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The Evolution of Orthopaedic Nursing

at the Hospital for Special Surgery
The First Orthopaedic Institution in the
United States
Barbara A. Kahn

The history of nursing began in London in the late 1800s with

the reform of unsanitary conditions by Florence Nightingale.
During the same period, the United States was bitterly fighting
the Civil War. Nursing had not developed as a profession,
and most of the duties performed by nurses were conducted
by men. Casualties of war required rehabilitation and care.
Crippled children were left to die because they were considered
a burden to society. Dr. James Knight founded the Hospital for
the Ruptured and Crippled in his home on Second Avenue. This
would later become a world-renowned orthopaedic institution
with exceptional nursing care. A historical analysis of nursing
education and practice are reviewed, along with the evolution
of the first orthopaedic hospital in the United States.

he history of nursing and orthopaedic surgery dates

back to the late 1800s. Both developed out of societal
need, advances in medical science, and a will to help those
afflicted with disease. Crippling disorders have plagued
mankind since the beginning of time. These unfortunate
people had no recourse except begging for survival. The
same premise exists today in all disciplines of medicine.
Nursing has played an integral part in caring for those
in need and affording patients, physicians, and hospitals the ability to function dynamically and superiorly.

Orthopaedic nursing continues to evolve

in a professional partnership with the
Hospital for Special Surgery, a premier
orthopaedic institution in New York City
that was the first orthopaedic hospital
founded in the United States.

Orthopaedic nursing continues to evolve in a professional

partnership with the Hospital for Special Surgery, a premier orthopaedic institution in New York City, which was
the first orthopaedic hospital founded in the United States.

The Beginning of the Modern

Nursing Movement
In 1860, Florence Nightingale (18201910) established the
first school of nursing at St. Thomas Hospital in London.
Nightingale was considered the pioneer of the nursing
profession because she brought unsanitary conditions to
the forefront while trying to reform the British military
healthcare system (Audain, 2004). For her time, she was
educated because her family believed that all their children,
including their daughters, should study history, mathematics, and multiple languages. She used her knowledge of
mathematics to interpret data collected during her service in the Crimean War. Through statistical analysis she
proved that the incidence of preventable deaths was caused
by unsanitary conditions and that with improvement in
sanitary methods, the death rate would decrease. As an
innovator of data collection, statistical analysis, and sanitary reform, Nightingale founded the nursing profession
and started what has become known as the Modern
Nursing Movement (Audain).
Agnes Hunt was born in England in 1867. She devoted
her life to the care of crippled children by opening the first
open-air orthopaedic hospital. She knew too well the
fate of those with chronic infirmity because she developed
osteomyelitis of her hip at the age of 9 after a bout of septicemia (Shropshire routes to roots, 2005). Tuberculosis of
the joints and osteomyelitis were common untreatable illness during this time. Ms. Hunt believed that continuous
exposure to fresh air would help eradicate the transmission
of airborne diseases. Florence House, an outpost of the
Barbara A. Kahn, BS, RN, ONC, Nurse Clinician, The Hospital for
Special Surgery, New York, NY.

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Salop Infirmary in Shrewsbury, opened in 1900 with openair sheds that served as patient wards. Hunt developed a
friendship and professional partnership with Dr. Robert
Jones, an orthopaedic surgeon in Liverpool. Florence
House became the Shropshire Orthopaedic Hospital located in Oswego. Long after their deaths, the hospital was
renamed the Robert Jones and Agnes Hunt Orthopaedic
Hospital and remains in Oswego servicing the community (Carter, 2001).

