Nursing has come a long way; it is not what it used to be.
After completing this chapter, you should be able to:
• Explain the early European contributions to nursing.
• Explain the events that have affected the roles of American nurses.
So, you have to study the history of nursing. Generally, the topic is considered boring. Well, be prepared for a different approach to the topic. Knowing the history of our profession guides our understanding of why we do what we do today. This understanding can be useful to us as we set our professional goals. Threads of nursing history can be found throughout the book. Understanding the history can often help in deciding what changes are needed, what changes are helpful, and what changes may be unnecessary. Let us begin with a look at where nursing began.
Nursing History: People and Places
Where Did It All Begin?
Most nursing historians agree that nursing, or the care of the ill and injured, has been done since the beginning of human life and has generally been a woman’s role. A mother caring for a child in a cave and someone caring for another ill adult by boiling willow bark to relieve fever are both examples of nursing. The word nurse is derived from the Latin word nutricius, meaning “nourishing.”
Roman mythological figures included the goddess Fortuna, who was usually recognized as being responsible for one’s fate and who also served as Jupiter’s nurse (Dolan, 1969). Even before Greek and Roman times, ancient Egyptian physicians and nurses assembled voluminous pharmacopoeia with more than 700 remedies for numerous health problems. Great emphasis was placed on the use of animal parts in concoctions that were generally drunk or applied to the body. The physician prescribed and provided the treatments and usually had an assistant who provided the nursing care (Kalisch & Kalisch, 1986). Some ancient medicine was based on driving out the evil spirit rather than curing or treating the malady (i.e., condition or illness). The treatments were often very foul and frequently included fecal material. By now you may be thinking of the saying, “The treatment was successful, but the patient died.”
Advancement of medical knowledge halted abruptly after the Roman Empire was conquered and the Dark Ages began. Any medical and health care knowledge that survived these dark times did so only through the efforts of Jewish physicians who were able to translate the Greek and Roman works (Kalisch & Kalisch, 1986). One bright spot was in Salerno, where a school of medicine and health was established for physicians and women to assist in childbirth. In fact, a midwife named Trotula wrote what may be considered the first nursing textbook on the cure of diseases of women (Dalton, 1900). Generally, nursing was performed by designated priestesses and was associated with some type of temple worship. Little information has survived about this early period. Historians have assumed that women assisted Hippocrates, but there is little information to support that. From these roots, nursing began to develop as a recognized and valued service to society (Jamieson & Sewall, 1949).
Why Deacons, Widows, and Virgins?
Paralleling the fall of the Roman Empire was the rise of Christianity. The early organization of the young Christian church, which was directly affected by the vision of Paul, included a governing bishop and seven appointed deacons. These individuals assisted the apostles in the work of the Church (the word deacon means “servant”). The deacon was directly responsible for distributing all the goods and property that apostles relinquished to the Church before they “took up the cross and followed.” The apostles were required to give up all material resources to achieve full status in the Church.
Women sympathetic to the Christian cause of aiding the poor were encouraged in this work by the bishops and deacons. Eventually, the deacons relinquished this work to women and established the position of deaconess for that purpose. To maintain a pure heart, these women were required by the Church either to be virgins or widows. The stipulation for widows, however, was that they had to have been married only once (Jamieson & Sewall, 1949). The deaconesses carried nursing forward as they ministered to the sick and injured in their homes. Phoebe, a friend of Paul’s and the very first deaconess in the young Christian church, has been called the first visiting nurse (Dana, 1936).
Treatments continued to be a mixture of scientific fact, home remedies, and magic. Eventually, an order of widows evolved that was composed of women who were free from home responsibilities and thus able to commit fully to working among the poor. The widows, although not ordained, continued to do the same work as the deaconesses. This was soon followed by the creation of the Order of Virgins as the Church began placing greater value on purity of body. Although deaconess orders were abolished in the Mediterranean countries, they thrived in other European countries. The traditional commitment to care for the poor and sick became invaluable in a society that generally had neither the time nor the inclination to aid them. Eventually, these women became known as nuns (from non nuptae, meaning “not married”).
This was a time of tremendous upheaval in the world. Wars, invasions, and battles were constant, and as a result of these encounters, the number of widows was significant. Society during this time did not have the sophistication or the means to handle the dependents of the soldiers killed in battle. As a means of survival, women joined the nuns as a form of protection from starvation and poverty. This was a dark and dreary time in which superstition, witchcraft, and folklore were predominant influences. Because of the need for physical protection, convents were built to shelter these women (Jamieson & Sewall, 1949). The convents became havens into which women could withdraw from ignorance and evil and be nurtured in traditional Christian beliefs (Donahue, 1985). The deaconesses, widows, and virgins continued to minister to and nurse the ill within the safety of the convent.
How Did Knighthood Contribute to Nursing?
The Holy Wars furthered the development of nursing in an interesting way. Because many Christian crusaders became ill while in Jerusalem, a hospital known as the Hospital of St. John was built to accommodate them. Those who fought in these Holy Wars had taken oaths of chivalry, justice, and piety and were known as knights. Often men trained in the healing arts accompanied the knights into battle. These male nurses cared for wounded or otherwise stricken knights. They usually wore a red cross emblazoned on their tunics so that in the heat of battle they could be easily identified and thus avoid injury or death (Bullough & Bullough, 1978).
The Hospital of St. John provided excellent nursing care. Many of the nurses who survived stayed to work with the hospital organizers. As the battles in the Holy Land continued, the nurses and knights organized a fighting force with a code of rules and a uniform consisting of a black robe with a white Maltese cross, the symbol of poverty, humility, and chastity. They ventured out to rescue the sick and wounded and transport them to the hospital for care; thus they became known as the Hospitalers (Kalisch & Kalisch, 1986). Male nurses dominated these orders. Other orders that emulated the Hospitalers developed in Europe, and more hospitals were opened based on the Hospital of St. John model (Donahue, 1985).
