United States Share in the Reorganization of the Czech Nursing School in Prague in 1920–1923

Background: The research was motivated by the efforts to deepen the present knowledge in the opinions of American experts, who, on the basis of their experience, paid more attention to the reorganization of nursing care than official bodies in inter-war Czechoslovakia. Aim: To clarify the role of Red Cross of America nurses and Rockefeller Foundation experts in the introduction of modern approaches in nursing at Czech nursing school in Prague in the years of 1920–1923. Methods: The study is based on the retrospective analysis of historical documents and periodicals originated from the activities of Red Cross of America and Rockefeller Foundation as two main American organizations being involved in the reorganization of nursing care in inter-war Czechoslovakia, including the American Journal of Nursing from the years of 1920–1923 and the voluminous History of the American Red Cross Nursing (New York, 1922). Ascertained data were compared with those from the Czech archival funds (Spolek diplomovaných sester – Association of Registered Nurses, Correspondence of Alice Masaryková) and with a detailed situation report on nursing conditions in Czechoslovakia by Frances Crowell from 1922. Outputs: The focus on the short period of 1920–1923 made possible to cover in more detail and in the broader context all difficulties which the American nurses were faced with. The research contributed to the present state of knowledge in three fields: 1. Data on the professional career of American nurses coming to Czechoslovakia evidence that they were trained experts who gained practical and organizational experience in nursing service during the World War I. 2. The main problem in teaching was the need for relation change between theory and practice in favour of practical subjects and for increase in the prestige of nurses. New courses on nutrition for people with disabilities, on bacteriology, ethics and history of nursing were incorporated into the curriculum. Managing children‘s home healthcare was another completely new element in teaching. 3. The recommendation of American nurses for the next improvement of education and nursing care included the proposal to establish a special nursing division at the Ministry of Health which ought to provide for nurses ́ authority and status, including requirement for their education, to keep files of registered nurses and to provide public health facilities inspections. Emphasis was also placed on expanding the network of state nursing schools. Conclusions: The research proved a range of problems which had to be solved at that time. The activities of American Red Cross nurses and Rockefeller Foundation experts in adverse conditions can be described as phenomenal feat whose influence has not yet been fully appreciated. Many problems solved at that time, like competence specifications, nursing standards or patient education, are topical even today.


INTRODUCTION
Current qualitative changes in nursing, such as establishment of regulated professions, introduction of a single scientific terminology or implementation of evidence-based practice, are the result of broad international cooperation, dating back to the period after the First World War, when the American Red Cross together with the Rockefeller Foundation started to promote the Anglo-Saxon model of nursing in healthcare within the contemporary global aid.Changing conditions in the current professional education of paramedical staff and definition of new competencies within the Single European legislation for the nurse profession encourage to explore different approaches and conditions in the past and to search for inspiration and similarities.Our thesis tries to answer three research questions: 1.What were the professional experience of American nurses on mission to Czechoslovakia in 1920, 2. How did the organization and content of education at Czech nursing school in Prague change under their influence and 3. What were the recommendations of the American Nurses for further improvement of teaching and nursing care after leaving Czechoslovakia in 1923?These problems have not been paid adequate attention from the Czech side.The work is based on detailed information about initiatives of the American Red Cross (ARC) in interwar Czechoslovakia, published both in extensive contemporary manual History of American Red Cross Nursing (New York, 1922), and on pages of The American Journal of Nursing.Also less detailed sources of Czech origin were used for comparison: journal Zprávy Československého červeného kříže ("News from Czechoslovak Red Cross") and archives of Spolek diplomovaných sester ("Association of Certified Nurses") and Correspondence of Alice Masaryková.From the perspective of the Rockefeller Foundation, the reports, evaluations and recommendations from Frances Elisabeth Crowell, summarized in a thesis by Elizabeth Vickers, are crucial on the condition of nursing in post-war Czechoslovakia.

