The development of professional nursing training in Catalonia started at the beginning of XX century, with the establishment of three nursing schools: one public and two private. Their aim was: to provide trained medical auxiliaries; to improve the care of patients, at home or in the hospital; to offer a social and economic rewarding profession for women; and to have a public health promoter, very closed to the people.
We mention some books employed before XX century, to train or inform the religious and laic people, how to give attention to the sick persons.
Books, Nursing schools, Programs
During the nineteen century in Catalonia, the assistance to sick people was provided on voluntary or charitable non-professional bases, by the own family or by religious orders. This was the same, at home or in hospitals and institutions. Only the rich people had the possibility to pay for a non-professional assistant, called "vetlladora" ("to look after"), to care for the general needs of the sick person as: to look after, to dress, feeding, cleaning, personal hygiene, etc.
Medical care to illness during the second half of nineteenth century was different according with the social class. Poor people were attended by traditional practitioners, using traditional remedies, applied by the same practitioner or by the family. The working class organized mutuality's for themselves and their families to get medical assistance at home or in medical institutions. Upper classes were assisted by medical doctors at her home.
Hospitals were public institutions to assist people without resources or without family to care for them. The buildings were old, with few medical, technical and hygienic facilities. The personnel on duty was formed by one medical doctor, one surgeon, one pharmacist and some members of religious orders to take care of in-patients, with some auxiliary personnel for cooking, cleaning, etc.
At that time was also very popular a type of books called "Domestic Medicine" or "Domestic Pharmacy", written by medical professionals or even by traditional healers to assist poor families or individuals to treat themselves, with natural and cheap resources, slight wounds and frequent symptoms or illnesses.
The influence of more advanced French and German medicine, represented by the theory and practice of L. Pasteur and R. Koch, arrived in Catalonia by the end of XIX century through the laboratory and field work of Doctor Jaume Ferran. He initiated in 1885 the human vaccination against cholera morbo and other epidemic infectious diseases, changing the medical paradigm from treatment to prevention.
The arise of medical specialties, with increasing use of technology for diagnostic and therapeutic procedures, demanded trained and skilled personnel to assist doctors job and patient's care. These changed the role of persons giving charitable attention to seek and poor people, to become a trained and professional auxiliary in the field of Medicine.
The training of people devoted to nursing care during the modern age was based on the tradition, the experience as well as in some books. In the year of 1624, a book entitled "Instrucción de Enfermeros" [1] appeared in Madrid written by Andres Fernandez, Major of the "Orden de los Mínimos", a laic society devoted to the care of sick people in the General Hospital of Madrid. Of this book appeared three more editions in 1651, 1664 and 1728. By the same century, the book "Ordinacions de la Infermeria" was published in Barcelona in 1655 with advices and procedures on how to treat sick people at home or in institutions. It had an actualization is 1802 [2].
In the XVIII century, the French book of Carriere was very popular, with translations to German, English, Italian and Spanish by Doctor Francisco Salvà, with the title: "Manual para el servicio de los enfermos" [3].
By the end of XIX century, a book addressed to the missionaries appeared with the colonial expansion in Africa: "Notasterapéuticas o sea instrucciones a los enfermerosparauso de los misioneros en Fernando Póo y demaspaises de infieles", written by Francisco Saurina Serra [4], from the "Sociedad de la Congregación de Misioneros".
At the beginning of XX century, we found a new manual written by tree women, primary school teachers [5], addressed to the instruction of woman in this field: "Lo cuidado del malalt". It was supervised by Dr. Joaquim March I Sala.
In the arising of nursing profession in Catalonia, we can found different contributing factors. The transit of population from rural to urban industrial areas changed the pattern of illness and the means to care for them. Hygienic movement demanded skilled personnel to inform and supervise the living conditions of the people. The transformation of hospitals, from charitable asylums to medical care institutions. The problem of wounded and ill soldiers from Spanish colonial wars. A social demand for a female prestigious and rewarding job. Changes in the practice of medicine with the need for trained auxiliaries.
