Regulation of Spanish Nursing: incorporation into the health profession (1850-1950)^a

ABSTRACT

OBJECTIVE

To know the evolution of the academic formation of the Spanish infirmary (1850-1950), describing the changes that transformed it into sanitary profession.

METHOD

Historical research in the exploratory-descriptive modality, with analysis and interpretation of information obtained from electronic databases, national, provincial and municipal archives, official gazettes and libraries.

RESULTS

In 1850 different health categories coexisted, however, the title of nurse did not emerge until 1915. With the boom that Community Health reached during that time, in 1924, the National School of Health was founded, creating in 1932 the specialties of Psychiatric Nurse, Pediatric Nurse and Visiting Nurse of Mental Hygiene.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Between 1915 and 1950 all nursing professionals had university training, therefore, through scientific knowledge these health professionals acquired their own identity within the health professions and they were able to provide specialized assistance for the care of people.

Keywords:
Nursing History; Nurse; Midwife; Health Occupations

RESUMO

OBJETIVO

Conhecer a evolução da formação acadêmica da enfermaria espanhola (1850-1950), descrevendo as mudanças que a transformaram em profissão sanitária.

MÉTODO

Investigação histórica na modalidade exploratória-descritiva, com análise e interpretação da informação obtida a partir de bases de dados electrónicas, arquivos nacionais, provinciais e municipais, gazetas oficiais e bibliotecas.

RESULTADOS

Em 1850 coexistiam diferentes categorias de saúde, no entanto, o título de enfermeiro só surgiu em 1915. Com o boom que a Saúde Comunitária atingiu nessa época, em 1924, foi fundada a Escola Nacional de Saúde, criando em 1932 as especialidades de Enfermeira Psiquiátrica, Enfermeira Pediátrica e Enfermeira Visitante de Higiene Mental.

CONCLUSÕES E IMPLICAÇÕES PARA A PRÁTICA

Entre 1915 e 1950 todos os profissionais de enfermagem tiveram uma formação universitária, pelo que, através dos conhecimentos científicos, estes profissionais de saúde adquiriram uma identidade própria no âmbito das profissões da saúde e puderam prestar assistência especializada para os cuidados de pessoas.

Palavras-chave:
História da enfermagem; Enfermeira; Parteira; Ocupações da Saúde

RESUMEN

OBJETIVO

Conocer la evolución de la formación académica de la enfermería española (1850-1950), describiendo los cambios que la transformaron en profesión sanitaria.

MÉTODO

Investigación histórica en la modalidad exploratoria-descriptiva, con análisis e interpretación de información obtenida en bases de datos electrónicas, archivos nacionales, provinciales y municipales, Boletines Oficiales y Bibliotecas.

RESULTADOS

En 1850 coexistían diferentes categorías sanitarias, sin embargo, el título de enfermera no surgió hasta 1915. Con el auge que alcanzó la Salud Comunitaria durante esa época, en 1924, se funda la Escuela Nacional de Sanidad, creándose en 1932 las especialidades de Enfermero Psiquiátrico, Enfermeras Pediátricas y Enfermeras Visitadoras.

CONCLUSIONES E IMPLICACIÓN PARA LA PRÁCTICA

Entre 1915 y 1950 los profesionales de enfermería poseían formación universitaria, por tanto, a través del conocimiento científico estos sanitarios adquirieron una identidad propia dentro de las profesiones de la salud. Se logró proporcionar una asistencia especializada para el cuidado de personas.

Palabras clave:
Historia de la Enfermería; Enfermera; Matrona; Ocupaciones Sanitarias

ABSTRACT

OBJECTIVE

To know the evolution of the academic formation of the Spanish infirmary (1850-1950), describing the changes that transformed it into sanitary profession.

METHOD

Historical research in the exploratory-descriptive modality, with analysis and interpretation of information obtained from electronic databases, national, provincial and municipal archives, official gazettes and libraries.

RESULTS

In 1850 different health categories coexisted, however, the title of nurse did not emerge until 1915. With the boom that Community Health reached during that time, in 1924, the National School of Health was founded, creating in 1932 the specialties of Psychiatric Nurse, Pediatric Nurse and Visiting Nurse of Mental Hygiene.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Between 1915 and 1950 all nursing professionals had university training, therefore, through scientific knowledge these health professionals acquired their own identity within the health professions and they were able to provide specialized assistance for the care of people.

