Grace Hospital School of Nursing
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Appalachia Health Care: The Grace Hospital School of Nursing
Pollitt, PA & Moore, K.M. (1992). Appalachian Health Care: The Grace Hospital School of Nursing. American Presbyterian 70:4 pp239-246.
Reprinted with permission from the American Presbyterian.
After the Civil War and Reconstruction, the South was in chaos. The economy was in shambles and many social institutions had been destroyed. The task of rebuilding society frequently fell to the churches. Many Protestant denominations sent mission workers, money, and supplies to help “uplift” impoverished communities. Between 1885 and 1895 the Presbyterians organized thirty-one schools in the Appalachian Mountains.In 1885 the Presbyterian Church, U.S.A., home missions board mentioned the mountaineers specifically in its annual report to the General Assembly:
Among Presbyterians, religion and knowledge go hand in hand; churches and schools supplement and assist each other…The Presbyterian Church does not prosper in ignorance or illiteracy. In pushing our missionary work into the South, we have struck another great mass of illiteracy, this time among the whites…The census tells the story…These hardy mountaineers are eager for schools…The first expressed want is an academy – and perhaps they are quite right, for if universal education is to be introduced in their States, as the common school system is in some other states, the first want is the education of their sons and daughters that they may become teachers.
Nestled in a picturesque valley in the Blue Ridge mountains of North Carolina lies the small town of Banner Elk. This once remote Appalachian community is the home of major and ongoing missions of the Presbyterian Church (U.S.A.). Three church related institutions – Lees – McRae College, Grandfather Home and Orphanage, and Grace (now Cannon) Hospital – were established around the turn of the century, primarily through the efforts of the Presbyterian Church, U.S., and the Reverend Edgar Tufts.
The influence of the Presbyterian Church was evident before Tufts’s arrival in the mountains of North Carolina. The Presbyterians began sending missionaries to the Appalachian region in the mid-1880s. When Tufts came to the mountains in 1897 as part of the home mission work of the Concord Presbytery, he met Mrs. Elizabeth McRae, a Presbyterian Church worker from Maxton, North Carolina. McRae, an active promoter of women’s involvement in schools, churches, and society, had started a small girls’ school near Banner Elk in the mid-1890s. The mission of Tufts and McRae was to establish institutions of social uplift as well as Presbyterian churches in the North Carolina mountains. Although their story and the stories of Lees-McRae College and the Grandfather Home are well documented, an integral part of the educational/care giving facilities initiated by the Presbyterian Church that has received little attention is the School of Nursing associated with Grace Hospital.
After the Lees-McRae Institute for Girls and its companion School for Boys in nearby Plumtree, North Carolina were on firm footing, Tufts turned his attention to another area of concern in the Banner Elk community – that of inadequate health care. When residents of the area became ill, they had to do the best they could with home remedies. To go to a hospital meant a hard trip over rough mountains. In the winter months many roads were impassable. Tufts prayed for a physician to come to the area to render the care and services of a Christian doctor. In 1908, his prayers were answered. With the cooperation of the Banner Elk community and the Presbyterian Church, Tufts supervised the building of a combined doctor’s residence and office, the first in Banner Elk. This small, plain, wood-framed facility had no central heat, electricity, or bathrooms, although there was sunning water during the warm months. The office consisted of two patient rooms, an operating room, and a laboratory.
Tufts recruited Dr. Charles Reed, a retired medical missionary to China, to open his practice in Banner Elk. Dr. Reed stayed for two years and was replaced by Dr. William Cummings Tate in 1910. Dr. Tate was a graduate of the University of Tennessee Medical College. Initially, Mrs. Tate did the cooking and laundry for the hospital and assisted her husband in surgery. Mrs. Mary Chappel, a nurse for almost fifty years at Grace Hospital, relates that in 1914 Miss Holmes, a graduate nurse, arrived in Banner Elk to work with Dr. Tate. At the time, most patients were treated in their homes and only those requiring surgery were hospitalized. Consequently, Dr. Tate spent much of his time making house calls, leaving Miss Holmes in charge of in-patients as well as out-patients at the hospital.
