year t o year: a comparison of the s t a f f l i s t s f o r t h i s p e r i o d r e v e a l e d t h a t t h e r e had been a complete changeover i n p u b l i c h e a l t h n u r s i n g s t a f f from 1952 t o 1954. Although t h i s p o l i c y was j u s t i f i e d on the grounds of adding v a r i e t y and breadth t o n u r s e s ' experiences (Department of H e a l t h and Welfare, 1946), t h e r e were s e v e r a l drawbacks. T r a n s f e r r i n g a f t e r one o r two y ears i n a h e a l t h u n i t prevented nurses from g e t t i n g t o know any one community w e l l . Loss of s t a f f due t o t r a n s f e r s and r e s i g n a t i o n s w i t h i n s h o r t p e r i o d s may have l e d t o l a c k of c o n t i n u i t y i n h e a l t h u n i t programs. On the p e r s o n a l s i d e , i t i s p o s s i b l e t h a t i t i n t e r f e r e d w i t h nurses forming s t r o n g r e l a t i o n s h i p s w i t h c o l l e a g u e s and l i m i t e d t h e i r s o c i a l l i f e i n the community. F u r t h e r , i t must have been u p s e t t i n g t o members of the p u b l i c t o f a c e numerous changes i n h e a l t h u n i t s t a f f . N e v e r t h e l e s s , t h e r e was m e r i t i n having a s y s t e m a t i c p l a n f o r s t a f f advancement w i t h i n the D i v i s i o n . PHNs who were judged t o posses l e a d e r s h i p p o t e n t i a l were encouraged t o accept new c h a l l e n g e s and were g r a d u a l l y g i v e n more r e s p o n s i b i l i t y (Tate, 1946). As mentioned p r e v i o u s l y , p o t e n t i a l l e a d e r s were g i v e n funding t o pursue advanced education and were expected t o take on s e n i o r p o s i t i o n s upon t h e i r r e t u r n . I n - s e r v i c e e d u c a t i o n was most a p p r o p r i a t e l y c a r r i e d out a t the l o c a l l e v e l ; t h e r e f o r e , time was s e t a s i d e f o r 75 monthly meetings and study groups f o r a l l the nurses i n a r e g i o n . T o p i c s were chosen a c c o r d i n g t o the needs i d e n t i f i e d by the PHNs: i n 1951, f o r i n s t a n c e , some of the groups s t u d i e d p r e n a t a l care, c i v i l defence, and the B a i l l i e - C r e e l m a n Report ( Department of H e a l t h and Welfare, 1951) . Sometimes an expert was i n v i t e d t o speak on a t o p i c ; a t o t h e r times the nurses h e l d i n f o r m a l d i s c u s s i o n s o r d i d some p l a n n i n g f o r a new program (South C e n t r a l H e a l t h U n i t , 1952) . I t i s l i k e l y t h a t these monthly meetings were a p p r e c i a t e d by s t a f f because many of them worked i n one-nurse o f f i c e s and were separated by a d r i v e o f s e v e r a l hours from t h e i r n e a r e s t c o l l e a g u e . Another aspect o f s t a f f development came i n the form of a monthly n e w s l e t t e r , P u b l i c  H e a l t h News and Views, produced by the H e a l t h Department s t a f f i n V i c t o r i a , t o which f i e l d s t a f f c o n t r i b u t e d (Department of H e a l t h and Welfare, 1946). The n e w s l e t t e r , c o n t a i n i n g book reviews, i n f o r m a t i o n updates, i d e a s from study groups, and personnel items, was d i s t r i b u t e d t o every u n i t . Apart from i t s e d u c a t i o n a l v a l u e , i t was an important communication l i n k f o r the PHNs around the p r o v i n c e (Board of H e a l t h , 1943). From time t o time, o p p o r t u n i t i e s were made a v a i l a b l e f o r s t a f f t o a t t e n d conferences o r s h o r t courses. In 1948, the need t o equip s e n i o r nurses f o r s u p e r v i s o r y p o s i t i o n s l e d the Department t o o f f e r a two-week course i n p u b l i c h e a l t h n u r s i n g s u p e r v i s i o n (see F i g u r e 7 ) . In 1954, a l l 76 F i g u r e 7. P r o v i n c i a l PHNs a t t e n d i n g the f i r s t s u p e r v i s o r y course i n V i c t o r i a , 1948. Photo c o u r t e s y of Nan Kennedy. Used w i t h p e r m i s s i o n . 77 s e n i o r n u r s e s , s u p e r v i s o r s , a n d PHNs w i t h s e n i o r i t y a t t e n d e d a p e d i a t r i c r e f r e s h e r c o u r s e , f u n d e d b y a N a t i o n a l H e a l t h G r a n t , i n V a n c o u v e r ( D e p a r t m e n t o f H e a l t h a n d W e l f a r e , 1 9 5 4 ) . J o i n t l y s p o n s o r e d a n d p l a n n e d b y t h e P u b l i c H e a l t h N u r s i n g D i v i s i o n a n d t h e D e p a r t m e n t o f P e d i a t r i c s a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a , t h e two-week c o u r s e c o v e r e d p r e n a t a l c a r e , common c h i l d h o o d c o m p l a i n t s , e m o t i o n a l d e v e l o p m e n t , a n d a l s o i n c l u d e d v i s i t s t o s e v e r a l p e d i a t r i c f a c i l i t i e s . On s e v e r a l o c c a s i o n s t h e D i v i s i o n o r g a n i z e d c o n t i n u i n g e d u c a t i o n c o u r s e s a n d b r o u g h t i n e x p e r t s t o meet p a r t i c u l a r p r o g r a m n e e d s . One s u c h c o u r s e was h e l d i n Nana i m o i n 1957 on t h e s u b j e c t o f p r e n a t a l s e r v i c e s ; 35 s e n i o r n u r s i n g s t a f f a t t e n d e d t h i s two-week s e s s i o n c o n d u c t e d b y a C o n s u l t a n t f r o m t h e M a t e r n i t y C e n t r e i n New Y o r k . A f t e r c o m p l e t i n g t h i s p r o g r a m , t h e p a r t i c i p a n t s w e r e r e s p o n s i b l e f o r s h a r i n g t h e i n f o r m a t i o n w i t h t h e f i e l d s t a f f a n d f o r u p d a t i n g t h e m a t e r i a l s a n d a p p r o a c h e s u s e d i n p r e n a t a l e d u c a t i o n a n d home v i s i t i n g . The f o l l o w i n g y e a r , t e n s t a f f n u r s e s w e r e s e l e c t e d l o c a l l y t o a t t e n d t h e A n n u a l C o n f e r e n c e o f t h e C a n a d i a n P u b l i c H e a l t h A s s o c i a t i o n i n Edmonton. A c c o r d i n g t o t h e 1955 A n n u a l R e p o r t , t h e s e n u r s e s b e n e f i t e d b y o b t a i n i n g i n f o r m a t i o n a b o u t new p r o g r a m s a n d b y m e e t i n g p u b l i c h e a l t h s t a f f f r o m a l l p a r t s o f C a n a d a . D u r i n g 1 9 5 5, a l s o , a PHN p a r t i c i p a t e d i n a n u r s i n g e x c h a n g e p r o g r a m a n d s p e n t t h e y e a r w o r k i n g i n E n g l a n d ( D e p a r t m e n t o f H e a l t h a n d W e l f a r e , 78 1955). Although l i t t l e d e t a i l i s a v a i l a b l e on how the arrangements were made, the i d e a o f such exchanges was viewed f a v o u r a b l y by the D i r e c t o r of P u b l i c H e a l t h Nursing who expressed her hope t h a t "the experience gained w i t h t h i s type o f h e a l t h agency w i l l j u s t i f y the e x t e n s i o n o f an exchange p l a n f o r p u b l i c h e a l t h nurses t o oth e r c o u n t r i e s " (Department o f H e a l t h and Welfare, 1955, p. 52). T h i s was a novel method of job enrichment, but t h e r e was no mention i n r e p o r t s f o r the l a t t e r p a r t o f the f i f t i e s t h a t t h i s experiment was ever repeated. Beyond l o c a l study groups and s p e c i a l courses, d e s c r i b e d above, t h e r e was another major event t h a t c o n t r i b u t e d t o s t a f f development: the annual " P u b l i c H e a l t h I n s t i t u t e " (Board o f Health, 1941). The I n s t i t u t e came i n t o b e i n g i n 1941 and was an expanded v e r s i o n of r e f r e s h e r courses t h a t had been o f f e r e d i n the pas t . I t s purpose was t o b r i n g t o g e t h e r a l l the Board of H e a l t h e m ployees— s a n i t a r i a n s , medical h e a l t h o f f i c e r s , and p u b l i c h e a l t h n u r s e s — f o r a c o n t i n u i n g education program (see F i g u r e 8 ) . N a t i o n a l and i n t e r n a t i o n a l a u t h o r i t i e s i n the p u b l i c h e a l t h f i e l d were brought i n as speakers and t h e r e were a l s o s e s s i o n s on p o l i c y changes and program reviews. The b e n e f i t s f o r PHNs were o u t l i n e d i n the D i r e c t o r ' s r e p o r t f o r 1950: The Annual I n s t i t u t e remains one of the most popu l a r and e f f e c t i v e methods of s t a f f e ducation. Here members of t he s t a f f have the o p p o r t u n i t y o f d i s c u s s i n g t h e i r h e a l t h problems i n an o b j e c t i v e manner i n r e l a t i o n t o 79 s i m i l a r problems throughout the Province, away from the immediate demands of the d i s t r i c t . (Department of H e a l t h and Welfare, 1950, p. 42) I t i s apparent t h a t one of the c h i e f advantages