Only 150 hospitals were in existence in

the 1860s, most of which did not accept
disabled or crippled individuals because
they were considered incurable.
The United States was also involved in conflict as the
Civil War began in 1861 and continued until 1865. There
were more than 600,000 casualties and an insurmountable
number of wounded. Nursing was dominated by males because society and military protocols mandated that women
were too frail to cope with the demands of caring for the
sick and injured (Stein, 2004). As a profession, nursing was
still in its infancy because no formal nursing schools had
yet been established. Casualties continued to increase, forcing the demise of gender restrictions. Seizing this opportunity, women immediately sprung into action. Dorothea Dix
was named Superintendent of the Women Nurses of the
U.S. Army by the Secretary of War. Dix had no formal training as a nurse, yet she set the standards for nursing applicants. Nurses were paid 40 cents per day and given food,
housing, and transportation. Their male counterparts received $20.50 per month with superior benefits. In 1862,
Clara Barton, who would become the founder of the
American Red Cross, brought food, clothing, and medical
supplies to the battlefields of the Union Army (Stein).
Although the Civil War ended in 1865, it was not until 1892
that the U.S. Congress recognized how valuable nurses
were to the war effort. This prompted the passing of a bill
that provided a $12 per month pension to military nurses
(Archer & Goehner, 1982).
Even with these acknowledgments, nursing was still
considered a matronly profession based on moral character, virtue, and discipline rather than education and skill. It
was becoming more socially acceptable to be a nurse, despite the intensity of the work load combined with the indecent wages. Still, it did not attract aristocratic women to
the profession, and the role of the nurse remained oppressive and subservient (Archer & Goehner, 1982).

the tenement houses. Lillian Wald would not begin her mission at the Henry Street Settlement until 1893. During this
period, 2030% of reported deaths resulted from tuberculosis. As a result of these communicable diseases, there was
an increase in bone and joint infirmity. The treatment of
these bone and joint diseases formed a large portion of
orthopaedic practice during this period (Rang, 2000).
Only 150 hospitals were in existence in the 1860s, most
of which did not accept disabled or crippled individuals because they were considered incurable. Dr. Knight, a physician practicing in New York City, was compelled to rehabilitate these unfortunate souls, mostly youngsters, and in
1863, he welcomed 28 children into his Manhattan home.
Ninety-Seven Second Avenue within the Lower East Side of
Manhattan would, from that time on, be known as the
Hospital for the Ruptured and Crippled (Figure 1). Dr.
Knight believed that bracing, exercising, and prayer would
heal those afflicted because surgery had a high mortality
rate (Time and effort, skill and gifts, vision and faith, n.d.)
(Figure 2). Mrs. Knight, family members, and hired domestics provided the necessary care for patients because there
was still no formal nursing school in the United States.

The First American

Orthopaedic Institution
Infection from tuberculosis and polio spread rampantly
through the community because the industrial revolution
led to overcrowding and unsanitary conditions in New
York City. Although tuberculosis had first been described
by Hippocrates in 300 BC, it became known as the White
Plague, and those who contracted it rarely survived.
Pasteur discovered the germ theory of disease in 1861, and
yet only a few blocks away from Dr. Knights home stood
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FIGURE 1. Dr. Knights home at 97 Second Avenue was the first

home of the Hospital for Special Surgery, known then as the
Hospital for the Ruptured and Crippled. Reprinted with permission from the Hospital for Special Surgery.
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FIGURE 2. Children with crooked spines are shown using an

exercise apparatus. Dr. Knight believed that bracing, exercise,
and prayer would heal the afflicted. Reprinted with permission
from the Hospital for Special Surgery.

Nursing Education
Bellevue Hospital School of Nursing, the first Nightingaleinfluenced nursing school in the United States opened its
doors in 1873 (Christy, 1970). Nursing duties in 1887 consisted of sweeping, mopping, cleaning windows, dusting
the wards, bringing coal to the furnaces, filling lanterns
with kerosene to supply light for assessments, and writing
nurses notes to assist the physicians. Nurses were expected
to work 7 days per week. Graduate nurses were given one
evening off per week, two if you went to church regularly.
Any nurse who smoked, drank, or frequented a beauty
shop or dance hall had her professional intentions scrutinized (Nursing history: Nurses duties and job description
in 19th century, 2004).

Orthopaedic Nursing
From 1870 to 1920
In 1870, the Hospital for the Ruptured and Crippled moved
into a formal institution on 42nd Street and Lexington
Avenue. The first recorded Supervisor of Nursing was
Miss. Ella S. Murdock, Matron of Nursing for the institution (Levine, 2004). Dr. Knight passed away on October
24, 1887, and Dr. Virgil Gibney filled the position in 1888.
His philosophy differed in that he viewed the Hospital
for the Ruptured and Crippled as an active surgical institution, not merely a convalescent home for the disabled. He
increased the number of surgical procedures exponentially and opened the first adult ward in 1903 (Time and
effort, skill and gifts, vision and faith, n.d.). A polio epidemic in 1907 served as a major challenge for the small institution because it could not possibly provide care for all
of those afflicted.
During this period, nursing salaries climbed to $50 per
month for 12-hour shifts. In 1909, there were only 7 graduate nurses on staff, including the Matron. By 1912, the
hospital again required expansion and moved to 42nd
Street between 1st and 2nd Avenues. More than 18,000 patients were being cared for on an inpatient and outpatient
basis. Many of the inpatients were still children with crip-

