The professionalisation of public health nursing in Europe dates back to the last third of the 19th century and first decades of the 20th century. [1] At that time, and especially in the inter-war period, Europe witnessed the formation of what has been called the “international health movement”, which helped establish a social and political context conducive to attaining higher levels of health and well-being. This was fostered by achievements such as the creation of public health authorities in Europe, [2] the development of public health driven by the Rockefeller Foundation [3] and the League of Nations, [4] and a structured, collective effort based on the work of experts. Ultimately, the aim was to establish a central frame of reference for the exchange of healthcare knowledge and practices. [5]

In this context and especially following the First World War, international organisations and agencies promoted a healthcare model based on improving public health, implementing models of care that would first meet the immediate needs of refugees and would subsequently consolidate national and international public health services. [6] Consequently, it was necessary to develop a new type of health professional and attempt to provide them with satisfactory training and working conditions. [7] The professionalisation of nursing had begun in England in the second half of the 19th century, and nurses, who became indispensable in the post-war period to carry out the humanitarian work of organisations such as the International Red Cross, formed one the professional groups that aroused most interest among health institutions and organisations. Public health nurses slotted perfectly into the new healthcare model developed in the fields of hygiene and social medicine. [8]

In the final decades of the 19th century, Spain lagged behind its neighbouring countries in many respects in all social spheres. In terms of health, communicable diseases and especially the so-called social diseases (e.g. tuberculosis, cholera, syphilis, trachoma and diphtheria) caused high rates of mortality and morbidity. However, at the turn of the century, a slow but steady change began in demography and health, generating a widespread desire for modernisation in accordance with the criteria and structures of other Western European countries. This laid the groundwork for the hygiene and social medicine movement, and public policies began to reflect a growing concern for public health. There were also early attempts at health service reform and a more outward-looking attitude emerged, embodied in an agreement on scientific and health collaboration with the Rockefeller Foundation. [9] It was at this time that the first steps were taken towards the professionalisation of public health nursing in Spain.

The international literature includes studies on the history of public health nursing in the international arena. [10] Our research group has explored the history of public health nursing in Spain. [11] On this occasion, our goal has been to highlight the relationship between the international and Spanish contexts, analysing factors in the former that exerted influence on the process of professionalisation of public health nursing in Spain. [12] To this end, we will first examine the initiatives implemented by European institutions aimed at consolidating public health nursing in Europe, in comparison with the case of Spain. Then, we will describe the transformation in health and demography witnessed in Spain and discuss how this led to the inception of public health nursing, analysing those elements of the international context that were decisive in the process of nursing professionalisation in Spain.

After the First World War, the alarming epidemiological situation combined with the need for nurses in countries devastated by the war generated a climate of international cooperation promoted by the League of Red Cross Societies, which held its first meeting in Cannes in 1919. This meeting was attended by the nursing delegation, which advised the League to prioritise the professional development of public health nursing and suggested that this could be achieved by organising international public health courses to train groups of nurses in this field. [13] The courses were successfully created, generated a high level of interest and were delivered for eighteen years, training a total of 350 nurses from 47 countries. [14] The students were subsequently responsible for directing public health nursing programmes in their respective countries, although such training was adapted to the social, political and health profile of each country, as in the case of Spain. [15]

Following its creation in 1919, the League of Nations also prioritised the need to combat and prevent the most prevalent diseases and carry out urgent health interventions. In consequence, the League created a Hygiene Committee in 1923, charged with establishing the League’s health policy guidelines. [16] Its director, Dr. Hazeman, and the technical adviser and nursing expert for the Hygiene Section, the American nurse Hazel Avis Goff, [17] together coordinated the debate on the situation and perspectives of public health nursing in Europe. Goff collaborated regularly with the Rockefeller Foundation’s International Health Board, exemplifying the Rockefeller Foundation’s involvement in the League of Nations Hygiene Committee. Through the incorporation of health experts, in this case an expert in public health nursing, the Foundation’s principles and guidelines were disseminated among international organisations such as the League of Nations. [18] Goff contributed to the debate on nursing education and analysed public health nursing in Europe, producing reports on ten European countries: Austria, [19] Bulgaria, [20] Greece, [21] Finland, [22] Hungary, [23] Yugoslavia, [24] Norway, [25] Poland, [26] Czechoslovakia [27] and Romania. [28] These countries were selected and the reports written in line with the recommendations of the 1931 European Conference on Rural Hygiene. [29] The fact that the Conference’s recommendations included establishing the present situation of public health nursing in the above-mentioned countries indicates the importance attributed in the field of hygiene and social medicine to the work of nurses in the community. Spain was not included in these reports, probably because it was already undergoing a major transformation in health promoted by the Rockefeller Foundation, as we shall see in subsequent sections. [30]