All these factors forced the government to regulate by low the profession of nurse (R.O. May 7, 1915).
This was the first private school to open their doors in Catalonia. It was a branch of the Institut de la Dona queTreballa (Institute for the Working Woman), an institution sponsored by a savings bank, with the aim to protect, train and give social services for the working women (maternal and child health, professional education, residential facilities, loans, etc.).
This Institute had a medical-surgical clinic for the attention of their associates. To staff that health service without religious personnel, forced them to open the Nursing School in order to furnish their own workers, well trained.
The first group [6] of students started in 1917, with a training Program of seventy lessons, covering all aspects of human anatomy, physiology, pathology, nursing care, nursing ethics, diseases, transport of patients, disinfection, hygiene, intoxications, etc.
The second year of training had the following syllabus:
• Human anatomy and physiology, Dr. Albert Ponjoan
• Notions of therapy and practical pharmacy, Dr. Fidel Saval
• Principles of Natural sciences applied to medicine, Dr. Fidel Saval
• Human pathology, Dr. Lluis Trias de Bes
• Principles of surgery: theory and practice, Dr. Joaquim Soler Dopff
• Mother and child health, Dr. Salvador Goday
• Professional ethics, Josep Rodes
The number of registered students between the year 1920 and 1931 were 598. It means a number of 50 new students admitted by year.
This school was very active, offering monographic short courses:
• Ophthalmology notions and ocular hygiene. 10 lessons; by Dr. Francesc Bordas
• Maternología. 9 lessons; by Dr. Santiago Dexeus
• Tuberculosis. 9 lessons; by Dr. Conrad Xalabarder
• Emergency surgery. 12 lessons; by Dr. Joaquim Soler Dopff
• Orthopedic course. 10 lessons; by Dr. Severi Izaguirre
• Woman physiology, pathology and hygiene. 10 lessons; by Dr. Albert Ponjoan
• Anesthesia. 8 lessons; by Dr. Joaquim Soler Dopff
• General and special hygiene. 9 lessons; by Dr. Lluis Trias de Bes
• Laboratory for nurses. 11 lessons; by Dr. Francesc Forcada
• Clinical dietetics. 10 lessons; by Dr. Jacint Vilardell
A course for specialization in Nurse Obstetrics and Gynecology, including 20 lessons, was done by Drs. Dexeus, Farriols, Torruella, Marques, Gil-Vernet, Goday and Salarich.
An Association of former students was organized to maintain the contact, organize refreshing sessions and published a News-Bulletin [7].
In the field of technical or professional training, this school was the first officially in the area of health, promoted by the new Catalonia regional government. It was planned initially by his president Enric Prat de la Riba and his health counselor doctor Miquel A. Fargas.
Doctor Fargas, in his "memorandum" addressed to the Trustees of the institutions of Charity, Maternity and Orphans in 1914, described his project for creating a new "Institució Maternal Catalana" (Catalan Maternal Institution), and mentioned the need for a body of nurses at the service of charity institutions of the Mancomunitat. This involved the need of training such specific health personnel. He wrote: "We need midwifes and nurses. They must be laywomen, while the religious orders not want to follow the medical orders. Beside the midwifes can existthe nurses, trained as a real profession" [8].
Also at the "memorandum" regarding the reorganization of the Catalan service for the assistance of mentally ill, presented by the regional minister of Charity doctor Agustí Riera in 1915, he said: "It's not enough to build buildings in quantity and quality in the appropriate situation, we must arrange appropriate personnel in quantity and trained to offer technical assistance, with proper retribution".
These statements are pointing the purpose of the government and the need of the institutions to have "appropriate personnel" and the planning of training them. But the lack of an appropriate health institution to do the practical training delayed the creation of the Nursing School [9].
