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Margarete Sandelowski, PhD, RN, FAAN

AbstractAfter World War II, a debate ensued over whether nurses should perform intravenous (IV) therapy. The debate was

resolved by permitting nurses to do venipunctures as physicians ̓agents and by recirculating the familiar tautology: if

nurses were already doing venipunctures, they must be simple enough for nurses to do. The vein was a portal of entry for

nurses, but one with limited access. What was ultimately ceded to nurses was not full jurisdiction over a domain of nursing

practice, but rather a limited settlement in a domain of medical practice. The debate over IV therapy demonstrated how

technology, in combination with ideology, can both create and destroy nursing jurisdictions.

rom the earliest days of American trained nursing, nurses and technology have been fundamentally linked. Wheth-er or not they thought of them as technology, nurses have

always used a variety of tools, instruments, and machines in-cluding thermometers and cardiac monitors, enema cans and respirators, and beds and infusion pumps to appraise, treat, and comfort patients.1 Indeed, it would be difficult to conceive of nursing without these tools of the trade and the techniques, di-visions of labor, and social relations surrounding them. Many nurses also have perceived these devices as means to move them closer to scientific medicine, which they and the Ameri-can public generally view as embodied in technology. By using these technologies, nurses “vicarious[ly] participate[d]2 in the prestige accorded medicine by virtue of its technology.

But nurses also have had a persistently equivocal relation-ship with the tools of their trade. Although perceiving technol-ogy as enhancing both patient care and the scientific and social status of nursing, nurses have long been concerned that nursing not be defined or eroded by technology. As one nurse remarked in the early 1930s, good nursing care was “not a mere series of procedures strung like beads on the wire of a doctorʼs orders ... [it was] neither just ʻrote memory ̓nor ʻmechanical skill.ʼ”3

Approximately 20 years later, Hildegard Peplau4 found the es-sence of nursing to reside in the interpersonal, as opposed to the technical, relationship with patients. Almost 50 years later, Virginia Henderson encouraged nurses to “preserve the essence of nursing in a technological age.”5 And today, nurses continue to worry about maintaining the proper balance between “high-tech” and “high-touch” care.6

The post-World War II period was a time when nurses be-came particularly concerned with the relationship between “true”7 and technical nursing. Nursing became “intrinsically linked”8 to the hospital and nurses thereby lost the relative au-tonomy they had enjoyed caring for patients in their homes. Approximately 60% of nurses were employees of hospitals, as opposed to private entrepreneurs or agents of public health.9

Nurses were increasingly charged in this period with carry-ing out an array of tasks delegated to them by physicians, and many nurses feared that these tasks were crowding out true nursing.10

Moreover, pharmacologic, technological, and other treatment innovations, such as antibiotic and intravenous therapy, early ambulation, and earlier hospital discharge, were undermining the value of the bed and body work that had comprised the natu-ral core of trained nursing since its beginnings. Whereas bath-ing patients to reduce the fever from an infection used to be a life-saving activity, an injection of penicillin now eradicated the infection, and it did so faster, more effectively, more reliably, and with much less effort. Antibiotic therapy transformed many infectious diseases from potentially mortal conditions requiring intensive bedside nursing to highly treatable, short-term condi-tions. Similarly, the intravenous infusion of fluids was a more efficient way to hydrate sick patients than coaxing them to take fluids by mouth. Patients were not only staying in hospitals for shorter periods of time, but also staying in their beds for less time while they were in the hospital. Between 1931 and 1951, the average general hospital stay declined from 14 to 10 days.11

By the early 1950s, bedrest was declining as a general mode

Reprinted by permission of Wolters Kluwer Health via the Copyright Clearance Center s̓ Rightslink® service. “Margaret Sandelowski, Venous Envy: The Post-World War II Debate over IV Nursing, Advances in Nursing Science, Volume 22, (1), pages 52-62.”

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of therapy, and patients were increasingly getting out of bed within 2 days of surgery.12 No longer were patients “condemned to weeks of imprisonment in bed,”13 nor was the greatest part of the nurseʼs day spent “around, about, and with the bed.”14 The traditional bed and body work of the nurse became literally less vital to patients and figuratively less dramatic than new drug and surgical treatment approaches.