By 1923, the hospital was averaging five patients per night and the need for more space was critical. Mrs. Helen Hartley Jenkins, a friend of Dr. Tate’s from New York, kept informed about his work through a magazine, The Southern Mountain Worker. In 1924, she donated twenty-two thousand dollars to build a twenty-five-bed hospital which was named after her sister, Grace. According to Mrs. Chappel, the new hospital had running water, electricity, and a coal-fired furnace. The kitchen was on the first floor along with living quarters for the director of nursing and the dietitian. Patient rooms were on the second and third floors and the operating room and nurses’ quarters were on the top floor.
The hospital, initiated by the Presbyterians, experienced growth and success. Consequently, a second physician, Dr. Rhonda Hardin from nearby Boone, North Carolina, joined Dr. Tate in 1925. The hospital was a benefit to the mountain residents and a successful mission for the Presbyterian Church, hospital workers made it so – even in the face of hardship. Mary Chappel recounts some of the hard times in the new hospital. One doctor made house calls (on horse-back) while the other cared for the hospital and clinic patients. Since both doctors needed to be present for all but emergency operations, operations were scheduled at night. While there was electricity, it was unreliable at best. Chappel, as operating room supervisor, administered the anesthesia while “Granny” Bradley, who lived in the Hardin household next door to the hospital, volunteered to hold a flashlight to supplement or supply the light by which the doctors operated. There was not enough electricity for the autoclave to sterilize the instruments needed in the operating room; so after the kitchen had been cleaned after the midday meal, the oven and boiling water were used to sterilize the equipment. Chappel remembers working frequently until the early morning hours to finish all the scheduled operations. She also recalls the doctors returning form house calls in the winter with their feet frozen in the stirrups. Nurses would heat water and pour it over the doctors’ feet to free them from the stirrups, being careful not to burn the horses.
Edgar Tufts and Elizabeth McRae established the Grace Hospital School of Nursing to fit “young women to meet the emergencies of life and to render efficient and effective service to those in need.” Apparently, Dr. Tate and Miss Homes trained some local women to take care of patients prior to the opening of the School of Nursing. In the May 1920 issue of The Pinnacles (the student newspaper of Lees-McRae Institute), this brief statement is found: “Grace Hospital…is doing a valiant service starting some 25-30 girls in the profession of trained nurse.” However, in 1924, whatever training had occurred before was replaced by the newly organized school of nursing.
The course work was for a period of three years. During the first year (which included a four-month probationary period) twelve courses were taken. They were Theory and Practice (of nursing), Drugs and Solutions, Elementary Hygiene, Materia Medica (pharmacology), Elementary Dietetics, Bandaging, Nursing Technics, Elementary Bacteriology, Anatomy and Physiology, Ethics, History of Nursing, and Bible. During the second year the students studied Surgery and Gynecology, Materia Medica and Therapeutics, Urinalysis and Laboratory, Nursing Technics, Special Lectures, Nursing in Medical Diseases, Nursing Ethics, Bedside Clinics, and Bible. Third-year courses encompassed Pediatrics, Medical Diseases, Obstetrics, Dietetics, Bible, and Special Studies and Affiliations.
Mrs. Mary Pritchett, a former student nurse at Grace Hospital, recalls that lectures were delivered primarily by the Superintendent of Nurses. Miss Harriet Bell was the first Superintendent. The women who followed Miss Bell as Superintendent of Nurses were Miss Florence Illidge; Miss Georgia Plyler (a graduate of Columbia College); Miss Hazel Nutter (a graduate of Grace Hospital in Morganton, North Carolina); Miss Leila Crowe; Miss Maye Lowe (a graduate of Young Harris College and New Hampshire State Hospital School of Nursing); Miss Margaret Pritchard; and Miss Elizabeth Nelson. There were no classrooms in the hospital; therefore, the classes were held in whatever space was available including empty patient rooms and doctors’ offices. The classroom instruction and lectures were supplemented by demonstrations and clinical teaching by staff nurses. Pritchett also recalls that in addition to patient care, nursing students were responsible for housekeeping, record keeping, and serving food trays.
Nutrition was an integral part of the curriculum. “Cookery” and dietetics were demonstrated in the diet kitchen. A full course of lectures encompassing the study of foods, the caloric system of dieting, and the application of various diets to treat disease was studied.
