CHAPTER XXI
The Neuropsychiatric Nurse
Lieutenant Colonel Charlotte R. Rodeman, ANC, USA (Ret.)
GENERAL CONSIDERATIONS
The history of psychiatric nursing in World War II is brilliant in some specific achievements but totally inadequate as viewed from the total picture. It was brilliant in spots because of the concentrated earnest endeavors of a relatively small number of people who recognized the need for such specialized nursing and overcame great obstacles in attempting to provide it. The total picture was inadequate however, in part because of the cumbersomeness of War Department machinery in quickly establishing necessary facilities and in part because of the apparent failure on the part of all concerned to recognize the need for specially trained nurses in this field if a good job in psychiatry was to be accomplished. A factor of no small importance was the shortage of nurses in the first two years of war.1
In World War I, neuropsychiatric personnel including nurses and attendants were assigned directly from the draft,2 but no such arrangements were made in World War II. In fact, there was great difficulty in retaining trained psychiatric nurses and attendants in neuropsychiatric work.3 Most nurses were rotated through the different services of a hospital. It appeared that surgical services were usually more successful in keeping trained surgical or operating-room nurses permanently assigned than the neuropsychiatric services.
Between July 1940 and August 1945, 65,371 nurses were commissioned in the ANC (Army Nurse Corps),4 with a maximum of 57,285 on duty as
1Menninger, William C.: Education and Training in Neuropsychiatry. [Original Manuscript.]
2The draft refers only to male attendants and male nurses who were not eligible for appointment in the Army Nurse Corps. The Medical Department made a conscientious effort to recruit nurses qualified in neuropsychiatric nursing and attempted to identify such qualified nurses in the Corps for appropriate assignment. See Medical Department of the United States Army in the World War. Neuropsychiatry. Washington: U.S. Government Printing Office, 1929, vol. X, pp. 27-29.-A. L. A.3Menninger, William C.: Psychiatry in a Troubled World: Yesterday's War and Today's Challenge. New York: The Macmillan Co., 1948, p. 341.
4It is of interest to know that the Army Nurse Corps was authorized by statute in 1901, but that its members had neither officer nor enlisted status in its beginning. In a reorganization of 1920, nurses were given the relative rank of officers from second lieutenant to major. In March 1942, the Superintendent and the Assistant Superintendent were commissioned in the AUS (Army of the United States) as colonel and lieutenant colonel, respectively. In December 1942, the relative rank for the corps as a whole was extended through colonel and the pay of grade authorized. It was not until June 1944, however, that Army nurses were commissioned as officers, AUS, for the duration of the war, plus 6 months. The commissions became permanent in 1947. Graduate male nurses, who are most useful on psychiatric services with predominantly male patients, were not commissioned in the Army Nurse Corps until 1955.-R. J. B.
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of V-J Day (2 Sept. 1945).5 Few States at that time listed psychiatric nursing experience as a prerequisite for licensure as a nurse.6 A study of over 75,000 nurses who entered the Army and Navy Nurse Corps during the war showed that only 16 percent 'had had any undergraduate training in psychiatry in their home school or through affiliation' and only '0.7 percent * * * had had any postgraduate work in psychiatry.'7
Most nurses 'who entered the Army after September 1940 knew little about the administration of Army hospitals.'8 Likewise, the nurses with Army administrative experience, who were assigned as chief nurses, had had little or no experience with hospital neuropsychiatric sections and services that developed so quickly.
Before World War II, there had been little need for trained psychiatric nurses in the Army. Patients who were psychiatrically ill were kept in Army hospitals only until arrangements were made for them to be sent either to St. Elizabeths Hospital in Washington, D.C., or to such other Federal institutions which could provide long-term custodial care or treatment.9 With the declaration of a national emergency before the outbreak of war, new hospitals were rapidly built on military posts to provide care for the large number of men being drafted into the Army. The typical hospital had closed neuropsychiatric wards designed to give maximum security. The nurses' office was separated from the patient area by a heavy iron grillwork door that was locked when not in use. Open wards were similar to those used for other clinical services. Space and facilities for anything but custodial care were limited in both types of wards. Many chief nurses questioned the need for nurses for patients who were neither physically ill nor confined to bed. The nurse, nominally assigned to psychiatric wards, often actually served much of the time on medical or surgical wards and visited the psychiatric wards to prepare reports and perform other ward administration tasks. In some hospitals, she spent little time in patient areas, especially in the locked-ward section.
This lack of recognition of psychiatric nursing as a clinical nursing specialty resulted in psychiatric patients being under the care of nurses with varying backgrounds; some nurses were well qualified by both education and experience while others had no training and experience in this branch of nursing and also had no desire to work in this field. Well-qualified psychiatric nurses might be assigned to hospitals with no psychiatric wards, while hospitals designated to have neuropsychiatric sections
5Information from Nursing Division, Surgeon General's Office, 1 May 1946. (Personnel Division, Adjutant General's Office, reported 54,128 as total ANC strength.)
6Fitzsimons, L. W.: Facts and Trends in Psychiatric Nursing. Am. J. Nursing 44: 732-735, August 1944.
7Menninger, 'Psychiatry in a Troubled World,' op. cit., pp. 118-119.
8Smith, Clarence McKittrick: The Medical Department: Hospitalization and Evacuation, Zone of Interior. United States Army in World War II. The Technical Services. Washington: U.S. Government Printing Office, 1956, p. 32.9This is a common misconception. In actuality, after World War I, psychiatric sections of the medical services existed in all large Army hospitals where definitive treatment was performed. See chapter I, pages 8-9.-A. J. G.