FIGURE 3. A nursery school tailored to the physical limitations

of patients with cerebral palsy. Reprinted with permission from
the Hospital for Special Surgery.

pling diseases and long recoveries. To accommodate these

children, the Hospital for the Ruptured and Crippled established classrooms so the children could continue their education while hospitalized. Manhattan Public School 401
was established on the childrens ward with special desks
and equipment enabling the patients to do homework,
take tests, and return to school on discharge (Time and
effort, skill and gifts, vision and faith, n.d.) (Figure 3).

Orthopaedic Nursing
From 1929 to 1960
The depression during the 1930s brought on a rapid
change in the nursing profession. Economic instability
forced nurses out of the private-duty sector and into the
hospital. The financial deficits made it difficult for institutions to pay wages to nurses; therefore, student nurses
were caring for hospitalized patients and hoped to become
graduates (Oermann,1997). According to Lynaugh (1993),
the passage of the Works Progress Administration (WPA)
bill in 1935 provided nurses with greater work opportunities. The Social Security Act changed the traditional domination of business-oriented entrepreneurial self-sufficiency
in healthcare and provided for government-supported
health and welfare (Lynaugh). The end of the 1930s altered
nursing practice yet again. Nursing organizations sought
to improve educational and practice standards when World
War (WW) II began in 1939, causing an acute shortage
of nurses. Medical treatment radically changed as sulfonamide, the first systemic bacteriostatic antibiotic, became
available in 1935, followed by penicillin in 1940 and chloramphenicol in 1947 (Rang, 2000).

Nursing and Orthopaedics

During WWII
Under the leadership of Dr. Philip D. Wilson Sr., Surgeon
in Chief of the Hospital for the Ruptured and Crippled,
six physicians and three nurses sailed for England to become the first American hospital group to serve overseas.
(Hospital Unit of Allied Relief Fund, Inc., Off to Britain,
1940) (Figure 4). At first they provided care in a mobile

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The School of Practical Nursing

FIGURE 4. A group of physicians, nurses, and ancillary personnel headed for England under the direction of Dr. Philip D.
Wilson Sr. (top left). Reprinted with permission from the Hospital
for Special Surgery.

unit designed for orthopaedic cases. As Dr. Wilson would

explain, 60% of war casualties were injuries sustained by
the bones and joints. Additionally, he believed that antibiotic medications would prove to be invaluable in saving
the lives and limbs of those with open wounds (Hospital
Unit of Allied Relief Fund, Inc., Off to Britain). By 1940, a
500-bed American hospital functioned under Dr. Wilsons
direction. Eighty American nurses were recruited to staff
the hospital in Basinstoke, England. Nurses working
overseas were required to be members of the Red Cross
Nursing Service and willing to remain in England for a
minimum of one year (Finds Doctors Needed, 1941).

On January 7, 1955, The Hospital for Special Surgery

School of Practical Nursing (HSSSPN) admitted its first
class under the direction of Miss Dean Smith (Time and
Effort, Skill and Gifts, Vision and Faith, n.d.). The school
was nondiscriminatory and graduated more than 50 students per year (Figure 5). The purpose of the school was
to provide nursing students with the knowledge and skill
needed for bedside care under the supervision of the registered nurse (RN) and physician. In 1956, 45 licensed
practical nurses (LPNs) were employed at HSS under the
supervision of only 25 RNs (Clapp, 1961). The philosophy
of the schools faculty supported continued education. As a
result, 75% of the LPN graduates furthered their nursing
education and completed an associate degree in nursing
that enabled them to obtain RN licensure. As the hospital
ventured toward acute care, the need for RNs increased,
and in 1961, there was almost a threefold increase in RN
employment (Clapp). HSS developed a Nursing Pathways
Program where nurses could acquire funding to support
their advancement to the associate-degree level in exchange
for a 2-year work commitment after graduation.
Miss Smith became the director of nursing in 1965. She
was an outstanding nursing leader within the institution,
well respected and fondly remembered by several nurses
who had been working at HSS for more than 30 years.
RNs Pat Reeves and Carol Crescenzo both worked as practical nurses under Miss Smith. They describe her during
an interview as, a person who exhibited the ultimate in
warmth and professionalism. She was a disciplinarian
who knew every nurses name and upheld standards of
nursing yet, she was approachable and supportive of her
staff. According to both nurses, there were no registered
floor nurses on the night shift back in the 1970s. The floors

