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Library of Congress Cataloging-in-Publication Data
Role development in professional nursing practice / [edited by] Kathleen Masters. – Fourth edition.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-284-07832-9 (pbk.)
I. Masters, Kathleen, editor.
[DNLM: 1. Nursing–standards. 2. Nursing–trends. 3. Nurse's Role. 4. Philosophy, Nursing.
5. Professional Practice. WY 16]
RT82
610.73–dc23
2015022040
6048
Printed in the United States of America
19 18 17 16 15
10 9 8 7 6 5 4 3 2 1
Dedication
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.
Contents
Preface
Contributors
xv
xix
UNIT I: FOUNDATIONS OF PROFESSIONAL NURSING PRACTICE
1
1
3
2
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 Kingdom
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
Conclusion
References
3
6
8
9
10
13
22
23
25
27
28
39
40
41
43
Frameworks for Professional Nursing Practice
49
Kathleen Masters
Overview of Selected Nursing Theories
Nurse of the Future: Nursing Core Competencies
Overview of Selected Non-Nursing Theories
Relationship of Theory to Professional Nursing Practice
Conclusion
References
51
84
87
88
89
92
X
3
4
5
6
CONTENTS
Philosophy of Nursing
99
Mary W. Stewart
Philosophy
Early Philosophy
Paradigms
Beliefs
Values
Developing a Personal Philosophy of Nursing
Conclusion
References
100
101
103
104
106
110
112
114
Foundations of Ethical Nursing Practice
117
Janie B. Butts and Karen L. Rich
Ethics
Ethical Theories and Approaches
Professional Ethics and Codes
Ethical Analysis and Decision Making in Nursing
Conclusion
References
118
121
126
129
134
135
Social Context of Professional Nursing
137
Mary W. Stewart, Katherine Elizabeth Nugent, Rowena W. Elliott, 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
Conclusion
References
138
139
143
146
148
151
156
166
166
Education and Socialization to the Professional Nursing Role
173
Kathleen Masters and Melanie Gilmore
Professional Nursing Roles and Values
The Socialization (or Formation) Process
Facilitating the Transition to Professional Practice
Conclusion
References
174
176
180
181
183
CONTENTS
7
Advancing and Managing Your Professional Nursing Career
UNIT II: PROFESSIONAL NURSING PRACTICE AND THE
MANAGEMENT OF PATIENT CARE
Patient Safety and Professional Nursing Practice
185
187
190
193
194
197
198
199
201
202
205
207
Jill Rushing and Kathleen Masters
Patient Safety
Critical Thinking, Clinical Judgment, and Clinical Reasoning in Nursing Practice
Conclusion
References
9
185
Mary Louise Coyne and Cynthia Chatham
Nursing: A Job or a Career?
Trends That Impact Nursing Career Decisions
Showcasing Your Professional Self
Mentoring
Education and Lifelong Learning
Professional Engagement
Expectations for Your Performance
Taking Care of Self
Conclusion
References
8
XI
Quality Improvement and Professional Nursing Practice
207
216
231
233
237
Kathleen Masters
Healthcare Quality
Measurement of Quality
The Role of the Nurse in Quality Improvement
Conclusion
References
237
240
249
251
253
Professional Nursing Practice
10 Evidence-Based
Kathleen Masters
255
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
Conclusion
References
255
257
258
259
262
265
268
270
XII
11
CONTENTS
Patient-Centered Care and Professional Nursing Practice
273
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
Conclusion
References
in Professional Nursing Practice
12 Informatics
Kathleen Masters and Cathy K. Hughes
Informatics: What Is It?