Keywords:
Nursing History; Nurse; Midwife; Health Occupations

INTRODUCTION

Contextualization of the topic

In Spain, the unification of medicine and surgery in 1843 gave rise to a new profession, the “Practitioners in the Art of Healing”, health professionals (nurses of today) who established themselves in rural areas where the population could not be served by a doctor-surgeon.¹

By 1850, there was a very diverse group of professionals such as midwives, barbers, dentists, podiatrists, ministers and bleeders (romanticists) who held the skills of caring for people, with very different legislative frameworks.^2,3 The midwife was the only female figure in the health professions of the time to be considered an assistant to the physician. Their functions extended to postpartum care, and the advising of the mothers on hygienic-dietary care for their newborns.⁴

However, in the history of nursing, the image of the nurse was linked to that of a woman with limited economic resources, as well as cultural knowledge who cared for the sick.^3,5 Therefore, the infirmaries of this time were linked to domestic service, among its functions were cleaning, dressing and feeding the sick. Additionally, the infirmary had the responsibility of making the patients feel comfortable and well rested on their journey to be nursed back to health. On the other hand, employed nurses were also responsible for performing the toilet and cleaning of the house in exchange for boarding and food.⁵ On the contrary, in the case of the male, namely the practitioner, he performed his care role in a remunerated manner as a minor surgeon in hospitals.^4,6

In addition, care for the sick was provided outside of the home by both the nurse and religious orders, which associated the care of the sick with Christian charity.⁷ At this time, the Order of St. John of God, popular in in-home care, specified ways of administering food to the sick, the application of the drug prescribed by the doctor and the realization of the grooming without forgetting the comfort of the spirit.^5,7

The Law on Bases for Public Instruction (1857), known as the Moyano Law, regulated the theoretical-practical formation of the health professions that existed so far, including within practitioners to bleeders, podiatrists, dentists and attendees of deliveries.^1,8 This law also created the title of midwife, unifying midwives and teachers in childbirth.⁸ It even recognized the need for theoretical-practical training to assist women at the time of birth of their children.^4,8 However, the Moyano Law did not contemplate the role of nurses, since their activity was not considered a health profession, but a trade.⁸

In 1858, internationally Florence Nightingale argued that nursing was more than just administering medicines and poultices, an issue that raised the need for training for all those who provided health care.⁹ In that period of time, the international Red Cross movement began.⁵ This entity enhanced the health training of all persons caring for those injured in armed conflict, forming in Spain in 1864.³ In turn, Concepción Arenal, a relevant figure in the socio-health context of 1870, denounced the poor conditions of care in hospitals.^3,10 This revealed the lack of quality nurse care, and advocated for professional nursing care.^3,10-12 Once these needs and concerns about obtaining quality professional nurse care were made aware, Federico Rubio and Galí founded in 1897 the first School of Nursing located in Madrid.¹³

The demand for nursing professionals to provide quality assistance began to grow, which lead to the Royal Order of May 7, 1915, by which the Ministry of Public Instruction and Fine Arts, created the qualification of Nurse at the request of the Servants of Mary. This allowed women both religious and lay people, to officially register once the necessary knowledge and skills had been acquired.^14,15

The objective of this research is to know the university training of nursing staff in Spain between 1850-1950. How did the care offered by nurses through a domestic service activity become a professionalized health activity? The research is limited to the period 1850-1950 because, during this time, Spain was subject to multiple military, political, and social turbulence, which aroused the emergence of different laws and Royal Decrees.

METHOD

This is a historical study with exploratory and descriptive approach of the objective of study, through the direct and indirect knowledge of the events that occurred in the time period between 1850-1950.

To carry out this review, a number of phases were established. In the first a bibliographic search was carried out in the electronic databases: Scielo, Dialnet, Cuiden, MEDLINE/PubMed, CINAHL (Cumulated Index of Nursing and Allied Health Literature), Science Direct, as well as in Google Academic. The keywords and descriptors used were: nurse (“education, history, legislation, organization and administration”), health occupations (“education, history, legislation and prevention and control”) and midwives (“education and history”). Twenty-four articles were collected, of which five were discarded because they were outside the study period, maintaining nineteen of these.