The altruistic spirit of nursing was also seen in the craftsmen’s guilds. Although their primary purpose was to provide training and jobs through the practice of apprenticeship, the guilds provided care and aid for their members when they became old and could no longer work at their trade. The guilds also assisted members and their families in times of illness and injury. The apprenticeship system—in which experience is gained on the job but no formal education is provided—once served as a model for the training of nurses (Donahue, 1985). This system is no longer used and is now considered to have been detrimental to the evolution of nursing.
What nursing gained during this period of history was status. The altruistic ideal of providing care as a service performed out of humility and love became the foundation for nursing. The recognition of the value of hospitals grew; all across Europe, cities were building their own hospitals. A general resurgence in the demand for trained doctors and nurses contributed to the building of medical schools and the development of university programs in the art and science of healing.
What About Revolts and Nursing?
Revolts—not the kind that led to battles but revolts of a social nature—were common. There were battles, too; however, the social revolts had a more direct impact on nursing. The revolution of the spirit, more commonly known as the Renaissance, ushered in new concepts of the world: the discovery of the laws of nature by Newton, the exploration of unknown lands, and the growth of secular interests (humanism) over spiritual ones. In this era emerged several outstanding humanists who were to become saints (Donahue, 1985). Interestingly, these saints are shown in depictions as needing nursing care or as giving care to a wounded or injured person.
In Europe, the Protestant Reformation began primarily as a religious reform movement but ended with revolt within the Church. Many hospitals in Protestant countries were forced to close, and those loyal to the Church that operated them were driven out of the country, resulting in a significant shortage of nurses (mostly nuns) to care for the ill and injured. The poor and ill were considered a burden to society, and those hospitals that remained operational in the Protestant countries became known as “pest houses.” To fill the need for nurses, women (many of whom were alcoholics and former prostitutes) were recruited. Generally, during this period, a nurse was a woman serving time in a hospital rather than a prison (Donahue, 1985; Jamieson & Sewall, 1949).
The industrial and intellectual revolutions that followed the Reformation all had significant impacts on nursing. During the Industrial Revolution, as production of much-needed goods was streamlined through industrial innovation, craftsmen left the rural life to work in factories. The intellectual contributions of scientists, many of whom were physicians, combined with the inventions of the microscope, thermometer, and pendulum clock, advanced our knowledge and understanding of the world. The invention of the printing press allowed for easier sharing of information, which further contributed to experimentation. Finally, a disease that was feared worldwide was conquered when Edward Jenner (1749–1823) proved the effectiveness of the smallpox vaccination.
Throughout these revolutions, however, the maternal and infant death rates continued to be high. In fact, before his pioneering work in antisepsis in obstetrics, Ignaz Phillipp Semmelweis (1818–1865) observed that patients giving birth in hospitals under the care of educated physicians had significantly higher death rates than women giving birth at home or in clinics with the assistance of midwives.
Despite all the knowledge gained during this time of revolution, society was generally callous toward the plight of children. Children were abandoned without apparent remorse, and poor families who were desperate to reduce the number of mouths to feed practiced infanticide. These families had no reliable form of birth control except abstinence. Because it was common practice for the woman hired as a wet nurse to sleep with the infant, many infants were inadvertently suffocated. Donahue (1985) reported that, during this period, 75% of all children baptized were dead before they reached the age of 5 years. Because of the persistence of these sad conditions, children’s and foundlings’ hospitals were established. Eventually, laws were enacted to aid these unfortunate victims (Donahue, 1985).
Existing health care conditions for the ill and injured continued to contribute to high mortality rates. Some sources reported hospital mortality rates as high as 90%. Conditions in the armies were no better. In any military action, mortality rates were high. Reports from the battlefront during the Crimean War suggested that battles were postponed because there were too few able-bodied soldiers to fight. Dysentery and typhoid were the military’s nemeses. If a soldier was wounded, infection invariably resulted. Hospitals generally offered no guarantee of survival. In any event, these occurrences had a serious effect on military strategies. If men are ill or injured, battles cannot be won.
Florence Nightingale: The Legend and the Lady
First, let us discuss the legend. Published works about Florence Nightingale before the 1960s generally presented the legend. Most authors agreed that she was beautiful, intelligent, wealthy, socially successful, and educated. She certainly had an ability to influence people and used every Victorian secret to accomplish her desires. Although Nightingale believed it improper to accept payment for her services, she did demand financial support for materials, goods, and staff to accomplish her programs and goals. Some historians believe that it was through Nightingale’s influence that Jean Henri Dunant, a Swiss gentleman, provided the aid to the wounded that laid the foundation for the organization of the International Red Cross (Bullough et al., 1990; Dodge, 1989; Dossey, 2000).
Regardless of what actually happened between Dunant and Nightingale, her interest and ambition lay in becoming a nurse. Her family was upset because of this decision. As described by Dossey (2000), Florence (or “Flo” as her family and friends called her) began her journey as a mystic when she was 16 years old. Her experience of a sudden, inner “knowing” took place under two majestic cedars of Lebanon in Embley (England), one of her sacred spots for contemplation. She claimed to receive the following in her awakening moment: “That a quest there is, and an end, is the single secret spoken.” Energized by her contact with the Divine Reality or Consciousness, Florence “worked very hard among the poor people” with “a strong feeling of religion” for the next 3 months (Dossey, 2000, p. 33) (Critical Thinking Box 6.1, Fig. 6.1, and Box 6.1).
