A History Of The Development Of Nursing Education In The Community Of .

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Loyola University Chicago Loyola eCommons Dissertations Theses and Dissertations 1990 A History of the Development of Nursing Education in the Community of the Sisters of the Third Order of Saint Francis, Peoria, Illinois Mary Ludgera Pieperbeck Loyola University Chicago Follow this and additional works at: https://ecommons.luc.edu/luc diss Part of the Education Commons Recommended Citation Pieperbeck, Mary Ludgera, "A History of the Development of Nursing Education in the Community of the Sisters of the Third Order of Saint Francis, Peoria, Illinois" (1990). Dissertations. 2894. https://ecommons.luc.edu/luc diss/2894 This Dissertation is brought to you for free and open access by the Theses and Dissertations at Loyola eCommons. It has been accepted for inclusion in Dissertations by an authorized administrator of Loyola eCommons. For more information, please contact ecommons@luc.edu. This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License. Copyright 1990 Mary Ludgera Pieperbeck

LOYOLA UNIVERSITY OF CHICAGO A HISTORY OF THE DEVELOPMENT OF NURSING EDUCATION IN THE COMMUNITY OF THE SISTERS OF THE THIRD ORDER OF SAINT FRANCIS, PEORIA, ILLINOIS A DISSERTATION SUBMITTED TO THE FACULTY OF THE GRADUATE SCHOOL OF LOYOLA UNIVERSITY OF CHICAGO IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY BY SISTER MARY LUDGERA PIEPERBECK, O.S.F. PEORIA, ILLINOIS OCTOBER 1990

COPYRIGHT BY SISTER MARY LUDGERA PIEPERBECK, 1990 ALL RIGHTS RESERVED ii

SISTER MARY LUDGERA PIEPERBECK, o.s.F. LOYOLA UNIVERSITY OF CHICAGO ABSTRACT A HISTORY OF THE DEVELOPMENT OF NURSING EDUCATION IN THE COMMUNITY OF THE SISTERS OF THE THIRD ORDER OF SAINT FRANCIS, PEORIA, ILLINOIS This historical usefulness follows and of the the is parallel temporal the mal nursing of and education the day. Special An almost is followed from the creation of The historical paths merge advances of the late nine-teen th work, confusion in 1901. The account is a such as prevailing social values, meaning economics, trials, difficulties and joys during a period problems is program experiences of ordinary people within the context, changes. growth Saint Francis. of about particular many present twentieth century forces the order to start a for- the social the on the teaching of nursing. technological and story to nursing order that is now the Sisters of the religious when It of modern nursing from the Crimean War placed Order was conducted to determine the in understanding the present. Nightingale emphasis Third past growth Florence the study still of It also brings to light the time. with which nursing has struggled in the past struggling which has The study been today, including the educational caused by social and scientific follows nursing education as nursing iii

emerges as a emerging Emphasis profession. is placed upon the curriculum as required by professional and govern- mental agencies. The study Order the also by its looks at nursing demands placed upon expanding network of hospitals. ally, sister Order started its first school of nursing. schools of staff. nursing Demands governmental demands three year Wars the effect as In 1901, the Students in the the hospital's nursing by technological advances and for a more formal education. the creation of five hospital-based which granted a These diploma in nursing, to become registered nurses (R.N.) state licensure examination. a The two World demand for nurses, and this study examines of federal and data programs of on the Order's schools. was collected by researching the ar- of the Community. archives used made graduates the Information the by schools created chives were met the taking were agencies were enabling by nurses were trained on the job. Initi- Further data was obtained through the Catholic Dioceses of Peoria and Rock- ford, Illinois; the historical holdings of public and Catholic newspapers quette of Peoria, Rockford, Keokuk, Iowa and Mar- Michigan; public and private libraries of Peoria and Rockford and the Historical Societies of these two cities. cal Findings of context and response to the the close research with are related in an historia discussion of the sisters' movement within the nursing profession to iv

require the baccalaureate degree governmental and academic recognition for the baccalaureate nursing to be granted taken entry level to nursing. in steps the professional degrees The as by to receive both the two remaining schools operated by the Order is set forth in some detail. v

