Question

Describe the evolution of the hospital as a social institution. Be sure to define this term and using at least one (1) example of how the hospital is an institution.

• What role does religion play relative to the hospital as an institution? Be specific.

• What does “institutionalization” mean relative to hospitals/medicine?

Answer 1

The hospital has had its periods of advancement and of decline. It has experienced its golden ages and its dark ages. Like other fundamental institutions, it has existed on sentiment, interest, tradition, and custom. Nevertheless, it holds an important place in the life of the people.

In the early history of the hospital, very little rational attempt was made to improve it. Even as late as the eighteenth century there was a cultural lag between hospital improvement and the scientists. They did not apply their knowledge to hospitals. It was not until other groups began to exert a dominating influence that the attitude toward the hospital began to be changed from the primary level to a more intellectual level. The culture of the nineteenth century, the strong humanitarian movements, the development of science, were forces favorable to hospital advancement. The transition of the hospital from the old order to the new fills a classical chapter in the history of the achievement of the hospital.

As a result of the abuses which entered into the medieval hospitals, the care of the patients was grossly neglected. With the dawn of the Renaissance in Western Europe, the care of the sick and injured began to be improved. Physicians studied the ancient Greek writers, whose works had been copied and preserved by the monks in the monasteries. Anatomy became a recognized study. Dissection was performed, which had been forbidden by the church. The dissemination of knowledge and the opportunity for clinical study were en­couraged. Other more concrete factors that contributed directly to the care of the sick and the improvement of the hospital were: sanitary science; control of pain, hemorrhage, infection ; changes in hospital construction, the basic principles by which the hospital is gov­erned, its organization, standardization, de­partmentalization.

Contributing Factors
Sanitary Science. In the reign of Queen Elizabeth attempts were made to reduce the number of residents in dwelling houses. When the epidemics of cholera and jail, or typhus, fever broke out, with their devastating consequences, further efforts were made to control the spread of contagious diseases. Early in the eighteenth century, many authors began writing on the importance of air. Foremost among these was Boerhaave of the medical school of Leyden. He and his students be­came the "prime movers" in the development and practical application of sanitary science in treating the sick. The work of John Howard, the English philanthropist, was effective in drawing public opinion to the subject Of reform in sanitary conditions, which resulted in im­proved management of both hospitals and prisons.

Control of Pain, Hemorrhage, and Infection. The gradual improvement in medical science, too, was a major factor in improving the care of the sick. Better care of the sick and injured in the hospital came about largely through the works of Sydenham in the latter part of the seventeenth century. Of him Hag­gard says, "Thomas Sydenham gave medicine the form it holds today. He made it a disci­pline to which experimental science and mathe­matical science could make their contribu­tions."' Until this time medicine had not gone beyond the curative medicine of the Greek physicians, Hippocrates and Celsus. In the sixteenth century, Ambroise Pare, the famous military surgeon, with his contemporaries abolished the use of the cautery for the control of hemorrhage, and introduced the ligature. Almost three centuries later, through the work of Long and Morton, who demonstrated the use of ether (1842), the fear of pain and sur­gery received its final blow.

In the nineteenth century, as a result of the advance made in the basic sciences, further improvement took place in the hospitals. Through the classical work of Pasteur, prov­ing the germ theory of disease, Lister (who accepted Pasteur's work) introduced his doc­trine of antisepsis, by the use of the carbolic spray. In this way the dreaded infection of surgical wounds was brought under control.

But the most outstanding contribution to hospital safety was made by the famous Eng­lish nurse, Florence Nightingale. As a result of her work as a hospital organizer and ad­ministrator, men, women, and children today approach the hospital with confidence instead of fear, and look upon it as a place where efficient and scientific help may be obtained.

