ORIGINAL ARTICLE
DOI: 10.11606/issn.1806-6976.v11i3p145-152

 

Training nurses and care/ministering when dealing with tuberculosis, nervous and mental diseases (1920s)

 

 

Mary Ann Menezes Freire^I; Carolina de Oliveira Faber^II; Flávia Ramos Fernandes Guimarães^III; Wellington Mendonça de Amorim^IV

^IPhD, Assistant Professor, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
^IIRN
^IIIMaster’s student, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
^IVPhD, Associate Professor, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil

Correspondence

 

 

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ABSTRACT

In this study we analyze the Goldmark Report recommendations for the adjustment in the training of nurses in two areas: tuberculosis and nervous and mental diseases. The method used here was the historical research based on documentary analysis. The results showed that Nursing Schools and Courses at the time met the requirements more of its institutions, sponsors and trainers, rather than following the report’s guidelines to include in their curricula, materials specific for tuberculosis and mental diseases. We conclude that the Goldmark Report identified the resistance of nurses in dealing with this issue. However, recommendations were left behind that had an impact on these training courses in the 20th century.

Descriptors: Nursing; History of Nursing; Mental Health; Public Health.

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Introduction

Tuberculosis and mental illness have a discriminatory and exclusionary character. For decades it discusses the need for treatment of people suffering from these diseases, to take place near his/her community and away from the hospital, stigma and segregation. Despite the Psychiatric Reform, nurses accumulate crystallized experiences, which disregard the particularities of individuals and neglecting the care demands of each situation. Studies show the need to build teaching technologies that enable a training bringing knowledge and a process in everyday life. Seeking to raise awareness of health professionals, aimed at including openness and the expansion of citizenship ^(1-4).

In Brazil in the early twentieth century, mental illness and tuberculosis stood out in the Brazilian public health scenario. Tuberculosis was fatal in half of the affected population, the result of poor living conditions of the urban middle classes who lived in crowded tenements common in the center of the Federal District in Rio de Janeiro. Unhealthy places without ventilation, that provided the spread of disease.

With the ‘Carlos Chagas Reformation, a government body was established to combat tuberculosis based in Rio de Janeiro and called the Prophylaxis Inspectorate of Tuberculosis. Its objective was to create dispensaries and sanitariums, where they would perform treatments, medicalization and prophylaxis of tuberculosis. Such as tuberculosis, the situation of the mentally ill also need special attention. However, it was not contemplated by the reformation, possibly because this group was under the responsibility of another government agency; the Support Services for Assistance Psychopaths.

The hospice was the place for rehabilitation of the mentally ill, while the doctor was the figure to be respected and the nurse executor of medical order. The Hospices however, were overcrowded as a result of urbanization and political and economic interests aimed at sanitation, interdicting the free movement of madmen, beggars and drunkards ⁽⁵⁾. Institutionalization was part of a social strategy ⁽⁶⁾, viewed as this type of citizen should be isolated from society.

In this context, the education and professionalization of nurses began in the Professional School of Nurses (Escola Profissional De Enfermeiros e Enfermeiras - EPEE), an annex of the National Hospital for the Insane in the Federal District in 1890 ⁽⁷⁾.

The year 1919 in the United States, was the start of a research on the situation of nursing in the US, which resulted in the Goldmark Report published in 1923. This report was elaborated by a committee particularly created for the study of Nursing Education, generating impact worldwide repercussions and affecting subsequently the establishment and evolution of the American nursing model ⁽⁸⁾. The scope of Goldmark Report on issues related to nursing can be highlighted in “Nurse Functions”, “Nurse Training”, “Training Courses for Subsidiary Nursing Group”, “University School of Nursing” and “Graduate Courses”. Issues discussed in this document for the American nursing.

The story, like science, is an unfinished process that operates by the logic of accumulation of knowledge ⁽⁹⁾. This way considering the conformation of the Brazilian health policy at the time of the Carlos Chagas Reformation and the diagnosis that resulted in the document called Goldmark report, we attempted to elucidate issues concerning the training of the nurse and nursing care in situations concerning tuberculosis and nervous and mental diseases, as well as the organization of public health nursing in the early 1920s, in Brazil.