PREFACE One of teaches us present. ical and values of historical research is that it how useful the past can be in understanding the Nursing, as it is today, was formed by its histor- antecedents. development based and the upon Throughout of history, the scope, nature nursing and nursing education has been what people believed about the learning process what was known about health and disease. times, Since ancient the development and evolution of nursing and nursing education, within the social context of those times, throws light upon many of the problems with which nursing is struggling today; and the and scientific its lack of power, its educational confusion makeup of its practitioners. changes The impact of social on nursing and nursing's impact on society are ongoing processes. A hundred years ago, there was objection from within and without the profession to nurses continuing their education. ago, Today new This scenario is repeated today. the it question is problems, Seventy-five years of nursing licensure was hotly debated. again a major concern. Because these are not an understanding of the past may bring addi- tional clarity to the decisions that shape the future. This the historical account provides a focused backdrop on foundation of a specific religious community and the development of nursing and nursing education within that vi

It community. is whose Francis, the Sisters of the Third Order of st. corporate headquarters are located in Peoria, Illinois. The as well the of history the Attention without and the nursing sisters nursing and foundation of the community as education taught by the community of is intimately intertwined with the development and nursing education within the United States. has the been given community to whose selected leaders within and ideas and careers influenced impacted much of the course of the development of nurs- ing and nursing education either positively or negatively. Special development been study emphasis within documented considers they developed rate information community as is given the community. in the archives to the nursing education Limited information has of the community. This the types of nursing education programs as over well time. to It provides detailed and accu- the present and future members of the as employees of the community's health care institutions and the general public. vii

ACKNOWLEDGMENTS I Rev. am especially indebted to my dissertation director, Michael Perko, S.J., Ph.D., Professor of Educational Leadership and Policy Studies at Loyola University of Chicago, who make through his assistance and guidance has helped to this research project a reality. extended to My gratitude is also the other members of my committee: Dr. Joan K. Smith and Dr. Gerald Gutek. A special religious thank you congregation particular to the goes for sisters to their in my sisters within the prayerful support, in the motherhouse infirmary. I also want to express my appreciation to Sister M. Ildefonsa, my religious superior and friend, and the sisters at Saint Francis Medical Center for their help and support. I am and staff ing, who years. support so many also very grateful to Dr. Sharon Foss, faculty at Saint Francis Medical Center College of Nurskept the "home fires burning" during the last few Last, of but not least, I appreciate very much the my dear friends, Paul and Mary Lindauer, who in ways helped me in my educational endeavors and in completing this project. Finally, Germany, who I am also truly indebted to my family in West were a great support through their patience, understanding and encouragement during the last few years. Sister Mary Ludgera Pieperbeck, O.S.F. viii

DEDICATED TO MY RELIGIOUS COMMUNITY THE SISTERS OF THE THIRD ORDER OF SAINT FRANCIS EAST PEORIA, ILLINOIS. ix

TABLE OF CONTENTS PAGE . ii COPYRIGHT. . . . . . . . . . . . . ABSTRACT. . . iii . . vi PREFACE . ACKNOWLEDGEMENTS . viii DEDICATION . . . . . ix TABLE OF CONTENTS . . . . . . . . . . x .xii LIST OF TABLES . . . . xiii LIST OF ABBREVIATIONS CHAPTER I. HISTORICAL PERSPECTIVES II. HISTORICAL BEGINNINGS . 1 . 19 Events in nursing and nursing education in the United States from 1860-1965. Influence of religious women on nursing . . 42 and nursing education in the United States, 1860-1965. III. FOUNDATION OF THE COMMUNITY OF THE SISTERS OF THE THIRD ORDER OF SAINT FRANCIS IN THE MIDWESTERN UNITED STATES AND THE DEVELOPMENT OF HOSPITALS AND NURSING WITHIN THE ORDER . . 53 IV. COMMUNITY HISTORY OF NURSING EDUCATION FROM 1901-1965 AND THE ESTABLISHMENT OF NURSING EDUCATION PROGRAMS BETWEEN 1901-1920 . . . . . 131 St. Joseph's Hospital School of Nursing, Keokuk, 1901-1945 . . . . . . 135 St. Francis Hospital School of Nursing, Peoria, Illinois, 1905-1965 . . 140 St. Anthony Hospital School of Nursing, Rockford, Illinois, 1915-1965 . . 159 st. Joseph's Hospital School of Nursing, Menominee, Michigan, 1918-1921 167 St. Joseph's Hospital School of Nursing, Bloomington, Illinois, 1920-1962 . . . . 168 x