The Impact of Legislation on Health Informatics
Nursing Informatics Competencies
Basic Computer Competencies
Information Literacy
Information Management
Current and Future Trends
Conclusion
References
and Collaboration in Professional Nursing Practice
13 Teamwork
Sharon Vincent and Kathleen Masters
Healthcare Delivery System
Nursing Models of Patient Care
Roles of the Professional Nurse
Interprofessional Teams and Healthcare Quality and Safety
Interprofessional Collaborative Practice Domains
Interprofessional Team Performance and Communication
Conclusion
References
Issues in Professional Nursing Practice
14 Ethical
Janie B. Butts and Karen L. Rich
Relationships in Professional Practice
Moral Rights and Autonomy
Social Justice
Death and End-of-Life Care
Conclusion
References
274
276
278
293
294
295
301
301
302
304
307
311
314
319
320
321
325
326
328
332
335
338
339
343
344
347
348
353
355
360
370
371
CONTENTS
and the Professional Nurse
15 Law
Kathleen Driscoll, Kathleen Masters, and Evadna Lyons
XIII
375
The Sources of Law
Classification and Enforcement of the Law
Nursing Scope and Standards
Malpractice and Negligence
Nursing Licensure
Professional Accountability
Conclusion
References
376
378
381
384
387
392
400
402
Appendix A Standards of Professional Nursing Practice
Appendix B Provisions of Code of Ethics for Nurses
Appendix C The ICN Code of Ethics for Nurses
Glossary
Index
405
407
409
411
429
PrefaCe
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 a professional nurse.
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 fourth edition, the chapter content is conceptualized,
when applicable, around nursing competencies, professional standards, and recommendations from national groups, such as Institute of Medicine reports.
The chapters included in Unit I provide the student nurse with a basic foundation in areas such as nursing history, theory, philosophy, ethics, socialization into
the nursing role, and the social context of nursing. All chapters have been updated,
and several chapters in Unit I have been expanded in this edition. Revisions to
the chapter on nursing history include the addition of contributions of prominent
nurses and achievements related to nursing in the United Kingdom, Canada, and
Australia. The theory chapter now includes additional nursing theorists as well
as a brief overview of several non-nursing theories frequently used in nursing
research and practice. The social context of nursing chapter now incorporates
not only societal trends, but also trends in nursing practice and education. The
chapter related to professional career development in nursing has been completely
rewritten for this edition.
The chapters in Unit II are more directly related to patient care management.
In the fourth edition, Unit II chapter topics are presented in the context of quality
and safety. Chapter topics include the role of the nurse in patient safety, the role
of the nurse in quality improvement, evidence-based nursing practice, the role of
the nurse in patient-centered care, informatics in nursing practice, the role of the
nurse related to teamwork and collaboration, ethical issues in nursing practice,
and the law as it relates to patient care and nursing. Most Unit II chapters have
undergone major revisions with a refocus of the content on recommended nursing
and healthcare competencies.
PrEfaCE
The fourth edition continues to incorporate the Nurse of the Future:
Nursing Core Competencies throughout each chapter. The Nurse of the
Future: Nursing Core Competencies “emanate from the foundation of nursing
knowledge” (Massachusetts Department of Higher Education, 2010, p. 4) and
are based on the American Association of Colleges of Nursing’s 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 (KSA)
BOARD OF HIGHER EDUCATION NURSING INITIATIVE
NURSING CORE COMPETENCIES
im Qu
pr alit
ov y
em
en
t
Safety
s
Leade
rship
Nursing
knowledge
d
ication
Commun
ali
sio
n
PR
A
CT
IC
E
ofe
s
Team
w
colla ork and
bora
tion
ed
as
-b e
em tic
st ac
Sy pr
sm
re
nte
-ce
t
n
ie are
Pat
c
Pr
d
e
bas
ce- e
n
e
tic
id
Ev prac
ENVIRONMENT
TICE
AC
PR
ic
at
rm
fo
In
PR
AC
TI
CE
The science and practice of nursing
PRACTICE ENVIRO
NM
EN
T
XVI
K-Knowledge
S-Skills
A-Attitudes
Source: Modified from Massachusetts Department of Higher Education. (2010). Nurse of the
future: Nursing core competencies (p. 5). Retrieved from http://www.mass.edu/currentinit
/documents/NursingCoreCompetencies.pdf
PrEfaCE
reflecting cognitive, psychomotor, and affective learning domains are specified
for each competency. The KSA 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, 2010, p. 4).