The objectives were defined, being: characterizing tuberculosis, nervous and mental diseases when training nurses in nursing courses and schools in the Federal District of Brazil - in the transition between the 2^nd and 3^rd decade of the century XX and analyzing the Goldmark Report’s recommendations for adjustment in the training of nurses in two special areas; tuberculosis and the nervous and mental diseases.

In this study we sought to contribute to the understanding in a reformist health policy period in nursing care to two special groups: tuberculosis and that of nervous and mental diseases, which needed to be addressed before the stigmatizing force hanging over this part of the population, thus permitting the settlement of a historical knowledge that in turn, can be related to the nursing practice.

 

Methodology

It is from the historical perspective, based on document analysis, since currently, the term document has all traces of the past, capable of a historical analysis ⁽¹⁰⁾. The reading of a document must be guided by questions in order to search for specific things rather than a superficial content ⁽¹⁰⁾.

As a result of time delimitation around the year 1923, the publication of Goldmark Report in the United States was demarcated and in Brazil, its dissemination.

The search for these documents occurred in the following collections: Sectorial Archive Nurse Maria de Castro Pamphiro - EEAP - UNIRIO, The Library of Ministry of Finance in Rio de Janeiro, Anna Nery’s Center of Nursing Documentation in Rio de Janeiro, and the Scientific Laboratory Approaches in History Nursing (Lacenf). The source is the author’s choice in accordance with existing documents from the selection and organization of the information that interest you ⁽¹⁰⁾.

The documents were research and institutional reports. Of these, the following sources were selected: the entitled document ‘’Report of the Committee for the Study of Nursing Education. Nursing and Nursing Education in the United States. New York (USA): Macmillam Company; 1923’’, known as the Goldmark Report with the select chapter ‘’Nursing Three Special Branches’’; the report called History of the Brazilian Red Cross (1908-1923) and the report called Polyclinic of Nurses Course in Botafogo published in 1919.

Regarding the preferred source of the study, the choice was made by the criterion of thematic relationship, the chapter referring to tuberculosis, venereal diseases and nervous and mental diseases. However, what stood out in this current study is the area of ​​tuberculosis and nervous and mental diseases. It is noteworthy that the translation of chapter fragments presented in developing study, was the author’s responsibility.

The critical literature support referred to productions that were about the History of Brazil, Public Health and the History of Nursing Schools. The analysis and interpretation of data were grouped by the links between the information obtained from the documents and the historiographical production of the subject matter ⁽¹¹⁾.

 

Analysis and Discussion

Confronting tuberculosis and nervous and mental diseases in courses and nursing schools, in Rio de Janeiro, RJ

The nursing schools that appeared at the time was the Professional School of Nurses and Nurses (Escola Profissional de Enfermeiros e Enfermeiras - EPEE), the School of Nurses of the National Department of Public Health (Escola de Enfermeiras do Departamento Nacional de Saúde Pública - DNSP), the Polyclinic of Nurses Course in Botafogo and the Brazilian Practice School of the Red Cross Nurses. According to the curricula of these schools, the disciplines of hygiene and prophylaxis notions were present, however not with the emphasis that the Goldmark Report recommended, because with the studied severity of tuberculosis at that time, the Federal District in Rio de Janeiro expected that the teaching of such a great importance would be implemented to the study of this disease.

The importance of allocating at least one course focused on the nervous and mental diseases was also pointed out by the Goldmark Report, however, according to analysis held in schools, most of them faced difficulties to put their students in this field of practice. Also because nursing only approached the mentally ill in the end of 1940, contradicting thus the precepts of modern nursing, who showed concerns for the mentally ill ⁽⁷⁾.

