WEBVTT 00:00:07.730 --> 00:00:37.560 [National Library of Medicine, Cataloging in Publication, Dorothy M. Smtih, R.N. (Videorecording)] 00:00:43.770 --> 00:00:49.800 [Department of Health, Education, and Welfare, Public Health Service, National Institutes of Health, National Library of Medicine] 00:00:52.540 --> 00:01:00.230 [A National Medical Audiovisual Center Production] 00:01:00.230 --> 00:01:16.390 [in cooperation with Sigma Theta Tau, National Honor Society of Nursing, Distinguished Leaders in Nursing] 00:01:16.390 --> 00:01:24.200 [Dorothy M. Smith, R.N., Dean Emeritus, College of Nursing, University of Florida, April 1979] 00:01:24.200 --> 00:01:32.090 [Interviewed by Linda H. Aiken, Director of Research, Robert Wood Johnson Foundation] 00:01:32.090 --> 00:01:44.410 [Introduction by Nell Watts, Executive Officer, Sigma Theta Tau] 00:01:44.410 --> 00:02:03.320 Nell Watts: Welcome to another edition of Distinguished Leaders in Nursing, a series designed to introduce notable American nurses who have demonstrated their professional leadership and helped to shape nursing practice in science into a significant force for improving healthcare. 00:02:03.320 --> 00:02:26.200 I'm Nell Watts, Executive Officer of Sigma Theta Tau International Nursing Honor Society. Our society joins with the National Medical Audiovisual Center at Atlanta to bring you this series. Sigma Theta Tau was founded in 1922 to promote a scientific education for nurses at the university level. [Nell Watts, Executive Office, Sigma Theta Tau] 00:02:26.200 --> 00:02:46.400 Today, it is an important and dynamic force in the field of nursing. It promotes research, creativity, and leadership through grants and awards, conferences, and publication of scholarly papers. Today's distinguished guest is Dorothy Smith, who has made an important and significant contribution to nursing. 00:02:46.400 --> 00:03:06.910 Dorothy Smith was one of the first nurse educators to say that faculty, even the dean herself, should be involved in nursing practice. In 1941, she earned her BS degree from Teachers College, Columbia University, and in 1947, she received a master's degree from Harvard University. 00:03:06.910 --> 00:03:27.330 Dorothy Smith was assistant dean at Duke University from 1948 to 1952, and was dean and professor of nursing at the College Of Nursing at the University of Florida in Gainesville from 1956 until her retirement in 1971. Dean Smith has published extensively. 00:03:27.330 --> 00:03:39.940 Many of her publications focus on the collection of clinical data, establishing objectives based on a nursing diagnosis, and carefully monitoring treatments devised to handle nursing problems. 00:03:39.940 --> 00:04:02.990 She's been active in professional organizations and received numerous honors and awards. Dean Smith will be interviewed by one of her former students, Dr. Linda Aiken, who is currently the Director of Research, Robert Wood Johnson Foundation. And now, I proudly present our special guest, Dorothy Smith, and her interviewer, Linda Aiken. 00:04:02.990 --> 00:04:15.780 Linda Aiken: Dorothy, it's a great pleasure for me to be a part of this Distinguished Leaders in Nursing Series. We've known each other for a long time, I was your student, I was a young faculty member with you. 00:04:15.780 --> 00:04:45.470 So I was a part of your professional life and thus, I know some of your experiences, some of the things that are important to you, and I'd like to spend the time that we have together today exploring what nursing was like in your career, what you think your important accomplishments were, your frustrations, and where you see nursing going. And maybe it makes sense for us to start with the University of Florida. 00:04:45.470 --> 00:05:03.940 I see that as the real pinnacle of your career, your very innovative program there, and maybe I should ask you to start out by describing what nursing was like during the mid-50s and how you got to the University of Florida, and how that program evolved. 00:05:03.940 --> 00:05:08.550 Dorothy M. Smith: Well, it's really nice to have you here Linda. Sorry, what's it been, 15 years? 00:05:08.550 --> 00:05:10.040 Aiken: 15 years, yes. 00:05:10.040 --> 00:05:40.460 Smith: Goodness. One of the biggest accomplishments I feel and I really did an accomplishment, accomplish is seeing graduates like you go on to do the kind of work here, doing, and I think that's really exciting for me. Next to seeing patients taken cared of. The--of course I graduated from a diploma program in 1936, so I've seen a lot of changes in nursing. 00:05:40.460 --> 00:06:19.440 But, I would say that my experiences at two places really form the basis for some of my thinking about what we try to do with the University of Florida. I left New England in 1947 to go to Duke University, and I was, went down there to teach sciences and nursing. And I stayed there five years and when I left, I was an assistant dean. 00:06:19.440 --> 00:07:10.960 The problem at Duke was that essentially, in the middle of a very renowned campus, Duke, and along with a very renowned medical school and hospital, they had a school of nursing. And some of the best students I've ever seen came to Duke, into nursing, really brilliant young women, a few men. They came because of the academic prestige really of Duke University, came from all over the world. 00:07:10.960 --> 00:07:31.240 And in the middle of all this was essentially a hospital program, without the usual academic standards that every other school in the university or every other college in the university have. 00:07:31.240 --> 00:07:36.250 Aiken: Would you say that was particular to Duke or was that the state of nursing education at that time? 00:07:36.250 --> 00:08:12.200 Smith: That was the state of nursing education at that time, but it seemed to me very deplorable that a uniiversity of Duke's standing would allow this vocational program in the middle of its campus. So it was a state, you're right, but I couldn't understand how educators could allow this kind of exploitative program. 