+1(978)310-4246 credencewriters@gmail.com


Select a nurse theorist and write a paper describing the background of the theorist, the
theory, and its application to nursing practice. The paper should address the following:

1. Describe the background of the nurse theorist and the various social and professional
issues that influenced the development of the theory.

2. Identify the major concepts and relational statement of the nursing theory. Concepts
common to most nursing theories include: Person, health, nursing, and environment.

3. Describe the assumptions made by the nurse theorist. To what extent are these
assumptions compatible with your personal philosophy of nursing?

4. Apply the theory to a clinical situation and describe how its use will improve nursing
care or influence the way care is given.


The paper must be typed in APA format with a minimum of 1000 words (excluding first
and references page) with a minimum of 4 evidence-based references using the
required Arial 12 font. Follow the APA example paper under the folder APA tools. Make
sure references are used according to APA guidelines and electronic references must
be from reliable sources such as CDC.

The Pedagogy
Role Development in Professional Nursing Practice, Fifth Edition
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interactive approach addresses different learning styles, making this the
ideal text to ensure mastery of key concepts. The pedagogical aids that
appear in most chapters include the following:
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Library of Congress Cataloging-in-Publication Data
Names: Masters, Kathleen, editor.
Title: Role development in professional nursing practice / [edited by]
Kathleen Masters.
Description: Fifth edition. | Burlington, Massachusetts : Jones & Bartlett
Learning, 2018. | Includes bibliographical references and index.
Identifiers: LCCN 2018023086 | eISBN 9781284152920
Subjects: | MESH: Nursing–trends | Nursing–standards | Professional
Practice | Nurse’s Role | Philosophy, Nursing
Classification: LCC RT82 | NLM WY 16.1 | DDC 610.73–dc23
LC record available at https://lccn.loc.gov/2018023086
Printed in the United States of America
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This book is dedicated to my Heavenly Father and to my loving family:
my husband, Eddie, and my two daughters, Rebecca and Rachel. Words
cannot express my appreciation for their ongoing encouragement and
support throughout my career.
© James Kang/EyeEm/Getty Images
A History of Health Care and Nursing
Karen Saucier Lundy and Kathleen Masters
Classical Era
Middle Ages
The Renaissance
The Dark Period of Nursing
The Industrial Revolution
And Then There Was Nightingale . . .
Continued Development of Professional Nursing in the United
The Development of Professional Nursing in Canada
The Development of Professional Nursing in Australia
Early Nursing Education and Organization in the United States
The Evolution of Nursing in the United States: The First Century of
Professional Nursing
The New Century
International Council of Nurses
Frameworks for Professional Nursing Practice
Kathleen Masters
Overview of Selected Nursing Theories
Overview of Selected Nonnursing Theories
Relationship of Theory to Professional Nursing Practice
Philosophy of Nursing
Mary W. Stewart
Early Philosophy
Developing a Personal Philosophy of Nursing
Competencies for Professional Nursing Practice
Jill Rushing and Kathleen Masters
Nurse of the Future: Nursing Core Competencies
Critical Thinking, Clinical Judgment, and Clinical Reasoning in
Nursing Practice
Education and Socialization to the Professional Nursing Role
Kathleen Masters and Melanie Gilmore
Professional Nursing Roles and Values
The Socialization (or Formation) Process
Facilitating the Transition to Professional Practice
Advancing and Managing Your Professional Nursing Career
Mary Louise Coyne and Cynthia Chatham
Nursing: A Job or a Career?
Trends That Affect Nursing Career Decisions
Showcasing Your Professional Self
Education and Lifelong Learning
Professional Engagement
Expectations for Your Performance
Taking Care of Self
Social Context and the Future of Professional Nursing
Mary W. Stewart, Katherine E. Nugent, and Kathleen Masters
Nursing’s Social Contract with Society
Public Image of Nursing
The Gender Gap
Changing Demographics and Cultural Competence
Access to Health Care
Societal Trends
Trends in Nursing
Safety and Quality Improvement in Professional Nursing
Kathleen Masters
Patient Safety
Quality Improvement in Health Care
Quality Improvement Measurement and Process
The Role of the Nurse in Quality Improvement
Evidence-Based Professional Nursing Practice
Kathleen Masters
Evidence-Based Practice: What Is It?
Barriers to Evidence-Based Practice
Promoting Evidence-Based Practice
Searching for Evidence
Evaluating the Evidence
Implementation Models for Evidence-Based Practice
Patient Education and Patient-Centered Care in Professional
Nursing Practice
Kathleen Masters
Dimensions of Patient-Centered Care
Communication as a Strategy to Support Patient-Centered Care
Patient Education as a Strategy to Support Patient-Centered Care
Evaluation of Patient-Centered Care
Informatics in Professional Nursing Practice
Kathleen Masters and Cathy K. Hughes
Informatics: What Is It?
The Effect of Legislation on Health Informatics
Nursing Informatics Competencies
Basic Computer Competencies
Information Literacy
Information Management
Current and Future Trends
Leadership and Systems-Based Professional Nursing Practice
Kathleen Masters and Sharon Vincent
Healthcare Delivery System
Nursing Leadership in a Complex Healthcare System
Nursing Models of Patient Care
Roles of the Professional Nurse
Teamwork, Collaboration, and Communication in Professional
Nursing Practice
Kathleen Masters
Interprofessional Teams and Healthcare Quality and Safety
Interprofessional Collaborative Practice Domains
Interprofessional Team Performance and Communication
Ethics in Professional Nursing Practice
Janie B. Butts and Karen L. Rich
Ethical Theories and Approaches
Professional Ethics and Codes
Ethical Analysis and Decision Making in Nursing
Relationships in Professional Practice
Moral Rights and Autonomy
Social Justice
Death and End-of-Life Care
Law and Professional Nursing Practice
Kathleen Driscoll and Kathleen Masters
The Sources of Law
Classification and Enforcement of the Law
Nursing Scope and Standards
Malpractice and Negligence
Nursing Licensure
Professional Accountability
Appendix A
Appendix B
Provisions of Code of Ethics for Nurses
The ICN Code of Ethics for Nurses
© James Kang/EyeEm/Getty Images
Although the process of professional development is a lifelong journey, it
is a journey that begins in earnest during the time of initial academic
preparation. The goal of this book is to provide nursing students with a
road map to help guide them along their journey as professional nurses.
This book is organized into two units. The chapters in the first unit
focus on the foundational concepts that are essential to the development
of the individual professional nurse. The chapters in Unit II address
issues related to professional nursing practice and the management of
patient care, specifically in the context of quality and safety. In the Fifth
Edition, the chapter content is conceptualized, when applicable, around
nursing competencies, professional standards, and recommendations
from national groups, such as Institute of Medicine reports. All chapters
have been updated, several chapters have been expanded, and two new
chapters have been added in this edition. The chapters included in Unit I
provide the student nurse with a basic foundation in such areas as
nursing history, theory, philosophy, socialization into the nursing role,
professional development, the social context of nursing, and professional
nursing competencies. The social context of nursing chapter has been
expanded to incorporate not only societal trends but also trends in
nursing practice and education that are changing the future landscape of
the profession. The chapters in Unit II are more directly related to patient
care management and, as stated previously, are presented in the context
of quality and safety. Chapter topics include the role of the nurse in
patient safety and quality improvement, evidence-based nursing practice,
the role of the nurse in patient education and patient-centered care,
informatics in nursing practice, the role of the nurse related to teamwork
and collaboration, systems-based practice and leadership, ethics in
nursing practice, and the law as it relates to patient care and nursing.
Unit II chapters have undergone revision, with a refocus of the content on
recommended nursing and healthcare competencies as well as
recommendations from faculty using the text in the classroom.
The Fifth Edition incorporates the revised Nurse of the Future:
Nursing Core Competencies: Registered Nurse throughout each chapter.
The 10 essential competencies that are intended to guide nursing
curricula and practice emanate from the central core of the model that
represents nursing knowledge (Massachusetts Department of Higher
Education, 2016) and are based on the American Association of Colleges
of Nursing (AACN) Essentials of Baccalaureate Education for
Professional Nursing Practice, National League for Nursing Council of
Associate Degree Nursing competencies, Institute of Medicine
recommendations, Quality and Safety Education for Nurses (QSEN)
competencies, and American Nurses Association standards, as well as
other professional organization standards and recommendations. The 10
competencies included in the model are patient-centered care,
professionalism, informatics and technology, evidence-based practice,
leadership, systems-based practice, safety, communication, teamwork
and collaboration, and quality improvement. Essential knowledge, skills,
and attitudes (KSAs) reflecting cognitive, psychomotor, and affective
learning domains are specified for each competency. The KSAs identified
in the model reflect the expectations for initial nursing practice following
the completion of a prelicensure professional nursing education program
(Massachusetts Department of Higher Education, 2016).
This new edition has competency boxes throughout the chapters that
link examples of the KSAs appropriate to the chapter content to Nurse of
the Future: Nursing Core Competencies required of entry-level
professional nurses. The competency model is explained in detail in
Chapter 4 and is available in its entirety online at
The Fifth Edition also includes applicable AACN essentials
incorporated as key outcomes throughout each chapter to assist faculty
with the alignment of curricular content with criteria required by
accreditors. The key outcomes also demonstrate for students the link
between expectations included in the competency model, the
expectations embodied in the essentials document, and the chapter
content. A discussion of the AACN (2008) Essentials of Baccalaureate
Education for Professional Nursing Practice is also included in Chapter 4.
This new edition continues to use case studies, congruent with
Benner, Sutphen, Leonard, and Day’s (2010) Carnegie Report
recommendations that nursing educators teach for “situated cognition”
using narrative strategies to lead to “situated action,” thus increasing the
clinical connection in our teaching or that we teach for “clinical salience.”
In addition, critical thinking questions are included throughout each
chapter to promote student reflection on the chapter concepts.
Classroom activities are also provided based on chapter content.
