BADGES/PINS OF NURSING AND MIDWIFERY SCHOOLS IN SLOVENIA FROM 1925 UNTIL EARLY 1980s

Introduction: Many nursing and midwifery schools in many countries around the world awarded or still award graduation badges or pins to their graduates. All graduates from different parts of the former Kingdom of Yugoslavia and later the Republic of Yugoslavia educated in Slovenian healthcare schools received badges from these schools. Some of the graduates later employed in medical institutions across former Yugoslavia wore these badges on their uniforms. The main purpose of this historical research was to establish which Slovenian health care schools awarded the graduation badges and what they looked like. It was also investigated why the badges ceased to be awarded and what motivated Angela Boškin Faculty of Health Care in Jesenice to reintroduce awarding the badges. Methods: Due to a lack of written sources, we conducted 393 face to face and telephonic interviews with former badge recipients across Slovenia. Their existing badges were photographed. On the authors’ initiative, a private collection of badges was started. Results: It has been established that in the 20 century all Slovenian secondary health schools awarded badges. The Nursing College, Ljubljana also awarded graduation badges. Five different types of badges in many variants were issued. The first badges were awarded to graduates by Slovenian oldest Preliminary communication Acta Med Hist Adriat 2020; 18(2);317-336 Prethodno priop}enje https://doi.org/10.31952/amha.18.2.6


Introduction
Old nurses and midwives' badges or pins (hereinafter: nursing badges) are rare in Slovenia. After finding such a badge mixed with numismatic material, the badge evoked the author's interest as an amateur numismatist. A search of the accessible literature was performed, and to the author's knowledge, there were no extensive writings on this topic in Slovenian or even in the worldwide literature.
The tradition of presenting nursing badges originated in the 1860s at the Nightingale School of Nursing at St. Thomas Hospital in London. Florence Nightingale having been recently awarded The Red Cross of St. George for her selfless service for the injured and dying in the Crimean War, chose to extend her honour to her most outstanding graduate nurses by presenting each of them with a medal for excellence. 1 Later on, awarding all graduates with badges became a tradition in Great Britain and the United States of America. The graduation badges are actually medals presented to nurses as honorary awards for their hard study and work and are important evidence of successful competition of medical nursing education. The badges represent symbolic initiation and admission to the nursing profession. The badges were created with the purpose of fostering pride in a noble profession, and for creating a sense of loyalty to the issuing body. 2 Graduation badge attached to the nursing uniform became an important part of nurses' professional identity, gave her a sense of self-confidence and increased her authority. The graduation badges provided an eloquent proof of the foundation and evolution of nursing schools. In addition, the badges are evidence of the history of nursing. The badges are beautiful miniature works of art, and they are undoubtedly important artefacts of Slovenian cultural heritage.
The first graduation badges, together with graduation certificates, were presented to newly graduated nurses in the United States of America at the end of the 19th century. 3 Old British nursing badges are presented in a comprehensive review by Meglaughlin. 4 In the Austro-Hungarian Empire, the State School for Patient Carers awarded badges beginning with the first generation of graduates in 1915. Wearing badges on uniforms was obligatory and prescribed by law. 5 Currently, there is no evidence that anyone from the territory of today's Slovenia, who was trained to become a certified patient carer in Vienna (in today's term -to be a nurse) before the breakup of the Austro-Hungarian Empire, was presented with a graduation badge of the school along with a graduation certificate. Following the Austrian model, the nurses educated in the newly formed Kingdom of Serbs, Croats and Slovenes, were presented with graduation badges to wear on their uniforms. Graduation badges were presented at schools for nurses in Belgrade, Zagreb and Ljubljana. The nurses had to wear graduation badges on their uniforms. The badges that certified nurses received in Croatia before World War II have already been described by Željko Dugac and Katarina Horvat. 6 The badges which were presented to nurses and midwives in Croatia from 1914 to 1990 were already described in detail by Zlatko Brbora in 2015. 7 Graduation badges awarded to graduates of School for Childcare Nurses are described by Branko Beštak. 8 Before World War II, several Slovenes were trained at schools for nurses either in Zagreb or in Belgrade, they were presented with badges of the Croatian or Serbian schools respectively. Some Croats studied for nurses or midwives in Slovenia, and they received graduation badges   Dugac, Ž., Horvat, K. (2013), Službeno, praktično i elegantno: o uniformama sestara pomoćnica-medicinskih sestara od 1920-ih do 1940-ih godina u Hrvatskoj, Acta medico-historica Adriatica, 11(2), 251-74. 7 Brbora, Z. (2015). Službene značke i odore medicinskih sestara, primalja i bolničarki u Hrvatskoj (1914.-1990.), Dubrovnik: Samozaložba, 1-23. 8 Beštak, B. (2006). Značka škole za dječje njegovateljice Medicinskog fakulteta u Zagrebu, Obol XLIV (58), 65-67. from Slovenian schools. Dugac cites an example where a nurse, who graduated in Belgrade but worked in Zagreb during the period of the Independent State of Croatia -NDH (1941)(1942)(1943)(1944)(1945), World War II), was advised not to wear her graduation badge which she had received in Belgrade. 9 Several nurses, midwives, and childcare workers from different regions of Yugoslavia who trained in Slovenia and were later employed in Croatia wore their Slovenian graduation badges on their uniforms. 10,11 The main purpose of this paper in addition to preserving the knowledge about graduation nursing badges was also to establish which Slovenian secondary schools for nurses and midwives and colleges awarded graduation badges and what they looked like.