In the nineteenth century three other factors influenced the hospital in the care of the sick. Steam sterilization was introduced in 1886. Thus marked the beginning of surgical asepsis —the sterilization of everything that comes in contact with the wound. In 1895 Roentgen's

X ray became a valuable adjunct as a diag­nostic and therapeutic measure, and the use of physical therapy, hydrotherapy, and heliother­apy began to assume a more prominent place.

Contributions
As long as the Church of Rome had control of the hospital, no change was made in its construction. The hospital was considered as a church institution. The wards were clustered around the chapel, for life centered in the chapel.

It was not until the latter part of the nine­teenth century that a change was made in its structure. Medical men and surgeons began to concern themselves with the problem of hospital design and construction. Until this time very little attention had been given to it. The French Academy of Sciences is given credit for being the first among the scientific bodies to promulgate principles and rules for hospital design.

The importance of proper ventilation and air were more fully recognized. To meet these requirements, the pavilion system was adopted in preference to the old block system. By the pavilion system is meant a detached block of buildings separate from any other pavilion the hospital may have, or adminis­trative offices. The first hospital to be built on the new plan was erected in Stonehouse, England (1756-64). It was proportioned to the number of sick that it might accommodate, as well as being capable of containing, the largest number of beds that might be placed in it with safety, together with suitable nurses' rooms, wards, utility rooms, lavatories, baths, and water closets.2

The modern hospital (especially in a large community) has its reception rooms, solariums, dining rooms, diet kitchens, toilets, baths, nurses' living quarters, recreation rooms, laundry, power plant, mortuary, store, and other accommodations housed separately. Sometimes the surgical unit, too, is isolated except for connecting passages. It may occupy the top floor, have a skylight and side windows, and anesthetizing, recovery, and sterilizing rooms. In some institutions, the obstetrical unit is also isolated, except for connecting pas­sages.

The site of the hospital, too, has received consideration. It is to be built where ample fresh air can be obtained, away from neigh­boring buildings, the dust of the streets, rail­roads, traffic, and manufacturing plants, and the wards are to be exposed to sunlight at least part of the day.

It has become a recognized fact that in the present era no building or group of buildings has more care, pains, and expense lavished upon it than the hospital, and none imposes greater and more complex problems upon the architect.

Basic Principles
Since the hospital no longer fulfills the double role of being a place for the sick and an almshouse, as it did during its early history, sound basic principles have been formulated whereby it is governed, for the protection of both its patients and itself. These are as fol­lows:

1. "The primary objective of the hospital is the service it can render the sick and injured, reward, financial gain, and other activities being secondary considerations.
2. "The ethical principles governing the entire per­sonnel are the same as those governing the physi­cian as an individual.
3. "Patience, delicacy, and respect for confidence are regarded as characteristic of the acts of all deal­ing with the sick in the hospital.
4. "The hospital is expected to employ only those of upright character and sound morals.'"

The patient is the focus of attention in the hospital. Its attitude, therefore, is that what­ever effort is necessary for securing or ex­pending money is put forth for the purpose of providing the most efficient and effective care for the patient to the best advantage.

For various reasons a hospital code of ethics is essential in governing each member of its personnel. The hospital deals with two great phenomena, life and death. Often the confi­dence of the patient in the physician, or the one caring for him, may be a deciding factor in his life. Again, any discussion before the patient of his case may result in misapprehension. Real evils may be magnified, or new ones may be created; for patients are not usually acquainted with medical terminology.

The confidential information, too, of the patient, pertaining to himself, his relatives, his friends, or what has been obtained through observations or examination, is to be held as a sacred trust. It is incumbent upon each one connected with the hospital to avoid any indis­cretion or fault that would "decrease efficiency or lessen the trust of the patient." All personal feelings are to be submerged, and kindness, consideration, forbearance, firmness, and the comfort of the patient, made the rule in service.

