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Shirley Carew Titus
School of Nursing

B: 1892 Alameda, California | D: 1967 San Francisco, California

Diploma, St. Luke’s Hospital School of Nursing, San Francisco, 1915; Social Service School, San Francisco Polyclinic and Post-Graduate College, evening classes, 1915; B.S. and Diploma, Administration of Schools of Nursing, Teachers College, Columbia University, New York, 1925; M.A., University of Michigan, 1929; University of Grenoble, Grenoble, France, 1938-1939.

Assistant principal, St. Luke’s Hospital School of Nursing, San Francisco, California, 1915-1917; assistant in the prevention of infant and maternal mortality, Children’s Bureau, United States Department of Labor, Washington, D.C., 1917-1919; assistant superintendent of nurses, Barnes and St. Louis Children’s Hospitals, St. Louis, Missouri, May to October 1919; superintendent of nurses and principal of School of Nursing, Columbia Hospital, Milwaukee, Wisconsin, 1920-1924; director of nursing, University of Michigan Hospital School of Nursing, 1925-1930; professor of nursing education and dean, School of Nursing, Vanderbilt University, 1930-1938; director of nursing, Children’s Hospital, Los Angeles, abt. 1939-1942; executive director, California State Nurses’ Association (CSNA), 1942-1955.

A graduate of San Jose High School, Titus grew up on a prune ranch in Santa Clara County, which in 1915 had 7 million fruit trees. Titus was a senior at St. Luke’s Hospital in February of 1915, when the Panama-Pacific International Exposition opened in San Francisco. World fairs were wildly popular events and she undoubtedly would have attended it. In the Palace of Education perhaps she would have viewed the exhibit where mothers brought their children for free health conferences with physicians and nurses, an initiative of the Children’s Bureau of the U.S. Department of Labor. Did this scene inspire her to cross the country to Washington, D.C. to apply? In any case, by 1917 Titus was setting up bureau-sponsored child health conferences in rural schools and churches. For at least part of the time, Titus worked with one other nurse and Dr. Frances S. Bradley, a specialist in children’s diseases, who had been at the exposition in San Francisco. According to Dr. Bradley, the doctor and nurse “weigh, measure, question into the present and past, and suggest future action,” seeing one mother and child at a time in a private room. Afterward the mother was given helpful literature to take home and a written list of “defects or tendencies needing attention” and “suggestions as to the nutrition and general hygiene of the child.” We know that Titus visited multiple sites in the Blue Ridge Mountains and in Jones County, Mississippi. These child welfare conferences were well-received by the public.

Titus developed a keen interest in dietetics and nutrition education, although her own student experience went badly. As a nursing student, Titus was rotated to the diet kitchen for three months. The first two weeks she was “silver girl” and had to dry and polish all the silver. The next two weeks she made broths and gruels. “I am sure that I cut up at least 10,000 cold and clammy chickens and that each of these 10,000 chickens was centipedic in construction!” The rest of her experience “was just about as valuable,” she said. “I left this service with what almost proved a never-ending dislike for dietetics and anything allied to it.”

While at University of Michigan Hospital School of Nursing, Titus acted to make coursework on nutrition and dietetics more interesting to the students by teaching cooking on a “meal basis” and integrating “feeding the patient” into case studies. In the June 1927 issue of AJN, she described in detail a ten-point program to improve dietetics instruction at Michigan. In 1929 Titus chaired the Subcommittee on Dietetics within the Committee of Education of the National League of Nursing Education, which prepared the latest standard curriculum for schools of nursing on the elements of nutrition and cookery. The course, conducted by a dietician, consisted of 45 hours divided between lecture and laboratory work. Content included nutritive values of foods; principles of simple cookery; foods for convalescent patients; and diets prescribed for treatment of various diseases.