The work carried out by the League of Nations through its Hygiene Committee, together with Goff’s contribution as expert adviser in the field of public health nursing, formed the basis of systematic efforts to establish suitable training in public health nursing and organised, effective nursing services in Europe. [31]

After the disruptions of World War II, the World Health Organisation (WHO), funded in 1948, formed Nursing Expert Committees composed of leading international figures of the time. [32] These committees formulated new ideas and strategies for improving hygiene and nursing, which were published in several reports from 1950 onwards. [33]

To alleviate the continuing shortage of nurses in the 1940s, the WHO promoted the formation of a group of “nursing experts” and established a strategy of international alliances with the International Nursing Council (INC), the International Catholic Committee of Nurses and Medical-Social Assistants, the Nursing Office of the League of Red Cross Societies and the International Confederation of Midwives. [34] It also launched international nursing teams and proposed nursing school programme reforms, promoting basic training in public health that incorporated maternal and child care and nurse training for teaching and administration. [35]

The WHO’s novel approach not only paved the way for demands to improve general training and professional conditions, but above all highlighted the contribution of nursing to achievements in public health and social medicine, although it also revealed inconsistencies in some countries. Such was the case of Spain, as will be analysed below. In the following sections, I will first describe the social, political and health profile of Spain, and subsequently explore the influence of the international context on the development of public health nursing in Spain.

As indicated in the introduction, turn of the century Spain lagged far behind other Western Europe countries. The main differences stemmed from the predominantly rural nature of the economy and society. Land distribution, lease conditions and widespread technological backwardness meant that in Spain, the yield per hectare was five or six times lower than it was in countries such as Germany or Britain. Consequently, poor harvests led to repeated food shortages. Another significant difference was the illiteracy rate. In 1900, 63% of the Spanish population could not read or write, whereas in France, only 24% of the population was illiterate. Furthermore, the illiteracy rate was even higher among women, standing at 71%. [36]

Health in Spain was typical of a predominantly rural society. The average birth rate was around 35 per 1,000 inhabitants, and the mortality rate was around 25 per 1,000 inhabitants. In contrast, countries such as France or Britain presented birth rates of around 26 per 1,000 population and mortality rates of 19 and 17 per 1,000 population, respectively. The mortality rate for the under-fives was very high, standing at 420.31 per 1,000 live births, whereas the same figure for France was around 194 per 1,000. While Europe generally had witnessed a 50% population increase over the 19th century, in Spain the population had only increased by 20%. [37]

Nonetheless, as mentioned earlier, the turn of the century witnessed the beginning of a slow but steady change in demography and health, in line with the criteria and structures of other Western European countries. In response to demands from the labour movement and the general population alike, as well as the public debate promoted by the hygiene movement in line with international movements and the need for regeneration and progress, a general health act was passed in 1904 (the Instrucción General de Sanidad), ushering in a redesigned health service. [38] Social medicine, bacteriology and demographics formed the basis of two major initiatives in healthcare: health campaigns that intensified efforts to combat social diseases, and an outward-looking attitude embodied in an agreement with the Rockefeller Foundation’s International Health Board that proved decisive for expanding public healthcare to rural areas and providing grants to train health professionals. [39] Combined with the creation of the National School of Health as a specialist teaching institution, these initiatives contributed to the development of hygiene and public health and the beginning of the professionalisation of public health nursing in Spain. [40]