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might have few or no nurses qualified to care for psychiatric patients (p. 305).10
There had been no special training in the Army for psychiatric nurses before World War II, and no plans for developing such training were in progress at the beginning of this war. Although programs for training were established and carried out in various hospitals during the war, they were hampered by the inability to get War Department approval for an Army-wide school. This situation existed despite the efforts of both the Nursing Division and the Neuropsychiatry Consultants Division of the SGO (Surgeon General's Office). Like most of the developments in psychiatry in World War II, each progressive step was painfully made and only after tedious educational efforts toward those in authority who had no background in this specialty. That the Nursing and Neuropsychiatry Consultants Division regarded the development of psychiatric nurses essential did not appear to be sufficient reason for approving a formal school. Some of the obstacles were in the Surgeon General's Office; many more were at higher echelons.
INSERVICE TRAINING
Unsuccessful Attempts to Establish Formal Courses
Soon after the School of Military Neuropsychiatry was established at Lawson General Hospital, Ga., in December 1942 (p. 43), courses in neuropsychiatric nursing were also planned. A neuropsychiatric nurse was assigned as instructor and the course was outlined. During the next 10 months that the school remained at Lawson General Hospital, the neuropsychiatric nursing course never materialized. The reasons given were the shortage of nurses and the reluctance of hospital commanders to permit nurses to attend the course, as it was believed that they could not be spared from what were considered more pressing nursing activities.
During the latter part of 1943, Col. Florence A. Blanchfield, Superintendent, Army Nurse Corps, prepared extensive plans for courses in psychiatric nursing in several Army hospitals. For reasons unknown, these plans were not concurred with by the Training Division of the Surgeon General's Office.11 Although the Neuropsychiatry Consultants Division
10Shortly before Pearl Harbor, the Superintendent of the Army Nurse Corps requested that the names of nurses qualified in neuropsychiatric nursing be sent to the Surgeon General's Office (see example letter, Maj. Julia O. Flikke, ANC, Superintendent, to Capt. Ida W. Danielson, ANC, Headquarters, Sixth Corps Area, 28 Nov. 1941). Early in 1943, War Department directive (WD Circular No. 34, 1 Feb. 1943) stated that nurses with psychiatric training and experience should be assigned to such work 'as far as the exigencies of the service will permit.' The Surgeon General notified service command surgeons to maintain a current list of all nurses so qualified (Letter, Maj. Gen. James C. Magee, The Surgeon General, to Commanding General, Headquarters, Seventh Service Command, 20 Mar. 1943, subject: Army Nurse Corps) in an effort to insure their assignment where they were most needed.-A. L. A.
11In Technical Manual 12-406, 'Officer Classification, Commissioned and Warrant,' 30 October 1943, psychiatric nursing was recognized as a specialized field of nursing and coded as MOS (Military Occupational Specialty) 3437, In describing the requirements for awarding this MOS, TM 12-406 stated that nursing experience in a neuropsychiatric ward was essential. It strongly recommended postgraduate training in psychiatric nursing but did not make such training mandatory.-A. L. A.
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concurred in the plans, little real effort was made to implement the training of neuropsychiatric nurses, probably because of the untimely death of the director (Col. Roy D. Halloran) and the subsequent change in the directorship of that division.
In October 1943, the School of Military Neuropsychiatry was moved to Mason General Hospital, Brentwood, Long Island, N.Y. Again, plans were made to conduct a postgraduate course for nurses at this hospital. This was finally accomplished in February 1944, but approval to make this an official ASF (Army Service Forces) school was never granted. Nurses assigned to Mason General Hospital were to be given 'such didactic instructions as may be feasible with their duty assignment.' It was presumed that there would be enough nurses in the hospital so that a limited number would be allowed time off the wards to attend classes; also, the Second Service Command had authorized an overstrength of 10 nurses. However, many hospitals, again, had such heavy workloads that nurses could not be spared to attend the course unless replacements were furnished.
Local Programs
On 5 April 1944, Lt. Col. Ruth I. Taylor, ANC, Headquarters, First Service Command, received information that a course in neuropsychiatric nursing had been started at the Station Hospital, Camp Edwards, Boston, Mass., on 3 April 1944. There are no data available concerning the authorization of the course or why and by whom it was initiated.
On 3 June 1944, in a letter to The Surgeon General, Colonel Taylor stated that the first course in neuropsychiatric nursing would be completed on 30 June 1944 and that 15 nurses would complete the course. Further, that because of the reduced number of patients at Camp Edwards the school would be transferred to Cushing General Hospital, Framingham, Mass., on 1 July 1944. Colonel Taylor recommended that three full-time nursing instructors be assigned to the school at Cushing General Hospital and that the school be approved by The Surgeon General so that an authorized certificate could be presented upon satisfactory completion of the course.
In reply to Colonel Taylor, on 16 June 1944, The Surgeon General concurred with the establishment of a school in the First Service Command at any locality deemed advisable. The Surgeon General, however, did 'not deem it advisable to authorize or approve a neuropsychiatric nursing school.' While The Surgeon General did not object to the issuance of a certificate of completion, he advised that a local certificate be used since the 'Certificate of Proficiency, Various Courses, Special Schools, U.S. Army' (MD Form 60e) was not to be used for local courses.
In December 1943, authority was given to provide a 3 month affiliation in neuropsychiatric nursing at Fitzsimons General Hospital, Denver, Colo., for student nurses from St. Joseph's Hospital School of Nursing in
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Denver. In May 1944, Army and cadet12 nurses were also accepted in the course as students. In June, The Surgeon General authorized official recognition for the course by issuing a certificate to ANC officer graduates.
Service Commands Establish Formal Training
In the fall of 1944, because of continued failure to obtain Army-wide approval for a postgraduate course, all service commands were encouraged to establish their own schools for neuropsychiatric nurse training. By the summer of 1945, each service command had developed such a course for its nurses.