Additional resources not connected to this text, but applicable to the
content herein, include a toolkit focused on the nursing core
competencies available at
http://www.mass.edu/nahi/documents/NursingCoreCompetenciesToolkitMarch2016.pdf and teaching activities related to nursing competencies
available on the QSEN website at http://qsen.org/teaching-strategies/.
Although the topics included in this textbook are not inclusive of all
that could be discussed in relationship to the broad theme of role
development in professional nursing practice, it is my prayer that the
subjects herein make a contribution to the profession of nursing by
providing the student with a solid foundation and a desire to grow as a
professional nurse throughout the journey that we call a professional
nursing career. Let the journey begin.
—Kathleen Masters
American Association of Colleges of Nursing. (2008). The essentials of
baccalaureate education for professional nursing practice. Retrieved
from http://www.aacnnursing.org/Education-Resources/AACNEssentials
Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses:
A call for radical transformation. San Francisco, CA: Jossey-Bass.
Massachusetts Department of Higher Education. (2016). Nurse of the
future: Nursing core competencies: Registered nurse. Retrieved from
Kathleen Masters, DNS, RN
Professor and Dean
University of Southern Mississippi
College of Nursing
Hattiesburg, Mississippi
© James Kang/EyeEm/Getty Images
Janie B. Butts, PhD, RN
University of Southern Mississippi
College of Nursing
Hattiesburg, Mississippi
Cynthia Chatham, DSN, RN
Associate Professor
University of Southern Mississippi
College of Nursing
Long Beach, Mississippi
Mary Louise Coyne, DNSc, RN
University of Southern Mississippi
College of Nursing
Long Beach, Mississippi
Kathleen Driscoll, JD, MS, RN
University of Cincinnati
College of Nursing
Cincinnati, Ohio
Melanie Gilmore, PhD, RN
Associate Professor (Retired)
University of Southern Mississippi
College of Nursing
Hattiesburg, Mississippi
Cathy K. Hughes, DNP, RN
Teaching Assistant Professor
University of Southern Mississippi
College of Nursing
Hattiesburg, Mississippi
Karen Saucier Lundy, PhD, RN, FAAN
Professor Emeritus
University of Southern Mississippi
College of Nursing
Hattiesburg, Mississippi
Katherine E. Nugent, PhD, RN
Professor and Dean (Retired)
University of Southern Mississippi
College of Nursing
Hattiesburg, Mississippi
Karen L. Rich, PhD, RN
Associate Professor
University of Southern Mississippi
College of Nursing
Long Beach, Mississippi
Jill Rushing, MSN, RN
Director of BSN Program
University of Southern Mississippi
College of Nursing
Hattiesburg, Mississippi
Mary W. Stewart, PhD, RN
Director of PhD Program
University of Mississippi Medical Center
School of Nursing
Jackson, Mississippi
Sharon Vincent, DNP, RN, CNOR
University of North Carolina
College of Nursing
Charlotte, North Carolina
© James Kang/EyeEm/Getty Images
Foundations of Professional
Nursing Practice
© James Kang/EyeEm/Getty Images
A History of Health Care and
Karen Saucier Lundy and Kathleen Masters
Learning Objectives
After completing this chapter, the student should be able to:
Identify social, political, and economic influences on the
development of professional nursing practice.
Identify important leaders and events that have significantly
affected the development of professional nursing practice.
Key Terms and Concepts
Greek era
Roman era
Florence Nightingale
Chadwick Report
Shattuck Report
William Rathbone
Ethel Fenwick
Jeanne Mance
Mary Agnes Snively
Goldmark Report
Brown Report
Isabel Hampton Robb
American Nurses Association (ANA)
Lavinia Lloyd Dock
American Journal of Nursing (AJN)
Margaret Sanger
Lillian Wald
Jane A. Delano
Annie Goodrich
Mary Brewster
Henry Street Settlement
Elizabeth Tyler
Jessie Sleet Scales
Dorothea Lynde Dix
Clara Barton
Frontier Nursing Service
Mary Breckinridge
Mary D. Osborne
Frances Payne Bolton
International Council of Nurses (ICN)
Although no specialized nurse role per se developed in early civilizations,
human cultures recognized the need for nursing care. The truly sick
person was weak and helpless and could not fulfill the duties that were
normally expected of a member of the community. In such cases,
someone had to watch over the patient, nurse him or her, and provide
care. In most societies, this nurse role was filled by a family member,
usually female. As in most cultures, the childbearing woman had special
needs that often resulted in a specialized role for the caregiver. Every
society since the dawn of time had someone to nurse and take care of
the mother and infant around the childbearing events. In whatever form
the nurse took, the role was associated with compassion, health
promotion, and kindness (Bullough & Bullough, 1978).
Classical Era
More than 4,000 years ago, Egyptian physicians and nurses used an
abundant pharmacologic repertoire to cure the ill and injured. The Ebers
Papyrus lists more than 700 remedies for ailments ranging from
snakebites to puerperal fever (Kalisch & Kalisch, 1986). Healing
appeared in the Egyptian culture as the successful result of a contest
between invisible beings of good and evil (Shryock, 1959). Around 1000
B.C., the Egyptians constructed elaborate drainage systems, developed
pharmaceutical herbs and preparations, and embalmed the dead. The
Hebrews formulated an elaborate hygiene code that dealt with laws
governing both personal and community hygiene, such as contagion,
disinfection, and sanitation through the preparation of food and water.
The Jewish contribution to health is greater in sanitation than in their
concept of disease. Garbage and excreta were disposed of outside the
city or camp, infectious diseases were quarantined, spitting was outlawed
as unhygienic, and bodily cleanliness became a prerequisite for moral
purity. Although many of the Hebrew ideas about hygiene were Egyptian
in origin, the Hebrews were the first to codify them and link them with
spiritual godliness (Bullough & Bullough, 1978).
Disease and disability in the Mesopotamian area were considered a
great curse, a divine punishment for grievous acts against the gods.
Experiencing illness as punishment for a sin linked the sick person to
anything even remotely deviant. Not only was the person suffering from
the illness but also he or she also was branded by society as having
deserved it. Those who obeyed God’s law lived in health and happiness,
and those who transgressed the law were punished with illness and
suffering. The sick person then had to make atonement for the sins, enlist
a priest or other spiritual healer to lift the curse, or live with the illness to
its ultimate outcome (Bullough & Bullough, 1978). Nursing care by a
family member or relative would be needed, regardless of the outcome of
the sin, curse, disease-atonement-recovery, or death cycle. This logic
became the basis for explanation of why some people “get sick and some
don’t” for many centuries and still persists to some degree in most
cultures today.
The Greeks and Health
In Greek mythology, the god of medicine, Asclepias, cured disease. One
of his daughters, Hygieia, from whom we derive the word hygiene, was
the goddess of preventive health and protected humans from disease.
Panacea, Asclepias’ other daughter, was known as the all-healing
“universal remedy,” and today her name is used to describe any ultimate
cure-all in medicine. She was known as the “light” of the day, and her
name was invoked and shrines built to her during times of epidemics
(Brooke, 1997).
During the Greek era, Hippocrates of Cos emphasized the rational
treatment of sickness as a natural rather than a god-inflicted
phenomenon. Hippocrates (460–370 B.C.) is considered the father of
medicine because of his arrangements of the oral and written remedies
and diseases, which had long been secrets held by priests and religious
healers, into a textbook of medicine that was used for centuries (Bullough
& Bullough, 1978).
In Greek society, health was considered to result from a balance
between mind and body. Hippocrates wrote a most important book, Air,
Water, and Places, which detailed the relationship between humans and
the environment. This is considered a milestone in the eventual
development of the science of epidemiology as the first such treatise on
the connectedness of the web of life. This topic of the relationship
between humans and their environment did not recur until the
development of bacteriology in the late 1800s (Rosen, 1958).
Perhaps the idea that most damaged the practice and scientific
theory of medicine and health for centuries was the doctrine of the four
humors, first spoken of by Empedocles of Acragas (493–433 B.C.).
Empedocles was a philosopher and a physician, and as a result, he
synthesized his cosmologic ideas with his medical theory. He believed
that the same four elements that made up the universe were found in
humans and in all animate beings (Bullough & Bullough, 1978).
Empedocles believed that man [sic] was a microcosm, a small world
within the macrocosm, or external environment. The four humors of the
body (blood, bile, phlegm, and black bile) corresponded to the four
elements of the larger world (fire, air, water, and earth) (Kalisch &
Kalisch, 1986). Depending on the prevailing humor, a person was
sanguine, choleric, phlegmatic, or melancholic. Because of this strongly
held and persistent belief in the connection between the balance of the
four humors and health status, treatment was aimed at restoring the
appropriate balance of the four humors through the control of their
corresponding elements. Through manipulating the two sets of opposite
qualities—hot and cold, wet and dry—balance was the goal of the
intervention. Fire was hot and dry, air was hot and wet, water was cold
and wet, and earth was cold and dry. For example, if a person had a
fever, cold compresses would be prescribed; for a chill the person would
be warmed. Such doctrine gave rise to faulty and ineffective treatment of
disease that influenced medical education for many years (Taylor, 1922).
Plato, in The Republic, details the importance of recreation, a
balanced mind and body, nutrition, and exercise. A distinction was made
among gender, class, and health as early as the Greek era; only males of
the aristocracy could afford the luxury of maintaining a healthful lifestyle
(Rosen, 1958).
In The Iliad, a poem about the attempts to capture Troy and rescue
Helen from her lover, Paris, 140 different wounds are described. The
mortality rate averaged 77.6%, the highest as a result of sword and spear
thrusts and the lowest from superficial arrow wounds. There was
considerable need for nursing care, and Achilles, Patroclus, and other
princes often acted as nurses to the injured. The early stages of Greek
medicine reflected the influences of Egyptian, Babylonian, and Hebrew
medicine. Therefore, good medical and nursing techniques were used to
treat these war wounds: The arrow was drawn or cut out, the wound
washed, soothing herbs applied, and the wound bandaged. However, in
sickness in which no wound occurred, an evil spirit was considered the
cause. The Greeks applied rational causes and cures to external injuries,
whereas internal ailments continued to be linked to spiritual maladies
(Bullough & Bullough, 1978).