DESCRIPTION OF RESEARCH STRATEGY
Activity of US nurses at nursing school in Prague between 1920 and 1923 was the criterion for selection of sources and literature.Information was obtained from the following databases: PROQUEST, EBSCO, JSTOR, GOOGLE Scholar, BMC, OVID, PubMed, Kramerius, Badatelna.eu,My Heritage and Ingenta Connect.Through these we found a total of 45 titles, of which 24 were excluded for not matching with the objectives set.We used a total of 13 articles, four monographs, one thesis and two archives from the Prague City Archives and the Masaryk Institute -Archives of the ASCR.Hardly accessible archives stored in the US remained unused.The obtained data was divided into three thematic categories: 1. representatives of American institutions, 2. forms of foreign aid, 3. organization of studies.

The First World War and formation of a two-year nursing school
The beginnings of nursing field in the newly created republic were very modest.In 1918, only ten registered nurses were trained among the first graduates of two-year state nursing school falling under the General Hospital in Prague.Although the school, divided to the Czech and German section from the beginning, was founded in 1914, lessons launched in May 1916 for lack of teachers, and only 15 students were accepted to each of the two sections.Theoretical training at Czech school led by Františka Fajfrová was provided by graduates of the Viennese school of nursing Olga Holubková, Gizela Bártová and Božena Březinová (1).According to Viennese model, teaching of medical disciplines prevailed over practical nursing subjects in Prague at that time.Lessons of practical subjects were based on a manual by Florence Nightingale Notes on Nursing, published in Czech translation in 1874.
The First World War escalated in many health and social problems solved with a substantial contribution of the Red Cross.A general increase of prestige of this organization on the international field led to establishment of a separate branch also in Czechoslovakia on February 6, 1919.The need for skilled nursing forces was very urgent at that time, thus the nursing education faced the challenge of increasing the number of qualified health care personnel and improving their vocational training.Alice Masaryková was well aware of this and as the first president of the Czechoslovak Red Cross (CSRC), she started negotiations with representatives of ARC and the Rockefeller Foundation (RF) on future assistance and cooperation in Paris the same year.

The Paris negotiations with representatives of the American Red Cross
ARC sent about 600 trained nurses and their assistants to work in post-war continental Europe, Russia and the Middle East during the years 1918-1922.Most of them exercised in Poland, Czechoslovakia, the Balkans and in Siberia.Meaning of such missions consisted not only in improving nursing care on a global scale, but also in strengthening of US influence in the world to beyond the political level (2).The ARC set supporting of professional nursing education as a priority.Thanks to the initiative of Alice Masaryková and her father the Prague School became the first ARC destination in Central Europe, and there were also schools in Poznan and Warsaw based with the support of ARC a little later (3).
At the mentioned meeting in Paris in 1919, it was agreed that the Czech part of the Prague nursing school will pass into administration of the CSRC in 1920, while the German section will remain in state hands, which guaranteed better financial security.
Lessons in German classes proceeded in a traditional style of Viennese nursing school, while Czech section under the administration of the CSRC outstanded by much stronger interconnections with the United States, allowing implementation of modern approaches tested and proven in Anglo-Saxon countries into Czech nursing.Marion Geneth Parsons, qualified nurse from municipal hospital in Boston, who returned from military service as a head nurse of the British Expeditionary Force General Hospital at that time, was entrusted with leading and reorganization of Czech school for three years.Her mission in Prague was financed by the ARC at the request of the Czechoslovak Government.Alotta M. Lentell, qualified nurse and former deputy director of nursing school at the Newton Lower Falls Hospital in Massachusetts, who served with the Red Cross in La Panne in Belgium in 1915 and at the Naval Health Service in 1918-1919, was selected for the position of assistant for the future director (4).These two experienced nurses were subsequently joined by three American colleagues: Blanche Kacena, Pansy Besom and Rachel Torrance.
The expectations from the American side were great.Alice Fitzgerald, head nurse of the European division of ARC, graduated from a prestigious nursing school at Johns Hopkins University, expressed very optimistic about this project: "I feel that Czecho-Slovakia is going through a period of readjustment during which they seem to be in a very receptive mood.This is rather well shown by the fact that sixty women who are third-year medical students have been taking lessons in Home Hygiene and Care of the Sick from the Red Cross nurses now in Prague.As Dr. Alice Masaryk, who is fostering this undertaking, points out, these future doctors will necessarily have a better understanding of the nursing profession than they ever had before, and through personal experience will realize that nursing should no longer be considered a degrading piece of work."(4).