PAGE V. TRENDS IN NURSING AND NURSING EDUCATION IN THE UNITED STATES, 1965-1990 . . . . . . . . 176 Influence of Vatican II on religious institutes of women . . . . . . . . . . . . . 182 The Sisters of the Third Order of st. Francis history of nursing education during the period from 1965-1990 . . . . . . . . . 186 St. Francis Hospital School of Nursing, Peoria, Illinois, . . . . . . . 186 St. Anthony Hospital School of Nursing, Rockford, Illinois . . . . . . . 199 VI. SUMMARY AND CONCLUSION . . 210 BIBLIOGRAPHY . . 222 VITA . . . 230 APPROVAL . 232 . xi

LIST OF TABLES Page Table I. II. Community Register from 1877 - 1887 76 Ages of Patients, 1879 - 1888 . . . . . 83 III. Housekeeping Record . . . . . . 115 IV. Basic RN Program Change from Previous Year, by Type of Program: 1963 to 1982 . . . 194 v. Basic RN Program Change froM Previous Year, by Type of Program: 1963 to 1982 . . 195 xii

LIST OF ABBREVIATIONS I. Motherhouse Archives, Peoria, Illinois . . . . MAPI II. St. Francis Medical Center College of Nursing . . Files . . . . . . . . . . . . SFCoNF III. IV. Archives of the Diocese of Rockford, Illinois . . . . . . . . . . . . . . ADRI st. Anthony College of Nursing Files .SACoNF xiii

CHAPTER I HISTORICAL PERSPECTIVES Introduction History, tion, a nature war, be pinpoint a it primarily and particular as we a or a community, must by its subjective. It is difficult to time or place for the beginnings of know it. late been deals with a nation, a civiliza- profession selective a nursing always whether Nursing, as it is known today, is nineteenth century development. It has around, although not always clearly identified as an occupation separate from medicine. In early mother, civilization, since the time of the first women have carried the major responsibility for the nourishing elderly and the nurturing of children and for caring for and aging members of the family. these people was those methods that largely by trial The education of and error, advancing appeared successful and by the sharing of information with one another. Medicine close was dominated by superstition and magic and a relationship existed between religion and the healing arts. In primitive societies, illness and suffering were thought to result flicted on a from some evil spirit that may be in- person as punishment or curse for failing to

2 do as own the wanted. 1 gods Each primitive society had its curative agents, taboos and practices. were shared These practices as countries warred and conquered one another, with the more effective practices surviving. Religious nursing and and care leaders This and for and myths medical practice. of was cared beliefs the sick much was separate were the foundation of The responsibility for cure and injured was given to religious based from the on a faith healing concept. care of sick people who were in the homes by relatives. Most of the caretak- ers were women. Influence of Christianity The with first continuity in the history of nursing began the rise of Christianity. Christ's teaching admonished people to placed women and men on a parity, and the early Church made both men women ined had love and care for their neighbors. and women opportunities earlier. 2 dignified deacons, role, It a His precepts with equal rank. Unmarried for service that were never imag- gave single women a meaningful and religious coll\l[litment, to help the sick, the injured and the poor. With the establishment of churches in the Christian 1Janis Rider Ellis and Celia Love Hartley, Nursing in Today's World, (Philadelphia: J. B. Lippincott Company, 1988), 11. 2 Ibid., 16.

3 era, groups was the aged, were organized as orders whose primary concern care slaves Christian history had of and love. were the sick, the poor, orphans, widows the prisoners, Of particular of significance in nursing much in common and shared many characteristics. They "Corporal similar and widows charity and They out deaconesses, out and virgins. carried the done responsibilities Spiritual by Works of Mercy". practicing the Their influence diminished in the fifth and sixth centuries. 3 Influence of Monasticism The sixth development and seventh centuries of the Christian era, gave the impetus and orders, young their and strength to religious col1llllitment. choice with large well Through the men and women were able to follow careers of while it role of monastic orders, starting with the the living a Christian life. establishment of Monasticism, monasteries, played a in the preservation of culture and learning, as as offering refuge to the persecuted, care to the sick service care to the poor, and education for the uneducated. The of the sick fell increasingly on these religious, but primarily on the women. 4 Prior to the Reformation, women were respected by the 3 Ellis and Hartley, Nursing in Today's World, 16. 4 sister Charles Marie Frank, The Historical Development of Nursing, (Philadelphia: W.B. Saunders Company, 1952), 82-84.