00:08:12.200 --> 00:08:49.970 Students, fundamentally, were providing care on the basis of the needs of the hospital, rather than on the basis of what they needed in order to learn. For example, right after I arrived, one of the students, who later became a faculty member for us, had been in the operating room for nine months, because they were having problems getting staff in the operating room. 00:08:49.970 --> 00:09:28.190 She didn't need to be in the operating room for nine months. It happened that she liked it, but it certainly wasn't an educational experience. Helen Nahm, whom I'm sure you've heard of, was there in charge of their graduate program. And, she and I worked very hard for the entire five years to try to get the university, to make this a collegiate program, leading toward a--leading to a baccalaureate degree rather than a hospital program. [Head shot of Helen Nahm] 00:09:28.190 --> 00:09:52.580 The physicians were very much against it, hospital administration was against it. This may seem funny to you but maybe it doesn't, but a lot of nurses were against it, too. And we did not succeed, although we laid the groundwork and about a couple of years after we left -- she left before I did -- 00:09:52.580 --> 00:10:17.380 it did become a baccalaureate program in nursing. So that was a very important experience for me because I saw how little nurses and physicians and hospital administrators and educators thought of nursing really. 00:10:17.380 --> 00:10:41.970 Aiken: Do you think that these--the concerns about the lack of comparability in nursing education to the other academic programs has contributed to some of the nursing schools moving way over to the side of becoming, or trying to become, basically academic programs with very little input into the health side of things? 00:10:41.970 --> 00:11:17.330 Smith: In a revision of our book, I speak of three revolutions in nursing. And, the first one is--was headed by Florence Nightingale who demonstrated that nursing had an impact on mortality and morbidity rates of British soldiers in the Crimean War, and therefore, training, which was what it was called, of nurses became an acceptable thing. 00:11:17.330 --> 00:11:45.480 And these schools did develop throughout the world although her first school was financed apart from the hospital, it was not under the control of the hospital financially. In this country when schools started, they all became financially dependent on hospitals. Second revolution is just what you just said and what we were trying to do at Duke. 00:11:45.480 --> 00:12:07.700 And that is nursing tried to get,and did succeed to some extent, nursing education into the general stream of education, rather than hospital-based... into the universities and colleges, and this conflict, this revolution is still going on although there has been some progress. 00:12:07.700 --> 00:12:39.890 Now, the reason that I was interested particularly in getting nursing to be academically respectable was not because I felt that was important that we'd be academically respectable or if we could put degrees after our names. I felt that--I don't know if you remember or not, but medical education moved from doctor's offices into universities by Flexner, the Flexner Report. 00:12:39.890 --> 00:12:56.230 Fundamentally, when it was discovered that in order for the physician to do his job, he had to have a scientific background, and that background could usually only be obtained in the university. 00:12:56.230 --> 00:13:20.340 Now I had had the notion, not the notion but the belief through my experience with patients, that in order to give scientifically-based nursing care, a nurse had to have a good scientific base, not only in physiology, but in some of the social sciences as well. 00:13:20.340 --> 00:13:40.070 And that those courses or that kind of learning, generally could only be obtained on a college campus. That was the reason for it, not just so that we could get a degree and say we were a professional or whatever. Because I was concerned primarily about the care the patients were getting. 00:13:40.070 --> 00:14:00.460 After Duke, after I left Duke, I was exhausted from this fight and it really was a fight. And so I went up and joined Helen Nahm at the accrediting service and I worked for two years with the National League for Nursing Accrediting Societies Association, which I really didn't like. 00:14:00.460 --> 00:14:22.220 I knew I wouldn't stay because I don't like traveling all that much. But during that two years, I did have an opportunity to visit, to get data for accreditation, to visit schools all over the country, both ollegiate and diploma. And I saw the perfectly horrible. 00:14:22.220 --> 00:14:51.630 I saw schools that should never have existed because they didn't have any prepared faculty and the students were not, either intelligence-wise or motivated in any other way, to be there. I saw students being exploited in hospitals in the same way that they had been for years. 00:14:51.630 --> 00:15:31.150 And I saw the collegiate programs being not much else than some courses added on to an essentially diploma program. In other words, they would give English and History, and you name it. But the nursing part of it was not any different than what I had in 1934. And in fact was not as good because it was too dispersed. 00:15:31.150 --> 00:15:58.210 Meanwhile, I guess you probably know from having known me all these years, I have never stopped working with patients, and physicians actually. So I happened to be one of a few educators who think that patients who need several disciplines, including medicine and nursing, I got angry, you know when they push nurses around but that doesn't mean the patients don't need doctors as well as nurses. 