Roman Era
During the rise and the fall of the Roman era (31 B.C.–A.D. 476), Greek
culture continued to be a strong influence. The Romans easily adopted
Greek culture and expanded the Greeks’ accomplishments, especially in
the fields of engineering, law, and government. For Romans, the
government had an obligation to protect its citizens not only from outside
aggression, such as warring neighbors, but also from inside the
civilization, in the form of health laws. According to Bullough and
Bullough (1978), Rome was essentially a “Greek cultural colony” (p. 20).
Galen of Pergamum (A.D. 129–199), often known as the greatest
Greek physician after Hippocrates, left for Rome after studying medicine
in Greece and Egypt and gained great fame as a medical practitioner,
lecturer, and experimenter. In his lifetime, medicine evolved into a
science; he submitted traditional healing practices to experimentation and
was possibly the greatest medical researcher before the 1600s (Bullough
& Bullough, 1978). He was considered the last of the great physicians of
antiquity (Kalisch & Kalisch, 1986).
The Greek physicians and healers certainly made the most
contributions to medicine, but the Romans surpassed the Greeks in
promoting the evolution of nursing. Roman armies developed the notion
of a mobile war nursing unit because their battles took them far from
home where they could be cared for by wives and family. This portable
hospital was a series of tents arranged in corridors; as battles wore on,
these tents gave way to buildings that became permanent convalescent
camps at the battle sites (Rosen, 1958). Many of these early military
hospitals have been excavated by archaeologists along the banks of the
Rhine and Danube rivers. They had wards, recreation areas, baths,
pharmacies, and even rooms for officers who needed a “rest cure”
(Bullough & Bullough, 1978). Coexisting were the Greek dispensary
forms of temples, or the iatreia, which started out as a type of physician
waiting room. These eventually developed into a primitive type of
hospital, places for surgical clients to stay until they could be taken home
by their families. Although nurses during the Roman era were usually
family members, servants, or slaves, nursing had strengthened its
position in medical care and emerged during the Roman era as a
separate and distinct specialty.
The Romans developed massive aqueducts, bathhouses, and sewer
systems during this era. At the height of the Roman Empire, Rome
provided 40 gallons of water per person per day to its 1 million
inhabitants, which is comparable to our rates of consumption today
(Rosen, 1958).
Middle Ages
Many of the advancements of the Greco-Roman era were reversed
during the Middle Ages (A.D. 476–1453) after the decline of the Roman
Empire. The Middle Ages, or the medieval era, served as a transition
between ancient and modern civilizations. Once again, myth, magic, and
religion were explanations and cures for illness and health problems. The
medieval world was the result of a fusion of three streams of thought,
actions, and ways of life—Greco-Roman, Germanic, and Christian
(Donahue, 1985). Nursing was most influenced by Christianity with the
beginning of deaconesses, or female servants, doing the work of God by
ministering to the needs of others. Deacons in the early Christian
churches were apparently available only to care for men, whereas
deaconesses cared for the needs of women. The role of deaconesses in
the church was considered a forward step in the development of nursing
and in the 1800s would strongly influence the young Florence
Nightingale. During this era, Roman military hospitals were replaced by
civilian ones. In early Christianity, the Diakonia, a kind of combination
outpatient and welfare office, was managed by deacons and
deaconesses and served as the equivalent of a hospital. Jesus served as
the example of charity and compassion for the poor and marginal of
Communicable diseases were rampant during the Middle Ages,
primarily because of the walled cities that emerged in response to the
paranoia and isolation of the populations. Infection was next to
impossible to control. Physicians had little to offer, deferring to the church
for management of disease. Nursing roles were carried out primarily by
religious orders. The oldest hospital (other than military hospitals in the
Roman era) in Europe was most likely the Hôtel-Dieu in Lyon, France,
founded about 542 by Childebert I, king of Paris. The Hôtel-Dieu in Paris
was founded around 652 by Saint Landry, bishop of Paris. During the
Middle Ages, charitable institutions, hospitals, and medical schools
increased in number, with the religious leaders as caregivers. The word
hospital, which is derived from the Latin word hospitalis, meaning service
of guests, was most likely more of a shelter for travelers and other
pilgrims as well as the occasional person who needed extra care (Kalisch
& Kalisch, 1986). Early European hospitals were more like hospices or
homes for the aged, sick pilgrims, or orphans. Nurses in these early
hospitals were religious deaconesses who chose to care for others in a
life of servitude and spiritual sacrifice.
Black Death
During the Middle Ages, a series of horrible epidemics, including the
Black Death or bubonic plague, ravaged the civilized world (Diamond,
1997). In the 1300s, Europe, Asia, and Africa saw nearly half their
populations lost to the bubonic plague. Worldwide, more than 60 million
deaths were attributed to this horrible plague. In some parts of Europe,
only one-fourth of the population survived, with some places having too
few survivors alive to bury the dead. Families abandoned sick children,
and the sick were often left to die alone (Cartwright, 1972).
Nurses and physicians were powerless to avert the disease. Black
spots and tumors on the skin appeared, and petechiae and hemorrhages
gave the skin a darkened appearance. There was also acute
inflammation of the lungs, burning sensations, unquenchable thirst, and
inflammation of the entire body. Hardly anyone afflicted survived the third
day of the attack. So great was the fear of contagion that ships carrying
bodies of infected persons were set to sail without a crew to drift from
port to port through the North, Black, and Mediterranean seas with their
dead passengers (Cohen, 1989).
Medieval people knew that this disease was in some way
communicable, but they were unsure of the mode of transmission
(Diamond, 1997); hence the avoidance of victims and a reliance on
isolation techniques. During this time, the practice of quarantine in city
ports was developed as a preventive measure that is still used today
(Bullough & Bullough, 1978; Kalisch & Kalisch, 1986).
The Renaissance
During the rebirth of Europe, political, social, and economic advances
occurred along with a tremendous revival of learning. Donahue (1985)
contends that the Renaissance has been “viewed as both a blessing and
a curse” (p. 188). There was a renewed interest in the arts and sciences,
which helped advance medical science (Boorstin, 1985; Bullough &
Bullough, 1978). Columbus and other explorers discovered new worlds,
and belief in a sun-centered rather than an Earth-centered universe was
promoted by Copernicus (1473–1543). Sir Isaac Newton’s (1642–1727)
theory of gravity changed the world forever. Gunpowder was introduced,
and social and religious upheavals resulted in the American and French
revolutions at the end of the 1700s. In the arts and sciences, Leonardo
da Vinci, known as one of the greatest geniuses of all time, made a
number of anatomic drawings based on dissection experiences. These
drawings have become classics in the progression of knowledge about
the human anatomy. Many artists of this time left an indelible mark and
continue to exert influence today, including Michelangelo, Raphael, and
Titian (Donahue, 1985).
The Reformation
Religious changes during the Renaissance influenced nursing perhaps
more than any other aspect of society. Particularly important was the rise
of Protestantism as a result of the reform movements of Martin Luther
(1483–1546) in Germany and John Calvin (1509–1564) in France and
Switzerland. Although the various sects were numerous in the Protestant
movement, the agreement among the leaders was almost unanimous on
the abolition of the monastic or cloistered career. The effects on nursing
were drastic: Monastic-affiliated institutions, including hospitals and
schools, were closed, and orders of nuns, including nurses, were
dissolved. Even in countries where Catholicism flourished, royal leaders
seized monasteries frequently.
Religious leaders, such as Martin Luther, who led the Reformation in
1517, were well aware of the lack of adequate nursing care as a result of
these sweeping changes. Luther advocated that each town establish
something akin to a “community chest” to raise funds for hospitals and
nurse visitors for the poor (Dietz & Lehozky, 1963). Thus, the closures of
the monasteries eventually resulted in the creation of public hospitals
where laywomen performed nursing care. It was difficult to find laywomen
who were willing to work in these hospitals to care for the sick, so judges
began giving prostitutes, publically intoxicated women, and povertystricken women the option of going to jail, going to the poorhouse, or
working in the public hospital. Unlike the sick wards in monasteries,
which were generally considered to be clean and well managed, the
public hospitals were filthy, disorganized buildings where people went to
die while being cared for by laywomen who were not trained, motivated,
or qualified to care for the sick (Sitzman & Judd, 2014a).
In England, where there had been at least 450 charitable foundations
before the Reformation, only a few survived the reign of Henry VIII, who
closed most of the monastic hospitals (Donahue, 1985). Eventually,
Henry VIII’s son, Edward VI, who reigned from 1547 to 1553, endowed
some hospitals, namely, St. Bartholomew’s Hospital and St. Thomas’
Hospital, which would eventually house the Nightingale School of Nursing
later in the 1800s (Bullough & Bullough, 1978).
The Dark Period of Nursing
The last half of the period between 1500 and 1860 is widely regarded as
the “dark period of nursing” because nursing conditions were at their
worst (Donahue, 1985). Education for girls, which had been provided by
the nuns in religious schools, was lost. Because of the elimination of
hospitals and schools, there was no one to pass on knowledge about
caring for the sick. As a result, the hospitals were managed and staffed
by municipal authorities; women entering nursing service often came
from illiterate classes, and even then, there were too few to serve (Dietz
& Lehozky, 1963). The lay attendants who filled the nursing role were
illiterate, rough, inconsiderate, and often immoral and alcoholic.
Intelligent women and men could not be persuaded to accept such a
degraded and low-status position in the offensive municipal hospitals of
London. Nursing slipped back into a role of servitude as menial, lowstatus work. According to Donahue (1985), when a woman could no
longer make it as a gambler, prostitute, or thief, she might become a
nurse. Eventually, women serving jail sentences for such crimes as
prostitution and stealing were ordered to care for the sick in the hospitals
instead of serving their sentences in the city jail (Dietz & Lehozky, 1963).
The nurses of this era took bribes from clients, became inappropriately
involved with them, and survived the best way they could, often at the
expense of their assigned clients.