of the I n s t i t u t e , a p a r t from i t s e d u c a t i o n a l v a l u e , was the chance i t a f f o r d e d PHNs t o meet, exchange i d e a s , and b u i l d bonds (see F i g u r e 8 ) . In p a r t i c u l a r , the nurses who worked alone i n remote areas must have a p p r e c i a t e d the group support. The venue, d u r i n g the f o r t i e s and f i f t i e s , was another a t t r a c t i v e a spect: i t was h e l d a t the Empress H o t e l i n V i c t o r i a d u r i n g the E a s t e r h o l i d a y p e r i o d . A week i n V i c t o r i a i n the S p r i n g was undoubtedly a bonus f o r the nurses from the i n t e r i o r and n o r t h of the p r o v i n c e . P a r t i c i p a n t s p a i d f o r t h e i r accommodation and meals and the H e a l t h Department f i n a n c e d the program, t r a n s p o r t a t i o n , and a banquet. A c c o r d i n g t o Monica Green (1984), who was a s t a f f nurse i n the e a r l y f o r t i e s and then became D i r e c t o r i n 1948, the s o c i a l component served as a morale bo o s t e r f o r s t a f f . The h i g h l i g h t of the s o c i a l program was the annual banquet where s t a f f performed s k i t s s a t i r i z i n g t h e i r work s i t u a t i o n s . As the H e a l t h Department expanded and a c q u i r e d more s p e c i a l i z e d s t a f f members, the need arose f o r separate s e s s i o n s a t the I n s t i t u t e f o r the v a r i o u s d i s c i p l i n e s (Department of H e a l t h and Welfare, 1951). In 1952, f o r i n s t a n c e , the nurses had one f u l l day of s t r i c t l y p u b l i c h e a l t h n u r s i n g content. Papers were presented on t r e n d s i n F i g u r e 8. P u b l i c h e a l t h s t a f f on the s t e p s o f the Parl i a m e n t B u i l d i n g s , V i c t o r i a , a t the time of the Annual I n s t i t u t e , 1949. Photo c o u r t e s y of Norma C l a r k . Used wi t h p e r m i s s i o n . 81 maternal c a r e , v i s i o n - t e s t i n g , and the f a m i l y o f the t u b e r c u l o s i s p a t i e n t ; the day concluded w i t h a panel d i s c u s s i o n on n u r s i n g s u p e r v i s i o n (Department of H e a l t h and Welfare, 1952, p. 40). Thus, the program was geared t o the p r a c t i c e needs and c u r r e n t i n t e r e s t s o f the s t a f f nurses. I t i s e v i d e n t t h a t the P r o v i n c i a l H e a l t h Department o f f e r e d a s t a f f development program t h a t was designed t o meet the c o n t i n u i n g e d u c a t i o n needs of PHNs. As d e t a i l e d above, t h e r e were v a r i o u s means of s t i m u l a t i n g the exchange o f i d e a s among the nurses and f a c i l i t a t i n g t h e i r p r o f e s s i o n a l growth. In p a r t i c u l a r , the annual I n s t i t u t e made a s i g n i f i c a n t c o n t r i b u t i o n t o c o n t i n u i n g e d u c a t i o n and served t o r a i s e morale and engender l o y a l t y w i t h i n the H e a l t h Department. The monthly study groups and the n e w s l e t t e r helped t o combat i s o l a t i o n d u r i n g t h i s p e r i o d . I t i s d i f f i c u l t t o f i n d f a u l t with t h i s comprehensive program, but one of i t s shortcomings may have been t h a t some of the e d u c a t i o n a l events were l i m i t e d t o s e n i o r s t a f f . From the p o i n t o f view of the s t a f f nurse t h i s may have been r e s e n t e d ; on the oth e r hand, i t may have served as an i n c e n t i v e t o a t t r a c t PHNs t o s e n i o r p o s i t i o n s . O v e r a l l , these e f f o r t s had a p o s i t i v e i n f l u e n c e on the p r o f e s s i o n a l development of p u b l i c h e a l t h nurses and enhanced t h e i r work i n t h e community. Supply and Demand i n P u b l i c H e a l t h Nursing The war years and t h e i r aftermath focussed a t t e n t i o n on 82 the i s s u e o f supply and demand i n r e l a t i o n t o p u b l i c h e a l t h nurses. As communities became more aware of t h e i r unmet h e a l t h needs, t h e r e was an i n c r e a s e d demand f o r p u b l i c h e a l t h s e r v i c e s : I n d i c a t i v e o f t h i s i n c r e a s i n g h e a l t h consciousness i s the request from v a r i o u s c e n t r e s f o r i n f o r m a t i o n c o n c e r n i n g the establishment o f a P u b l i c H e a l t h Nursing S e r v i c e . At the presen t time, and f o r some months now, the demand f o r P u b l i c H e a l t h Nurses has f a r exceeded the supply. (Board o f Health, 1941, p. 87) Thus, p r e s s u r e from m u n i c i p a l governments was brought t o bear on p r o v i n c i a l a u t h o r i t i e s t o extend s e r v i c e s t o more communities. Even i n p l a c e s where p u b l i c h e a l t h n u r s i n g was e s t a b l i s h e d , t h e r e were p e r i o d i c d i f f i c u l t i e s i n keeping p o s i t i o n s f i l l e d . In 1942 s e v e r a l n u r s i n g d i s t r i c t s were c l o s e d t e m p o r a r i l y due t o u n a v a i l a b i l i t y o f PHNs (Board o f He a l t h , 1942). Another f a c t o r t h a t i n f l u e n c e d demand was the r a p i d p o p u l a t i o n growth of the 1940s. The p o p u l a t i o n of B r i t i s h Columbia i n c r e a s e d by 42% d u r i n g the p e r i o d from 1941 t o 1951 (the g r e a t e s t percentage i n c r e a s e o f any p r o v i n c e f o r t h a t census p e r i o d ) , w i t h the no r t h e r n and i n t e r i o r r e g i o n s of the p r o v i n c e e x p e r i e n c i n g the g r e a t e s t growth (Department of H e a l t h and Welfare, 1951). N a t u r a l l y , t h i s p l a c e d c o n s i d e r a b l e s t r a i n on h e a l t h s e r v i c e s p a r t i c u l a r l y i n the areas undergoing unprecedented settlement. The e x i s t i n g s u pply o f n u r s i n g and medical personnel was inadequate t o meet the demand. The Second World War had an i n d i r e c t e f f e c t on the need 83 f o r p u b l i c h e a l t h nurses i n B r i t i s h Columbia. The i s s u e of the shortage of h e a l t h p r o f e s s i o n a l s was made e x p l i c i t by a major survey on h e a l t h s e r v i c e s i n Canada conducted d u r i n g the war under the a u s p i c e s of the Canadian M e d i c a l Procurement and Assignment Board (1945). T h i s Board was e s t a b l i s h e d i n 1942 by the f e d e r a l government t o "secure p h y s i c i a n s f o r the armed f o r c e s and a t the same time t o endeavour t o p r e s e r v e adequate medical s e r v i c e s f o r the c i v i l i a n p o p u l a t i o n " (Canadian M e d i c a l Procurement and Assignment Board, 1945, p. x i x ) . In 1943, the Board conducted the N a t i o n a l H e a l t h Survey t o determine the e x i s t i n g supply of medical personnel and the c u r r e n t s t a t u s o f h e a l t h s e r v i c e s i n each p r o v i n c e . With r e s p e c t t o p u b l i c h e a l t h , the r e p o r t i n d i c a t e d t h a t s e r v i c e s were s t r a i n e d due t o e n l i s t m e n t o f p u b l i c h e a l t h p h y s i c i a n s and a d m i n i s t r a t o r s . C o n d i t i o n s i n B r i t i s h Columbia were r e p o r t e d by Dr. G. F. Amyot, P r o v i n c i a l H e a l t h O f f i c e r a t the time, who s t a t e d t h a t the Board of H e a l t h had been " s e r i o u s l y d e p l e t e d " (p. 118). Dr. Amyot's d e s c r i p t i o n of the s i t u a t i o n and i t s impact on p u b l i c h e a l t h n u r s i n g was r e p o r t e d as f o l l o w s : Owing t o the r e d u c t i o n i n the number of medical men i n a l l areas of the Province, the medical p r a c t i t i o n e r s remaining were overloaded t o the extent t h a t those who had been c a r r y i n g out d u t i e s as medical o f f i c e r s of h e a l t h and s c h o o l h e a l t h i n s p e c t o r s have had t o c u r t a i l t h e i r work t o a v e r y l a r g e extent....To o f f s e t t h i s , the p u b l i c h e a l t h nurses were performing d u t i e s not f o r m e r l y p e r m i t t e d of such a group. Four p u b l i c h e a l t h nurses were u r g e n t l y needed and any c u r t a i l m e n t i n t h i s s e r v i c e would c o n s t i t u t e a s e r i o u s menace t o the 84 p u b l i c h e a l t h work. (p. 119) In B r i t i s h Columbia and elsewhere i n Canada, p u b l i c h e a l t h s e r v i c e s had been reduced t o a minimum and PHNs f i l l e d the gaps l e f t by p h y s i c i a n s who were engaged i n m i l i t a r y medical s e r v i c e . For t h i s reason p u b l i c h e a l t h nurses were urged t o remain on the "home f r o n t " t o serve the c i v i l i a n p o p u