Evolution of Nursing Education in Portugal—a historical analysis of the Nursing School at the Hospital Geral de Santo António in Porto (1896-1947)
Vieira, F.1; Silva, H.2; Pinto, P.3
The history of nursing in Portugal is a theme that is beginning to be researched and analyzed in greater detail, perhaps as a result of the belated political awareness of the importance of standardizing the criteria followed in the training of nurses. Such standardization was eventually introduced by Decree-Law No. 36219, of April 10 1947, and provided better healthcare for patients. The unquestioned importance that has been attached to nursing and its teaching in recent years4—withthe creation by Law No. 821/89 of a degree course in Nursing and its consequent inclusion in the list of courses offered at the Polytechnic, followed by the approval in September 1999 by the Ministries of Education and Health of a university degree in Nursing—has led to increased research in the area of health sciences and health education and, consequently, to the study of the evolution of this latter phenomenon.
This paper will focus on the creation and consolidation of the Nursing School at the Hospital Geral de Santo António in Porto in the period from its foundation in 1896, as a result of the social welfare activities undertaken there by the Santa Casa da Misericórdia do Porto5 with the aim of training technicians to help with the treatment and care of patients, to 1947, the year when the state recognized the serious gaps that existed in nursing education and itself assumed responsibility for training qualified nurses to provide healthcare.
This paper therefore seeks to answer some of the questions relating to the evolution of nursing education in Portugal, particularly those relating to the development of the institution that is under study here. The foundation of the Nursing School at the Hospital Geral de Santo António will be looked at and a description made of the courses taught there. This study will also take into account the various attempts made to modernize the school, with the aim of increasing the quality of nursing, as well as the changes made to the school’s regulations, which helped to improve the quality of nursing care.
Through the specific study of a single institution and its training procedures, we hope to contribute towards improving knowledge about the past, present and future of nursing education in Portugal.
Results and Discussion
1. Some considerations about the state of nursing at the beginning of nursing education in Portugal
Very little is known about the state of nursing in mid-nineteenth century Portugal.6 Studies of the pre-Nightingale period in other European countries are also rare.7 If hospital and sanitary requirements were more demanding because of the technical advances in sciences such as chemistry or biology, nursing and ancillary staff still had no specialist knowledge. This lack of knowledge and the consequent need for a well-prepared support staff called for a change in the training of hospital workers, which would eventually lead to the development of the nursing profession.8
The concept of a hospital at that time was completely different from what it is now, for it was considered to be a place for the treatment of beggars, delinquents or individuals who were too poor to pay for home care. This is why nursing and ancillary staff tended to originate from the disadvantaged, and therefore less conscientious, social classes.9
In Porto, at that time, hospitals showed considerable improvements in such areas as clinical disinfection and the treatment of patients, as we can see from the Report of the Activities of the Santa Casa da Misericórdia do Porto, which refers to some technical improvements carried out, in 1874, at the Hospital Geral de Santo António, which was the property of that charitable institution:
The great care that we have always taken to make our main institution adequate to the aims of its great mission (...) is due to the fact that it has had several Administrations, which have gradually succeeded in endowing the Hospital Geral de Santo António with the best hygienic conditions. With this aim in mind, some of the old wards were afforded greater and better ventilation, while, for those situated in the new part of the building, the most appropriate principles of science were applied, guided by the lessons that the medical practice does not cease to teach us.10
These technical improvements were only very occasionally accompanied by the necessary training of the caregivers,11 since hospitals felt the need to incorporate new staff to overcome the shortage of nursing and ancillary workers. Although the religious orders had been suppressed in Portugal in 1834, they were reinstated from 1850 onwards, enabling them to regain their importance and credibility in society and return to their welfare activities in the form of charitable organisations.12
The debate about whether it was better to employ lay nurses or religious professionals, stimulated by the urgent need for personnel in the domain of healthcare, was further fuelled by various accusations that the nuns were answerable to the religious hierarchy in detriment to the medical and administrative corps. A Portuguese weekly medical journal (A Medicina Contemporânea) devoted several articles during this period to criticizing religious workers in Portuguese hospitals, giving several reasons and examples for this.13
Costa Simões14 was to be the most prominent defender of exclusively lay nursing, considering that, in most of the foreign hospitals that he had visited, religious caregivers were a permanent “nuisance to the regularity of the service.”15
