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• 1 media/providen_students_mock_operation.jpeg 2022-06-13T21:28:31+00:00 Nursing Education in the United States: An Historical Overview 98 image_header 2023-01-17T18:33:27+00:00
  Black men, and especially Black women, have been providing nursing services since their ancestors arrived in the United States in bondage. Enslaved African women provided healing and midwifery labor for both Black and white communities, transmitting African medical and herbal knowledge to succeeding generations of African Americans.1 Some even ran slave hospitals on large plantations.2 Sojourner Truth is often recognized as an abolitionist and women’s rights activist, but she also worked as a nurse for the family that owned her. During the Civil War Harriet Tubman and Susie King Taylor both nursed Union soldiers and recently freed African Americans. Besides these well-known women, hundreds of Black men and women (many who escaped from slavery) served as nurses during the Civil War.3
  After the war, formerly enslaved African Americans and their descendants found themselves struggling to be recognized as full citizens, as racism and the legacy of slavery continued to impact American society. Regardless of the time period – Reconstruction (1865-1877), Jim Crow (1870’s-1950’s) or the Civil Rights era (1950’s-1960’s), American institutions, including schools, places of worship, the media, and the law reflected the racial ideology that Black people were inferior. Nursing was no exception.     
  White nurse leaders worked to restrict access to formal nursing education for African Americans.  These elites did not believe that African Americans fit the image of the “ideal nurse.”  Regardless of how white nurses have viewed them, Black nurses have held a special place in their communities. Nursing schools have often provided a route into the middle class for Black women who otherwise had limited economic opportunities. Black communities have provided significant support to Black nurses who wanted to pursue their education, and in turn Black nurses have been central in the fight for healthcare equity and access for Black Americans.4 Black nurses have often been the most trusted healthcare professionals in Black communities.5
  
  As the history below will show, African American nursing students and nurses have had had to contend with three intersecting realities:
   

  "they [are] Black, female, and in a profession still striving for equality and respect within the medical community.”6 

  
  Then and now Black nurses’ struggles for equal educational opportunities has been about more than their own jobs or careers.

  THE NIGHTINGALE SCHOOLS

  The widespread illness and injury of the Civil War helped to raise awareness about the importance of nursing in the United States.7
  
  White women and nurse leaders began establishing nursing schools soon after the war in the 1870’s, during a racist white backlash to the gains that African Americans had made during the Reconstruction era. The emergence of the modern profession of nursing is generally associated with Florence Nightingale, and wealthy white women and nurses in the United States created programs based on the Nightingale model. The founders of these schools believed that nurses should be white middle and upper-class unmarried women who followed strict Victorian etiquette rules. In reality, these programs admitted many working-class white women, but largely excluded Black women.8
  
  
  For example, the New England Hospital for Women and Children had racial quotas allowing only one Jewish and one Black student in each class. Mary Eliza Mahoney, the daughter of formerly enslaved parents, graduated from the program in 1879, becoming the first African American woman to earn a diploma in nursing. She was one of only seven Black students who graduated from the school by the time it closed in 1951.9 Mahoney’s story illustrates the difficulties that Black nurses faced in getting trained and their determination to gain education despite continued efforts by white leaders to exclude them.  
  
  In these Nightingale-model schools, female nurses acted as administrators and instructor. Yet by the late 1800’s, changes in medicine gave male hospital administrators and doctors the power to shift nurse training from these schools to apprenticeship programs based in hospitals.
   

  HOSPITAL-BASED APPRENTICESHIP PROGRAMS & THE RISE OF JIM CROW

  Scientific medical advances in the late 1800’s allowed doctors and nurses to perform increasingly complex medical procedures, many of which were only possible in a hospital setting and required specialized technical skills. Hospital administrators and physicians (most of whom were male) realized that student nurses provided cheap skilled labor that improved patient outcomes. They pushed for nurse training programs that would be based in hospitals, and the Nightingale-model schools, who relied on hospitals for resources, could do little to oppose this change.10 In these hospital apprenticeship programs, student nurses worked long hours running most of the hospitals’ operations, and they received little classroom instruction.11 These new nurse training programs emerged during the beginnings of the Jim Crow era that followed Reconstruction and they discriminated against Black Americans like many other institutions did during this time.
  