CRITICAL THINKING BOX 6.1Consider all that you have heard about Florence Nightingale. Now, think about the idea that she was a mystic. What does that mean?
Nightingale’s parents felt that hospitals were terrible places to go and that nurses were, in most cases, the dregs of society. Hospitals were certainly not places for women of proper social upbringing. Although she was forbidden to do so, Nightingale studied nursing (in secret). After a fortuitous meeting, a relationship developed between Nightingale and Sidney and Elizabeth Herbert, an influential couple who were interested in hospital reform. Impressed with Nightingale’s analytical mind and her ability to apply nursing knowledge to the critical situation in the hospitals (Bullough & Bullough, 1978; Bullough et al., 1990), they encouraged her to study nursing at Kaiserswerth School, run by Lutheran deaconesses (Dolan, 1969). Her family, of course, was very unhappy. In fact, Dodge (1989) reported that the event precipitated a family crisis, because they threatened to withdraw financial support.
Nightingale accepted a position as administrator of a nursing home for women, the Institution for the Care of Sick Gentlewomen in Distressed Circumstances. She hired her own chaperone and went to work at reforming the way things were done. Nightingale’s interest in hospital reform was insatiable. She visited hospitals and took copious notes on nursing care, treatments, and procedures. She sent reports on hospital conditions to Sidney Herbert, the British Secretary of War. Secretary Herbert then assigned her other hospitals to review. The reviews always included recommendations for improving nursing care. From this early background of experiences, Nightingale was now ready for her greatest mission—the Crimean War. The legend was on the way (Bullough et al., 1990).
In 1854, soldiers were dying, more from common diseases than from bullets. Bullough and colleagues (1990) reported that the Crimean War was a series of mistakes. No plan was made for supplying the troops, no plan was in place to maintain the environment in camps, and no provisions were available to care for the injured after the battle. When Herbert appointed Nightingale as head of a group of nurses to go to Crimea, she had already developed a plan of action. In fact, some historians believe that she was already planning to go in an unofficial capacity. The announcement caused a sensation, and when Nightingale began a rigorous selection process for accepting nurses, many volunteered, but few were chosen. She cleaned up the kitchens, the wards, the patients, and improved the general hygiene. From there, the legend grew.
She was clever; after demonstrating the effectiveness of her methods, she withdrew her services. Naturally, all that she had accomplished was done under the scrutiny, skepticism, suspicion, and anger of the physicians. Without the services of the nurses, the abominable conditions quickly returned, and finally the physicians begged her to do whatever she wished—just help! Nightingale responded to the pleading. The actual number of soldiers who benefited from the care of her nurses was immeasurable.
Nightingale’s great success prompted her to begin developing schools of nursing based on her knowledge of what was effective nursing. Eventually, many schools in Europe and America used the Nightingale model for nursing education. The program was generally 1 year in length, and classes were small. Many women wanted to become nurses; however, only 15 to 20 applicants were accepted for each class. The goals of her programs included training hospital nurses, training nurses to train others, and training nurses to work in the district with the sick poor (Dolan, 1969). Nightingale had changed society’s view of the nurse to one of dignity and value and worthy of respect. As a tribute to Nightingale, Lystra Gretter, an instructor of nursing at the old Harper Hospital in Detroit, Michigan, composed “The Nightingale Pledge,” which was first used by its graduating class in the spring of 1893. It is an adaptation of the Hippocratic Oath taken by physicians (Box 6.2).
In any legend, the truth is often mixed with myth. The stories surrounding Florence Nightingale are many. What is interesting is that, before the 1970s, authors tended to deify Nightingale or establish her as a saintly person. These myths make for interesting reading. Early nurse historians also contributed to these myths by their interpretations of Nightingale’s work. But myths have a purpose. They can be used to explain worldviews of groups of people or professions at a given time, and they provide explanations for practice beliefs or natural phenomena. Myths tend to maintain a degree of accuracy when the truth is lost. The trick is to separate myth from fact and story from legend and to draw conclusions regarding the occurrences. This is no easy task when one studies Florence Nightingale. Therefore, it is important to read a variety of studies across several time periods before drawing conclusions about the legend and the lady.
In summary, Florence Nightingale had certain characteristics that assisted her in becoming successful during the strict Victorian times in which she lived. She was extremely well educated for her time. She had traveled throughout the world and had the advantage of personal wealth and a gift for establishing relationships with persons of influence and philanthropic spirit. Most portraits depict her as an attractive woman with pleasant features. Contemporary historians agree she had tremendous compassion for all who suffered. She was very strong-willed, a characteristic that carried her through the period of the Crimean War. She had the ability to analyze data and draw relevant conclusions, on which she based her recommendations. Her students of nursing received better preparation than most physicians. She was 36 at the end of the war, and when she returned home, she became a virtual recluse until she died at age 90. She did have some physical ailments: Crimean fever, sciatica, rheumatism, and dilation of the heart, each of which could have crippling side effects and contributed to her becoming bedridden (Bullough et al., 1990). According to Dossey (2000), “In 1995, D.A.B. Young, a former scientist at the Wellcome Foundation in London, proposed that the Crimean fever was actually Mediterranean fever, otherwise known as Malta fever; this disease is included under the generic name brucellosis” (p. 426). Because of the widespread Crimean fever that the soldiers encountered, it is thought that Nightingale was most likely exposed to this disease through ingesting contaminated food, such as meat or raw milk, cheese, or butter. It seems a logical assumption that Nightingale’s 32-year history of debilitating, chronic symptoms is compatible with a diagnosis of chronic brucellosis. In any event, the legend and the lady had a significant effect on American nursing as we know it today (Bullough & Bullough, 1978; Bullough et al., 1990; Dodge, 1989; Dolan, 1969; Dossey, 2000).
