From Baltimore to Italy: The contribution of Grace Baxter (1869–1954) to the development of Italian nursing

Introduction

The introduction of nurse education into Italy was heavily influenced by foreign residents. One of these was Anna Fraentzel Celli (1878–1958) ¹ who was born in Berlin, and married an Italian, was a feminist and a nurse, heavily involved in research into malaria with her husband when they settled in Rome. With the help of the doctors she worked with she set up the Scarpetta Clinic to train daughters of the aristocracy in nursing. ² She was a role model for many other women and in the development of institutions dedicated to the training of nurses. ³ Recently documents from the Archives of the Camerata Hospital (Florence, I) have been discovered which enhances significantly the history of Italian nursing. Grace Baxter (1869–1954), was of English parentage and introduced the Nightingale training model into Italy. ⁴

During the First World War, a group of Anglo-American benefactors founded, on the hill of Fiesole, a hospital reserved for the Italian Wounded. The nearby Charitable Society (1922) managed a free Dispensary for medical assistance to the poor of the parish (1922–1931). In 1931, the Camerata Hospital was founded as a general hospital with 50 beds. A Nurses Training School was also established there. In 1936, the hospital was merged into that of Sant’Antonino and Luigi Campolmi in Fiesole for financial reasons. ⁵

The Nurses Training School continued to function and was of great importance since there were only seven other Schools in Italy at that time: Rome (three), Milan (one), Naples (one), Trieste (one), and Venice (one). The Red Cross had also established schools in Bari, Bologna, and Bolzano. ⁶ In Florence, training courses for nurses were carried out at the Anna Meyer Paediatric Hospital and at the San Salvi Asylum. One of the key figures in the history of the boarding School for Nurses in Camerata was Grace Baxter (1869–1954).

Her work was a part of the emancipation of women that became prevalent at the end of the nineteenth century. In that period, many women's association was founded, with a broad spectrum of goals, amongst which the integration of women into the world of work was fundamental. ⁷ During the London International Council of Women of 1899, where this was actively debated, many dealt with a woman's career in nursing. Florence Nightingale (1820–1910) had paved the way for the formalisation of the role of women in health-care. In the first half of the 20^th-century many Schools of Nursing had been founded, based on the Nightingale's model at St Thomas’ Hospital in London, offering the possibility for women to attend professional nurse training. ⁸ In Italy, where a training model was lacking, the role of foreign women was pivotal in the establishment of Nursing Schools. In this scenario, Grace Baxter's contribution was fundamental.

Grace Baxter

Grace Baxter was born in Florence (1869). Florence was popular with wealthy British families, including that of Florence Nightingale, naming her after the city along with other British women of high social class. Alice Fitzgerald (1875–1962) (of American parentage) was also born there, another nurse who graduated from Johns Hopkins Hospital and was involved in treating injured soldiers during First World War.

Grace Baxter lived all her life in Italy, apart from some periods spent abroad for study and professional reasons. She graduated from the Johns Hopkins Hospital in Baltimore, where she worked as head nurse. ⁹ Information about her life is sketchy. In 1895, she was invited by Amy Turton (1859–1942) to Naples (Italy), to find a Nursing School, following the English model. ¹⁰ Amy Turton, who was of Scottish descent, was also born in Florence in the English colony. She subsequently lived there and had, with Florence Nightingale's help, enrolled and graduated from the school of the Royal Infirmary in Edinburgh (1893–1894). ⁸ From 1896 to 1913, Grace Baxter designed and then managed the Blue Cross School in Naples. This was associated with the Jesus and Mary Hospital, where she taught practical nurse training. The theoretical side was entrusted to professors at the University of Naples. ¹¹ In 1901, she returned to the USA to acquire specialist skills in paediatrics. At the same time, she became Correspondent for the American Journal of Nursing, and for the Women's Union. In this role, she had the opportunity to publish periodic reports, sharing her experience as a pioneer in nursing education in Italy. ⁴