The first public health nurses (health visitors) appeared in Spain in the 1920s, again lagging behind other European countries but with strong support from international institutions such as the Rockefeller Foundation. [41] There are various reasons for this delay, the main ones being Spain’s very different socioeconomic situation, largely due to the lack of strong industrial development and associated consequences and the absence of a public health movement such as the one in England. With specific reference to the development of nursing as a profession, unlike England and other non-Catholic countries, Spain had a long and rich tradition of professional nursing in a hospital setting. However, this was partially responsible for the idea that care outside the hospital was not a nursing function. [42] Furthermore, although traditional forms of care delivered in family settings by nuns and mothers helped improve the health and well-being of the population, they also posed an obstacle to the process of nursing professionalisation. [43] Previously, in line with the new health act of 1904, Provincial Health Boards had been created and a ladies’ committee established to oversee home care and maternal and child health education. The tasks of this committee can be seen as a precedent for the work of the health visitor. [44]

Training for health visitors in the 1920s commenced with the programmes organised by the Red Cross and courses delivered at the National School of Health and the Child Care Schools. Professional health visitors were an innovation in Spain, and they were trained to play a key role in implementing the reformist health policy that had been gradually taking shape over the first thirty years of the 20th century. This process reached its culmination with the scientific and public health collaboration agreements signed with the Rockefeller Foundation in 1922, in which the Foundation undertook to cover the costs of a future school for health visitors and to fund suitable public health training for those who would teach there. [45] In 1931, prior to organising these training programmes, the Rockefeller Foundation engaged Elisabeth F. Crowell to conduct an analysis of the situation of nursing in Spain. [46]

Her report analysed the nursing education provided by schools located in Spanish hospitals in Madrid, Santander and Barcelona, and concluded that the requirements for admission to nursing schools were inadequate, that the courses were characterised by disorganised theoretical teaching delivered by doctors and that practical experience was unsupervised. She also highlighted the absence of professionals with an accurate conception of what a nursing school should be, indicating that this severely hindered the professionalisation of nurses. [47]

Besides these aspects, Crowell also examined the project for a National Public Health Nursing School, identifying the need for places to carry out effective practical experience and the desirability of raising the future school’s admission requirements. She also indicated the need to provide suitable training for management and teaching staff by providing grants to study abroad. This latter question was resolved through a training programme in which fourteen nurses participated between 1931 and 1934, studying in the United States for an average of two years to prepare them to teach at the school, which was scheduled to open in Madrid in late 1935. [48]

Experienced nurses predominated among those awarded such grants, although there were also four newly graduated nurses. Their mean age was 29 years old, the mean duration of their overseas study was two years, and they all studied a relatively similar curriculum. First, they participated as special students in the activities of the Western University of Cleveland nursing school, where they studied subjects such as the fundamentals of nursing, advances in nursing, principles and methods of nursing education, social aspects of nursing and, of course, public health nursing. In addition to these theoretical and practical subjects, they spent several months in the East Harlem Nursing and Health Service in the city of New York. Of particular note, six of them also attended an advanced course for nursing teachers and supervisors at the Columbia University Teachers’ College in New York. However, none of this helped achieve the main objective: the incorporation of these professionals as teaching staff at the National Public Health Nursing School in Madrid was ultimately prevented by continuing delays in the launch of the school and the outbreak of the Spanish Civil War in 1936. [49]

Despite these ambitious plans for a postgraduate teacher training programme with a view to launching the Public Health Nursing School, the pressing need for professionals meant that public health nurse training could be delayed no longer. Thus, in 1933, a National School for Health Visitors was created, attached to the National School of Health, which was intended to provisionally fulfil the functions of the future institution. Three three-month courses were delivered between February 1933 and July 1935, training a total of 76 nurses. [50]

In the end, none of these initiatives became permanent. Despite demands from health visitors themselves for the construction of a building to house the future school or for the latter’s launch in January 1936, the tragic events of July 1936, heralding the outbreak of civil war, brought a halt to the development of this important programme to which so much effort and time had been devoted.