American Nursing: Critical Factors
What Was It Like in Colonial Times?
In colonial times, all able-bodied persons shared nursing responsibilities; however, when there was a choice, women were preferred as nurses. Early colonial historians described care for the ill and house chores as the responsibilities of nurses. Although most women of this era were considered dainty (Bradford, 1898), nurses were usually depicted as willing to do hard work. Some colonies organized nursing services that sought out the sick and provided comfort to those who were ill with smallpox and other diseases (Bullough & Bullough, 1978). There were few trained nurses, however, and most of the individuals who delivered nursing care in the five largest hospitals were men (Dolan, 1969). Eventually, women were hired at the command of George Washington to serve meals and care for the wounded and ill. The era ended with the enactment of the first legislation to improve health and medical treatment and to provide for formal education for society as a whole (Dolan, 1969).
What Happened to Nursing During the U.S. Civil War?
The period of the U.S. Civil War witnessed an improvement in patient care through control of the environment in which the patient recovered. The greatest problems for the Army stemmed from the poor sanitary conditions in the camps, which bred diseases such as smallpox and dysentery. The results were many deaths from inadequate nutrition, impure water, and a general lack of cleanliness.
Nurses who had some formal training were recognized as being major contributors to the relative success of hospital treatments. It was in this era that the value of primary prevention, or the prevention of the occurrence of disease by measures such as immunization and the provision of a pure water supply, became understood. Volunteer nurses, mostly women, served in hospitals caring for those wounded soldiers fortunate enough to have survived the trip from the battlefield. Their patients were nursed in a clean environment and were provided with adequate nutrition. The likelihood of their recovering was significantly improved. Astute physicians observed that patients cared for by nurses generally recovered well enough to return to the battlefield. Families, too, saw that when nurses had control over the environment, their ill or injured loved one was more likely to recover—and return home.
As the United States moved into the industrial age of the early 1900s, Victorian values began to permeate the middle and upper middle classes. Social concerns focused on protecting families from the diseases of the crowded urban areas, and the demand for improved health care increased.
How Did the Roles of Nurses and Wives Compare During the Victorian Era?
The Victorian era had a significant effect on nurses, primarily because they were women. The parallelism between the idealized view of the Victorian woman and the traditional nurse is stunning. The effect of many of the values and beliefs of this era, some historians report, is still felt by women today.
The typical upper-class Victorian household consisted of a husband, who earned a living outside of the home and maintained total control of the family finances, and his wife, who maintained harmony within the home and raised their children. Women’s work was generally restricted to philanthropic and voluntary work; women attended teas and other social functions to raise money for organizations and people in need.
Most women were considered fragile and dainty. They were often ill. It has been suggested that some women used illnesses and frailty as a form of birth control to prevent the numerous pregnancies that most women experienced. Some historians concluded that it was through their weaknesses that women gained control and attention. If the wife was ill or frail, maids or servants were hired, but if the wife was healthy, the husband would expect more from her. The Victorian wife was expected to “be good.” She was esteemed by her husband but had limited power within the confines of the home and society. She was expected to be hardworking and able to maintain harmony while at the same time being submissive to the demands of her husband. Generally, this fostered dependence on the dominant male figure—the Victorian husband (Rybczynski, 1986).
Let us examine nursing during this same time, especially within the hospital organization. Nurses generally were women who wanted to avoid the drudgery of a Victorian marriage. They were required to be single to make a complete commitment to their vocation. Schooled in submission, women were expected to be equally accommodating within the hospital organization. A good nurse worked for harmony within the hospital. She was expected to be hardworking and submissive. The doctor and the hospital administrator were frequently the same person, usually a man who expected position and power to go hand in hand. Patients were admitted only if they had income and could afford to pay for the services. It was the physician who generated income, and good nurses were expected to help him continue to maintain power. Because the system rewarded people for being ill, there was little incentive to be healthy. Social values contributed to dependence on the health care system. From this milieu came the reformers (Bullough & Bullough, 1978; Davis, 1961; Kalisch & Kalisch, 1986; Stewart, 1950).
Who Were the Reformers of the Victorian Era?
The Victorian era, although a time of repression for women, was also a time of reform. A list of important names in nursing reform includes M. Adelaide Nutting, Minnie Goodnow, Lavinia L. Dock, Annie W. Goodrich, Isabel Hampton Robb, Lilian D. Wald, Isabel M. Stewart, and Sophia Palmer, among others (Jamieson & Sewall, 1949; Kalisch & Kalisch, 1986). These women, who had in common a comfortable upper middle-class background, intelligence, and education, also had in common a desire to reach beyond the constraints that society imposed on them. As society began to realize the important role that nurses played in treating the ill and injured, it also began to understand the need for training programs that would better educate nurses. Reformers focused on establishing standards for nursing education and practice. Among their accomplishments were the organization of the American Nurses Association and the creation of its journal (until 2006, when American Nurse Today became the official journal of the ANA), the American Journal of Nursing, and the enactment of legislation to require the licensure of prepared nurses. This protected the public from inadequate care provided by people who were not trained as a nurse (Maness, 2006; Christy, 1971; Dock, 1900).
What Were the Key Challenges and Opportunities in Twentieth-Century Nursing?
Wars, influenza, the Great Depression, HIV/AIDS, and rapid technological advancements during the twentieth century affected the nursing profession. Table 6.1 summarizes some key historical and nursing events along a timeline.
How Did the Symbols (Lamp, Cap, and Pin) of the Profession Evolve?
As mentioned previously, Florence Nightingale acquired the nickname “Lady with the Lamp” while caring for soldiers during the Crimean War. Throughout the night, she would carry her lamp while checking on each soldier. For many historical scholars, this image of Nightingale more accurately represents Longfellow’s poetic imagination in his 1857 Santa Filomena than the historical record (Grypma, 2010). Here is a link to this famous poem: www.theatlantic.com/past/docs/unbound/poetry/nov1857/filomena.htm.