Standardization
A distinctive aspect in the advancement of the hospital has been its standardization, char­acteristically termed the "hospital betterment period." The standardization of hospitals in the United States began in 1918 through the efforts of the American College of Surgeons, which has explained the movement in these words : "Hospital standardization is, essen­tially, an effort to have all hospitals emulate the practices and ideals of those that are achieving the best results for the good of the patient."4 Its program is the dissemination of knowledge of advanced methods and principles that have been successfully used in the more progressive institutions; to study practices and interchange opinions; to be alert for every new idea that may improve hospital service, as well as closely observing its effectiveness; to con­duct surveys ; and to rate each hospital annu­ally so that there may be no relaxing of its requirements.

Standardization has been purely voluntary, but hospitals have nobly cooperated with the movement. To assist hospitals, a minimum standard has been set up, the basic principles of which are as follows :

1. A modern physical plant, properly equipped for the comfort, safety, and scientific care of the patient.
2. Clearly stated constitution, bylaws, rules, and regulations, setting forth organizations, duties, re­sponsibilities, and relations.
3. A carefully selected governing board having complete and supreme authority for the management of the institution.
4. A competent, well trained executive officer or administrator with authority and responsibility to carry out the policies of the institution as author­ized by the governing board.
5. An adequate number of efficient personnel, properly organized and under competent supervision.
6. An organized medical staff of ethical, compe­tent physicians and surgeons for the efficient care of the patients and for carrying out professional pol­icies of the hospital, subject to the approval of the governing board.
7. Adequate diagnostic and therapeutic facilities with efficient technical service and under competent medical supervision.
8. Accurate and complete medical records, promptly written and filed in an accessible manner so as to be available for study, reference, follow up, and research.
9. Group conferences of the administrative staff and of the medical staff to review regularly and thoroughly their respective activities in order to keep the service and the scientific work on the highest plane of efficiency.
10. A humanitarian spirit in which the best care of the patient is always the primary consideration." 5

The approved hospital is considered to be one of the greatest assets in a community, for two specific reasons : (a) the patient is assured of scientific care, and (b) to encourage co­operation between hospitals, and provide op­portunities for the exchange of ideas which has been made effective through hospital conferences.

Nursing is no longer a vocation, but a profession. Since the time of Florence Nightingale, it has formed a definite part of hospital organization. Formerly nurses were trained under an apprenticeship system. They were exploited by hospitals, but this did not seem to occur to them, because of their high ideal of consecration to service. In this early period of the history of nursing, emphasis was placed upon the practical aspect of the work.

With the development of the school of nursing, theory began to be recognized as of equal importance with practice. Attention began to be focused on better education for nurses, which meant better care for patients. To protect the nurse from further exploitation, and assure her that she was receiving the proper education in her school of nursing to fit her for the profession, nurses (through their various organizations) formed a Committee on the Grading of Nursing Schools.' The work of the committee covered eight years. Its final report is given in "Nursing Schools Today and Tomorrow." As a result of this work, schools were placed on a sound basis, for no hospital today is allowed to operate a nursing school which is not listed on the registry of the Amer­ican Medical Association. In addition, the committee considered the better education of nurses as important. It advised specialized training for nurses, and endeavored to supply sufficient nursing service.

The work of this committee has been an outstanding achievement in the field of nursing and in hospital service. A different kind of woman now enters the profession—one who does not consider nursing as a good vocation alone, or look upon it from the viewpoint of the idealism of its service; but one who also views it in its broader perspective, thinking of its ,educative and social service. The nurse is an educator and a social worker whether she is ,conscious of it or not. Dr. Haven Emerson goes so far as to say :

"I have often felt that there is among the nursing group the largest potential power for the correction of social ills that exists within the country, because nobody else knows what is the horror, the fear, that 'hangs over people from unemployment, as the nurse does. Nobody sees what it means to be politically "hounded the way the nurse does of the home which is subject to political catastrophe. The nurse knows well what it means for a family breadwinner to suffer a reduction of wages. The nurse is the eyes and conscience of the community in seeing and judging those matters which adversely affect the health and life, the survival of babies and children and parents in the home."