l a t i o n (Board of H e a l t h , 1941). The N a t i o n a l H e a l t h Survey a l s o c o n t a i n e d a r e p o r t prepared by the Canadian Nurses A s s o c i a t i o n , on the n u r s i n g s i t u a t i o n i n Canada. Based on data o b t a i n e d i n 1943 through r e g i s t r a t i o n of a l l c i v i l i a n nurses by N a t i o n a l S e l e c t i v e S e r v i c e and a separate survey by the CNA, the r e p o r t showed the e x i s t e n c e of a nation-wide shortage of nurses i n a l l types of i n s t i t u t i o n s and p u b l i c h e a l t h agencies. At t h a t time t h e r e were 52,483 c i v i l i a n nurses, of whom only 22,136 (42.2%) were employed i n n u r s i n g . There were 25,298 non-p r a c t i s i n g nurses whose reason f o r i n a c t i v e s t a t u s was marriage. Of the 7,216 nurses who l e f t the p r o f e s s i o n between 1939 and 1943, 84% d i d so because of marriage. The s e r i o u s n e s s of the n u r s i n g supply problem was d i s c u s s e d by N. D. F i d l e r (1947) i n an a r t i c l e p u b l i s h e d i n the Canadian J o u r n a l of P u b l i c H e a l t h . F i d l e r , a nurse-educator, was the D i r e c t o r of the M e t r o p o l i t a n School of N u r s i n g i n Windsor, O n t a r i o . In examining the 1943 CNA s t a t i s t i c s and s e v e r a l l a t e r r e p o r t s , she concluded t h a t the shortage was caused, not by a l a c k of people undertaking 85 t r a i n i n g , but r a t h e r , due t o the l o s s o f q u a l i f i e d nurses t o marriage. F i d l e r a l s o p o i n t e d t o o t h e r f a c t o r s t h a t compounded the problem: h i g h wastage of student nurses due t o poor c o n d i t i o n s i n n u r s i n g t r a i n i n g and improper use of nurses t o perform non-nursing d u t i e s . She f e l t t h a t measures t o conserve the e x i s t i n g supply were needed and s t a t e d t h a t i t was important t o "use nurses f o r n u r s i n g " (p. 514). The complex i s s u e of the supply o f nurses was c r e a t e d by f o r c e s both e x t e r n a l and i n t e r n a l t o the n u r s i n g p r o f e s s i o n . I t i s apparent from the above t h a t the n u r s i n g supply problem was experienced n a t i o n a l l y and t h a t a l l areas of n u r s i n g p r a c t i c e were a f f e c t e d . P u b l i c h e a l t h agencies a c r o s s Canada were beset by d i f f i c u l t i e s i n r e c r u i t m e n t and r e t e n t i o n o f PHNs; the need t o remedy t h i s s i t u a t i o n was one of the m o t i v a t i n g f o r c e s behind the B a i l l i e - C r e e l m a n Report (McArthur, 1951). The f i n d i n g s d e s c r i b e d i n the Report of  the Study Committee on P u b l i c H e a l t h P r a c t i c e i n Canada (Canadian P u b l i c H e a l t h A s s o c i a t i o n , 1950) r e v e a l e d s e v e r a l problems t h a t were common t o most agencies a c r o s s the c ountry. These i n c l u d e d inadequate s a l a r i e s and l a c k of annual increments, u n d e r u t i l i z a t i o n of support personnel and v o l u n t e e r s , and decreased job s a t i s f a c t i o n due t o r o u t i n e d u t i e s and l a c k of room f o r c r e a t i v i t y . Moreover, s e r i o u s u n d e r s t a f f i n g p l a c e d a heavy burden on e x i s t i n g s t a f f t o c a r r y out e s s e n t i a l programs. Another f a c t o r c l o s e l y 86 r e l a t e d t o working c o n d i t i o n s was the q u a l i t y o f the o f f i c e space occupied by p u b l i c h e a l t h agencies. The r e p o r t ' s authors were c r i t i c a l i n t h e i r a p p r a i s a l of the f a c i l i t i e s they v i s i t e d as p a r t of the study: With few exc e p t i o n s , h e a l t h departments are u n a t t r a c t i v e p l a c e s t o which the average mother would h e s i t a t e t o take her c h i l d r e n o r h e r s e l f f o r h e a l t h s e r v i c e s , and the average tax-payer would c e r t a i n l y not be impressed by the appearance of the housing o f the h e a l t h agency. The g e n e r a l l y poor housing f a c i l i t i e s a l l o c a t e d t o h e a l t h agencies are another i n d i c a t i o n o f the "poor r e l a t i o n " s t a t u s of p u b l i c h e a l t h i n the minds of governments and the p u b l i c g e n e r a l l y . I f the p u b l i c i s t o be a t t r a c t e d t o the e x c e l l e n t s e r v i c e s t h a t p u b l i c h e a l t h can o f f e r a community, s u r e l y the c e n t r e s a t which these s e r v i c e s are o f f e r e d should a t l e a s t be c l e a n , a t t r a c t i v e , c e n t r a l l y l o c a t e d and l a r g e enough t o permit the f u l l f u n c t i o n i n g o f a good program, (p. 24) The above comments were w r i t t e n from the p e r s p e c t i v e o f improving the image of p u b l i c h e a l t h agencies, but i t i s apparent, a l s o , t h a t inadequate work environments must have had a n e g a t i v e e f f e c t on s t a f f morale. Other suggestions were made t o agencies t o enhance working c o n d i t i o n s , namely: t o r a i s e s a l a r i e s and p r o v i d e b e n e f i t s , t o o f f e r c o n t i n u i n g e d u c a t i o n on the job, t o pr o v i d e r e g u l a r s t a f f e v a l u a t i o n s , and t o arrange f o r more c l e r i c a l a s s i s t a n c e f o r PHNs. The message o f the B a i l l i e - C r e e l m a n Report was c l e a r : the shortage o f PHNs was l i n k e d t o s e r i o u s inadequacies w i t h i n h e a l t h agencies; the s i t u a t i o n c o u l d be improved i f agencies (and the v a r i o u s governments) responded t o the recommendations f o r improved working c o n d i t i o n s . P u b l i c h e a l t h n u r s i n g i n B r i t i s h Columbia was not 87 immune t o the problem of r e t e n t i o n o f s t a f f t o meet the demand o f the p e r i o d . In 1949 t h e r e were 111 p u b l i c h e a l t h nurses, 67 (63%) of whom had been on s t a f f f o r l e s s than t h r e e years (Department of H e a l t h and Welfare, 1949). Turnover was h i g h : t h a t year t h e r e were 28 r e s i g n a t i o n s and 41 new appointments. R e s i g n a t i o n s continued a t a r a t e o f 26% per yea r i n t o the e a r l y f i f t i e s (Department of H e a l t h and Welfare, 1952). The problem o f r e c r u i t m e n t and r e t e n t i o n o f s t a f f was of p a r t i c u l a r concern i n l i g h t o f the needs of the p r o v i n c e ' s p o p u l a t i o n a t t h a t time. The h i g h b i r t h r a t e i n the post-war p e r i o d c r e a t e d a g r e a t demand f o r m a t e r n a l - c h i l d s e r v i c e s i n l o c a l communities and, as t h i s c o h o r t moved i n t o s c h o o l age, a d d i t i o n a l demand was produced. The d i f f i c u l t y o f meeting the demands brought about by p o p u l a t i o n changes was e v i d e n t i n the 1958 Annual Report of the South C e n t r a l H e a l t h U n i t (Kamloops Region): "We have had the a d d i t i o n o f onl y one nurse t o our s t a f f i n the p a s t f i v e y e ars though the sc h o o l p o p u l a t i o n has i n c r e a s e d by n e a r l y 3,000 i n t h a t p e r i o d " (1958, p.4). S o l u t i o n s were r e q u i r e d t o conserve the supply d u r i n g a p e r i o d o f i n c r e a s e d demand; i n B r i t i s h Columbia's P r o v i n c i a l H e a l t h S e r v i c e s e v e r a l steps were taken t o minimize t h i s d i f f i c u l t s i t u a t i o n . The i s s u e o f personnel p o l i c i e s was c e n t r a l t o m a i n t a i n i n g an adequate supply o f PHNs. T h i s was r e c o g n i z e d by Heather K i l p a t r i c k , the f i r s t D i r e c t o r o f P u b l i c H e a l t h 88 Nursing, who wrote: Although some prog r e s s has been made, complete adjustments i n s a l a r i e s have not been accomplished as y e t and t h e r e i s no u n i f o r m i t y i n the p r o v i s i o n of c o s t o f l i v i n g bonuses. Work i s s t i l l g oing on wit h r e g a r d t o f o r m u l a t i n g a pension p l a n , but as y e t est a b l i s h m e n t o f t h i s d e s i r a b l e f a c t o r i n working c o n d i t i o n s has not been a t t a i n e d . These matters are of v i t a l importance t o the workers and e f f o r t s t o b r i n g about s a t i s f a c t o r y c o n d i t i o n s are be i n g continued. (Board o f Health, 1942, p. 74) Concerns about such i s s u e s l e d t o the formation, i n 1943, of an o r g a n i z a t i o n through which the PHNs c o u l d d i s c u s s common problems and make t h e i r views known t o the D i r e c t o r o f P u b l i c H e a l t h