The nurse’s cap design evolved from the traditional garb of the early deaconesses or nuns who were some of the earliest nurses to care for the sick. More recently, the cap’s use was to keep a female nurse’s hair neatly in place and present a professional appearance. There were two types of cap styles: one was a long nurse’s cap, which covered most of the nurse’s head; the other was a short nurse’s cap, which sat on top of the head. The design of the cap identified the nurse’s alma mater, which differentiated graduates from their respective nursing programs. Typically, a black band sewn on the cap signified a senior-level student or graduate status and sometimes identified the head nurse on a clinical unit. The origin of the black or navy band is unknown; some historical scholars believed the black band was a sign of mourning for Florence Nightingale. By the late 1970s, the hat had disappeared almost completely, as have “capping” ceremonies when the new students passed a probationary period of the program to receive their nursing cap. Also, the rapid growth of the number of men in nursing necessitated a unisex uniform.
The nursing pin is a 1000-year-old symbol of service to others (Rode, 1989). The Maltese cross worn by the knights and nurses during the Crusades is considered the origin of the nursing pin. The most recent ancestor of the pin is the hospital badge that has been worn to identify the nurse since its inception more than 100 years ago. The nursing pin was given by the hospital school of nursing to the graduating students to identify them as nurses who were educated to serve the health needs of society. As schools of nursing flourished, each designed their own unique pin to represent their unique philosophy and beliefs. The pin is still worn as part of the nurse’s uniforms today.
What Are the Key Events and Influences of the Twenty-First Century?
The beginning of the current millennium was marked with the Year 2000 problem, or Y2K, signifying problems that originated from mainframe computers that were keeping computer documentation data in an abbreviated two-digit format (98, 99, 00) rather than a four-digit year (1998, 1999, 2000). The computer would interpret 00 as 1900 rather than 2000. In newspapers and magazines, there were reports of widespread fear and concern that a massive computer calamity would lead to a global financial crisis, hospital support system shutdown, nuclear meltdowns, collapse of air-traffic control systems, loss of power, and so on. Throughout the world, organizations had to fix and upgrade their computer systems.
Dramatic events following the World Trade Center attacks in New York City on September 11, 2001, affected all aspects of life, including more focus on nursing disaster management and emergency preparedness. Natural disasters, such as Hurricane Katrina in 2005 (Gulf Coast) and Superstorm Sandy in 2012 (East Coast) called on nurses to respond to events that they had not previously experienced. The Ebola outbreak that began in West Africa and spread to the United States in the fall of 2014 pushed nursing to focus on early identification, isolation, monitoring, and quarantine (CDC, 2014).
In early 2010, the passage of the Affordable Care Act, also referred to as “health care reform” or “Obamacare,” was signed into law. Although it will take 10 years to fully implement the reform, it provides for a comprehensive national health insurance program. There continues to be controversy since the passage of the act, with some states suing the federal government, stating that it is unconstitutional to mandate that individuals buy health insurance. The Supreme Court ruled that the health care law was constitutional in 2012; however, politicians and the public still have dividing opinions on the implementation of the reform.
History of Nursing Education
What Is the History of Diploma Nursing?
The oldest form of educational preparation leading to licensure as an RN in the United States is the diploma program. Education in diploma schools emphasized the skills needed to care for the acutely ill patient. Graduates received a diploma in nursing, not an academic degree. From 1872 until the mid-1960s, the hospital diploma program was the dominant nursing program. Currently, there are approximately 42 diploma programs accredited by the Accreditation Commission for Education in Nursing (ACEN); this represents the smallest percentage of all basic RN programs (ACEN, 2016). Perhaps one of the reasons for this decline was that the courses offered by hospitals frequently did not provide college credit. Although most diploma programs are associated with institutions of higher learning, where the graduates receive some college credit, graduates still may not receive college credit for the nursing courses.
What Is the History of Associate Degree Nursing?
The associate degree nursing program has the distinction of being the first and, to date, only educational program for nursing that was developed from planned research and controlled experimentation. Since its beginning in 1951, the associate degree nursing program has grown to more than 1092 programs, producing more graduates annually than either diploma or baccalaureate programs (NLN, 2014).
In 1951, Mildred Montag published her doctoral dissertation, The Education of Nursing Technicians, which proposed education for the RN in the community college. Dr. Montag suggested that the associate degree program be a terminal degree to prepare nurses for immediate employment. According to Dr. Montag, there was a need for a new type of nurse, the “nurse technician,” whose role would be broader than that of a practical nurse but narrower than that of the professional nurse. The technical nurse was to function at the “bedside.” The duties of the technical nurse, according to Dr. Montag, would include (1) giving general nursing care with supervision, (2) assisting in the planning of nursing care for patients, and (3) assisting in the evaluation of the nursing care given (Montag, 1951).
In 1952, the American Association of Junior Colleges established an advisory committee. Along with the National League for Nursing (NLN), this committee was to conduct cooperative research on nursing education in the community college. The goals of this Cooperative Research Project were threefold: (1) to describe the development of the associate degree nursing program, (2) to evaluate the associate degree graduates, and (3) to determine the future implications of the associate degree on nursing. The original project was directed by Dr. Montag at Teachers College of Columbia University and included seven junior colleges and one hospital from each of the six regions of the United States.
In the proposed technical nursing curriculum, there was to be a balance between general education and nursing courses. Unlike the diploma programs, the emphasis was to be on education, not service. At the end of 2 years, the student was to be awarded an associate’s degree in nursing and would be eligible to take the state board examinations for RN licensure (now called the NCLEX-RN® Exam).