During Titus’s five years in Ann Arbor, several improvements were made to the quantity and quality of instruction. Instruction in nursing theory and practice was correlated; for example, if a student were taking courses in medical nursing, her clinical rotation would be in medical nursing also. The instructing-supervisor system was fully implemented. A review of the curriculum pruned away non-essentials, repetitions, and overlapping of subject material. A popular new course was added, “The Place of the Nurse in Modern Society,” which focused on problems a nurse would face after graduation, such as how to apply for a position and how to manage money. Upon request of the director of the hospital, the official name of the school was changed to the University Hospital School of Nursing of the University of Michigan. In 1929, the school was re-accredited by the New York State Department of Education after a lapse of six years.

The students were more connected to campus life. Instruction in the basic sciences, which had been conducted by nursing faculty, was transferred to the campus proper. Students also participated to a greater extent with women’s sports and social activities on campus. They were not yet charged University participation fees, but soon would be. The preliminary education of nursing students and undergraduate University students was similar. In Titus’s time, applicants to the school had to meet entrance requirements for the literary college; that is, graduation from an accredited high school. Nationally, that did not become an admission requirement for nursing school until 1940.

Titus faced some immediate challenges and discomforts when she arrived in Ann Arbor on July 1, 1925. Titus stayed at the men’s Michigan Union for a short time, then moved in to Couzens Hall, the new nurses’ dormitory where she was to live, as its first and only occupant. Couzens Hall was still incompletely furnished. Her room had a bed and chair, but no door, window shade, or screen. The outside doors had no locks. On July 11, 1925 the local newspaper reported that the street was closed to traffic due to paving operations, postponing occupancy by 175 nurses. Fortunately, the new hospital, with its massive increase in bed capacity, was not yet open.

Young women were socialized to become poised, civic-minded adults, with proper attitudes and behaviors, as they lived in the nurses’ residence, which played an important educational role. Over the five years Titus was director of nursing, wholesome leisure time activities and gracious living at Couzens were supported through the generosity of alumni and community groups. Improvements were made to the stage curtains, footlights and scenery, and the Dramatic Club produced two or three plays a year. More equipment was purchased for the gymnasium at Couzens to allow for indoor sports such as table tennis and volleyball, which were enjoyed by students and faculty alike. Private donations of bedding plants and completion of a small pond enhanced the beauty of the grounds around Couzens. In the living room where formal teas were held, the tea table was adorned by a beautiful Russian samovar, dripper, and tray given by one of the nursing classes. The social director of the School of Nursing, a Couzens Hall resident, played an important role in structuring time for leisure activities and teaching proper social etiquette. Titus felt that the social director, with a proper educational background, could also teach applied psychology, by bringing awareness to the students’ own mental processes and helping students to develop the “proper mental attitude toward illness or pain” (AJN, March 1922). The student government, with the assistance of Titus, revised the school constitution, by-laws, and rules. By tying “late leaves” to scholarship, the Student Council exerted a marked effect on the scholastic achievement of the school.

As Shirley Titus began her first year as director of nurses in the summer of 1925, the new University Hospital opened to patients, bringing the hospital “face to face with a serious economic problem relative to its nursing service, which arose out of a sudden and very great expansion in bed capacity.” Of necessity, graduate nurses were employed in significant numbers to work general duty. An “interesting and effective” plan was devised to pay for them, which Titus described in the March 1927 issue of AJN. Graduate nurse personnel were classified as “budget, non-revenue bearing” or “non-budget, direct-revenue bearing.” Budgeted positions were filled by graduate nurses serving as administrative assistants, instructors, head nurses, clinic nurses, and so on. Salaries were met from the general income of the hospital. The director of nursing had little flexibility to change these positions until the next budget period. Non-budget nurses consisted of graduate nurses doing general duty. The cost of these nurses was directly charged back to the patient receiving care. The director of nursing could employ general duty nurses as need demanded.