The Nurse of the Future: Nursing Core Competencies graphic illustrates
through the use of broken lines the reciprocal and continuous relationship
between each of the competencies and nursing knowledge, that the competencies can overlap and are not mutually exclusive, and that all competencies are
of equal importance. In addition, nursing knowledge is placed as the core in
the graphic to illustrate that nursing knowledge reflects the overarching art
and science of professional nursing practice (Massachusetts Department of
Higher Education, 2010, p. 4).
This new edition has competency boxes throughout the chapters that
link examples of the KSA appropriate to the chapter content to Nurse of
the Future: Nursing Core Competencies required of entry-level professional
nurses. The competency model in its entirety is available online at www.mass
.edu/currentinit/documents/NursingCoreCompetencies.pdf.
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 www.mass.edu/nahi/documents/Toolkit-First%20Edition
-May%202014-r1.pdf and teaching activities related to nursing competencies
available on the QSEN website at www.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
References
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. (2010). Nurse of the future: Nursing
core competencies. Retrieved from http://www.mass.edu/currentinit/documents
/NursingCoreCompetencies.pdf
XVII
Contributors
Janie B. Butts, PhD, RN
University of Southern Mississippi
College of Nursing
Hattiesburg, Mississippi
Cynthia Chatham, DSN, RN
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
Rowena W. Elliott, PhD, RN, FAAN
University of Southern Mississippi
College of Nursing
Hattiesburg, Mississippi
Melanie Gilmore, PhD, RN
University of Southern Mississippi
College of Nursing
Hattiesburg, Mississippi
XX
CONTribuTOrS
Cathy K. Hughes, DNP, RN
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
Evadna Lyons, PhD, RN
East Central Community College
School of Nursing
Decatur, Mississippi
Katherine Elizabeth Nugent, PhD, RN
Dean, College of Nursing
University of Southern Mississippi
Hattiesburg, Mississippi
Karen L. Rich, PhD, RN
University of Southern Mississippi
College of Nursing
Long Beach, Mississippi
Jill Rushing, MSN, RN
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
UNIT I
Foundations of Professional
Nursing Practice
© robertiez/iStock/Getty Images Plus/Getty
© robertiez/iStock/Getty Images Plus/Getty
CHAPTER 1
A History of Health Care
and Nursing
Karen Saucier Lundy and Kathleen Masters
Learning Objectives
After completing this chapter, the student should be able to:
1. Identify social, political, and economic influences on the development of professional
nursing practice.
2. Identify important leaders and events that have
significantly affected the development of professional nursing practice.
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 pharmacological 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
Note: This chapter is adapted from Lundy, K. S., & Bender, K. W. (2009). History of community
health and public health nursing. In K. S. Lundy & S. Janes (Eds.), Community health nursing:
Caring for the public’s health (2nd ed., 62–99). Sudbury, MA: Jones and Bartlett.
© robertiez/iStock/Getty Images Plus/Getty
Key Terms and Concepts
»
»
»
»
»
»
»
»
»
»
»
»
»
»
»
»
»
»
»
»
»
Greek era
Roman era
Deaconesses
Florence Nightingale
Reformation
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
3
4
Key Terms and Concepts
» 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)
ChaPTer 1 A History of Health Care and Nursing
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 he or she also
was branded by all of 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, Hygeia, 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 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
Classical Era
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
reoccur 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 cosmological 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 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, while internal ailments continued to be linked to spiritual
maladies (Bullough & Bullough, 1978).
5
6
ChaPTer 1 A History of Health Care and Nursing
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 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
Middle Ages
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—GrecoRoman, Germanic, and Christian—into one (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,
while 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 society.
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 Lyons, France, founded about
542 by Childebert I, king of France. 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
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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.
The Dark Period of Nursing
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 poverty-stricken 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,
low-status 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 crimes such 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.
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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).
In the New World, 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
The Industrial Revolution
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 the 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, rather than the other way
around. Such relocations meant giving up not only farming, but 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 reformers such 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
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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, the mentally ill, 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 impact.
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
And Then There Was Nightingale . . .
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 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.
Florence Nightingale was the second child born on May 12, 1820, to the
wealthy English family of William and Frances Nightingale in her namesake
city, Florence, Italy. 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).