In the hospital the nurse contacts all depart­ments. An interrelationship exists between her and the medical staff, the adjunct depart­ments, and the administration. Often she is the only confidante of the patient. She must keep a correct record of her observations, of symptoms, or of any physical or mental changes of the patient. She must cooperate with the administration in reporting the seriously ill. No hospital today is considered efficient which does not have a well qualified, well disciplined nursing staff. Good nursing service is one of its greatest assets.

Hospital Functions.—Institutions origi­nate because of fundamental human needs. They survive because they satisfy these needs. They are based upon a nuclei of interests, tra­dition, and custom. They are among the more stable forms of control.'

The hospital in its social structure compares favorably with the nature of other human institutions. It, too, has been built up around a nuclei of sentiment, tradition, custom, and interests. By the nature of its complex organization, its particular type of function, its per­sonnel, the hospital has become one of the most firmly established social institutions.

Its chief interest is the patient. It primary function is the care of the sick and injured for whom it must provide the type of care and service which will result in the most effective cure or improvement of the patient. All other functions are subordinate to it ; but have be­come a part of the responsibility of the hospital, because they contribute indirectly to the care of the patient.

Nursing as a social institution is as old as the human race, but nursing as a profession is a nineteenth century innovation. Through their national and State organizations, nurses have raised the status of nursing from a state of exploitation to a profession. Today, the nurse receives part of her formal education in other institutions of learning, and part of her theoretical and practical training in the hos­pital.

The Patient.—The patient, who is the most important person in the hospital, is no passive observer of all that it attempted for his resto­ration to health and participation in normal society.

Illness is a reality through which new values may be developed and attitudes changed. The patient finds his normal course of life rudely interrupted. He has been accustomed to em­ployment ; now he must submit to enforced idleness. In his active life, he has had no time for contemplation ; now he has more time than he desires. He has been accustomed to making his own decisions; now they are made for him. He is advised regarding practically every detail of his bodily affairs, which formerly he con­sidered as his own private business.

In his illness, his understanding may be en­hanced by contact with others, or his prejudices may be deepened, his fears strength­ened. He may be overcome by discourage­ment, or he may defeat it. He may learn new values by making modifications and finding satisfactions and new strength through direc­tion and growth within himself. He must learn to accept his limitations and improve his capacities. He must get adjusted to his diag­nosis and treatment and his hospitalization. Through his contact with the hospital per­sonnel, he is taught daily adaptation and ad­justment to his condition and to his environ­ment.

Every member of the hospital personnel contributes directly or indirectly to the educa­tion of the patient. While he is in the hospital, he can be taught certain health concepts and the prevention of a possible recurrence of his present illness. For example, if his illness has been due to a dietary problem, he may be instructed in certain facts of nutrition. If he has a special diet, he may be guided in his adaptation of his diet to a normal routine of life. He may be taught the benefits of creative recreation, and the principles of healthful living.

To help the patient more effectively, in his education and rehabilitation, medicosocial serv­ice has been introduced into hospitals and is becoming an accepted part of clinical medicine. Medicosocial service is not a twentieth cen­tury innovation, but dates from the monastic almoner of the Middle Ages. The present hospital social service, as a new profession, is but thirty years old. Dr. Richard Cabot is credited with being the first to integrate med­ical social service into the plan for satisfactory medical care. It is now a recognized fact that effective medical care must contribute to the total personality. Between disease and poverty there exists an intimate relationship, as also between a satisfactory income and adequate medical care, and between social maladjustment and social integration. What hospital social service is has been adequately defined by Lewis: "Hospital social service is an attempt to interpret and adjust the terms of one to the other, the patient's medical liabilities to his social assets."4 Its objective is to "save human life for some purpose, safeguard human rela­tionships precious to the person."

The purpose of medical social service is defined by MacEachern:

"The purpose of medical social work in the hospital is to obtain and apply such understanding of the patient as will enable the institution, the physicians, and other agencies to comprehend and treat his ill­ness more effectively."

