1 IN 1963 SISTER CLARE MARIE, an experienced nurse educator at St. Francis Xavier University, expressed concern over the “power” of nursing assistants and “the responsibility [they were] taking, or being made to take” on hospital wards. She then asked “Are they getting out of control?”1 Nursing assistants, despite the interest of professional leaders such as Sister Clare Marie during the 1950s and 1960s, have not attracted much attention from historians of health care. Indeed, there have been relatively few analyses of the many occupational groups that constituted the health care labour force.2 At the same time, many of the existing analyses focus on one group of workers and often in one setting.3 Tracey Adams, in her study of dental assistants, cautioned that “by focusing on only one profession of a relatively small size, one risks losing sight of the interdependence and interaction”4 among different groups. Another unfortunate result of focusing exclusively upon one profession is that it normalizes the existing division of labour in health care and reinforces perceptions that this division of labour is rational or even “natural.”5 There remains, then, a profound need for historical analyses of a greater range of health care workers and their interactions with one another.6

2 Recently, nursing historians have acknowledged that “one of the issues for nursing history that continues to have relevance for current health care debates concerns the category of ‘nurse’: who is a nurse, what constitutes nursing work, and to what degree (if any) is ‘nurse’ a universal category of identity.”7 Though rarely acknowledged, nursing practice in Canada is constituted by a number of different groups, each with its own history, including registered nurses,8 registered psychiatric nurses,9 and a third group who have worked under the supervision of these first two groups of nurses. This last category encompassed both regulated and unregulated workers. Regulated workers were known as “registered” or “certified” nursing assistants, while unregulated workers included practical nurses, nursing auxiliaries, nursing aides, and nursing attendants.10 Most studies of nursing pay only passing attention to nursing assistants,11 and yet, after the Second World War, they constituted the fastest growing segment of the nursing labour force. The demand for these workers was shaped by a variety of initiatives at the federal, provincial, and local levels. Programs such as the National Health Grants enhanced educational opportunities for health care workers and prompted both an expansion of available services and new ways of delivering those services. The arrival of federally cost- shared hospital insurance further drove a demand for staff and, specifically, shaped debates about the composition of the labour force in nursing.12 The introduction of registered nursing assistants in the Maritime provinces during the 1950s and 1960s offers an opportunity to understand the changing division of labour in health care and the renegotiation of nursing practice.

3 An array of workers were involved in nursing care by the early 20th century, including registered nurses and a variety of unregulated workers who performed some aspects of nursing care. Most of these workers were trained on-the-job, but some provinces, such as Quebec and Manitoba, introduced training programs for assistants to registered nurses as early as the 1920s.13 Beginning in the 1930s, nursing leaders tacitly accepted the presence of these other workers in the hospital. Evidence for this shift may be found in the National League of Nursing Education (NLNE) in the United States. While the NLNE agreed to provide guidelines for the education of nursing aides and practical nurses in 1932, it also maintained its position that hospitals should ideally be fully staffed with graduate nurses.14 When this ideal proved impossible to achieve, subsidiary workers gradually found their way onto hospital wards although the timing and nature of their introduction varied considerably from setting to setting.

4 The expansion of Canada’s hospitals following the Second World War, combined with the introduction of new or enhanced services, exacerbated an already difficult situation for many hospital nurses, who reported being overworked and understaffed. In order to meet growing demand, hospitals began to look at other kinds of workers to perform some aspects of nursing labour. The shortage of nurses during the Second World War, which Evelyn Mallory thought to be “definite and widespread,” meant that it was necessary to ensure that “available nursing resources” were being appropriately utilized. Mallory noted that if some duties were redefined as “non-nursing tasks,” they would have to be assigned to someone else.15 The Winnipeg General Hospital mobilized a large number of women through the Canadian Red Cross Voluntary Aid Detachment (VAD) to provide help to nurses. During 1943 the VAD provided more than 25,000 hours of free nursing labour, thereby alleviating the strain on registered nurses. At the Winnipeg General, these practical nurses filled the labour need in the immediate post-war period and, by the early 1950s, there were 25 practical nurses and 75 other “non-professional” staff. While Kathryn McPherson argues that nursing’s “leaders and administrators applauded the introduction of subsidiary workers,”16 there were significant debates among nursing’s leaders. The Canadian Nurse regularly reported on the issue of nursing labour and the efforts to introduce, educate, and regulate these workers.17 In the years immediately preceding the introduction of hospital insurance in 1956, there was a widespread perception that both hospital beds and occupancy rates were increasing and that the availability of registered nurses was not keeping pace.18