The Women's Union began in 1899 in Milan with the aim of coordinating the national associations that already existed to defend women's rights, in particular those of workers, and also of children. The National Women's Union was very interested in nursing, made proposals for the creation of nursing schools and developed relationships with the Italian Red Cross. ¹² In 1901, Anna Fraentzel Celli conducted an investigation into the state of Italian nursing. ¹² This was published in the Union magazine. Grace Baxter contributed an article about the Blue Cross School in Naples. ¹¹

Grace Baxter participated in the management of the aftermath of the Calabrian–Sicilian earthquake (1908–1909). She became teacher of the Red Cross’ voluntary nursing course in Naples. In 1909, amongst her students was Her Royal Highness Princess Hélène of Orléans, Duchess of Aosta (1871–1951). ⁴

In 1914, Grace Baxter resigned from the Jesus and Mary Hospital to serve as a nurse during the First World War. ⁴ She was appointed Superintendent of Nurses in the American Hospitals for Italian Wounded. She worked in Florence at the territorial hospital nr. 10, where the Camerata Hospital was subsequently founded. ⁴

The American hospital was equipped to provide ‘moral treatment’ to convalescents. Besides activities such as reading, playing music, singing, and playing bowls, Grace Baxter introduced a school for reading and writing, ‘for patients whose education had been neglected’ ¹³ no doubt inspired by Anna Fraentzel Celli.

After the war, Grace Baxter came back to Naples, where the Blue Cross Hospital reopened in 1920, after having added a Boarding School for Nurses. ¹⁴ Here, the students lived according to the Florence Nightingale model for nurse training, where they had to graduate from a boarding school annexed to a hospital, in order to acquire hygiene and moral education. Meanwhile, she was Head Nurse in the Dispensary in S. Domenico. However, because of Fascist self-sufficiency laws, all foreign directors of Nursing Schools, such as Grace Baxter, were dismissed (1929) and the autonomy of the Nursing Schools was drastically limited. ⁹ She came back to Florence where she was enlisted as a teacher at the voluntary nursing course of the local Red Cross.

Grace Baxter at the Camerata Hospital

From 1930, Grace Baxter's name appears in the archive documents preliminary to the founding of the Camerata Hospital. She was personally involved in the establishment of the Nurses Training School, of which she became Inspector (1931–1932). ⁴

In 1932, she published in Italian her Manuale pratico per l’infermiera: tecnica dell’assistenza agli infermi [Practical manual for the nurse: technique of nursing the sick], which went to a second edition in 1938. ¹⁵ She held many positions within the Camerata Hospital: She was an honorary member of the Charitable Society, a member of its Board of Directors, and a consultant to the Board of Directors of the Nurses Training School (1935–1936). ¹⁶ Although She never took a direct management role in the School, the letters she wrote to the Legal Advisor and the Director of the Hospital testify to her activities as advisor and inspirer of the entire course.

Grace Baxter died in Florence on 9 February 1954, at the age of 85, after having received numerous honours. ⁴

Philosophy

Grace Baxter's philosophy of nursing can be surmised from her publications and the archival material that has recently been found. In her manual, she began by stating that the difference between a professional and a non-professional nurse was in the scientific approach. Since the progression of medicine determined the progression of nursing, a new collaboration between both of them was required. However, the dividing line between medical and nursing skills was clear and must always be respected. ¹⁵ She stressed great importance of training. As Florence Nightingale taught, a nurse worthy of the name must have attended a 2-year school attached to a hospital otherwise she would always remain a non-professional. Practical training was essential and could not be replaced by any theoretical instruction.

She recognised ethics as a fundamental part of the nurses’ work. She understood that nursing was a calling, vocation, profession, and practice. She defined ethics in nursing, concentrating more on the virtues that would make a good nurse, rather than focussing on nurse's behaviour in relation to the patient. ¹⁷ She listed the virtues of the true nurse as education, courtesy, respect and concern. The behaviour towards the patient would follow accordingly. ¹⁵ Discipline was a fundamental requirement, in an almost military vision of the role, the student nurse was like a simple soldier. The trained nurse was similar to the trained soldier. The doctor, the hospital director, and the head nurse were the officers.