During the second phase, due to the historical nature of the study, four books were reviewed in the Library of the University of Castilla la Mancha (Campus de Toledo), six books in the Public Library of Castilla-La Mancha, one book and two book chapters in the archive of the Faculty of Medicine of the Complutense University of Madrid, two books and one book chapter in the documentation center of the Spanish Red Cross, two books in the archive of the Provincial Council of Toledo, and three books in the Municipal and Provincial archives of Toledo. In total, twenty-one documents, fifteen books and three chapters were used, excluding those that did not focus on training and training for the sick. Additionally, grey documentation on the subject and time of study was revised, with a total of 2 titles consulted and quoted. Finally, in the third phase, a manual and electronic review was carried out in official documents drawn from the Official State Bulletins (BOE), the Ministry of Education and Vocational Training, as well as the Ministry of Culture and Sport. These laws were used because they focus on the regulations of the study period (1850-1950). These establish theoretical-practical education, curriculum, academic training, university access, the number of training courses, as well as the creation of specialist nursing among other issues. Eleven documents submitted in the investigation were used. Access to these writings was made possible by the collaboration of the public authorities cited, who made the study material available to researchers, as well as a search in public domains of those documents.

RESULTS AND DISCUSSION

Unification of health professions in Spain

During the second half of the nineteenth century in Spain there were a wide variety of male professionals dedicated to health care. Among them, it is worth highlighting the figure of the minister. The minister was recognized as the professional predecessor of the nurse who, together with the Romanticist, can be considered as the minor surgeons of the time.^1,3 Likewise, the most recognized female health figure in this period was that of the midwife.¹⁶ She assisted the women during pregnancy, postpartum, and lactation without exceeding the limits set by the doctor, which ensured the recovery of the mother while guiding the feeding of the newborn.^4,6 In turn, she was to prove the cleansing of blood by the parish priest of his place of origin, for in case of urgency for the death of the newborn it would be she who administered the sacrament of Baptism.⁵

On the other hand, the nurse in 1850, unlike the practitioner and the midwife, carried out care attached to the domestic field, which was considered secondary.^6,7 The emergence of the well-known Law of Bases for Public Instruction was very important in Spain (known as the Moyano Law) in 1857, which regulated all the health professions existing in the country except nursing. This was because their performances were considered household chores performed by low-skilled people.⁵ Moreover, at that time the care of the insuring sick was carried out by religious congregations, such as the Order of St. John of God.^7,9,13

The first plan of study for the theoretical and practical training of practitioners and midwives was published in 1861, which derived from the above-mentioned Law on the Basis of Public Instruction.⁵ This plan established the duration of academic training, detailed the subjects of study and set the minimum age for starting instruction (men 16, women 21).⁹ It even defined the qualities that an applicant should possess for admission. In addition, it specified that women had to justify their good life and customs by means of a certificate issued by the parish priest of their place of origin.³

It is worth noting the figure of Concepción Arenal thinker and humanist, whose contributions had a great influence on the health and hygiene bases of the time. Specifically, in 1870, he argued that in order to carry out quality care, the people who carried out this care should possess essential qualities such as kindness, humility, firmness, accuracy and perseverance.^3,11 Such complaints were directed at the inequalities generated by socio-economic, disease-causing and inducing structures of countless social problems that inexorably led people to misery.^17:21

In this sense, they had to take care of the poor with empathy, making if that be the case, a visit to their home without questioning the conditions of hygiene or poverty of the same.^11,12

In order to enroll in nursing studies, a woman had to present permission from the husband or be a widow.¹⁶ That regulation was amended in 1874, as a result of the creation of the title of surgeon-dentist, since it was a restriction on the competences of practitioners.⁶

However, in 1888 due to the intrusiveness between midwives and practitioners, it became necessary to promulgate a new Ministerial Order that was in force until the Royal Decree of April 27, 1901, which attaches the teaching of practitioners to the Faculty of Medicine, incorporating the obstetric contents in the academic formation of these.¹⁷ They are later referred to as “Authorized Practitioner for Assistance to Normal Births”.⁴