In addition, sharper distinctions began to be formally drawn between the true, or professional, nurse and the technical one. Mildred Montag,15 the nurse educator who introduced the idea of community college education to train the nurse technician, divided the labor of nursing, conceiving of nursing functions as on a continuum from the very simple to the complex. Believing that much of the nurseʼs bedside work entailed only simple to minimally complex functions, she proposed that they could be safely delegated to nurses with only a technical (as opposed to a professional) education. In a historic and ironic twist of words, the technical nurse was now the kind of nurse who performed what nurses had always thought of as true nursing functions-that is, bedside care-while the professional nurse was the kind of nurse who performed technical functions, or the execution of complex medical tasks and hospital administration. What was now increasingly deemed “natural”16 in nursing was not bedside nursing, but rather the continued acceptance of tasks handed over to nurses by physicians. Nurses both lamented and saw as inevitable this inversion of nature.

One post-World War II event that exemplified the dilemma concerning true and technical nursing was the debate over whether nurses should perform intravenous (IV) therapy. In this article, I focus on this debate in the years between 1945 to 1970 and suggest its implications for contemporary nurs-ing. I refer to nurses as female throughout this article, since nurses were largely conceived of and discussed as women in this period.

The Emergence of IV TherapyOne new and very visible apparatus of patient care after

World War II was IV therapy. Until World War II, venipunc-ture, or the piercing of the vein with a needle to draw blood for laboratory analysis or to administer blood, fluids, or drugs, was a procedure wholly in the physicianʼs realm. IV therapy was considered highly dangerous because of the risk of introducing infectious agents in the course of penetrating the vein-an espe-cially mortal danger in the pre-antibiotic era-and because of the rapidity with which any agent injected directly into the blood stream could cause serious injury or death. As one physician noted, “nature never intended that the human being be fed and watered by vein, and, therefore, the insult of such a procedure should be respected.”17 Yet, as this same physician noted, feed-ing and watering patients by vein had become an increasingly popular (as opposed to emergency) mode of therapy by 1935. In the early 1940s, one in every eight patients at Strong Me-morial Hospital in Rochester, New York received IV therapy.18

The use of IV equipment at the University Hospital of Cleve-land increased by 177% between 1938 and 1953.19

Although nurses were neither formally taught nor explicitly legally permitted to enter patients ̓veins before World War II,

they became increasingly responsible for all of the before and after care associated with IV therapy.20-22 They gathered and as-sembled the appropriate equipment for the procedure, prepared the patient for it, ensured (or themselves carried out) the steril-ization and maintenance of IV equipment, and observed the pa-tient afterwards for any untoward effects. Because physicians increasingly declined to stay with patients for the time it took for large amounts of fluids and blood to flow into the body, nurses were increasingly charged with ensuring and regulating the flow of these fluids and with watching the patient for any signs of infiltration, allergic response, or fluid overload.

Ensuring the flow of fluids was a difficult affair for both patient and nurse. Any patient movement could dislodge the needle, and any drop in the rate or temporary cessation of flow could cause blood to clot, thereby permanently stopping the flow. IV equipment through the 1940s included relatively in-flexible metal needles and rubber tubing that were difficult to sterilize, manipulate, and hold in place. Patients had to have their arms (the usual site for IV therapy) restrained, which tended to cause discomfort and to interfere with mobility. Ac-cordingly, nurses bore the responsibility for securing the site of therapy while ensuring the comfort of the patient. As IV thera-py expanded to include more drugs, nutrients, and blood prod-ucts, nurses also were expected to know the uses and effects of the different agents prescribed for instillation into the vein so they could recognize the signs and symptoms of any local or systemic reactions and quickly notify the physician.

Although IV therapy entailed much more than just venipunc-ture, and the greatest danger from IV therapy was in the period after venipuncture-when whatever agent introduced into the vein was coursing through the body-it was venipuncture alone, or the discrete act of penetrating the vein with a needle, that initially defined IV therapy as a medical as opposed to a nurs-ing act. One traditional legal “test” of what constituted medical (as opposed to nursing) practice was the “piercing or sever-ing of human tissues,”23 but nurses had been piercing human tissues since the late nineteenth century. Nurses administered medications subcutaneously by hypodermic injection, and they infused large amounts of fluid subcutaneously by hypodermoc-lysis injection.

