Glennis Zilm Writes:

This delightful paper by an historian who has been researching the topic for a number of years now cuts through several disciplines to provide valuable – and new – insights, and raise important questions . Thank you, Linda.

As I am always interested in “background,” I did a bit of digging into where, when, and why the Voluntary Aid Detachments were formed. A few is very sketchy – and perhaps you might want to comment on it further later, although it is among the unimportant bits!

* I am interested in your statistics at the opening of your paper, and the sources related to the Canadian information. It must have been a tremendous effort to find this kind of information and to collate it. But it is wonderful for a Canadian perspective and helps toward a greater understanding. I find it quite startling to discover that were such large numbers of Canadian VADs – and shocked that I was not more aware of these large numbers despite all the reading I have done on Military Nursing in WW1. It is now largely an unknown story, and your work is going a long way to redress this.

I am also interested in knowing whether the Americans contributed to the VAD efforts or whether this was strictly a product of the British Empire? (Although I know the US did not enter the war until much later; it still did have, however, a military medical corps with nurses.)

* I want to stress how important this work is, and how it adds new dimensions. It “expands” the scholarship on nursing’s past as well as brings some new insights and ways of looking at social history, women’s history, and feminism of the early 20th century.

* I have a comment related to some points you raised in one of your other, earlier articles; you commented about concerns by the medical, military, and nursing establishments held opinions that the unpaid, voluntary VAD nurses were young, “frivolous and vacuous,” and only interested in jaunting around Europe. This was compounded by some cartoons and postcards of the time showing them as flirting with the wounded on the wards. And, because of this, VADs faced even more censure from the professional nurses and nursing associations. This was despite support from the Canadian Red Cross Society and the Canadian Branch of the St. John Ambulance Association (?Brigade), and also the Young Women’s Christian Association (ywca), and the International Order of the Daughters of the Empire (IODE).

Such criticism was not new: Similar kinds of comments had arisen in earlier European Wars about the “camp followers”; while this was sometimes true, often these consisted of the wives and sisters of military men trying to provide some care for them. Further, one might suggest that Florence Nightingale rather promulgated the same images in comments about Mary Seacombe during her preparations for the Crimean War. (This now is not considered a politically correct image of FN and is getting “modified”!)

* I think your work raises some additional “thinking points” related to reasons that bright young women of this time turned to the VADs as an appropriate, expeditious, and relevant way for young women to begin to break away from society’s paternalistic restrictions and expectations. It seems to me that Florence Nightingale’s vision of nursing had itself provided a way for middle-class and upper-middle-class women to seek careers from the mid-1800s to the end of the century. The Boer War and World War 1 put now put nurses into the spotlight.

The growing feminism and desire of more young women in the early 1900s to have a more equal, more active place in society was a new social realism. Nurses had begun to achieve this status. So teachers, bank clerks, secretaries, and other working women, as well those as from the upper classes and university graduates, who also were exhibiting feminist qualities, considered joining the VADs. The patriotism, shortages of male workers, and necessities of the war made it possible for these young women to explore new work frontiers while allowing society to retain maternal and madonna‑ like images. It was a stepping stone as they began to take up other feminist concerns, such as suffrage and social equality issues.

* Your work also highlights the highly protective approach nurses have taken toward the profession, and their concerns over encroachment from those not as well prepared. This has been a constant throughout the history of modern nursing from Florence Nightingale to the present. The suggestion that nursing assistants with little educational preparation (“training”) could be brought in to do the work of “trained” nurses was an important issue in the pre-war period; this was the time that nurses were forming provincial associations and lobbying for registration to protect the public from untrained or ill-prepared women from calling themselves nurses. So the concerns you have raised in some of your work, including today’s presentation, about the CNA’s position are illuminating. And they it is also relevant to show that when shortages of nurses came about, such assistants are welcomed.

I believe this pattern continues today, with some opposition to Licensed Practical Nurses and a reluctance to teach “team nursing” (as it was called in the 1940s and 1950s during times of nursing shortages). I do not believe that most what-one-might-call “nursing philosphers” have considered these aspects. So it is intriguing that an historian should make this point.

Linda, I know you are working on a book and I am so looking forward to it and to the opportunities you will have there to raise all these issues in depth. Thank you so much for such a stimulating presentation.

(This Small Army of Women. Forthcoming UBC Press)

 

Dr. Susan Duncan Writes:

Thank-you Dr. Quiney for bringing to life these accounts of nursing in WW1 and the contributions of the Volunteer Aid Detachment nurses (VADs) “volunteer nurses” and military nurses. Your work inspires reflections on themes that are familiar in the nursing context of today.

I have been asked to address the following question:

What issues or directions can we identify in the relationship between professional nursing and Volunteer Detachment nurses and how might they resonate with the issues of today?

There are many lenses from which to view history and its relationship to the present, and the critical feminist lens is particularly relevant to analyzing gender and power relationships in nursing. Dr. Quiney’s analysis highlights the social and professional tensions between Volunteer Aid Detachment Nurses and nurses and between what Dr. Quiney acknowledges as “nursing’s hard won professional standards” and maternalistic and gendered interpretations of nursing’s mission and work.