Nursing. Known as the P u b l i c H e a l t h Nursing C o u n c i l , i t convened each year a t the I n s t i t u t e t o d e a l w i t h matters such as uniforms, p o l i c y changes, and employee b e n e f i t s . The C o u n c i l e l e c t e d a p r e s i d e n t and voted on r e s o l u t i o n s brought forward from the r e g i o n a l study groups. I t served as a " u n i f y i n g " f o r c e f o r the n u r s i n g s t a f f (Department of He a l t h and Welfare, 1950, p. 42) and was c o n s i d e r e d t o be "a very democratic o r g a n i z a t i o n , " a c c o r d i n g t o Nan Kennedy, a C o u n c i l p r e s i d e n t from 1950-1952 (personal communication, May 19, 1988). On oc c a s i o n , the group chose d e l e g a t e s t o r e p r e s e n t the p u b l i c h e a l t h n u r s i n g s t a f f a t n a t i o n a l and i n t e r n a t i o n a l meetings, i n c l u d i n g a meeting of the I n t e r n a t i o n a l C o u n c i l o f Nurses i n 1949 and the 1950 CNA Convention (Department of He a l t h and Welfare, 1949, 1950). In 1951 the Nursing C o u n c i l agreed t o form a Personnel P r a c t i c e s Committee t o make r e p r e s e n t a t i o n on b e h a l f of the PHNs t o the C i v i l S e r v i c e Commission. T h i s was t h e i r f i r s t 89 s t e p i n c o l l e c t i v e b a r g a i n i n g f o r improvements i n s a l a r i e s and b e n e f i t s . Low s a l a r i e s f o r PHNs i n the P r o v i n c i a l S e r v i c e were a b a r r i e r t o r e c r u i t m e n t throughout the f o r t i e s and f i f t i e s , a c c o r d i n g t o the D i r e c t o r of P u b l i c H e a l t h N u r s i n g (Department of H e a l t h and Welfare, 1953, 1954). In 1953 the Personnel P r a c t i c e s Committee presented a b r i e f t o the B r i t i s h Columbia C i v i l S e r v i c e Commission recommending a r e v i s e d s a l a r y schedule more i n l i n e w i t h t h a t o f the M e t r o p o l i t a n H e a l t h S e r v i c e of Greater Vancouver; t h i s was granted the f o l l o w i n g year ( P u b l i c H e a l t h Nursing C o u n c i l , 1954). The Committee continued i t s a c t i v i t y through the decade, s e c u r i n g f u r t h e r s a l a r y increments from time t o time, but always l a g g i n g behind the M e t r o p o l i t a n H e a l t h S e r v i c e . F i g u r e s f o r 1957, f o r i n s t a n c e , show a monthly s t a r t i n g s a l a r y of $318 f o r a PHN i n Vancouver, whereas a P r o v i n c i a l PHN r e c e i v e d $290. T h i s was w e l l below the $315 minimum PHN s a l a r y recommended by the R e g i s t e r e d Nurses A s s o c i a t i o n of B r i t i s h Columbia ( P u b l i c H e a l t h Nursing C o u n c i l , 1958). The f r u s t r a t i o n w i t h s a l a r y l e v e l s remained a concern f o r the nurses, as shown i n the f o l l o w i n g e x c e r p t from a l e t t e r t o the C i v i l S e r v i c e Commission prepared by the Personnel P r a c t i c e s Committee: The members of the P u b l i c H e a l t h Nursing C o u n c i l of the Department of H e a l t h of the P r o v i n c e of B r i t i s h Columbia were p l e a s e d t o r e c e i v e a s a l a r y i n c r e a s e i n A p r i l 1959, b r i n g i n g the s t a r t i n g s a l a r y f o r P u b l i c H e a l t h Nurse Grade I t o $324.00 per month. Previo u s t o t h i s s a l a r y i n c r e a s e t h e r e had been a d e t e r i o r a t i o n i n morale amongst the p u b l i c h e a l t h n u r s i n g s t a f f and much d i f f i c u l t y was experienced i n r e c r u i t m e n t 90 of q u a l i f i e d nurses....The p u b l i c h e a l t h nurses employed d u r i n g t h i s p e r i o d of low morale hope never t o experience a g a i n the l a c k of advancement, and even c u r t a i l m e n t , of needed programs....Many of our experienced nurses remained i n the s e r v i c e o n l y through a sense of l o y a l t y t o the p u b l i c and through a s a t i s f a c t i o n f e l t i n s e r v i n g t h e i r communities. ( P u b l i c H e a l t h Nursing C o u n c i l , 1959) The l e t t e r went on t o request, once again, an a d d i t i o n a l i n c r e a s e t o b r i n g s a l a r i e s i n t o l i n e w i t h those r e c e i v e d by t h e i r c o u n t e r p a r t s i n G r e a t e r Vancouver whose s a l a r i e s were a f u l l 10% h i g h e r i n 1959. The wording of t h i s b r i e f h i g h l i g h t s the p e r s i s t e n c e and d e t e r m i n a t i o n on the p a r t of the nurses t o achieve t h e i r g o a l of reasonable compensation f o r a demanding j o b . The Nursing C o u n c i l ' s accomplishments i n s a l a r y n e g o t i a t i o n s and other aspects of working c o n d i t i o n s y i e l d e d some p o s i t i v e r e s u l t s t h a t helped t o r a i s e morale and develop a s t r o n g i d e n t i t y w i t h i n the P u b l i c H e a l t h Nursing D i v i s i o n . I t should be p o i n t e d out t h a t , d e s p i t e the e f f o r t s and achievements of the C o u n c i l i n the f i f t i e s , t h e r e remained many i s s u e s r e g a r d i n g working c o n d i t i o n s t h a t were c a r r i e d over t o the next decade. As d e s c r i b e d above, the nurses themselves took a c t i o n t o a l l e v i a t e some of the problems i n p u b l i c h e a l t h n u r s i n g . There were a l s o s e v e r a l measures taken by the a d m i n i s t r a t i o n w i t h i n the H e a l t h Department t o d e a l w i t h the supply problem. One of these was the establishment of a t r a i n e e or i n t e r n s h i p program, beginning i n 1948, t o compensate f o r the l a c k o f q u a l i f i e d PHNs i n the p r o v i n c e (Department o f H e a l t h and Welfare, 1948). Under t h i s scheme a l i m i t e d number of 91 nurses who l a c k e d a p u b l i c h e a l t h diploma o r a n u r s i n g degree were h i r e d and p r o v i d e d w i t h some on-the-job t r a i n i n g t o equip them t o perform a m o d i f i e d p u b l i c h e a l t h n u r s i n g r o l e . A f t e r a p e r i o d of s a t i s f a c t o r y performance, they were awarded b u r s a r i e s through the N a t i o n a l H e a l t h Grants t o enable them t o take the c e r t i f i c a t e course. Upon completion of t h e i r s t u d i e s they were expected t o r e t u r n t o the H e a l t h Department f o r a t l e a s t two ye a r s . T h i s was c e r t a i n l y a pragmatic way o f combatting the problem o f the PHN shortage through the f i f t i e s ; once t h i s program was underway, the He a l t h Department had a guaranteed supply o f t e n t o f i f t e e n newly q u a l i f i e d PHNs each year. The P r o v i n c i a l S e r v i c e found another s o l u t i o n i n the employment of married nurses. Although not as mobile as s i n g l e women, they were a v a l u a b l e resource from which v a c a n c i e s were f i l l e d . F or the most p a r t , they were q u a l i f i e d PHNs who had worked f o r s e v e r a l y ears b e f o r e r e s i g n i n g t o be married. During the f o r t i e s when t h e i r s e r v i c e s were i n demand, many of these experienced PHNs r e t u r n e d t o work i n t h e i r home communities and were viewed as an a s s e t (Department of H e a l t h and Welfare, 1948). By 1953, married PHNs accounted f o r about 20% of the D i v i s i o n ' s s t a f f (Green, 1984). In t h i s way, the shortage o f t r a i n e d PHNs had a f a v o u r a b l e impact on those married nurses who e i t h e r wished or needed t o work. P r i o r t o the f o r t i e s , many agencies d i d not h i r e married women; the i n c r e a s e d demand 92 d u r i n g the war and afterwards f o r c e d a r e v e r s a l i n employment p o l i c y . In t h i s r e gard i t i s noteworthy t h a t the f o l l o w i n g r e s o l u t i o n was passed a t the 1944 Annual Meeting of the Canadian P u b l i c H e a l t h A s s o c i a t i o n : Whereas d i s c r i m i n a t i o n a g a i n s t the m a r ried p u b l i c h e a l t h nurse w i t h r e f e r e n c e t o employment has e x i s t e d i n the p a s t , and Whereas married nurses have c o n t r i b u t e d s u b s t a n t i a l l y t o the maintenance of e s s e n t i a l s e r v i c e s d u r i n g the war emergency, and Whereas some of these nurses may wish t o c o n t i n u e i n the f i e l d o f p u b l i c h e a l t h n u r s i n g , t h e r e f o r e Be i t r e s o l v e d t h a t the P u b l i c H e a l t h Nursing S e c t i o n of the Canadian P u b l i c H e a l t h A s s o c i a t i o n recommend t o employing agencies t h a t , i n the f u t u r e , a p p l i c a t i o n s from married