Disease has always been recognized as a potent social factor. It disrupts family life, frustrates cherished ambitions, demands physi­cal and mental adjustments, focuses the mind on body functions which have, heretofore, not entered into one's consciousness. There are emotional instability and character manifesta­tions which in health were more or less under control. The patient's religious resources are often severely drained, his confidences en­hanced or severely shaken. Pain, fear, worry, the feeling of insecurity, inadequacy, and helplessness not infrequently form the mental environment in which the patient lives.

The services of the medical social worker are varied, but the major activities are:

1. "Inquiry into the social situation of the hospital patients, and the reporting of the findings to the re­sponsible physician.
2. "Determining, in collaboration with the physi­cian, the factors in the social situation pertinent to the patient's health, and stating these as medical social problems or diagnosis.
3. "Setting up, in collaboration with the physician, a possible goal or best estate for the patient to aim for, given the medical problems and the social situa­tion of the patient, and distinguishing the role the social worker is to play in the plan for helping the patient achieve his goal.
4. "Executing the social worker's part in the plan for helping the patient achieve his best estate."

The medical social worker, by finding out the patient's general health problems, his eco­nomic, domestic, and industrial status, estab­lishes an understanding of him, and in turn helps him to understand the things he needs to know for his personal welfare, sees that he is properly cared for, and, if possible, restored to health. If he needs help during his period of convalescence or chronic care, she assists him, by making contacts with other social agencies. She helps him to become adjusted to his environment, especially where there is a home environment or emotional disturbances that affect his health.

An understanding of the patient as he usually lives, thinks, feels, and acts, as well as knowledge of his usual place of abode or physical environment, is essential in order to give medical care that will embrace the whole health problem of the individual. This infor­mation the medical social worker is able to furnish.

Medical social service has not yet become an established department of the hospital in the same sense as the clinical laboratory or other departments. Emerson believes that it should become an integral part of hospital organiza­tion, however. Such a department is to be provided for in the hospital budget, in order that a study may be made of the patient's social and economic conditions, as well as his physical and psychic states. Thus the treatment may be more accurate and effective. The editors of Modern Hospital, in a beautiful tribute to medical social service, state :

"The social service is the conscience of the hos­pital. Without it, rules and regulations would be far more rigid and the policies of the hospital far more inflexible. . . .

"Social service, in its most typical form, warms the heart of the scientist and prevents him from becoming reconciled to suffering. If the patient does not get the full benefit of its ministrations, the fault, as a rule, lies elsewhere. When the physician or surgeon has done his best and has not succeeded, it is the social worker who is left holding the bag."

Every well integrated social institution makes its contributions to society. The hospital as a social institution has materially contributed (I) to the community, (2) to the public welfare, and (3) to the advancement of civilization. Were the hospital suddenly to be withdrawn from a community, there would be seen an immediate effect upon the health, busi­ness success, and general well being of a large percentage of the citizens.

I. Contribution to Community Life. The aim of the hospital is at all times to keep the population it serves in good health and "fit for the problems and work of life." To attain this end, the hospital has, through its own com­munity organizations—national, State, and local—raised its professional standards where­by better service is rendered to the sick of the community. The leading medical associations. as the American College of Surgeons, the American Medical Association, the American Hospital Association, and the • American Nurses' Association, have originated to benefit the health and happiness, not only of the imme­diate community, but of society in general.

"Organizations tend to multiply until they cover the whole range of human interests." In the hospital, organizations have multiplied and tend to cover the whole range of the one supreme human interest for which hospitals were instituted—the care of the sick and injured.

As a community medical center, the hospital promotes the public health and the general wel­fare of the people. As a commercial enter­prise, the hospital also contributes to the com­munity. It gives steady employment to a large number of citizens, whose salaries and wages find their way into business. It pays large sums of money for its supplies and its equip­ment. Not infrequently, persons will come to the community because they wish to be in the hospital. Sometimes their relatives and friends come to stay. This all brings trade to the com­munity.

