Accepted Manuscript

Investing in Nursing and Midwifery Enterprise to Empower Women and StrengthenHealth Services and Systems: Commentary and Context

Julie Fairman, PhD, RN, FAAN, Nightingale Professor Nursing, Chair, Director

PII: S0029-6554(15)00269-9

DOI: 10.1016/j.outlook.2015.09.001

Reference: YMNO 1069

To appear in: Nursing Outlook

Received Date: 24 August 2015

Accepted Date: 9 September 2015

Please cite this article as: Fairman J, Investing in Nursing and Midwifery Enterprise to Empower Womenand Strengthen Health Services and Systems: Commentary and Context, Nursing Outlook (2015), doi:10.1016/j.outlook.2015.09.001.

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Title: Investing in Nursing and Midwifery Enterprise to Empower Women and

Strengthen Health Services and Systems: Commentary and Context

Julie Fairman, PhD, RN, FAAN

Nightingale Professor Nursing

Chair, Biobehavioral Health Sciences Department

Director, Barbara Bates Center for the Study of the History of Nursing

University of Pennsylvania

School of Nursing

Fairman@nursing.upenn.edu

Corresponding author: See above.

Permanent address: 217 Glenn Rd, Ardmore, PA 19003

Conflicts of interest: No financial interest. The author participated in the IOM

workshop that formed the basis of the papers in this commentary.

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Abstract

This commentary provides historical context to the papers by Salmon and Maeda,

and Pittman and Salmon in this issue. The papers emerged from the 2014 Institute

of Medicine's (IOM) global workshop and its subsequent report, Empowering

Women and Strengthening Health Systems and Services through Investing in

Nursing and Midwifery Enterprise: Lessons from Lower-Income Countries:

Workshop on Nursing and Midwifery Enterprise. Although nursing and midwifery

enterprise have helped women achieve higher social status and economic security

across time and place, their combination with intentionality in the modern context

is new and offers an innovative mechanism for empowering women. Historical

episodes offer evidence for the need for a stable source for enterprise services and

funding and the need for women in the professions and in the communities they

serve to work together towards common goals pertaining to health.

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Introduction

Salmon, Maeda, and Pittman, in their body of work in this issue, provide an

interesting and fruitful counterpoint to rhetoric surrounding the failures of the

American health system. Instead of focusing on payment and costs of traditional

care that are physician or institutionally driven, both papers concentrate on how an

empowered workforce of women might achieve health system reform aims. They

provide both a broad overview and focused case studies of ways that nursing,

midwifery and nursing care workers, the largest group of providers in the world,

could achieve a triple aim of women’s empowerment and increased social status,

better access to care for their communities, and better use of an underutilized

nursing workforce in the United States (US).

Salmon’s and Maeda’s article1 focuses on the 2014 Institute of Medicine’s

(IOM) global workshop and its subsequent report, Empowering Women and

Strengthening Health Systems and Services through Investing in Nursing and

Midwifery Enterprise: Lessons from Lower-Income Countries: Workshop on Nursing

and Midwifery Enterprise.2 Pittman and Salmon3 present a series of three case

studies from across the globe that may have characteristics translatable to the

United States. Both papers provide a springboard for health policy and investment

strategies that are potentially sustainable and scalable and could significantly

improve our models of care.

Empowerment and Nursing and Midwifery

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The authors’ ideas, in our current context, are fresh and very exciting. Their

combination of intentionality, noted by Salmon and Maeda, and an organized

approach to enterprise within the context of nursing are novel ideas. Nursing and

midwifery as vehicles to empower women by increasing their social and economic

status is, however, historically contingent and reflects the context of the time period,

place, and economics. Nurses and midwives, for example, have had a contentious

history. Public health nurses and their allies (wealthy women and medical public

health officers) were instrumental in driving midwives from practice in the early

20th century.4 The Maternal Child Association in New York City and the Frontier

Nursing Services in West Virginia are examples of institutions that survived. Nurses

have also been adept, at particular times, at protecting the profession above the

public’s needs. Nurses’ battle to claim the title of nurse is one that has endured from

the early decades of the 20th century to our current time and is one that has

disenfranchised women, such as nurses’ aides and community health workers who

nursed.5 On the other hand, nurses have been flexible in meeting the particular

crises of our public and private health care: Nurses created a workforce that

supported the growth of hospitals6, nurses moved into expanded practice roles in

the 1960s to fill a primary care shortage7, and nurses embraced business

fundamentals in the 21st Century to provide higher value and quality of care at

lower prices. Nursing has empowered women but also disempowered certain

groups of women.