5 The popular press fuelled the idea that there was a shortage of health care workers and especially of registered nurses during the 1950s and 1960s.19 Nursing leaders, such as Helen Mussallem, contested this idea, preferring instead to frame it not as a “shortage of nurses but shortage of nursing.”20 In an address to the 100th annual meeting of the Canadian Medical Association in 1967, Mussallem pointedly declared that there was “no shortage of qualified nurses” in Canada. For Mussallem, the executive director of the Canadian Nurses’ Association and a distinguished nursing leader, the issue was that qualified nurses were no longer practicing.21 While the question of a nursing shortage was relative, subjective, and very much dependent upon context, the consistent narrative concerning a “nursing shortage” was a critical dimension of the reorganization of nursing labour that took place in the 1950s and 1960s. Here is a case, following Taylor and Whittier, where the “public discourse about an issue can be thought of as a set of interpretive packages that frame or give meaning to an issue.”22

6 For nursing work, the idea of a labour gap prompted calls for the increasing employment of “nursing aides, practical nurses, and other types of auxiliary nursing personnel.”23 In 1946, Helen King likened nursing assistants and other subsidiary workers to a “crutch.” According to King, these workers were introduced to help hospitals while they were “temporarily incapacitated” by the shortage of staff during the war. But once their utility was established, there was a shift toward including these workers “permanently on the staff.” She cautioned that nursing “may regret the step of including the untrained helper into a professional sphere. We may find that our standards are lowered, that they may displace the highly-trained nurse and offer serious competition in years to come.”24 A few years later King, the assistant director of nursing service at the Vancouver General Hospital, thought that “auxiliary nursing personnel” were now “a recognized part of the medical team.” She wrote that just a few years ago head nurses “resented” nurse aides, but now, if the head nurse had an experienced nurse aide on her ward, “she does not care to part with her.” King also highlighted the “fluctuating demands” that characterize a general hospital and made staff planning difficult. She noted that when “nurse aides” were most in need, they were also in short supply. For King, the “solution is in the operation of a school where nurse aide students all received a prescribed training and from which a hospital can employ reliable workers.”25

7 By the mid-1950s, most provinces in Canada were offering some kind of program for training nursing aides or assistants. For its part, the Canadian Nurses’ Association reported in 1951 on the preparation and use of auxiliary workers and the legislative framework in which they worked. This committee defined nursing assistants and delineated their scope of practice.26 The intention of the committee’s report was to ensure a clear division of labour between registered nurses and nursing assistants. The Canadian Nurses’ Association also drafted a “Suggested Curriculum Guide” for the schools preparing nursing assistants, which was revised in 1956.27 By the early 1960s, according to David Brown, who was writing in the The Canadian Nurse, nursing assistants had become a “very formidable work force.”28 Dorothy McKeown, describing developments in Nova Scotia, noted “In a matter of a few years, a rapid growth has taken place in the area of practical nursing in Nova Scotia. The nursing assistant has advanced from an obscure position to an accepted place on the health team.” McKeown also added “Traditionalists have had some difficulty in accepting this fact.”29 L.O. Bradley wrote in The Canadian Hospital that “there can be no doubt that the growing supply of the certified nursing aides and assistants has permitted the hospital construction program to continue.”30 At the same time, Bradley thought the shortage of “qualified nursing personnel” was having an “effect on the quality of nursing care” and that there was a need to “act wisely – and quickly – for patients’ sake!”31

8 Nursing assistants were clearly a vexing issue in the middle of the 20th century. They captured the attention of the Registered Nurses’ Association of Nova Scotia (RNANS) as early as 1941. That year, Hope Mack chaired a committee that explored practical nursing and concluded that the RNANS had “a problem that must be faced.” In the early 1940s RNANS research identified more than 600 practical nurses in Nova Scotia, prompting the organization to consider both the role that this existing labour force was to play in nursing care and how (and whether) it should grow to meet the needs of hospitals in a period of labour shortage. RNANS officials concluded that it should determine the “status, training, salary and work to be done” by practical nurses.32 From the beginning, then, registered nurses in Nova Scotia staked their claim to participating in and preferably directing, any further division of labour in nursing practice.

9 New Brunswick nurses were also concerned with the regulation of practical nurses and, in 1951, the New Brunswick Association of Registered Nurses (NBARN) began exploring the regulation of these workers to ensure that they were adequately prepared to perform specific duties. Over the next several years, a number of developments took place that enhanced that organization’s control of nursing assistants. In 1954, the NBARN established an Advisory Committee to Practical Nursing Schools, and work proceeded on developing an appropriate curriculum for this new category of health care worker. Creating a quicker path to practice and better retention of nursing assistants led Nova Scotia’s Hospital Insurance Commission to conclude in 1958 that “the only logical solution is to use nursing assistants more than at present,” and that it was “more desirable to expand existing schools for nursing assistants at this time than to expand, to any great degree, schools of nursing. Also it is more desirable to establish new schools for nursing assistants than to establish new schools of nursing.”33

