Читать книгу Discipline of Nursing - Michel Nadot - Страница 15

The hospital is an institution that, as a care environment, shapes practices and connects the people who reside there. While this environment transforms its mission, expands or benefits from new equipment, then new knowledge emerges and will be acquired by those who work or live in the hospital. In fact, the hospital environment in a way describes the nature of the background in which care is given. This environment becomes central when the foundations of the discipline and the space and time in which knowledge is created must be rediscovered. “The institution thus shapes the interpretative procedures of situations. Institutions are shaped by models of rationality that they develop reflexively” [DEM 99].

The foundations of the nursing discipline are rooted in hospital space and time. The lay era of the discipline, by linking language to “the only truly scientific concepts that were those related to the geometry of space and time” for Thom, gave meaning to the knowledge in use. The nursing discipline did not grow “above ground”. Hospital spaces allowed the knowledge of care and assistance to life to exist. This knowledge could then be transformed into deeds and words. “Only concepts that can be geometrized and related to space and time are susceptible to universalization and therefore scientificity (…). We know and act only locally” [THO 83]. Hospital space and time as an environment thus determined the first scientific element of the discipline still to be born. With the birth of the hospital, these traditions of language became important for the quality of knowledge and the background of discursive events dear to Foucault in which the nursing discipline could appear. The framework was set. These are the reasons why we place the care environment (the hospital) as the first and central concept that conditions the unique perspective of the so-called “nursing” sciences. For many theorists today, the care environment is also a central concept that characterizes the substance of the nursing discipline [DAL 08a]. Space refers to place, time is what escapes and reminds us of our condition as mortals. These two elements allow us to perceive movement.

Without these two particular dimensions, space and time, language first, discipline second, as signs of human activity, cannot exist. For he or she who could hold this language would have had no place to speak or to make speak, to write or to make write, and consequently, no discursive activity to carry out either. For Auffray “space and time are the familiar benchmarks within which we interpret what we perceive of the world around us, especially movement. This has been the case since the beginning of humanity” [AUF 96]. Therefore, identifying the space in which knowledge of action begins is fundamental to account for the transformation of tacit knowledge into scientific knowledge and to recover the knowledge of care that inhabits the discipline. The first words pertaining to lay care thus constituted “a set of anonymous, historical rules, always determined in time and space, which have defined at a given time and for a given social, economic, geographical or linguistic area, the conditions for exercising the enunciative function” [FOU 69].

From the Middle Ages to the end of the 18th Century in Europe, particularly in French-speaking Switzerland, cities had their lay hospital institutions to “take care” of people who were often marginalized or lonely and bear the miseries of life. These institutions, financed by the bourgeoisies of the time, began to organize themselves in many ways, but were very often inspired by the ordinary family dynamic associated with models from old-style communities, inns, farms or various collective households. For example, the Geneva hospital in 1744 (a Protestant canton), which could accommodate about 136 people for a population of 14,400 inhabitants around 1590, already represented a veritable spatial mosaic through its multiple work and speech spaces, among which was the “general hospital”, more often referred to as “the house”, the cellar, the bakery, the butcher’s shop, the stables, the factories, the house of correction, the shoemaker’s shop, the school for the children housed in the hospital, the tailor’s room, the mills, the granary of the seed collector, the hospital funds (the countryside with farms, vineyards, meadows and gardens, the forests of Jussy, des frères, de Bay, of La Petite Grave and Céligny)⁴, the hospital shop, the houses belonging to the hospital (staff accommodation), the temple of the house, the refectory, the shops and pyres, the large kitchen, the room “of the bourgeois women and girls”, the room “of the poor of the house”, the room “of the working class”, the room “of the able-bodied women and girls”, the room of the sick “both men and boys and women and girls received in the house”, the room of passers-by and beggars, the room of “those bleeding, epileptic and others” who had unfortunate illnesses, the room of “those who suffered from venereal diseases, shameful illnesses or of a particular character” [NAD 93].