Nursing had, during this era, virtually no social standing or
organization. Even Catholic sisters of the religious orders throughout
Europe “came to a complete standstill” professionally because of the
intolerance of society (Donahue, 1985, p. 231). Charles Dickens, in
Martin Chuzzlewit (1844), created the enduring characters of Sairey
Gamp and Betsy Prig. Sairey Gamp was a visiting nurse based on an
actual hired attendant whom Dickens had met in a friend’s home. Sairey
Gamp was hired to care for sick family members but was instead cruel to
her clients, stole from them, and ate their rations; she was an alcoholic
and has been immortalized forever as a reminder of the world in which
Florence Nightingale came of age (Donahue, 1985). The first hospital in
the Americas, the Hospital de la Purísima Concepción, was founded
some time before 1524 by Hernando Cortez, the conqueror of Mexico.
The first hospital in the continental United States was erected in
Manhattan in 1658 for the care of sick soldiers and slaves. In 1717, a
hospital for infectious diseases was built in Boston; the first hospital
established by a private gift was the Charity Hospital in New Orleans. A
sailor, Jean Louis, donated the endowment for the hospital’s founding
(Bullough & Bullough, 1978).
During the 1600s and 1700s, colonial hospitals with little
resemblance to modern hospitals were often used to house the poor and
downtrodden. Hospitals called “pesthouses” were created to care for
clients with contagious diseases; their primary purpose was to protect the
public at large rather than to treat and care for the clients. Contagious
diseases were rampant during the early years of the American colonies,
often being spread by the large number of immigrants who brought these
diseases with them on their long journey to America. Medicine was not as
developed as in Europe, and nursing remained in the hands of the
uneducated. By 1720, average life expectancy at birth was only around
35 years. Plagues were a constant nightmare, with outbreaks of smallpox
and yellow fever. In 1751, the first true hospital in the new colonies,
Pennsylvania Hospital, was erected in Philadelphia on the
recommendation of Benjamin Franklin (Kalisch & Kalisch, 1986).
By today’s standards, hospitals in the 1800s were disgraceful, dirty,
unventilated, and contaminated by infections; to be a client in a hospital
actually increased one’s risk of dying. As in England, nursing was
considered an inferior occupation. After the sweeping changes of the
Reformation, educated religious health workers were replaced with lay
people who were “down and outers,” in prison or had no option left but to
work with the sick (Kalisch & Kalisch, 1986).
The Industrial Revolution
During the mid-1700s in England, capitalism emerged as an economic
system based on profit. This emerging system resulted in mass
production, as contrasted with the previous system of individual workers
and craftsmen. In the simplest terms, the Industrial Revolution was the
application of machine power to processes formerly done by hand.
Machinery was invented during this era and ultimately standardized
quality; individual craftsmen were forced to give up their crafts and lands
and become factory laborers for the capitalist owners. All types of
industries were affected; this new-found efficiency produced profit for
owners of the means of production. Because of this, the era of invention
flourished, factories grew, and people moved in record numbers to work
in the cities. Urban areas grew, tenement housing projects emerged, and
overcrowding in cities seriously threatened individuals’ well-being
(Donahue, 1985).
Workers were forced to go to the machines, not the other way
around. Such relocations meant giving up not only farming but also a way
of life that had existed for centuries. The emphasis on profit over people
led to child labor, frequent layoffs, and long workdays filled with stressful,
tedious, unfamiliar work. Labor unions did not exist, and neither was
there any legal protection against exploitation of workers, including
children (Donahue, 1985). All these rapid changes and often threatening
conditions created the world of Charles Dickens, where, as in his book
Oliver Twist, children worked as adults without question.
According to Donahue (1985), urban life, trade, and industrialization
contributed to these overwhelming health hazards, and the situation was
confounded by the lack of an adequate means of social control. Reforms
were desperately needed, and the social reform movement emerged in
response to the unhealthy by-products of the Industrial Revolution. It was
in this world of the 1800s that such reformers as John Stuart Mill (1806–
1873) emerged. Although the Industrial Revolution began in England, it
quickly spread to the rest of Europe and to the United States (Bullough &
Bullough, 1978). The reform movement is critical to understanding the
emerging health concerns that were later addressed by Florence
Nightingale. Mill championed popular education, the emancipation of
women, trade unions, and religious toleration. Other reform issues of the
era included the abolition of slavery and, most important for nursing,
more humane care of the sick, the poor, and the wounded (Bullough &
Bullough, 1978). There was a renewed energy in the religious community
with the reemergence of new religious orders in the Catholic Church that
provided service to the sick and disenfranchised.
Epidemics had ravaged Europe for centuries, but they became even
more serious with urbanization. Industrialization brought people to cities,
where they worked in close quarters (as compared with the isolation of
the farm) and contributed to the social decay of the second half of the
1800s. Sanitation was poor or nonexistent, sewage disposal from the
growing population was lacking, cities were filthy, public laws were weak
or nonexistent, and congestion of the cities inevitably brought pests in the
form of rats, lice, and bedbugs, which transmitted many pathogens.
Communicable diseases continued to plague the population, especially
those who lived in these unsanitary environments. For example, during
the mid-1700s, typhus and typhoid fever claimed twice as many lives
each year as did the Battle of Waterloo (Hanlon & Pickett, 1984).
Through foreign trade and immigration, infectious diseases were spread
to all of Europe and eventually to the growing United States.
The Chadwick Report
Edwin Chadwick became a major figure in the development of the field of
public health in Great Britain by drawing attention to the cost of the
unsanitary conditions that shortened the life span of the laboring class
and threatened the wealth of Britain. Although the first sanitation
legislation, which established a National Vaccination Board, was passed
in 1837, Chadwick found in his classic study, Report on an Inquiry into
the Sanitary Conditions of the Labouring Population of Great Britain, that
death rates were high in large industrial cities, such as Liverpool. A more
startling finding, from what is often referred to simply as the Chadwick
Report, was that more than half the children of labor-class workers died
by age 5, indicating poor living conditions that affected the health of the
most vulnerable. Laborers lived only half as long as the upper classes.
One consequence of the report was the establishment in 1848 of the
first board of health, the General Board of Health for England
(Richardson, 1887). More legislation followed that initiated social reform
in the areas of child welfare, elder care, the sick, mentally ill persons,
factory health, and education. Soon sewers and fireplugs, based on an
available water supply, appeared as indicators that the public health
linkages from the Chadwick Report had an effect.
The Shattuck Report
In the United States during the 1800s, waves of epidemics of yellow
fever, smallpox, cholera, typhoid fever, and typhus continued to plague
the population as in England and the rest of the world. As cities continued
to grow in the industrialized young nation, poor workers crowded into
larger cities and suffered from illnesses caused by the unsanitary living
conditions (Hanlon & Pickett, 1984). Similar to Chadwick’s classic study
in England, Lemuel Shattuck, a Boston bookseller and publisher who had
an interest in public health, organized the American Statistical Society in
1839 and issued a census of Boston in 1845. Shattuck’s census revealed
high infant mortality rates and high overall population mortality rates. In
1850, in his Report of the Massachusetts Sanitary Commission, Shattuck
not only outlined his findings on the unsanitary conditions but also made
recommendations for public health reform that included the bookkeeping
of population statistics and development of a monitoring system that
would provide information to the public about environmental, food, and
drug safety and infectious disease control (Rosen, 1958). He also called
for services for well-child care, school-age children’s health,
immunizations, mental health, health education for all, and health
planning. The Shattuck Report was revolutionary in its scope and vision
for public health, but it was virtually ignored during Shattuck’s lifetime.
Nineteen years later, in 1869, the first state board of health was formed
(Kalisch & Kalisch, 1986).
And Then There Was Nightingale . . .
Florence Nightingale (Figure 1-1) was named one of the 100 most
influential persons of the last millennium by Life magazine (“The 100
People Who Made the Millennium,” 1997). She was one of only eight
women identified as such. Of those eight women, including Joan of Arc,
Helen Keller, and Elizabeth I, Nightingale was identified as a true “angel
of mercy,” having reformed military health care in the Crimean War and
used her political savvy to forever change the way society views the
health of the vulnerable, the poor, and the forgotten. She is probably one
of the most written about women in history (Bullough & Bullough, 1978).
Florence Nightingale has become synonymous with modern nursing.
Figure 1-1 Engraving From 1873 featuring the English reformer and founder of modern nursing,
Florence Nightingale.
© traveler1116/E+/Getty Images
Born on May 12, 1820, in her namesake city, Florence, Italy, Florence
Nightingale was the second child in the wealthy English family of William
and Frances Nightingale. As a young child, Florence displayed incredible
curiosity and intellectual abilities not common to female children of the
Victorian age. She mastered the fundamentals of Greek and Latin, and
she studied history, art, mathematics, and philosophy. To her family’s
dismay, she believed that God had called her to be a nurse. Nightingale
was keenly aware of the suffering that industrialization created; she
became obsessed with the plight of the miserable and suffering people.
Conditions of general starvation accompanied the Industrial Revolution,
prisons and workhouses overflowed, and persons in all sections of British
life were displaced. She wrote in the spring of 1842, “My mind is
absorbed with the sufferings of man; it besets me behind and before. . . .
All that the poets sing of the glories of this world seem to me untrue. All
the people that I see are eaten up with care or poverty or disease”
(Woodham-Smith, 1951, p. 31).
Nightingale’s entire life would be haunted by this conflict between the
opulent life of gaiety that she enjoyed and the misery of the world, which
she was unable to alleviate. She was, in essence, an “alien spirit in the
rich and aristocratic social sphere of Victorian England” (Palmer, 1977, p.
14). Nightingale remained unmarried, and at the age of 25, she
expressed a desire to be trained as a nurse in an English hospital. Her
parents emphatically denied her request, and for the next 7 years, she
made repeated attempts to change their minds and allow her to enter
nurse training. She wrote, “I crave for some regular occupation, for
something worth doing instead of frittering my time away on useless
trifles” (Woodham-Smith, 1951, p. 162). During this time, she continued
her education through the study of math and science and spent 5 years
collecting data about public health and hospitals (Dietz & Lehozky, 1963).