10 Registered nursing assistants were “trained” in a variety of settings to meet specific needs. The federal Department of Veterans’ Affairs, for example, operated a school for nursing assistants in Halifax’s Camp Hill Hospital, and St. Martha’s Hospital in Antigonish initiated its program in March 1957. The course at St. Martha’s was open to individuals between the ages of 17 and 40 who had completed Grade 9, or equivalent education. The course lasted ten months, was comprised of three months of classroom work and a seven-month clinical placement, and followed a curriculum approved by the Board of Registration for Nursing Assistants and the provincial government. The course was intended to provide the student with theory and experience in basic procedures in several services, including pediatrics, obstetrics, medical and surgical nursing, care of the aged, and even disaster nursing. At St. Martha’s, an important Catholic hospital in Nova Scotia, the course was also “permeated with the ideal of complete Christian living.”34

11 For its part, Nova Scotia’s Department of Health, together with RNANS, studied the feasibility of establishing a nursing assistant program. “It was felt by those engaged in the early planning,” commented one participant in this process, “that the nursing assistant, having completed her course, would be able to make a significant contribution to the nursing service of the province.” The presence of nursing assistants also allowed hospitals “to utilize the services of the professional nurse to the best advantage, and have her free to perform those functions for which she was specifically trained.”35 Nursing leaders such as Sister Catherine Gerard suggested that practical nurses be brought under a system of “licensing” as early as 1945, but it took some time to move in this direction.36 The government passed “An Act to Provide for the Training Examination and Registration of Nursing Assistants” in 1954, although it took until June 1957 for a board to be appointed.37

12 The terms that would thereafter regulate the training, examination, and registration of nursing assistants were then established, and the composition of the board included government officials, physicians, administrators, and nurses as well as one member appointed by the school of nursing assistants and one who was a certified nursing assistant.38 The first meeting of the Board of Registration of Nursing Assistants was held in Province House on 27 June 1958. During the first year, 157 persons were registered as certified nursing assistants. A waiver clause, in effect until 31 December 1960, permitted individuals to be registered without writing examinations. Fees were established for nursing assistants, and a uniform suggested that would clearly differentiate certified nursing assistants from others.39 There were still, though, important issues to be worked out, including the proportion of nursing assistants to nurses. In Nova Scotia, in response to personnel planning in the period of hospital insurance, a ratio of two nurses for every nursing assistant in hospitals was suggested, while in “chronic treatment units” the ratio would be one nurse to every three nursing assistants.40

13 In New Brunswick, an amendment to the Registered Nurses Act in 1958 gave the NBARN authority over nursing assistants. Its new legislative obligations included responsibility for the education and supervision of nursing assistants as well as examining qualifications of the existing labour force. The NBARN established several committees, wrote by-laws, and established a registry.41 Emma Boyd (née Waugh), a graduate of the New Brunswick Technical Institute, was the first person to be entered into the registry when it was created in 1958. Her sister, Lillian, also registered that year.42

14 Prince Edward Island passed legislation in 1952 to provide for “the training, licensing and practice of nursing auxiliary personnel.” The province’s minister of health, A.W. Matheson, who promoted the legislation, acknowledged that it was difficult to find an adequate number of RNs for PEI’s hospitals. There was also a sense that admission to nursing schools was becoming stricter and that many willing young women were not able to become registered nurses. The Charlottetown Patriot reported that the “standard” for becoming an RN was high and that while this “is necessarily so,” it excluded many young women; moreover, “girls with a grade of education considerably lower than that which can qualify a girl for a course leading to an R.N., often make exceptionally fine nurses. In some cases . . . they become better nurses than do those with the higher education.”43

15 By 1960, each of the Maritime provinces had relevant legislation, schools for nursing assistants, and mechanisms to assess credentials and to differentiate those who were eligible to be registered from others. In December 1959 NBARN established a credentials committee that created a registry to effectively differentiate trained nursing assistants from other kinds of auxiliary labour. All graduates of schools for nursing assistants in New Brunswick were sent application forms. Six such schools were in operation in 1960 at hospitals in Bathurst, Tracadie, Chatham, two in Campbellton (Hôtel-Dieu de Saint-Joseph and Soldiers’ Memorial Hospital), and the New Brunswick Technical Institute in Moncton. During 1959-60, NBARN educational consultant Alice Potter visited all of the schools to ensure that they were meeting the curricular and practical standards that had been established by the Canadian Nurses’ Association.44 Individuals who were working as nursing assistants, but who lacked the formal education, were eligible to be registered without examination through a waiver clause upon the recommendation of their supervisor. During the first year, 483 nursing assistants were registered in this way. The waiver period ended on 31 December 1961 and, thereafter, applicants would be registered only through examinations (held twice a year in English and French) or through the consideration of the credentials committee.