These talking spaces of course had their occupants with their lifestyles and languages. As early as 1759, the Freiburg Hospital (Catholic canton) could accommodate between 80 and 110 people for a town with a population of about 6,100. The distribution of the premises in Freiburg in 1759 demonstrated some differences with those of the Geneva hospital in 1744. It is rather classes (from the first to the eighth) and statuses that we are talking about. Thus, we can distinguish the apartments of the hospital staff, their family and servants, the men’s dormitory, the women’s dormitory (the dormiaudes), the servants’ room, which were often, as the texts say, “fed, housed, heated, lit, whitewashed and medicated”, the room or stove for the sick or krankenstube, the children’s room (kinderstube), a space (often in the basement) for the inpatients, foolish, chained, dumb⁵ and a space for the “poor passers-by” who were often “foreign beggars, French deserters, prowlers” [NAD 93, NAD 12b].

There was also an investment in stone⁶. “In the 15th century, the hospital became a large landowner with a high income” [ROD 05] and made the institution a source of liquidity for the municipal authorities. This situation was not unusual in many medieval hospitals. Sometimes it worked, sometimes it did not, because of wars, bad management, spoliations or difficulties in maintaining the constructed heritage. The Freiburg Hospital was managed to function as usual between the 14th and early 19th Centuries (over five centuries), despite the invasion, economic and disciplinary problems caused by Napoleonic troops as early as March 2, 1798. The hospitals of the Franche-Comté region near the Franco-Swiss border were also destroyed, particularly in the 15th Century. This remark shows the difference that could sometimes exist between hospitals with regard to the integrity of the places and structures. Out of 33 establishments listed by Nicole Brocart, “three were reported destroyed between 1363 and 1376, twelve were destroyed in 1435 and 1459, and eleven again between 1479 and 1484”. The 15th Century proved to be particularly disastrous for the Franc-Comté hospitals, “whose temporality was turning into a time of ruin and lesser value”. The difficult economic situation also contributed to compromising their management and reducing their revenues [BRO 98].

The urban or rural space where there were hospitals, some of which have now disappeared, was “a highly compartmentalized world, a mosaic of territories with extremely diverse statuses. We can speak of an atomized urban fabric” [WAL 94]. The size of the regions was often a function of the accessibility threshold. In the 18th Century, this threshold was defined as 2 hours of walking, or 8 km or 10 to 20 km by stagecoach. Cities were then used as staging posts in the era of slow transport. “Nomadism was also a fundamental feature of the population structure in the 18th century” [WAL 94]. Under these conditions, small, medium or large towns at the same time welcomed travelers who could not afford an inn and made their properties and the products of hospital work bear fruit. This may also explain the presence of small hospitals as well as hospitality houses along the communication routes.

Around the hospital, in buildings sometimes adjoining it, it was not uncommon to find, depending on the size of the town, functional buildings such as barns, stables, attics, sheds, stores, an oven, a butcher’s shop or slaughterhouses, as well as buildings that could be used as functional housing for employees. In comparison with the urban Geneva hospital, the rural lay Bulle hospital in 1738, had only one floor, a kitchen, the “poile des pauvres” (6–12 places in “two poorly constructed bedframes”⁷), the “poile du gardien de l’hôpital” (functional housing), a room with a bunk, toilets, a barn and an enclosure with a garden and goat’s field. Also in the same area of the hospital in 1722 and on either side of it, the “Fleur-de-lys” and “De la Mort vivante” arrangements. It was thus a very “hospitable” district, which was on the outskirts of the town of Bulle. In 1763, it was noted by the public prosecutors of the Geneva hospital “that the wooden beds were subject to bedbugs and ringworms”. They were then replaced by iron beds between 1765 and 1808 [LOU 00].