By the early 1940s, they also were increasingly adminis-tering drugs by the deeper route of intramuscular injection, a practice that accelerated after World War II with the advent of penicillin and other antibiotics. But it was during World War II that nurses began to do venipunctures themselves, primar-ily to administer fluids intravenously to injured soldiers on the front lines. Nurses also performed venipunctures on the home front in hospitals since there were not enough physicians avail-able to continue to restrict this procedure only to physicians. During the war, Hartford Hospital, for example, had instituted a 6-month training program for nurses on the management of blood banks and the preparation and administration of intrave-nous agents. The program was so successful, it was continued and expanded after the war.24 Thus, by the end of World War II nurses were performing de facto, if not de jure, medical acts of piercing human tissues on orders and with instruction from, if hardly ever under the direct supervision of, physicians.

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Yet, venipuncture as a domain of nursing practice became highly contested after the war. Although there were physi-cians who had objected to nurses giving intramuscular injec-tions,25 the transfer of this mode of piercing human tissues to nurses did not seem to engender the controversy that nurses performing venipunctures did. IV therapy carried more risk to the patient than other needle therapies, but the performance of venipuncture by the nurse seemed to threaten more deeply the bodily penetration line traditionally drawn between doctoring and nursing. For many physicians, non-physician performance of venipunctures was a serious incursion into medical terri-tory, entailing an activity closer to performing surgery than to simply giving an injection. (Some IV therapy actually entailed surgical incisions, or cut-downs, to insert cannulas into veins.) For nurses, venipuncture exposed them to the serious risk of being charged with practicing medicine without a license. In 1943, the Attorney General of New York specifically declared venipuncture the illegal practice of medicine if performed by anyone other than a physician.

Accordingly, in the late 1940s through the 1960s, questions were raised concerning whether venipuncture was a medical or nursing act and whether nurses ought to be allowed to continue to perform it, except in extreme emergencies such as a war or natural disaster. Whereas venipuncture was viewed before World War II as unequivocably a medical act, after the war it became a borderline procedure on the “fringe of medical prac-tice,”26 with nurses, physicians, hospital administrators, and lawyers debating how it should be defined and whether nurses should perform it.

Enter the Vein and Expand NursingFor nurse proponents of nurses performing venipunctures,

the vein was an entry point into a new field of practice for nurs-es. In the late 1940s, articles began to appear in the nursing and hospital literature urging nurses to take up IV therapy as a way both to upgrade women already in nursing and to entice more women into nursing.27 IV therapy was promoted, much like X-ray and laboratory work had been promoted in the 1920s and 1930s,28 as a new nursing specialty that would advance nurses and nursing. Like X-ray and laboratory work for nurses, IV therapy was advanced as a nursing specialty built around a technology that for most Americans embodied marvelous ad-vances in medical science.

As IV therapists, nurses would relieve the physician short-age, improve hospital efficiency, and make IV therapy a more effective and less painful treatment for patients. Like the “tem-perature nurse”29 before her, who took all of the temperatures of all the patients on a unit in one specified period of time, one IV nurse could administer all elective IV treatments to the pa-tients on a unit within a given time period. She could then more easily and closely supervise all of these patients, thereby allow-ing more efficient scheduling of other events in the physicianʼs and patientʼs day. Moreover, as a specialist, the IV nurse thera-pist would have the current knowledge about blood and fluid products and the apparatus to dispense them that the average practicing physician could not have.

Having a nurse therapist who was highly skilled to find and

insert needles into veins on the first try was preferable to hav-ing rotating and unskilled house officers repeatedly piercing patients in their efforts to find a vein. Having a cadre of IV therapists was invaluable in the event of major disasters with large casualties and in emergency cases where veins were dif-ficult to find, such as in patients with burns or in severe shock. Indeed, the ideal applicant to be trained as an IV therapist was a registered nurse who was both technically capable and conge-nial.24,30 Technical capability and congeniality were twin traits that the trained nurse had always been expected to show.