As previously stated, the First Service Command had opened a school at Cushing General Hospital, on 1 July 1944. A total of 10 courses of 3 months' duration was given until the school closed on 8 January 1946. The course included 42 hours in psychiatry, 6 hours in neurology, 6 hours in psychology, and 64 hours in psychiatric nursing lectures, in addition to 5 to 8 hours daily of supervised clinical duty. The school graduated a total of 159 nurses. Capt. Hazel Halladay, ANC, conducted the school under the direction of Col. Jackson Thomas, MC, chief of the neuropsychiatric service. Lts. Helen Durkin, ANC, and Muriel White, ANC, were instructors.
After many difficulties, the Second Service Command began a course at Mason General Hospital, on 14 February 1944. Nine courses of 12 weeks' duration were given parallel to the courses in the School of Military Neuropsychiatry. A total of 153 nurses were graduated. Of the nurses assigned to the school, 21 did not complete the course; of these, 9 were duty personnel, assigned to Mason General Hospital, who, because of the needs of the nursing service, had to withdraw from the course; the remaining 12 were ship's duty and assigned to the school only on temporary basis while their ships were in port. The course included 120 hours of classroom instruction and 456 hours of supervised clinical training. Maj. A. Sue Kerley, ANC, served as director of the school along with her responsibility as the chief of nursing service. The course provided unusually rich clinical experience and profited considerably from its associa?tion with the School of Military Neuropsychiatry.
The Third Service Command opened a school on 18 June 1945, at Valley Forge General Hospital, Phoenixville, Pa. The 12-week course was given only once, with 19 ANC officers as students. The program included 135 hours of lecture and demonstration, and the remainder of the time was spent in supervised practice. Lt. Ursula M. Hickey, ANC, was the course director, and Lt. Col. Seymour Rosenberg, MC, was the chief of the neuropsychiatrjc service.
12These were senior students from civilian schools of nursing who elected and were accepted to serve their final 6 months before graduation in Army hospitals. For a discussion of the Cadet Corps Program authorized by Public Law 74, 78th Congress, see The United States Cadet Nurse Corps 1943-1948. PHS Publication No. 38. Washington: U.S. Government Printing Office, 1950.-R. J. B.
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In the Fourth Service Command, a school was established at Kennedy General Hospital, Memphis, Tenn., in April 1945. Three courses were conducted, graduating a total of 44 ANC officers. The students in the first class were nurses assigned to Kennedy General Hospital, while the last class had nurses from nine different hospitals in the Fourth Service Command. The course was directed by Capt. Isabelle Mason, ANC, the supervisor of the neuropsychiatric nursing service, under the direction of the chief of the neuropsychiatric service, Lt. Col. Samuel Paster, MC. The course provided 22 hours in psychiatry, 34 hours in psychiatric nursing, 16 hours in neurology, 14 hours in special therapies, 7 hours of training films, 16 hours of demonstrations, and 3 hours in military regulations and varied clinical training.
The Fifth Service Command school at Darnall General Hospital, Danville, Ky., was unable to accept Army nurses from other hospitals because of the lack of housing facilities. However, a 3-month course for senior cadet nurses was established on 1 March 1945, with 71 cadets attending. Capts. Frances Williams, ANC, and Henrietta Rogers, ANC, made up the teaching staff. A total of 36 hours of lectures was given and the remaining time was spent in clinical practice under supervision.
The Sixth Service Command began a 3-month course on 13 August 1945 at Vaughan General Hospital, Hines, Ill. The course here operated under several handicaps caused by the demobilization at the end of hostilities. The director of the course was changed several times (one being separated from the service), and the students were utilized as ward personnel because of the shortage of nurses at the time. A total of 120 hours of lectures and demonstration was given, with the remaining time spent in providing nursing services. Maj. Helen Gray, ANC, was the first director, followed by Captain Larkin, ANC, then by 2d Lieutenant Larson, ANC. Ten nurses completed the course.
In the Seventh Service Command, a course was begun as an affiliation for students from the St. Joseph's Hospital School of Nursing in Denver, on 1 December 1943, at Fitzsimons General Hospital. During the next 2 years, 8 courses were given of 12 weeks' duration, graduating 82 affiliate students and 29 Army nurses. This course continued to be given for students of St. Joseph's Hospital School of Nursing.
The Eighth Service Command established a course at McCloskey General Hospital, Temple, Tex., on 20 October 1944. Five courses of 3 months' duration were given, graduating a total of 71 students. The course provided 32 hours of didactic instruction in psychiatry, 10 hours in military psychiatric administration, 4 hours on liaison with special services, and 62 hours in psychiatric nursing. The course was given under the direction of Lt. Col. Guy C. Randall, MC, chief of the neuropsychiatric service, and Capt. Madeline Weiss, ANC.
Three schools each of 3 months' duration were organized in the Ninth Service Command. Bushnell General Hospital, Brigham City, Utah, estab?
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lished a course on 1 April 1945, with 27 nurses attending, and a second course with 24 nurses began on 1 July 1945. Dewitt General Hospital, Auburn, Calif., conducted one course beginning on 17 July 1945, and Dibble General Hospital, Menlo Park, Calif., started its one class on 23 July. These two courses each had 24 students. Each hospital had a full-time nursing instructor, and all the courses had the same general plan, with 207 hours of didactic instruction and varied clinical duty. Students were selected from all the hospitals in the Ninth Service Command and, in most cases, returned to their original station upon completion of the course.
A total of 585 nurses and 296 cadet nurses completed these courses in the hospitals in the nine service commands. Considering the many obstacles which were presented in establishing the service command courses, most of them were well conducted, and able instruction was given in view of the knowledge of psychiatric nursing at the time.