nurses be c o n s i d e r e d on the same b a s i s of q u a l i f i c a t i o n s , experience and i n d i v i d u a l circumstances as those from unmarried nurses. (CPHA, 1944, p. 489) The u t i l i z a t i o n of married p u b l i c h e a l t h nurses d u r i n g the war and the continued need f o r t h e i r s e r v i c e s i n the l a t e f o r t i e s and e a r l y f i f t i e s l e d t o t h e i r acceptance by peers and a d m i n i s t r a t o r s . Although the i d e a of married women having independent c a r e e r s was not g e n e r a l l y accepted i n Canadian s o c i e t y a t t h a t time (Pierson,1986), i t seems t h a t w i t h i n the m i l i e u of p u b l i c h e a l t h n u r s i n g t h i s i d e a was more f a v o u r a b l y r e c e i v e d . Another measure t o r e t a i n s t a f f and maximize t h e i r e f f e c t i v e n e s s was the u t i l i z a t i o n of l a y support s t a f f t o a s s i s t the PHN. T h i s idea was one of the recommendations of the B a i l l i e - C r e e l m a n Report (CPHA, 1950). Time s t u d i e s conducted by the P u b l i c H e a l t h Nursing D i v i s i o n i n 1950 showed t h a t the nurses were spending over 10% of t h e i r time on c l e r i c a l work, p r e p a r i n g s u p p l i e s , and c l e a n i n g equipment 93 (Department of H e a l t h and Welfare, 1950). On the s t r e n g t h o f these s t u d i e s , c l e r i c a l a s s i s t a n c e was p r o v i d e d a t c e r t a i n h e a l t h u n i t s . Progress i n t h i s r e g a r d was somewhat slow, however, and nurses continued t o spend c o n s i d e r a b l e amounts of time on non-nursing f u n c t i o n s . F i n a l l y , i n 1957 the f i r s t h e a l t h u n i t a i d e s were h i r e d t o f r e e the PHNs from some of these t a s k s . In u n i t s where t h i s type of h e l p was a v a i l a b l e , i t allowed the nurses t o use t h e i r s k i l l s t o the f u l l e s t and presumably enhanced job s a t i s f a c t i o n . Although the P r o v i n c i a l H e a l t h S e r v i c e experienced d i f f i c u l t i e s due t o the shortage of PHNs, i t managed t o a v o i d some of problems t h a t were common elsewhere i n the country (Kerr, 1941). As shown by the B a i l l i e - C r e e l m a n Report, B r i t i s h Columbia's H e a l t h Department had the h i g h e s t percentage of t r a i n e d PHNs of any p r o v i n c i a l agency (Canadian P u b l i c H e a l t h A s s o c i a t i o n , 1950). The r e p o r t a l s o showed t h a t the P r o v i n c i a l H e a l t h S e r v i c e had one of the b e s t r a t e s of PHN coverage i n Canada: one nurse f o r every 4,000 people. Other p r o v i n c e s had r a t i o s of 1:6,000 (Manitoba) and 1:10,500 (New Brunswick), and the r a t i o f o r Canada as a whole was 1:5,200. Furthermore, as d i s c u s s e d p r e v i o u s l y , the H e a l t h Department had an e x t e n s i v e program o f c o n t i n u i n g education, something t h a t many o t h e r agencies l a c k e d a t the time. The f i n d i n g s of another study c a r r i e d out around the same time a l s o c a s t a f a v o u r a b l e l i g h t on the a d m i n i s t r a t i o n of p u b l i c h e a l t h n u r s i n g s e r v i c e s i n B r i t i s h 94 Columbia. T h i s was a 1949 study of the P r o v i n c i a l P u b l i c H e a l t h N u r s i n g D i v i s i o n conducted by L u c i l e P e t ry, A s s i s t a n t Surgeon-General of the U n i t e d S t a t e s P u b l i c H e a l t h S e r v i c e , as p a r t of a l a r g e r examination of h e a l t h s e r v i c e s i n the p r o v i n c e (Department of H e a l t h and Welfare, 1949). Her comments were quoted i n the department's r e p o r t f o r t h a t y e a r : The H e a l t h Branch of the Department of H e a l t h and Welfare has an e x c e e d i n g l y w e l l - c o n c e i v e d p l a n f o r p u b l i c h e a l t h n u r s i n g s e r v i c e i n the P r o v i n c e and has succeeded i n implementing the p l a n e x t e n s i v e l y . . . . The nurses i n t h i s s e r v i c e are g e n e r a l l y w e l l prepared and r e c e i v e expert and dynamic l e a d e r s h i p . A s t i m u l a t i n g p e r m i s s i v e atmosphere pervades the s e r v i c e , and c o - o p e r a t i v e p l a n n i n g i s e v i d e n t both among the nurses themselves and between n u r s i n g s e r v i c e and the a d m i n i s t r a t i o n . (Department of H e a l t h and Welfare, 1949, p. 55-56) A l l t h i n g s c o n s i d e r e d , the endeavours of the P r o v i n c i a l H e a l t h S e r v i c e t o maintain a h i g h standard d u r i n g a time of g r e a t demand were s u c c e s s f u l . The i n c r e a s e d demand began d u r i n g the war and continued w i t h the p o p u l a t i o n boom of the post-war e r a . A combination of f a c t o r s l e d t o a severe shortage of q u a l i f i e d PHNs; c h i e f among these were low s a l a r i e s , poor working c o n d i t i o n s , and l o s s of nurses t o marriage. By t a k i n g a c t i o n on some of the c a u s a t i v e f a c t o r s , the PHNs themselves p l a y e d a p a r t i n b r i n g i n g about improved working c o n d i t i o n s . A d m i n i s t r a t i v e i n i t i a t i v e s t o d e a l w i t h the s i t u a t i o n were a l s o r e s p o n s i b l e f o r advancing p u b l i c h e a l t h n u r s i n g i n the p r o v i n c e . I n f l u e n c e of Other Agencies 95 The v o l u n t a r y o r g a n i z a t i o n s and v a r i o u s community s e r v i c e groups p l a y e d a p a r t i n p u b l i c h e a l t h n u r s i n g d u r i n g t h i s p e r i o d . Most n o t a b l e were two agencies w i t h a h i s t o r y o f involvement i n Canadian p u b l i c h e a l t h : The V i c t o r i a n Order of Nurses (VON), and the Canadian Red Cross S o c i e t y . In a d d i t i o n , l o c a l s e r v i c e c l u b s p r o v i d e d f i n a n c i a l a s s i s t a n c e and the s e r v i c e s of v o l u n t e e r s . Branches of the VON e x i s t e d i n V i c t o r i a , Surrey, G r e a t e r Vancouver, O l i v e r , Gibsons, and s e v e r a l o t h e r communities (Board of Health, 1943). As a v o l u n t a r y agency, the VON was o n l y a c t i v e i n those communities t h a t had requested i t s s e r v i c e s ; i t s work was viewed as b e i n g "supplementary t o t h a t of the o f f i c i a l agency" (Creasy, 1939, p.321). In the e a r l y years VON s t a f f , most of whom were t r a i n e d PHNs, c a r r i e d out a v a r i e d program of bedside n u r s i n g , newborn v i s i t s , and p r e n a t a l i n s t r u c t i o n . A nurse w i t h the VON i n V i c t o r i a d u r i n g the f o r t i e s r e c a l l s b e i n g sent t o the M a t e r n i t y Centre A s s o c i a t i o n i n New York t o study a p r e n a t a l e x e r c i s e program t h a t she i n c o r p o r a t e d i n t o t h e i r c l a s s e s (Short, 1987). In 1950 the VON and the o f f i c i a l agency combined f o r c e s and began o f f e r i n g one p r e n a t a l program i n the V i c t o r i a area (Department of H e a l t h and Welfare, 1951). In other communities, the h e a l t h u n i t s t a f f c o n c e n t r a t e d on the p r e v e n t i v e p a r t of p u b l i c h e a l t h and the VON took r e s p o n s i b i l i t y f o r the v i s i t i n g n u r s i n g s e r v i c e (the fo r e r u n n e r of home c a r e ) . T h i s arrangement 96 worked s a t i s f a c t o r i l y because each group of nurses had c l e a r l y d e l i n e a t e d f u n c t i o n s w i t h i n the community and t h e r e was l i t t l e chance f o r d u p l i c a t i o n of s e r v i c e (Empey, 1948). In B r i t i s h Columbia, the Canadian Red Cross was a p i o n e e r i n the f i e l d , having p l a c e d Red Cross p u b l i c h e a l t h nurses i n i s o l a t e d d i s t r i c t s d u r i n g the e a r l y 1920s ( H i l t z , 1 9 6 7 ) . Lack of funds f o r c e d t h i s s e r v i c e t o be d i s c o n t i n u e d ; however, by the next decade the Red Cross responded t o the c r i t i c a l need f o r h e a l t h s e r v i c e s i n remote communities by opening outpost h o s p i t a l s and n u r s i n g s t a t i o n s ( P o r t e r , 1960). E v e n t u a l l y , 18 outpost h o s p i t a l s were e s t a b l i s h e d with the nurses p r o v i d i n g outreach s e r v i c e s i n c l u d i n g home v i s i t i n g , immunization, and c h i l d h e a l t h s e r v i c e s . In a d d i t i o n t o the p r o v i s i o n of n u r s i n g care, the Red Cross p l a y e d a c a t a l y t i c r o l e i n the development of p u b l i c h e a l t h s