Nursing and Orthopaedic

Leadership
Back in New York, the Hospital for the Ruptured and
Crippled continued to service the community as a specialty
hospital dedicated to the science of orthopaedics. In 1940,
it would change its name to The Hospital for Special
Surgery (HSS). The hospital leaders acknowledged that
the institution would need to affiliate with a major medical
center to become world renowned. Dr. Wilson also realized
that orthopaedic conditions were becoming more complex
and would require the support of other specialties if it
were to provide competent care to its patients (Time and
Effort, Skill and Gifts, Vision and Faith, n.d.). The affiliation between HSS and New York Hospital-Cornell Medical
Center occurred in 1949 with the fourth and last relocation
of the hospital to 70th Street and the East River in 1955.
During this time, the United States prospered under the
leadership of President Eisenhower. Interest rates were
low, oil was inexpensive, and the average length of stay for
patients treated at HSS was 25 days. Orthopaedic treatments revolutionized the field as the first total joint replacements and arthroscopic procedures were being done
in the operating rooms (Sculco, 1987).
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FIGURE 5. The hospitals School for Practical Nursing, under

the direction of Miss Dean Smith. The graduates of this yearlong
course assume an important role in the hospitals program of
nursing care. Reprinted with permission from the Hospital for
Special Surgery.
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were run by the practical nurses under the direction of the

nursing supervisor and although the work was hard nobody wanted to leave HSS to work anywhere else. One
can still sense the gratification and comradeship experienced by nurses working during this time.

Standards of Nursing Practice

Educational Requirements
Doreen Johnson graduated from the HSSSPN in 1969. She
experienced a spectrum of orthopaedic nursing and nursing education while at HSS. Johnson continued to Pace
University and graduated with an associate degree in 1973.
She then received her baccalaureate degree in nursing
from Pace University in 1981. She completed a Masters in
Nursing Administration degree from Hunter University in
1994. Johnson has been an active member of the National
Association of Orthopaedic Nurses since 1970 and has held
many executive board positions. Her nursing experience at
HSS started with practical nursing, then progressed to registered nursing on the adult orthopaedic unit as she continued in her nursing education. She went on to become
an assistant head nurse and a head nurse and then assumed her current role as nurse educator for the institution. Ms. Johnson had experienced an array professional
and educational levels available to the orthopaedic
nurse. The authors interest in her personal career was
sparked by the controversy over standards of nursing
practice and education. When Ms. Johnson was asked
how she felt about the upward mobility of nurses and the
need for higher education requirements, she passionately remembered bedside nursing back in the day
under the supervision of Miss Smith. She believed that
there was a certain pride and camaraderie shared by all
nurses that is not as visible today. She recollected a loyalty to the profession and a dedication to the patient and
to ones fellow colleagues. Nurses helped each other in a
shared community. She acknowledges that the longer
length of stay facilitated nurse-patient relationships, and
this is something that is not readily available today. Ms.
Johnson also expressed her feeling that, the core of
nursing is at the bedside and that practical nurses enjoyed bedside nursing (D. Johnson, personal communication, November 11, 2004). The author also chose to interview Pat Reeves and Carol Crescenzo, RNs who
recounted more than 30 years of memorable moments at
HSS as they continue to work on the same-day surgery
unit. They shared a feeling that nursing had become deprofessionalized and that patient care would become increasingly compromised by the lack of bedside nursing
and staffing shortages (P. Reeves & C. Crescenzo, personal communication, November 12, 2004).
Diploma schools throughout the country began to falter
in the 1960s as more associate and baccalaureate programs became available. The HSSSPN remained an active
teaching facility until 1996, when it graduated its last
class. The hospital continued to grow under the direction
of Dr. Philip Wilson Jr. Staff appointments were increasing, and the number of patients treated in 1988 far surpassed prior years, with the addition of new operating
rooms. The average length of stay in 1988 was down to
10 days, a substantial decrease from 30 years ago when the
average stay was 25 days (Sculco, 1987).

