Lillian Wald (March 10, 1867 – September 1, 1940)

Guardian of the Discipline

Co-authored by
Deborah Lindell, Adeline Falk-Rafael, Jacqueline Fawcett

Lillian Wald (retrieved from https://www.vnsny.org/timeline/#prettyPhoto)

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).

References

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.

“The Family” about 1905. Standing, left to right: Jane Hitchcock, Sue Foote, Jene Travis. Second row, seated: Mary Magoun Brown, Lavinia Dock, Lillian D. Wald, Ysabella Waters, Henrietta Van Cleft. In Front: ‘Little Sammy’ Brofsky who ran everybody’s errands and ‘Florrie’ Long, the Coob’s little daughter and the “baby of the house.” (retrieved from https://www.vnsny.org/who-we-are/about-us/history/)

Who Will be the First? More Random Thoughts of a Sleeper Awake

Once again, with apologies to J. S. Bach, composer of Cantata no. 140, Sleepers Awake, these are my random thoughts of “Who Will be the First?” among nursology leaders while I was a sleeper awake one very early morning (see our first “sleepers awake” post: What if?). Here are my random “Who will be the first?” musings:

  • Who will be the first dean/director/chairperson to re-name the college/school/department/ program nursology?
  • Who will be the first Chief [Nursology] Officer to re-name the clinical agency department nursology?
  • Who will be the first journal editor to re-name the journal … Nursology or Journal of … Nursology?
  • Who will be the first “edge runner” or other nursologist recognized for innovative work to be referred to as a nursologist?
  • Who will be the first president or executive officer to re-name the association/academy/ council [Country or State] Nursology Association or [Country] Academy of Nursology or International Council of Nursology?

Again inspired by imagining these possibilities, I asked other Nursology.net management team members!

Adeline Falk-Rafael

  • Who will be the first newscaster/journalist to refer to nursologists or Nursology In the media?

Margaret Dexheimer Pharris

  • Who will be the first political leader to propose a Universal Access to Nursologists system for a country, state/department/region, city, and/or community?

Danny Willis

  • Who will be the first nursologist to lead peace, social justice, caring, and healing efforts throughout the world toward universal wellbeing/wellbecoming for all of humanity?

Rosemary William Eustace

  • Who will be the first nursologist to theorize “task shifting of nursing services and roles” in advancing nursing knowledge and the future of nursing as a profession within other “traditional” and “emerging” disciplines in health care?

Marian Turkel

  • Who will be the first academic dean to say we are advancing the discipline and profession of nursology by preparing nursologists? Nursologists practice nursology through the lens of nursological theory and the multiple patterns of knowing, with a focus on holistic practices such as mindfulness, centering, healing arts, aromatherapy, and coming to know the patient and family as person. The clinical practice sites for nursologists would expand beyond the hospital into healing centers, physician practices, and community centers.

Marlaine Smith

  • Who will be the first to graduate with a PhD in Nursology?

We invite all readers of this blog to contribute their own random thoughts–whether generated as a sleeper awake or during another phase of living–of “Who Will be the First?”

What If? Random Thoughts of Sleepers Awake

With apologies to J. S. Bach, composer of Cantata no. 140, Sleepers Awake these are my random thoughts of “What If?” about our discipline while I was a sleeper awake one very early morning.

  • What if Florence Nightingale (circa 1859) founded modern nursology (rather than nursing), titled her book, Nursology: What it is and What it is not, and established the first college/school/department/program of nursology to prepare nursologists?
  • What if we referred to ourselves as nursologists, rather than nurses or advanced practice nurses or nurse practitioners or even “practitioners of nursing” (Orem & Taylor, 1986, p. 39)?
  • What if Dock and Stewart (1938) wrote A Short History of Nursology (instead of A Short History of Nursing)?
  • What if our conceptual models originally were called paradigms, as these abstract and general “horizon[s] of expectation” (Popper, 1965, p. 47) for disciplinary activities are called in other disciplines?
  • What if health was widely regarded as encompassing wellness, illness, and disease, so that wellness would be promoted, and illness and disease would be prevented, rather than health being promoted (who would want to promote illness and disease)?
  • What if NANDA-I was NATA, such that D = Diagnosis were replaced with T = Trophicognosis, which Levine (1966) used as the label for judgments stemming from assessments of each patient’s health (wellness, illness, disease) condition?

Inspired by these possibilities, I asked my Nursology.net management team colleagues to also share their “sleepers awake” inspirations!

Peggy L. Chinn

  • What if all healthcare providers (regardless of discipline) were to base their interactions with patients on nursology fundamental principles and values? If we did this, there would be no computer screens in the room where the interactions take place, or at least they would be way off in the corner and ignored until a basic relationship was established. Every person in the room would be acknowledged, there would be lots of eye contact, and a focus on hearing and listening. That would be for starters!
  • What if there were nursology think tanks happening regularly and often all over the world?
  • What if all undergraduate students had a “Nursology 101” course?
  • What if all current nurses were required to have a continuing education “Nursology 101” course to maintain licensure?
  • What if the accreditation criteria for all nursing programs at all levels addressed the nature of the focus of the discipline in the structure of the curriculum?