What Is the History of Baccalaureate Nursing?
The early baccalaureate nursing programs were usually 5 years in length and consisted of the basic 3-year diploma program with an additional 2 years of liberal arts. In 1909, the University of Minnesota offered the first university-based nursing program. It offered the first Bachelor of Science in Nursing degree and graduated the first bachelor’s degree–educated nurse. By 1916, there were 13 universities and 3 colleges with baccalaureate nursing programs. A 2014 survey conducted by the American Association of Colleges of Nursing (AACN) found that total enrollment in entry-level nursing programs leading to the baccalaureate degree, was 189,729—up 4.2% from the previous year and a 10.4% increase in RN-to-BSN programs (AACN, 2014). The increased enrollment in the RN-to-BSN programs marks the twelfth year of enrollment increases, which is evidence of the priority that RNs place on continuing their education. According to NLN’s (2014) biennial survey of schools of nursing, there are 740 baccalaureate nursing programs.
What Is the History of Graduate Nursing Education?
Graduate nursing programs in the United States originated during the late 1800s. As more nursing schools sought to strengthen their own programs, there was increased pressure on nursing instructors to obtain advanced preparation in education and clinical nursing specialties.
The Catholic University of America, in Washington, DC, offered one of the early graduate programs for nurses. It began offering courses in nursing education in 1932 and conferring a master’s degree in nursing education in 1935.
The NLN’s Subcommittee on Graduate Education first published guidelines for organization, administration, curriculum, and testing in 1957. These guidelines have been revised throughout the years and reflect the focus in master’s education on research and clinical specialization.
Until the 1960s, the master’s degree in nursing was viewed as a terminal degree. The goal of graduate education was to prepare nurses for teaching, administration, and supervisory positions. In the early 1970s, the emphasis shifted to developing clinical skills, and the roles of clinical specialists and nurse practitioners emerged. By the late 1970s, the focus again shifted back to teaching, administration, and supervisory positions (McCloskey & Grace, 2001).
In response to health care reform, the number of master’s programs has increased. Enrollments in master’s degree programs rose by 6.6%, and by 3.2% in research-focused and 26.2% in practice-focused doctoral programs (DNP). In 2014 NLN reported that 113,788 students were enrolled in master’s programs, 5290 were enrolled in research-focused doctoral programs, and 18,352 were enrolled in practice-focused doctoral programs in nursing (AACN, 2014).
The Nurse’s Role: The Struggle for Definitions
What Do Nurses Do?
As a student, you study nursing texts that explain theories, skills, principles, and the care of patients. Every text has at least one introductory chapter that describes nursing and its significance. By examining many of these introductory chapters of nursing texts, you can generate a rather extensive list of roles (Anglin, 1991). From this list of roles, six major categories can be determined (Table 6.2). The most traditional role for nurses is that of caregiver. The nurse as teacher or educator is often referred to when discussing patient care or nursing education. The role of advocate had been very controversial in the early 1900s; however, patient advocacy has become the essential nursing role since the 1980s and has become more of a priority of the profession (Hanks, 2008). Nurses were also expected to be managers ever since the first formal education or training program was instituted. Another interesting role for the nurse is that of colleague. The final role is that of expert.
What Is the Traditional Role of a Nurse?
The role of the nurse as caregiver has engendered the least amount of controversy. This role has been thoroughly documented, not only in writing but also through art, since early times. Nurses and nursing leaders agree that this is their primary role. As students, your caregiving skills will be measured constantly through skill laboratories, clinical evaluation proficiency, and, eventually, through licensure testing and staff evaluations. All of these mechanisms are used to evaluate your ability to be a caregiver.
Imagine a nurse providing care. Generally, the picture that most often comes to mind is someone, usually female, in a white uniform caring for a patient who is ill. This picture is the romanticized version of caregiving continually portrayed in movies, television, and novels. We know that caregiving takes place in many settings: clinics, homes, hospitals, offices, businesses, and schools, among others. We can probably agree that caregiving is an important role for nurses and that it is why most of us chose nursing. Studies examining the role of caregiver continue to be undertaken, and our understanding of the role is expanding (Benner, 1984; Leininger, 1984; Watson, 1985). Without a doubt, caregiving is an important role, one that is essential to nursing.
Did You Know You Would Be a Teacher or Educator?
Teaching patients about their therapy, condition, or choices is critical to the successful outcome of some prescribed treatments. For example, nurses have learned through research that knowledge can reduce anxiety before and after surgery. Teaching becomes especially important when patients have to make treatment choices and decisions about their care. With the volumes of information available regarding health care, it is even more important that nurses help patients understand what they need to know to make wise decisions regarding their health. Discharge plans also provide an opportunity for patient education. Home care includes teaching as a reimbursable activity. Agency charting procedures all require documentation of patient education. All nursing textbooks include sections on what the nurse needs to emphasize regarding patient education. With all this evidence, there is little doubt that the educator role is an important one for the nurse (Fig. 6.2).
Teaching is planned to strengthen a patient’s knowledge regarding making decisions about treatment options, and it is an essential nursing intervention (Alfaro-LeFevre, 1998). In many ways, the nurse as an educator is also an interpreter of information, and this leads us to the next role for discussion.