e r v i c e s i n two s i g n i f i c a n t ways. I t was a major f o r c e behind the establishment of p u b l i c h e a l t h n u r s i n g programs a t Canadian u n i v e r s i t i e s . P r o v i n c i a l l y , i t i s c r e d i t e d w i t h p r o v i d i n g the funding f o r the f i r s t t h r e e y e a r s of the diploma course i n p u b l i c h e a l t h n u r s i n g a t the U n i v e r s i t y of B r i t i s h Columbia (Gray, 1942). The f i r s t graduates of t h i s course, served i n outpost h o s p i t a l s and p r o v i n c i a l n u r s i n g d i s t r i c t s . L a t e r , when h e a l t h u n i t s were b e i n g developed d u r i n g the f o r t i e s and f i f t i e s , g r a n t s from the Red Cross and o t h e r agencies were used f o r the 97 c o n s t r u c t i o n o f modern h e a l t h c e n t r e s from which the o f f i c i a l programs were d e l i v e r e d . At t he l o c a l l e v e l , community o r g a n i z a t i o n s a l s o c o n t r i b u t e d t o the advancement of p u b l i c h e a l t h . As h e a l t h u n i t s developed, v a r i o u s s e r v i c e c l u b s donated funds f o r equipment and promoted the work of the h e a l t h department. In some communities, s e r v i c e o r g a n i z a t i o n s p r o v i d e d c a p i t a l f u n d i n g f o r h e a l t h c e n t r e c o n s t r u c t i o n . In 1955, f o r example, the Ladner Kinsmen's Club r a i s e d funds and spearheaded the community's e f f o r t t o b u i l d a c e n t r e from which the p u b l i c h e a l t h program c o u l d operate (Department o f He a l t h and Welfare, 1955). Another form o f a s s i s t a n c e was p r o v i d e d by h e a l t h u n i t v o l u n t e e r s ; these were l a y people who r e g u l a r l y helped the PHNs w i t h t a s k s such as weighing babies a t c h i l d h e a l t h conferences o r a c t i n g as r e c e p t i o n i s t s a t immunization c l i n i c s . The C e n t r a l Vancouver I s l a n d H e a l t h U n i t had f o r m a l i z e d Women's A u x i l i a r i e s a s s o c i a t e d w i t h i t s programs i n Duncan, Nanaimo, and Port A l b e r n i ( C e n t r a l Vancouver I s l a n d H e a l t h U n i t , 1953). T h e i r purposes, as o u t l i n e d i n the 1953 Annual Report were: 1. To a c t as a l i a i s o n between the P u b l i c H e a l t h U n i t and the g e n e r a l p u b l i c . 2. To a s s i s t by g i v i n g v o l u n t a r y h e l p i n p u b l i c h e a l t h p r o j e c t s . 3. To a s s i s t f i n a n c i a l l y i n worthy p r o j e c t s . (p. 1) Some examples o f the m a t e r i a l a i d g i v e n by the Women's A u x i l i a r i e s a t t h a t time i n c l u d e d o f f i c e f u r n i s h i n g s , a f i l m 98 p r o j e c t o r and screen, and o t h e r equipment. I t i s e v i d e n t t h a t numerous hours of v o l u n t e e r time went i n t o these p r o j e c t s over the years and t h i s was acknowledged i n annual r e p o r t s . The 1959 Report from the same h e a l t h u n i t i n d i c a t e d t h a t v o l u n t e e r i s m was s t i l l s t r o n g a t the end o f the decade: We would l i k e t o express our g r a t i t u d e t o the many v o l u n t e e r s who have helped us d u r i n g our P o l i o C l i n i c s and t o the f a i t h f u l group who h e l p us a t C h i l d H e a l t h Conferences and o t h e r c l i n i c s every week of the year. We t h i n k t h a t the c o n t r i b u t i o n these women make t o the community i s c o n s i d e r a b l e . I t r e c e i v e s v e r y l i t t l e p u b l i c i t y but i s q u i e t l y and c o n s c i e n t i o u s l y g i v e n and h e l p s our s e r v i c e run the smoother. (p. 29) The e x c e r p t s c i t e d above c o n t a i n some key words t h a t h e l p t o e x p l a i n the phenomenon of v o l u n t e e r i s m i n p u b l i c h e a l t h work a t t h a t time. There was the n o t i o n t h a t c e r t a i n p r o j e c t s were "worthy" of f i n a n c i a l a i d and, a l s o , t h a t t h e r e was m e r i t i n donating time t o these p r o j e c t s . Many aspects of the program were viewed by the p u b l i c as u s e f u l and important; hence, the c o n t r i b u t i o n made by the v o l u n t e e r t o such programs was v a l u e d . These women were d e s c r i b e d as " f a i t h f u l " and " c o n s c i e n t i o u s , " an i n d i c a t i o n t h a t they took t h e i r v o l u n t e e r work s e r i o u s l y . C e r t a i n l y , e f f o r t s t o prevent p o l i o and t o p r o t e c t the h e a l t h of c h i l d r e n had a major impact on the p o p u l a t i o n and t h i s seems t o have been r e c o g n i z e d a t the community l e v e l . The C e n t r a l Vancouver I s l a n d H e a l t h U n i t was not alone w i t h r e s p e c t t o involvement of a c t i v e v o l u n t e e r s i n s e v e r a l a s p e c t s of the program (Department of H e a l t h and Welfare, 99 1952, 1953; S e l k i r k H e a l t h U n i t , 1956, 1957; Skeena H e a l t h U n i t , 1953). Throughout the p r o v i n c e s e r v i c e c l u b s were g a i n i n g p o p u l a r i t y and were a b l e t o m o b i l i z e support f o r l o c a l improvement p r o j e c t s ; t h i s was r e f l e c t i v e o f the growing community mindedness of the post-war e r a . P u b l i c h e a l t h programs were among the b e n e f i c i a r i e s o f these c h a r i t a b l e endeavours. The h i g h degree of v o l u n t a r y p a r t i c i p a t i o n i n n u r s i n g programs i n d i c a t e d g e n e r a l awareness o f the importance of p u b l i c h e a l t h n u r s i n g a t t h a t time. In t u r n , the h e a l t h u n i t s t a f f acknowledged the v a l u e of the s e r v i c e s rendered by v o l u n t e e r s and thereby s u s t a i n e d i n t e r e s t and commitment. From these accounts o f l o c a l and p r o v i n c i a l v o l u n t a r y e f f o r t s , i t can be seen t h a t a p o s i t i v e a t t i t u d e toward community s e r v i c e p r e v a i l e d d u r i n g t h i s p e r i o d . Agencies such as the Red Cross and the VON pl a y e d a for m a t i v e r o l e i n h e a l t h s e r v i c e s development. At the l o c a l l e v e l , the p o s t -war community s p i r i t c r e a t e d support f o r p u b l i c h e a l t h programs and, i n p a r t i c u l a r , p u b l i c h e a l t h n u r s i n g b e n e f i t e d from the involvement o f the v o l u n t a r y s e c t o r . Summary In summary, t h i s chapter began wi t h an overview of the o r g a n i z a t i o n and a d m i n i s t r a t i o n o f p u b l i c h e a l t h i n B r i t i s h Columbia d u r i n g the 1939 t o 1959 p e r i o d . The r o l e o f the p u b l i c h e a l t h nurse was i l l u s t r a t e d by d e s c r i b i n g the 100 v a r i o u s a s p e c t s o f p r a c t i c e d u r i n g the same p e r i o d (see F i g u r e 9). As d i s c u s s e d i n the l a t t e r p a r t o f the chapter, a number o f f a c t o r s had an impact on the development of p u b l i c h e a l t h n u r s i n g . The s o c i a l and p o l i t i c a l c o n t e x t of the time, the educa t i o n o f nurses, and programs f o r s t a f f development were f o r c e s t h a t a f f e c t e d p u b l i c h e a l t h nurses and t h e i r p r a c t i c e i n the community. The i s s u e o f supply and demand i n the f i e l d was presented; t h i s i n c l u d e d a d i s c u s s i o n o f the measures taken t o a l l e v i a t e the shortage of PHNs. F i n a l l y , the p a r t p l a y e d by v o l u n t a r y h e a l t h agencies and community s e r v i c e o r g a n i z a t i o n s was d e s c r i b e d as the l a s t o f these i n f l u e n c e s . 101 F i g u r e 9. Norma Tucker ( C l a r k ) , PHN, i n f r o n t o f the P o r t A l b e r n i o f f i c e , C e n t r a l Vancouver I s l a n d H e a l t h U n i t , 1950. Photo co u r t e s y of Norma C l a r k . Used w i t h p e r m i s s i o n . 