The Royal Order of August 9, 1904, adjusted the existing curriculum and described the necessary formalities to pursue the university careers of the practitioner and midwife. Thus, it was obligatory that in order to carry out these studies the applicants admitted to having passed the baccalaureate at a normal school of education, to present medical certificate that would show their good health, pay the corresponding fee of five pesetas of the time (for right to entrance) and pass the entrance test to the university.¹⁷ Once the applicant had been enrolled, they had to pay fifteen pesetas per academic year (theoretical-practical training of two courses) and, in order to obtain the degree, it was essential to pass the final year after the twenty-five pesetas subscription for the right to review.^16,17

In 1915, nurses had the possibility of acquiring an academic training to provide care with a theoretical and scientific basis through a Royal Order created at the request of the Servants of Mary, which enabled the degree of Nursing.^17:39-46 The congregation defended a replica of the Italian model that they knew and based on it they created in Spain a trained, feminine, lay, professional nursing program, at the service of the emerging ideals of equity and social justice. From this moment on, they gained both social and public recognition.^9,10,14,15

In addition, these professionals developed observational skills, active listening techniques and skills that allowed them to discover the reality of each patient in their environment.¹⁸ It was therefore through university education that nursing changed its employment activity linked to domestic service, by a qualified and professionalized activity, including within the medical sciences.^14,15 In this regard, the poor conditions of care for the sick were eradicated within the hospitals of the time, since these nurses had greater knowledge in the field of care.¹⁸

These healthcare systems managed to correct the inequalities that Concepción Arenal denounced and carried out the ideas he defended in his manual of the “Visitador del Pobre”.¹⁰ In addition, with their professionalization and specialization, they improved child and maternal hygiene, prevented preventable diseases and launched vaccination programs.¹⁸

The first documented examinations of Nursing were carried out at the Central University of Madrid in 1916, being from that moment when it was considered that the Spanish nursing was being deeply renovated and academically formed.¹⁸ The curricula were updated again with the Royal Decree of 7 October 1921, creating minimum of subjects that professionals were to take along with concentrating the actions of nurses mainly in the field of Community Health that was being established.¹⁷

Thus, a model of care much closer to the person was applied compared to that used by doctors, addressing health problems with a humanist approach, a fact that favored the encounter between scientific and popular health culture.^19,20

The re-installation of the Directorate General of Health occurred in 1922, because since 1904 the municipalities were obliged to issue Hygiene Regulations detailing the duties and functions of the local authorities.^18,19 The health professions involved in that regulation provided a higher level of physical and social well-being and were able to extend the scientific principles of public health throughout the national territory, including hard-to-reach rural areas.¹⁸ Finally, with the Provincial Health Regulations on the 20^th of October 1925, the Provincial Institutes of Hygiene and the secondary centers of Rural Hygiene emerged.^18,20,21 These reforms were based on the American rural health system, pioneering the Rockefeller Foundation institution that facilitated the emergence of these centers elsewhere in Spain.²⁰

It can be said that the rise of the nursing profession paralleled the introduction of Community Health in Spain, an emerging modality among the health professions of the time, with the aim of intervening against: 1) existing child morbid mortality; (2) the unhealthiness of housing; 3) bad eating habits and 4) lack of care related to the misery situation of the population, which reached the significance of social scourge.²²

Among the challenges to be achieved with Community Health, there was the monitoring of risk groups, health education and early diagnosis of health problems in the population.²³ It should be noted that between 1902 and 1912 beneficial-based postpartum institutions such as “Milk Drops” and “Office for Infants” were established, which could be seen as an initiation into community health that currently focused on infants and children.²²

To avoid professional intrusiveness at the time, the Royal Order of February 24, 1927, officially forced all those who practiced that profession in any establishment or health institution to officially register as nurses.^7,14

In the 1930s and coinciding with the Second Republic, Community Health, hygiene and prevention became particularly relevant, being the work carried out by nurses specialized in hygiene and childcare, indispensable for the implementation of prevention campaigns.^8-10

These advances enabled nurses to provide the population with higher quality health care, thus increasing the well-being of people.^5,23

In this sense, Pittaluga, director of the National Institute of Health, stated that, thanks to the good work of the nurse, the medical and social needs in the rural area were met, and the hygienic habits of people with special emphasis on the child and post-fall population were improved. Vaccination programs were even implemented, which expanded public health throughout the country and prevented common diseases.^20,24,25 It was stated that “A modern hygiene school cannot exist, or at least cannot perform its functions, if it is not supported by the existence of a School of Health Nurses.”^26:158

To achieve these objectives, the Councils and the Rockefeller Foundation were supported.²¹ Consequently, since 1931, Primary or Secondary Rural Hygiene Centers have been established throughout the Spanish territory, which were located in small populations in order to carry out preventive health care aimed at alleviating the health problems of the time, such as: infant mortality, tuberculosis, venereal diseases, malaria, typhus, trachomatis, among others (Figure 1).^19,20

Figure 1
Monitoring of health problems of the time (1930).