  As Black nurse leader and activist Mabel K. Staupers described the emergence of Jim Crow:

  “America was developing rigid patterns of discrimination and segregation against Negroes in every section of the nation…Every area of living was affected and nursing was no exception. This was the period when battles to establish the rights of Negroes as freedmen were lost. ‘Black codes’ were set up by law in the South and by custom in the North, where they were observed just as relentlessly. Hospitals and nursing schools followed the pattern both in admission of students and in the care of patients.”12

   
  Most hospital-based nurse training programs excluded Black students completely. The institutional racism of the Jim Crow era meant that some southern nursing programs that had once accepted Black students were now legally prohibited from doing so.13
  
  Racism in the healthcare system also affected Black patients. Hospital care was improving in this era, yet Black Americans were denied the benefits of these advances. Black patients often could not get admitted to public hospitals or were sent to segregated wards. When they could get hospital treatment, Black people were often treated by racist white medical staff, creating deep distrust in the Black community regarding the healthcare system. Certain statistics indicate that while white Americans’ health outcomes were improving at the beginning of the 1900’s, the health of Black Americans was deteriorating.14
  
  Black physicians, nurses, their communities, and their white allies responded by creating a network of Black hospitals and nurse training schools, often with financial help from white philanthropists and the Black community. These institutions served as the cornerstone of healthcare for the African American community throughout the Jim Crow years.
  
  BLACK NURSING SCHOOLS
  
  Between the 1880’s and 1920’s between twenty-five to ninety Black nursing schools and between one hundred to two hundred Black hospitals rose across the United States.15 Black physicians founded many of these institutions, some because they cared about helping prospective Black nurses, and some because they were barred from white-run hospitals and needed a place to treat patients and build their own careers. Many were concerned about healthcare disparities, and they found a lot of support from the Black community in creating hospitals that cared for Black patients.16 Black communities, particularly Black women, played a critical role in forming and sustaining these institutions. Black women’s clubs across the country recruited nursing students, organized collections of hospital supplies, and raised funds to pay salaries and improve facilities.17 
  
  These hospitals and nursing schools were part of the self-help tradition of Black activism that had wide acceptance among Black Americans in the late 1800’s and early 1900’s. In this tradition, Black communities focused on creating opportunities denied to them by white Americans. In 1925, only 54 of 1,642 accredited nursing schools in the United States admitted Black students (three percent). 25 of those 54 schools were attached to Black hospitals or hospital wards.18 
  
  
  
  These Black hospitals and nursing schools filled a crucial gap. They provided increased healthcare access for Black communities while creating paths for young Black women to gain middle class employment in a time when African Americans faced systemic racism, poverty, and lack of services.19
  
  However, because government help was minimal and the Black community had limited money, these institutions often relied on financial support from white philanthropists and foundations, which was a mixed blessing. White-run foundations, particularly the Rockefeller Foundation and Rosenwald Fund, provided critical funding that allowed Black nursing schools to survive. Yet relying on white capital meant navigating white donors’ demands and attempts to take control. And some philanthropists only donated out of self-interest, concerned that disease in the African American community could spread to the white community. Some Black leaders also worried that accepting white charity for Black institutions reinforced segregation, when the Black community should have been fighting for integration.20
  
  The state of Black healthcare and nursing schools differed to some extent depending on the region of the country.
  
  NURSING SCHOOLS IN THE SOUTH
  
  
  
  The majority of nursing schools that admitted Black students were located in the South and were attached to segregated hospitals or hospital wards. White hospitals and healthcare professionals in the South refused to treat Black patients, leaving Black hospitals to care for a large, high-need population with few resources.22 Some Black doctors set up hospitals in homes or one-room buildings with minimal equipment. Because of patriarchal norms, these physicians often expected female nursing students to run the hospitals’ daily operations, without giving students any standardized training in return. This treatment of Black student nurses was worse in the South because Black physicians had the fewest opportunities in this region and thus often needed to open their own hospitals in order to be able to practice medicine.23 In this way racism and patriarchy combined to impact Black female nursing students’ learning and working conditions.
  
  Southern hospitals also frequently “hired out” Black nursing students to provide services to wealthy white families or to poor, rural Black communities. This service could be lucrative for struggling Black hospitals and helped them to build goodwill in the white community, whose financial support they needed (white healthcare institutions already received this type of funding). Historian Darlene Clark Hine has argued that the hiring out of student nurses was exploitative, forcing female workers who had few options to venture out into unpredictable situations in the community with little support or pay.24 
  
  And yet, these student nurses also provided crucial services and were at times “the first black health-care professionals ever to appear in many of the small black…communities in the South.”21 These students provided healthcare with little training, often without a doctor present, leading them to quickly develop skills that they would use in future positions. This dynamic, in which Black nurses became exceptionally skilled because they worked in environments with high expectations and few resources, repeated itself in Northern hospital-based nursing schools.
  