Margaret Dexheimer Pharris

  • What if the National Institute for Nursing Research (NINR) only funded proposals based on nursology and contributing to nursology?
    • Jacqueline Fawcett: Following from Dr. Pharris’ question, What if NINR was called the National Institute of Nursology (NIN) or the National Nursology Institute (NNI)?
  • What if there was a nursologist in every community who could know and attend to people across care settings (community, hospital, homeless shelter, long-term care. etc.)? The nursologist–rooted in nursology’s patterns of knowing–would truly know and care for each person and the people who are important to that person, and would collaborate with other nursologists and other healthcare providers within each setting to ensure that the person’s sense of health is honored and nurtured.

Danny Willis

  • What if nursologists always clearly communicated the value added by our knowledge and presence?

Rosemary William Eustace

  • What if all nursologists worldwide are made aware of the impact of nursology on our diverse roles, specialties, training and contributions in meeting overall health outcomes and challenges as part of the 21st century (so-called) nursing campaigns?
  • What if nursologists claim that meaningful healthcare transitions, mutual goal attainments and positive client outcomes would not be possible without the nursologist–client interactions as a vital step to quality health care, such as in keeping with King’s (1992) Theory of Goals Attainment? (See https://nursology.net/nurse-theorists-and-their-work/kings-conceptual-system/)

Marian Turkel

  • What if there was another curriculum revolution and nursologists would have a curriculum focused on nursing as a human science/caring science? For academics this would mean letting go of sacred cows to advance nursing knowledge focused on caring, ethics, health as expanding consciousness, meaning, patterning, presence, and relationships.
  • What if the curriculum for nursologists moved beyond the traditional patterns of knowing (aesthetic, empirical, ethical, and personal (Carper, 1978) to include intuitive, mystical, and spiritual patterns of knowing
    • Jacqueline Fawcett
      Following from Marian Turkel’s second question, readers of this blog may want to read a recently published paper about spirituality as another pattern of knowing (Willis & Leone-Sheehan, 2019). In addition, White (1995) identified sociopolitical knowing as another pattern of knowing. Since that time, Chinn and Kramer (2019) have identified and refined the meaning of emancipatory knowing as still another pattern of knowing. And lest we forget, Munhall (1973) wrote about unknowing as a pattern of knowing, “as a condition of openness” whereas knowing “leads to a form of confidence that has inherent in it a state of closure” (p. 125).

Marlaine Smith

  • What if Nursology 101 was offered for students, or better yet, required for all students enrolled in a university? The course would focus on an introduction to phenomena such as human wholeness, human-environment-health relationships, the nature of health, healing, well-being/becoming, and caring in the human health experience.

In closing, we invite all readers of this blog to contribute their own random thoughts–whether generated as a sleeper awake or during another phase of living–of “What Ifs?”

References

Carper, B. A. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Science, 1(1), 13–23.

Chinn, P. L., & Kramer, M. K. (2019). Knowledge development in nursing: Theory and process (10th ed.). St. Louis, MO: Elsevier Mosby.

Dock, L. L., & Stewart, I. M. (1938). A short history of nursing: From the earliest times to the present day (4th ed.). New York: G. P. Putnam.

King, I. M. (1992). King’s theory of goal attainment. Nursing Science Quarterly, 5, 19–26.

Levine, M. E. (1966)Trophicognosis: An alternative to nursing diagnosis. In American Nurses’ Association Regional Clinical Conference (Vol. 2, pp. 55–70). New York: American Nurses’ Association.

Munhall, P. L. (1973). ‘Unknowing’: Toward another pattern of knowing in nursing. Nursing Outlook, 41, 125-128.

Orem, D. E., & Taylor, S. G. (1986). Orem’s general theory of nursing. In P. Winstead-Fry (Ed.), Case studies in nursing theory (pp. 37–71). New York: National League for Nursing.

Popper, K. R. (1965). Conjectures and refutations: The growth of scientific knowledge. New York, NY: Harper and Row.

White, J. (1995). Patterns of knowing: Review, critique, and update. Advances in Nursing Science, 17(4), 73-86.

Willis, D. G., & Leone-Sheehan, D. M. (2019). Spiritual knowing: Another pattern of knowing in the discipline. Advances in Nursing Science, 42, 58–68. https://doi.org/10.1097/ANS.0000000000000236

 

Nursology think tanks, anyone?