For Nightingale, her entire life would be haunted by this conflict between
the opulent life of gaiety that she enjoyed and the plight and 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
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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; throughout her writings,
she poured out her detestation of the life of an idle woman (Nightingale,
1979, p. 5). 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).
And Then There Was Nightingale . . .
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 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 Herbert 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 took
the challenge from Sir Herbert 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). The nurses were
faced with 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 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
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with reducing that rate to 2% within 6 months of her arrival at Scutari. She
did this through careful, scientific epidemiological 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. Through her resilience
and 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
And Then There Was Nightingale . . .
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 of not only the soldiers but for
society in general (D’Antonio, 2002).
Returning Home a Heroine: The Political Reformer
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, 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, nevermore the 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 historical foundation of
the field and distinguishes us from other scientific disciplines, such as medicine.
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 brotherin-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
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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.
And Then There Was Nightingale . . .
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. She believed nursing involved “divergencies too great for a single standard to be applied” (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, “SickNursing 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. She wrote in 1891 that “There are more people to pick us up and help
us stand on our own two feet” (Attewell, 1996). 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
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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 “Hospitals
are but an intermediate stage of civilization. The ultimate aim is to nurse the
sick poor in their own homes (1893)” (Attewell, 1996). She also wrote in
regard to visiting families at home: “We must not talk to them or at them but
with them (1894)” (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
Scores have 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
And Then There Was Nightingale . . .
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 post-traumatic 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). She
said, “There is no such thing as amateur nursing.”
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. She stated, “Never think that you have
done anything effectual in nursing in London, till you nurse, not only the
sick poor in workhouses, but those at home.”
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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
of 1907, Nightingale was honored with the Order of Merit by King Edward
VII, the first time 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 Kingdom
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
The Development of Professional
Nursing in Canada
Marie Lollet 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
duties such 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
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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, 2009).
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 hospital-based 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 healthy 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
The Development of Professional Nursing in Australia
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 provides funding for nurses to
further their education and for research related to nursing care (CNF, 2014).
The Canadian Association of Schools of Nursing is the organization that
promotes national nursing education standards and is the national accrediting
agency for university nursing programs in Canada (n.d.).
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, 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 (The 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,
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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 Government, 2009). 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. It is
from this organization that 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, 2014).
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
Early Nursing Education and Organization in the United States
27
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 Australian 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
CrITICaL ThINKING QUeSTIONS V
stable, subservient, white female workforce because student
nurses served as the primary nursing staff for these early
Some nurses believe that Florence Nightingale
hospitals. Minority nurses found limited educational opporholds nursing back and represents the
tunities in this climate. The first African American nursing
negative and backward elements of nursing.
school graduate in the United States was Mary P. Mahoney.
This view cites as evidence that Nightingale
supported the subordination of nurses to
She graduated from the New England Hospital for Women
physicians, opposed registration of nurses,
and Children in 1879 (Sitzman & Judd, 2014b).
and did not see mental health nurses as part
Nursing education in the newly formed schools was
of the profession. Wheeler (1999) has gone so
based on accepted practices that had not been validated by
far as to say, “The nursing profession needs
research. During this time in history, nurses primarily relied
to exorcise the myth of Nightingale, not
on tradition to guide practice, rather than engaging in research
necessarily because she was a bad person, but
to test interventions; however, scientific advances did help
because the impact of her legacy has held the
to improve nursing practice as nurses altered interventions
profession back too long.” After reading this
based on knowledge generated by scientists and physicians.
chapter, what do you think? Is Nightingale
During this time, a nurse, Clara Maass, gave her life as a
relevant in the 21st century to the nursing
volunteer subject in the research of yellow fever (Sitzman &
profession? Why or why not?V
Judd, 2014b).
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ChaPTer 1 A History of Health Care and Nursing
A significant report, known simply as the Goldmark Report, Nursing and
Nursing Education in the United States, was released in 1922 and advocated
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 States
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.
The Evolution of Nursing 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 each other (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 selfinduced abortion, Sanger devoted her life to teaching women about birth
control. A staunch activist in th...
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