In her book, Grace Baxter dealt with the main topics of the nursing technique: care of the rooms and of the different kinds of beds, admission of the sick, management of bedridden patients, the importance of the aseptic technique, choice of nutrition and administration of therapies.

The last chapter dealt with the dead patient. ¹⁵ Her broad vision was particularly enlightened. She was firmly of the opinion that the aim of training was not in providing nurses to assist the wealthy. She struggled to promote high standards in her course. She wanted to foster high moral values, to improve the conditions of society, and, through the reform of assistance in hospitals, asylums, kindergartens, and schools, follow the poor sick into their homes, to fight, under the guidance of the doctor, the scourge of tuberculosis and syphilis, malnutrition, vice, and misery. ¹⁸

The selection of prospective nurses was crucial. When Grace Baxter worked in Naples, she had to admit women who had neither scholastic background nor the moral and intellectual values required in the profession. As the course developed, these types of women no longer enrolled, realising they did not have the necessary aptitudes. The problem was therefore solved spontaneously. ¹⁹ Doctors appreciated the difference between educated nurses and untrained nurses and wanted those trained by Grace Baxter's school.

During their educational studies, nursing students had the opportunity to practice very important skills. They took an active part in the preparation of the operating theatre, in the sterilisation of instruments, and in assisting with operations. On the wards, they had to take care of the patient's hygiene, measure their temperature and pulse, accompany the doctors on their rounds, and undertake the therapeutic instructions, under the direction of Grace Baxter herself. ¹¹

The watershed of 1901

In 1901, Grace Baxter and Amy Turton represented Italy at the Third International Congress of nurses, held in Buffalo New York, USA. Both contributed with reports which were then published. ²⁰ Amy succinctly and accurately described hospital nursing in Italy, recalling the stages of the path to professionalisation. The first training school for nurses in Italy was founded in Rome (1892–1893), but no Matron was appointed since trained nurses did not yet exist. ¹⁸ The surgeon and his assistants gave the lectures, but they had no competence in nursing the sick. Moreover, the ethics of nursing at the time was misguided and the girls refused to do the unpleasant tasks that they did not consider fit for their role. ¹⁰ In 1895, at the Woman's Hospital in Rome ‘San Giovanni’, the administration organised some lectures; these were mandatory for the nuns and the servant nurses. The Hospital of Santa Maria Nuova in Florence followed this example, but the oblates, who worked as nurses, refused to attend the lessons. The experiment was not repeated, as it was considered useless. ¹⁰ The fact that nuns and the religious held the role of the nurses compromised their effectiveness since they were prohibited from performing services related to the genital organs. ¹⁰

Grace, for her part, focused on the situation at the Blue Cross Hospital of Naples School that she had been managing for some years. At the time this represented the institution that came closest to the English model, although lacking a boarding school which opened in 1920. ¹⁰ In the same year, Grace published an article in the American Journal of Nursing presenting an accurate report of the beginnings of the first Italian School of Nursing, broadly based on the Nightingale model. ²¹ She mentioned the difficulties encountered in organising the school, since her views were judged contrary to the philosophy of the institution. She had to reach a compromise to avoid offending the local sensibilities by dismissing any servants, even if they were incompetent. ²¹ In her letters, which have been recently discovered, she complained about having little time for teaching, since she was too busy with bureaucracy; she personally corrected the notes taken by the students, to avoid mistakes and misunderstandings. ²²

However, in another report regarding the Blue Cross in Naples, Grace Baxter stated that she was satisfied. She carried out practical teaching and managed six wards: two of medicine and four of surgery. At the end of the course, the students could take an examination, which on passing declared them suitable for independent management of patients in their homes. This created places at the hospital for newcomers. ¹¹ She also managed to organise a children's surgical ward in the Jesus and Mary Hospital. ²³