4 Church. Women of prominent families were encouraged to be involved in charitable activities outside the home, such as nursing. tion, The each Crusades, the Renaissance and the Reforma- had a profound influence on the status of women and therefore on nursing. The Crusades, the Renaissance and the Reformation The almost Crusades, two exposure of (1096-1291). They created an great religious and military enterprises as well important The stimulants to nursing and hospital work. nursing Knights was salem On years to other civilizations and cultures and a mingling were litary It hundred swept through Europe, lasted for thoughts and people. Under the leadership of the Church, they as which orders evolved as a result of the crusades. Hospitallers organized as to of St. John was one such order. staff two hospitals located in Jeru- well as to defend the hospitals and its patients. their symbol Mi- habit, its members wore the Maltese Cross, a which became the forerunner of the nursing pin as it is known today. 5 Secular orders this time. They with the of nurses also came into existence at operated much like the monastic orders, exception that members were not bound by the vows monastic vocation of at life any and time. therefore The could terminate their Bequines of Belgium and the 5 Ellis and Hartley, Nursing in Today's World, 18.

5 Alexian ing education form to Brothers are examples of secular orders. of offered to these dedicated people was in the apprenticeship. someone The nurs- A new member usually was assigned more experienced and would learn from that per- son. 6 The Renaissance diffusion the across buying other and alism lar sick interfaces. of and the demand for, goods from an expanded concept of what were in the commercial towns, permeated also invaded the church, the commitment to the the injured changed. During the Renaissance, a new impetus was given to the arts and learning. al New of discoveries thought education. became The This reviv- learning also affected medicine and with it nursing. in medical science corrected some of the erroneous theories of disease. ic Commercially, Concepts of individualism and nation arising and and life. development of the part of western social thought. As this secu- spirit, society natural cultural created of became the the selling cultures necessities was a to eventually Thus, several part of the Reformation, It took the era of scientif- formalize and nursing centuries elapsed before nursing academic a nursing religious educational community. 7 movement that started 6 Ellis and Hartley, Nursing in Today's World, 19. 7 Philip A. Kalisch and Beatrice Ralisch, The Advance of American Nursing, (Boston: Little, Brown and Co., 1986), 19-22.

6 with rt the work resulted and the of Martin Luther, began in Germany in 1517. in a revolt against the supremacy of the Pope formation of the Protestant churches across Europe Monasteries especially were in closed those and religious orders were banned, countries were the kings and lords embraced the Protestantism. 8 The role by Reformation brought of women in society. Roman Catholic occuring, many closed. a change in the Most nursing care had been given sisters, but with the religious changes relatively good Catholic hospitals were With t.he loss of Christian loving care by the sis- ters, care of would take the job. nursing lost Church, the ill and unfortunate fell to whomever When deprived of the dignity of the its social standing and respectable women no longer entered nursing. ed tremendous Hospital care was relegat- to "uncommon" women, a group comprising prisoners, pros- titutes and drunks. portrayed in The typical hired nurse was accurately Charles Dickens' novel: Martin Chuzzlewit in the personage of Mrs. Sairy Gamp petent woman an unsympathetic, incom- who contributed much to human suffering. She was uncouth, always tipsy, dirty, and dishonest. 9 Women, forced to faced work with earning their own living, were as domestic servants and, although nursing 8 Ellis and Hartly, Nursing in Today's World, 19. 9 charles Dickens, Martin Chuzzlewit, (New York: Macmillan Co., 1910), 312-313.