16 Registering graduates of approved programs and those employed as nursing assistants was straightforward for the credentials committee, but it still needed to work out some other details. Permitting registration or rejecting a candidate were only two of the available choices, and evidence from the credentials committee reveals the complexity of the process. The committee presented potential registrants with a number of pathways to practice. Evidence from the case files offers insight into the work of the credentials committee and how decisions were made with respect to who was eligible to be registered and why. In this way, the case files also provide important evidence of the emerging conceptualization of nursing assistants in these years. Mrs. Alice Mott attended the Soldiers’ Memorial School of Nursing from May 1929 to December 1930. The committee learned that she had “kept in touch with nursing since that time.” The ruling in this case was that Mott must spend three months receiving supervised experience in “all the areas of nursing,” after which she could write the registration examinations. Miss Hazel Sirett was registered as an assistant nurse with the General Nursing Council for England and Wales, and registered in Nova Scotia as a nursing assistant. While there were no records available to assist the committee, she was “well recommended” and was registered on this basis.45 Margaret Boreland completed a course for psychiatric nursing assistants at the Provincial Hospital in Lancaster from September 1954 to May 1955. The credentials committee recommended that she enter a school for nursing assistants for three months to acquire specific education in the “Care of Mother and Child” and “Nursing of Children,” as well as gaining two weeks’ additional, supervised clinical experience in a general medical and surgical ward in a general hospital. The credentials committee also insisted that Miss Boreland pass the registration exam.46 The committee expressed concern if candidates lacked courses on the “Care of the Mother and Child” and “Nursing of Children” because these were important areas of work for nursing assistants. At a 1962 meeting, the committee became aware that two of the schools for nursing assistants (Hôtel-Dieu, Campbellton, and Hôtel-Dieu, Bathurst) were not including their male students in their course on “Nursing Care of Children.” The committee pointed out that it was an expectation that all nursing assistant students, including men, complete the required course.47

17 Former students of nursing were treated very much on a case-by-case basis. When a former nursing student applied, having attended Hôtel-Dieu in Edmundston for one year from September 1951 to September 1952, she was told she would be allowed to write the registration exams if she completed “content as to the Care of the Mother and Child and Nursing of Children.” And if she passed her exams, she could be registered as a nursing assistant. In this case, she did not complete the nursing assistant course but, in the view of the credentials committee, a single year of nursing education was considered to be comparable.48 Mrs. Sylvia Mersereau attended Montreal’s Royal Victoria Hospital for one-and-a-half years beginning in September 1928, and subsequently worked in New Brunswick for 30 years and was, apparently, “well recommended.” The committee permitted Mrs. Mersereau to be registered without any further education if she passed the exams. In contrast, Mrs. Florence Moore, who had been a nursing student in Bathurst from February to November 1935, was “not eligible for registration.” There was no record of her courses and she lacked hospital experience. Clearly, the credentials committee, which was initially composed of registered nurses, did not want nursing students who had abandoned their studies to be automatically eligible to work and be registered as nursing assistants. The committee took an especially dim view of women who were re- entering the workforce, claiming qualifications earned through their military service. Mrs. Doris Andrews, for example, attended a very brief hospital assistants’ course while a member of the Royal Canadian Air Force (RCAF). The course, which went from 12 March to 8 April 1943 at the RCAF Training School in St. Thomas, Ontario, was considered to be insufficient. She was ruled ineligible for registration and it was recommended that she complete the nursing assistant course.49

18 It is also clear that the credentials committee had a good deal of discretion, and authority. But this did not always go unchallenged. Individual applicants would sometimes seek clarifications regarding the decisions of the committee and, occasionally, apply again.50 In at least one instance, Miss Alice Ganong, the director of nursing at the Kings County Hospital in Sussex, wrote to the registrar of the NBARN to question the committee’s ruling concerning applicants from that hospital. While it is an interesting example of resistance to the authority of committee, or at least to specific rulings, this appeal was unsuccessful.51

19 Another issue that faced nursing assistants concerned reciprocal registration. In a general sense, the credentials committee readily recognized nursing assistants who were registered in other provinces as long as the registration requirements were considered comparable to those in New Brunswick. Workers from Newfoundland, which did not have either legislation or a registry, were referred to the credentials committee. Quebec also lacked a legally constituted body to register nursing assistants. They were eligible to register with the Quebec’s professional nursing association, the Association des infirmières de la province de Québec, but did not have to do so. There was also a separate organization, the Association des gardes- malades auxiliaires de la province de Québec, that registered nursing assistants. The NBARN offered reciprocity, however, only to those who had registered with the professional nurses’ governing body.52