  NURSING SCHOOLS IN THE NORTH 
  
  Structural racism differed in the North, but still created healthcare inequities. As large numbers of African Americans migrated to northern cities in the late 1800’s and early 1900’s, many white northerners reacted by shifting their communities to practices of racial segregation similar to those in force in the South. Black people in the North faced employment discrimination, with the additional challenge of needing to compete for jobs with newly arrived European immigrants. In northern and midwestern cities like New York, Chicago, Detroit, and Kansas City, white residents refused to allow Black newcomers to move into their neighborhoods, forcing them to live in crowded, substandard conditions. This situation allowed infectious diseases to spread quickly and led to high rates of sickness and Black infant mortality.25
  
  Few northern nursing schools accepted Black students, and when Black students could get nurse training, they faced other obstacles. In New York, for example, students at Harlem Hospital, a Black nursing school, complained that they could not get affiliations in psychiatry and communicable diseases as white nursing students at other schools were able to. Mabel Staupers argued that education and employment opportunities for Black nurses in New York were “as limited as in certain areas of the South.”26 However, because Black doctors had more opportunities in the North than the South, they were more able and willing to advocate for Black nurses.
  
  
  Chicago exhibited many similar dynamics to other northern cities. Dr. Daniel Hale Williams founded Provident Hospital and Training School in 1891 in response to the reality that Chicago had no schools of nursing that admitted Black nurses, no hospitals where Black doctors could practice, and few hospitals that admitted Black patients.28
  
  
  
  Across all regions of the United States, Black nursing students experienced many similar challenges and opportunities. Black nursing schools struggled to maintain high standards, due to limited funds. Additionally, the focus of most Black hospitals was not, ultimately, on student’s education and professional advancement. Black doctors needed “a constant supply of obedient, disciplined, and inexpensive workers”30 to run their hospitals. Ideas about gender roles at the time also led many nursing school administrators to maintain strict rules about female students’ lives in order to safeguard their “morality.” 31
  
  Black student nurses also had to contend with the fact that white superintendents ran many Black nursing schools. Ethel Johns noted the racial tension between Black nursing students and white supervisors in a Kansas City hospital. While schools with Black supervisors had fewer resources, she could sense a “windy spirit of conscious race enterprise,” a feeling of solidarity between supervisors and students in these all-Black institutions.32
  
  Student and graduate nurses did not always accept these difficult conditions. Student nurses at Tuskegee Institute threatened a student strike, thus successfully pressuring the hospital to reduce demands on students.33 Students at Harlem Hospital, led by Salaria Kee, waged a successful protest against the system of reserving certain dining room tables for white nurses and administrators.34 
  
  In response to the educational and employment discrimination that Black nurses faced, Martha Minerva Franklin, a Black nurse leader, helped to organize the creation of the National Association for Colored Graduate Nurses (NACGN) in 1908. Franklin recognized that such an organization “would gain recognition for [Black nurses] and would in time make it possible for them to serve the America public without racial bias.”35 Among the NACGN’s many early efforts was a focus on raising the standards of Black schools of nursing and forcing inadequate schools to close. NACGN leaders understood that Black nurses would only gain professional acceptance if the standards of the schools they attended improved.36 These are just a few of many examples of how Black nurses fought to shape the conditions of their labor.
  
  Despite structural limitations, these schools served a crucial role for thousands of Black women and for the Black community. Nursing schools provided the beginning of a professional career path for thousands of Black women. Because the schools were attached to hospitals, the costs for students were often much lower than college tuition, allowing women from working-class backgrounds to enroll.37 Student nurses also built close relationships with their classmates through the difficult conditions of nursing school, relationships they would rely on as graduated and often became the only professionals who provided real and sympathetic healthcare for the African American community.
  