According to analysis in the EPEE curriculum, we realized that despite being an active school in a mental hospital, it did not only prepare nurses for just that cause.  So much that the course offered subjects such as “General Anatomy, Physiology and Hygiene” and “Spa Therapy and Internal Affairs”, among others, described in the creation decree. However, the school had operational difficulties, many candidates did not meet the prescribed conditions ⁽¹²⁾, such as; being older than 14 years of age, able to read and write properly and meet elementary arithmetic, be vaccinated, not suffer any mental illness and display a well-mannered character. This was a point also highlighted by the Goldmark Report, seen as to how the best-prepared young women did not seek to act in the area of ​​mental illness. This because of the stigma of the disease, a derogatory attribute pointing out that carrier of this stigmatizing disease was not entirely human and should be avoided especially in public places ⁽¹³⁾. About Tuberculosis, the school’s curriculum did not show materials only meant for this disease. This, being contrary to the scenario of that time which demanded nurses to have knowledge about it, being able to identify it as soon as possible, taking care of those affected by it, and teaching the population about prophylactic measures. It was present in the curriculum matters of moral hygiene, individual and hospital. Therefore, it is believed that with the importance of tuberculosis at that time, there were discussions on the subject within such matters.

Now the Polyclinic Nurses Course in Botafogo created in 1917, would select their candidates through a scrupulous examination regarding the conditions of moral character, basic instructions and health (14). The course was ten months divided into two series and the materials that were included in the curriculum were: “Medical Surgical Care of the Sick,” “Anatomy and Physiology Chair” and “Hygiene Chair”.

The Practice School of Nurses of the Brazilian Red Cross was only for females due to their natural zeal and fidelity for those of the weaker sex ⁽¹⁵⁾. The school was designed to train professionals, devoted nurses, educated and able to give patients care and scientific assistance, to work in hospitals, nursing homes and home care ⁽¹⁵⁾. It is evidenced by the materials present in the course curriculum that special attention was not given to tuberculosis or to nervous and mental diseases. This being a similar problem identified in US nursing and registered in Goldmark Report. However, during the opening speech by the director and professor of the course, Dr. Getulio dos Santos ideas were mentioned as compatible to the ideas of Goldmark Report, such as; the importance of nurses to act as educators, disseminating the dangers of the contagious diseases, the ideal of a nurse to act as medical cooperator and a great observer, noticing the smallest changes of the patient and facilitating medical diagnosis.

Finally, the School of DNSP Nurses implemented the program that was temporarly recommended by the Goldmark Report for two years and four months in duration and divided into five stages which the last was being destined for public health nursing ⁽¹⁶⁾. Your resume, established by Decree No. 16,300 / 1923 was inspired by the Standard Curriculum for Schools of Nursing and among different subjects, stood out: “Hygiene and Public Health,” “Nurse Art on Mental Illness and Nervous” and “ Nurse Art on Tuberculosis “(not a compulsory subject). At a first glance the School of DNSP looked willingness to address two issues relevant to population health at the time, addressing tuberculosis and mental illness as recommended by the Goldmark Report. However, they kept away for a long time from the psychiatry and their nurses did not frame the mentally ill on the list of patients receiving their care ^(7).

The training offered by the School prepared their students to fight against one of the most terrible scourges of mankind; tuberculosis, which at the time was a major cause of death among the population living in the Federal District in Rio de Janeiro. The nurse had the tough job of going against poor living conditions, informing the population about the importance of personal hygiene and at home and removing those affected by tuberculosis from their own houses ⁽¹⁶⁾, which strengthened the disease’s stigma because the affected one stayed separated from the others.

The same did not occur with mental illness as mentioned in the curriculum and was not included in the care for these patients by students of the School. As recorded in a student’s history in 1925, the article “The Nurse Art on Mental Illness and Nervous” was not given, yet replaced by venereal diseases ⁽¹⁷⁾. It is believed that this substitution has occurred not only because of the stigma related to mental illness, but also because of the unsanitary conditions and overcrowded places where this disease took place. Taken into account that the school had young female students from “good family” who could not be exposed to such risks.