20 In New Brunswick, a province that had a legislative framework, a formally constituted registry, and well-established schools, there was still considerable debate about who could be a nursing assistant and who was to be excluded from this area of nursing practice. Nevertheless, the number of registered nursing assistants continued to grow. As early as 1962, a planning committee was created, consisting of seven RNAs and two RNs, to set up a separate association for nursing assistants. It held its first meeting on 1 March 1963 and a grass-roots movement took hold, with RNAs in local communities forming local chapters. On 18 June 1965, the first meeting of the Association of New Brunswick Registered Nursing Assistants was held in Moncton. This was a voluntary association, without any real authority or power. Nevertheless, the creation of this body was the first step toward a new legal organization.53 By the end of the 1960s, there were nearly 1,000 active nursing assistants registered in New Brunswick. Of these, 943 were women and 49 were men. It is also worth pointing out that of the women, 544 were married (57.6 per cent), suggesting that this was a common site of married women’s paid work. Marital status for the men was not reported.54

21 In PEI the nursing complement had increased since the implementation of hospital insurance, at least in the assessment of Dr. O.H. Curtis, the executive director of the Hospital Services Commission, who also served as the deputy minister of health. Hospitals in rural areas such as Souris, Montague, and O’Leary had all hired additional nurses. A short-term solution was to entice former nurses back into the labour force. Mary Bolger, the executive secretary of the PEI Association of Registered Nurses, thought that improved salaries – in some cases 50 per cent more than in recent years – had helped to reactivate RNs who had stopped working.55 There were other suggestions to meet the immediate labour force needs, such as recruiting more men to the nursing profession.56 This was also a period when other provinces were recruiting nurses internationally. The Saskatchewan Hospital Association, for example, stated:

22 Despite the efforts to reactivate retired nurses, encourage men to enter the profession, and recruit internationally, the situation was a serious one. PEI’s hospital insurance plan went into effect on 1 October 1959 and resulted in unprecedented demand for services. Dr. Hubert MacNeill, PEI’s minister of health, thought that hospitals were “filled to overflowing due to the new hospital insurance plan” and “nurses and nursing assistants are badly needed.”58 Hospital administrators struggled with the demands of the Hospital Insurance Commission, which now had a substantial say on matters such as staffing levels and salaries. The O’Leary Community Hospital resorted to using all available space to accommodate patients that very same month.59 In September 1960, the Board of Trustees at Prince County Hospital held an emergency weekend meeting to discuss either limiting admissions or closing part of the hospital because of an inadequate number of nurses. The hospital board felt that it needed ten additional RNs to maintain the nursing complement.60 Expenses at the hospital were also growing. Demand for laboratory and x-ray services doubled in the first year, increasing costs for the hospital since it could no longer bill for these diagnostic services. At the same time, nurses threatened to care for only the most critical cases unless they achieved wage parity with nurses in New Brunswick. They achieved a new wage schedule early the next year, further increasing the cost of care. Judson Logan, the manager of the Prince County Hospital, acknowledged that hospital insurance had reduced the hospital’s autonomy and that the path to implementation had been “rough travelling” for the hospital.61

23 Throughout this period, Prince County Hospital had been making effective use of nursing assistants. The nursing director reported that nursing assistants were plentiful but that they “actually added to the work of the registered nurse staff in some respects” because they had to be supervised.62 Despite the claims of this nursing director, such supervision actually served the interests of registered nurses both in terms of defending their work and placing them in a supervisory position vis- à-vis nursing assistants. For its part, the government of PEI was already moving toward a substantial reconfiguration of nursing labour in the province. In 1960, the provincial government revised the “Licensed Nursing Assistants’ Act” that had been passed in 1952.63 One of the changes in the new act empowered the minister of health to create “one or more schools for the purpose of educating nursing assistants” or to allow other institutions to operate such a school. The new legislation also prohibited any schools for nursing assistants from opening without the approval of the government. This effectively limited the ability of hospitals to open schools to meet the growing demand for nursing assistants, while simultaneously ruling out the possibility that a commercial school could be established in the province.

24 Hubert MacNeill announced plans for a single school of nursing assistants in February 1960,64 and the Department of Health operated this Central School of Nursing Assistants to ensure that Island hospitals were adequately staffed with a mix of RNs and nursing assistants. Supervisors in hospitals across Prince Edward Island identified potential students who were then sponsored by the hospital. An early brochure for the program noted that the sponsoring hospital would employ a potential student “as a Nursing Aide for an agreed period of time prior to taking the Course, in order to evaluate her suitability for the work.”65 Hospitals continued to pay students during their training and, for their part, students promised to remain with their sponsoring institution for a year following completion of the course. The first class from the new Central School for Nursing Assistants graduated in April 1961.66 The next year, three classes of ten students each were admitted in January, April, and September.67