When Did the Nurse Become an Advocate? Nurse in the Role of Advocate
A useful definition of the term advocate is “one who pleads a cause before another.” The first advocacy issue, arising early in the 1900s, concerned nursing practice. Public health and visiting nurses were the majority (approximately 70%), and hospital nurses were the minority (approximately 30%) of working nurses. Working as a private duty nurse or visiting nurse was a source of income for women who had no other means of support. Because there was no way to determine the credentials of the visiting nurse, many impostors worked in that capacity. Lavinia L. Dock, Sophia Palmer, and Annie W. Goodrich, three nursing leaders, deplored this situation and endeavored to protect the public from unscrupulous “nurses” (Dolan, 1969; Goodnow, 1936). Dock was an excellent nurse who believed in fairness to qualified nurses and to the public. She advocated that all practicing nurses be measured by a “fair-general-average standard,” as determined by written examination, and be rewarded with licensure on attainment of the standard (Christy, 1971).
Palmer’s proposed solutions were similar. Many hospitals were sending out inexperienced undergraduates to do private duty nursing while not reporting the income. She advocated a training school in which students of nursing would learn to provide care under a qualified nurse, and she supported the implementation of a registration process for all qualified nurses to protect the public from incompetent, unqualified nurses.
Goodrich advocated compulsory legislation that would ensure that graduates or trained nurses would be the only ones who could work as nurses. She pleaded for the registration of qualified nurses, not only for the protection of the nurse but also for the protection of the community. Goodrich also fought against correspondence or home-study programs for nurses, which were a greater menace to the public’s safety than people realized. Such legislation, she believed, would encourage talented young women who were intellectually prepared for scientific education to select nursing as a career. The role of the advocate, as understood by these three early nursing leaders, was to protect the public from unqualified nurses (Christy, 1969; Dock, 1900; Palmer, 1900).
From this beginning, the role of advocate grew. Public health nurses served as advocates in factories and communities during the Industrial Revolution. Many municipal boards of health hired visiting nurses to work as inspectors in the factories to protect the workers from health hazards and to help prevent accidents. Communities were finding that the nurse as advocate for the factory worker had inestimable value. Visiting nurses were also proving very effective in preventing the spread of communicable diseases. Hospital nurses also worked as advocates for the patients while giving care. Nurses were crucial in protecting patients from harm when they were too ill to protect themselves. Nurses were also responsible for providing measures to relieve pain, and they strove to make their patients happy and comfortable, even if it meant breaking the rules sometimes (Hill, 1900). During the 1970s and 1980s, the responsibility of the nurse as advocate was expanded to include speaking for their patients when they could not speak for themselves (Sovie, 1983). Nurses returned to work in churches in the primary role of advocate under the Granger Westberg model for parish nursing. The members of the congregation where a parish nurse practiced found affirmation and support as they reached to improve their physical, emotional, and spiritual health (Striepe, 1987).
Historically, consumers, administrators, and courts have not shared the perception of the nurse as advocate. The findings of a study done in 1983 indicated that consumers did not recognize the nurse as an initiator of health care (Miller et al., 1983). Consumers also believed that physicians would protect the rights of the patient. Miller and colleagues (1983) concluded that although nurses were serving as mediators between patients and institutions, changes rarely occurred within the institutions as a result of this role. Patient advocacy was directly related to the power and authority allowed the nurse by the particular system. Nurses generally became advocates whenever the issue involved patient care; however, they had little power to be truly effective as an advocate when the concerns involved the medical regimen or health care services (Miller et al., 1983). Examples of advocacy included questioning doctors’ orders, promoting patient comfort, and supporting patient decisions regarding health care choices.
With the need for informed consent, advance directives, and treatment choices, patients more than ever need an advocate to interpret information, identify the risks and benefits of the various treatment options, and support the decision they make. However, nurses are extending their roles as advocates in providing patient care to initiatives that improve patient safety and recognize the nursing profession as a key player in providing all individuals access to quality health care.
For example, the American Nurses Association (ANA) has endorsed the Registered Nurse Safe Staffing Act of 2015. If passed, this law would require Medicare-funded hospitals to develop and implement safe staffing plans for nurses. Nurses providing direct patient care along with nurse managers would comprise a nurse staffing committee that would evaluate staffing needs of the health care institution with an overall goal of ensuring nurse-to-patient acuity ratios are optimal to deliver safe patient care, reduce patient readmissions, and improve nursing staff retention (ANA, 2015). With the inception of the Affordable Care Act, ensuring access to health care for the public remains an ongoing concern.
Considering this, the Coalition for Patients’ Rights (CPR) consists of over 35 organizations with dedicated members who are on the frontline in ensuring that all health care professionals be able to practice fully to the extent of their education, scope, and practice in providing quality health care (CPR, 2016). With registered nurses comprising the largest group of health care professionals, CPR in collaboration with several professional nursing organizations recognize that nurses are and will continue to play an integral role in providing quality health care to the public. For a complete listing of current CPR coalition members, check out http://www.patientsrightscoalition.org/Main-Menu/About-Us/List-of-Coalition-Members.html.
What Is the Role of Manager of Care?
Even Florence Nightingale recognized the need for nurses to be managers. She insisted that nurses needed to organize the care of the patient so that other nurses could carry on when they were not present. There were four major eras in the development of the nurse as manager. During the first period, lasting until about 1920, a nurse manager was known as the charge nurse. Charge nurses were responsible for teaching the nursing students what they needed to know and for directing the care that the students provided. The charge nurse was autocratic. This nurse had absolute authority over the student.
During the second era, lasting until 1949, the term supervisor was used to describe the role of nurse manager. The supervisor continued to be responsible for the students; however, the role had expanded to include enforcing agency policies, developing improvements in the care of the ill, and being responsible for the effective use of the ward’s resources. Nurses were more involved in the patient care process. Hospital administrators were relying on nursing expertise to establish policies for patient care and hospital administration. This era ended with the publication of Esther Lucille Brown’s report (1948) recommending that nursing education be separated from hospital administration.