In this system, the open wards of up to eighteen beds were staffed by students. These patients received no itemized charge for nursing care. The patients in private rooms, semi-private rooms, and four-bed wards were nursed by graduate nurses. These patients were charged four dollars a day for nursing care. In case of a shortage of general duty nurses, private duty nurses were called in at six to eight dollars a day per nurse. In case of a decline in hospital census, more of the general duty staff were assigned to care for “special care” patients. Using a ratio of 4:1 as a guideline, the director of nursing had freedom to meet varying staffing needs. Titus said, “The foregoing plan has been in operation for some fifteen months and has proven to be most satisfactory. The hospital authorities know that the patients are receiving good nursing care at a moderate cost and that this cost is being met as the expense arises; they are, therefore, no longer harassed with an ever-mounting nursing bill or complaints from under-nursed and poorly-looked-after patients.”

The University of Michigan honored Titus in the following ways. The Shirley C. Titus Graduate Scholarship was established by the Class of 1930 in recognition of Titus’s outstanding service as director of the School of Nursing. In 1977 the Shirley Titus Distinguished Professorship was established by the University of Michigan Board of Regents. Its first incumbent was Dr. Beatrice Kalisch, professor and chair of the Maternal-Child Nursing faculty.

In 1930 Titus left the University of Michigan to become professor of nursing education and first dean of Vanderbilt University School of Nursing in Nashville, Tennessee. Serving for eight years, she accomplished her charge to reorganize the curriculum to include public health nursing and allow students to take certain courses in the college of arts and science. In the May 1935 issue of AJN Titus argued that all nurses should receive basic public health nursing education. “Because nursing education took firm root in the hospital before preventive medicine had developed in this country, we have simply gone on assuming that the basic preparation of the nurse should be entirely curative in nature. There seems to be no reason why the basic course should not be so arranged that the student nurse could be prepared for all first-level positions wherever they might be—with or without the hospital—except that the hospital would cease to make a profit out of operating a school of nursing.” She argued that all schools could incorporate prevention into the basic curriculum if they could determine how to fund it. In the case of Vanderbilt, students were charged tuition, but the bulk of the money to support this initiative was supplied by a grant from the Rockefeller Foundation, an option available to very few schools. Titus proposed that public money in support nursing education might be the best option.

As executive director of the California State Nurses’ Association (CSNA), she became a change agent for the economic plight of nurses, who worked hard for low pay. In 1943 she won approval from the War Labor Board for a statewide salary increase for nurses. In her 1943 AJN article, “Economic Security Is Not Too Much to Ask,” Titus asserted that as employed professionals, nurses needed the protection of, and had the legal right to, collective bargaining. In 1946 the American Nurses’ Association approved the use of collective bargaining by nurses by adopting the report “Principles of an Economic Security Program,” prepared by a committee chaired by Titus. California hospitals were induced to reduce the work week to 44, then 40 hours.

Titus received national recognition for her work on behalf of the profession. In 1976 the Shirley Titus Award was established by the American Nurses’ Association to recognize the significant contribution that an individual nurse has made in the ANA economic and general welfare program. In 1982, Titus was inducted into the American Nurses’ Association Hall of Fame.

Shirley Carew Titus was born in Alameda, California in April 1892. In her retirement Titus resided for many years with Mary Dodd Giles at Strawberry Manor, California in Marin County. She died at the home of her sister, Adele B. Titus, in San Francisco in March 1967 at age 74. Her inurned remains were committed to Olivet Memorial Park in Colma, California.

Sources for this article about Shirley Titus by Janet Tarolli include:

American Nurses’ Association Hall of Fame Inductees (available online); American Red Cross, Nursing Services Annual Questionnaire for Shirley Titus (1945); Find a Grave (available online at; Frances Sage Bradley Papers, Stuart A. Rose Manuscript, Archives, and Rare Book Library, Emory University, finding aid available online at ; histories of agriculture and prune ranching in Santa Clara County, California; History of Columbia Hospital School of Nursing, Milwaukee, Wisconsin, available online at; Official Guide of the Panama-Pacific International Exposition, 1915; Pacific Coast Journal of Nursing; President’s Report to the Board of Regents, University of Michigan; Scalpel, University of Michigan Training School for Nurses; United States Federal Census; United States Social Security Death Index; University of California at Los Angeles official publications; University of Michigan Board of Regents records; University of Michigan official publications.