Though advertised as an educational institution, the School of Nursing continued to view its work as a ministry. In keeping with the original mission of the Presbyterian Church, nursing students were also given ethical training and, in their College Catalog, were “constantly reminded that their profession was a calling of high moral standard and an opportunity for Christian service.” As a result of the strict policies and guidelines of the school, as well as the classroom and clinical requirements, graduates of the Grace Hospital School of Nursing were eligible to take the State Board of Nursing examination to become registered nurses.
In order to be admitted, each applicant had to have a high school diploma or its equivalent, but additional college work was preferred. It was desired that each applicant be a Christian and between the ages of eighteen and thirty-five. Student nurses were given a stipend of ten dollars per month the first year, eleven dollars per month the second year, and twelve the third year. Mary Pritchett remembers the four students who were initially enrolled: Fuchia Wade, Madge Luttrell, Martha Paine, and Bernice Brown.
As was a common practice in nursing schools in the early years, students were often admitted on an individual basis and trained along an apprenticeship model. Students would apply for admission, and if they met the criteria, they would be accepted. Students would start as soon after acceptance as possible. There were no formal classes with beginning and graduation dates. Students would arrive at the hospital, be assigned to a floor and start to work. They were encouraged to attend whatever clinical teaching, lectures, and demonstrations were available and compatible with their individual work schedule. The content of the lectures often centered around the diagnoses of the patient currently being treated, rather than a comprehensive, pre-planned curriculum.
A strict code of conduct was enforced. Students addressed not only their instructors, but each other by title and last name throughout the program. They were forbidden to speak to the boys attending Lees-McRae College. The 1929 catalog for Less-McRae College describes the rules of Grace Hospital School of Nursing which stayed in effect until the school administration c hanged in 1949:
Rules of Conduct – Grace Hospital School of Nursing
1. Nurses are to rise and remain standing when speaking to physicians, surgeons, Superintendent or her assistants, while they are on duty.
2. Nurses are not to engage in or allow a patient to render personal service to them. This means sewing, errands, etc. If an emergency should arise and the need be urgent, the patient, if able to do so, may take a message for the nurse.
3. No nurse is to go off duty before reporting to the nurse in charge. On returning to duty the nurse is to report her return to the one in charge.
4. If for any reason a nurse is unable to go on duty in the morning, she must let the superintendent know at once.
5. No nurse is to consult a doctor without first reporting to the superintendent.
6. Nurses are not to take drugs of any kind for their own use, neither are they to prescribe for or give out drugs to another nurse.
7. Nurses are not to receive visitors while on duty, or receive visitors in the wards. When necessary, permission may be received from the superintendent to see a caller for five or ten minutes in the waiting room, when a nurse is on duty.
8. No nurse is to return to the wards when off duty, take visitors to her room, or take visitors through the building without first obtaining permission from the Superintendent or her assistant.
9. No nurse is to return to her room while on duty without first obtaining permission from the one in charge.
10. No nurse is to go visiting or shopping while in uniform.
11. Nurses are to wear full uniform at all times while on duty. Shoes must be noiseless, well fitting and practical. Uniforms will be inspected the first of every month.
12. Clothes must be plainly marked on bands with full names. Clothes an articles left lying about or unmarked, will be placed in the pound and can be redeemed upon paying a fine for same.
13. Laundry and bed linen are to be taken to the Laundry in laundry squares every Wednesday morning before breakfast. One ordinary size and one small laundry bag are needed.
14. All nurses are to be in their rooms by ten P.M. All lights are to be out by ten thirty P.M….Quiet must reign after ten P.M. All lights are to be turned out upon leaving a room.
15. One late permit will be allowed a week. During the study months nurses are allowed one evening out a week. Nurses leaving the building after seven P.M. or planning to stay out after that time are to sign in a book for that purpose, and the superintendent to be notified of same.
16. Night nurses are to be in bed at ten and remain until five.
17. Rooms are inspected weekly. Until other arrangements are made, nurses are to clean their own rooms every Friday or Saturday.
18. Nurses are not to visit in the kitchen other than at the times designated for lunches.
19. Meal hours:
Breakfast for day nurses 6:30 A.M.
Breakfast for night nurses 7:00-7:30 A.M.
Dinner – first 12:40 P.M.
Dinner – second 1:10 P.M.