Financial aid from other American organizations
Czechoslovakia, considered to be a country with ideal conditions, received financial support also from the RF as the first in Central Europe.It remains unknown to what extent the Czechoslovak project anticipated the single model health program, which should have been applied throughout the whole region (5).The nursing school in Prague also received financial contributions from The International Committee of the Red Cross in Geneva, The League of Red Crosses, Herbert W Hoover Foundation, Young Men's Chris-tian Association (YMCA) and Young Women's Christian Association (YWCA), followed by Fund of Charles Crane, a wealthy American businessman, slavophil and personal friend of Tomáš G. Masaryk, whose funds paid the construction of school building (6).

Study internships in the US
At the meeting in Paris, the ARC committed to pay two fellowships of Czechoslovak nurses in the United States each year.The RF was even more generous, because total of 22 Czech students travelled abroad at its expense during the very first three years.Božena Březinová and Františka Růžičková were sent out as the first ones in 1920 and they headed to Massachusetts nursing school of General Hospital in Boston.However, they had to undergo language training first, so they started studying on January 1, 1921.Moreover, health problems occurred in some Czech nurses, derailing the original plans.Božena Březinová suffered a nervous breakdown shortly after starting the school.She was sent for examination at MacLean Hospital, where she remained until the autumn of 1921, and then returned back to Czechoslovakia.Vilma Černá, a recent graduate of the Prague nursing school, already partly trained by Marion Parsons, arrived in the US instead of her.She worked at Presbyterian Hospital in New York first to become more familiar with American methods in nursing, and then she joined Columbia University as a special student in management of nursing schools.However, her study was less effective due to insufficient knowledge of English, and she was reclassified to the Massachusetts General Hospital in the summer of 1922.She returned to Prague in September of the same year and worked as an assistant of Marion Parsons (7), but she died shortly after returning home (8).