Books: Vern L. Bullough, Olga Maranjian Church, and Alice P. Stein, American Nursing, A Biographical Dictionary (1988); Alida Frances Pattee, Teacher’s Dietetic Guide, Containing the Latest Standard Curriculum State Board Requirements in Dietetics and State Board Examination Questions (1929); Frank Morton Todd, The Story of the Exposition, Being the Official History of the International Celebration Held at San Francisco in 1915 to Commemorate the Discovery of the Pacific Ocean and the Construction of the Panama Canal, Volume Four (1921).

Select writings by Shirley Titus: “Health Morale of Student Nurses” (AJN March 1922); “Nursing Care of Nephritis” (AJN June 1926); “Meeting the Cost of Nursing Service: An Interesting and Effective Plan in Use at the University of Michigan Hospital” (AJN March 1927);“A Practical Aspect of the Teaching of Dietetics” (AJN June 1927); “The Place of Extra-Curricular Activities in Schools of Nursing” (AJN November 1927); “Pre-Professional Education of the Nurse” (AJN January 1928); “Graduate Nursing” (AJN February 1931); “The New Scutari” (September 1933); “Vanderbilt University School of Nursing” (Journal of the Association of American Medical Colleges, March 1935); “Present Trends in Nursing Education” (AJN May 1935); “Economic Facts of Life for Nurses” (AJN September 1952).

Newspapers: Advocate (Baton Rouge, Louisiana); Asheville Citizen-Times (Asheville, North Carolina); The Atlanta Constitution (Atlanta, Georgia); Augusta Chronicle (Augusta, Georgia); Battle Creek Enquirer (Battle Creek, Michigan); The Bradford Era (Bradford, Pennsylvania); The Capital Times (Madison, Wisconsin); The Daily News-Journal (Murfreesboro, Tennessee); Detroit Free Press (Detroit, Michigan); The Dothan Eagle (Dothan, Alabama); The Evening News (Wilkes-Barre, Pennsylvania); Evening Star (Washington, D.C.); Green Bay Press-Gazette (Green Bay, Wisconsin); The Herald-Press (Saint Joseph, Michigan); The Indianapolis News (Indianapolis, Indiana); The Indianapolis Star (Indianapolis, Indiana); Jones County News (Ellisville, Mississippi); Knoxville News-Sentinel (Knoxville, Tennessee); Lansing State Journal (Lansing, Michigan); The Laurel Leader (Laurel, Mississippi); Leader-Telegram (Eau Claire, Wisconsin); Lincoln Journal Star (Lincoln, Nebraska); The Los Angeles Times (Los Angeles, California); Macon Telegraph (Macon, Georgia); Middlesboro Daily News (Middlesboro, Kentucky); Milwaukee Journal Sentinel (Milwaukee, Wisconsin); The Montgomery Advertiser (Montgomery, Alabama); News-Journal (Mansfield, Ohio); The News-Record (Neenah, Wisconsin); The Oshkosh Northwestern (Oshkosh, Wisconsin); The Palm Beach Post (West Palm Beach, Florida); The Pittsburgh Courier (Pittsburgh, Pennsylvania); Pittsburgh Post-Gazette (Pittsburgh, Pennsylvania); The Pittsburgh Press (Pittsburgh, Pennsylvania); The Post-Crescent (Appleton, Wisconsin); Repository (Canton, Ohio); Riverside Daily Press (Riverside, California); Sacramento Bee (Sacramento, California); San Diego Union (San Diego, California); San Francisco Chronicle; San Francisco Examiner; San Luis Obispo Telegram-Tribune (San Luis Obispo, California); Sausalito News (Sausalito, California); State Times Advocate (Baton Rouge, Louisiana); Tallahassee Democrat (Tallahassee, Florida); The Tennessean (Nashville, Tennessee); Times-Picayune (New Orleans, Louisiana); Wausau Daily Herald (Wausau, Wisconsin); The Wilkes-Barre Record (Wilkes-Barre, Pennsylvania).