00:15:58.210 --> 00:16:23.310 And so ever since I graduated, regardless of what job I had, and this was true even when I was working in New York with the league, I did spend time with patients. When I was in New York, I'd go to Bellevue because I had affiliated there. And so, my experience with patients and all of these things I was saying in nursing, made me believe that, you know, it was a bad shot. 00:16:23.310 --> 00:16:56.530 And so, I went to Hartford. After I left New York, I went to Hartford Hospital for no money, really. To see if I could--and they took me because I didn't charge them anything -- to see if I could get faculty to practice nursing while they were teaching 'cause I had the idea that you could only learn something from seeing somebody do it and getting paid for doing it. 00:16:56.530 --> 00:17:27.150 And actually, I was able in nine months to get some young faculty working with patients, and students learning from the patients and the faculty in this way, maybe five or six, two or three later came to Florida. I saw--the other thing I saw as I went around the country was anybody who worked with patients was kind of second-class on faculties. 00:17:27.150 --> 00:17:51.700 They had people called clinical instructors, and then they had people taught in a classroom, and the people who taught in the classroom who talked about nursing always got more money than the people who worked with the patients. They had more voting privileges, they had more social prestige, and this bothered me. 00:17:51.700 --> 00:18:26.850 In the hospitals, I saw the money--most of the highest, highest pay went to the nurses on the hospital who never saw a patient. In other words, the director of nursing, the supervisors, the head nurses, the assistant head nurses all got better pay, more privileges such as weekend, than anyone who try to do anything directly with the patient. 00:18:26.850 --> 00:19:02.320 This concerned me because I've always felt that nursing, the heart of nursing was a primary relationship with the patient, whether the patient be in a clinic or in a home, or in the hospital, but this primary relationship, this was the heart of nursing. And here were four-fifths of the nurses getting paid for never having a primary relationship. This bothered me. 00:19:02.320 --> 00:19:20.800 Aiken: And one of the things that sets you so apart from other nurses is the fact that you are known as a clinician despite the other roles, be it educator roles, administrator roles, whatever, you have always been known as a clinician. How do you explain that, and were there others? 00:19:20.800 --> 00:19:54.820 Smith: Well, I can't explain it, except I guess I took literally what I thought nursing was. And, I did have some experiences in my nursing school I think that it was a diploma program but we were never really exploited because the hospitals stopped taking students in during the Depression in order to give some nurses some jobs. And so, I saw nurses doing tremendous things with patients. 00:19:54.820 --> 00:20:25.920 And I learned from people who were working with patients, not from people who were telling you what to do but couldn't do it. Also, I have to admit that there is something in my genes or my learned behavior that definitely points toward making people as comfortable and as productive as possible. You know that. 00:20:25.920 --> 00:20:27.110 Aiken: Yes. 00:20:27.110 --> 00:20:51.780 Smith: I mean, I want students or patients to grow and continue to grow, and I'll do anything to help them do it. And I could have been in law, or medicine, or anything else, but there is something in me that wants to make people comfortable and then productive, and I don't think people are productive unless they first get some of their basic needs met. So, I don't know why-- 00:20:51.780 --> 00:21:04.530 Aiken: Was there anything about the diploma programs? It's not unusual to hear people pining away for the old diploma nurses, and they were the very best. I'm sure you've heard that, I hear it all the time. 00:21:04.530 --> 00:21:05.420 Smith: Yeah. 00:21:05.420 --> 00:21:11.820 Aiken: And the sense that the new breed of nurses, they don't have the link with the patient anymore. Was there anything about the diploma program or-- 00:21:11.820 --> 00:21:42.850 Smith: No, I don't think so. I think it was more a generational thing. I think that in my diploma program that I was lucky, I was one of the few, we were--in one of the few diploma programs where we were not exploited as they were in other areas of Boston. I also had good experience with physicians. You know, I--we also learned at a time when you could have a primary relationship with patients. 00:21:42.850 --> 00:22:23.500 I think that my generation grew, you know, grew up in a time where making a living was important, education and working hard were supposed to enable you to make a living, people were a little closer. I think it's more of a generational thing. I think World War Two changed a lot of things because many nurses went into the service and when they came back, they had educational benefits. 00:22:23.500 --> 00:22:39.100 They did not want to go back to working with the patients. Even in my day, most nurses when they graduated became head nurses or assistant head nurses. So that's one of the problems. I don't know why. 00:22:39.100 --> 00:23:00.580 I guess that--when I went to get my baccalaureate degree at Teachers College, I came in contact with Virginia Henderson, and Fran Reiter, and Helen Bunge, all people who believe pretty much as I did. Now, Fran Reiter did work with patients, but the others didn't. 00:23:00.580 --> 00:23:38.980 But they still believe that there was something--oh, I'll tell you why I worked with patients. There is this emotional thing which I mentioned, of helping, but I find the challenge of giving care to people, intellectually stimulating as well as emotionally satisfying. Now, most of my peers and most nurses have not been able to find this kind of intellectual stimulation. 