Changes in organization of studies
Teaching staff of the Czech nursing school, initially formed by Marion Parsons and Alotta Lentell, soon expanded with Blanche Kacena, a Czech-American qualified nurse, trained specialist in the management of nursing schools, who spoke Czech as the only one of the American nurses.Knowledge of Czech language allowed her to pursue the supervision of hospital regulations and to manage the practical training at hospital departments without an interpreter (9).
Also other workers of ARC were involved in teaching according to needs.Pansy Besom, graduated from nursing school in Delaware, who worked both in the public health service in Stamford, Connecti-cut, as well as a children's home care nurse in Boston, was one of the most experienced.She worked in the operating room and dispensary in Poland and Czechoslovakia, and was also an instructor of nursing courses.As a director of the ARC Nursing Service in Czechoslovakia, she supervised the construction and management of child health centres and participated in the implementation of a complete health and social records on each child in the country.Besom was particularly interested in methods of monitoring a child, when he is back home, because there was no plan in this respect (10).May Louise White was her assistant.Apart from them, there were more instructors of home care in cooperation with the CSRC, such as Mary H. Bethel (7).Rachel Torrance, assistant to Helen Scott Hay, a head nurse of the European division of the ARC, was also engaged in teaching in the years 1920-1922.Torrance worked as head nurse in Belgrade the year before and became director of nursing school in Sofia in 1923 (7).
In addition to the two-year study, the headmistress organized also four-month nursing courses, which, however, had to be taught mainly by doctors from Prague University because of language barrier.Reorganization of school required new contents of studies.A need to change the ratio of theory and practice in favour of practical subjects deemed most urgent.Parsons gradually incorporated lessons of cooking and nutrition of invalids and course of bacteriology into the curriculum, putting an emphasis on ethics and the history of nursing newly (7).Mary McDowell, major American social worker, founder of the house for immigrants at the University of Chicago (Hull House) and a close friend of Alice Masaryková, prepared a new curriculum of the school during her stay in Czechoslovakia in 1921 (11).English lessons and transition from German to English literature were among the most significant introduced changes.The newly conceived nursing studies were focused on receiving broad perspective and social sensibilities as well as expertise and skills.The curriculum included anatomy, psychology, bacteriology, physiology, hygiene, internal, surgical and gynaecological nursing, infant and child care, psychiatry, hospital administration, civic education and laws on public health and social care.The last mentioned subject included nursing practice in the field and demanded involvement of a well-trained nurse (9).
Edition of manual American Red Cross Textbook on Elementary Hygiene and Home Care of the Sick, written by leading expert Jane Arminda Delano, founder of the nursing division the ARC and director of nursing schools in New York and Philadelphia, was a significant act for the dissemination of knowledge about modern approaches in nursing.It was a translation of the second version of the text modified by Anne Hervey Strong, professor of nursing at Simmons College in Boston.This book, which was translated from English in 1921 by Jaroslav Lenz, head physician of the St. Elizabeth's Hospital in Prague, was so modern in its time that the basic care was provided according to its sophisticated principles long after the Second World War (12,13).
From the beginning it was clear that one school is not enough and it will be necessary to establish another one (14).This, however, failed for several reasons for a long time.Responsibility of Prague institute was therefore greater, as they provided not only qualified care for patients, but they also had to prepare nurses for the profession of future teachers, management personnel and leading representatives of their field as the only institution in Czechoslovakia at that time.
Despite all the problems, American nurses perceived their mission in Czechoslovakia as successful.Mainly the short-term courses were among the most popular, attended regularly by about 60 students.About half of them were non-Prague students who were accommodated in a school building.The pursuit of proportional representation motivated the school management to accept girls not only from Prague but also from Moravia and Slovakia (15).The students originated mostly in lower middle class and there was a monthly fee of 70 Czechoslovak crowns required from all of them initially.It was not easy to attract also the girls from higher social groups for studies.Persistent stereotypes about nursing as a profession for wealthy ladies with no qualifications was supported also by the approach of many doctors, who preferred to employ nurses with the lowest possible education and held a generally hostile attitude towards the nursing school (7).
The school board of trustees consisted of nine members, among who there was a representative of provincial political administration, director of the CSRC, minister of public health and physical education, director of General Faculty Hospital, three professors from the Medical Faculty of Charles University, president of the Ladies Club and the headmistress of the school (1).Parsons gradually managed to train this committee so that its members were aware of what demands should they make on future teachers and where to lead the school.They lacked experience in teaching.The doctors needed to be explained, what was the value of good nurses.However, it caused certain conflicts, because some members of the board of trustees from the government and university as well as broader medical community were initially hostile to the school led by Parsons.It turned out that the main problem lied in misunderstanding of Czech mentality by the American director, who viewed herself as a kind of saviour, and did not want to understand the attitudes of Czech experts.This is suggested by a letter from Marion Parsons from May 1920 addressed to Clara D. Noyes, Director of Nursing Division of the ARC, in which the author expresses her belief that Europeans need American nurses more than anything else (2).However, there were also doctors, who were able to get over these squabbles, understood the intention of Parsons and cooperated closely with the school.Among them there was mainly the internist Professor Ladislav Syllaba, who entrusted his two departments to the school for training (7).