Nevertheless, the new health service designed by the health authorities slowly began to include health visitors. [51] Health policies during the Second Republic incorporated intense State involvement in health campaigns against tuberculosis [52], trachoma [53] and infant mortality. [54] In order to carry out a health programme such as the one launched by the Republic, health visitors were essential. It was at this point that the first Health Visitor’s Association was founded and the first scientific publications were made. Public health nurses became actively involved in health campaigns through targeted and coordinated actions against infectious diseases, and entered the fields of childcare and maternal and child

For example, they played a major role in the tuberculosis [55] and trachoma campaigns; in the latter case, by carrying out interventions in schools which targeted children with the disease. [56] Besides conducting school medical inspections, supporting the work of local physicians and ophthalmologists and delivering health and hygiene education, they began to work with families and the community. For each schoolchild with trachoma, nurses opened a family file and carried out home visits to assess risk factors and detect any other members of the household affected by the disease. These were then treated and monitored by the hygiene clinic, and educated about healthy habits and hygiene. As with most of what were known as social diseases, a strictly medical approach was insufficient: it was also necessary for health professionals to carry out social work. In this respect, health visitors played a crucial role, acting as intermediaries between the three groups involved: schoolchildren and teachers; other health institutions and medical and specialist services; and other families and the general population. [57] They also played a central role in what was known as the “child care movement” and in mother and child hygiene campaigns. [58] The work carried out with mothers through home visits is a prime example of the outreach and health education activities performed by health visitors.

As has been shown, nurses played a prominent role in the fields of care and public health, consistent with the guidelines issued by international health organisations and institutions.

Besides preventing the launch of the public nursing school, the outbreak of civil war in July 1936 brought a halt to the professional and personal development of many of the nurses who had benefitted from the advanced study programme, with serious consequences for the progress of nursing. As a result of Spain’s political and social situation and international isolation, many of these nurses experienced great difficulty in continuing their professional activity. Others adapted to political change and even occupied important posts in the health system under the Franco regime. [59] Some went into exile abroad, as did many other professionals and researchers, forming a large group of people now obliged to lead their lives elsewhere. [60] For example, four of the nurses who had received grants from the Rockefeller Foundation went into exile in Venezuela, where they integrated into Venezuelan society and actively participated in the development of nursing there, directing the first school of nursing and creating a professional nursing journal. [61] Thus, although the exile of the health and scientific community as a result of the civil war and the Franco dictatorship represented a damaging loss of human resources in Spain, and in the case of nursing, halted the project to create a public health nursing school, it benefitted Venezuela since the exiled Spanish nurses actively participated in the development of professional nursing there.

Meanwhile, in Spain, the political, social and cultural constraints imposed by the newly established Franco dictatorship represented a major setback in the process of nursing professionalisation. Many of the political actions implemented under Franco’s totalitarian system were based on opposition to the former regime, entailing an abrupt change of direction in many of the earlier Republican initiatives. New health policies and guidelines had a severe impact on the emerging discipline and the first professional achievements it had attained during the Republican period. One of the initiatives carried out by the new regime’s health authorities was to restructure the proposed Public Health Nursing School project. Alterations were made to the building constructed to house the school to accommodate a National School for Health Instructors. In the words of its first director, Dr. José Fernández Turegano, the school had a dual practical and moral mission: an educational function aimed at training, but also a spiritual one, aimed at creating the necessary vocation. [62] Students boarded at the school, and religion and political education were included among the subjects they studied. Religious education was considered essential, since those responsible for the school thought that daily religious practice would elevate student morality. Meanwhile, political education was delivered by instructors from the Women’s Section of the Spanish Falange and the JONS, [63] the only official political party in Spain, which adhered to a fascist ideology. [64] The aim of this training was to foment a sense of vocation and patriotism, linking the nursing function to the role once again assigned to women in Spanish society under the Franco regime, that of a wife and mother relegated to the domestic sphere. [65] At the same time but independently of the school, the role of Social Health Visitor was created in January 1942, together with a body of Rural Health Advisors, under the sole control of the Spanish Falange and the JONS. [66] The professional activity of these nurses incorporated social, religious and political propaganda, always under the supervision of the religious authorities and provincial party officials. Their work went beyond healthcare and was used as a vehicle for social, political and religious intervention. [67]