  Women like Anna De Costa Banks (Hampton graduate, 1893), Carrie Bullock (Provident graduate, 1909), and Petra Pinn (Tuskegee graduate, 1906) went on to work in public health nursing and become nurse superintendents. Other Black women, like Rita E. Miller (Mercy graduate, 1924), Mary Elizabeth Carnegie (Lincoln graduate, 1936) and Estelle Massey Osborne (graduate of St. Louis City Hospital #2, 1923) went into academia, becoming nurse educators and researchers. Many also became activists fighting to desegregate the nursing profession, a struggle that would begin to gain victories by the 1940’s. As Darlene Clark Hine wrote:

  “The walls of segregation were destined to collapse under their relentless assault.”38

   

  UNIVERSITY-BASED NURSING PROGRAMS

  
  Black and white nursing leaders had argued for many years for the need to raise the standards of nursing education. White nurse leaders criticized the hospital-based training model. They believed that nurses should study in university-based programs that would train students in scientific knowledge and medical skills. Male physicians and hospital administrators generally opposed this shift, fearing that they would lose cheap student nurse labor and their control over medical knowledge. Yet white nurse leaders helped to found dozens of undergraduate nursing programs by the 1930’s.
  
  Black nurse leaders agreed with white nurse leaders' criticisms of hospital-based training, but they also knew that a shift towards university-based programs would only make conditions worse for prospective Black nurses. Most collegiate nursing programs did not accept Black students. As the average white nurse began to earn a bachelor’s degree in nursing, Black nurses’ diplomas suddenly had less value, and they had even fewer possibilities for jobs and good wages. White nurses got most leadership positions available in the field and were even running a third of Black nursing schools in the 1930’s.39 By the 1940’s, Black nurse activists were pressing Black colleges and universities to open nursing programs, and a few opened in that decade. 
  
  Yet most white-run nursing programs still refused to admit Black students. In 1941, the dean of the Yale University School of Nursing wrote to a Black applicant that “[I] regret to tell you that we have no Negro students in the School [sic] nor Negro nurses on staff,” and recommended applying to an all-Black medical college in Tennessee.40
  
  Black nurses would not accept this reality. With the leadership of like Estelle Osborne and Mabel K. Staupers, the NACGN would become a powerful force organizing against segregation in nursing education in the years leading up to and during World War Two. 
   
  WORLD WAR TWO & THE FIGHT FOR INTEGRATION
  Frustrated by the limited benefits of the New Deal for African Americans and spurred on by the anti-Nazi, pro-democracy rhetoric sweeping the United States in the 1940’s, African American activists began a more militant push for integration and equality. Black nurse activists and their allies were no exception. 
  
  The outbreak of World War Two spurred a massive outpouring of government resources, including a demand for nurses. The activists of the NACGN, aided by funding from the Rosenfeld Fund, began a relentless push to eliminate the Army and Navy Nurse Corps’ racial quotas and restrictions.
  
  Frances Payne Bolton, a white congresswoman and supporter of the NACGN, introduced the Bolton Act of 1943, which created the U.S. Cadet Nurses Corps, intended to train nurses as quickly as possible to meet wartime needs. According to the Act, if nursing students agreed to work in certain essential fields, the federal government would pay for their tuition and other expenses. NACGN activists rallied Black nurses across the country to pressure their representatives and senators to sign the antidiscrimination clause of the bill, which denied Bolton Act funding for any schools that discriminated against students based on gender, marital status, ethnicity, or race. Funding from the act allowed Black nursing schools to significantly increase their enrollment and encouraged some white schools to begin accepting Black students. NACGN activists also did important work recruiting Black women to enroll in nursing programs after the passage of the Act.41
  
  The NACGN’s activism also led the War Department to announce in January 1945 that all nurses would be accepted into the Army and Nurse Corps, regardless of race.
   
  THE INTEGRATION YEARS
  Black nurses won significant victories against racism and segregation during World War Two, culminating with the American Nurses Association taking formal steps in 1948 to allow all Black nurses to join. This marked the end of formal segregation in American nursing.42 Additionally, increased funding from the federal government, along with continued financial support from the Rosenwald Fund and General Education Board, allowed several Black colleges and universities to create new nursing programs in the 1950’s.43
  
  Yet as Mary Elizabeth Carnegie, a Black nurse leader and activist wrote, “1951 marked the end of one era in the fight for equality for all nurses and the beginning of another.”44 Integration was not a simple, smooth, or straightforward process. 
  
  White institutions resisted integration as much as they could. In 1951, only twenty percent of the 1,170 nursing school in the U.S. officially admitted Black students. In 1962, eighty-two percent admitted all students regardless of race.45
  The burden of integration fell mostly on the small numbers of Black students and nurses who entered newly integrated nursing schools and hospitals. 
  