Recognition of the nursing profession
The intentions of CSRC to raise the level of the nursing profession by improving education and by adopting proven approaches and experience of well--trained American nurses were influenced by many factors.These included an unequal relationship between doctor and nurse and the following attitudes toward nursing profession, conditions of the nursing profession, involvement of the nursing school graduates and last but not least, different approaches to education of nursing.Advancement and recognition of the nursing profession depended a lot on changing the mindset of the whole society.Not only in Europe, but also in the United States of the first half of the 20th century, the overwhelming view was that nursing was limited to a certain area of knowledge, and thus should not interfere with the medical competence.On the other side, medicine had the right to intervene in nursing.According to the then generally accepted opinion, a doctor needed education, while a nurse required training.Also the exams, which put greater emphasis on rational solutions to practical problems to the detriment of analytical and conceptual skills, corresponded to practical lessons.This approach reinforced hierarchy in relationships doctor -nurse and was the cause of routine approach to nursing.The power relationship doctor -nurse was influenced by a number of social tools, which led to restriction of the education of nurses in terms of depth and extent possibilities.It was based on the assumption that knowledge of nursing women is based on empiricism, while male -medical cognition has its foundation in scientific theories (16).
Paradoxically, also Alice Masaryková made it difficult to build respect for the nursing profession, when she used her authority to strengthen the perception of nursing as a hospital function that can be performed by religious and less educated nurses, while she considered social work, for which she founded a school in Prague, the domain of educated women.American researcher Elizabeth Vickers considers that Masaryková supported thereby the hesitation of ministerial officials, who did not understand the issue of nursing and therefore were reluctant to implement innovative reforms (17,18).The ARC, supported by the School of Nursing Alumni Association (later the Association of Registered Nurses), tried to influence the change of this attitude by their activities and outreach and massive help also came from women-doctors, who had more friendly relationship to the nurses.

Material and social conditions in the early post-war years
However, not only prejudices made it difficult to introduce modern methods of nursing in Czechoslovakia.Absolutely unsuitable material and social conditions for learning and working of nurses initially represented a serious problem.Hospitals, whose equipment was robbed by the retreating armies at end of the war, could not provide even the minimum facilities for research work and a general lack of funds made it impossible to remedy this situation immediately.Clara D. Noyes, who conducted an inspection tour around Europe in the fall of 1920, brought an eloquent testimony about these issues.In her report, she recounts extreme conditions, where the whole department of General Hospital in Prague could be given just one bar of soap, serving for the needs of doctors, nurses and patients.There were deficiencies in equipment of hospital department, food was poor, linens were missing, very few kitchen and bathroom facilities were available and hot water supply was periodically interrupted (9).When inspecting the school, Noyes highlighted the inadequate tools for teaching of nursing subjects, poorly constructed and monotonous diet (black bread without butter and boiled potatoes or sausage) and small portions for students that were pale and anaemic, but had to show tremendous performance.Based on these findings, Paris office of the ARC sent 18,000 francs to Prague, divided between the students so that they were not dependent on poor hospital diet and they could buy something and cook on their own (7).Eliminating these deficiencies, unlike other problems of nonmaterial nature, was matter of a relatively short period of three years.

Main tasks of the School of Nursing Alumni Association
Also the School of Nursing Alumni Association, established in 1921, and renamed Spolek diplomovaných sester ("Association of Certified Nurses"), seven years later, promoted the changes.This professional organization inspired by the American example tried to raise interest in the field among young women with higher education, advocated for more dignified social conditions of nurses in hospitals and ensured maintaining high ethical level of nursing profession (19).One of its major tasks was the issue of management of nursing care and the associated efforts to establish the position of civil superior nurse.This initiative responded to the situation after World War I, when the most numerous group of nursing staff in hospitals was mainly consisting of unskilled members of Catholic religious orders and deaconesses of the Evangelical Church, while Czech and German registered nurses performed nursing care only rarely.And yet the chief doctor could control only civil nursing staff and the nuns were supervised by Mother Superior, into whose authority he could not intervene.That is why graduates of nursing schools, who usually held the positions of a head nurse in hospitals, faced incomprehension in most of the nursing staff -nuns.The absence of management of nursing work in hospitals before 1920 resulted in practice in that many tasks that should be performed by nurses (measurement of pulse and temperature, injecting) were carried out by young doctors.In this situation, enforcement of the position of civil superior nurse was urgently required (20).