In 1953, a further change in nursing education, introduced a new qualification, Technical Healthcare Assistant (Spanish initials: ATS). [68] This occurred at a time of intensifying ideological and educational regression in Spanish society, and was based on a model of gender discrimination. Its creation signified a major check on the process of nursing professionalisation in Spain, distancing the discipline still further from international trends. With this new modification, the name “nurse” was lost and nurses were obliged to adopt the new title, ATS, reflecting neither their history nor their healthcare functions. [69] The new qualification underlined the auxiliary, technical nature of nursing and differentiated teaching content and organisation by gender. This was evident in the curriculum, which now contained different subjects according to gender (e.g. “Domestic Studies” for women and “Forensic Autopsy” for men). Similarly, boarding was compulsory for female students, but not for male students. [70]

Throughout the 1950s, 1960s and 1970s, the situation deteriorated for nurses, as the gender gap widened and the subordinate nature of the profession was accentuated. [71] Nurses’ labour rights, in particular those of public health nurses and educators, were also eroded and there were major deficiencies in continuing education. After completing their studies, nurses lost all supervisory contact or training from the Directorate-General for Health, their relationship with this institution being reduced to bureaucratic aspects. From the 1940s onwards, no advanced training courses were offered, which not only diminished nurses’ level of professional competence but also undermined their incentive and motivation. [72] In 1977, after the restoration of democracy and much lobbying, nurses gained access to a university education through the university nursing diploma. Recently, with the latest university reform, the diploma has been transformed into a degree in nursing and nurses have also gained access to master’s degrees and doctorate programmes. [73]

As has been shown, the development of public health nursing in Spain in the first decades of the 20th century was influenced by factors in the international arena that had a considerable impact on the discipline’s process of professionalisation. Changes in demography and health in Spain, echoes of the international health movement that emerged in Europe in the inter-war period and the Rockefeller Foundation’s promotion of healthcare models based on improving public health, all helped advance the process of nursing professionalisation in Spain and develop the healthcare specialism of public health nursing. The training of these nurses, delivered in Spain and the United States, facilitated the first professional achievements. Nurses served as counsellors and mentors in families’ everyday lives through home visits and health education, and as mediators between popular and scientific culture. They played a direct role in the study of the causes of infant mortality, analysing families’ living conditions and financial situation, and the domestic and social environment. As has been traditional in nursing activity in Spain and abroad, nurses worked closely with the general population, forging strong links with people in the community, and as a professional group, they constituted the front-line troops in the battle for regeneration.

However, the grave consequences of the military coup, the ensuing Spanish Civil War and the subsequent dictatorship truncated the incipient process of development ushered in during the Second Spanish Republic and rendered it impossible to consolidate or build on earlier advances in the fields of healthcare and public health nursing. The process of modernising healthcare was halted, as was that of the professionalisation of public health nursing in Spain achieved in the first third of the 20th century. This process was delayed for more than forty years, a loss that merits consideration in the historical and ethical debate on the extent to which the Franco dictatorship observed the principles that should govern the actions of politicians in their capacity as stewards of the population’s well-being. National and international institutional initiatives and political, social and personal efforts alike were all thwarted in the early stages of the Franco dictatorship, bringing a halt to social progress and improvements in public health and highlighting the ethical implications of the regime’s policies.

The new regime’s health authorities redirected health policies. Through home interventions, health visitors were expected to restore families’ morale, establish surveillance mechanisms and supply information to the authorities. Health goals were discarded, to be replaced by other issues related to political and social control. The work of nurses lost its legitimacy once it became clear that their activities served an ideological purpose.

Furthermore, the Franco regime widened the gender gap in Spanish society, leading to situations of discrimination and inequality for women. This retrograde step for professional nursing cannot be separated from the emphasis placed on the traditional role assigned to women in Spanish society, who were relegated to the role of wives and mothers and excluded from decision-making. As women, nurses were expected to help foment patriotism, but only in the manner decreed by the political regime that the Franco dictatorship embodied.

In contrast to the momentum and consolidation of public health nursing in the international arena over the course of the 20th century, the reverse occurred in Spain, where the emphasis placed on an auxiliary and subordinate role carried out almost exclusively in hospitals led to a severe deterioration in the discipline, heightening its isolation and hindering its process of professionalisation.

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