During a tour of Egypt in 1849 with family and friends, Nightingale spent
her 30th year in Alexandria with the Sisters of Charity of St. Vincent de
Paul, where her conviction to study nursing was only reinforced (Tooley,
1910). While in Egypt, Nightingale studied Egyptian, Platonic, and
Hermetic philosophy; Christian scripture; and the works of poets, mystics,
and missionaries in her efforts to understand the nature of God and her
“calling” as it fit into the divine plan (Calabria, 1996; Dossey, 2000).
The next spring, Nightingale traveled unaccompanied to the
Kaiserwerth Institute in Germany and stayed there for 2 weeks, vowing to
return to train as a nurse. In June 1851, Nightingale took her future into
her own hands and announced to her family that she planned to return to
Kaiserwerth and study nursing. According to Dietz and Lehozky (1963, p.
42), her mother had “hysterics” and scene followed scene. Her father
“retreated into the shadows,” and her sister, Parthe, expressed that the
family name was forever disgraced (Cook, 1913). In 1851, at the age of
31, Nightingale was finally permitted to go to Kaiserwerth, and she
studied there for 3 months with Pastor Fliedner. Her family insisted that
she tell no one outside the family of her whereabouts, and her mother
forbade her to write any letters from Kaiserwerth. While there, Nightingale
learned about the care of the sick and the importance of discipline and
commitment of oneself to God (Donahue, 1985). She returned to England
and cared for her then ailing father, from whom she finally gained some
support for her intent to become a nurse—her lifelong dream.
In 1852, Nightingale wrote the essay “Cassandra,” which stands
today as a classic feminist treatise against the idleness of Victorian
women. Through her voluminous journal writings, Nightingale reveals her
inner struggle throughout her adulthood with what was expected of a
woman and what she could accomplish with her life. The life expected of
an aristocratic woman in her day was one she grew to loathe, and she
expressed this detestation throughout her writings (Nightingale, 1979). In
“Cassandra,” Nightingale put her thoughts to paper, and many scholars
believe that her eventual intent was to extend the essay to a novel. She
wrote in “Cassandra,” “Why have women passion, intellect, moral activity
—these three—in a place in society where no one of the three can be
exercised?” (Nightingale, 1979, p. 37). Although uncertain about the
meaning of the name Cassandra, many scholars believe that it came
from the Greek goddess Cassandra, who was cursed by Apollo and
doomed to see and speak the truth but never to be believed. Nightingale
saw the conventional life of women as a waste of time and abilities. After
receiving a generous yearly endowment from her father, Nightingale
moved to London and worked briefly as the superintendent of the
Establishment for Gentlewomen During Illness hospital, finally realizing
her dream of working as a nurse (Cook, 1913).
The Crimean Experience: “I Can Stand Out the
War with Any Man”
Nightingale’s opportunity for greatness came when she was offered the
position of superintendent of the female nursing establishment of the
English General Hospitals in Turkey by the secretary of war, Sir Sidney
Herbert. Soon after the outbreak of the Crimean War, stories of the
inadequate care and lack of medical resources for the soldiers became
widely known throughout England (Woodham-Smith, 1951). The country
was appalled at the conditions so vividly portrayed in the London Times.
Pressure increased on Sir Sidney to react. He knew of one woman who
was capable of bringing order out of the chaos and wrote a letter to
Nightingale on October 15, 1854, as a plea for her service. Nightingale
accepted the challenge and set sail with 38 self-proclaimed nurses with
varied training and experiences, of whom 24 were Catholic and Anglican
nuns. Their journey to the Crimea took a month, and on November 4,
1854, the brave nurses arrived at Istanbul and were taken to Scutari the
same day. Faced with 3,000 to 4,000 wounded men in a hospital
designed to accommodate 1,700, the nurses went to work (Kalisch &
Kalisch, 1986). They found 4 miles of beds 18 inches apart. Most soldiers
were lying naked with no bedding or blanket. There were no kitchen or
laundry facilities. The little light present took the form of candles in beer
bottles. The hospital was literally floating on an open sewage lagoon filled
with rats and other vermin (Donahue, 1985).
By taking the newly arrived medical equipment and setting up
kitchens, laundries, recreation rooms, reading rooms, and a canteen,
Nightingale and her team of nurses proceeded to clean the barracks of
lice and filth. Nightingale was in her element. She set out not only to
provide humane health care for the soldiers but also to essentially
overhaul the administrative structure of the military health services
(Williams, 1961).
Florence Nightingale and Sanitation
Although Nightingale never accepted the germ theory, she demanded
clean dressings; clean bedding; well-cooked, edible, and appealing food;
proper sanitation; and fresh air. After the other nurses were asleep,
Nightingale made her famous solitary rounds with a lamp or lantern to
check on the soldiers. Nightingale had a lifelong pattern of sleeping few
hours, spending many nights writing, developing elaborate plans, and
evaluating implemented changes. She seldom believed in the “hopeless”
soldier, only one who needed extra attention. Nightingale was convinced
that most of the maladies that the soldiers suffered and died from were
preventable (Williams, 1961).
Before Nightingale’s arrival and her radical and well-documented
interventions based on sound public health principles, the mortality rate
from the Crimean War was estimated to be from 42% to 73%. Nightingale
is credited with reducing that rate to 2% within 6 months of her arrival at
Scutari. She did this through careful, scientific epidemiologic research
(Dietz & Lehozky, 1963). Upon arriving at Scutari, Nightingale’s first act
was to order 200 scrubbing brushes. The death rate fell dramatically
once Nightingale discovered that the hospital was built literally over an
open sewage lagoon (Andrews, 2003).
According to Palmer (1982), Nightingale possessed the qualities of a
good researcher: insatiable curiosity, command of her subject, familiarity
with methods of inquiry, a good background of statistics, and the ability to
discriminate and abstract. She used these skills to maintain detailed and
copious notes and to codify observations. Nightingale relied on statistics
and attention to detail to back up her conclusions about sanitation,
management of care, and disease causation. Her now-famous “cox
combs” are a hallmark of military health services management by which
she diagrammed deaths in the army from wounds and from other
diseases and compared them with deaths that occurred in similar
populations in England (Palmer, 1977).
Nightingale was first and foremost an administrator: She believed in a
hierarchical administrative structure with ultimate control lodged in one
person to whom all subordinates and offices reported. Within a matter of
weeks of her arrival in the Crimea, Nightingale was the acknowledged
administrator and organizer of a mammoth humanitarian effort. From her
Crimean experience on, Nightingale involved herself primarily in
organizational activities and health planning administration. Palmer
contends that Nightingale “perceived the Crimean venture, which was set
up as an experiment, as a golden opportunity to demonstrate the efficacy
of female nursing” (Palmer, 1982, p. 4). Although Nightingale faced initial
resistance from the unconvinced and oppositional medical officers and
surgeons, she boldly defied convention and remained steadfastly focused
on her mission to create a sanitary and highly structured environment for
her “children”—the British soldiers who dedicated their lives to the
defense of Great Britain. Because of her insistence on absolute authority
regarding nursing and the hospital environment, Nightingale was known
to send nurses home to England from the Crimea for suspicious alcohol
use and character weakness.
It was through this success at Scutari that she began a long career of
influence on the public’s health through social activism and reform, health
policy, and the reformation of career nursing. Using her well-publicized
successful “experiment” and supportive evidence from the Crimea,
Nightingale effectively argued the case for the reform and creation of
military health care that would serve as the model for people in uniform to
the present (D’Antonio, 2002). Nightingale’s ideas about proper hospital
architecture and administration influenced a generation of medical
doctors and the entire world, in both military and civilian service. Her
work in Notes on Hospitals, published in 1860, provided the template for
the organization of military health care in the Union Army when the U.S.
Civil War erupted in 1861. Her vision for health care of soldiers and the
responsibility of the governments that send them to war continues today;
her influence can be seen throughout the previous century and into this
century as health care for the women and men who serve their country is
a vital part of the well-being not only of the soldiers but also of society in
general (D’Antonio, 2002).
Returning Home a Heroine: The Political
When Nightingale returned to London, she found that her efforts to
provide comfort and health to the British soldier succeeded in making
heroes of both herself and the soldiers (Woodham-Smith, 1951). Both
had suffered from negative stereotypes: The soldier was often portrayed
as a drunken oaf with little ambition or honor, and the nurse as a tipsy,
self-serving, illiterate, promiscuous loser. After the Crimean War and the
efforts of Nightingale and her nurses, both returned with honor and
dignity, never again downtrodden and disrespected.
After her return from the Crimea, Florence Nightingale never made a
public appearance, never attended a public function, and never issued a
public statement (Bullough & Bullough, 1978). She single-handedly
raised nursing from, as she put it, “the sink it was” into a respected and
noble profession (Palmer, 1977). As an avid scholar and student of the
Greek writer Plato, Nightingale believed that she had a moral obligation
to work primarily for the good of the community. Because she believed
that education formed character, she insisted that nursing must go
beyond care for the sick; the mission of the trained nurse must include
social reform to promote the good. This dual mission of nursing—
caregiver and political reformer—has shaped the profession as we know
it today. LeVasseur (1998) contends that Nightingale’s insistence on
nursing’s involvement in a larger political ideal is the historic foundation of
the field and distinguishes us from other scientific disciplines, such as
How did Nightingale accomplish this? She effected change through
her wide command of acquaintances: Queen Victoria was a significant
admirer of her intellect and ability to effect change, and Nightingale used
her position as national heroine to get the attention of elected officials in
Parliament. She was tireless and had an amazing capacity for work. She
used people. Her brother-in-law, Sir Harry Verney, was a member of
Parliament and often delivered her “messages” in the form of legislation.
When she wanted the public incited, she turned to the press, writing
letters to the London Times and having others of influence write articles.
She was not above threats to “go public” by certain dates if an elected
official refused to establish a commission or appoint a committee. And
when those commissions were formed, Nightingale was ready with her
list of selected people for appointment (Palmer, 1982).