He mentions the relatively minor importance that was given to technical work in comparison with religious practice, and the insubordination of the directors of technical services, who only recognized the authority of the leaders of the congregations. Contrary to what was generally believed, religious caregivers did not work for free: they were in fact a major expense, due to their salaries and the refusal on the part of religious nurses to give treatment to some patients, which led to the need to hire ancillary staff.16
At the end of the nineteenth century, there was widespread resistance to the employment, in the main Portuguese hospitals, of religious caregivers attached to the religious orders, largely because of the comments that had begun to reach Portugal about certain international examples17, as well as the negative political atmosphere surrounding the re-establishment of religious institutions, which did, in fact, lead to their expulsion and the nationalization of their property and assets in 1910.18
Only the main national hospitals managed to avoid the employment of religious caregivers amongst their staff. In the smaller local hospitals, however, religious nurses continued to be employed well into the twentieth century. Indeed, in around 1920, there was much discussion about the reintroduction of religious nurses into Lisbon’s Civil Hospitals.19
With a lag of several decades in relation to the pioneering ideas included in the Nightingale20 and Kaiserwerth models for the creation of schools with the aim of training qualified nurses, the first attempts to introduce professional training for Portuguese nurses date from the 1880s.
The first courses in scientific nursing in Portugal date from 1881, 1886 and 1896 (at the Hospitals of Coimbra, Lisbon and Porto). The first course was created in Coimbra by Costa Simões, the driving force behind the introduction of nursing education in Portugal, the same man that was to lay the foundations for the training of nurses at the Hospital Geral de Santo António, as part of his demands for the reorganization of this hospital in 1883.
With the initiative that he introduced in Coimbra in 1881, Costa Simões’ intention was to “[…] give better instruction to nurses and to train the servants of the Hospital so that they will be able to compete to fill any vacancies for nurses, due to the absence of trained personnel, equipped with the simple notion of a primary education […].21”
Despite his determination to improve the care that was provided at the hospitals of the University of Coimbra, his plan was not implemented, showing that these ideas were little more than the isolated wish of certain restricted sectors in the administration of that institution.22
The Lisbon Nursing School opened in 1886, under the supervision of Tomás de Carvalho (1819-1897), the director of the Medical-Surgical School. The school’s course was aimed at the scientific education of nurses working at the hospital (Hospital Real de São José and Annexes23) and the Portuguese state contributed towards the expenses of the school. However, it did not last, due to the low level of literacy of the applicants. The school was opened again in 1901 because the hospital’s nurses continued to be poorly prepared for their work.24
2.The Nursing School of the Hospital Geral de Santo António: some brief notes (1896-1942)
The Santa Casa da Misericórdia do Porto was the first private institution to take responsibility for the training of nursing personnel. Its nursing school was founded after the approval by the Civil Governor of Porto of the Regulations for the Technical Services of the Hospital Geral de Santo António, on June 15, 1896.
The creation of this school was designed to improve the quality of the care provided by the hospital workers, which had given rise to constant complaints by the medical staff because of the fear that it aroused in the patients.25
At my clinic, it frequently happened that, imprisoned by illness in the miserable jail of a tiny and infected hovel, I would find poor unfortunate creatures who were deeply horrified at the prospect of entering the Hospital.26
In that sense, the Report of the Activities of the Santa Casa da Misericórdia of 1888 confirms the poor quality of the services provided by the nurses, characterizing them as:
incapable, sloppy, providing a service far worse than that of the least rigorous demands, harmful to the Hospital and to the patients, so that no measure, either of punishment or reward, can bring about a more satisfactory service: they are mercenaries, looking for an occupation in which love for one’s fellow man is not an incentive.27
The head of the Santa Casa da Misericórdia, the Count of Samodães, attempted to solve this problem, proposing the introduction of religious caregivers at the hospital and being of the opinion that the patients would be well treated, since such carers would regard their profession as a “duty imposed by the priesthood.”28However, this measure was not implemented, perhaps because of the resistance that he met with from the medical corps, through the proposal made by Costa Simões in 1883 when he was hired to reorganize the internal regulations and operative procedures of the Hospital Geral de Santo António.29
In the Report of the Board of Directorschaired by Maximiliano de Lemos, also a defender of lay nursing, for the financial year of 1895-96, a new set of regulations was proposed for the hospital that included the organization of a course for nurses, the final goal of which would be to improve the quality of nursing practices.30 This represented an attempt to overcome the lack of quality in the services that were provided, by giving specific training to the personnel and to anybody else wishing to receive this.