The experience at the Camerata 1931–1938

The boarding school for nurses in the Camerata was founded in 1931. It had the patronage of Her Royal Highness, Princess Hélène d’Orléans, Duchess of Aosta, thanks to the intervention of Grace Baxter, who, as stated earlier, had been her teacher in Naples. ⁴ The Duchess of Aosta was always grateful to Grace Baxter and personally showed her appreciation on many public occasions, underlining that ‘what she had been able to do during the war was entirely due to Miss Baxter's teaching at Naples’. ²⁴ In a letter dated 18^th January 1930, Grace informed the Director of the Camerata Hospital that they had obtained the patronage and the protection of the Duchess for the Nursing School, guaranteeing that the new school would not compete with that of the Red Cross. ²⁵ In May, The Duchess was also invited to visit the hospital to see the progress of the Nursing School. ²⁶

The President was Georgiana Sheldon who lived at Villa La Torricella in San Domenico, close to the Camerata Hospital. She was a member of the Lyceum Club International in Florence which was founded in1908 by Constance Smedley (1876–1941) to promote “emancipation through cultural education and technical and professional training of women with a view to their playing an active role in society”. ²⁷ Its importance was that it served as a sorting centre for nurses in Florence. ⁷ Donna Bianca Garbasso, vice president of the Lyceum Club, was designated a member of the honorary committee of the School, confirming the close relationships between these institutions. ¹⁶ The director of the Nursing School for the first year was Caterina Damele, who had graduated from the Italian hospital in New York. ⁵

By 1931, seven students had already been admitted, one of whom interrupted the course to get married, while the others completed the State diploma. In 1932, there were eight students. In 1933, Abel Drakes became director of the School, when 13 students were admitted. They boarded at a cottage with a garden near the hospital. In addition to the basic obligatory courses, the school also offered theoretical and practical courses in pharmacology, dermosyphilopathy, ophthalmology, otolaryngology, and electrotherapy, which took place both in the hospital and in the outpatient clinic. In August 1935, the director of the School passed to Maria Gaydou due to the resignation of Abel Drakes who was appointed to a management post at a hospital in London. In the last year of activity of the Nursing School, there were 14 students: five graduated in 1935, and six in 1936. All of them had excellent ratings and found work in public institutions without needing private assistance. ¹⁶

What was, then, Grace Baxter's role in the Nursing School of Camerata? In the early 1930s, when the hospital and school were founded, Grace was a nurse with great scientific competence, acquired in her studies in America, with a long didactic experience and proven organisational skills acquired in Naples. Therefore, her contribution to the opening and organisation of the school was fundamental. Her foresight is demonstrated by her solicitude in selecting and recruiting nurses long before the opening of the hospital so that it could immediately operate at full efficiency. ²⁸ Although she never became the Director of the School, maybe due to the regulations at the time, in her role as inspector she was always a point of reference for organisational, bureaucratic, or didactic problems. Grace Baxter is also remembered as a teacher at the School, and, in 1934, a member of the commission for the final examinations to gain the professional nurse diploma. ²⁹ From the excerpt of a letter that she sent to a former classmate (both of the 1894 class) at Johns Hopkins Hospital, Mrs. Harriette Caroline Iglehart, we know that their previous year's students had already achieved excellent results in the first examination session so much so that ‘the Examining Board was positively surprised’. ³⁰ The numerous letters written to William Frederick Copinger, Legal Advisor of the Charitable Society, confirm her dedication and constant commitment, even when she was abroad. ³¹

There is an absence of documentation for the period from 1938 to 1954 in the middle of which was the tragic experience of the Second World War, which has left a void in the archive.

Conclusions

Grace Baxter's life confirms the important role of foreign nurses in disseminating the Nightingale model in Italy at the beginning of the twentieth century. She was involved in the international movement for the emancipation of women by promoting the proper education of nurses in both Florence and Naples which raised the standards and provided these young women with gainful employment independent of benefactors. Her life came into contact with other important women of the time for nurse education in Italy including Her Royal Highness Princess Hélène d’Orléans, Duchess of Aosta, Amy Turton, and Anna Fraentzel Celli. Of note is how many of her students were nursing injured soldiers and civilians in the First World War.

Grace Baxter's contribution to the history of Italian nursing resulted in the secularisation of the profession away from the attitudes of the nuns, permeation of relevant ethical standards, and the beginning of professionalisation of nurses in Italy in accordance with Florence Nightingale's teaching.