Recommendations of the Goldmark Report for adjustment in the training of nurses in two special areas: tuberculosis and the nervous and mental diseases

In 1923 there was the publication of the Goldmark Report and among innumerous issues related to nursing education, the report stressed the need to increase the training of nurses in special areas such as: tuberculosis, venereal diseases and nervous and mental diseases.

“In the US it has been accepted as the truth that out of the 100 people 90 are infected with Tuberculosis, 2 have an active disease and 8 or 9 will die because of it. But in 1921 this rate fell by almost 50%. This fall, in addition to social and economic factors, the early detection of early cases and contacts and instruction in basic hygiene habits, has been a determining factor “⁽¹⁸⁾.

In the late 19^th century and early 20^th century in Brazil, its dissemination was mainly due to poor living conditions and poverty in which the population found itself in ⁽¹⁸⁾. The main weapon against tuberculosis was the daily change in individual habits which was given through the patient’s education, which were your family and your community and by showing the importance of the individual habits of hygiene and cleanliness of the house ^(18-19).

“Equally important is the discussion organized campaign against tuberculosis and prevention technique; their economic and social aspects and its influence across the social environment; the complex issue of industrial rehabilitation and location” ⁽¹⁸⁾.

The importance of creating sanatoriums was emphasized by the Goldmark Report. In these, the nursing profession would continue teaching prevention and education measures for people already affected by Tuberculosis since in general hospitals such measures were set aside in favor of a focused look only based on the clinical part. Another strategy used by the Americans was the creation of clinics and camps for tuberculosis patients for a certain period, where they would receive follow-up nurses who would provide care to patients and their families and would inform about prevention ⁽¹⁹⁾. Hence the importance of creating partnerships between sanatoriums and nursing schools.

However, these alliances faced great obstacles such as; difficulties in ensuring an adequate nursing service, resulting in little effort to have conventions by sanatoriums and hospitals for tuberculosis, those who kept the nursing school had difficulties recruiting students and usually the sanatoriums and hospitals for tuberculosis gave preference to nursing service for former patients or those in an inactive stage of the disease ⁽¹⁹⁾.

Hiring former patients for a care provided to Tuberculosis, was a way of convincing the American public health. Seen as they tended to care in a more compassionate way and encouraged patients to follow the prescribed treatment and seeking an occupation. The nurse who dealt with tuberculosis had to have four basic requirements: provide care to those with tuberculosis in their family, provide sufficient support for the family to maintain a normal life, protect the community, teaching the family, the patient and the community about the prevention and educate the public to support efforts to prevent the spread of this disease ⁽²⁰⁾. Concurrent with the fact that these American nurses had to represent their self as ideal agents in order to act in the treatment of customers with tuberculosis. Few could finish the nursing program, due to the weakness caused by the disease and the many hours of practical classes.

“On the other hand, only a small fraction, which is a total in some institutions of no more than 10% of nursing students are able to complete the course through additional training in a general hospital that is needed to comply with most of the laws in the states in order to register them” ⁽¹⁸⁾.

Despite the need for hand labor in tuberculosis care identified by the Goldmark Report, it was wondered till what point it was worth it for nurses to have a single expertise. A trained and registered nurse specialized in tuberculosis was only able to take care of tuberculosis and the generalist nurse is prepared to provide care in general. The second would have greater recognition, but Tuberculosis was a major public health problem and demanded for skilled labor.

“In an attempt to broaden the training, some tuberculosis institutions send their students to general hospitals, and there they would receive theoretical and practical lessons that are not taught in specialized institutions. Yet even with this supplement, a tuberculosis institution offers an unbalanced program (many practical hours and little theoretical) and so, decreasing the educational value for the nursing education” ⁽¹⁸⁾.

Other problems identified in institutions specialized in tuberculosis were the lack of competent teachers to teach and supervise the practical activities and the lack of equipment used in teaching. Despite them, it was stated in the Goldmark Report that the gained experience in a reputable sanatorium would allow nurses to have an early recognition of the symptoms, which was very valuable for nursing practice in the care of being affected by this disease.