Finally, the Government of Catalonia, under the approval of the Parliament, on November 30, 1917, took the action to open the school of Nursing in Barcelona (Escola Especial d'Infermeres Auxiliars de Medicina). "The practical training of this School, will be done in someone public medical-charitable institution; and regarding the basic theory, it shall be make use of existing facilities".
The instruction length for two years, with contends of the following type:
• General culture and humanities
• Natural and physical sciences
• Medical and hygienic concepts
• Training for the service to seek patients
The aim of the school was [10]:
a) The professional improvement of personnel in charge of the attention of infants, impaired and seek people in the establishments ruled by the Mancomunitat.
b) The training of general and specialized professional nurses, for the public and private practice, in health institutions and domestic service.
On June 27, 1918 the organization chart of the School was approved by the Government, presented by the minister of Charity doctor Agustí Riera.
The syllabus designed by Angels Bosch Alsina, head of the nursing school of Santa Madrona, foresee for the first year: reinforcement of general knowledge and theory of medicine and hygiene; and for the second year: theory and practice of medicine and hygiene. After that, they were awarded with a Diploma of Nurse by the Mancomunitat of Catalonia [11].
They also have the possibility to get a certificate of specialization, after four months of practices in:
• Provincial Maternity: "Baby-sitter"
• Mental clinic: "Mental ill assistant"
• Industrial institute: "Laboratory assistant"
The Board of trustees was formed by:
• President: Dr. Agustí Riera Pau, minister of Charity
• Members: Àngels Bosch Alsina
Dr. Salvador Cardenal Fernandez, Dean House of Charity
Dr. Ricard Zariquiey Cerraró, Dean Provincial Maternity
Dr. Andres Martinez Vargas, Dean Medical School
• Secretary: M. Àngels Mateu Pla
The teaching topics were, for the:
First year - Human anatomy, physiology and pathology.
General Nursing: clinical symptomatology, bromatology and therapy.
Rudiments of physic and chemical
Professional ethics
Practices of Physiotherapy
Broadening general knowledge
Second year - Rudiments of Hygiene and Bacteriology.
Professional ethics
Broadening general knowledge
Practices in medical and surgical wards
The members of the Faculty were:
-Dr. Baltasar Pijoan Soteras: Bromatology, Semiology and Therapeutics with practical training
-Dr. Ramon San Ricard: Anatomy, Physiology and general Pathology
-Dr. Josep Alomar Estades: Hygiene and Bacteriology
The first promotion elapsed between 1918 and 1920 for graduation.
At that time, the school was restructured, to overcome some organic and functional problems. Dr. Baltasar Pijoan was nominated as a Secretary and Head of studies; and Miss Anna Judas as a teacher for General culture and Head of administration. The professional ethics was in charged to Josep Tarré.
An innovative aspect of this nursing school was the outdoors or extension courses to promote the in-service training of personnel, with lower or updated specialized formation.
• 1920 Courses for the religious personnel of the charity institutions in Girona, Lleida [12] and Tarragona
• 1921 Practical course in Sabadell
• 1922 Practical course in Lleida and Sabadell
• 1923 Practical course in Terrassa
On September 1920, the first specialization course on Laboratory Assistant started by doctor Alomar, for graduated nurses interested to work in these fields.
A proof of the social and professional dynamics of these initial nurses promotions was the creation in 1920 of the "Associaciód' Infermeres de la Mancomunitat de Catalunya" (a professional association), as an instrument of professional representation and continuous education. The activities promoted or developed by this institution were [13]:
• 1921 Course of Maternology by professor Nubiola, chair of Obstetrics in the Medical School
• 1922 Twenty lessons of Pediatrics, by doctor Pompeu Pascual
• 1923 thirty lessons of Massage and medical gymnastics, by doctor Joan Vendrell
• 1924 Curs on "Works of professional appliance"
This Association also started to publish a newspaper with information for her associates.