00:23:38.980 --> 00:23:58.860 They may have been able to find the emotional satisfaction, but for bright people that's not enough. Now, why I found it, it's because I have a curiosity about what makes people sick and what makes then well, and how you can improve the quality of life, I've always had that. 00:23:58.860 --> 00:24:31.060 And, I think that's part of...and nursing in general has not worked to get a science of caring, or a science of comfort, or a science of improved quality of living, I guess this is sort of what I'm talking about. Now why, I don't know. Now, I know the reason that people don't go on with it, like I did, because you don't get paid for it. I never got paid for it, I didn't get paid for it at Florida or anywhere else. 00:24:31.060 --> 00:25:09.570 You don't...you get a lot of criticism, as you know. You are dealing, if you're really trying to further the scientific element of this, you're dealing with hurting, dying, miserable, complaining people. And sometimes, you can't stop the dying, you can't stop the hurting, you can't even do very much about the problems that made them the way they are, and that's a big drain. 00:25:09.570 --> 00:25:32.950 And I submit that most nurses have not been really educated to be able to cope with this. In order to cope with it, you have to have a fairly satisfying life outside that you can run to. And you have to be convinced that what you're doing is important. 00:25:32.950 --> 00:25:47.930 But you know that it's draining. And doctors can walk away, PTs can walk away. If you're really a nurse the way I am, you can walk away, you get a drink of water, or take some time off, but you don't--you'll really hang in there with the problems. 00:25:47.930 --> 00:26:18.110 So I think that's probably one of the reasons too, I know there were not very many of us. And I just believe, always have believed that nursing is a discipline that we need to find out a lot more about this program but--and the only way we can find it out is by continually working with people whether they're...wherever they are. 00:26:18.110 --> 00:26:33.790 Aiken: Is one of the reasons why you decided to take on a challenge at the University of Florida, the fact that you wanted to have a laboratory to try to link people up and to try to share the intellectual excitement you found in clinical work? 00:26:33.790 --> 00:26:52.710 Smith: Yes. Actually, I had planned--after I left Hartford, I had planned a trip to go and do work with the physician and do staff nursing 'cause I was sick to death of all the, hoop-de-la and the non-nursing activities that people were getting paid for. 00:26:52.710 --> 00:27:13.860 And people--by this time I had gained a reputation of sorts and people found out here that I was available and so they asked me to come and look at the job because this was a brand new place, as you know, in 1955. And I said, "No, I didn't want the job," and they finally prevailed on me 'cause I didn't want administration. 00:27:13.860 --> 00:27:38.550 They finally prevailed upon me to come. And I found that the president of the university was someone whom I could work with. The provost of the health center was a non-medical man which I felt would be a help in getting doctors and hospital administrators and nurses together. 00:27:38.550 --> 00:27:43.910 Aiken: So it was a health center concept, instead of a medical center. 00:27:43.910 --> 00:28:01.290 Smith: It was called the health--nobody calls it the health center but that's the name still on the building. The dean of the medical school had this interest in general practice. He felt that there had been too much specialization in medicine. 00:28:01.290 --> 00:28:32.990 And he was very much interested in a concept of interdisciplinary work, whether it'd be in education or whether it'd be with patients or in the clinics or whatever. And so, these people, all, here was a brand new place, no buildings or anything yet. They seemed to be at least relatively agreeable to the kinds of things that I was talking about. The hospital hadn't been built. 00:28:32.990 --> 00:28:40.680 Aiken: How do you explain that? Is that it happenstance of the people? Weren't you at that time controversial and wasn't this idea somewhat... 00:28:40.680 --> 00:28:54.930 Smith: I wasn't as controversial then as I later became. I was somewhat controversial 'cause I was always with patients but I wasn't nearly as controversial as I became. It was a fluke. 00:28:54.930 --> 00:28:57.640 Aiken: Even today, there are very few health centers in the country. 00:28:57.640 --> 00:29:20.500 Smith: Right, right, right. This was very fortuitous. The reason that we were successful for 14 or 15 years was a fortuitous people, place, time. That's sad but that's the way it was. So I decided to take the job and I laid down some conditions. 00:29:20.500 --> 00:29:42.410 And I didn't think they'd take them, and they did. And one of the conditions was that I would be in charge of not only the college of nursing but also the nursing service of our teaching hospital. And there were at least two reasons for this. 00:29:42.410 --> 00:30:25.480 One was to guarantee faculty practice privileges because I felt that students needed to really see people working with patients. The other, another one was to actually speak for nursing in the health center council rather than having nursing education and the nursing service divided. And along with this, I insisted that the hospital administrator be a member of the health center council. 00:30:25.480 --> 00:30:45.530 In most places, the hospital administrator was under their dean of medicine. And therefore, the dean of medicine spoke for the hospital as well as medicine. So there were these three things. There were other reasons but those were the most important ones. 00:30:45.530 --> 00:31:04.790 You see, I don't know if you remember or not, I know, that when medicine looks for a facility for its students to learn, it looks for a facility where their faculty can practice and their students follow, but how does nursing do it? 00:31:04.790 --> 00:31:12.240 Aiken: Well, nursing asks for invitations to go in and have their students looked after by the staff on the units. 00:31:12.240 --> 00:31:32.170 Smith: Yeah, that's right. Or they look for a place for the students to practice and there are contracts of a student practice. Now, that was one of the things that made me very controversial in the very beginning. And this still exists, right? I don't get out too much to go around but it still exists, right? 