Menninger,13 in his summary of the aforementioned courses, made the following recommendations:
1. Recognition of an Army Service Forces level should be obtained not only to give the course dignity and standing, but to insure a record of the nurse's completion of training so that she can and will be subsequently assigned as a psychiatric nurse.
2. The students should be accepted as students and not merely used as additional nursing staff to cover the wards. If the course is to be recognized as such, the nurse should be assigned for no other purpose.
3. The selection methods were faulty. In some instances the nurses had no interest in the course, in others they had enrolled as an escape from a previous situation, perhaps with the hope of a change of scenery. In other instances it certainly was .not clear to the nurses why they should have been chosen to take the course.
4. The facilities and equipment in most instances were quite inadequate including everything from classroom facilities to the library. The course was forced into being a kind of incidental activity to the psychiatric service.
5. The instructress should have definitely outlined position and relationships. Preferably she should be the Chief Nurse of the Psychiatric Service with an assistant to look after the details of running the nursing service.
This author would add the recommendation that a course should be established and conducted in one installation with qualified teaching and supervising personnel so that all students will be provided with the same types of experiences; also, that students should be chosen with regard not only to personality and intelligence but also to sincerity of interest in this important field of nursing.
Postwar Training Authorized
In 1946, the School of Military Neuropsychiatry was moved from Mason General Hospital to Fort Sam Houston, Tex., and became a part of the Medical Field Service School. The psychiatric nursing course was
13See footnote 1, p. 631.
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transferred at the same time and became the only source of training in neuropsychiatric nursing (fig. 53) in the Army; students were drawn from the entire Army Nurse Corps. At first, the course was given partly in conjunction with the course in military neuropsychiatry for medical officers. Army Nurse Corps instructors were assigned and the facilities of Brooke General Hospital were used to provide the students with clinical experience (fig. 54).
This course was 32 weeks long with a capacity of 25 students. The first class started on 17 June 1946 and was graduated in January 1947.14
14This course continued to be given at Brooke Army Medical Center once or twice each year until 1957. The content of the course was changed, as necessary, to keep in step with current philosophy of psychiatric nursing.-C. R. R.
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OVERSEA THEATERS
Information about psychiatric nursing in oversea theaters15 was obtained from quarterly and annual reports of hospitals in oversea theaters and from the author's own experiences. Although reports from all hospitals assigned overseas were not available, it can be assumed that the information obtained was representative. This information indicated
15The service command programs just described were started so late in the war that they provided few nurses for oversea units before the war ended. Although this volume is primarily concerned with neuro?psychiatry in the Zone of Interior, a few examples of psychiatric nursing problems and methods of coping with them are included to underscore the need that existed for an Army-wide program of training and effective utilization.-A. L. A.
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that the type of care given to psychiatric patients depended entirely on the attitudes of administrative personnel in charge of the hospital and on the desire and ability of psychiatric personnel to provide good care.
Pacific Ocean Areas
In SWPA (Southwest Pacific Area), several hospitals were designated as neuropsychiatric hospitals. As this related to qualified nurses, Maj. (later Col.) Pauline Kirby, ANC, Assistant Director of Nursing, SWPA, reported, as follows:16
A Psychiatric Nursing Supervisor was placed on duty in the Office of the Chief Surgeon, Hq [Headquarters], USASOS [U.S. Army Services of Supply]. Her first function was to make a survey of nurses in SWPA to determine the number of nurses psychiatrically trained and experienced, who would be available for assignment to-
(1) Hospitals designated to treat minor psychiatric cases,
(2) Closed wards of general hospitals, or specially designated station hospitals carrying psychotic patients.
Thus, an effort was made to assign qualified nurses where patients with psychiatric disorders were hospitalized. Major Kirby reported that the first hospitals specially designated for treatment of minor psychiatric disorders were the 141st Station Hospital, Mime Bay, and the 148th Station Hospital, Oro Bay, both opened for this purpose in January 1944. In February 1944, nurses selected on the basis of personality, intelligence, psychiatric nursing training, and experience were assigned to these installations. The next hospital to care for minor psychiatric cases was the 18th Station Hospital, which accepted patients on 30 March 1944. Specially selected nurse personnel were also assigned here.
During the establishment of these hospitals, it was the duty of the psychiatric nursing supervisor to supervise nursing activities, confer with the nurses, and make suggestions on how to improve the standards of psychiatric nursing care. During hospital visits, she suggested to the commanding officers of the respective hospitals treating minor psychiatric disorders that the nurses-
1. Be given a course in dynamic psychiatry.
2. Be permitted to attend and participate in case conferences.
3. Meet daily with the ward officers to discuss their patients.
The 18th Station Hospital gave 17 lectures on dynamic psychiatry in May and June 1944 and repeated the course in July and August for the benefit of the nurses assigned to the hospital since the initial course was given. Major Kirby included in the ANC history17 the following outline of a lecture on the role of the nurse in an Army neuropsychiatric hospital which was given in this course:
1. JUST BEING HERE. The 'refreshing effect' of having a woman around.
16History of Psychiatric Nursing in SWPA, 1 January-30 June 1944. [Official record.]
17Ibid.
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2. PLAYING THE MOTHER ROLE. The Army has many father substitutes-few mother substitutes. What it means.
3. AS A RECORDKEEPER Importance of accurate, complete, vivid notes. Future use in evaluating patients' working ability. Usefulness of nurses' notes in getting case-summary. A continued record of patients' day-by-day behavior.