The additional purposes of the research were to: -write an article that would be of help in preparing nursing badges exhibitions and serve as a manual for badge collectors -enable identification of badges worn by nurses on uninscribed photographs -establish the manner in which badges were awarded -find out how nurses felt about wearing badges -examine why nurses agreed or refused to wear badges -discover what happened to awarded badges -find out how many nurses still kept their badges -learn where the nurses kept their badges -explore why badges ceased to be awarded -find out what motivated the Angela Boškin Faculty Health Care, Jesenice to reintroduce the tradition of awarding nurses with graduation badges -test our hypothesis that many Slovenian nurses/midwives do not sufficiently appreciate their graduation badges The paper is primarily a descriptive piece of graduation badges. Any deeper analysis of the purpose and meaning of badges, as well as the reasons for the ceasing of awarding of badges, are beyond the scope of this paper.

Methods
A systematic review of domestic and foreign literature was carried out via electronic databases Google search engine, COBIB.SI Biomedicina, dLib.si Slovenica, digital archives of Slovenian Nursing Review and web sites of Schools for Health Care. Search words in Slovene, English and German were used to search for potential written sources containing whatever data about badges. A review of archives and jubilee catalogues of nine former Slovenian nursing/midwives' secondary schools and Nursing College, Ljubljana was performed. In addition, the search across BSN diplomas, bachelor's and master's theses, and doctoral dissertations related to the history of nursing and newspapers published around the dates of nursing graduation ceremonies was conducted. Data about the evolution of Slovenian nursing/midwifery schools were gathered from two written sources. 12,13 A written request was sent to the Nurses and Midwives Association of Slovenia and all nine Schools for Health Care, the successors of the former Slovenian schools for nurses/midwives, for any information about the graduation badges. Unfortunately, no additional valuable data were obtained from these written requests. An overview of sources from different countries concerning the awarding of graduation badges was carried out to enable the authors to compare with the tradition of awarding badges in Slovenia. Photographs exhibiting badges on the nurses/midwives' uniforms were collected as well.
A private collection of badges has been started. Badges were bought at auctions, antiquities shops, and flea markets.
Due to the lack of data about the badges in written sources, we decided to interview nurses, midwives, and rarely relatives of deceased nurses/ midwives across Slovenia. In the pilot interviewing, we established that awarding badges ceased from the late 1970s to the early 1980s. Therefore, we concluded that the interviewing of mostly retired persons would be needed. For this reason, the most significant part of face-to-face interviews was conducted at apartments and nursing homes across Slovenia. The minor part of still working nurses and midwives was interviewed at hospitals. Some interviews were conducted over the phone or by e-mail. A semi-structured series of the predetermined open-ended questions was prepared to carry out the research. The data obtained from interviews were written down. All interviewees were asked if they still kept their badge and a photograph of their badge was taken with their permission.
From June 2013 to December 2016, 346-time consuming interviews were carried out. Many elderly interviewees were suffering from different diseases, and many of them were hospitalised or treated in rehabilitation facilities, which significantly prolonged the interviewing period as we had to wait one month or more to conduct many interviews. In an effort to collect whatever missing data about the badges, 47 additional interviews were conducted in the first half of 2018.

Results
Only one short article in Slovene describing and depicting two nursing badges was found. 14 The nursing or midwife badges are only barely mentioned in some Slovene written sources. 15,16,17,18 The authors were able to find some papers and handbooks concerning badges published in different foreign countries. 19 In this paper, the graduation badges issued and awarded by nursing and midwives' schools in Ljubljana are described and depicted in the order of the year of their foundation.
The badges awarded by the eight remaining nursing schools across Slovenia have the same shape and design as the badges awarded in Ljubljana and are therefore only mentioned in this paper.