By the early 1960s, hospitals were increasingly establishing IV therapy programs and IV therapy teams largely comprised of nurses trained by and under the nominal supervision of phy-sicians, typically anesthesiologists, surgeons, or pathologists. Citing the need for nurses to keep up with the demands of mod-ern medicine, to free physicians from certain “bedside” proce-dures,31 and to end treatment delays for patients waiting for busy house officers to start their IVs, nurses and physicians called for more nurses to “enter [the patient s̓] vein.”32 Nurse proponents viewed IV therapy as yet another function that nurses had “in-herited”31 from physicians and venipuncture as the last in a line of needle punctures “ceded”32 to nurses. These proponents were pleased to participate in yet another medical innovation that had, not so long ago, been considered daring and even danger-ous, but was now accepted and even taken for granted.

In order to ensure their legal safety, nurses worked to have venipuncture declared a legal nursing act. The 1943 New York State ruling that venipuncture was illegal if performed by any-one other than a physician was reversed in 1961 after the New York State Nurses Association asked the Attorney General to review that ruling.33 Nurse specialists increasingly occupied themselves with learning how to use IV needles, what sizes and types of devices were suitable for different patients and different fluids, and other aspects of the paraphernalia and pro-cedures for entering, drawing blood from, and instilling agents into veins. They even helped design special carts to hold IV equipment. By 1973, nurse specialists had established the In-travenous Nursing Society and, in 1975, the Journal of Intrave-nous Nursing was published.

IV Nursing?Yet not all nurses and physicians agreed in this period that

venipuncture was a procedure appropriately delegated to nurs-es, even with restrictions placed on the kinds of agents nurses could inject or on when nurses could do venipunctures (typi-cally, when there was no physician available or when physi-cians asked nurses to do them). In part because of the continu-ing legal ambiguity surrounding IV therapy, nurse educators debated whether to teach venipuncture to their students and many continued not to teach venipuncture and/or permit stu-dents to perform them through the 1970s.34,35

There continued to be wide variation within and across states as to whether professional nurses were permitted to do veni-punctures and hang blood, and what medications they were permitted to add to an intravenous line already in place. Ac-cording to the results of a national survey published in 1962,36

22 states reportedly had no ruling covering the IV administra-

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tion of medications by nurses in hospitals. Only Maryland re-quired that physicians administer IV medications. Other states permitted registered nurses and/or medical technicians to ad-minister IV medications under medical supervision. In Indiana, nurses ̓authority to give IV medications was implied because it was not excluded, and in Virginia the definition of nursing practice was broad enough to include IV administration as IV therapy involved the administration of medications prescribed by physicians. As the attorney-author of this report concluded, nurses might administer IV medications, but they might do so also “with qualms about their legal rights to perform this func-tion.”36 (p41)

In addition to the legal ambiguity of performing IV thera-py, there was the professional ambiguity of whether a prac-tice built around a medical procedure was a nursing specialty. Early leaders in nursing had always sought to define nursing as something more than mere doing and nurses as something more than physicians ̓assistants.24 But the assumption of IV therapy as a nurse function reinforced the identification of technical procedures with true nursing and the role of the nurse as the physicianʼs hand. Moreover, it reified the one-nurse-to-one-technique approach to nursing at a time when nurses were also seeking to reestablish the one-nurse-to-one- patient approach that previously characterized nursing. Indeed, some nurses re-portedly became “so occupied with the technicalities involved” in IV therapy that they were cautioned not to forget the patient “on the end of the tubing.”37

As IV specialists, nurses were accommodating both physi-cians, who wanted to rid themselves of the work of IV therapy, and hospital administrators, who wanted to provide the most services for the least cost. Although by the mid-1960s nurses in some hospitals were performing IV therapy as part of their total care of the patient,38 the prevailing practice was to have IV therapy performed by specially trained nurses whose contact with patients was confined to IV therapy.