During the third period, lasting until 1970, the nurse was referred to as a coordinator. The nurse coordinator no longer had responsibility for the nursing education of the students but was expected to motivate staff, be innovative, and solve problems. Coordinators were active in improving patient care and were expected to maintain harmony within the institution. Many nurse coordinators had few skills in and little knowledge of middle management. They basically learned by trial and error how to be effective.
The last period, from 1970 to the present, is a series of waves. Nurses gained recognition as managers and were able to function in that role. Hospital nurses gained middle-management positions and proved their abilities. The period before diagnostic-related groups (DRGs) saw escalating hospital costs and growth in the numbers of employees and services. From this growth came significant efforts to control the costs of health care. The term manager is used most often now in the nursing literature, but you may find it used to describe any of the four periods.
Can Nurses Be Colleagues?
The role of colleague is a vital one in any profession. The status of colleague within health care generates pictures of nurses, doctors, and pharmacists discussing, on an equal basis, problems and concerns related to health care. In nursing, we have made great progress in achieving the status of colleague. Interprofessional collegial relationships are strengthening, due in part to the increasing utilization of health care-related services taking place in community and homecare settings (Naylor, 2011). Interprofessional collaboration is essential to the changes taking place with health care delivery models.
Between 1960 and the present, the term collaborator has been adopted for this role. The definition of this word means “a person who works jointly on an activity or project; an associate.” A secondary definition means “a person who cooperates traitorously with an enemy; a defector.”
The primary definition may be the most fitting description of the role. Nurses are interested in developing collaborative relationships with doctors, pharmacists, and other health professionals. The literature is abundant with discussions of these relationships and consistently describes these relationships as collaborative (Hahm & Miller, 1961; Kelly, 1975; Quint, 1967; Seward, 1969; Tourtillott, 1986; Wisener, 1978).
Where Does This Leave the Role of Colleague?
Nursing education has promoted the term collaborator over colleague. Students in their educational experiences are seldom offered the opportunity to practice the role of colleague and therefore have only a vague understanding of the role. However, public health nurses throughout American history have not only understood the role but probably have attained a greater degree of collegiality than any other practice area of nursing. Public health nurses are not the majority within the profession. Nevertheless, they continue to enjoy and maintain the essence of the role (Anglin, 1991). As a colleague, one recognizes nurses with expertise and relies on those nurses for their expertise in the interest of improving patient care and advancing the profession. The essence of the role is mutual respect and equality among professionals, both intradisciplinary and interdisciplinary (Anglin, 1991). The Interdisciplinary Nursing Quality Research Initiative (INQRI) recognizes the valuable role nurses play in advancing and improving patient care and continues to validate the nurse as a deliverer of quality patient care through conducting extensive interdisciplinary research (INQRI, n.d.).
What About Experts?
There is one other role in which nurses are often found. This role is called expert. It is a conglomerate of advanced formal or informal education, certification, and acquired or recognized expertise. The role includes academicians, historians, nursing educators, clinicians, professional educators, researchers, research consumers, theorists, nurse technologists, and the leaders within the profession. The American Academy of Nursing recognizes some of these individuals and votes to bestow on them the honor of Fellow. There are many nurses who are experts in an area of practice, whether it be in clinics, at the bedside, in nursing homes, or in other settings. As nurses with special expertise, they are called on to provide testimony in courts and at government hearings or to share information and knowledge with other nurses, which is their obligation to the profession. This sharing can be done through mentoring, guest speaking, performing in-services, offering continuing-education programs, contributing to publications, and writing technical articles. These experts are usually the nurses who create the momentum that moves the profession forward. This is a role that should be recognized, encouraged, and rewarded.
Conclusion
The history of nursing provides a wealth of knowledge about where we have been and illustrates for us the lessons that have been learned. Few of us know the specifics of how nursing evolved into the discipline that it is today; however, the study and review of our rich history provides the context for where we will be tomorrow. At the end of this chapter is a listing of relevant websites and online resources on the history of nursing.
So history naturally informs nursing knowledge, both imaginatively and practically. As historian Joan Lynaugh observed, nursing history is “our source of identity, our cultural DNA.” Nurses love nursing history when it illuminates their imaginations and they can feel its meaning in their bones. Indeed, nursing history offers all nurses an exciting future in ideas (Meehan, 2013, p. 13.)
What do nurses do? There is no simple answer. We agree that nurses care for patients—hence nurses are caregivers. We agree that nurses teach patients what they need to know to make informed choices—and therefore nurses are educators. We also agree that the role of manager exists in some form, and so we manage our practice and patients’ care. We can even define the role of advocate. The role of colleague is gaining clarity with an increased focus on nurses’ role in interprofessional collaboration. We are consistent in using the term collaborator; however, the term colleague is frequently referenced in nursing education and research, as compared to clinical practice, but progress is being made in recognizing the nurse as a colleague in all settings where nurses practice.
Finally, we have experts whom we may or may not recognize—and on whom the profession depends to provide the leadership for the whole. These roles merely provide a beginning for you to understand the profession you have chosen—nursing. May you become proficient in these roles and develop into an expert who will then provide the leadership for nursing in the future.
The future is not the result of choices among
Alternative paths offered;
It is a place that is created,
Created first in the mind and will,
Created next in activity.
The future is not some place we are going to,
But one we are creating.
The paths to it are not found, but made.
And the activity of making them
Changes both the maker and the destiny.
Anonymous, 1987
Relevant Websites and Online ResourcesAmerican Association for the History of Nursing
Black Nurses in History
Canadian Association for the History of Nursing
Clendening History of Medicine Library—Florence Nightingale Resources
Frontier Nursing Service
Images from the History of Medicine
Margaret M. Allemang Society for the History of Nursing (Canadian)
Museum of Nursing History
Nursing History and Health Care
