Historical Perspectives: Influences on the Present

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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.
Upon this scene entered Florence Nightingale.

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).
Consider all that you have heard about Florence Nightingale. Now, think about the idea that she was a mystic. What does that mean?

FIG. 6.1 Florence Nightingale: The legend (mystic, visionary, healer) and the lady.
BOX 6.1Nightingale and Mysticism
What is mysticism? It is considered to be a universal experience of enlightenment obtained via meditation or prayer that focuses on the direct experience of union with divinity, God, or Ultimate Reality, and the belief that such experience is a genuine and important source of knowledge. It is characterized by a call to personal action, because the person is uncomfortable with the world as it is. Underhill (1961) describes five (nonlinear or nonsequential) phases in the spiritual development of a mystic: awakening, purgation, illumination, surrender, and union.
Awakening: At age 16, Nightingale experienced her first call from God and on three other occasions later in life when she heard the voice of God again.
Purgation: Nightingale spent her later teen years and young adulthood (approximately 17 years) separating herself from the affluent lifestyle and worldly possessions that characterized her early life.
Illumination: For Nightingale, this period began when she accepted her first superintendent position at Harley Hospital in London, which propelled her to battle for better conditions during the Crimean War invasion and later, when she returned to England, to fight for reform of the army medical department.
Surrender: This “dark night of the soul” period for Nightingale is thought to have begun approximately 6 years after the Crimean War when she was in her late 30s and continued to her late 60s, a time characterized by her chronic ill health and episodes of stress, overexertion, and depression.
Union: The last 20 years of Nightingale’s life (ages 70 to 90) were engendered with an appreciation of the blessings in her life and feelings of peace, joy, and power. Social action and issues no longer spurred the driving force in her life.
Data from Dossey, B. (2005). Nursing as a spiritual practice: The mystical legacy of Florence Nightingale. Retrieved from www.altjn.com/perspectives/spiritual_practice.htm; Underhill, E. (1961). Mysticism. New York: Dutton.
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.
The nurses made rounds day and night, and the legend of the lady with the lamp was born.
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).

BOX 6.2Nightingale Pledge
I solemnly pledge myself before God and in the presence of this assembly, to pass my life in purity and to practice my profession faithfully. I will abstain from whatever is deleterious and mischievous, and will not take or knowingly administer any harmful drug. I will do all in my power to maintain and elevate the standard of my profession and will hold in confidence all personal matters committed to my keeping and all family affairs coming to my knowledge in the practice of my calling. With loyalty will I endeavor to aid the physician, in his work, and devote myself to the welfare of those committed to my care.
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).
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