Easy Enough for a Nurse to Do, But Not as a NurseFor their part, physicians, who maintained the right to de-

cide what medical and, by association, what nursing practice entailed,39 found ways to permit nurses to do venipunctures without ever defining it as a component of nursing practice. George Lull, the physician secretary and general manager of the American Medical Association, argued that the administra-tion of IV therapy constituted something more than just nursing practice. Accordingly, if the nurse administered it, it was not as a nurse, but rather as an agent of the physician.26

Charles Letourneau, a physician serving on the Council on Professional Practice of the American Hospital Association, ad-vocated the legalization of venipuncture and other procedures that nurses were already performing without legal protection, but with physician consent. He referred to venipuncture as a simple technique that could be taught to nurses and other non-physi-cians.26 Peter Terenzio, the assistant director of Roosevelt Hospi-tal in New York, noted that IV therapy was becoming as routine as a backrub and was no longer an “awe- inspiring”26 measure. Moreover, in an emergency anyone could do a venipuncture. In-deed, since civilians in civil defense programs were already be-

ing trained to do venipunctures and technicians in blood banks were already routinely doing them, the de facto performance of venipunctures by non-physicians could not be illegal.

In short, the argument for legally allowing nurses to do veni-punctures rested on the fact that they and other non-physicians had done them and were still doing them, and on the assertion that if nurses were doing them, it was not as nurses but rather as physicians ̓assistants.

Moreover, reprising an increasingly familiar tautology that served to denigrate nursing skills, if nurses (and others) were doing venipunctures, they must be simple enough for nurses and others to do. Although venipuncture itself used to exempli-fy the body piercing rule by which medicine was distinguished from nursing, what now distinguished medicine from nursing in the matter of IV therapy was the continuing right to pre-scribe it and to delegate its execution to others.

Accordingly, what was ultimately ceded to nurses was not “full jurisdiction” over a domain of nursing practice, but rath-er a “limited settlement”40 in a domain of medical practice. Nurses were ceded the legal permission to do the work of IV therapy, but not the authority to control that practice. Venipunc-ture was not redefined as an act of nursing, nor was IV therapy redefined as a nursing measure extending the traditional nu-tritional or comfort work of the nurse. Venipuncture and IV therapy remained medical functions that nurses were legally allowed to perform for physicians. By performing this work, nurses relieved the physician shortage without obligating phy-sicians themselves to increase their numbers. Physicians had always been careful to keep their numbers low enough to pre-serve their market value. Moreover, by doing this ostensibly routine work, nurses permitted physicians to continue to attend to the “awe-inspiring” work of health care while still maintain-ing control over the work they no longer wished to perform. Indeed, the assumption of IV therapy by nurses permitted the “delegation of [the] dangerously routine work”41 that, as soci-ologist Andrew Abbott argued, tends to undermine profession-al prestige. As IV therapy became less mortally dangerous to patients and ostensibly as routine as a backrub, it became more professionally dangerous to physicians ̓dominance to continue to administer it.

In short, the assumption by nurses of the work of IV therapy allowed, in Abbottʼs words, the “extension of dominant effort without division of dominant perquisites.”41 Although IV ther-apy as a specialty practice returned registered nurses to the pa-tientʼs bedside, a space increasingly occupied by lesser-trained nursing personnel specifically created to offset the shortage of registered nurses, these nurses returned to the bedside, not as nurses, but rather as agents of physicians.

IV nursing, as it was legally defined and commonly viewed in joint medical and nursing policy statements through the 1960s,41 extended what generally everybody understood to be doctoring, not nursing. While relieving the physician shortage, the assumption of IV therapy by nurses did nothing to relieve the much lamented post-World War II professional nursing shortage or resolve the problem of what constituted true nurs-ing. Indeed, the assumption of this task by nurses further com-plicated nurses ̓efforts to define nursing work and to establish

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a distinctive nursing identity. The irony was that professional nurses were once again performing medical tasks, while the newly invented and rapidly proliferating technical nurses and nurses ̓aides were performing true nursing. The debate over IV therapy underscored not only how hard it had become to define nursing, but also how important it had always been-to physi-cians-to define nursing in ways that did not “encroach” on but nevertheless served medicine.42