Recommendations of the American side
Not only public opinion in Czechoslovakia was divided in looking at the nursing education, even the American organizations had different ideas about its form.ARC together with CSRC led by Alice Masaryková generally tended to accept the creation of a broad network of rapid training of volunteer nurses, whose services could be used immediately in the case of an epidemic or armed conflict.On the other side, the approach championed by leaders of the RF was more sophisticated strategy, inspired by the example of US nursing schools.It can be seen relatively well from the first detailed situation report on the state of nursing in Czechoslovakia from 1922 (17), written by Frances Elisabeth Crowell, member of the International Health Division of RF, an experienced nurse and social worker, who dealt with improving nursing education and nursing standards.In the years 1917-1923, she played an important role in the organization of dispensaries in the fight against tuberculosis in France and then she worked subsequently in division of RF for study programs based in Paris until 1940.
The report states that a number of political and social factors affects the condition of nursing.The new Czechoslovak Republic as a multi-ethnic state formation was a mixture of languages, cultures and religions.The conditions were different in Bohemia and Carpathian Ruthenia.There was no unified hospital system.Charity care was underdeveloped and private clinics operated only for paying patients.Although they started to build new hospitals, there was still a shortage of beds.Crowell criticized in particular inadequate sanitary conditions in Czechoslovak hospitals.In any case, it was not the criticism focused only on Czechoslovakia.Crowell was similarly strict in the evaluation of sanitary conditions in Pittsburgh, where she worked for some time.She was aware that deficiencies in hygiene are not just a question of money, but it is primarily the problem of organization.The report also highlights poor social conditions of lay nurses that had to eat and stay right in the rooms of patients.The nuns were in advantage compared to them, because their accommodation and privacy was ensured by monastic seclusion.The author also criticized totally inadequate salary of nurses, which reached barely half the earnings of office clerks and teachers, and equated quite aptly the status of nurses to position of better maids, whose master was a doctor (17).
On the other hand, Frances Crowell could appreciate that there were hospitals with clean beds and comfortably secured patients even in such difficult conditions, which was true especially for children's hospitals, in which both monastic and lay nurses worked.Regularization and definition of nurse professionals with definition of their competencies and educational requirements should have been the first step to improve the professionalization of the field.The suggested Nursing Department at the Ministry of Health was to supervise the standardization of education in nursing schools, control the exams, keep records about registration of nurses and carry out inspections of public healthcare establishments.A two--year program of the nursing school in Strasbourg, which included training for hospital and home care, should have served as a model educational program for the ministry.Crowell also urged the cooperation with the German section of the nursing school during the implementation of this program.As social work had a higher prestige than nursing in Czechoslovakia thanks to Alice Masaryková, the two-year program was designed as a combination of nursing and social care with the possibility of specialization in the second year of study.The strongest argument of Crowell for the combined type of educational program arose from the need to introduce teaching of patient education.However, the introduction of these innovations into practice was not easy, because it met a variety of bureaucratic obstacles.The problem was that the Czech nursing school was managed by the CSRC, which was a private entity, while RF was focused on cooperation with public institutions, disagreeing, however, with the proposal to get the CSRC under the control of the Ministry of Health at the same time (17).
These strict criteria, that Frances Crowell tried to apply during her medical inspection in Europe, were paradoxically considered insufficient by some of her American colleagues and she was accused that her program did not meet the standards of the American nursing education.Such an assessment, however, did not reflect the European reality: what Americans perceived as inadequate, was often the maximum possible from the European perspective.Credit of Crowell was just in the fact that thanks to her experience, she was able to prevent mechanical transmission of US standards to conditions of individual European countries (18).
The conference of directors of nursing schools from Prague, Poznan and Warsaw, chaired by Henry O. Eversole, Director of the European Office of the RF was organized in Prague from May 30 to June 1, 1922, concurrently with the inspection of Frances Crowell.This meeting, where a total of 15 American of nurses presented their speech, including Marion Parsons, Alotta Lentell and Blanche Kacena, was one of the first opportunities to exchange views and experiences from current development of nursing education in Central Europe.A number of actual sub-topics were discussed.There were discussions over whether it was possible to create a standard curriculum in schools in different European countries, how the League of nursing education could help the graduates to be prepared better for courses abroad, how to overcome difficulties with a foreign language, what subjects could the nurses from ARC teach with the help of an interpreter, what rights should be granted to studying nuns, and what the government wanted and could do to create job opportunities and increase the salaries (22).
Even before the conference of directors, in the week 18 to 25 April 1922, a conference of local ARC registered nurses took place in Prague, where Marion Parsons, Pancy Besom and Rachel Torrance exchanged knowledge and experience with Czech nurses, who should take the lead in school after their planned leave from Czechoslovakia (22).
The nurses of ARC reorganized the content of studies at Czech nursing school and developed a network of model training stations for practical training of volunteer Red Cross nurses at various Czechoslovak clinics in the years 1920-1923 (23).When they were leaving Czechoslovakia, the nursing education was already in quite consolidated state, however, the Czechoslovak nurses had a greater share of work still ahead.Now it depended mainly on them alone, how much and in what timeframe they would succeed in putting the recommendations, presented at the conference of directors of nursing schools and further elaborated in the situational report of Frances Crowell, into practice.Although Emilie Ruth Tobolářová, who was trained in London, finally did not become a successor of Marion Parsons, as the representatives of ARC originally expected (8), the true successor Sylva Macharová, graduated from the nursing school in Vienna, did not impede the American approaches in nursing to have a supporter in the increasingly numerous School of Nursing Alumni Association.