The Santa Casa da Misericórdia do Porto delegated to the Hospital’s Board of Directors the responsibility for organizing and inaugurating the course, which, according to the local newspaper Comércio do Porto,31 began on October 1, 1896, and has remained in place up to the present day.
Initially, the lessons were centered around the provision of medical treatment, the application of dressings, and the concepts of sepsis and antisepsis, the intention being to provide students with practice in the application of compresses and basic knowledge about the pathogenic progress of wounds.
Writing in the report of the Board of Directors in 1895-96 about the nursing course at the Hospital Geral de Santo António, Maximiniano de Lemos stated as follows:
The plan of studies is considerably simplified in the project that I present, being limited to practice in the application of dressings and bandages and basic education in asepsis and antisepsis. As, however, it is my intention to give greater guarantees to nursing personnel, another level of education is provided by the administrative course, designed to supply the necessary instruction for those working in more senior positions, whose employment should be favored. (152)
The course was compulsory for the nurses and ancillary staff at the hospital and it was also open to other individuals from outside the hospital. It was essentially a theoretical course, with two weekly lessons, one for men and one for women. Besides the professional course (first year), there was a one-year administrative course, exclusively for nurses, male or female, who had successfully completed the professional course.
The course syllabus was related with the necessary administrative procedures of the different wards, and included some notions of the history of the Santa Casa da Misericórdia do Porto. The need for a successful performance in the course was also mentioned: those who failed the exam more than once were punished with either demotion or dismissal.32
The 1897-98 report of the activities of the Santa Casa da Misericórdia do Porto also contains information about teaching. Indeed, we know that the course was taught by only one teacher, Evaristo Saraiva, a medical doctor, who compiled a manual in Portuguese expressly for this course, which was published at least twice (1896 and 1904).33 These measures seem to have been designed to tackle the negative professional perception of nursing, an aim that seems to have been successfully achieved, not least because of the continued teaching of the course over time, contrary to what happened in the courses taught in Lisbon and Coimbra. This success was clearly highlighted by the positive reports of activities published by the Santa Casa da Misericórdia do Porto.34
The continued existence of this course over time is confirmed in the official reports of the hospital’s Board of Directors, where mention is made of the name of the students attending the nursing course, right from its very foundation. In fact, at the end of each academic year, teachers sent the results of the examinations to the hospital’s Board of Directors, informing them of the names of the students of nursing practices and the grades that they were awarded.
The data relating to the students from the first year of the nursing course are quite complete.35 For the year 1897-98, all that is mentioned is that the teacher sent the results of the examinations, with no reference being made to either the names of the students or the grades that they obtained. After reviewing this documentation, between 1896-97 and 1946-47, we found a total of 1,961 students who attended the first year of the course in nursing—53.95% of whom were females and 46.05% males. The number of students enrolled varied from year to year, with a minimum of 6 students in 1921-22, and a maximum of 108 students in 1934-35. The average number of students enrolled was roughly 38 each year. It should be noted that in the first year of the course, in 1896-97, there were a total of 47 students.
While, in other European countries, the nursing profession showed a tendency to become mostly female, the enrolment rates for male students were surprisingly high, with male students being in the majority for 20 of the 50 years under study.
A total of 733 students enrolled for the second year of the nursing course (between 1919-20 and 1946-47), 54.71% of whom were females and 45.29% males.