Since the development of nurse training schools in the 1880s and 1890s in

the United States, nursing has been a mechanism particularly for working class

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white women to gain a stable occupation and to achieve middle class status.

Although superintendents specifically sought out the daughters of white farmers,

preachers, and teachers, the quintessential middle class occupations, for their

training schools, it was working class women who saw nursing as a springboard to

middle class status and values.8 The World War II Army Nurse Cadet Corp (insert

photo here) (Caption: Marceline Adamson Salmon, Army Nurse Cadet Corp circa

1940s) (as well as the Navy) offered primarily white women from lower and middle

income families an opportunity to support the war effort, achieve officer rank and

its benefits, and to gain training that provided a path to middle class status and

values.9 After the war, nurses in hospitals and clinics, and those returning from the

battlefields, used their training to supplement family incomes or to remain

independent, if single. Nurse training was one of the few occupations that granted

nurses from many racial and ethnic groups entry into solid middle class status and

embodied values, even as some, such as African American nurses and men, were

relegated to segregated hospitals and work spaces, and were denied full

engagement in the Armed Forces during World War II.10

As Salmon and Maeda note, “Empowerment entails providing a vehicle to

increase a woman’s status in their family and community and in institutions in

which they practice.”11 In contrast, historian of nursing Patricia D’Antonio wrote,

“…most women and men who chose to do nursing’s work wanted to do good. But

they also wanted to do well…in the social spaces they occupied in their own

communities, neighborhoods, and families…” 12 Nurses have provided that

unacknowledged safety net of health care services to families and communities that

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are not priced out or included in health care costs. They provided (and still do) a

sort of “back porch” commodity that was and is a critical health resource rooted in

their community identity.13 Their work with families and communities bestowed

status and power on nurses which was not always replicated in the more formal

hospital institutions. This was especially true for nurses of color who were typically

more educated than their community members.14

Nursing offered US women opportunities for economic stability. Even

through the Depression Era and in times of nurse workforce oversupply, nurses

found employment when many others could not. The federal government provided

employment through rural health programs, maternal and child health programs

(through Shepard Towner programs), and other mechanisms when state programs

were financially unsustainable.15 Post World War II nurses tended to stay longer in

the work force than before the war, when many, if they married, left the workforce.

Post-war nurses became part of the two-income household economy that fueled the

post-war middle class economic boom and consumption culture.16 Steady work and

income, in addition to the value of their middle class identity as a nurse, was and

remains a key factor for the profession to empower women who constitute most of

the workforce.

As with any historical idea, empowerment of women through nursing and

midwifery was also historically complex and was shaped by class and race. Post

World War II, nurses struggled to distance themselves from other women in health

care, such as nursing aides, as they attempted to gain greater power in patient care.

In the 1960s and 1970s, during the rise of second wave feminism, there was on the

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part of some, as Ellen Baer noted in her New York Time Editorial in 1991, a

“feminist disdain for nursing.”17 Many feminists perceived nursing and midwifery

as professions dependent on medicine, during a time when women were fighting to

enter the medical profession itself. Some feminists saw medicine, rather than

nursing, as part of their liberating gender and class rhetoric. On the other hand, the

Women’s Health Movement of the 1960s and 1970s was a response to the overt

paternalism of male physicians, particularly in the area of women’s health. Nurses

participated in women’s health clinics, and some women who were deeply involved

in the movement entered nursing and midwifery as a second career in the decades

of the 1980s and 1990s, because they understood these roles offered viable careers

and authority in women’s health care.18

Intentionality

Even as training school superintendents were seeking the right kind of

woman for their classes, women actively sought out training in hospital nursing

schools and institutions of higher education. Intentionality, thus, was multi-

directional. Hospital training schools did not spend many resources to bring women

into nursing, and in many instances, women of racial and ethnic minorities, and of

some religions (e.g. Jews, Mormons, and Catholics at points in time) were

purposefully excluded from the profession or were only allowed entry through

segregated or religious affiliated schools at least until after World War II.19 Even so,

those who entered training understood how they contributed to their own survival

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as single women and how they contributed to the survival of their families through

their income. Their work bestowed benefit beyond their impact on health.