The first school for nurses in Slovenia was founded at the Institute for Social and Hygienic Protection of Children in Ljubljana. The schooling started on January 3, 1924. The monovalent school lasted for one year. It educated both secular and religious nurses. The graduates were presented with an upright oval silver-plated badge, the work of the academic sculptor Alojz Dolinar (1893-1970). 20 (Fig.1, left). In 1931, the school was transformed into a three-year school with polyvalent education and was renamed. Graduates were awarded a newly designed graduation badge. The badge was the work of the academic sculptor France Gorše (1897-1986). 21 It has the shape of an equilateral trapezoid and is silver-plated. The front face of the badge depicts a relief of a woman in profile with the raised right hand holding a lamp -a symbol of the nurse with the lamp (The Lady with the Lamp) ( Fig.1, right). Along the bottom edge is the inscription: ŠOLA ZA ZAŠČITNE SESTRE V LJUBLJANI (The School for Nurses in Ljubljana).
In 1929, the School for Children's Nurses was established at the Institute for Social and Hygienic Protection of Children. The schooling was in the form of 6 months course. In the 1930s, schooling was initially extended to one year. 22 Graduates received graduation certificates and badges. The artist who 21 Ibid. 22 Pirc, I. (1938), 437.   (Fig.3,  left). After World War 2 the school was renamed as ŠOLA ZA OTROŠKE NEGOVALKE (School for Childcare Workers). 23 The presented graduation badges are identical to the badges given by the School for Children's Nurses, and the new title of the school and no maker's mark are the only differences. (Fig.3, right) 23 Gradišek   Due to the health reform of Maria Theresia, the Empress of the Austro-Hungarian Empire, Doctor Gerhard van Swieten founded a School for Midwives in Ljubljana, as early as 1753. 24 The school began to present graduation badges to its graduates only after World War II. Two various graduation silver-plated badges are known. The first, rectangular-shaped shows an image of a midwife with a diaper-wrapped new-born baby in her lap in relief and the word around the edges: BABIŠKA ŠOLA LJUBLJANA (School for Midwives, Ljubljana). The badge was awarded until the early 1960s (     From 1950 to 1974, nine secondary schools of nursing were established in all major cities in Slovenia (Maribor, 1947;Celje, 1954;Murska Sobota, 1960;Nova Gorica, 1961;Piran, 1961;Jesenice, 1962;Ljubljana, 1962;Novo Mesto, 1963;Slovenj Gradec, 1974). At the end of the school year, all medical nursing 25 Gradišek, A.  From the beginning headmasters pinned the badges on the uniforms of newly graduated nurses (Fig. 5), later graduates received their graduation certificates and badges wearing civilian clothes.
In the school year 1981/82, a major reform of secondary education was carried out in Slovenia. Among other modifications, the awarding of graduation badges was ceased in the early 1980s. , Jesenice gave the initiative to restore the tradition of awarding graduation badges to students that have successfully finished their education (Fig.6). A question about the motives for her initiative was sent by e-mail to Prof. Savič. In her reply, the former Dean Skela Savič stated that the FZAB wanted to elevate the recognisability of the study of nursing as well as the recognisability of the nursing profession. Additionally, Prof. Skela Savič thought that graduation badges strengthen self-image and responsibility of the graduates and also present a great commitment to the faculty which awards them. 26  logo by MA marketing, Vrhnika, and it is manufactured by the engravers Lavrih in Šentvid at Stična and Tomšič, Vrhnika. On the round, partially enamelled badge there is the school's logo, the name of the faculty is inscribed on the edge in Slovene and English. The logo presents the outline of two persons, whose heads are marked with Swarovski crystals, and it can be interpreted in several ways, one of them being the relationship between a student -a future nurse and a patient (Fig.7). The badge uses magnets to attach easily to all clothing.

Discusion
Some nursing schools stopped awarding badges calling them obsolete and unnecessary since identification badges (ID badges) are mandatory in health institutions.
In 1999 Callander -Grant undertook a telephone survey of 30 nationwide nursing colleges in Great Britain and ascertained that the financial considerations were a major contributing factor of many colleges in their decision not to present graduation badges anymore. The additional reasons for ceasing awarding badges could be an amalgamation of many nursing schools in larger nursing colleges, and some of those have not designed badges. 27 The Dean of University of Applied Health Sciences, Zagreb, Prof. Racz, PhD informed us that in 2013 his predecessor ceased awarding badges with the purpose of redistribution of financial resources to the students needy of financial support. 28 No reason for cessation of awarding badges in Slovenia can be found in written sources. We presume that financial motives were among the main reasons to cease awarding badges in Slovenia too.