Addendum
Notice in ANS 1:3 (April 1979) of 2nd NTTT gathering

What if we had a host of small nursology think tanks happening all over the world?  Sound impossible?  No, it is not impossible, and we have an historial model from which to build!  As Jacqueline Fawcett observes in her reflections below, this Nursology blog can be viewed as a think tank of sorts.  And, we can also envision ways for face-to-face nursology think tanks to happen! If you are inspired by this idea, don’t wait for someone else to do it – invite a few friends and colleagues, and do it!   Here is the model as Jacqui and I experienced it:

Dr. Margaret Newman

In 1978, Margaret Newman initiated a very simple idea with great influence – she called for a few of her colleagues around the country to gather at a designated airport hotel and spend a couple of days in deep discussion about the development of nursing theory.  She called the gathering a “Nursing Theory Think Tank (NTTT)”   There was no agenda, no note-taking, and no expectation for outcomes.  Everyone who was invited to participate each year made their own hotel reservation at a designated hotel near an airport hub, and Margaret arranged with the hotel to provide a small conference room for two days free of charge.  There were about a dozen people invited each year – often a handful of people who had attended in the past, and typically 2 or 3 who had not attended before and were doing significant work in the realm of nursing theory or philosophy (now of course known as nursology!). Margaret’s own book Health as Expanding Consciousness was in production at the time of the first gathering, and published early in 1979.

I attended about 2 or 3 of the gatherings – and the photo shown below is my only record of anything that happened one of the years I attended!  I know Margaret was there (she always was!), and since she is not in the photograph I am guessing that she might have taken the photo!  As you can see from the photo, this event happened in an era when nurses generally “dressed up” for such an occasion, but the fact is that the gatherings were very informal, and often peppered with humor, story-telling and sharing of life experiences.  There was always someone quick to remind the group that we were under no obligation to be “productive” – but of course, significant “productive” things happened as a result of these gatherings. Since we were all as busy as we could be with our very productive careers, we more than welcomed the opportunity to have this kind of discussion with no pressure – not even the pressure of taking notes!

My experience of these discussions had a lasting influence, affirming some of the ideas I was working on, challenging me to think at a deeper level about specific aspects of my work, and prompting me to take my ideas to a deeper level of understanding, But equally important, I had the opportunity to hear from other nursologists, learn about their perspectives, and come to appreciate not only who they were as individuals, but the importance of their ideas. So I have always carried with me the importance of this kind of free-flowing opportunity to just talk, challenge one another and deepen our understandings of our ideas and of one another as individuals.

It was at the NTTT that Jacqueline Fawcett and I first met in person – probably in about 1981 or 2.  When I founded Advances in Nursing Science  in  1978, someone suggested that Jacqui was a young scholar who would be a wonderful addition to the review panel – and she has served faithfully in this capacity ever since! While we have known one another all these years, serving together on the management team for Nursology.net is our first opportunity to work closely together.  Here are Jacqui’s reflections of the NTTT:

My notes indicate that that the Nursing Theory Think Tank (NTTT) began in
1978 and ended in 1988. My recall of the decade of existence of the NTTT
are as follows.

The NTTT was begun by Dr. Margaret A. Newman. The first meeting, in 1978,
was at State College, PA, when Margaret was on the faculty at Pennsylvania
State University. I was exceptionally honored to be invited to join the NTTT in 1978. The members, including those who were invited and those who joined later,
included Margaret, of course, as well as Ellen Egan (Margaret’s former NYU
classmate), Ardis Swanson (Margaret’s former NYU faculty colleague), June
Brodie and me (former students in Margaret’s NYU theory development course),
Beverly Hall, Lorraine Walker, Kay Avant, Elizabeth See, Peggy Chinn, Afaf
Meleis, and Barbara Carper. We met approximately once each year, typically
for a weekend in the fall season, at a hotel near an airport.

The NTTT discussions focused on the current and desired future state of
nursing knowledge. Most discussions were informal and wide-ranging; others
were more formal discussions, based on papers presented by NTTT members. I
presented a paper for discussion at the NTTT meeting in Dallas, TX, in
September 1982, which was published along with a critique by June Brody in
1984: Fawcett, J. (1984). The metaparadigm of nursing: Present status and
future refinements. *Image: The Journal of Nursing Scholarship, 16*,
84‑87; Brodie, J. N. (1984). A response to Dr. J. Fawcett’s paper: “The
metaparadigm of nursing: Present status and future refinements. Image: *The
Journal of Nursing Scholarship, 16,* 87-89.

I presented another paper for discussion at the NTTT meeting in Austin, TX,
in October 1986, which was published in 1989: Fawcett, J. (1989). Spouses’
experiences during pregnancy and the postpartum: A program of research and
theory develop­ment. *Image. The Journal of Nursing Scholarship, 21,*
149-152.

Although the NTTT ended in 1988, many of the members have continued to
contribute to the development of nursology. To the extent that the blog
posts on nursology.net might be considered a contemporary NTTT, all
nursologists are invited to submit blogs and publish their ideas about all
matters nursology in journal articles, book chapters, and books.

Addendum – added to this post on December 2, 2018 – I discovered a notice published in ANS 1:3 (April, 1979) describing the first NTTT in October, 1978, announcing the second think tank planned for March 1979, and inviting interested nursologists to contact Margaret Newman.

“Seated, L to R, Peggy Chinn, Beverly Hall, Jacqueline Fawcett, Elizabeth See
Standing, L to R, Afaf Meleis, Kay Avant, Lorraine Walker, Ellen Egan, Ardis Swanson”