Located on the outskirts of the town or village, the hospital, since the Middle Ages, has been a community that requires a minimum of organization. It is close to a spring, a river or the ditches of the town⁸. From a cadastral and architectural point of view, the main “built volumes” (the largest buildings) of a small town in the Middle Ages, particularly in Freiburg (see Figure 2.1), Bulle and Romont, up to the end of the 18th Century, were the castle, the church, the hospital and the “fief bourgeois” (town house or town hall).

The lay hospitals under the Ancien Régime, particularly in French-speaking Switzerland, then bore a name whose very term, “l’hospital”, lospitaul or l’épetau or l’épetô in 1749⁹, recalled a mission of welcoming, providing hospitality and protection to human beings. These terms were confused with the terms “maison” or “ménage” mentioned above. In other regions or countries, we found similar characteristics to this space and time that we have just presented. For example, a bourgeois hospital was founded in Porrentruy in 1406, and a bourgeois hospital also existed in Neuchâtel in 1539 [DON 00]. Also in 1377, the hôpital de Lausanne (the Lausanne hospital) bought a pair of shoes and a few lengths of cloth to make a garment for a hospital employee (Jaqueta Botlery) [MOS 05].

Figure 2.1. A lay hospital on Catholic soil in 1606.

(source: Musée d’art et d’histoire de Fribourg. Plan of Freiburg by Martin Martini – Copperplate engraving published in 1606. Photo B. Rochat 2006, retouched to highlight the hospital building)

This practice of providing shoes and work clothes was common for hospital servants, as very often their meager salary was paid in cash and in kind. There were also establishments in France similar to those in French-speaking Switzerland. In 1745, for example, the governess of the hôpital français d’Avranches (French hospital of Avranches) was paid an annual salary of 100 pounds and employed six servants to help her, who were given 30 pounds a year in addition to food and lodging [NAD 93]. Finally, in Montbéliard (France), for example, in the 15th Century, when the town had 1,500 inhabitants, the establishment with its outbuildings, kitchens, barns, stables and cowsheds had a capacity of 12 beds and a 13.77-meter-long façade on the street [CUS 86, BRO 98]. With its kitchen, cellar, equipment, barn, stables, garden, meadows and vineyard, this establishment was very similar to other establishments in Switzerland (Bulle, Romont, Yverdon, for example). With its 12 hectares of cultivable land, “the hospital at the end of the 15th century was a notable agricultural owner in the Montbéliard area” [CUS 86]. Near Montbéliard, the city of Belfort also (600 inhabitants in 1442) had its lay hospital with 10 beds [BRO 98]. Similarly in Canada, we know of Jeanne Mance who had a first hospital built in Ville-Marie (Montreal) in 1642 with a capacity of 8 beds (six for men and two for women). In this new work space thus created, “it seems that Jeanne Mance was, from 1642 to 1653, the only resource person in the colony in matters of health, assisted by servants, between one and four, and at least two other women of the colony: the wife of Louis d’Ailleboust and Madame de la Bardillière” [YOU 05].

These “maisons”, this “ménage”, this “hôpital” and ultimately this institution, needed to function. Only, “institutions don’t think, they don’t have goals or motivation. Only the flesh and blood participants in institutional life think, have goals and reasons to act” [DEM 99]. A hospital institution is therefore not just a set of rules or functions, but “a set of normative schemes that allow both situational and discourse settings of practical interactions between people and with the world. As schemas, norms are reflexive procedures, linking knowledge and capacities” [DEM 99]. So, which participants can we rely on to make a healthcare institution work?

Generally speaking, the activity of the staff and their know-how are close to the traditional occupations of women on large farms or in collective households. Women (governesses or servants) may serve the hospital (caring for residents) according to a maternalistic ideology. “When the rector was married, his wife was, as it were, a partner in the hospital management” [ROD 05]. The men (servants), if any, were more likely to have outside activities on the estate (maintenance, leaf removal, harvesting, livestock supervision, etc.). A sort of handyman, they were also in charge of the heavy work. The Romont hospital (Switzerland) in 1733, for example, had a “master of low works” to help the gardienne (caretaker). He was housed in the hospital [NAD 12b].