7 was considered one. The hard. a pay domestic service, it was not a desirable was poor, the hours long and the work was The nurse was considered the lowest of servants. In Catholic service countries not affected by Protestantism, to the sick and the poor continued in those instis- ti tutions staffed by religious. Institutions conducted by municipal authorities were not as fortunate. tant countries, In the Protes- religious were not replaced and the lowest classes were induced to work in hospitals. 10 The ward Reformation which between and the vocation of nursing was headed. The period 1500 and 1860 saw nursing conditions at their worst is sometimes referred to as the dark period of nursing. Europe and helped to precipitate the disaster to was devastated by plagues, epidemics, famine, filth horror; and, the poor suffered the most. New hospitals were built, but the lack of knowledge of hygiene and sanitation was were responsible for serious epidemics. made worse deliberate by The situation mismanagement, inadequate staffing and exploitation. Social reform was needed and in- evitable. 11 Contributions by Some Religious Communities Some abandoned of the the sick religious and the orders poor. that remained, never They were sincerely 1 Frank, The Historical Development of Nursing, 133. 11 Ellis and Hartley, Nursing in Today's World, 21.

8 interested they in the provided mental service asylums, visited the care in superior to any motivated by their desire to and their They workhouses. homes, ministering also to their of Mercy poor. other nursing love available. They were of God, concern for the sick and help those in distress in a very caring manner. as the Sisters of the Visitation of Mary, the orders Sisters of for the sick and poor in hospitals, orphanages sick the ill and those in need and The care provided by the religious orders, was far needs. Such of Charity of st. Vincent de Paul, and the Sisters gave much time and service to the sick and the The Sisters of Charity became an outstanding nursing order because nursing they training received that a systematic program of included experience in the hospital and in the home. 1 2 Early Reformers A number of leading citizens among the philanthropists, doctors, reform in nursing. Nursing Fliedner ful writers and clergy felt the great need for The founding of the Deaconess School of at Kaiserswerth, Germany, by Pastor and Mrs.Theodor in 1836 was one of the earliest and most success- attempts at nursing education reform. school offered The Kaiserswerth a three-year program which included duties, 12 Kalisch and Kalisch, The Advance of American Nursing, 40-41.

9 such as cleaning, care in women's and men's wards. equally the and laundry, and cooking as well as nursing Students were all treated all had a three-month beginning of their training. to have a character certificate from a probationary period at Each student was required reference from a clergyman, a health physician and written permission from her nearest male relative to enter the schoo1. 13 The curriculum bedside ethics art lectures instructions by physicians. in the theory and Pastor Fliedner taught and religious doctrine, and Mrs. Fliedner taught the and the trained to physician care. for included practice of nursing. implicitly was follow responsible for Because the nurses were the physician's orders, the both nursing and medical The school was the first organized training school nurses. Florence Nightingale was a student at Kaiser- swerth for a brief time, and her training and experience there was incorporated in her school of nursing later. 14 The Birth of Modern Nursing The from the the time of nursing and nursing education of Florence Nightingale and the founding of first Nightingale school affiliated with the St. Thomas Hospital a development in London in 1860 is the story of the evolution of profession. Formal nursing education was the inevitable 13 Frank, The Historical Development of Nursing, 188. 14 Kalisch and Kalisch, The Advance of American Nursing, 41.

10 result of the need for trained nurses, competent to assist physicians, care for nursing and both ethically and hospitalized education began intelligently prepared to and private patients. Modern with the founding of the Nightin- gale school at st. Thomas. 1 5 Florence socially During and Nightingale prominent her English born family in 1820 to a wealthy, in Florence, Italy. numerous travels, she visited many institutions became facilities was aware of the pitiful conditions in most health and hospitals. She read a great deal and became an expert on hospital organization and reform. 16 Florence modern Her nursing. first Through Nightingale She administration, and determination death two a had percent heroine proven of in knowledge to soldiers rate occured the founder of a new era in health care. during the Crimean War. Nightingale's unique talents for organization and wounded considered symbolizes recognition Miss is at change Scutari, of health and nursing care, the she poor conditions of the managed to reduce the English soldiers from fourty-two percent to two months. 17 When the war ended, she was to the English people, but more importantly, she that competently trained nurses were a means to 15 Kalisch and Kalisch, The Advance of American Nursing, 41. 16 I b'd 1 . , 42-44. 17 I b'd 1 . , 51.