4. AS A SUPERVISOR of certain occupational projects, ward policies, etc.
5. AS AN ADMINISTRATIVE OFFICER.
(a) Recordkeeping
(b) Bed check
(c) Ward management
(d) Administration of the 'Adjustment Index'
6. EDUCATIONAL DUTIES OF THE NURSE.
(a) As a teacher-
(1) of junior nurses
(2) of wardmen
(3) of patients
(b) As a student-
(1) learning from cases and case records
(2) learning from these lectures
(3) learning from informal talks with ward officer
(4) learning from attendance at group therapy assemblies
(5) learning from watching patients at play and work
(6) learning from attendance at case-conference
7. THE NURSE AS AN INTERVIEWER.
8. AS A BEDSIDE NURSE for patients requiring medication, diets, etc. Nursing care in narcosynthesis.
9. AS AN OBSERVER-
(a) of the patient at play
(b) of the patient at rest
(c) of the patient at work
It was also suggested by the psychiatric nursing supervisor that nurses attend the arts and crafts classes held for recreational workers by the American Red Cross and that educational programs for nurses be continuous.
Major Kirby further reported that specially selected nurses were also assigned to the 171st and 233d Station Hospitals, both of which operated sections for the care of minor psychiatric disorders. The 116th, 124th, 108th, and 364th Station Hospitals all had sections for the care of psychotic patients, but no mention of the assignment of trained psychiatric nurses to these hospitals was made.
A quarterly report, dated 1 January-31 March 1944, from the 116th Station Hospital indicated that there were psychiatric nurses assigned, as follows: 'Two psychiatric nurses from this hospital have served in plane evacuations to the Mainland and have reported little difficulty during the trip.'
18The 'adjustment index' was the revision of an earlier 'psychoneurotic inventory' developed by Lt. Col. (later Col.) S. Alan Challman, MC, Neuropsychiatric Consultant for the Southwest Pacific Area, in October 1943. It comprised a set of 74 questions which required a 'yes' or 'no' answer and which permitted the discrimination between simple adult maladjustment and psychoneurotic patients. Nurses could monitor the administration of this questionnaire.-R. J. B.
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A quarterly report of the 51st General Hospital, in Hollandia, dated 1 October-31 December 1944, indicated a fairly adequate neuropsychiatric staff and some training, as follows:
The Neuropsychiatric Service * * * a total of 276 beds * * * we have nine well trained Psychiatric Nurses as permanent personnel and six others on temporary duty.
* * * The nurses are made aware of their part in the overall picture and are instructed
to chart all actions of the patients to be used as an aid in the making of the final diagnosis. Insulin shock therapy is being started and all personnel trained in its use.
A quarterly report, dated 1 April-1 July 1945, of the 60th General Hospital in the Philippines stated that the neuropsychiatric section had a capacity of 68 beds. Since facilities for security wards were not available at this hospital, only cases amenable to open-ward care were accepted for admission. Three nurses on the professional staff were under the direction of a well-trained neuropsychiatric nurse.
It was the writer's own experience in this theater to be the only psychiatric nurse assigned to a station hospital (174th). There was never more than one psychiatric ward in this hospital and acute psychotic patients were usually evacuated as soon as possible because facilities were such that proper care of these patients was not feasible. Much of what was done for patients depended on what could be done with native supplies for occupational therapy, such as coconut shells and wood from packing crates. In Milne Bay, the occupational therapy program consisted of planting quite an extensive garden with seeds obtained from Australia, transplanting flowers from the jungle, building tables and shelves for the ward, and painting peanut and dehydrated coffee cans for use as ashtrays and wastebaskets. The recreational program provided mainly for movies, reading, and games in the Red Cross recreation hut.
For a period of 4 months, the writer was assigned to the 118th General Hospital outside of Sydney, Australia. There were two closed and three open wards here, with an adequately trained staff. Treatment consisted of some insulin therapy, narcotherapy, group therapy, hydrotherapy, and occupational and recreational therapy.
The writer was also assigned to a general hospital in New Guinea for a short period of time. The picture here was vastly different. There were very few trained psychiatric nurses, and little was done for patients. The writer was able to get an occupational and physical reconditioning program started on the ward to which she was assigned but there was little interest or enthusiasm shown among the nursing staff, most of whom tended to avoid patient contact, because of lack of experience with and fear of psychiatric patients. Consequently, most of the actual care of closed-ward patients was provided by the enlisted men assigned, most of whom also had little or no experience in psychiatric nursing, The nurses acted in a supervisory capacity, having patient contact only when giving medications.
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That this type of situation existed in other hospitals in this theater is borne out by the following comments from a chief of a psychiatric section of a general hospital in response to a letter of 16 February 1945, from Lt. Col. (later Col.) S. Alan Challman, MC, the Neuropsychiatric Consultant, SWPA:
One phase of the nursing problem can be covered in the following figures. The table of organization calls for 125 nurses and we have available, as of 20 February 1945, 78 nurses of our own. The Nursing Office tells me that they must count on 8 to 10 nurses being out daily because of sickness. Our own Nursing Staff has been augmented by nurses from three separate organizations during our stay here. In short, we must depend on 78 nurses to operate the hospital with assistance when it is available.
There are 58 wards to be operated in addition to the clinics, operating room, nursing administration, etc.
Under these circumstances, the Neuropsychiatric Section runs more smoothly with a minimum of nurses that we can depend on rather than having inexperienced nurses, who are unknown quantities, introduced into the section for varying periods of time which are usually brief. I feel definitely that no nurse should be given responsibility on an NP ward until we know her abilities and she has become familiar with our methods.
Over a period of time, it has been found practical to delegate all possible duties to the enlisted men.
The nurses on the NP Section are not in any real sense psychiatric nurses but act in a supervisory capacity, answer the phone, and take care of the (nursing) ward administration.