25 With the opening of the school, the training program for attendants at Riverside Hospital, the province’s only mental health facility, was discontinued.68 This change “caused a temporary shortage of staff for the women’s wards” at Riverside, and “to fill this gap several young women have been employed as ward aides.”69 Classes continued to be held at Riverside Hospital under the direction of Jean Dunning, who was recruited from Montreal to direct the new initiative. Following their time at Riverside, students were placed in one of Prince Edward Island’s three major hospitals for six months. Providing clinical experience in the Charlottetown Hospital, Prince County Hospital, or Prince Edward Island Hospital was an important strategy. Some hospitals, as well as individual physicians, continued to emphasize the importance of local training. When Mary Wright became the head nurse in Prince County’s operating room in 1954, one doctor reportedly told her that she “may be all Wright but you went to the wrong school.” Wright had attended Prince Edward Island Hospital for her nursing education, rather than Prince County Hospital’s own school. She followed this up with further post-graduate courses at Toronto’s St. Michael’s College and was therefore exceptionally qualified to be a head nurse.70 While humorous, the comments of the doctor suggest the ongoing significance of local training. The nursing assistant program effectively sidestepped this issue by engaging all of the province’s major hospitals to provide practical experience. Students would also return to Riverside Hospital for additional classroom work and to gain experience in mental health.71

26 During 1962, Riverside had to deal with a number of resignations. The hospital’s complement was reduced by six RNs and three nursing assistants, illustrating the challenge that many PEI hospitals were facing. According to the annual report for the province, nurses left the province to gain more nursing experience, better salaries, or shorter hours. The shortage of nursing labour prompted the “temporary employment of additional Ward Aides for the female wards.”72 The following year, as nursing assistants again became available, they displaced the ward aides. In 1963, Riverside employed 25 registered nurses, 22 licensed nursing assistants (LNAs), 49 male attendants, and 15 ward aides. Interestingly, the male attendants and aides who were hired were “immediately assigned to ward duty without being given any orientation to the work.”73

27 It did not take long for nursing assistants to begin to assert their authority. The LNAs lobbied the Board of Governors at Riverside Hospital for “equal pay for equal work” and their request was forwarded to the health minister. They received a salary adjustment in September 1962 and were awarded a basic salary that was five dollars a month more than that given to (untrained) male attendants.74 The struggle for better wages and working conditions was just beginning. As Linda Kealey has noted, during the 1960s low wages and poor working conditions prompted many nurses across Canada to consider unionization.75 Others protested with their feet and sought better-paid employment opportunities elsewhere.

28 Another strategy used by nursing assistants was to organize themselves into provincial associations. In Nova Scotia nursing assistants had informally organized during the 1950s but in the early 1960s a proper organization was created, the Nova Scotia Certified Nursing Assistants Association. This new body advocated on behalf of the nursing assistants, but all the important questions of approving schools, establishing curriculum, examining candidates, and registering those who were successful remained within the purview of RNANS.76 Despite their position of power, registered nurses clearly had concerns about the expanding number of nursing assistants on the wards and the relationship between the two groups.

29 RNANS also lobbied the Nova Scotia Hospital Association to ensure that clear boundaries were maintained between the tasks assigned to nursing assistants and those assigned to registered nurses and, significantly, to ensure that the salaries of assistants be on the recommended scale and that they “not be increased through successive increments to an amount higher than that earned by the (beginning) Registered Nurse.”77 At the same time, RNANS defined nursing assistants in relation to registered nurses. Nursing assistants, according to RNANS, “may perform functions of the practice of nursing . . . only under the supervision of a Registered Nurse,” thereby ensuring that RNs had effective control of nursing labour on the wards.78

30 RNANS reflected the ambivalence of registered nurses toward nursing assistants, but clearly nursing’s professional organizations were in a position to assert their authority over nursing practice during this period. In addition to this work at the hospital and provincial level, RNANS also regularly commented on national developments regarding hospital insurance. Not surprisingly, nursing’s professional leaders highlighted the need “to ensure and safeguard high standards of nursing service” through approving nursing education standards, standards of nursing care, standards for preparing “auxiliary nursing groups,” clear “personnel polices” for both groups, and standards of “registration and control” for both groups in nursing.79 When hospital insurance was passed, RNANS argued that its implementation must account for “nursing services by professional and auxiliary personnel.”80 At the end of the 1950s, Harvey Agnew observed that “of much concern in planning are the varied effects of the shortage of nursing and other personnel, skilled and unskilled. Some of these effects are evident now; others are certain to develop.”81 Acknowledging both groups of nurses reflected their interrelationship. Nursing practice in the Maritimes was now recognized to include two groups – registered nurses and registered nursing assistants.