We propose that there are some additional reasons besides the causes for refusing to wear the badges gathered by our interviewing. The badges were not personalised by engraving nurses' names or their initials and the graduation dates.
In addition, in most countries around the world, nursing graduates hear an explanation about the meaning and symbolism of awarding badges which are then awarded to graduates ceremoniously by nursing school leadership or in some cases by the graduate's family members. Many colleges and universities awarded the badge/pin at a separate graduation ceremony (pinning ceremony). 29 In Slovenia, the badges were simply pinned on the uniform or civil clothes or handed out. For these reasons, many nurses were not emotionally attached to their badges that in addition were not manufactured of precious metals, and that is why so few nurses have kept their badges. Some of the newly educated nurses did not attend the graduation ceremonies and confirmed our hypothesis that some Slovene nurses, as opposed to their foreign counterparts, are not aware of the meaning and importance of awarded badges, they do not prize them enough and are not interested in what happens to their badges. As wearing of the badges was not mandatory, and some nurses had never worn the badges, the majority of nurses abandoned wearing badges.
In some medical facilities, all employees wear identically coloured scrubs and identical ID badges. Nurses not wearing graduation badges cannot be identified by patients as nurses. From a distance, neither an ID badge nor a graduation nurse badge is clearly readable. However, since graduation nurse badges are issued only for nurses, only nurses are allowed to wear them. Unlike the ID badge, only a distinct graduation badge provides the information about where a nurse graduated. Wearing a badge from a top-ranked college or faculty would promote this educational institution and increase the patient's confidence.
Many nursing schools around the world have decided to cease presenting badges to newly graduated nurses. Some health facilities now advise staff not to wear badges for a variety of health and safety reasons, such as infection prevention. 30 Despite all this, many schools in English-speaking countries still award badges. There are some reasons for the reintroduction of awarding badges. 31, 32 The majority of newly established nursing schools, particularly in the United States of America, have decided to design and award their badges.
Unlike Slovenia, there is a great interest in nursing badges in Western Europe and North America among nurses as well as the public at large. Graduation badges are highly appreciated amongst nurses. Collecting and trading nursing badges is popular. Some Nursing Associations organise 'bring a badge' day meetings to enable nurses to display their badges. 33 Nurses who have lost their badges, and even relatives of already deceased 30 nurses, may try to replace the lost badge by purchasing it somewhere, e.g. on eBay.
It seems that at least someone in Slovenia became aware of the importance of graduation badges. In 2013 graduates from the Angela Boškin Faculty of Health Care, Jesenice received an explanation about the history and significance of the badges prior to receiving their BSN badges. Unfortunately, the next award ceremony occurred without any explanation of the meaning of the badges and the graduates were not invited to wear the badges. It would be appropriate to accentuate the meaning of wearing badges prior to awarding them to graduates. Everyone should know what their badge means. In many countries, some nurses proudly wear their graduation badges pinned on their uniforms or ID badges. ID badges do not appear to be a major reservoir for pathogenic organisms. 34 Why should graduation badges represent a greater hazard if they are regularly cleaned.
Graduation nurse badges can be popularised by organising badge exhibitions, writing about this topic, and encouraging people to wear and collect badges. In Slovenia, a comprehensive public collection of nurse badges still does not exist. The author's collection of badges consists so far of all variants of badges and includes more than 30 pieces. We are aware that some undoubtedly existing badges have not yet been discovered. The dates of the badges described in this paper were retrieved only by authors time-consuming face to face interviewing of many nurses and midwives across Slovenia. As the research is very time consuming, more researchers would be needed for further research. The authors of this paper would be grateful for any additional data concerning the badges of graduate nurses. 34 Ota, K., Profiti, R., Smaill, F., Matlow, AG., Smieja, M. (2007), Identification badges: a potential fomite? Can J Infect Control., 22(3), 162, 165-6.

Conclusion
We can argue that the former Slovenian nurses and midwives' graduation badges are almost completely forgotten.
Unfortunately, today not only the public but many healthcare professionals, including nurses and midwives, are unaware that the history of nursing is expressed in once awarded badges. The badges provide evidence of the foundation, operation and development of healthcare schools. For this reason, graduation badges are worth to be studied and should be preserved for future generations as an important aspect of the history of the nursing profession. The badges should be not only careful treasured by their recipients but also collected for display in the planned future Slovenian Museum of Nursing History.
Fortunately, after nearly four decades of cessation of awarding the badges, the awarding of the badges has been reintroduced at one of the Slovenian nursing schools.
The badges are important artefacts of Slovenian cultural heritage. Oral history about nursing badges will quickly disappear if no one writes or researches about them. If the collection of graduating badges does not continue, the badges might one day disappear forever.