Nightingale and Military Reforms
The first real test of Nightingale’s military reforms came in the United
States during the Civil War. Nightingale was asked by the Union to advise
on the organization of hospitals and care of the sick and wounded. She
sent recommendations back to the United States based on her
experiences and analysis in the Crimea, and her advisement and
influence gained wide publicity. Following her recommendations, the
Union set up a sanitary commission and provided for regular inspection
of camps. She expressed a desire to help with the Confederate military
also but, unfortunately, had no channel of communication with them
(Bullough & Bullough, 1978).
The Nightingale School of Nursing at St.
Thomas: The Birth of Professional Nursing
The British public honored Nightingale by endowing 50,000 pounds
sterling in her name upon her return to England from the Crimea. The
money had been raised from the soldiers under her care and donations
from the public. This Nightingale Fund eventually was used to create the
Nightingale School of Nursing at St. Thomas, which was to be the
beginning of professional nursing (Donahue, 1985). Nightingale, at the
age of 40, decided that St. Thomas’ Hospital was the place for her
training school for nurses. While the negotiations for the school went
forward, she spent her time writing Notes on Nursing: What It Is and
What It Is Not (Nightingale, 1860). The small book of 77 pages, written
for the British mother, was an instant success. An expanded library
edition was written for nurses and used as the textbook for the students
at St. Thomas. The book has since been translated into many languages,
although it is believed that Nightingale refused all royalties earned from
the publication of the book (Cook, 1913; Tooley, 1910). The nursing
students chosen for the new training school were handpicked; they had
to be of good moral character, sober, and honest. Nightingale believed
that the strong emphasis on morals was critical to gaining respect for the
new “Nightingale nurse,” with no possible ties to the disgraceful
association of past nurses. Nursing students were monitored throughout
their 1-year program both on and off the hospital grounds; their activities
were carefully watched for character weaknesses, and discipline was
severe and swift for violators. Accounts from Nightingale’s journals and
notes reveal instant dismissal of nursing students for such behaviors as
“flirtation, using the eyes unpleasantly, and being in the company of
unsavory persons.” Nightingale contended that “the future of nursing
depends on how these young women behave themselves” (Smith, 1934,
p. 234). She knew that the experiment at St. Thomas to educate nurses
and raise nursing to a moral and professional calling was a drastic
departure from the past images of nurses and would take extraordinary
women of high moral character and intelligence. Nightingale knew every
nursing student, or probationer, personally, often having the students at
her house for weekend visits. She devised a system of daily journal
keeping for the probationers; Nightingale herself read the journals
monthly to evaluate their character and work habits. Every nursing
student admitted to St. Thomas had to submit an acceptable “letter of
good character,” and Nightingale herself placed graduate nurses in
approved nursing positions.
One of the most important features of the Nightingale School was its
relative autonomy. Both the school and the hospital nursing service were
organized under the head matron. This was especially significant
because it meant that nursing service began independently of the
medical staff in selecting, retaining, and disciplining students and nurses
(Bullough & Bullough, 1978). Nightingale was opposed to the use of a
standardized government examination and the movement for licensure of
trained nurses. She believed that schools of nursing would lose control of
educational standards with the advent of national licensure, most notably
those related to moral character. Nightingale led a staunch opposition to
the movement by the British Nurses’ Association (BNA) for licensure of
trained nurses, one the BNA believed critical to protecting the public’s
safety by ensuring the qualification of nurses by licensure exam.
Nightingale was convinced that qualifying a nurse by examination tested
only the acquisition of technical skills, not the equally important
evaluation of character (Nutting & Dock, 1907; Woodham-Smith, 1951).
Taking Health Care to the Community:
Nightingale and Wellness
Early efforts to distinguish hospital from community health nursing are
evidence of Nightingale’s views on “health nursing,” which she
distinguished from “sick nursing.” She wrote two influential papers, one in
1893, “Sick-Nursing and Health-Nursing” (Nightingale, 1893), which was
read in the United States at the Chicago Exposition, and the second,
“Health Teaching in Towns and Villages” in 1894 (Monteiro, 1985). Both
papers praised the success of prevention-based nursing practice.
Winslow (1946) acknowledged Nightingale’s influence in the United
States by being one of the first in the field of public health to recognize
the importance of taking responsibility for one’s health. According to
Palmer (1982), Nightingale was a leader in the wellness movement long
before the concept was identified. Nightingale saw the nurse as the key
figure in establishing a healthy society. She saw a logical extension of
nursing in acute hospital settings to the community. Clearly, through her
Notes on Nursing, she visualized the nurse as “the nation’s first bulwark
in health maintenance, the promotion of wellness, and the prevention of
disease” (Palmer, 1982, p. 6).
William Rathbone, a wealthy ship owner and philanthropist, is
credited with the establishment of the first visiting nurse service, which
eventually evolved into district nursing in the community. He was so
impressed with the private duty nursing care that his sick wife had
received at home that he set out to develop a “district nursing service” in
Liverpool, England. At his own expense, in 1859, he developed a corps
of nurses trained to care for the sick poor in their homes (Bullough &
Bullough, 1978). He divided the community into 16 districts; each was
assigned a nurse and a social worker that provided nursing and health
education. His experiment in district nursing was so successful that he
was unable to find enough nurses to work in the districts. Rathbone
contacted Nightingale for assistance. Her recommendation was to train
more nurses, and she advised Rathbone to approach the Royal Liverpool
Infirmary with a proposal for opening another training school for nurses
(Rathbone, 1890; Tooley, 1910). The infirmary agreed to Rathbone’s
proposal, and district nursing soon spread throughout England as
successful health nursing in the community for the sick poor through
voluntary agencies (Rosen, 1958). Ever the visionary, Nightingale
contended that the goal is to care for the sick in their own homes
(Attewell, 1996). A similar service, health visiting, began in Manchester,
England, in 1862 by the Manchester and Salford Sanitary Association.
The purpose of placing health visitors in the home was to provide health
information and instruction to families. Eventually, health visitors evolved
to provide preventive health education and district nurses to care for the
sick at home (Bullough & Bullough, 1978).
Although Nightingale is best known for her reform of hospitals and
the military, she was a great believer in the future of health care, which
she anticipated should be preventive in nature and would more than likely
take place in the home and community. Her accomplishments in the field
of “sanitary nursing” extended beyond the walls of the hospital to include
workhouse reform and community sanitation reform. In 1864, Nightingale
and William Rathbone once again worked together to lead the reform of
the Liverpool Workhouse Infirmary, where more than 1,200 sick paupers
were crowded into unsanitary and unsafe conditions. Under the British
Poor Laws, the most desperately poor of the large cities were gathered
into large workhouses. When sick, they were sent to the workhouse
infirmary. Trained nursing care was all but nonexistent. Through
legislative pressure and a well-designed public campaign describing the
horrors of the workhouse infirmary, reform of the workhouse system was
accomplished by 1867. Although not as complete as Nightingale had
wanted, nurses were in place and being paid a salary (Seymer, 1954).
The Legacy of Nightingale
A great deal has been written about Nightingale—an almost mythic figure
in history. She truly was a beloved legend throughout Great Britain by the
time she left the Crimea in July 1856, 4 months after the war. Longfellow
immortalized this “Lady with the Lamp” in his poem “Santa Filomena”
(Longfellow, 1857). However, when Nightingale returned to London after
the Crimean War, she remained haunted by her experiences related to
the soldiers dying of preventable diseases. She was troubled by
nightmares and had difficulty sleeping in the years that followed
(Woodham-Smith, 1983). Nightingale became a prolific writer and a
staunch defender of the causes of the British soldier, sanitation in
England and India, and trained nursing.
As a woman, she was not able to hold an official government post,
nor could she vote. Historians have had varied opinions about the exact
nature of the disability that kept her homebound for the remainder of her
life. Recent scholars have speculated that she experienced posttraumatic
stress disorder (PTSD) from her experiences in the Crimea; there is also
considerable evidence that she suffered from the painful disease
brucellosis (Barker, 1989; Young, 1995). She exerted incredible influence
through friends and acquaintances, directing from her sick room
sanitation and poor law reform. Her mission to “cleanse” spread from the
military to the British Empire; her fight for improved sanitation both at
home and in India consumed her energies for the remainder of her life
(Vicinus & Nergaard, 1990).
According to Monteiro (1985), two recurrent themes are found
throughout Nightingale’s writings about disease prevention and wellness
outside the hospital. The most persistent theme is that nurses must be
trained differently and instructed specifically in district and instructive
nursing. She consistently wrote that the “health nurse” must be trained in
the nature of poverty and its influence on health, something she referred
to as the “pauperization” of the poor. She also believed that above all,
health nurses must be good teachers about hygiene and helping families
learn to better care for themselves (Nightingale, 1893). She insisted that
untrained, “good intended women” could not substitute for nursing care in
the home. Nightingale pushed for an extensive orientation and additional
training, including prior hospital experience, before one was hired as a
district nurse. She outlined the qualifications in her paper “On Trained
Nursing for the Sick Poor,” in which she called for a month’s “trial” in
district nursing, a year’s training in hospital nursing, and 3 to 6 months
training in district nursing (Monteiro, 1985).
The second theme that emerged from her writings was the focus on
the role of the nurse. She clearly distinguished the role of the health
nurse in promoting what we today call self-care. In the past, philanthropic
visitors in the form of Christian charity would visit the homes of the poor
and offer them relief (Monteiro, 1985). Nightingale believed that such
activities did little to teach the poor to care for themselves and further
“pauperized” them—dependent and vulnerable—keeping them unhealthy,
prone to disease, and reliant on others to keep them healthy. The nurse
then must help the families at home manage a healthy environment for
themselves, and Nightingale saw a trained nurse as being the only
person who could pull off such a feat.
By 1901, Nightingale lived in a world without sight or sound, leaving
her unable to write. Over the next 5 years, Nightingale lost her ability to
communicate and most days existed in a state of unconsciousness. In
November 1907, Nightingale was honored with the Order of Merit by King
Edward VII, the first time it was ever given to a woman. After 50 years, in
May 1910, the Nightingale Training School of Nursing at St. Thomas
celebrated its jubilee. There were now more than a thousand training
schools for nurses in the United States alone (Cook, 1913; Tooley, 1910).