00:31:32.170 --> 00:31:33.920 Aiken: Oh, yes, it certainly does. 00:31:33.920 --> 00:31:57.390 Smith: And it's, you see we did away with the apprenticeship method because we thought it wasn't academically sound. Now, there are dangers in the apprenticeship system but I know of no way for an art, which is what nursing is, to be learned unless it's some kind of apprenticeship. 00:31:57.390 --> 00:32:08.020 Actually, you've got your doctoral degree. Wasn't that an apprenticeship? Didn't you work under a faculty adviser whom you had-- 00:32:08.020 --> 00:32:09.420 Aiken: Very much so. 00:32:09.420 --> 00:32:10.240 Smith: Isn't that an apprenticeship? 00:32:10.240 --> 00:32:11.440 Aiken: Yes, it certainly was. 00:32:11.440 --> 00:32:31.070 Smith: Now it has dangers, as I know. But I don't know how else to do it in nursing while apprenticeship was seen as a vocational kind of thing. They threw out the baby with a bath tub or the bath tub or whatever. So... 00:32:31.070 --> 00:32:55.440 Aiken: Well, of course, one of the major stumbling blocks to developing this kind of system is that one must take on the responsibility and be accountable for patients who are there 24 hours a day. Now that certainly changes, the character of one's academic life and how you spend your time and that kind of thing. How did you handle that at the University of Florida? 00:32:55.440 --> 00:33:25.020 Smith: Well, we were very fortunate in getting together a group of faculty members who, by and large wanted to try this way. They believed that it ain't enough to want to try. We had a new hospital, small. We had very few specialists in medicine. 00:33:25.020 --> 00:34:01.200 We're kind of like a family and we had only 25 students in our beginning classes, able to get enough faculty who didn't get paid very well but enough faculty to do this kind of thing. The first nurses that we employed in the hospital by chance or by persuasion believed in it. We did away with supervisors per se as we did away with floats, we never had floats. 00:34:01.200 --> 00:34:29.560 We did away with head nurses per se and so we had a clinical hierarchy rather than an administrative hierarchy. And I'm a very good delegator. And I couldn't have done what I did if I wasn't. And what we did was to make the section, the other thing we did which was controversial, incidentally. 00:34:29.560 --> 00:35:02.920 We maintained the same old titles, like medical and surgical nursing, obstetrics, maternity, whatever, psychiatric nursing. At a time when people were beginning to talk about integration and moving away from the medical model, our thinking was--first of all, you cannot integrate anything if you don't have facts, you can't integrate curriculum, people integrate things in their heads but you can't integrate materials. 00:35:02.920 --> 00:35:35.390 But we decided to keep the same old names because of our practice value, a value on practice. If you were in a second year section or a growth and development section or a man section or a sickness section or a wellness section, where would you find the people to practice with and most important also, where would you find the doctors to collaborate with? 00:35:35.390 --> 00:35:36.450 Aiken: Yes. 00:35:36.450 --> 00:36:00.880 Smith: We believed thoroughly in physician-nurse collaboration. And if you are in a second year curriculum, you know, and you don't have a specialty, where are you going to find the man to collaborate with to work with patients, because we wanted our students to see collaborative patient care and collaborative research. 00:36:00.880 --> 00:36:23.260 Eventually, we never really got research off the ground, although we were beginning to. And so, we kept the same old titles because that's--because of our values. And as I said, everybody else was trying to move away from the medical model and using all kinds of euphemisms to do something or other. 00:36:23.260 --> 00:36:40.780 Aiken: Let me see if I can from my memory, take off a few things that I remember about Florida and see if those were conscious decisions on your part to try to deal with this overwhelming clinical responsibility that you took on. You decentralized the nursing service organizations, I know that. 00:36:40.780 --> 00:36:41.890 Smith: Right. 00:36:41.890 --> 00:36:43.760 Aiken: Clinical units were autonomous. 00:36:43.760 --> 00:36:44.790 Smith: Right. 00:36:44.790 --> 00:36:47.580 Aiken: And the nurses on those units took responsibility. 00:36:47.580 --> 00:37:07.550 Smith: Right. We had--I should--we should say right here, that we set up our units. The medical college delegated responsibility and authority to its resident. We delegated it to a nurse who happened to be called a Nurse-3. 00:37:07.550 --> 00:37:33.220 And hospital administration delegated to a unit manager 'cause of the things we definitely did was to get non-nursing duties away from nurses, so they could begin to practice as professional nursing which we hadn't completely worked out as much as we do today. And so, it was a triumvirate which organizationally, I guess, is not supposed to work. 00:37:33.220 --> 00:38:02.040 Actually, it did work except that hospital administration never would delegate authority to its unit manager. Why, I don't know. But medicine and nursing did. But hospital administration gave the responsibility but never gave the authority to the unit manager. So that this was a flaw and it did make for problems. 00:38:02.040 --> 00:38:26.170 Aiken: As I remember how the unit manager system worked, many of the traditional head nurse responsibilities were really assumed by the unit managers in terms of schedule, even the scheduling of the nurses which I remember was quite a big deal at the time whether a non-nurse could actually schedule all the nurses and things like that. 00:38:26.170 --> 00:38:41.770 Smith: The unit manager system was thought about and decided before the hospital opened. And, in other words, it wasn't something that was put in afterwards. This was one of the things that--this was another condition, really. 