This arrangement is far from ideal but again for practical purposes it seems to be the best solution.
* * * * * * *If you recall a discussion that we had early in our stay at APO 923, regarding the nursing problem you will recognize that the present situation contains no new fundamental issues. Our difficulties on the NP Section have not been unique in this hospital, and there has been general dissatisfaction with nursing policies rather than individual nurses. Possibly, it is the Army ideal that any nurse should be able to do any job at any time that has been at the root of the problem. This morning I asked the Nursing Office if they had any directive regarding psychiatric nursing and they never heard of any such document.19 In practice we are considered, as we actually are, a part of the Medical Service and the nursing standards are essentially those of medical nursing of which the NP Section has very little.
It has never been possible to get a charge nurse for the whole NP Section and the nursing service has insisted on administering the wards separately and supervision is carried on by the administrative staff who have, as a whole, a minimum of experience in psychiatric nursing.
In short and again from the practical angle, a minimum is expected of the nurses on the NP Section and the main load is carried by the ward officer and the enlisted men. As far as I know, our nursing problem has never been studied by a nurse with any psychiatric background or experience. The present arrangement has the only advantage that it works most smoothly under existing conditions.
It would be of assistance to know of any authoritative Army regulation defining the expected standards of psychiatric nursing care. It would be of assistance if there was a qualified consultant on psychiatric nursing who could advise us.
19War Department Circular No. 34, issued on 1 February 1943, urged the 'utilization of nurses with psychiatric training.'-R. J. B.
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It was evident from these comments that the psychiatric nursing situation in this organization was most unsatisfactory and that here indeed psychiatric nursing was not considered a specialized branch of nursing. It seemed to the writer, however, that the author of this letter was him?self taking a negative approach, with a defeatist attitude, and might have accomplished more had he made an effort to educate the administrative staff and train the assigned nursing personnel.
European Theater
Reports available from hospitals in the European Theater of Operations, U.S. Army,20 indicated that the functions of the psychiatric nurses depended largely upon the particular situation and the administrative staff of the hospital and that, in some instances, their main function had little to do with neuropsychiatric nursing activities.
The following points out the effort made to train nurses for psychiatric nursing in one hospital which went to England as a balanced general hospital, in January 1944, and was reorganized as a neuropsychiatric hospital shortly after arrival in England: 21
The difficulties encountered in reorganization were tremendously increased by the lack of trained psychiatric nurses. Of the 100 nurses originally in the organization, only one had a Neuropsychiatric Post Graduate Course, and only three had 3 months' affiliation in Neuropsychiatric Nursing while in training. The remainder had little or no previous experience or training. Classes were immediately started in Neuropsychiatric Nursing, and an intensive course was outlined and begun, in which was embodied not only those subjects immediately necessary to the successful operation of the hospital, but the presentation of each lecture was interwoven with an uplifting morale interspersion. The Table of Organization covering that of a balanced general hospital differed from that of a Neuropsychiatric Hospital, as far as the Army Nurse Corps is concerned, in that it required our transferring twenty-six nurses. Today the 96th General Hospital (NP) is staffed with fully capable and efficient Neuropsychiatric Nurses.
That the administrative personnel in this hospital made every effort to train nurses to give efficient care is further indicated by the following section of this 1944 report:
A plan was evolved whereby the nurses are rotated through each of the three sections, making highly specialized branches of nursing interesting to them, and making them familiar with the function and management peculiar to each section. A great deal of interest was thus created and the shortcomings in experience and training which existed at first have now entirely disappeared. A goodly portion of the nurses are now voicing a preference for a particular phase in Neuropsychiatric Nursing. The Nursing Staff has acquired a maturity of judgment in the handling of neuropsychiatric problems that is more than ordinary, in view of the time the organi?
20For a discussion of a neuropsychiatric training program for Medical Department personnel, including nurses, before the cross-channel invasion of Europe, see Medical Department, United States Army. Internal Medicine in World War II. Volume I. Activities of Medical Consultants. Washington: U.S. Government Printing Office, 1961, pp. 366-372.-A. L. A.
21Annual Report, 96th General Hospital (NP), for 1944.
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zation has been functioning. The administrative problems concomitant with the operation of this type of hospital have been solved in a very satisfactory manner.
Further comment on nursing in this hospital was taken from an interview with Maj. Alexander T. Ross, MC, on 26 July 1945. Major Ross had joined the unit in February 1944 as chief of the neurology service. He stated:
So many of the nurses came over as nurses of an ordinary general hospital. Very few of them had had any psychiatric experience, so it was therefore necessary to institute a course in psychiatric nurse training. This was handled by the psychiatric service and almost all of it was under the supervision of Major [William] Needles [MC]. Training helped them a great deal in understanding the handling of the psychiatric cases. They received much more insight into these cases and a little better understanding of what was wrong with them and how to treat them by this training.
The Annual Report for 1944, of the 36th General Hospital, stated, as follows:
In the neuropsychiatric service the principal consideration has been a physical set up that would assure security to the extremely disturbed patients. Throughout the department, hazards have been eliminated by the engineers and the ingenuity of the ward technicians. The artistic talents of the patients have been employed to decorate the walls of the combined dining room and recreation room with an assortment of cartoons, scenery and household pets.
Neuropsychiatric procedures used have included therapeutic shock by means of a French electro-shock machine, spinal punctures, encephalogram, narcotherapy, narcoanalysis and hydrotherapy. The Wechsler-Bellevue psychometric tests are given by the nurses to many open as well as closed ward patients. The results of these tests aid the doctor in confirming diagnosis. The test not only gives the patient's intelligence quotient, but also the psychological and emotional deviation of the behavior pattern.
