Glimpses of the Mass' Nurses Association's history 1903-2000
By Mary Ellen Doona
MNA Historian, Chair,
Lucy Lincoln Drown Nursing History Society

On April 27, 1910, four decades after Linda Richards received the first nursing diploma in 1873, the Massachusetts Nurses Association secured legislation to protect nursing practice. The law, which established the Board of Registration in Nursing, separated the registered nurse from individuals who passed themselves off as trained nurses on an unsuspecting public. One example of fraudulence, albeit a vivid one, was Jennie Toppham. She had been expelled from the Boston Training School (precursor to the Massachusetts General Hospital School of Nursing). Nonetheless, Miss Toppham called herself a nurse and worked for doctors in Cambridge and Massachusetts. In 1901 Miss Toppham was arrested for poisoning four of her patients. At her trial, she claimed to have killed one hundred!

Nurses take control of nursing

Miss Toppham and the doctors who had hired her were the kinds of persons the MNA sought to expose. With the nurse practice legislation of 1910 and its amendments since that time, the MNA declared nursing to be an independent and distinct discipline. The association then developed a Code of Ethics that stated that the profession was grounded in values which nurses were obliged to uphold. It worked for educational standards and created a uniform curriculum. Only nurses who had graduated from an approved training school – one connected with a general hospital and lasting three years – were eligible for membership in the MNA and entitled to take the licensure exam. Thus the association assured the public that the registered nurse they hired was an educated nurse and a graduate of a legitimate nursing program. By 1910, the MNA was the largest organization of health professionals. Through its activities, the association gave notice to doctors and hospitals that nurses would set standards to protect the profession and the public. Nurses intended to control nursing.

Down through the years, the MNA has continued to protect the autonomy of the profession and its practitioners. As in 1903 when the MNA was founded, and all the years since, professional standards, legislation, and ethics directed its efforts. When the center of nursing employment moved away from private practice in patients' homes to staff nursing in hospital wards and with visiting nurses associations, the MNA adapted itself to the new settings. When hospital care was transformed by medical advances, the association responded again. Constant in all this change was the concern for the integrity of nursing practice and the safety of the public.

Nursing transformed by war

Nursing was transformed more during World War II (1941-1946) than it had been during World War I (1914-1917). Once war was declared in 1941 nurses left staff duty positions on hospital wards for military commissions in Europe and the Pacific. Hospital wards throughout Massachusetts were stripped almost bare of nurses. The care of persons burned in the Coconut Grove fire during this time gave a preview of how nursing would change following the war. Penicillin (then a military secret), plasma and dressings, stockpiled in Boston's hospitals in the event of an enemy attack, were made available for the emergency. Although the nursing shortage was severe, nurses worked around the clock caring for the burn victims and made front-page news for their heroism.

The MNA gave its best efforts during the war and when the war was over took part in reorganizing the profession. Nurses returned from the war front, went off to college classrooms. Their entry to campuses was paid for by the GI Bill. Many of this war-tested generation of nurses took on the task of renewing the profession. They analyzed nursing functions and published standards of practice. They developed collegiate programs in nursing and made nurses part of the post-war knowledge explosion. Grateful for how nurses had cared for their men, the country invested in nursing education. The gratitude was expressed in federal grants for nursing education which in turn financed the development of nursing specialties.

Congress also subsidized new hospital construction but found nurses reluctant to work in them because of low salaries. The MNA supported ANA in 1946 when it voted to inaugurate an economic security program. The first formal resolution for an economic security program for Massachusetts was made at its 1951 convention. In keeping with the ethical tenet of justice, the association sought to improve nurses' compensation, benefits and workplace conditions by collective bargaining. State and federal laws protected nurses as they bargained for these rights. Another state earned the distinction of being first to use collective bargaining to address practice issues. By 1962, however, the MNA added collective bargaining to its strategies for protecting nursing practice.

Control stays in nurses' hands

The MNA countered the strategy of stratifying and dividing nurses in the hospital setting and fragmenting nursing power by use of per diem nurses. Much of this struggle over who would control nurses came to a head in 1973 when the Commonwealth tried to dissolve the Board of Registration in Nursing in favor of institutional licensure. Thousands of Massachusetts nurses from all across the state flooded into Faneuil Hall and thousands more spilled over into City Hall. Other nurses who were unable to get into either place rallied on City Hall Plaza. Nurses defeated institutional licensure and made real nursing's slogan: "To advance we must unite." Professional autonomy and the control of nursing stayed in nurses' hands.

Rights were the dominant theme for nurses of the 1960s and 1970s as they were for much of society. Civil rights and women's rights were vigorously defended. Of special significance to nurses was the right of patients to participate in decisions about their care. During this time, 1965, the American Nurses Association declared that education for nursing should take place in institutions of higher learning. This was the position that Massachusetts nurses had taken in 1903 when it tried to persuade Simmons College, then a new technical institution devoted to women, to introduce a nursing program. By the 1970s nursing had advanced as a learned profession with nurses using their research findings to improve patient care.

Ethics returns to center of practice

At a time when advances in science and the consequent technology made nursing care ever more complex and clinical judgment that much more essential, attempts were made to de-skill nursing practice. Patient care technicians were introduced and the numbers of professional nurses reduced. At the same time hospitals tried to limit nurses to technical care and made personal care by professionals more difficult to practice. Question such as were they the servants or masters of technology prompted deeper thinking about nursing's responsibilities. Along with other professionals, Massachusetts nurses had to deal with ethical implications of high tech care. Profound questions about the value of a patient's life returned ethics, humanity's oldest science, from the periphery to the center of nursing care.

The speed at which innovations were introduced made what was an extraordinary measure one day an ordinary measure the next. Decision-making regarding the use of extraordinary measures was the most dramatic of the ethical dilemmas. More common, were the moment-to-moment nursing decisions. More than ever before nurses were the human interface between the technology and the patient. Because nurses stayed with the patient, they knew their patients as persons. They were privy to the wishes of the patients and their families. This privileged position made nurses the professional with the best data for making ethical decisions, especially when the quality of a patient's life was weighed against scientific vitalism which insisted on life at any cost.

Challenges at the end of the centennial

In 1973 Congress passed legislation to halt the soaring cost of health care that economic principles of supply and demand could not control. Health maintenance organizations (HMOs) also were designed as a way to cut costs and to improve the quality of care. The center of health care moved away from research-oriented tertiary care facilities and towards preventive care in the community. Clinical judgment by professionals, however, took secondary place to bottom line thinking by insurers. A full evaluation remains to be done of managed care but its ability to cut costs and improve the quality of care is questioned. Congress, insurers and professionals are locked in a contest about who will establish the ground rules to ensure that containing costs is not done by cutting care. Several versions of a patient's bill of rights have been defeated in both houses of Congress. Election year politics of 2000 might push the patient's bill of rights into law.

In 2003 the MNA will mark its centennial. One hundred years ago nurses trained in hospitals that were changing from charitable to scientific institutions. It is too soon to know how history will view the change from hospitals to managed care. What is known for certain is that the MNA continues to serve nurses and the public as it did in 1903 when it was founded in Faneuil Hall. Amendments to the nurse practice act of 1910 reflect the changes in nursing practice. Most recently amendments have granted prescription writing to nurses in advanced practice. Insurers and health care plans include nurses among the professionals they reimburse for the cost of their care.

The MNA counters efforts to impede nursing's care of the public with the tried and true triad: legislation, ethics and standards of practice.