00:38:41.770 --> 00:38:56.560 And it had been tried in a couple of places, but it never worked and the reason we felt that it might not have worked was because it was put under nursing service rather than under hospital administration. Now, hospital administration didn't really want it. 00:38:56.560 --> 00:39:25.370 They were used to having nurses do all their work for them and they weren't sure they could get unit managers to do this kind of thing. And we had problems putting the unit manager system in because there were nurses who--they were so used to calling up the drug room or calling central supply or going to central supply or spending hours making out time slips, that they weren't sure what they were going to do, if they didn't do these things. 00:39:25.370 --> 00:39:31.020 They knew how to do these things but they weren't sure they could do whatever else it was that we were going to ask them to do. 00:39:31.020 --> 00:39:57.080 But we did get it working and except for the flaw of hospital administration, never really giving the authority to unit managers, which in later years meant that nurses were beginning to take more responsibility for this again because if a doctor went to the unit manager, the unit manager said I'm sorry I can't handle that, and the doctor would go to the nurse and she'd take it over and you were right back where you started from. 00:39:57.080 --> 00:40:32.290 Why hospital administration? We were trying--in a sense, we were trying to--it sounds presumptuous I guess, but we were trying to liberate hospital administration, too. And we were trying to get them to run a hospital and not be under the control of physicians or nurses that their job was different than nursing or medicine. And we all had to work together, but they seemed to be scared to death of doctors and that's the problem-- 00:40:32.290 --> 00:40:33.850 Aiken: Do you think that was-- 00:40:33.850 --> 00:40:35.840 Smith: Hospital administrators were a problem. 00:40:35.840 --> 00:40:47.830 Right. Well, hospital, the evolution of the discipline of hospital administration has been somewhat like the evolution of nursing and that's come a long way and the responsibilities have changed tremendously. 00:40:47.830 --> 00:41:08.520 And as I remember back in the mid '50s, the number of serious graduate programs in hospital administration were reasonably limited and I would assume that would be very difficult to get hospital administrators that could deal with a broad-based interdisciplinary concept like that. 00:41:08.520 --> 00:41:31.360 Smith: We had some well-prepared ones and we had some who started out fine. But they could not seem--they were more comfortable with, I guess you'd have to call it power coalitions. 00:41:31.360 --> 00:41:32.670 Aiken: Uh-hmm. 00:41:32.670 --> 00:42:00.320 Smith: I guess there had been some writings about the hospital administrator-nurse coalition or the hospital administrator-doctor coalition. Couldn't seem to work in a really interdisciplinary, what you call collegial relationship. And, 'cause doctors don't either very well and nurses don't, but they, it seemed to be, it seemed to be fearful, hospital administrators. 00:42:00.320 --> 00:42:17.760 And also, they had problems with running a hospital under the state system of supplies and whatnot. They had problems, I'll admit that. But that's--they ran scared. 00:42:17.760 --> 00:42:28.480 Aiken: Well, we've talked about the fact that you've decentralized this system that you implemented the unit manager system to try to free the nurse to nurse. 00:42:28.480 --> 00:42:49.760 The third big thing that I see that sort of was the glue to this whole thing was that you launched a huge developmental effort in the area of nursing assessment to try and make visible the contributions of nurses and to make it on a level on which collaboration could exist. Could you talk for a while about that? 00:42:49.760 --> 00:43:20.510 Smith: Well, what we did, that was another goal, was we developed a new technology, that's really what it is. We felt that, you know, if you're going to take non-nursing duties away from nursing and if there's anything that's really intellectual about nursing, then there has to be some kind of cognitive technology that necessitates all this education. 00:43:20.510 --> 00:43:30.760 If we don't have this, then we shouldn't have a baccalaureate program because you could teach people how to give shots and make beds and run machines anyway. 00:43:30.760 --> 00:44:02.960 But if you really need an underpinning of science, then there has to be some technology to demonstrate this. And McManus had said years ago that--and other people had said it too-- that nursing, clinical nursing is the same as medicine, except in that we assess, collect data, get problems, learn how to deal with the problems. Deal with them or not deal with them. 00:44:02.960 --> 00:44:45.640 And, this is a clinical process and it's basically cognitive although you do use techniques, manual techniques of one kind or another to get the data or to do the handling of the problem. Now, this, everybody would agree with this, essentially. But most nurses, we cannot still to this day get any agreement on what the database is. And nursing by and large has been more interested in pathology and disease than in the person. 00:44:45.640 --> 00:45:16.760 And my concept of care is person-oriented, not disease-oriented, not pathology-oriented, back to that primary relationship I was talking about. And so the database that we developed which took, you know, eight or nine years with everybody, you're fooled with it 'cause New York works with them. It took about eight or nine years and we tried all kinds of forms and finally we got one. 00:45:16.760 --> 00:45:47.470 Then right along about this time, the Weed's Problem-Oriented System for medicine came out. And medicine wasn't paying any attention to it. But we sort of latched on to it 'cause we thought it had some relevance for nursing. And so, we did develop a new technology which consists of a database, a problem list, progress notes, et cetera, the clinical process. 