102 CHAPTER FOUR SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS FOR FURTHER STUDY Summary T h i s study o f p u b l i c h e a l t h n u r s i n g i n B r i t i s h Columbia was designed t o examine one aspect o f Canadian n u r s i n g h i s t o r y w i t h i n a c i r c u m s c r i b e d time frame. The c e n t r a l r e s e a r c h q u e s t i o n was: What was the s t a t u s o f p u b l i c h e a l t h n u r s i n g i n B r i t i s h Columbia d u r i n g the 1939 t o 1959 p e r i o d ? The h i s t o r i c a l method was used t o c o l l e c t and analyze data from v a r i o u s primary and secondary sources; these i n c l u d e d annual r e p o r t s from p r o v i n c i a l h e a l t h u n i t s , annual r e p o r t s of the D i v i s i o n o f P u b l i c H e a l t h Nursing, j o u r n a l a r t i c l e s , and o r a l h i s t o r i e s . Data were s u b j e c t e d t o content a n a l y s i s t o r e v e a l themes r e l e v a n t t o the t o p i c . During t h i s p rocess i t became e v i d e n t t h a t s e v e r a l important f a c t o r s i n f l u e n c e d the e v o l u t i o n o f p u b l i c h e a l t h n u r s i n g throughout the s e l e c t e d p e r i o d . Data were c a t e g o r i z e d a c c o r d i n g t o the v a r i o u s i n f l u e n c e s and r e s e a r c h notes were w r i t t e n as a b a s i s f o r the h i s t o r i c a l account. The p r e s e n t a t i o n o f f i n d i n g s i n c l u d e d d e s c r i p t i o n s of the o r g a n i z a t i o n of p u b l i c h e a l t h s e r v i c e s and the r o l e of the p u b l i c h e a l t h nurse; t h i s was f o l l o w e d by a d i s c u s s i o n o f the impact of each of the f o r c e s on the s t a t u s o f p u b l i c h e a l t h n u r s i n g . 103 Conclusi o n s P u b l i c h e a l t h programs i n B r i t i s h Columbia evolved w i t h i n a w e l l - p l a n n e d o r g a n i z a t i o n a l s t r u c t u r e i n which the P r o v i n c i a l P u b l i c H e a l t h Nursing S e r v i c e p r o v i d e d s t r o n g l e a d e r s h i p . A c e n t r a l i z e d system f o r p u b l i c h e a l t h s e r v i c e d e l i v e r y throughout the p r o v i n c e c r e a t e d c o n s i s t e n c y i n programs and ensured a c c e s s i b i l i t y f o r the m a j o r i t y o f the p o p u l a t i o n . P u b l i c h e a l t h nurses were the f i r s t p u b l i c h e a l t h personnel i n most areas and were r e s p o n s i b l e f o r n u r s i n g d i s t r i c t s b e f o r e the advent of h e a l t h u n i t s . Once h e a l t h u n i t s were e s t a b l i s h e d i n the t h i r t i e s and f o r t i e s , p u b l i c h e a l t h nurses maintained t h e i r h i g h p r o f i l e through t h e i r involvement i n s c h o o l s , immunization c l i n i c s , and homes. They were r e s p e c t e d h e a l t h p r o f e s s i o n a l s because t h e i r work "made a d i f f e r e n c e " i n the l i v e s o f the f a m i l i e s w i t h whom they came i n c o n t a c t and i n the community a t l a r g e . T h e i r d i s t i n c t i v e uniform added t o t h e i r v i s i b i l i t y and i d e n t i t y i n the communities they served. P u b l i c h e a l t h n u r s i n g was c h a r a c t e r i z e d by a s t r o n g t e a c h i n g component i n most aspects o f p r a c t i c e . PHNs were a source o f h e a l t h i n f o r m a t i o n t o members of the p u b l i c ; they i n s t r u c t e d p arents i n i n f a n t care, conducted h e a l t h e d u c a t i o n c l a s s e s i n s c h o o l s , and taught f a m i l i e s how t o ca r e f o r i l l members a t home. T h i s d i f f e r e n t i a t e d p u b l i c h e a l t h n u r s i n g from h o s p i t a l n u r s i n g a t t h a t time and has remained an i n t e g r a l p a r t o f p r a c t i c e . P u b l i c h e a l t h 104 n u r s i n g was, and continues t o be, a unique branch o f n u r s i n g . Although much of the PHN's work was based on a s t a n d a r d i z e d program (such as s c h o o l h e a l t h ) , t h e r e was room f o r v a r i a t i o n depending on the needs of i n d i v i d u a l communities. Thus, programs were i n t r o d u c e d i n accordance w i t h the needs and r e a d i n e s s o f each community. For i n s t a n c e , p r e n a t a l c l a s s e s were i n t r o d u c e d over a ten-year p e r i o d as PHNs responded t o consumer demand a t the l o c a l l e v e l . When a PHN had implemented a new program s u c c e s s f u l l y o r m o d i f i e d an e x i s t i n g one, t h i s i n f o r m a t i o n was shared w i t h o t h e r nurses through n e w s l e t t e r s and r e g i o n a l study meetings. The 1950s saw the be g i n n i n g o f program e v a l u a t i o n a t the l o c a l l e v e l ; f o r example, PHNs ev a l u a t e d the e f f e c t i v e n e s s of p r e n a t a l c l a s s e s i n terms of outcomes and consumer s a t i s f a c t i o n . I n d i v i d u a l nurses and h e a l t h u n i t s p l a y e d a s i g n i f i c a n t p a r t i n shaping the d i r e c t i o n o f p u b l i c h e a l t h n u r s i n g . In a d d i t i o n , o u t s i d e f o r c e s were r e s p o n s i b l e f o r i n f l u e n c i n g the e v o l u t i o n o f p r o v i n c i a l p u b l i c h e a l t h n u r s i n g . Although funding f o r p u b l i c h e a l t h n u r s i n g was a problem due t o government f i s c a l r e s t r a i n t , B r i t i s h Columbia's P u b l i c H e a l t h Nursing S e r v i c e f a r e d w e l l i n comparison t o oth e r p r o v i n c e s . The p r o v i n c i a l government's p r o g r e s s i v e h e a l t h and s o c i a l p o l i c i e s , developed over the f i r s t h a l f o f the century, c r e a t e d a s t r o n g f o u n d a t i o n f o r 105 the d e l i v e r y o f p u b l i c h e a l t h s e r v i c e s a t the l o c a l l e v e l . As a r e s u l t , p u b l i c h e a l t h n u r s i n g f l o u r i s h e d d u r i n g t h i s p e r i o d ; i t was a time of program expansion and growth i n numbers. The p e r i o d from 1939 t o 1959 was one of s i g n i f i c a n t s o c i a l change f o r B r i t i s h Columbians. During the war years the r o l e of the PHN expanded due t o the shortage o f p h y s i c i a n s . P u b l i c h e a l t h nurses responded t o the changes o f the post-war p e r i o d by adapting t h e i r programs t o meet the needs o f the growing p o p u l a t i o n . Through study groups and c o n t i n u i n g education, PHNs were w e l l informed of changes i n the f i e l d . E d u c a t i o n f o r p u b l i c h e a l t h n u r s i n g was another important f o r c e t h a t had an impact on i t s s t a t u s . During the f o r t i e s and f i f t i e s the i s s u e of the most a p p r o p r i a t e p r e p a r a t i o n f o r p u b l i c h e a l t h n u r s i n g remained c o n t r o v e r s i a l . Leaders i n Canadian p u b l i c h e a l t h n u r s i n g c a l l e d f o r a g e n e r a l i z e d degree program, independent of any one h o s p i t a l s c h o o l of n u r s i n g , t h a t i n t e g r a t e d h e a l t h and i l l n e s s concepts. In B r i t i s h Columbia two paths t o p u b l i c h e a l t h n u r s i n g e x i s t e d : a one-year c e r t i f i c a t e course f o r r e g i s t e r e d nurses and a degree program. The c e r t i f i c a t e course was the most popular; the b a c c a l a u r e a t e program i n n u r s i n g a t the U n i v e r s i t y of B r i t i s h Columbia produced a r e l a t i v e l y s m a l l number of graduates per year. Although the c e r t i f i c a t e program was an e f f i c i e n t method of meeting the 106 demand f o r t r a i n e d PHNs, i t had may have i n h i b i t e d the advancement of p u b l i c h e a l t h n u r s i n g i n the long run because i t o b v i a t e d the need f o r a degree. L a t e r , when oth e r r e l a t e d p r o f e s s i o n a l s (such as s o c i a l workers, n u t r i t i o n i s t s , and mental h e a l t h workers) began t o be employed i n h e a l t h u n i t s and community agencies, i t may have been d i f f i c u l t f o r PHNs t o work on an equal f o o t i n g w i t h members of these o t h e r d i s c i p l i n e s . T h i s may e x p l a i n , i n p a r t , the d e c l i n e of the r o l e of p u b l i c h e a l t h n u r s i n g i n r e c e n t decades. The supply of graduate nurses w i t h p u b l i c h e a l t h p r e p a r a t i o n b a r e l y met the demand f o r t h e i r s e r v i c e s . In a t t r a c t i n g new graduates, the P r o v i n c i a l H e a l t h Department had t o compete wi t h the M e t r o p o l i t a n H e a l t h S e r v i c e of G r e a t e r Vancouver, a favoured employer among many nurses because of i t s l o c a t i o n and h i g h e r s a l a r i e s . T h i s f o r c e d the D i v i s i o n of P u b l i c H e a l t h Nursing w i t h i n the P r o v i n c i a l H e a l t h Department t o adopt some s t r a t e g i e s t o a t t r a c t and r e t a i n s t a f f . One such measure was the t r a i n e e p l a n whereby nurses were o f f e r e d funding t o take the p u b l i c h e a l t h n u r s i n g c e r t i f i c a t e course and had the s e c u r i t y of employment f o l l o w i n g i t s completion. Throughout the f o r t i e s and f i f t i e s a number of c r e a t i v e a c t i o n s were taken t o i n c r e a s e j