11 better health care. higher quality schools for ain. Thomas tise in areas care, in London in 1860. All of her exper- of nursing, nursing education, nursing and health care were incorporated into this became the model for all other schools worldapplied her learning experiences in nursing at Kaiserswerth, Gennany, her outstanding military nursing experience search training established the nursing school at It training developing Nightingale Hospital She by strongly supported in Great Brit- administration wide. care was the school. health nurses Miss st. of Her vibrant interest in promoting a in health and her at Scutari in the Crimean War, her re- care administration, nursing and nursing own genius in creating a new role for nurs- es.18 One nursing of the was The to She and physical. essential three train of the Nightingale school of was complete autonomy from the hospital: financial, organizational it hallmarks basic Florence Nightingale believed for nurses to teach and control nursing. aims of the Nightingale schools were: to hospital nurses, to train nurses to train others, and train public believed health nurses for the sick and poor. 19 that nursing had a separate body of knowledge 18 Kalisch and Kalisch, The Advance of American Nursing, 51-52. 19 Lucie Young Kelly, Dimensions Of Professional Nursing, 4th Ed., (New York: Macmillan Publishing Co. Inc., 1981), 33-36.

12 and role nurse her, function as separate from medicine. She viewed the a colleague of the physician, working with him or but having a distinct sphere of responsibility. "It is the surgeon who saves the person's life, but it is the nurse who helps the person to live. 11 20 Miss Nightingale planned a curriculum that included required classroom lectures and clinical experiences. believed that hospital education and visit homes the practice where of was not nursing; emphasis would She the sole center for students should also be on health teaching. overall, the Nightingale plan viewed the student as a learner, not as a worker. compromised experience such to by or The student's education was not tobe overwork, inadequate responsibilities as scrubbing and cleaning. detect they symptoms were to Students reasons. couraged be of theory and clinical non-nursing activities Students were to be taught and the reasons for these symptoms and given sufficient time to understand the in Miss Nightingale's program were en- to ask questions and to use the resources of their library and practice laboratory. 21 Florence great be Nightingale reforms trained crusaded for and brought about in nursing education, such as: nurses should in teaching hospitals associated with medical 20 Josephine Dolan, Nursing in Society, 14th ed., (Philadelphia: W.B. Saunders, 1978), 167. 21 rbid., 16a.

13 schools and organized for that purpose; nurses should be carefully selected and should reside in nurses' houses that would fit be matron to form discipline and character; the school would living, have the final authority over the curriculum, and all other aspects of the school; the curriculum would include experiences; records both teachers would quired theoretical be material and practical would be paid for their instruction; kept on the students, who would be re- to attend lectures, take examinations, write papers, and keep diaries. 2 2 Miss books, on Notes on community United in Nightingale was always a busy writer and her Nursing, Notes of Hospitals and two books health States. were widely read in Europe and the Her ideas stimulated the growing movement America to develop training schools for nurses. programs prospered and the Nightingale Nursing system spread to other countries, including the United States. Early American Health Services One phia the first American hospitals was the Philadel- Alms 1731, insane York of House, which and City also known as "Old Blockley, 11 erected in provided the was care for the sick, the indigent, the infirm. 23 founded The Bellevue Hospital in New on the almshouse plan in 1735. The 22 Ellis and Hartley, Nursing in Today's World, 24. 23 Frank, The Historical Development of Nursing, 175.

14 Pennsylvania and opened opened in while another New York City Hospital 1752, 1771. 24 in Revolution, by Hospital in Philadelphia was chartered in 1751 care mothers, At wives and churches Philadelphia Dispensary their homes, 1791. 25 these All in treatments. through drunkeness, was Some over New alleged common: American 1786, the Dispensary opening in abuses and inhuman yellow fever and cholera raged Revolting and problems Sisters operation In health care institutions had shocking of the women in hotels, homes. York neglect of the the the established to nurse the sick institutions. when of dedicated private a violence, occurance. took and Epidemics the resolved other with these things outbreak of sick and wounded soldiers was provided warehouses, in the of of indecencies, cruelties were a daily at Old Blockley were Mother Seton at Emmitsburg the hospital on a temporary basis. 26 The Founding of Early Schools of Nursing in America One tals strategy to improve the care of the sick in hospi- and system care. homes of in training Early the United nurses interest to States was to establish a provide competent nursing in nursing arose from a variety of 24 Frank, The Historical Development of Nursing, 177-178. 25 I b'd 1 , 180. 26 I b'd 1 . , 175-177.

15 sources as and they was expressed strove to Motivated care. peers and the children, by pioneering women physicians implement by a poor important changes in health lack of acceptance by their male quality of medical care for women

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