00:45:47.470 --> 00:46:23.840 Now, this--after we did this, then other people began developing other kinds of databases and it's our feeling that until nursing settles on one database, whether it's ours or somebody else's, then we're not going to get anywhere as far as teaching and research is concerned. Medicine has one database. If you're a specialist, you may get additional information or you may exclude certain parts of the history in physical, right? 00:46:23.840 --> 00:46:56.590 But essentially, they have one database. Medicine doesn't talk about a theoretical frame of reference or conceptual model or whatnot, unless, they're doing research on some pathology. But their clinical process is known and it's taken for granted and their teaching is around it. Now, they have conceptual frame of references for causes of disease but not for a curriculum. I don't understand all this that's going on in nursing right now. 00:46:56.590 --> 00:47:12.060 Aiken: Would it be fair to say that there are really two purposes of your nursing assessment methodology, one would be the patient care aspects, really to guide patient care in turn for the quality of nursing care. And the second would be to provide a base for research, clinical research. 00:47:12.060 --> 00:47:32.220 Smith: Right, right. I don't see how, without some kind of data that has a meaning on a chart, I don't see how we're ever going to do any research. You can't do research on patients slept well, ate well, anxious, cheerful, whatever, you know, you've seen what's on charts. You cannot do that kind of research. 00:47:32.220 --> 00:47:48.730 The other point I want to make is that unless nursing does have a database that's different than medicine, then it has no reason for being and might just as well be taught in medical schools as technicians or whatever. 00:47:48.730 --> 00:48:13.950 See, I think a team concept implies people on that team who operate from different frames of reference and look at phenomena from different standpoints. When I work with a physician, we may look at the same phenomena, the same lab report, the same symptom, but we'll look at it, he looked at nausea for example. 00:48:13.950 --> 00:48:37.260 Well, I wonder what's causing this. I look at it, I wonder how I can make this person work comfortable during this horrible symptom. Now, that doesn't mean that I am not also interested in what caused it and it doesn't mean that he is not interested in how she feels, but our operations are different because our primary concerns are different, do you see? 00:48:37.260 --> 00:49:10.710 It's really a different value system and a different frame of reference. And, now, the thing is, how to get--and patients know this. But how to get nurses to see that making a patient more comfortable who was nauseated is as exciting and fulfilling and worthwhile and respectable and intellectual as finding out what caused the disease. And that's, I don't know if we'll ever make it. 00:49:10.710 --> 00:49:26.620 Aiken: Would you characterize your work in developing this new technology for assessment, one of your most important contributions? If I asked you what you thought was most important in your career in terms of your contributions with lasting effect? 00:49:26.620 --> 00:49:28.210 Smith: Raising my data. 00:49:28.210 --> 00:49:31.660 Aiken: Okay, second. [Laughter] 00:49:31.660 --> 00:49:56.000 Smith: Second, I have to say that my--even though I would never get credit for it and I will never be completely known, most satisfying to me, next to Bobbie Ann, is in this order, are the patients whom I've helped and the students whom I've helped. 00:49:56.000 --> 00:50:21.160 And the fourth thing is my technology which will--but you see I think the others live on to, you know, you live on, Bobbie Ann lives on, the patients, they may never even know they owe me anything. But that doesn't matter. To me, those are the exciting things and those are the things I remember as far as a memorial, you know, maybe the technology. 00:50:21.160 --> 00:50:26.530 Aiken: Now, there are other institutions in the country that have tried to do what you did-- 00:50:26.530 --> 00:50:28.130 Smith: I know, I know, I know. 00:50:28.130 --> 00:50:40.470 Aiken: Now, do you, can you see the link there at least three programs that I know, Rochester, Case Western Reserve, and Rush. We have all tried to take responsibility for service. And... 00:50:40.470 --> 00:50:44.090 Smith: I know, um... 00:50:44.090 --> 00:51:19.800 Until, there are some people who say that until you--and maybe this is true. For example, Marion McKenna of Kentucky I think would be interested in doing this but maybe if we could begin to pay nursing faculty for their care of patients the way medical faculty are paid to some extent, then maybe that would do it. 00:51:19.800 --> 00:51:58.680 I don't see with the present...it may go, I hope so but I just think that today, there just aren't enough people who are fascinated as I'm fascinated. For example, again, the very problem of why people get sick. We don't know anything really about the multiple causes that make people get sick or make them get well, or make them have complications. 00:51:58.680 --> 00:52:26.740 Now, I just don't see enough people, faculty who are interested enough in these things to make it exciting to students to want to go into it for a career. And the pay is not that good and people--see, I never had anything. I was poor to start with so, you know, money--but that's not--that's again that's kind of a kooky attitude. 