Data for the administrative course are, however, fairly incomplete. In fact, for some years, there are no records of the students who attended the course. In spite of this, it can be seen that, between 1898-99 and 1940-41, the number of students was roughly 516, with 57.75% of females and 42.25% of males.
Only a few lines of information are available about the first regulations drawn up for the School of Nurses. As far as can be seen, the same structure seems to have been maintained until 1918, when a new set of statutes was approved. Despite the alterations made to the school’s rules, the same objectives were maintained—the practical and theoretical instruction of the staff—but the duration of the course was now established as two consecutive years. The first year was devoted to theoretical lessons—two weekly classes—and the second year was reserved for the practical part of the course, taught in the different sections of the Hospital in the form and under the terms decided by the Technical Directorate and the Board of Directors.36
To guarantee the average level of the knowledge gained by the students, these were obliged to take an examination at the end of the first year, which they had to pass in order to enrol in the next year of the course.At the end of the second year, the students would have to take a final exam, composed of both a theoretical and a practical part.
To gain admission to this course, students were obliged to fulfil certain requirements and to present a certificate of good health and a record of vaccinations over the previous seven years; a certificate confirming that they were aged between eighteen and thirty-five; a certificate of good behaviour and of good moral conduct; as well as a certificate showing that they had gained approval in the second-grade examination at a state establishment.
The theoretical course was taught on a twice-weekly basis, with attendance at the classes being compulsory for all students, who were allowed to record no more than six unjustified absences and no more than nine absences justified by the presentation of a medical certificate, each year.
The practical course was organized by the Technical Directorate, taking place in the different sections of the hospital and in its nursing wards. The students were obliged to be present at 9 a.m. on the appointed days, and they could not leave before 10:30, except under special circumstances. They also had to complete a three-month internship.
Assessment was based on an oral exam, which lasted for 20 to 30 minutes and was administered by a panel of two members. Marks were awarded out of 20 according to the following scale: below 10—fail; from 10 to 12—sufficient; from 12 to 15—good; from 15 to 18—very good; from 18 to 20—excellent.37
A new set of statutes was to be approved in 1935, showing major similarities with those of the Schools of Coimbra and Lisbon, which had been approved in 1920 (Decree-Law No. 6943) and 1922 (Decree-Law No. 8505) respectively, endowing the professional body with medical, anatomical and managerial concepts, which previously had rarely even warranted a mention.
The major difference was to be found in the duration of the course, which was now 3 years.Other minor differences related to the managerial bodies and the course curriculum.
The new three-year course now consisted of a theoretical part, as well as practical exercises connected with the hospital’s various departments and services, which were undertaken in the last two years of the course.
The three disciplines that now formed the core curriculum of the course of the School of Nurses—Theoretical Nursing, Practical Nursing and Hospital Administration, spread over the 3 years of the course, were intended to provide the students, in the second year, with a general preparation for performing the role of healthcare assistants, offering the chance to specialize in the third year in practical and more complete scientific areas.In 1946, the discipline of Ethics was created, taught by the priest Agostinho Alves da Cunha.
In the teaching of those three disciplines, the curriculum included notions of anatomy and human physiology; hygiene; pharmacy and toxicology; medical nursing and emergency resources; surgical nursing and emergency resources; surgical services and professional deontology. The programme also included general notions about administrative organization; the duties of nursing personnel and practice in filling in tables; diets; complaints; hospital organization; aid in general; public aid; private aid; hospitals; charitable hospitals (from the Santa Casa da Misericórdia)—their history and regulations; the duties of service inspectors; the duties and obligations of hospital receptionists.
The Nursing School was run by the president of the Board of Directors of the Hospital Geral de Santo António.As far as the teaching staff was concerned, this consisted of three teachers, two clinicians and a member of the hospital’s administrative staff.
There was also a School Management Board, composed of the Director of the Nursing School, the Hospital’s Technical Director and the teachers, whose specific tasks were to revise the programs; organize the timetables; evenly distribute the workload and teaching hours; evaluate the students’ skills and assess them on a half-yearly basis, as well as to provide a final classification in terms of marks; and distribute the work of the teachers during the very first session of the year.