Nightingale died in her sleep around noon on August 13, 1910 and
was buried quietly and without pomp near the family’s home at Embley,
her coffin carried by six sergeants of the British Army. Only a small cross
marks her grave at her request: “FN. Born 1820. Died 1910.” (Brown,
1988). The family refused a national funeral and burial at Westminster
Abbey out of respect for Nightingale’s last wishes. She had lived for 90
years and 3 months.
Continued Development of
Professional Nursing in the United
Although Florence Nightingale opposed registration, based on the belief
that the essential qualities of a nurse could not be taught, examined, or
regulated, registration in the United Kingdom began in the 1880s. The
Hospitals Association maintained a voluntary registry that was an
administrative list. In an effort to protect the public led by Ethel Fenwick,
the BNA was formed in 1887 with its charter granted in 1893 to unite
British nurses and to provide registration as evidence of systematic
training. Finally, in 1919, nurse registration became law. It took 30 years
and the tireless efforts of Ethel Fenwick, who was supported by other
nursing leaders, such as Isla Stewart, Lucy Osbourne, and Mary
Cochrane, to achieve mandated registration (Royal British Nurses’
Association, n.d.).
Another milestone in British nursing history was the founding in 1916
of the College of Nursing as the professional organization for trained
nurses. For a century, the organization has focused on professional
standards for nurses in their education, practice, and working conditions.
Although the principles of a professional organization and those of a
trade union have not always fit together easily, the Royal College of
Nursing has pursued its role as both the professional organization for
nurses and the trade union for nurses (McGann, Crowther, & Dougall,
2009). Today the Royal College of Nursing is recognized as the voice of
nursing by the government and the public in the United Kingdom (Royal
College of Nursing, n.d.).
The Development of Professional
Nursing in Canada
Marie Rollet Hebert, the wife of a surgeon–apothecary, is credited by
many with being the first person in present-day Canada to provide
nursing care to the sick as she assisted her husband after arriving in
Quebec in 1617; however, the first trained nurses arrived in Quebec to
care for the sick in 1639. These nurses were Augustine nuns who
traveled to Canada to establish a medical mission to care for the physical
and spiritual needs of their patients, and they established the first hospital
in North America, the Hôtel-Dieu de Québec. These nuns also
established the first apprenticeship program for nursing in North America.
Jeanne Mance came from France to the French colony of Montreal in
1642 and founded the Hôtel Dieu de Montréal in 1645 (Canadian
Museum of History, n.d.).
The hospital of the early 19th century did not appeal to the Canadian
public. They were primarily homes for the poor and were staffed by those
of a similar class rather than by nurses (Mansell, 2004). The decades of
the 1830s and 1840s in Canada were characterized by an influx of
immigrants and outbreaks of diseases, such as cholera. There is
evidence that it was difficult, especially in times of outbreak, to find
sufficient people to care for the sick. Little is known of the hospital
“nurses” of this era, but the descriptions are unflattering and working in
the hospital environment was difficult. Early midwives did have some
standing in the community and were employed by individuals, although
there is record of charitable organizations also employing midwives
(Young, 2010).
During the Crimean War and American Civil War, nurses were
extremely effective in providing treatment and comfort not only to
battlefield casualties but also to individuals who fell victim to accidents
and infectious disease; however, it was in the North-West Rebellion of
1885 that Canadian nurses performed military service for the first time. At
first, the nursing needs identified were for such duties as making
bandages and preparing supplies. It soon became apparent that more
direct participation by nurses was needed if the military was to provide
effective medical field treatment. Seven nurses, under the direction of
Reverend Mother Hannah Grier Coome, served in Moose Jaw and
Saskatoon, Saskatchewan. Although their tour of duty lasted only 4
weeks, these women proved that nursing could, and should in the future,
play a vital role in providing treatment to wounded soldiers. In 1899, the
Canadian Army Medical Department was formed, followed by the
creation of the Canadian Army Nursing Service. Nurses received the
relative rank, pay, and allowances of an army lieutenant. Nursing sisters
served thereafter in every military force sent out from Canada, from the
South African War to the Korean War (Veterans Affairs Canada, n.d.). In
1896, Lady Ishbel Aberdeen, wife of the governor-general of Canada,
visited Vancouver. During this visit, she heard vivid accounts of the
hardship and illness affecting women and children in rural areas. Later
that same year at the National Council of Women, amid similar stories, a
resolution was passed asking Lady Aberdeen to found an order of visiting
nurses in Canada. The order was to be a memorial to the 60th
anniversary of Queen Victoria’s ascent to the throne of the British
Empire; it received a royal charter in 1897. The first Victorian Order of
Nurses (VON) sites were organized in the cities of Ottawa, Montreal,
Toronto, Halifax, Vancouver, and Kingston. Today the VON delivers over
75 different programs and services, such as prenatal education, mental
health services, palliative care services, and visiting nursing, through 52
local sites staffed by 4,500 healthcare workers and over 9,016 volunteers
(VON, n.d.).
By the mid- to late 19th century, despite previous negativity, nursing
came to be viewed as necessary to progressive medical interventions. To
make the work of the nurse acceptable, changes had to be made to the
prevailing view of nursing. In the 1870s, the ideas of Florence Nightingale
were introduced in Canada. Dr. Theophilus Mack imported nurses who
had worked with Nightingale and founded the first training school for
nurses in Canada at St. Catharine’s General Hospital in 1873. Many
hospitals appeared across Canada from 1890 to 1910, and many of them
developed training schools for nurses. By 1909, there were 70 hospitalbased training schools in Canada (Mansell, 2004).
In 1908, Mary Agnes Snively, along with 16 representatives from
organized nursing bodies, met in Ottawa to form the Canadian National
Association of Trained Nurses (CNATN). By 1924, each of the nine
provinces had a provincial nursing organization with membership in the
CNATN. In 1924, the name of the CNATN was changed to the Canadian
Nurses Association (CNA). CNA is currently a federation of 11 provincial
and territorial nursing associations and colleges representing nearly
150,000 registered nurses (CNA, n.d.).
In 1944, the CNA approved the principle of collective bargaining. In
1946, the Registered Nurses Association of British Columbia became the
first provincial nursing association to be certified as a bargaining agent.
By the 1970s, other provincial nursing organizations gained this right.
Between 1973 and 1987, nursing unions were created. Today each of the
10 provinces has a nursing union in addition to a professional association
(Ontario Nurses’ Association, n.d.). One of the best known of these
professional associations is the Registered Nurses’ Association of
Ontario (RNAO). Established in 1925 to advocate for health public policy,
promote excellence in nursing practice, increase nursing’s contribution to
shaping the healthcare system, and influence decisions that affect nurses
and the public they serve, the RNAO is the professional association
representing registered nurses, nurse practitioners (NPs), and nursing
students in Ontario (RNAO, n.d.). Through the RNAO, nurses in Canada
have led the world in systematic implementation of evidence-based
practice and have made their best practice guidelines available to all
nurses to promote safe and effective care of patients.
As Canadians entered the decade of the 1960s, there was serious
concern about the healthcare system. In 1961, all Canadian provinces
signed on to the Hospital Insurance and Diagnostic Services Act. This
legislation created a national, universal health insurance system. The
same year, the Royal Commission on Health Services was established
and presented four recommendations. One of the recommendations was
to examine nursing education. Prior to this, the CNA had requested a
survey of nursing schools across Canada with the goal of assessing how
prepared the schools were for a national system of accreditation. The
findings of this survey, paired with the commission’s recommendation, led
to the establishment of the Canadian Nurses Foundation (CNF) in 1962.
The CNF (2014) provides funding for nurses to further their education
and for research related to nursing care. The Canadian Association of
Schools of Nursing (n.d.) is the organization that promotes national
nursing education standards and is the national accrediting agency for
university nursing programs in Canada.
Nursing in Canada transformed itself to meet the needs of a changing
Canadian society and in doing so was responsible for a shift from nursing
as a spiritual vocation to a secular but indispensable profession. Nurses’
willingness to respond in times of need, whether economic crisis,
epidemic, or war, contributed to their importance in the healthcare system
(Mansell, 2004). Canadian nursing associations agreed that starting in
the year 2000, the basic educational preparation for the registered nurse
would be the baccalaureate degree, and all provinces and territories
launched a campaign known as EP 2000, which later became EP 2005.
Currently, the baccalaureate degree earned from a university is the
accepted entry level into nursing practice in Canada (Mansell, 2004).
The Development of Professional
Nursing in Australia
In the earliest days of the colony, the care of the sick was performed by
untrained convicts. Male attendants undertook the supervision of male
patients and female attendants undertook duties with the female patients.
Attention to hygiene standards was almost nonexistent. In 1885, the poor
health and living conditions of disadvantaged sick persons in Melbourne
prompted a group of concerned citizens to meet and form the Melbourne
District Nursing Society. This society was formed to look after sick poor
persons at home to prevent unnecessary hospitalization. Home visiting
services also have a long history in Australia, with Victoria being the first
state to introduce a district nursing service in 1885, followed by South
Australia in 1894, Tasmania in 1896, New South Wales in 1900,
Queensland in 1904, and Western Australia in 1905 (Australian Bureau
of Statistics, 1985).
Australian nurses were involved in military nursing as civilian
volunteers as early as the 1880s (University of Melbourne, 2015);
however, involvement of Australian women as nurses in war began in
1898 with the formation of the Australian Nursing Service of New South
Wales, which was composed of 1 superintendent and 24 nurses. Based
on the performance of the nurses, the Australian Army Nursing Service
was formed in 1903 under the control of the federal government. The
Royal Australian Army Nursing Corps (RAANC) had its beginnings in the
Australian Army Nursing Service (RAANC, n.d.). Since that time,
Australian nurses have dealt with war, the sick, the wounded, and the
dead. They have served in Australia, in war zones around the world, in
field hospitals, on hospital ships anchored off shore near battlefields, and
on transports (Australian War Memorial, n.d.; Biedermann, Usher,
Williams, & Hayes, 2001). Other military opportunities for nurses include
the Royal Australian Navy and the Royal Australian Air Force.