The Vein and Other Dubious Portals of EntryNurse specialists in IV therapy, perhaps more than any other

agents, have contributed to the safe and effective implementa-tion of IV therapy. Their accomplishments here are especially notable now that blood-borne infections, such as the human immunodeficiency virus/acquired immune deficiency syn-drome (HIV/AIDS), again pose mortal threats. IV nurses have played an especially critical role in the increasingly rapid trans-fer of high-technology care from the hospital to the home and to improved product design. And they have demonstrated how true nursing can be preserved in a practice area originating in and organized around a technology. My interpretation of the beginnings of IV nursing is therefore not to be read as a dispar-agement of these nurses, nor as a denigration of the knowledge and skills they have, nor as an effort to designate IV nursing as “merely technical,”43 as opposed to true, or professional, nurs-ing. Instead, my interpretation is a reading of the conditions under which nursing roles are often ostensibly expanded.

The post-World War II assumption of IV therapy by nurses illuminates the dilemma nurses have historically faced, and continue to face, when new technologies demand new work and when patients require services that physicians are no longer willing to perform or that are deemed too expensive for physi-cians exclusively to perform. Nurses gained entry into patientsʼveins, like other portals of entry into new domains of practice, under tenuous circumstances. In the case of IV therapy, nurses were permitted to participate in a new domain of practice that enlarged their knowledge, enhanced their skills, and enhanced their value in health care. But it was at the cost of continued subordination of nursing to medicine by the movement of nurs-ing further into the jurisdiction of medicine, thereby threaten-ing the already endangered jurisdiction of true nursing. Yet if they had refused to assume the work of IV therapy, nursing (and arguably patients) would have been endangered also by the proliferation of non-nurse IV technicians.

The subordination of nursing by delegation and by the con-tinued threat of replacement by “technicians” continues. Nurs-es are still viewed like “Hamburger Helper”: that is, as physi-cian extenders. A contemporary case in point is the demand for acute care or tertiary nurse practitioners, which is directly re-lated to the decline in resident physicians in hospitals.44 Nurses are again being recruited and permitted to enter domains of medical practice to offset physician shortages. Although these nurse practitioners see themselves as providing, and make ev-ery effort to provide, more comprehensive nursing care, the public demand for them derives not from a demand for ex-panded nursing services but rather from a need to offset physi-cian shortages and to render health care more inexpensively.

That is, the public rhetoric around these nurse practitioners is not about nursing, but about medicine. Moreover, it is difficult for these nurses to operationalize the “nursing perspective”45

when their days are spent, as in the case of one neonatal nurse practitioner, “perform[ing] medical procedures, such as intuba-tion, lumbar puncture, umbilical line placement, and circumci-sion.”45 Indeed, such nurses are often compelled to hand over many of the bodily ministering, teaching, and interpersonal re-lationship functions comprising what has, since World War II, been viewed as true nursing to regular nurses, or to members of other established and emerging disciplines such as psycholo-gists, social workers, grief counselors, and lay patient advo-cates. While patients and their families undeniably benefit from the expert technical ministrations of acute care nurse practitio-ners, and acute care nurse practitioners undeniably make every effort to assimilate technical procedures into the fabric of true nursing, the profession of nursing per se arguably continues to be undermined. Specialty nursing practices built around tech-nologies remaining in medical jurisdiction serve primarily the interests of organized medicine and hospitals.

The resolution of the debate over IV nursing was, in large part, a resolution of words-yet another instance of the tortuous language practices that have been so effective in subordinating nursing. Words, whether they appear in laws, joint policy state-ments, or the public media, have been critical in shaping the conditions for nursing practice. Nursing is erased when nurses are described as performing IV therapy not as nurses, but rather as physician agents. Nursing skills are denigrated when tasks once considered awesome when performed by physicians are subsequently described as easy enough for a nurse to do when performed by nurses. The resolution of the debate over IV ther-apy shows again that skill is not an objective entity, but rather an ideological device46 used to maintain power. When primary and tertiary care nurse practitioners are promoted as the cost-effective alternative to high-priced physicians to execute so-called simple and routine tasks, their services are cheapened and demeaned.

In conclusion, the vein was a portal of entry for nurses, but one with limited access. The debate over IV therapy demon-strated how technology, in combination with ideology, can both create and destroy nursing jurisdictions.40

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