RESULTS
The research contributed to the current cognition of the problems in three areas: 1.Based on the obtained data about the career of American nurses, we managed to demonstrate on specific examples that trained nurses, who mostly gained practical experience in organizational and nursing service in the First World War in Europe, came to Czechoslovakia from the United States.It turned out that the language barrier was a big problem, that could be overcame thanks to the Czech-American origin of Blanche Kacena, who could therefore implement practical teaching at hospital more effectively.2. The main problem in teaching, that the American nurses tried to solve from the beginning, consisted in change in the ratio of theory and practice in favour of practical subjects as well as enhancing the prestige of nursing profession.Activities of foreign nurses from the ARC and experts from the RF in very difficult conditions during the early post-war years can be marked as a kind of phenomenal achievement, whose impact has not been sufficiently appreciated.We cannot overlook the parallel between the then efforts to boycott the implementation of new approaches in nursing and current trends of defending allegedly historically proven systems of nursing education in secondary schools.
Currently available research was limited by the availability of resources used.Future research should therefore focus primarily on the study of American archival funds, which may introduce new clarifying findings in this issue.
Marion Parsons as a director of the Prague nursing school incorporated new courses about nutrition of invalids, bacteriology, ethics and history of nursing into the curriculum already in 1920.The new curriculum was prepared by Mary McDowell during her stay in Prague in 1921.At last, Pansy Besom newly promoted teaching of health and home care for children headed by professional trainer.3. Recommendations of the American nurses included establishing a specific department of nursing at the Ministry of Health, which should adjust legislation regarding the competencies and status of nurses including requirements for their education.At the same time, it was supposed to keep records of registered nurses and carry out inspections of public healthcare establishments.From among other proposals we may appoint emphasis on expanding the network of state nursing schools and focus on promoting lessons of patient education.