Supper – first 5:50 P.M.
Supper – second 6:20 P.M.
Just as these rules seem excessive when compared to those listed in nursing school catalogs today, so did the number of hours spent on the floors. Hours of duty in 1929 were as follows: “Day nurses report on duty at seven A.M. and off duty at seven P.M. One-half day is given on Sunday when possible, otherwise when very busy, three or four hours. When possible, an afternoon a week is given. Night nurses report on duty at seven P.M. and off duty at seven A.M. The period of night duty is from four to six weeks, at the end of which time the nurse is allowed one day and one night off. Night duty averages every four months.”Furthermore, each nursing student was expected to attend at least one religious service on Sunday and a midweek service when possible. It should be noted that the Fair Labor Standards Act providing for an eight-hour work day did not take effect until October 24, 1940. Even then, nurses employed by an government agency or in homes, doctors’ offices, or private hospitals were exempt from the act’s regulations.
By 1927 Miss Bell had been replaced by Miss Florence Illidge as the Superintendent of Nurses. The staff and student nurses were living in rented houses in town. Because of the increasing number of people seeking the service of Grace Hospital, the nurses’ former living quarters in the hospital had been turned into patient wards. As crowding reached a critical level, Helen Jenkins once again donated enough money to build a new hospital. The new Grace Hospital, a sixty-bed facility, opened on April 30, 1932. The old hospital was remodeled and served as the Grace Hospital Nurses Training School Home. The new hospital had central heat, hot and cold running water year round, and adequate electricity for all hospital needs. Administrative offices were located on the first floor, medical patients were on the second floor, and the third floor was divided between surgical and obstetrical wards. A sun porch on the second floor was used as a pediatric ward, but due to the limited number of pediatric patients, it was used for overflow when all the beds were full on other floors. A sun porch on the third floor was the classroom space for the Grace Hospital School of Nursing. In addition to desks and chairs for all the students, there was room for a small library and equipment storage.
Mrs. Edith Redwine was hired as the first full-time instructor in 1932. Redwine was a 1904 graduate of St. Peter’s Hospital in Charlotte, and in 1918 served as the first president of the North Carolina League of Nursing Education. In this capacity, she spent three years visiting nursing schools across the state and writing recommendations to upgrade and standardize nursing education in North Carolina.  She contributed a wealth of knowledge and high standards to the Grace Hospital School of Nursing. By the mid-1930s, students were admitted as a class, with specific starting and graduating dates. Each class progressed through their training together; class sizes were small, probably never totaling more than twenty students in a single group.
In 1932 the trustees of the hospital – largely composed of local and state Presbyterians – approved the addition of a one-year training course for midwives. Several “granny midwives” were practicing in the region, sometimes with dire results. The trustees wrote, “It is believed that this one year course at Grace Hospital will prove a great blessing to the mountain communities and give many women a chance to perfect themselves in their chosen calling.”Apparently this “School for Maternity Workers” never materialized. While there are several mentions of the plans for the midwife training, there are no records of any classes actually being held.
By 1933 the hospital was staffed by one nursing superintendent, one night supervisor, one operating room supervisor, one orderly, one instructor, and twenty students. The students were the backbone of the labor force of the hospital. Probably because of the economic conditions imposed by the Depression, the stipends given to the students had been reduced to five dollars per month. Due, in part, to the sometimes overwhelming responsibilities, long hours and rigid expectations noted earlier, many students who started the program did not finish. According to Mary Pritchett, graduations of four or five students were not uncommon.
Grace Hospital School for Nursing continued to upgrade its admissions standards as educational opportunities in local communities improved. The 1935 catalog describes the necessary prerequisite courses and number of high school credits for admission to the nursing program as follows: English (4), Math – Algebra and Geometry (2), Social Science – History and Civics (2), Foreign Language – French or Latin (2), Science (2), and Electives (4). It was expected that “students must have an eighty percent average on her high school work, the high school record must be approved by the School of Nursing before she [could] enroll in Lees-McRae for her one year of college work.” At least one year of college work was also required prior to entrance into the nursing program. The year of college work was to include a course in Bible, Elementary Psychology, Abnormal Psychology, Physical Education, Chemistry, and Biology. Students had a prescribed series of courses to take once they were admitted to the School of Nursing. Some of these courses were taught through Lees-McRae College, and are described as follows in the college’s 1930 catalog:
Hygiene – The increasing knowledge of the importance of the prevention of disease make the study of hygiene and sanitation one of the most valuable factors in the education of one, who may by her understanding of the conditions which preserve health or cause disease, render as effective assistance in the prevention as in the cure of the manifold ills which afflict mankind.