Enterprise and Nursing and Midwifery

Combining intentionality and formal financial support through business

enterprises is a new idea. Historian Rosemary Stevens argues that health care has

always been a business, but it has cloaked its commercial interests in philanthropy

and voluntarism in order to maintain financial independence from the state.20

There are many examples throughout the history of nursing of wealthy

philanthropists funding schools of nursing or nursing services. Most of these were

directed to the improvement of health in a particular community and not

intentionally towards the nursing enterprise as defined by Salmon and Maeda.

Florence Nightingale believed “…every woman is a nurse…” and trained nurses were

a mechanism to reform hospitals as well as provide stable employment to women of

character. 21 The post-Crimean War Nightingale Fund paid for the St. Thomas’s

Training School at St. Thomas’s Hospital, London, England, as well as the trainees

and nurses who worked there. Elisabeth Mills (Mrs. Whitelaw) Reid, a wealthy

philanthropist, provided the money for the Ogden Mills Training School at the

Adirondack Cottage Sanatorium in New York in 1912.22 In addition to providing

training for nurses to care for tuberculosis patients, the school offered professional

training in an area with few other job opportunities. She also supported The Town

and Country Nursing Service. Whitelaw Reid and a mix of wealthy philanthropic

women believed nurses and local women working together could improve the

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health of rural communities.23 Midwives in early 20th century Irish, Russian, and

Italian communities served as independent contractors, but they were not

supported or franchised by external organizations.24

There are examples of nurses and midwives developing entrepreneurial

models of care that encompassed the business of healthy communities. These

organizations, for example, the Frontier Nursing Service in West Virginia, and the

Starr Center in Philadelphia, were started by entrepreneurial, wealthy,

philanthropic men and women who wanted to improve the health of communities.

They also saw the services of nurses as providing income (however slight) to the

organizations while offering reasonable paying jobs to nurses, midwives, and other

women in the community. Lucille Kinlein began her own practice in 1971 in College

Park, MD.25 She had no previous business experience, and she funded her

independent practice. She later extended her philosophy of self-care into the

Profession of Kinlein, an enterprise that included books, tapes, and other enterprise

products. None of these examples were supported by franchising organizations that

provided business skills or financing opportunities.

Conclusion

As we think about the power of nursing and midwifery to elevate women

across the globe to greater power and social status within their community through

enterprise while improving health systems, there are certain lessons and

imperatives for doing things differently than we have done in the past. First, a

stable source of funding is critical. There should be enterprise partners who have

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the capacities to finance and develop business support services. They should

partner with institutions that educate women as nurses, midwives, and other

caregivers. Sustainability has to be built in and not left to the next interested

philanthropist. The Starr Center, for example, lost its momentum when its

philanthropic patrons lost interest and when no one else was ready to fill the

breech. The Frontier Nursing Service was sustained through Medicare and Medicaid

funding.

Secondly, women must work together to sustain systems and services.

Marginalizing certain types of providers, as has happened between nurses and

nurses’ aides and between public health nurses and midwives, will not support

women’s empowerment, nor will it support successful enterprise. On the other

hand, new models of care that integrate caregivers other than nurses should

consider even greater integration, or we risk territorial and credentialing conflicts

that are divisive.

As we think about the best utilization of workforce and resources, women’s

empowerment through enterprise as a way to improve health services provides a

critical opportunity that is rooted in history but has a very modern shape. The

articles by Salmon, Maeda, and Pittman provide us with an innovative blueprint for

scalability and sustainability of the enterprise model.

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Acknowledgements: I would like to thank the RWJF, which has been incredibly

supportive, as well as my colleagues, Patricia D’Antonio and Cindy Connolly, who

read drafts and offered critique. Thanks also to Dionysia Petrakis who helped

format and edit this work.