31 Nursing practice, fundamentally, was organized around patient care. The introduction of new workers, alienating nurses from some of their historical roles, was a challenge to this key aspect of nurses’ identity. Registered nurses, at the same time, were being drawn away from the patients to do other tasks that had yet to be recontextualized as important to patient care, such as record keeping, coordinating the care of different providers, or helping to integrate diagnostic testing into the patient record and the patient experience. In the 1961 presidential address to RNANS members, Margaret Matheson posed the question this way:

Demand for nursing assistants continued to grow. When the Royal Commission on Health Services (the Hall Commission) surveyed 52 hospitals in Nova Scotia during 1964, it found 707 registered nursing assistants. Hospitals continued to make use of assistants who were not certified, with 531 employed among the institutions surveyed. This combination of regulated and unregulated workers still did not meet the labour needs. More than a dozen hospitals reported that they could not find sufficient staff and that they could employ another 127 registered nursing assistants if they were available. To meet the ongoing demand there were discussions of adding another training program, preferably in the south shore area. In Nova Scotia the board had registered over 1,800 persons since its inception, and of these 1,100 maintained their active registration.83 By the mid-1960s Nova Scotia had fewer than 3,500 RNs, one nurse for every 229 people in the province.84

32 The increasing reliance on nursing assistants in the Maritimes was an important indication that nursing labour was undergoing reorganization. It was also part of a national and international trend. Sandelowski pointed out that the number of registered nurses in the US doubled between 1950 and 1970. But RNs were outpaced there both by practical nurses, whose numbers nearly tripled during the same period (from 137,000 to 370,000), and by nursing assistants, whose numbers more than tripled (from 220,000 to 700,000).85 Across Canada there were 50,131 nurses in 1950 (one nurse for every 305 Canadians), a number that increased to 141,173 by 1970 (one nurse for every 151 Canadians). No national data were collected for nursing assistants, but evidence from Ontario reveals that the number of registered nurses grew from just under 44,000 in 1963 to 54,513 by 1967 (about a 24 per cent increase), while registered nursing assistants grew from 8,183 to 14,011 over the same period (a 71 per cent increase).86

33 The growing presence of nursing assistants posed a problem for registered nurses, who were spending more time charting, measuring, weighing, doing blood pressure readings, and other technical tasks. Nurses were becoming “skilled technicians” and shedding other tasks.87 Cynthia Toman has illustrated how nurses were able to use their technical skills, in combination with their education, to “enhance their qualifications.”88 But some of the abandoned tasks, which have been eloquently described as “the intimate bed and body work”89 of nursing, were at the very core of nursing’s professional identity. On the one hand, some nursing theorists could see ready benefits in routinizing work both for the convenience of managers and to enhance the quality of nursing care.90 On the other hand, registered nurses “lamented the loss of what they perceived to be the natural functions of the nurse to lesser-trained personnel, and of the ‘unmediated relationship’ they once had with their patients.”91 Others expressed concerns that rationalization would undermine nursing’s hard-won professional status and make RNs vulnerable to threats from below. If in the process of labour rationalization some of the tasks of nursing practice were relinquished to other workers, what would become of the registered nurse?

34 The short answer was that registered nurses were charged with directing the tasks of assistants and of supervising them and, through this, would still be very much connected to bedside care. The longer answer was that the division of labour depended upon context and the care that was necessary. There were, of course, debates about the distribution of tasks, scope of practice, where and how nursing assistants would be trained or educated, and matters of regulation. Linda Kealey has described the post-war decades for nursing as characterized by several interconnected developments, including “more specialization among nurses; devolution of more ‘caring’ tasks to nursing assistants and orderlies; increased use of technology learned on the job; increased responsibilities, including more paperwork; higher case loads; more emphasis on efficiency; and more supervision of other staff – most of which also led to less time for patients.”92 As McPherson has noted, different “categories of caregivers” were being arranged both “according to their skill and, to some degree, gender.”93 Nurses retained control over a range of tasks, including charting, administering medications, inserting catheters, and taking blood pressures. Nursing assistants shared a range of tasks with registered nurses, including preparing equipment, personal care of the patient, and some aspects of nursing therapy. Routine tasks, such as organizing supplies, ensuring that a ward was well stocked with supplies, and providing personal patient care, came to be performed by nursing assistants or other unregulated workers. Over time, and particularly as nursing assistants came to be certified, the division of labour became sharper. The formal division of labour, which could be enshrined in legislation or in policy, was important; but it was not always the specific task but rather the patient’s circumstances, including acuity, that could determine whether a task fell to a registered nurse, a nursing assistant, or a practical nurse.