As well as in the tuberculosis area, education and prophylaxis were seen as important weapons against these diseases in mental health. The mental health area was facing major problems they needed to prepare and equip institutions in order to train specialized nurses. At that time the asylum model prevailed and having a greater concern in separating patients instead of promoting appropriate treatment. For the Goldmark Report modern medicine emphasized early diagnosis, especially when done during childhood. This by recognizing symptoms and anomalies and from there providing a greater mental balance through the rehabilitation of these patients.

This advance also occurred in Brazil in the 1920s and 1930s, through greater movement in the field of psychiatry. However, educational institutions structured in the American model, which the Nursing School of the DNSP was first to announce, did not prepare their nursing students to work in psychiatric hospitals and mental hygiene programs ⁽²⁰⁾.

At that time there was a lot of prejudice against the nursing work in psychiatric hospitals because it was seen as a degrading and unhealthy activity. This prejudice was also given due to the stigma of mental illness because of the aggressiveness of patients, overcrowding and unsanitary of hospices.

It is noteworthy that the PSN had difficulties in recruiting females from “good family”, as these would have to deal with psychopaths and would be subject to episodes of violence.

“Due to of the difficulty of recruiting students, institutions were forced to lower their demands related to education in order to have a minimum number of women who were dedicated to mental hospitals. Being detrimental to this area required nurses to not only have knowledge in psychiatry as well as general knowledge, but also because many mental patients had escalations of clinical symptoms and with the appearance of bodily diseases even more serious mental illnesses “⁽¹⁸⁾.

The training of nurses in the mental health area should not be focused only on training a nurse for the specialist care of mental cases. An institution should be able to teach them how to detect small signals as well as serious problems. This nurse does not have to be only a caretaker, she needs to be also perceptive. These characteristics are deemed necessary and outlined in the Goldmark Report for the training of a nurse in the mental health area and was also desired by the Brazilian nursing schools.

This training should take place through lectures, lessons about clinical mental illness and demonstrations, “the practical training is of paramount importance and must always be accompanied by the theoretical basis” ⁽¹⁸⁾.

Modern medicine marked a psychiatric nurse acting as a cooperator of the doctor, because most of its time was spent next to its patient being able to detect early symptoms and facilitating medical diagnosis. “For this to happen it is necessary to lower the amount of patients per nurse, this way it will be possible to give better care and a better psychiatric supervision” ⁽¹⁸⁾.

 

Final considerations

Just like in the US, tuberculosis presented himself as a serious public health problem in Brazil. The Goldmark Report looked on this subject when training American nurses. It must be noted that also in Brazil, specifically in the Federal District of Rio de Janeiro, the recommendations contained in the Report began to stand out after its publication showing that this is way for a possibility of being implemented by the training institutions of nurses, especially in what it refers to the curricular adjustments.

Also for mental illness, the Goldmark Report noticed that from the perspective of modern medicine, this specialty pointed the training of a psychiatric nurse acting as a co-operator of the medical officer. For this to happen, it was proposed a lower proportion of patients for each nurse, and that these prepared nurses would contemplate matters related to mental health. Only like this nurses could provide a better care and more adequate supervision to the psychiatric practice field.

With regard to schools and nursing course at the time of the Goldmark Report, it can be inferred that these met more the requirements of their sponsors and educational institutions. This rather than seeking alignment with the guidelines of the Goldmark Report in the sense contemplating their curriculum with specific materials for tuberculosis and mental illness.

One has to keep the proportions and institutional peculiarities, but it can be inferred that the stigma while being a deep derogatory attribute, probably influenced the delay in approaching these two issues in the field of Nursing Schools and Courses. Caused perhaps by force of transmission of tuberculosis and the oscillation between isolation and aggressiveness of mental illness.

 

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Correspondence
Mary Ann Menezes Freire
Estrada do Mendanha, 1531
Rua D, Quadra D, Lote 14
Bairro: Campo Grande
CEP: 23087-286, Rio de Janeiro, RJ, Brasil
E-mail: maryannmfreire@gmail.com

Received: Oct. 6^th 2014
Accepted: May 19^th 2015