Baccalaureate Education
In 1985, the American Nursing Association (ANA) recommended that state nursing associations establish the
Bachelor of Science in Nursing (BSN) degree as the minimum educational requirement for RN licensure and associate-degree nursing as the minimum for practical level
licensure (Lewis, 1985). In 1984, according to Martha
Rogers, nursing theorist and Professor Emerita at New
York University, there was limited progress in support of
an educationally sound and socially motivated system of
higher education in nursing proportionate with changing
times and human need. She also believed that nursing had
three levels of practice but only two levels with licensure
requirements because the profession has never licensed for
the baccalaureate degree. The baccalaureate level, in her
opinion, was the cornerstone of nursings educational system (Rogers, 1984).

In 1985, the American Nursing

Association (ANA) recommended that
state nursing associations establish the
Bachelor of Science in Nursing (BSN)
degree as the minimum educational
requirement for RN licensure and
associate-degree nursing as the
minimum for practical level licensure.

According to Jacqueline Kostic, MS, RN, CNAA, former Vice President of Nursing at the HSS, there has been
an evolution of nursing at HSS as educational requirements for nurses grew in response to the complexities of
patient needs and orthopaedic advancements. Practical
nurses provided excellent care for patients with chronic
illnesses, but now the orthopedic patient is treated more
acutely (J. Kostic, personal communication, November
12, 2004). Kostic had been at HSS for the past 14 years
until her recent retirement. Under her leadership, there
has been an increase in baccalaureate-level nurses to
more than 65%. She has implemented the professional
practice model that requires masters-prepared nurses for
leadership positions and a BSN for staff nursing positions. Currently, there are 230 BSNs and 20 practical
nurses providing patient care. This is a monumental shift
of care compared with the staffing ratio reported in 1965.
The satisfaction of the nursing staff has been maintained
as there was only a 7% turnover of RNs in 2003 compared
with the national average of 15.5%.
The hospital was awarded Magnet status for nursing
excellence by the American Nurses Credentialing Center
(ANCC) in 2003 under the direction of Kostic. Magnet status was developed in 1993 and is defined as an acknowledgment of those institutions committed to the delivery of
quality nursing, excellence in the provision of nursing
services while providing an environment that recognizes
and rewards professional nursing (Magnet Award Status,
2004). Additionally, Magnet status signifies that the
Magnet-awarded institution promotes autonomy and in-

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dependent decision making by the nursing staff and reflects excellence in recruitment and retention of these
nurses (Kuhar et al., 2004). When considering whether to
apply for the Magnet award, the institution must aspire to
the 14 standards defined by the ANCC (Kuhar et al.). It is
a remarkable achievement for any institution to receive.

Magnet status was developed in 1993

and is defined as an acknowledgment
of those institutions committed to the
delivery of quality nursing and excellence
in the provision of nursing services
while providing an environment that
recognizes and rewards professional
nursing.

The Future
The future of orthopaedic nursing and nursing in general
provides the evolution toward critical thinking, technology,
planning, and education. Ms. Kostic (J. Kostic, personal
communication, November 12, 2004) expanded on the
need for role adaptation of the nurse toward critical thinking and planning rather than execution of patient care.
She believes that advanced technology will play a greater
role in supporting nurses and physicians. She also acknowledges the importance of educating ancillary personnel because as the role of the nurse changes, so should
that of the entire team. The ability of supportive staff to
provide patient care will be essential. Ms. Hunter sees
nursing becoming a dominant profession within the
healthcare system because we are still striving to become
respected professionals within our society.
HSS is a far cry from the Hospital for the Ruptured and
Crippled located within the house of Dr. Knight on
Second Avenue in the 1860s. It is an institution that had a
vision, tremendous leadership, and the ability to become
one of the premier orthopaedic institutions in the entire
country. Through specialized knowledge, skill, and adherence to values and ethics, professionals have provided service to our medical community for more than 140 years.
Professional nursing practice remains paramount in its

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success, and HSS will continue to strive for excellence

and outstanding nursing care in the years to come.

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