Nursing registration in Australia began in 1920 as a state-based
system. Prior to 1920, nurses received certificates from the hospitals
where they trained, the Australian Trained Nurses Association (ATNA), or
the Royal British Nurses’ Association in order to practice. Today nurses
and midwives are registered through the Nursing and Midwifery Board of
Australia (NMBA), which is made up of member state and territorial
boards of nursing and supported by the Australian Health Practitioner
Regulation Agency. State and territorial boards are responsible for
making registration and notification decisions related to individual nurses
or midwives (NMBA, n.d.).
Around the turn of the 20th century, in order to create a formal means
of supporting their role and improve nursing standards and education, the
nurses of South Australia formed the South Australian branch of ATNA.
From this organization the Australian Nursing and Midwifery Federation
in South Australia (ANMFSA) evolved (ANMFSA, 2012). The Australian
Nursing and Midwifery Accreditation Council (ANMAC) is now the
independent accrediting authority for nursing and midwifery under
Australia’s National Registration and Accreditation Scheme. The ANMAC
is responsible for protecting and promoting the safety of the Australian
community by promoting high standards of nursing and midwifery
education through the development of accreditation standards,
accreditation of programs, and assessment of internationally qualified
nurses and midwives for migration (ANMAC, 2016).
In the late 1920s, two nurses, Evelyn Nowland and a Miss Clancy,
began working separately on the idea of a union for nurses and were
brought together by Jessie Street, who saw the improvement of nurses’
wages and conditions as a feminist cause. What is now the New South
Wales Nurses and Midwives’ Association (NSWNMA) was registered as
a trade union in 1931 (NSWNMA, 2014). Through the amalgamation of
various organizations, there is now one national organization to represent
registered nurses, enrolled nurses, midwives, and assistants doing
nursing work in every state and territory throughout Australia: the
Australian Nursing and Midwifery Federation (ANMF). The organization
was established in 1924 and serves as a union for nurses with an
ultimate goal of improving patient care. The ANMF is now composed of
eight branches: the Australian Nursing and Midwifery Federation (South
Australia branch), the NSWNMA, the Australian Nursing and Midwifery
Federation Victorian Branch, the Queensland Nurses Union, the
Australian Nursing and Midwifery Federation Tasmanian Branch, the
Australian Nursing and Midwifery Federation Australian Capital Territory,
the Australian Nursing and Midwifery Federation Northern Territory, and
the Australian Nursing and Midwifery Federation Western Australia
Branch (ANMF, 2015).
Early Nursing Education and
Organization in the United States
Formal nursing education in the United States did not begin until 1862,
when Dr. Marie Zakrzewska opened the New England Hospital for
Women and Children, which had its own nurse training program (Sitzman
& Judd, 2014b). Many of the first training schools for nursing were
modeled after the Nightingale School of Nursing at St. Thomas in
London. They included the Bellevue Training School for Nurses in New
York City; the Connecticut Training School for Nurses in New Haven,
Connecticut; and the Boston Training School for Nurses at
Massachusetts General Hospital (Christy, 1975; Nutting & Dock, 1907).
Based on the Victorian belief in the natural abilities of women to be
sensitive, possess high morals, and be caregivers, early nursing training
required that applicants be female. Sensitivity, high moral character,
purity of character, subservience, and “ladylike” behavior became the
associated traits of a “good nurse,” thus setting the “feminization of
nursing” as the ideal standard for a good nurse. These historical roots of
gender- and race-based caregiving continued to exclude males and
minorities from the nursing profession for many years and still influence
career choices for men and women today. These early training schools
provided a stable, subservient, white female workforce because student
nurses served as the primary nursing staff for these early hospitals.
Minority nurses found limited educational opportunities in this climate.
The first African American nursing school graduate in the United States
was Mary P. Mahoney. She graduated from the New England Hospital for
Women and Children in 1879 (Sitzman & Judd, 2014b).
Some nurses believe that Florence Nightingale holds nursing back
and represents the negative and backward elements of nursing. This
view cites as evidence that Nightingale supported the subordination of
nurses to physicians, opposed registration of nurses, and did not see
mental health nurses as part of the profession. After reading this
chapter, what do you think? Is Nightingale relevant in the 21st century
to the nursing profession? Why or why not?
Nursing education in the newly formed schools was based on
accepted practices that had not been validated by research. During this
time, nurses primarily relied on tradition to guide practice rather than
engaging in research to test interventions; however, scientific advances
did help to improve nursing practice as nurses altered interventions
based on knowledge generated by scientists and physicians. During this
time, a nurse, Clara Maass, gave her life as a volunteer subject in the
research of yellow fever (Sitzman & Judd, 2014b).
A significant report, known simply as the Goldmark Report, Nursing
and Nursing Education in the United States, was released in 1922 and
advocated for the establishment of university schools of nursing to train
nursing leaders. The report, initiated by Nutting in 1918, was an
exhaustive and comprehensive investigation into the state of nursing
education and training resulting in a 500-page document. Josephine
Goldmark, social worker and author of the pioneering research of nursing
preparation in the United States, stated,
From our field study of the nurse in public health nursing, in
private duty, and as instructor and supervisor in hospitals, it is
clear that there is need of a basic undergraduate training for all
nurses alike, which should lead to a nursing diploma.
(Goldmark, 1923, p. 35)
The first university school of nursing was developed at the University
of Minnesota in 1909. Although the new nurse training school was under
the college of medicine and offered only a 3-year diploma, the Minnesota
program was nevertheless a significant leap forward in nursing
education. Nursing for the Future, or the Brown Report, authored by
Esther Lucille Brown in 1948 and sponsored by the Russell Sage
Foundation, was critical of the quality and structure of nursing schools in
the United States. The Brown Report became the catalyst for the
implementation of educational nursing program accreditation through the
National League for Nursing (Brown, 1936, 1948). As a result of the
post–World War II nursing shortage, an associate degree in nursing was
established by Dr. Mildred Montag in 1952 as a 2-year program for
registered nurses (Montag, 1959). In 1950, nursing became the first
profession for which the same licensure exam, the State Board Test Pool,
was used throughout the nation to license registered nurses. This
increased mobility for the registered nurse resulted in a significant
advantage for the relatively new profession of nursing (“State Board Test
Pool Examination,” 1952).
The Evolution of Nursing in the
United States: The First Century of
Professional Nursing
The Profession of Nursing Is Born in the United
Early nurse leaders of the 20th century included Isabel Hampton Robb,
who in 1896 founded the Nurses’ Associated Alumnae, which in 1911
officially became known as the American Nurses Association (ANA);
and Lavinia Lloyd Dock, who became a militant suffragist linking
women’s roles as nurses to the emerging women’s movement in the
United States. Mary Adelaide Nutting, Lavinia L. Dock, Sophia Palmer,
and Mary E. Davis were instrumental in developing the first nursing
journal, the American Journal of Nursing (AJN) in October 1900.
Through the ANA and the AJN, nurses then had a professional
organization and a national journal with which to communicate with one
another (Kalisch & Kalisch, 1986).
State licensure of trained nurses began in 1903 with the enactment of
North Carolina’s licensure law for nursing. Shortly thereafter, New Jersey,
New York, and Virginia passed similar licensure laws for nursing. Over
the next several years, professional nursing was well on its way to public
recognition of practice and educational standards as state after state
passed similar legislation.
Margaret Sanger worked as a nurse on the Lower East Side of New
York City in 1912 with immigrant families. She was astonished to find
widespread ignorance among these families about conception,
pregnancy, and childbirth. After a horrifying experience with the death of
a woman from a failed self-induced abortion, Sanger devoted her life to
teaching women about birth control. A staunch activist in the early family
planning movement, Sanger is credited with founding Planned
Parenthood of America (Sanger, 1928).
By 1917, the emerging new profession saw two significant events
that propelled the need for additional trained nurses in the United States:
World War I and the influenza epidemic. Nightingale and the devastation
of the Civil War had well established the need for nursing care in wartime.
Mary Adelaide Nutting, now professor of nursing and health at Columbia
University, chaired the newly established Committee on Nursing in
response to the need for nurses as the United States entered the war in
Europe. Nurses in the United States realized early that World War I was
unlike previous wars. It was a global conflict that involved coalitions of
nations against nations and vast amounts of supplies and demanded the
organization of all the nations’ resources for military purposes (Kalisch &
Kalisch, 1986). Along with Lillian Wald and Jane A. Delano, director of
nursing in the American Red Cross, Nutting initiated a national publicity
campaign to recruit young women to enter nurses’ training. The Army
School of Nursing, headed by Annie Goodrich as dean, and the Vassar
Training Camp for Nurses prepared nurses for the war as well as home
nursing and hygiene nursing through the Red Cross (Dock & Stewart,
1931). The committee estimated that there were at most about 200,000
active “nurses” in the United States, both trained and untrained, which
was inadequate for the military effort abroad (Kalisch & Kalisch, 1986).
At home, the influenza epidemic of 1917 to 1919 led to increased
public awareness of the need for public health nursing and public
education about hygiene and disease prevention. The successful
campaign to attract nursing students focused heavily on patriotism, which
ushered in the new era for nursing as a profession. By 1918, nursing
school enrollments were up by 25%. In 1920, Congress passed a bill that
provided nurses with military rank (Dock & Stewart, 1931). Following
close behind, the passage of the Nineteenth Amendment to the U.S.
Constitution granted women the right to vote.
Lillian Wald, Public Health Nursing, and
Community Activism
The pattern for health visiting and district nursing practice outside the
hospital was similar in the United States to that in England (Roberts,
1954). American cities were besieged by overcrowding and epidemics
after the Civil War. The need for trained nurses evolved as in England,
and schools throughout the United States developed along the
Nightingale model. Visiting nurses were first sent to philanthropic
organizations in New York City (1877), Boston (1886), Buffalo (1885),
and Philadelphia (1886) to care for the sick at home. By the end of the
century, most large cities had some form of visiting nursing program, and
some headway was being made even in smaller towns (Heinrich, 1983).
Industrial or occupational healt…
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