ob s a t i s f a c t i o n and t o keep morale h i g h . S t a f f nurses were a b l e t o p a r t i c i p a t e i n c o n t i n u i n g e d u c a t i o n events, conferences, and r e g i o n a l study groups. The annual 107 I n s t i t u t e and the monthly n e w s l e t t e r f a c i l i t a t e d on-going communication among PHNs and between a d m i n i s t r a t o r s and s t a f f . I t i s e v i d e n t t h a t the a d m i n i s t r a t i o n r e c o g n i z e d the problems of PHNs working i n i s o l a t i o n from o t h e r c o l l e a g u e s ; p r o v i d i n g o p p o r t u n i t i e s t o s o c i a l i z e and study w i t h other PHNs was e s s e n t i a l t o the maintenance of s t a f f morale. A c c o r d i n g t o PHNs who p r a c t i s e d d u r i n g the f o r t i e s and f i f t i e s , t h e r e was a tremendous camaraderie among the p r o v i n c i a l PHNs and many l a s t i n g f r i e n d s h i p s were formed a t t h a t time. The P u b l i c H e a l t h Nursing C o u n c i l brought a l l the n u r s i n g s t a f f i n c l u d i n g s u p e r v i s o r s , c o n s u l t a n t s , and the D i r e c t o r t o g e t h e r i n an o r g a n i z a t i o n t o d e a l w i t h the concerns o f the PHNs. Through the s t r e n g t h o f group decision-making and c o l l e c t i v e a c t i o n , i t was p o s s i b l e t o i n s t i t u t e a number of improvements i n working c o n d i t i o n s . I t i s apparent t h a t the c r e a t i v e s t r a t e g i e s employed by the H e a l t h Department t o ensure a f a v o u r a b l e working environment helped t o o f f s e t some of the problems i n h e r e n t i n the nature o f p u b l i c h e a l t h n u r s i n g . PHNs worked i n r e l a t i v e i s o l a t i o n and faced many d i f f i c u l t s i t u a t i o n s i n t h e i r d a i l y p r a c t i c e : outbreaks o f communicable d i s e a s e s , f a m i l i e s l i v i n g i n poverty, parents a d j u s t i n g t o the b i r t h o f a handicapped c h i l d . They needed support from c o l l e a g u e s and r e l i e f from the s t r e s s of t h e i r demanding w o r k — t h i s was p r o v i d e d through study groups and g a t h e r i n g s o f p u b l i c 108 h e a l t h nurses. D e s p i t e the problems experienced by p u b l i c h e a l t h nurses, t h e i r work was rewarding because they knew t h a t i t was worthwhile. T h i s was v a l i d a t e d by the v o l u n t a r y support r e c e i v e d by h e a l t h u n i t s d u r i n g the 1939 t o 1959 p e r i o d . L o c a l communities v a l u e d p u b l i c h e a l t h n u r s i n g endeavours as demonstrated by many i n s t a n c e s of fund r a i s i n g and p u b l i c i t y f o r p u b l i c h e a l t h programs. The v a l u e s of p u b l i c h e a l t h n u r s i n g were congruent with s o c i e t y ' s v a l u e s a t t h a t time; t h i s c r e a t e d a p o s i t i v e atmosphere i n which p u b l i c h e a l t h n u r s i n g developed and prospered. P u b l i c r e s p e c t and knowledge of the importance of t h e i r r o l e i n the community, c o n t r i b u t e d t o p u b l i c h e a l t h nurses' s t r o n g i d e n t i t y d u r i n g t h i s time. Recommendations For F u r t h e r Study A number o f q u e s t i o n s f o r f u r t h e r r e s e a r c h arose from t h i s h i s t o r i c a l study. The focus of t h i s study was B r i t i s h Columbia; i t would be u s e f u l t o examine the e v o l u t i o n of p u b l i c h e a l t h n u r s i n g i n other Canadian p r o v i n c e s and o t h e r c o u n t r i e s . Due t o the e x i s t e n c e of separate m e t r o p o l i t a n agencies i n t h i s p r o v i n c e , i t would be i n t e r e s t i n g t o compare t h e i r development over the same p e r i o d with the f i n d i n g s of t h i s study. E d u c a t i o n was shown t o be a major f a c t o r i n the development of p u b l i c h e a l t h n u r s i n g . What impact have 109 changes i n n u r s i n g e d u c a t i o n s i n c e 1960 had on t h i s branch o f nursing? In what ways have p u b l i c h e a l t h n u r s i n g courses a t Canadian u n i v e r s i t i e s changed s i n c e t h e i r i n c e p t i o n i n the 1920s? What i s the h i s t o r y of graduate programs i n p u b l i c h e a l t h n u r s i n g i n the U n i t e d S t a t e s and Canada and how have they shaped the d i r e c t i o n of p r a c t i c e ? S p e c i a l i z a t i o n w i t h i n p u b l i c h e a l t h n u r s i n g i s another area f o r f u r t h e r study. There i s a need t o document the development of o f f i c i a l home care and long term care programs and the r e s u l t i n g fragmentation of p u b l i c h e a l t h n u r s i n g . What i s the h i s t o r y of home care and l o n g term care i n the p r o v i n c e and what impact have these programs had on p u b l i c h e a l t h nurses? What other h e a l t h p o l i c y changes have i n f l u e n c e d n u r s i n g i n the community? A number of PHNs l e f t t h e i r p o s i t i o n s t o work i n the f i e l d o f i n t e r n a t i o n a l h e a l t h w i t h the World H e a l t h O r g a n i z a t i o n and o t h e r agencies. I t would be i n t e r e s t i n g t o study t h i s group of nurses i n terms of t h e i r m o t i v a t i o n and p r e p a r a t i o n f o r overseas work. What impact d i d they have on the c o u n t r i e s i n which they worked? What impact d i d they have on Canadian n u r s i n g when they returned? At the n a t i o n a l l e v e l , p u b l i c h e a l t h nurses had two o r g a n i z a t i o n s d u r i n g the f o r t i e s and f i f t i e s . These were the P u b l i c H e a l t h Nursing S e c t i o n of the Canadian Nurses A s s o c i a t i o n and the P u b l i c H e a l t h Nursing S e c t i o n of the Canadian P u b l i c H e a l t h A s s o c i a t i o n . Reports of the 110 a c t i v i t i e s o f these s e c t i o n s w i t h i n the l a r g e r bodies of the CNA and CPHA are found i n the n a t i o n a l j o u r n a l s , the Canadian Nurse and the Canadian J o u r n a l o f P u b l i c H e a l t h . In l i g h t o f the c u r r e n t i n t e r e s t i n the formation o f s p e c i a l t y groups a t the n a t i o n a l l e v e l , an examination of the h i s t o r y o f these two groups c o u l d be h e l p f u l . How d i d these o r g a n i z a t i o n s develop and what l e d t o t h e i r d e c l i n e ? What were the purposes of the two groups and what d i d they achieve f o r p u b l i c h e a l t h nursing? To what extent d i d the e x i s t e n c e o f two s i m i l a r groups d i v i d e p u b l i c h e a l t h nursing? P u b l i c h e a l t h nurses were among the f i r s t community workers i n the p r o v i n c e . I t would be u s e f u l t o compare the development of p u b l i c h e a l t h n u r s i n g w i t h the experiences o f ot h e r o c c u p a t i o n a l groups i n the community. For i n s t a n c e , how d i d s o c i a l work and community mental h e a l t h evolve i n B r i t i s h Columbia? F i n a l l y , i n l o o k i n g a t developments i n p r a c t i c e , i t would be i n t e r e s t i n g t o t r a c e the beginnings of r e s e a r c h i n t o p u b l i c h e a l t h n u r s i n g problems. What types of problems were i d e n t i f i e d ? What r e s e a r c h methods were used? How were r e s u l t s used and communicated t o others? I t i s apparent t h a t the area o f p u b l i c h e a l t h n u r s i n g h i s t o r y i s r i f e w i t h q u e s t i o n s f o r study. The i d e n t i t y o f f u t u r e p u b l i c h e a l t h nurses w i l l be strengthened by knowledge o f the p a s t . I l l In c o n c l u s i o n , t h i s study has h i g h l i g h t e d the importance of paying a t t e n t i o n t o nursing's c o l l e c t i v e past. When problems are encountered i n c u r r e n t s i t u a t i o n s , knowledge of the past can i l l u m i n a t e and provide s o l u t i o n s . Indeed, many lessons are hidden i n our h i s t o r y ; i t i s the r e s p o n s i b i l i t y of today's nurses t o ask questions t h a t w i l l l e a d t o a g r e a t e r understanding of our h e r i t a g e . 112 References Allemang, M. M. (1973). Development i n i d e a s about n u r s i n g e d u c a t i o n i n the U n i t e d S t a t e s and Canada, 1873-1950. In Proceedings of the Colloquium on  N u r s i n g Research (pp.5-14). Montreal: M c G i l l U n i v e r s i t y P r e s s . Allemang, M. M. (1985). Development of community h e a l t h n u r s i n g i n Canada. In M. Stewart, J . Innes, S. S e a r l , & C. 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