Likewise, the government of the Second Republic promoted the social security program as a way of addressing the medical problems of the population. In addition, during this period, several health insurances were promoted, including: 1) Compulsory Sickness Insurance; 2) Compulsory Maternity Insurance and 3) Occupational Accident Insurance. The main political-health objectives of such insurances were both “to provide the peasant with the minimum level of physical well-being, without which there is neither the dignity of men nor awareness of citizens”^20:8, and extending the scientific principles of health to the majority of the peasant population.^25,27,28

A Path to Specialization in Nursing Studies

The changes that Community Health was gradually introducing in the country, associated with the need for well-trained professionals who managed to reduce child mortality, motivated the promulgation of the Royal Decree of May 23, 1923. The Royal Decree sparked the creation of the National School of Puericulture.^26:154,29 This led to the appearance of the visiting nurse for children.^24,30 Thus, the rise of Community Health led to the promulgation of the Royal Decree of 9 December 1924, which motivated the merger between the National Institute of Hygiene and the King's Hospital for Infectious Diseases, giving rise to the National School of Health. ^18:81

Finally, the Ministerial Order of May 16, 1932, created the titles of Psychiatric Practitioner, Pediatric Nurse, Psychiatric Nurse, Health Nurses, Nurse Nurses, Hygiene Visitors, and Nurses Visiting Children.^17:46,15 The appearance of the National School of Health, fueled the project to create a National School of Health Visitors, which was truncated by the Civil War in 1936.^26,28,31 (Table 1).

Table 1
Laws/Ministerial Orders/ Madrid Gazette

Document	Date	Matter
Public Instruction Bases Act”MoyanoLaw”	9 September 1857	It establishes theoretical-practical education for all health professions. Create the Matron's degree.
Royal Decree	21 November1861	First curriculum for practitioners and midwives also regulates the duration of their academic training.
Royal Decree	16 November 1888	Regulates intrusiveness in the professions of Matron and practitioners.
Madrid Gazette	27 April 1901	He wrote the teaching to the Faculty of Medicine and incorporates the obstetric contents into the academic training of the practitioner.
Madrid Gazette	9 August 1904	Describes the steps required to access the university studies of Matron and practitioner.
Royal Order	7 May 1915	Creation of the University of Nursing degree.
Royal Decree	7 October 19	It established the minimum number of courses that nurses were required to take in relation to community health.
Royal Decree	23 May 1923	Create the National School of Childcare.
Royal Decree	9 December 1924	Origin and creation of the National School of Public Health
Provincial Health Act	20 October 1925	Creation of the Provincial Institutes of Hygiene and secondary centres of Rural Hygiene.
Ministerial Order	16 May 1932	Creation of Specialists: Psychiatric Practitioner, Psychiatric Nurse, Health Nurses, Nurse Mental Hygiene Visitors and Nurses Visiting

• ^*
  Source: author's own creation.

At this time, the State Administration was frustrated, and the health model was paralyzed due to ideological confrontation, which destroyed the peaceful coexistence of the Spaniards and finally led to the Civil War of July 17, 1936.³¹ During the war the demand for qualified personnel, which included nurses, practitioners and midwives, was considerable.³² This was due to the urgent need to care for the wounded, which were civilians and military on both sides, who were in unsanitary conditions and suffering both infectious and war-related diseases.^33-36

During the armed conflict, health training was linked to national and international institutions operating on both sides of the front.^37.38 Thus, nurses trained and qualified on the popular side were referred to in different forms: nurses of war, campaign and military; while on the national side were nurses and volunteer ladies.^36,37

