Philadelphia General Hospital Photo Collection

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The Philadelphia Almshouse and the General Hospital Training School for Nurses

The two historically significant institutions featured in this photo collection, the Philadelphia Almshouse and the Philadelphia General Hospital School of Nursing, share a closely intertwined history.

Established in 1732, the Philadelphia Almshouse was the oldest public facility in the United States to contain a hospital. The Almshouse was structured on the tenets of 18th century poor relief policies that called for the institutionalization of indigent and marginal members of society as opposed to direct financial aid. As was typical with tax supported almshouses, the Philadelphia Almshouse provided a number of diverse services, including housing for the elderly and poor, maintenance of a house of correction, psychiatric facility, foundling institution and workhouse, accommodations for indigent women about to give birth and the operation of a hospital. The almshouse served as the main center of relief for Philadelphians with few social resources. Additionally, as Philadelphia was home to several medical schools, the hospital section of the almshouse took an early role in medical education by allowing medical students to utilize its facilities for clinical learning experiences.

As the city grew and the population of those in need increased, the city moved the Almshouse to larger facilities several times over the course of its existence. In 1835, the Almshouse was relocated to its final site on the west side of the Schuylkill River. Also in 1835, the hospital department of the almshouse was renamed the Philadelphia Hospital. The hospital functioned as a center of medical education, providing valued clinical material in the form of patients for Philadelphia medical schools, including the University Of Pennsylvania School Of Medicine.

By the mid-19th century, the needs of medical practice and education demanded more systematized and orderly nursing care than provided by the assortment of semi-trained and non-trained workers used for care delivery, many of whom were patients or former patients themselves. The Board of Guardians, which was the governing board of the Almshouse, recruited Alice Fisher, a protege of Florence Nightingale, to the position of Chief Nurse charging her with opening a training school for nurses which would carry out the dual functions of educating a new type of nurse worker and providing a reliable source of patient caregivers in the form of student nurses. Fisher arrived in Philadelphia in 1884 and quickly and successfully established the Philadelphia General Hospital (PGH) School of Nursing, one of the largest and most prestigious hospital based school of nursing operating in the United States.

Through her work at PGH, Fisher created a scheme of nursing care which insured the delivery of medical treatments based on the best scientific knowledge of the day. The presence of trained nurses in the hospital established the orderly environment, which permitted physicians to carry out new, more complex treatment regimens demanded by advances in scientific medicine.

The school prospered and was renowned for not only its educational excellence, but also its leadership role in professional activities. The PGH School of Nursing was an active member of the Associated Alumnae of the United States and Canada (now the American Nurses Association), an early organizer of the Pennsylvania State Nurses Association, and an innovator in nursing education.

At the beginning of the 20th century, the city transferred all almshouse services that operated outside of a solely medical scope off the campus and the hospital, renamed Philadelphia General Hospital in 1902, began a new, more promising era as a freestanding municipal hospital. Yet Philadelphians demonstrated ambivalence towards the institution. Publically, PGH was often depicted as a place where substandard care prevailed. In addition, the institution received frequent accusations of acting as a pawn for political operatives and represented the worst in government run services. In spite of this, the reputed excellence of the nursing and medical staff made it an indispensible medical care facility. For those who depended on the institution in time of need, PGH remained a critical safety net providing essential services to those denied health care in voluntary institutions due to their poverty or race.

As the debates on the merits and value of a tax-supported hospital continued, the PGH School of Nursing thrived. By the 1930s, the school's enrollment averaged 500 students, many of whom were recruited from the Pennsylvania region and all of whom represented the typical demographic characteristics of student nurses at the time. Students were predominantly young, white, single and female. While the school continued to improve its educational standards over the course of the 20th century, it also retained elements of the 19th century model of hospital-based apprenticeship training in which students delivered the majority of patient care in return for their education. Yet, the school's graduates received well-deserved accolades for their expertise as bedside nurses; expertise gained while caring for complex patient situations on the wards of PGH.

By the end of World War II, changes in health care created an environment in which debates about the role of tax supported hospitals raged. The 1946 Hospital Survey and Construction Act (Hill-Burton Act) expanded and modernized hospital facilities nationwide but emphasized the vast differences between voluntary and tax supported institutions' physical plants, many of which survived in a state of severe deterioration. The civil rights movement successes led hospitals to end abhorrent segregation polices which denied African Americans access to most facilities allowing them a greater choice of health care institutions when ill. Finally, the passage of Medicare and Medicaid in 1965 radically changed re-imbursement for health care services by providing millions of elderly and indigent Americans with the means to pay for care in the voluntary and private hospital systems.

As the role of hospital care evolved, changes in nursing education occurred as well. For decades, nursing and health care leaders called for nursing education to take place in institutions of higher education rather than traditional hospital based programs. By mid-20th century this movement achieved success with the proliferation of degree granting nursing programs in both community and four-year colleges. The opportunity to obtain a college degree decreased the former appeal of hospital based nurse education programs. The PGH School, as did hospital schools across the country, experiencing a reduced number of applicants, attempted to stem the loss of students by reaching out to groups previously ignored by nursing education programs, i.e., members of ethnic minorities, men and older students. This revision of PGH's demographics was a reflection of contemporary trends in nursing and healthcare education in general. A newly constructed nursing education building, funded by the 1964 Nurse Training Act added a modern flair to the school's appeal. Yet, despite success in these efforts, troubles continued to plague the school and hospital.

By the 1970s, a variety of seemingly intractable factors converged and threatened PGH's survival. A nationwide nursing shortage hit PGH especially hard endangering patient safety. Numerous bureaucratic difficulties stymied the procurement of necessary supplies and equipment required to deliver hospital care. Contractual disagreements with affiliating medical schools failed to reach resolution. Furthermore, a declining patient census reduced the need for the number of beds maintained by the hospital. Costs involved in replacing PGH's deteriorating physical structure, in need of extensive repairs, proved unaffordable. Finally, a series of exposes in local newspapers laid bare the many deficiencies from which PGH suffered.

In 1976, Philadelphia decided to abandon a centuries old tradition of tax supported hospital care and announced the closure of PGH and its illustrious school of nursing. Although many Philadelphians questioned the wisdom of this decision, trends seemed to point in the direction of a diminishing role for tax supported institutions. Debate continues today on the prudence of dismantling institutions such as PGH, because while it struggled to maintain services similar to those provided in the voluntary and private sectors, it did serve its constituency with dependability. Despite the controversy surrounding the closure, Philadelphia carried out its intention. In 1977, the last class of the PGH School of Nursing graduated. Shortly after, the hospital closed. During the 92 years of its existence, over 5500 graduates successfully completed the PGH program of studies, many of whom achieved significant status as leaders of the profession as well as countless others who maintained excellent and long standing nursing practices throughout the country and the world.

The individuals pictured in this photo collection, some known, some anonymous, comprise a living testament to the evolution of the nursing profession in America. Through the study of the history of institutions such as PGH, we come to a fuller understanding of the impact and role of nurses to healthcare as a whole.