Guardian of the Discipline
Deborah Lindell, Adeline Falk-Rafael, Jacqueline Fawcett
A recent article in the American Journal of Nursing (Pittman, 2019) reignited our interest in Lillian Wald’s landmark accomplishments, most notably co-founding, with Mary Brewster, of the Henry Street Settlement in New York City in 1893 (Dock & Stewart, 1938). “Their work” according to Dock and Stewart (1938), “led to the next development of visiting nursing by their relating it to all the social, economic and industrial conditions that affected their patients’ lives” (p. 162).
Pittman (2019) in her recent American Journal of Nursing article highlighting the importance of Wald’s practice as a model for the future, explained, “Wald’s model of care [involved] nurses working side by side with social workers at the intersection of medicine and society” (p. 46). Another perspective would be to think of Wald’s work as an approach to health care delivery that encompasses complementary services provided by nursologists and social workers.
A hallmark of Wald’s approach was prevention of illness and disease and promotion of wellness. Her approach was such that everyone had a nursologist for primary care, and that the nursologist referred those needing treatment for disease to a physician. We can only wonder how differently the health care system would have evolved if Wald’s model had indeed been become THE approach to health care.
Similarly, we can only wonder what would have happened had Wald’s model been incorporated and implemented as part of Grayce Sill’s (1983) proposal for the establishment of nursologist owned and operated corporations that contracted with all clinical agencies for provision of nursologists’ services (see our tribute to Grayce Sills here). Alternatively, we can only wonder would could happen if Wald’s model were to be incorporated into Parse’s (2019) proposal for establishment of “community centers owned and managed by [nursologists] that are regionally situated to offer services to a group of families in a region” (p. 169).
Wald’s delivery model, the focus of Pittman’s recent article. was extremely important because it allowed the nursologists to be, in Wald’s words, in an “organic relationship with the neighbourhood” and, therefore, allowed for the “development of community coalitions for influencing health and social policy” (Falk-Rafael (1999, p. 27). The delivery model followed Nightingale’s model of district “health nursing,” which Wald re-created as public health nursing. It was a model, however, that facilitated the enactment of Wald’s conceptual model of nursing, which Falk-Rafael has argued followed the Nightingale model (Falk-Rafael, 1999, 2005). Like Nightingale, Wald considered the patient to be the central focus of practice and viewed the “patient” as the individual, family, or community within the context of society; valued caring and compassion; and emphasized a holistic, person-centered, multi-determinant view of health. It is Wald’s conceptual model that informed nursing practice and without which, the delivery model would not have achieved the success alluded to in Pittman’s AJN article.
Wald, as Nightingale before her, understood from providing care to those members of society who were impoverished, disenfranchised, and otherwise vulnerable, that many of the health issues they faced could be prevented by upstream actions focused on changing/enacting public policies. Like Nightingale, Wald’s delivery model ensured nursing care to address immediate health concerns “downstream,” while simultaneously working “upstream” to shape policies affecting health. She lobbied for health care for those who were impoverished and established rural and school nursing. Moreover, again like Nightingale, Wald recognized the value of measuring outcomes. For example, she published narratives and graphs describing and depicting the dramatically lower death rates, overall and by age group, of 3535 children with pneumonia cared for in the home during 1914 by Henry Street nursologists compared to those admitted to hospitals (Wald, 1915, pp 38-39). Nor was Wald alone in her political activism among nursologists of the Henry Street Settlement (see “The Family” photo below). Lavinia Dock, the noted suffragist, and Margaret Sanger, who defied the Comstock Laws to provide contraceptive information to women and who established the forerunner of Planned Parenthood, were also Henry Street nursologists (Falk-Rafael, 2005).
Lillian Wald’s accomplishments extended beyond, albeit were connected with, the Henry Street Settlement. For example, she was elected the first president of the National Organization for Public Health Nursing “twenty years after [she] had gone to Henry Street to live and her name was known in many countries” (Dock & Stewart, 1938, p. 166). Earlier, Wald had contributed to the initiative to control the spread of tuberculosis, when she and Mary Brewster “bought sputum cups as part of their first equipment” for the Henry Street Settlement (Dock & Stewart, 1938, p. 325). Later, Wald contributed to the life insurance movement when, in 1909, she “arranged with Dr. Lee K. Frankel of the Metropolitan Life Insurance Company to have the Henry Street Visiting Nurses give their service to the sick industrial policy holders of that company, as a certain rate per visit” (Dock & Stewart, 1938, p. 344). In doing so, she increased health care accessibility to people who otherwise could not afford it and hoped to expand such accessibility through more partnerships with both the private and government sectors. In addition, Wald proposed what became the United States Children’s Bureau, which was established by Congress in 1912 (Dock & Stewart, 1938).
Lillian Wald’s work is an exemplar of Critical Caring, a mid-range theory rooted in the conceptual frameworks of Nightingale, Watson, and critical feminist social theories. This theory also emphasizes both downstream and upstream nursing as essential for population health and shares with Nightingale and Wald the tenet that justice-making is a manifestation of caring and compassion (Falk-Rafael, 2005).
Dock, L. L., & Stewart, I. M. (1938). A short history of nursing: From the earliest times to the present day(4thed.). New York, NY: G. P. Putnam’s Sons.
Falk-Rafael, A. R, (1999). The politics of health promotion: Influences on public health promoting nursing practice in Ontario, Canada from Nightingale to the nineties. Advances in Nursing Science,22(1), 23.
Falk-Rafael, A. (2005). Speaking truth to power. Nursing’s legacy and moral imperative. Advances in Nursing Science, 28, 212-223.
Jewish Women’s Archive. “Lillian Wald.” (Viewed on July 26, 2019) <https://jwa.org/womenofvalor/wald>
Parse, R. R. (2019). Healthcare venues in transition: A paradigm shift? Nursing Science Quarterly, 32, 169-170.
Pittman, P. (2019). Rising to the challenge: Re-Embracing the Wald model of nursing. American Journal of Nursing, 119(7) 46-52.
Wald, L. (1915) The house on Henry Street.New York, NY: Henry Holt.