35 Hospital and unit managers were successful in identifying certain aspects of nursing labour that could be divided into more basic tasks, and they advocated the use of other kinds of workers to complete these tasks. The increasing division of labour on the wards, what managers or efficiency experts might have described as a process of rationalization, prompted resistance among duty nurses. On the wards, individual workers could hold fast to the techniques they learned in their nursing schools as one way of limiting the impact of new categories of workers and the administrators promoting the further division of nursing work. Nurses proved resistant to rationalization in part because of their awareness of their craft technique, earned through apprenticeship experiences during their education. Registered nurses, for their part, argued that the use of auxiliary nursing personnel might be entirely suitable to feed a stable, chronic patient; but if a patient was in a more distressed state, these same tasks might well fall to the registered nurse. The contextual nature of care offered something of a counterbalance to rationalization and, although it could not stem the tide of nursing assistants, it at least helped ensure that registered nurses would continue to have a strong voice in the renegotiation of nursing practice.

36 Nursing’s leadership ensured that RNs supervised the work of nursing assistants on the wards and, through this supervision, played an important role in containing the further division of labour. This was exceedingly difficult to do, and in many settings registered nurses and assistants shared duties and performed similar tasks – “a fluidity that further blurred the boundaries” between the two groups of workers.94 In response, registered nurses began to take an increasingly active role in the regulation of nursing assistants. This included creating and approving curriculum, teaching, developing examinations, and registering a sub-segment of nursing auxiliaries – in a word, regulating a new category of worker, the “registered nursing assistant.” This effectively allowed registered nurses to participate in the growing division of labour within nursing while ensuring that they maintained the critical position of RNs at the top of any nursing hierarchy. In this way, registered nursing’s leadership could permit the expansion of the nursing workforce without fully capitulating to the demands of hospital managers, administrators, and health department officials who were interested in opening up nursing practice to a wider pool of workers.

37 The idea of nursing assistants “taking” responsibility, raised by Sister Clare Marie in 1963 and referred to in the introduction, is very different from the idea that nursing assistants were “being made to take” responsibility.95 Recognizing that these were distinct processes, each with their own challenges, registered nurses and their professional organizations expressed ambivalence about nursing assistants. Nursing practice provides an opportunity to explore how groups interacted with one another, with their employers, and with the state during a period when health care’s division of labour was rapidly changing. An analysis of nursing work that includes consideration of nursing assistants, who have largely been ignored by nursing historians, exposes some of the complexity that went into the renegotiation of health care work during the 1950s and 1960s.

38 Registered nurses expressed concerns over the rise of nursing assistants and fears that nursing assistants could displace registered nurses; they also responded in different ways to these concerns. Nursing leaders attempted to carefully delineate the scope of practice of nursing assistants and ensure that registered nurses were in a supervisory role vis-à-vis nursing assistants. There were also attempts to limit the number of nursing assistants. There were suggestions that nursing assistants should be phased out and the nursing labour be redistributed between two groups of registered nurses – those who were university educated and those prepared at the diploma level.96 There were attempts to bring nursing assistants under regulation, either through amending nursing acts or through passing new acts to regulate nursing assistants. Through these strategies, registered nurses attempted to assert their authority over nursing assistants, achieve a degree of control over nursing assistants’ work, and help ensure the ongoing dominance of registered nurses.

39 The relationship between nursing assistants and registered nurses was, then, contested. The growing division of labour that characterized the mid-20th century hospital in Canada and, specifically, the example of nursing assistants in the Maritimes, can appropriately be viewed as part of an effort to rationalize health care work. Barbara Melosh has argued “Most efforts to standardize nursing procedures . . . ended in dismal failure.”97 Nursing’s craft traditions proved remarkably resistant to efforts to speed up work or other practices in the name of “efficiency,” but the increased public funding for health services and hospitals led to further demands for accountability, productivity, and efficiency within the public sector as early as the 1960s.98 The introduction of RNAs, however, offered an effective means of enhancing managerial control, through carefully parsing some tasks to this ever- expanding group. RNs recognized this, and nursing leaders in the Maritimes and elsewhere expressed concerns about the rapid growth of RNAs and the need for regulation.

40 Ann Rhéaume, in her analysis of contemporary New Brunswick, has noted that there is an “ongoing debate” in the health services literature about the “advantages and disadvantages of a heterogeneous skill mix in nursing.”99 Such debates are deeply embedded in the history of Canada’s health care system. Critical perspectives on the renegotiation of nursing practice offer important insights into the organization of care offered to patients, the organization of hospital labour, and the active participation of governments, educators, professional organizations, and providers in the debates over who should provide care. The growth in the number of nursing assistants, both in absolute terms and relative to the number of registered nurses, illustrates the renegotiation of nursing’s scope of practice and the accompanying reorganization of nursing labour that took place during the 1950s and 1960s. The growing consciousness of nursing assistants of their work as a discrete and important part of the nursing labour force, expressed through their demands for a greater role in the regulation of their work, the creation of provincial organizations to represent the interests of RNAs, and their demands for better pay and working conditions suggests that by the end of the 1960s, nursing assistants in the Maritimes were taking an active, if constrained, role in the renegotiation of nursing practice.