Practical Nursing – The practical work of nursing is now almost universally taught by demonstration. In the course every effort is made to describe the procedures used in the general care of patients.
Bacteriology and Essentials of Medicine – For the purpose of familiarizing students with the bacterial causes of disease and to give a comprehensive course of medical diseases and their scientific view point of treatment.
While the academic component of the Grace Hospital School of Nursing met the highest standards of the North Carolina League for Nursing Education, the clinical component was hampered by the size of the hospital. Nationally, standards for nursing schools were becoming more comprehensive. What was started as a small mission hospital by the Presbyterian Church, Grace Hospital and its School of Nursing had evolved into a training ground for registered nurses (R.N.s): these students needed experience in psychiatric nursing, pediatric nursing, and advanced medical-surgical nursing. Although Grace Hospital offered excellent experience in basic medical-surgical nursing and obstetrics, it could not provide the diversity of patients required in the other areas to give students the depth of experience they needed to sit for State Boards. In the early 1940s, to broaden students’ experience and comply with North Carolina League for Nursing Education standards, Grace students did part of their clinical work away from Banner Elk. Dorothea Dix State Mental Hospital in Raleigh was used as the clinical site for psychiatric nursing, and the Children’s Free Hospital and General Hospital, both in Louisville, Kentucky, were used respectively for pediatrics and advanced medical surgical nursing. 
Although the school received a Class A rating and accreditation from the North Carolina Board of Nursing Examiners, this arrangement proved unmanageable. Supervising and housing students in distant cities, as well as coordinating students in the first and second years on campus at Banner Elk, were more than one instructor could handle. Grace Hospital had neither enough money nor student demand to hire a second teacher for the nursing school. Additionally, the hospital relied on student labor to staff the hospital and with a third of the students off campus, the hospital was chronically understaffed. After World War II, with the increasing number of hospital admissions, the doctors found themselves too busy with patient care and administrative duties to spend much time formally teaching in the school of nursing.
Due to the difficulty in meeting the demands of the North Carolina Board of Nursing Examiners, lack of funds, and the small staff, the Grace Hospital School of Nursing admitted its last class in 1949. An article in The Pinnacles, June 1954, reads: “Some years ago Grace Hospital was forced to abandon its training for R.N.s because the patient load became so great that the doctors were not able to give time to the teaching and educational programs necessary to adequately prepare R.N.s In lieu of the R.N. program, Grace Hospital now operates the Banner Elk School of Practical Nursing….”
Even before the last R.N. class graduated, the North Cortina Department of Public Instruction’s Department of Trade and Industrial Education, in cooperation with Grace Hospital, initiated a pioneer program in practical nursing. These practical nursing students lived and took classes in a newly built nurses’ home on the campus of Lees-McRae College. They used Grace Hospital as their clinical site. The training lasted one year and emphasized the basic, general care of hospitalized patients. Costs of the program were shared between the hospital and the Department of Public Instruction. Mrs. Mary Louise Pritchett, a 1938 graduate of Grace Hospital School of Nursing, taught the Practical Nursing program from 1954 to 1965. Miss Blalock and Miss Shook, also a Grace graduate, taught with Pritchett during this period. When the community college system began in the early 1960s, the Banner Elk School of Practical Nursing came under the auspices of Catawba Valley Community College in Hickory, North Carolina. As more community college campuses were developed, the administration of the practical nursing program in Banner Elk moved first to Caldwell Community College in Lenoir in 1965, and currently to Mayland Community College near Spruce Pine, North Carolina.
Due to the dedication to mission work by the Presbyterian Church and the efforts of people like Edgar Tufts, Elizabeth McRae, and Helen Hartley Jenkins, Grace (now Cannon) Hospital has provided almost seventy years of uninterrupted nursing education for the Appalachian mountain women. This legacy of the Presbyterian Church continues to serve the residents of the North Carolina Appalachian region.