00:52:26.740 --> 00:52:54.540 I always feel like well, somebody will give it to me, or I'll get it sooner or later. Economics, social prestige, doctorates in other fields, for example. Once you get a doctorate in another field, you've worked hard for that. That's a point of view, it's very hard to go back. I don't mean you personally, but it's very hard for a person who gets a doctorate in something and worked and slaved for it. 00:52:54.540 --> 00:53:21.740 To then take away that point of view and go back and get another point of view. Whether the doctorates in nursing are going to do it or not. I don't know. I'm not very optimistic. I think people will be talking about it for a long time. But, and I think they could learn a great deal from our program and the things that happen which they might be able to prevent. I don't know how committed they are, if it's just a...I don't know. 00:53:21.740 --> 00:53:27.150 Aiken: Well, in some ways, this is a problem across all of the professional disciplines-- 00:53:27.150 --> 00:53:28.080 Smith: I guess, yeah. 00:53:28.080 --> 00:53:34.820 Aiken: --in terms of the rewards systems of universities which some people would argue have become more rigid as time has gone on, in terms of... 00:53:34.820 --> 00:53:35.620 Smith: Their views. 00:53:35.620 --> 00:53:55.260 Aiken: having to have certain academic credentials and having to publish a certain number of papers a year and in addition to teaching loads. And, I think many nursing faculty are sort of buckling under the load of that and trying to decide. If you have a certain reward system, how can you take time out for a clinical practice when that's not a part of it? 00:53:55.260 --> 00:54:14.640 But in terms of direct payment if the, you know, I take you at face value on that, I know there are nursing schools that are trying to develop faculty payment plans where nurses are reimbursed, either the school or nurses directly, for at least a certain proportion of the clinical practice revenues-- 00:54:14.640 --> 00:54:26.420 Smith: That I think would help. I think limiting the number of students, I think most programs take far too many students to do this kind of thing. You definitely would have to limit the number of students. 00:54:26.420 --> 00:54:40.770 There are some programs that never should have schools because they do not have access to hospitals where there are good physicians or good care programs. You know, I'm not saying that just because they're in the boondocks means they are not any good. 00:54:40.770 --> 00:55:09.330 But I really think that by and large, with all of its faults, the best place for a baccalaureate program is where there is a medical school in a teaching hospital, and physical therapy and occupational therapy. That's doesn't mean there aren't problems, you know, the problems we had. But I can't see, at a baccalaureate degree someplace where they have no access really to anybody to work with. Did you see what I'm getting at? 00:55:09.330 --> 00:55:10.210 Aiken: Yes. 00:55:10.210 --> 00:55:19.410 Smith: Those programs should be at an AA level--type, I don't mean level, I don't like that word but an AA-type program. 00:55:19.410 --> 00:55:40.370 Aiken: One of the fascinating things to me is that 1956, you were trying to put together an education service program that today seems still be on the cutting edge. You are bound to be 20 years before your time and you are bound to have felt a certain number of frustrations because of that. 00:55:40.370 --> 00:55:48.100 Do you get positive feelings from knowing that you were that far ahead or do you have a frustrated feeling? 00:55:48.100 --> 00:56:13.100 Smith: No, I didn't have any positive feelings for being that far ahead. But, and I certainly had frustrations while at the university because there were all kinds of problems but I don't...I feel very good about what we tried to do because we did what we believed in. 00:56:13.100 --> 00:56:39.230 And I think if you do what you believe in, you're going to take ups and downs and we did. And I think we've turned out some great people and we made an impression, you know, regardless of whether... they can't discount this historical fact that it did work for a while. 00:56:39.230 --> 00:56:43.630 Aiken: Well, let me just see if I can sum up and it's very difficult to sum up the computation-- 00:56:43.630 --> 00:56:49.250 Smith: How do you--incidentally, how do you feel about having graduated from this kooky program? 00:56:49.250 --> 00:57:07.500 Aiken: Well, it's made me an oddball, all of my professional career. And it's made no other place quite as good as the University of Florida was, but on the other hand it always gave me a vision of what nursing could be in which I have continued to strive for as I think my classmates have. 00:57:07.500 --> 00:57:32.870 Smith: Yeah, yeah. Well, a psychiatrist once told us that we were bound to turn out frustrated students because when they got out and saw, you know, that everything wasn't the way we wanted it to be and I said, "Well, that was just too bad." I felt it was better to tell people what was possible, rather than them never knowing what was possible. But-- 00:57:32.870 --> 00:57:49.190 Aiken: Well Dorothy, you've been a clinician, a role model for all of us. I would agree with you that maybe one of the most lasting things that you've done is, that you've touched the lives of a series of students who are now out there and trying to implement some of the ideas that you tried. 00:57:49.190 --> 00:58:05.300 And, this has been a very exciting afternoon for me to have a chance to get back and talk about old times and I think you're certainly a person that will always live in my mind as being one of the real pillars of nursing and in many other people's. 00:58:05.300 --> 00:58:10.670 Smith: Well, thank you very much. I haven't forgotten you. 00:58:10.670 --> 00:58:17.070 [Music playing over image of smallish mid-century ranch home with trees in front yard and water pooled on driveway.] 00:58:17.070 --> 00:58:24.060 [Distinguished Leaders in Nursing] 00:58:24.060 --> 00:58:32.410 [Dorothy M. Smith, R.N., Dean Emeritus, College of Nursing, University of Florida, April 1979] 00:58:32.410 --> 00:58:39.740 [Interviewed by Linda H. Aiken, Director of Research, Robert Wood Johnson Foundation] 00:58:39.740 --> 00:58:46.130 [A National Medical Audiovisual Center Production] 00:58:46.130 --> 00:58:56.670 [in cooperation with Sigma Theta Tau, National Honor Society of Nursing] 00:58:56.670 --> 01:00:18.150 [Distinguished Leaders in Nursing]