It is interesting to note that in this report nurses are only mentioned in the giving of intelligence tests. It would seem that nurses here were primarily occupied with activities that are the concern of psychology. It is reasonable to assume that there were no psychologists assigned here but it is also reasonable to assume that it would be more practical to train one or more enlisted men to administer these tests and permit the nurses to concentrate on nursing activities.
The history of the 30th General Hospital, Belgium, for the period from 1 January to 30 June 1945 indicated that nurses here were also utilized primarily in other than nursing activities:
The nurses in the department did a very fine job in interviewing patients before they were examined by the psychiatrists. Using the NP form designed by Colonel Garrard, they eliminated unimportant information, saving the doctors a good bit of time. Miss Brooks (who replaced Miss Fenney) did most of the intelligence testing in cases where such examinations were necessary. Miss Pardee replaced Miss Isler when the latter went back to the States. Both nurses manifested a fine interest in the work and in psychiatry in general, performing admirably in routine nursing and in some aspects of psychotherapy.
Here again the only activities which were not made specific were 'routine nursing,' which may or may not mean actual psychiatric nursing.
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However, 'some aspects of psychotherapy' might have included so-called nursing therapy, an integral part of psychiatric nursing.
Mediterranean TheaterThe Annual Report for 1944, of the 51st Station Hospital in the Mediterranean Theater of Operations, U.S. Army, described its experience with neuropsychiatric nursing, as follows:22
* * * 1 January 1944, the 51st Station Hospital was located in a medical center at Oran, Algeria. It was at this site that the unit was converted to a Psychiatric Hospital. Although only 15 of the nurses had previous Psychiatric training, the remaining 10 nurses cooperated with the Psychiatric Medical Officers who held special classes in order to orient all the nurses. After caring for surgical patients, it was quite a transition to care for patients who appeared physically sound but were mentally unstable.
The 51st Station Hospital assigned nurses in areas other than traditional nursing, as is indicated in the following:
Five nurses were assigned as Recreational Supervisors in addition to their regular type duties. These nurses work in liaison with the Red Cross Social Service Workers. They were with the patients during organized activities, even participating. This has been a big factor in the therapy program. Once a patient's confidence had been won, the nurses played a very important role by securing information that ofttimes the soldier was not inclined to tell the ward officer. This information often helped the doctor make a diagnosis which otherwise could have been quite difficult.
Even though these nurses were assigned as recreational supervisors, participation in organized activities can be considered a nursing activity, and such activities are part of nursing care in most psychiatric hospitals.
The report from the 262d Station Hospital in the Mediterranean theater, for 1944, showed that its Neuropsychiatric Section had a bed capacity of 60. The only comment on psychiatric nursing was as follows: 'The personnel consisted of one Psychiatrist, three nurses, two of whom had previous Psychiatric experience, and the third nurse quickly became very proficient after experience on the Section.'
Iceland Base Command
A report dated 6 June 1945 by Lt. Col. Wilfred Bloomberg, MC, Neuropsychiatric Consultant, First Service Command, gave the following report on the 92d Station Hospital, Iceland Base Command.
There are two nurses assigned to the Section, both trained in NP work, and both of them only recently arrived, replacing other trained NP nurses. One of the two now present, Lt. Hagar, the Chief Nurse, had four months at Danvers (Mass.) State Hospital, and since entry into the Army has worked on NP wards, five months at
22Training on a theaterwide basis was also reported. For example, U.S. Army nurses and British Army nurses completed a 6-week course in psychiatric nursing at the 114th Station Hospital, North Africa, in the latter part of 1943. See Annual Report, Medical Section, North African Theater of Operations, U.S. Army. for 1943, pp. 279-281, 343.-A. L. A.
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Lovell General Hospital, five months at Camp Edwards Hospital, and in addition has had the First Service Command course in Military Neuropsychiatric Nursing. The second nurse, Lt. West, is also NP trained from Providence, R.I. These two officers are thoroughly competent, but suffering somewhat from lack of sufficient work to keep them both busy.
The section at this hospital had one closed and one open ward. At the time of the consultant's visit, there were four closed-ward and seven open-ward patients.
NEUROPSYCHIATRIC NURSING ON HOSPITAL SHIPS
The only information available concerning psychiatric nursing on hospital ships (fig. 55) was an account written by 2d Lt. Helen Sands, ANC, of the 211th Hospital Ship Complement, who was assigned in the Neuropsychiatric Section, U.S. Army Hospital Ship Emily H. M. Weder (pp. 339-343).
In her account, Lieutenant Sands stated that there were 10 nurses assigned to the neuropsychiatric section, all volunteers-most with a psy?
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chiatric affiliation as student nurses and many with previous psychiatric experience in the Army. Maj. Matthew Levine, MC, the psychiatrist of the unit, gave lectures on basic theory and principles of normal and abnormal behavior, during the time the unit was activating at Camp Kilmer, N.J. Also, during this time, the nurses worked on the neuropsychiatric section of the hospital 'accumulating valuable experience and knowledge of various specialized techniques.'
Lieutenant Sands did not give the actual number of beds in the neuropsychiatric section, but stated:
Each of the wards accommodates eighty patients. The NP section on one deck is divided into two large wards and it is here that our psychoneurotic cases are usually quartered * * *. The deck above contains rooms of four to six beds each, and the cell area which consists of five cells and a latrine. The cell area can be closed off from the remainder of the section if the patients are too disturbed. The variation in the size of the rooms in this section enables us to test the patient's adaptability to small groups, and to segregate them if that procedure becomes necessary.