Once the care environment had been constructed, the first written statements served as prescriptions. They focused on how to carry out the activities of daily living in a community. If we want to find the first knowledge of the care discipline, we need to find the first walls framing the word and the first texts indicating what needed to be done to make everything work. In general, as Louis-Courvoisier points out, “the importance of those involved in healthcare is inversely proportional to the information disclosed by the sources” [LOU 00]. This is also what we have seen repeatedly. Within the hospital in the lay age of knowledge, “the nursing staff was the real hub and representative of the influences of the various healthcare protagonists” [LOU 00]. This still seems to be true today, even though the hospital has changed a great deal. That is why in our conceptual model of nursing published in 2013, we sometimes refer to “cultural intermediaries”¹⁰ and “health mediators” to describe the professional role of nurses as intermediaries between the various health stakeholders [NAD 13]. In fact, as we also specify in this conceptual model, “any intermediary is a mediator, even if often it is not recognized as such” [DES 19].

1 1 For example, in the city of Freiburg (Switzerland), four public hospitals followed in the wake of the first: the hôpital Notre-Dame (Notre-Dame hospital), the hôpital des Bourgeois (the Bourgeois hospital), the hôpital cantonal I (Cantonal I hospital) and the hôpital cantonal II (Cantonal II hospital). The latter, which is still in operation, is today called the “Hôpital Fribourgeois”, on the Bertigny site in Freiburg. With each transformation, the existing staff is transferred to the new building and their knowledge also evolves with the characteristics of the new place.

2 2 Nothing new, but we tend to forget this when we talk today about nursing knowledge or “advanced practices”. “From the outset, one fact is clear: the general hospital is not a medical institution. In its functioning or in its purpose, the general hospital is not similar to any medical idea” [FOU 72].

3 3 For Teysseire, who was inspired by the abbot of St. Peter, “in the 18th century, a person was called poor if he had only his work to survive” [TEY 93].

4 4 At the end of the 18th Century, the Geneva hospital owned 180 hectares of forest, which represented about “18% of the forest heritage of the territory of the Seigneury of Geneva” [ZUM 85].

5 5 Mental patients were also received in hospitals, but they were not considered as patients to be treated; they were locked up and, if necessary, chained up [NIQ 21].

6 6 “Already in the 16th century, hospitals were extremely rich institutions, with a large amount of capital and a vast, though very heterogeneous, land heritage (fields, meadows, forests, vineyards, houses, mills, etc.)” [DON 03].

7 7 Gruerian hospital furniture, old wooden bed comprising three levels with a width of 1.20 m. On the other side of the border, the hôpital de Montbéliard (Montbéliard hospital) (eastern France) also had “twelve beds with mattresses, eiderdowns, pillows and crossbars” [CUS 86]. This bedframe was thus the predecessor of today’s electric bed.

8 8 This may initially have been a comprehensive benefit for daily hygiene (for the toilet or kitchen, for example) or for the need to dispose of daily waste. But it also proved a difficulty in ensuring hygiene, when insalubrity, dilapidated facilities or lack of ventilation in buildings promoted dampness.

9 9 Gruyère patois is a Franco-Provençal dialect spoken in the Gruyère district (south of the canton of Freiburg, Switzerland).

10 10 Daniel Teysseire, in his presentation of Tissot’s work (Avis au Peuple sur sa santé), points out the works written for the people, but by doctors and which are “intended to be read and used by social groups serving as a relay between doctors and the people” [TEY 93]. He calls these social groups “cultural intermediaries”. For the anthropologist Françoise Loux too, the notion of intermediaries is present in her reflections. Nurses are then “perceived by the patients as real intermediaries to whom it is possible to entrust more things than to the doctor”. Nurses “play a central role as informers and discreet intermediaries between doctors and healers” [LOU 83].