  Dr. Barbara Norman, one of the nurses who contributed to our oral history project, was one of two Black students who enrolled at Grant Hospital Nursing School in 1960. Dr. Norman recounts how, when she took the entrance exam, Grant’s staff “couldn’t understand how I was able to pass their admission exam, and [with] one of the highest scores, after graduating from a trade school. So, they said, ‘oh she couldn’t have done that by herself.’”  The school required her to retake the exam and undergo psychological testing before finally admitting her. 
  Phyllis Pelt, another contributor to our project, who enrolled at UIC’s College of Nursing in 1964, recounts how she and a white classmate studied together and submitted the same answers on an assignment, but her classmate received a higher grade. When Pelt inquired with the teacher, she remembers that “the teacher looked at the papers and she said, ‘You are lucky to even be in this school.’ She said, ‘So I'm not changing the grade.’” 
  
  Black nursing students like Norman and Pelt persevered, graduated, and went on to become leaders in their communities and fields.
  
  Black nursing students learned that surviving and thriving in majority-white institutions required that they not just be good enough, but that they excel beyond their peers. They saw excellence in education as a form of resistance against the racism that they continued to face in nursing schools after the end of legal segregation.46
  
  Integration badly hurt many Black nursing schools and hospitals. Black nursing schools and hospitals had always suffered from a lack of funding. When the Civil Rights Act of 1964 and the Medicare Act of 1965 forced hospitals to integrate, Black Americans sought out opportunities and treatment at better-resourced, white-run hospitals and schools. Even when Black hospitals sought to upgrade their facilities, Black and white patients continued to believe that Black doctors and nurses had worse training and provided inferior care. Many hospitals and schools were forced to close or merge with other institutions.47 The last Black nurse diploma program closed in 1982.48
  
  But integration also provided Black women with many new educational opportunities, and the number of Black nurses in the United States more than tripled between 1950 and 1960. The Nurse Training Act of 1964 funded many new university-based programs and improved conditions for Black nurses by withholding federal funds from nursing schools that enforced segregation or were not actively working towards integration.49
  
  Two-year associate degree of nursing (ADN) programs were also gaining steam in this period, aimed at quickly training skilled nurses to fill the post-war nursing shortage. ADN programs expanded along with the increase in community colleges. These programs greatly increased access to nurse training for students of color.50
  
  Yet by the 1970’s, Black nurse leaders noticed that even as Black nurses and nursing students were gaining access to more institutions, there were still few Black nurses in leadership positions. Black hospitals and nursing schools, which had been spaces for cultivating Black excellence and leadership, no longer existed. And many white-run nursing schools continued with racist admissions practices: they would now admit Black students, but only a small number with particularly strong educational records.51
  
  In response, in 1971, a group of Black nurses formed the National Black Nurses Association to continue advocating for the position of Black nurses and nursing students. 
   
  NURSING EDUCATION TODAY  
  Nursing education has continued to evolve since the 1970’s. Master’s programs have been created to train nurses in specialties like intensive care, oncology, and psychiatry, as well as to educate nurse practitioners, who have increasingly become crucial primary care providers, especially for historically underserved populations. Doctoral programs have also emerged in recent decades, providing avenues for advanced research and teaching in the field. 
  
  Dr. Angelique Richard (include link), who provided an oral history for our project, completed a PhD in Nursing at UIC in 1999 while raising a child as a single parent, and while working full-time as a nurse leader in several under resourced hospitals around the Chicago area. She now serves as the Chief Nursing Officer at Rush University Medical Center in Chicago.
   Black nurses and nursing students continue to face barriers in a field where white nurses often dominate. According to a 2008 survey, nurses from racial minority groups are more likely than white nurses to have baccalaureate or graduate degrees in nursing, but they are less likely to hold advanced and leadership positions in academic, research, and clinical practice.52
  
  As they did at the beginning of the 20^th century, nurse leaders today have also been pushing to require bachelor’s degrees for all nurses. This would eliminate associate degree of nursing programs, which, due to systemic education and economic inequalities, are often the most accessible and affordable options for Black Americans.53
  
  Systemic racism against Black healthcare students and providers also continues to be directly connected to inequities that impact the health of Black patients and communities. Student nurses graduated directly into the frontlines of the COVID-19 pandemic, often caring for deeply impacted communities of color. 
  
  Although the nature of systemic racism has shifted over the last one hundred fifty years ago, Black nurses continue to face challenges, whether in their educational path or in the inequality they see in the communities they serve. And Black nurses continue to achieve excellence and provide crucial healthcare services to communities across the United States. 
  
  Continue exploring our “Schools of Nursing” section to learn more about some of Chicago’s nursing schools that historically enrolled large numbers of Black students.
  
  Learn more about the stories of the Black Chicago nurses who participated in our oral history project here.
  
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