Lieutenant Sands described one trip from the Philippines to New Guinea, in which the neuropsychiatric section was filled to capacity, as their greatest test. She stated:
The greatest number of our patients were classified as psychoneurosis * * * [and were] well enough to be permitted use of open decks. Surprisingly few were interested * * * [and] said although they knew the planes flying overhead were ours, they couldn't help feeling afraid * * *. However, they adjusted very well * * *. The psychotic patients were our chief concern * * * about twenty-five of them, most of which were actively disturbed on embarkation. Those five cells * * * were inadequate.
Several of the psychotic patients were 'acutely ill physically,' and most of them had tropical skin diseases which the restraints had aggravated. While Lieutenant Sands described the psychiatric nursing challenge primarily, she also pointed out that 'medical and surgical nursing' skills were 'called upon' as well.
Nursing care on the Emily H. M. Weder thus consisted of keeping the psychoneurotic patients occupied with recreational activities, of encouraging them to discuss their anxieties and fears, and providing necessary care for any physical illness the patients might also have. Sedative wet sheet packs, sedation, and restraint were used as necessary with psychotic patients. As the need for these decreased, and the physical conditions of these patients improved, emphasis was placed on encouraging them to participate in group activities and to discuss their anxieties.
This account gave an almost ideal picture of an environment conducive to improvement on the part of the patients and of effective utilization of nurses working in a psychiatric team.
NEUROPSYCHIATRIC NURSING IN THE ARMY AIR FORCES
Although little was found concerning the neuropsychiatric activities of nurses assigned in AAF (Army Air Forces) hospitals, they were never-
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theless concerned with neuropsychiatric patients. Neuropsychiatric casualties occurred in the Army Air Forces and were channeled through or treated in AAF station, regional, or convalescent hospitals in the Zone of Interior.23 It may be assumed that efforts were made to assign nurses with psychiatric training and experience, since this was a policy laid down in War Department Circular No. 34, 1 February 1943.
Flight nurses were particularly involved with the air evacuation of neuropsychiatric patients in both the Zone of Interior and overseas. Although the early plans for air evacuation of patients banned the transport of psychiatric patients except in 'great emergencies,'24 this policy was changed late in 1944 when neuropsychiatric patients were accumulating rapidly in the Southwest Pacific Area, and hundreds were air evacuated.25 Many more could have been evacuated but higher authority, aware of the lack of isolation facilities on airplanes, considered neuropsychiatric patients a potential danger. However, air evacuation of all patients, generally, and particularly from ports of debarkation to specialized general hospitals, gained popularity as the war progressed.26
The development and training of flight nurses marked a new chapter in nursing history.27 The first formal graduation of flight nurses of the 349th Air Evacuation Group took place on 18 February 1943. After the first group of 39 were graduated, the school at which they had received training was officially designated as the Army Air Forces School of Air Evacuation, Bowman Field, Ky. A total of 1,079 flight nurses graduated from the course there. In late 1944, the course was moved to the AAF School of Aviation Medicine, Randolph Field, Tex., and 435 additional flight nurses completed the course between November 1944 and June 1946.
In discussing the program at Bowman Field, Link and Coleman made no mention of psychiatric nursing instruction. The course, however, reflected changing concepts in air evacuation of patients, and in describing the course conducted at Randolph Field, they wrote: 'Transportation of
23A separate AFNC (Air Force Nurse Corps) was created on 1 July 1949, coincident with the creation of the Air Force Medical Service. As a matter of interest, the following information on the number serving in AAF hospitals is cited from Link, Mae Mills, and Coleman, Hubert A.: Medical Support of the Army Air Forces in World War II. Department of the Air Force. Washington: U.S. Government Printing Office, 1955, p. 61:
Number of Nurses procured from the Surgeon General's Office (Army) | 1,625 |
Number of nurses procured from 1 January 1943 to 1 March 1944 by the Office of the Air Surgeon | 3,742 |
| Number of nurses procured by other agencies from 1 January 1943 to 10 May 1944 and assigned to duty with the Army Air Forces | ,557 |
Total procurement | 8,724 |
| Number of nurses transferred to Army Service Forces and Army Ground Forces from 18 December 1942 to 1 January 1945 | 3,489 |
| Number of nurses on duty in the Zone of Interior as of 1 December 1945 | 3,461 |
24Link and Coleman, op. cit., p. 384.
25Smith, op. cit., p. 444.
26Ibid., p. 358.
27Link and Coleman, op. cit., pp. 368-378.
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neuropsychiatric casualties, always a problem, was thoroughly covered in the program.'28
CONCLUSION
Although the Army neuropsychiatric nurse was expected to perform those duties relative to the care of neuropsychiatric patients, the military situation and her patients challenged her to do even more. Even though she may have been experienced in State or private hospital psychiatric work, she, like many State hospital trained psychiatrists, found a new type of patient under her care. These patients were not the 'psychotics' who constituted the population of most State hospitals but were, rather, frightened, maladjusted, inadequate, defective, homesick, lonely persons frequently labeled as psychoneurotic. Intuitively, and from experience in the nursing arts, these were the first patients to command her attention and to stir her to provide assistance. As she became more
experienced in neuropsychiatric nursing, she was able to spread her ministrations more widely.
The Army nurse was probably the most versatile and adaptable officer in the Medical Department and one of the most indispensable in certain medical programs during World War II. These nurses had a way of adapting themselves to a purpose that was unique wherever they served. In neuropsychiatry, they proved their value as members of the neuropsychiatry team. Like many young medical officers who, after exposure to neuropsychiatry in the Army, continued in the specialty in civilian life, so did many nurses. The experience during World War II and the diligent efforts of certain officers in the Medical and Army Nurse Corps pointed out the necessity for continued training and utilization of qualified nurses in the specialized neuropsychiatric area of nursing in both military and civilian practice.
28Link and Coleman, op. cit., pp. 374-376.