In comparison with the 1918 Regulations, the entry conditions for gaining access to the School’s course remained largely unaltered, as did the different activities of the school year and the number of absences that were allowed.
The exams were now considered to be both theoretical and practical. Again, these were conducted in the form of oral examinations, lasting no longer than half an hour. Marks were to be awarded in accordance with the following classification: from 0 to 9—insufficient; from 10 to 14—satisfactory; from 15 to 17—good; from 18 to 20—very good.38
Later, with the passing of Decree-Law No. 32612, of December 31, 1942, a committee would be appointed in order to study both the proposals presented and the implementation of the changes and improvements needed to achieve the aims referred to in Decree No. 4563 of July 9, 1918, and Decree No. 19060 of November 24, 1930.
Subsequently, Decree-Law No. 36219 of April 10, 1947 allowed for the teaching to be continued by private nursing schools, but nonetheless with the state intervening in matters relating to the adoption of plans and educational programs, and with the requirement that the jury appointed for the course’s final examinations should include members coming from the Ministry for Home Affairs.
This law therefore made all the Nursing Schools dependent on an official plan drawn up by the Portuguese state. Because of this, the relative specificities of the various courses of the curricula were standardized, guaranteeing the overall quality of nursing professionals and endowing the students with a level of knowledge that allowed for the implementation of a homogeneous healthcare policy nationwide.
As the nineteenth century drew to an end, a broader range of knowledge and scientific innovations was introduced to improve the hospital’s clinical hygiene and salubriousness, offering new training possibilities in Portugal, one of which was in the field of nursing education.
The training centre was the hospital, a place where poor people could be treated, as well as other people without sufficient financial resources to pay for home care.This troubled environment was responsible for the negative professional perception of the hospital’s ancillarystaff.
The first nursing schools in Portugal were centered around the Coimbra Hospitals in 1881, while, in 1886, the Lisbon Hospitals saw their attempts to follow suit thwarted, due to the low level of representation enjoyed by the members of the profession and the incompatibility between the work that was undertaken and the training that was provided.
Despite the constant debate about whether healthcare should be provided by lay or religious nurses, the decision generally centered around maintaining the group of professional workers and providing them with specialized teaching.In this sense, in 1896, under the leadership of the Santa Casa da Misericórdia do Porto, the Hospital Geral de Santo António set up the Nursing School, which was to continue in operation until the present day.
The original proposal of Maximiniano de Lemos led to the implementation of a simplified program, based on the provision of medical treatment, the application of dressings and bandages, and asepsis and antisepsis for the professional course. Also provided was another administrative course designed to improve the performance of the hospital’s management structure.
Subsequently, in 1918, a new set of statues established the basic structure for the Nursing Course.This was to be a two-year course with theoretical and practical components and subject to assessment. Classes took place twice a week and students were subjected to a three-month internship.
The regulations introduced in 1935 were similar to the ones that already existed at the Schools of Lisbon and Coimbra. The curriculum become more complex and the course now had a duration ofthree years. It was based on a combination of new clinical concepts and the old charitable traditions of the Santa Casa da Misericórdia, centered around three core disciplines: Theoretical Nursing, Practical Nursing and Hospital Administration. And, in 1946, the discipline of Ethics was introduced, which would be taught by a priest.
In 1942, Decree-Law No. 32612, of December 31, initiated a process for the standardization of all nursing education in Portugal, intended to homogenize education and provide training under equal conditions nationwide, which was finally implemented in 1947.
The study of the origins and evolution of the Hospital Geral de Santo António in Porto is considered to be of vital importance for understanding the development of nursing education in Portugal up to the present day, as much through its diachronic existence, as through its ethical, scientific and human motivations, which have adapted it to the present-day reality.
Anonymous (1932). “A infiltração religiosa”. A Voz do Enfermeiro, 4: 2.
Baly M. (1998). Florence Nightingale and the nursing legacy, building the foundations of modern nursing & midwifery. Philadelphia: BainBridgeBooks.
1Nursing School—Porto, Portugal, E-mail: firstname.lastname@example.org
2010, ISSN 1645-6432
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