2. Contribution to Public Welfare . In addition to its contribution to community life. the hospital also contributes to public welfare. As stated by Caldwell :

"Hospitals are human laboratories, and many, if not all, of the greatest lessons of medicine and surg­ery have been learned in them. The world would know little of the control of typhoid fever, the pre­vention of scarlet fever, the eradication of yellow fever, or any of the other achievements of modern medicine, if a profound study of these problems under competent supervision had not been afforded by our hospitals. And so the community benefits, not the individual alone, and whatever measure in dol­lars and cents the hospital costs the community, is returned a thousandfold."

Preventive medicine has been made possible through hospital cooperation. Hospitals con­tribute to the public health through improved techniques of treating the sick, better medical and nursing service, better organization, and better equipment. Their contribution has been epitomized by Bacon:

"Our hospitals constitute an endless road which twelve million patients travel yearly to health and happiness. To keep this road open we spend one billion dollars annually, not only in the care of the sick, but in training doctors, nurses, technicians, and health workers who form the nucleus for nation, There is no in­dustry in our land today that affords such steady employment to our people as the hospitals. Our doors are never closed. We care for the sick 365 days in the year, day and night. We must always be prepared for a peak load. We must give continu­ous and uninterrupted service at all times. We can­not shut down our plant and lay off our people be­cause of a financial depression. We must carry on some way. There are some small cities that are almost entirely dependent for their existence on the institutions of healing in their midst." '

People are rapidly losing their fear of hos­pitals. They come to them to be restored to health in the quickest time, and the patient's stay in the hospital has been materially shortened. It was reduced from thirty five days to twenty eight days a quarter of a century ago.

In 1938 the average stay in the hospital was eleven days. Twenty five years ago an opera­tion for the removal of the appendix invariably hospitalized the person for twenty one to twenty two days. Today, he leaves the hospital in ten days, ready to resume his duties. This is an economical feature not to be disregarded. He saves both time and money. Bacon has made this observation : "If you figure his salary at five dollars a day, you will readily see that this saving in time over twenty five years ago will pay his hospital bill if he has award bed!'

If emergencies arise, the hospital is always ready to take care of them. During epidemics, earthquakes, or other catastrophes, the sick and suffering are cared for regardless of whether they are able to pay or not. In time of war, the hospital personnel aids the soldiers at the front, while it endeavors to protect the health of the people at home. It works in cooperation with the Red Cross and other health agencies to benefit the health of the people. Many lives have been saved which have been a real econ­omy to the nation. Without healthy bodies, there can be no true moral education, physical success, or happiness.

The hospital knows no creed but that of service. It entertains no bias or prejudice, except against disease. It knows no interna­tional boundaries, for every nationality is included in its patient list. Its services are at the disposal of everyone who passes its doors for care. It is the most democratic of social institutions.

The existence of hospitals is evidence per se of a civilization superior to barbarism, a civilization in which people are more interested not only in the well being of themselves and their families, but also in the welfare of their neighbors. Hospitals have been a traveling companion of an improving civiliza­tion, of a progressive enlightenment, of a marked advance in science." '

3. Contribution to Civilization. Socio­logically the hospital has contributed to the advancement of civilization. It has stimulated inventive art. The instruments and machines used in treating the sick are among the most finely adjusted and the most intricate mech­anisms. It has stimulated creative art as re­vealed by the beautiful frescoes of the medi­eval hospitals, the murals, sculpture, wood carving, and architecture. It has fostered re­search in practically every aspect of scientific medicine.

The hospital, down through the ages of its recorded history, has been a dynamic institu­tion. It has slowly changed both tradition and custom, sometimes reluctantly, but usually tri­umphantly, to meet social needs. Again, the hospital is in a period of change attempting to develop ways and means whereby it may aid society and solve the problem of making the fund of medical knowledge available to every­one.