Historians Fairman & D’Antonio (2013) explore how history can shape our understanding of health policy and how it provides a way for us to think about policy issues in the current and future context. In that vein, I will offer some brief reflections on the policy issues and directions represented in the relationship between professional nursing organizations and the VAD nurses, and how they resonate today with respect to nursing organizations and relationships among nurses and with other members of the nursing team – and make some reference to the relationship to nursing and health system policy issues of today.

First, it is most important to acknowledge the remarkable valuable contributions of the VADs and military nurses during the war and the care of soldiers and during the post-war flu pandemic. Although there were clear boundaries around the roles of the VADs and professional nurses, they shared the title “nurse” and the VAD training program was a shortened and condensed program that was described as mirroring nursing programs of the day. Concerns of nurse leaders and responses included the denigration of nursing standards and threats to patient safety. The government discourse of the day referenced hospital economics, and the push for efficiency by replacing nurses with VADs where it made economic sense.

Dr. Quiney refers to how the nursing organizations were not in touch with one another and described the lack of communication between the civil and military branches of Canadian nursing: “that neither organisation could be alerted by the other regarding the potential threat of VAD incursion, and therefore were unable to co-operate on a joint solution “(demonstrated in Newell’s research, cited by Quiney).

Reflecting on Dr. Quiney’s findings, I was struck by how Jean Gunn and the CNATN Special Committee framed the policy problem at two points. In the first instance, the Special Committee in their brief to the Department of Militia and Defense presented a clear option for moving forward but they failed to “recognize that cost effective short-terms solution to the nursing shortage was the only concern of the military medical services”, thus the nurses’ solutions were not viewed as addressing the policy problem of the day. There was a significant difference of opinion over the definition of the policy problem and its solution between the Department of Militia and Defence and the CNATN. In the second instance, Jean Gunn and the CNATN moved forward with a progressive policy re-frame of the central issue of VADs and nursing’s professional status to one of redefining and advancing nursing’s role and contribution in an evolving system, and redirecting solutions and focus to the promise of public health nursing. This less confrontational re-frame allowed for the advancement of nursing education and practice.

Turning to present day, I recognize themes of the past that persist:

A central concern of the CNATN was the potential loss of nursing’s gains as a profession. Positioning nursing knowledge and science for maximum influence in nursing, health and public policy continues to challenge nurses in today’s context. Questions of how nurses will work together and with others persist. Relationships between registered nurses, licensed practical nurses and unregulated care providers, known as skill mix at point of care, are represented most often within a policy direction of substitution of less qualified personnel for professional registered nurses, despite evidence and tools available to assist with developing the nursing system that would lead to role differentiation and complementarity and collaborative nursing teams – for best nursing practice, patient and health outcomes in various settings – thus, the notion of role substitution was a concern of the CNATN after the war and the issues persists today.

We may look no further than the 2013 AGM, where the Canadian Nurses Association proposed a new membership model that would include LPNs as class of members with relatively minor influence in terms of votes, but with the potential to promote inclusiveness and collaboration among the two types of nurses. This proposal was highly contested by registered nurses and hotly debated on the floor of the assembly, and the motion was defeated. The issue with respect to two levels of nursing at the point of care remains unresolved in Canadian nursing today.

As an educator, I work with baccalaureate students who are questioning these relationships and struggling to understand how to relate to the nursing team: How should they be taught to collaborate and value LPNs and unregulated Health Care Assistants (HCAs), while also facing role substitution that may call into question the need for their nursing knowledge at the point of care.

As it the past, cooperative relationships among nursing organizations, and shared policy agendas remain critical if the profession is to advance. Nursing organizations with different mandates (professional, union ad regulatory) must communicate and work together on issues of a shared mandate and responsibility – as is the case with skill mix and defining the nursing system based on knowledge and science for the public good. With respect to nursing organizations promoting the role of the registered nurse, I relate to our recent experience in this province with the loss and rebuilding of a professional nursing association – the ARNBC. Relationships with the union, college and LPN Association of BC, and the NPABC are critical to rebuilding the profession – strides have been taken but challenges remain. Rebuild we must with courage and tenacity of VADs, nurses and organizations who served and made a difference in war, pandemic and in nursing’s professional legacy and advancement. We all recognize how health challenges of today also include threats of war, pandemic and the need for strength and collaboration among all nurses and organizations.

We are left with questions:

• How can we ensure that the nursing organizations and systems that our nursing graduates inherit do communicate and work together for nursing, patient care and health?

• How can re re-frame our policy agendas for maximum influence in the political context and what does history teach us in this regard?

Historical inquiry exposes the continuity of our most pressing policy challenges – for example the history of relationships among nursing organizations, sharing of power and uncovering exemplars of advancing the profession. Dr. Quiney’s research illuminates issues that are pervasive and for which policy directions must be taken. It is a valuable contribution to our collective awareness and I look forward to the discussion.

Thank-you.

Reference

Fairman, J. & D’Antonio, P. (2013). History counts: How history can shape our understanding of health policy. Nursing Outlook, 61, 346-352.