From 1921, the Faculty was formed by:
-Dr. Ramon San Ricard, Anatomy, Physiology, Pathology
-Dr. Baltasar Pijoan, Bromatology, Semiology and Therapy
-Dr. Josep Alomar, Hygiene, Bacteriology and Laboratory practices
-Mr. Josep Tarré, Professional ethics
-Mr. Sixte Cambra, Elementary of physics and chemistry
-Miss. Anna Judas, General culture
-Miss. Merce Vacarises, General and laboratory auxiliary
On September 1923, the direction of the School changed from the Department of Education to the Department of Health, which oriented the training according with his needs and health plans. Under the name of "Escola d'Infermeres Auxiliars de Medicinaid' Higiene Pública", were trained for the following tasks:
• Medical nurses, for clinics and hospitals
• Nurses for laboratories of hygiene
• Nurses for the fight against Tuberculosis
• Nurses for fight against Malaria
• Nurses to fight against the infant mortality
• School nurses
• Industrial nurses
• Rural nurses
• Nurses for deficient and mentally ill people
In the year 1921 the municipality of Sabadell, an emerging industrial city, sponsored a training course for nurses caring for the returned sick or wounded soldiers in the war of Africa [14], with the teachers from the Nursing School of the Mancomunitat of Catalonia, doctors San Ricard, Pijoan and Alomar [15].
By the second decade of twentieth century, the repatriation of sick and wounded soldiers from the colonial Spanish war in Morocco, pushed the Barcelona Assembly of Red Cross, to plan for the construction of their own hospital and the foundation of a School of Nursing, to train their own civil personnel. The activity of the International Red Cross and the aristocratic women of the fighting countries during the First World War, caring for the wounded and sick soldiers in their own institutions, was a powerful example.
On February 28, 1917 a Royal Order creating the Body of Red Cross Nurses Dames was published in Spain [16]. At the same time, the syllabus was presented for nurses' training of 35 lessons.
The first course of Nurses Dames in Barcelona started on March 28, 1918 in the hospital of the Medical Faculty [17]. The text book had been written by the professor Andres Martinez Vargas, Dean of the Faculty of Medicine and chair of Pediatrics, and published in January 1918, devoted to the Queen of Spain Victoria Eugenia honorary president of the Spanish Red Cross.
This book [18] of 530 pages, divided in 35 chapters, contains also two appendix devoted to the care of the mothers and children: "Código de la Madre" and "Cuidados con el niñosano y con el niñoenfermo". We can also found 13 practical lessons:
• Dressing for upper extremities
• Dressing for lower extremities
• Dressing of neck and head
• Bandage of the body. Manufacturing bandages
• Cure material preparation
• Bandages for immobilization and extension
• Topic cures
• Wounds
• Topic remedies
• Sterilization of cure instruments
• Devices for the transport of wounded
• Disinfection and sterilization
The first graduation was in April 17, 1920. At the same time we can see the continuity of this school with the announcement for the beginning of a new course [19].
On October 1924, the School was transferred to the new Red Cross owned hospital [20]. Other doctors participating in the teaching of the students were: Balarí, Martí Feced, Tusell, Lillo, Moltó. Doctor Garcia Tornel succeeds Martinez Vargas inthe direction of the School. He published in 1925 a new text book: Manual del Practicante y de la Enfermera [21].
Before the Spanish Civil War, other schools were opened by the Red Cross in different places of Catalonia as: Tarragona, Mataró, Maó. The courses were free of charge, allowing young women to get later on a profitable employment [22].
The social, technical and economic changes during the transit from the XIX to the XX century modified the concept of disease and the medical practice. These forced the professionalization of nurses.
Also the need for middle level jobs for women, the nursing profession was a social and economic rewarding employment.
The medical advances, the changing patterns of hospitals, the increasing medical technology and the raising awareness for public health, demanded specific trained auxiliary personnel to implement the medical orders.
The graduates from all these nursing schools were replacing the former religious empiric personnel in the public and private hospitals service.
All these nursing schools in Catalonia had a higher demand and fruitful results.