1 Marla E. Salmon and Akiko Maeda, “Investing in Nursing and Midwifery Enterprise

to Empower Women and Strengthen Health Services and Systems: An Emerging

Global Body of Work,” Nursing Outlook, n.d. 2 Institute of Medicine (IOM), “Empowering Women and Strengthening Health

Systems and Services through Investing in Nursing and Midwifery Enterprise:

Lessons from Lower-Income Countries : Workshop Summary” (Washington, D.C:

The National Academies Press, 2015). 3 Patricia Pittman and Marla E. Salmon, “Nursing and Midwifery Enterprise in Lower

Income Countries: Lessons for the United States on Women’s Empowerment and the

Advancement of Health,” Nursing Outlook, n.d. 4 Katy Dawley, “The Campaign to Eliminate the Midwife,” The American Journal of

Nursing 100, no. 10 (October 2000): 50–56, doi:10.2307/3522317; Christa Craven

and Mara Glatzel, “Downplaying Difference: Historical Accounts of African American

Midwives and Contemporary Struggles for Midwifery,” Feminist Studies 36, no. 2

(summer 2010): 330–58. 5 Champe S. Andrews, “The Campaign for Registration of Nurses in New York State,”

The American Journal of Nursing 3, no. 9 (June 1903): 695, doi:10.2307/3402269. 6 Charles E. Rosenberg, The Care of Strangers: The Rise of America’s Hospital System,

(Baltimore: Johns Hopkins University Press, 1995). 7 Julie Fairman, Making Room in the Clinic: Nurse Practitioners and the Evolution of

Modern Health Care, (New Brunswick, N.J: Rutgers University Press, 2008). 8 Patricia D’Antonio, American Nursing: A History of Knowledge, Authority, and the

Meaning of Work (Baltimore: Johns Hopkins University Press, 2010); Susan Reverby,

Ordered to Care: The Dilemma of American Nursing, 1850-1945, Cambridge History of

Medicine (Cambridge [Cambridgeshire] ; New York: Cambridge University Press,

1987). 9 Charissa J. Threat, Nursing Civil Rights: Gender and Race in the Army Nurse Corps,

Women, Gender, and Sexuality in American History (Urbana, IL: University of Illinois

Press, 2015). 10 Ibid. 11 Salmon and Maeda, “Investing in Nursing and Midwifery Enterprise to Empower

Women and Strengthen Health Services and Systems: An Emerging Global Body of

Work.” 12 D’Antonio, American Nursing, p. 181 13 Fairman, Making Room in the Clinic, 22. 14 D’Antonio, American Nursing. 15 Rima Apple, “‘Much Instruction Needed Here’: The Work of Nurses in Rural

Wisconsin During the Depression,” Nursing History Review 15 (2007): 95–111.

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16 Clifford E. Clark, Jr., “Ranch-House Suburbia: Ideals and Realities,” in Recasting

America: Culture and Politics in the Age of the Cold War, Lary May, ed.(Chicago, Ill:

University of Chicago Press, 1989), 171–94. 17 Ellen D. Baer, “The Feminist Disdain for Nursing,” New York Times, February 23,

1991, New York and Regional Edition edition, sec. Op-Ed. 18 Wendy Kline, Bodies of Knowledge: Sexuality, Reproduction, and Women’s Health in

the Second Wave (Chicago ; London: The University of Chicago Press, 2010); Sheryl

Burt Ruzek, The Women’s Health Movement: Feminist Alternatives to Medical Control

(New York: Praeger, 1978). 19 D’Antonio, American Nursing; Threat, Nursing Civil Rights. 20 Rosemary Stevens, In Sickness and in Wealth: American Hospitals in the Twentieth

Century (Baltimore: Johns Hopkins University Press, 1999). 21 Florence Nightingale, Notes on Nursing. What It Is, and What It Is Not., First

edition, digital library (New York, N.Y.: D. Appleton and Company, n.d.),

http://digital.library.upenn.edu/women/nightingale/nursing/nursing.html.

Accessed May 15, 2015. Preface, no page. 22 Staff, “Elisabeth Mills (Mrs. Whitelaw) Reid 1858-1931,” American Journal of

Nursing 31, no. 6 (1931): 716–17. 23 Arlene Keeling and Sandra B. Lewenson, “A Nursing Historical Perspective on the

Medical Home: Impact on Health Care Policy,” Nursing Outlook 61, no. 5 (September

2013): 360–66, doi:10.1016/j.outlook.2013.07.003. 24 Linda V. Walsh, “Midwives as Wives and Mothers: Urban Midwives in the Early

Twentieth Century,” Nursing History Review 2, no. 1 (1994): 51–65. 25 M. Lucille Kinlein, Independent Nursing Practice with Clients (Philadelphia, PA: J. B.

Lippincott, 1977).

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