On the other hand, the nurses trained in the Red Cross were called on both sides Professional Nurses, as the International Committee of the Red Cross established a double delegation. The one on the popular front was in Madrid and Barcelona; while that of the rebel side was installed in Burgos and Seville.^38,39

After the end of the Spanish Civil War (1939-1949), and in response to new advances and changes introduced in the formation of midwives, nurses, and nurse practitioners, the pedagogical manuals of the time were progressively adapted.^3,6,9,35 However, they all continued to concentrate their interest on the physical, moral, and scientific qualities that health professionals should possess; emphasizing subordination and respect for the figure of the doctor.⁶

The history of nursing reinforces the perception of García-Sierra, who warns in his book “Practitioner's Manual and normal deliveries” that he or the professional must be “educated, obedient, honest and virtuous to the highest degree having respect and absolute submission to the doctor. In addition, he will take care not to entrust to anyone what he must do on his own, for, before all, he must prove that he is only the one who knows, must and can execute them.”^29:2 (Figure 2).

Figure 2
Practitioner and Normal Birth Manual of the Time (1906)

Therefore, advances in diagnostic methods and the progress in antisepsis along with the discovery of penicillin and the formative development of healthcare professionals, enabled significant advances in the treatment of infectious pathologies.^9,18,26,35

In this sense, the Spanish health of the study period was home to multiple shortcomings, and, consequently, the Spanish State had to undertake a profound renewal of the State Health Administration. However, through the multiple changes promoted, social medicine was inserted into the health framework of public health.^20,30

After the Spanish war and after the post-war period in 1953, the nursing profession was reorganized with the creation of the title Assistant Health Technician (ATS), which brought together both women and men and gave way to a new model of care, which had a theoretical-practical training of characteristics, contents and legislation different from those of the period investigated.³¹

Conclusion

The results of the research on this historical period are useful, since the analysis of the documentation reveals an overview of the academic training of nursing in Spain, during a very convulsive historical moment and in a very specific social field. It also shows that, regardless of the status assigned to the nursing staff, these professionals provided quality care to the sick based on scientific knowledge acquired from their university education. Taking into account that the teaching was traced under the protection of medicine and therefore they owed obedience to the figure of the medical professional, without forgetting that the university training received allowed them, in the words of Concepción Arenal, to carry out their functions with accuracy, kindness, perseverance, humility, and firmness.

In turn, this autonomy was not only reflected in the social and labor level, but at the normative level of legal transformations that allowed Spanish nursing to develop as a discipline of the health sciences.

With their expertise, the nurses were able to act in the patient's home, as well as in rural hygiene centers, on the battlefield or hospitals. Eventually, nursing became a differentiated profession, with its own skills acquired through university studies. The role of a health profession that is not new at all and whose ontology focuses on caring for people is therefore expressed.

These professionals developed observational skills and active listening techniques autonomously which were based on scientific criteria. In addition, due to their theoretical-practical training they acquired essential qualities and skills. This allowed them to discover the reality of society as the true protagonist of personalized care for each patient, attending it in their environment in a holistic way.

Finally, this autonomy was not only reflected at the social and labor level, but at the legislative level of legal transformations, which took place in Spain and allowed nursing to develop as a discipline of health sciences. Many of these decrees were of vital importance in the reorganization of the health professions, even multitudinous in some periods.

ACKNOWLEDGEMENTS

Thank you to the General Archive of the Faculty of Medicine of the Complutense University of Madrid, the Documentation Center of the Spanish Red Cross, the Municipal Archive of Toledo, the Provincial Archive of Toledo and the Archive of the Provincial Council of Toledo. In addition, thank you to the president and secretary of the College of Nursing of Toledo, for their help in allowing us access to the collegial records of the time of study.

• a
  Associated Study, Research on History, Health and Gender, Spain and Portugal (HISAG-EP) linked to the Health Sciences Research Unit: Nursing (UICISA: E) of the Coimbra School of Nursing, (Portugal) and the Faculty of Physiotherapy and Nursing. University of Castilla-La Mancha (UCLM). Campus of Toledo, (Spain).

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Edited by

ASSOCIATE EDITOR:

Antonio Almeida Filho

Publication Dates

• Publication in this collection
  29 June 2020
• Date of issue
  2020

History

• Received
  07 Mar 2020
• Accepted
  29 Apr 2020