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1 Chapter 1 The Evolution of Professional Nursing
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Chapter 1The Evolution of
Professional Nursing
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• “We need to realize and to affirm anew that nursing is one of the most difficult arts. Compassion may provide the motive, but knowledge is our only working power. Perhaps, too, we need to remember that growth in our work must be preceded by ideas, and that any conditions which suppress thought, must retard growth. Surely we will not be satisfied in perpetuating methods and traditions. Surely we shall wish to be more and more occupied with creating them.”
» M. Adelaide Nutting, 1925
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Prehistoric Period
• Health beliefs– All natural phenomena, including illnesses, were
the work of the gods
• Health practices– Engaged in acts intended to deter evil gods and
demons
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Early Civilization
• Egypt– Health beliefs and practices• Valued personal health; preventive measures taken
to appease the gods• Developed specific laws on cleanliness, food use
and preservation, drinking, exercise, sexual relations, and a pharmacopoeia with more than 700 natural remedies
– Nursing• Little information available• Women were hired by privileged families to care
for the sick and to assist with childbirth; Shiphrah and Puah were midwives who saved the baby Moses
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Early Civilization
• Palestine– Health beliefs and practices• Developed the Mosaic Code, one of the first
organized methods of disease control and prevention
– Nursing• Little information available• Nursing and medical care were provided in the home
by male Hebrew priests and women (usually widows or maidens) who focused on both physical and spiritual healing and comfort
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Early Civilization
• Greece– Health beliefs
• Believed that the gods and goddesses of Greek mythology controlled health and illness
• Temples built to honor Asclepius, the god of medicine, were designated to care for sick
– Medical Science• Asclepius carried a staff intertwined with serpents, representing
wisdom and immortality; staff was the model for medical caduceus
• Hippocrates considered the “father of medicine”• Hippocrates was the first to attribute disease to natural causes
rather than supernatural causes and curses of the gods• Scientific approach; patient-centered approach
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Early Civilization
• India– Health beliefs and practices
• Vedas (2000-1200 BC), sacred Hindu books, were the source of information about health practices
• Focused on the use of magic, charms, herbs, and spices to cure disease and remove demons
– Medical science• Developed procedures to perform major and minor surgical
operations• Recorded extensive information about childhood diseases,
prenatal care, and conditions of the urinary and nervous systems
– Nursing• Hindu physicians performed major and minor surgeries
including limb amputations, cesarean deliveries, and suturing wounds
• Women did not work outside the home
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• China
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Early Civilization
• China– Health beliefs
• Teachings of Confucius (531-479 BC) had a powerful impact on health practices
• Believed in the yin and yang philosophy; an imbalance between the two would result in ill health
– Health practices• Used treatments to promote health and harmony
including acupuncture, hydrotherapy, massage, and exercise
• Used drug therapy to manage disease conditions and recorded over 1000 drugs
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Early Civilization
• Rome– Adapted health and medical practices from the
countries conquered and physicians enslaved (27 BC-476 AD)
– Established the first military hospital in Europe in Rome
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The Renaissance and the Reformation Period
• Major advancements in medicine: pharmacology, chemistry, and medical knowledge
• “Dark ages” of nursing– Religious orders became almost extinct as a result of
dissension between Roman Catholic Christians and Protestant sects
– Nursing no longer appealed to women of high social status; hospital care was regulated to common women, prisoners, thieves and drunks
– Nursing became an undesirable job with poor pay, long hours, and strenuous work that was considered menial
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The Renaissance and the Reformation Period
• Social conditions– Famine, plague, filth, and crime ravaged Europe– Nursing orders were established out of great
concern for social welfare• Sisters of Charity - recruited young women for nurse
training, developed educational programs, and cared for abandoned children• St. Vincent de Paul - established the Hospital for the
Foundling to care for orphaned and abandoned children
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The Colonial American Period
• Mexico– First colonists in Mexico were members of
Catholic religious orders– Hospital of the Immaculate - first hospital in
North America, built in 1524 in Mexico City; first medical school built at the University of Mexico
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• Colonial North America
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The Colonial American Period
• Colonial America– Health care was sadly deficient; life expectancy
was low, plagues such as yellow fever and smallpox were a constant threat
– Physicians were poorly trained and used crude methods of treatment such as bleeding and purgatives
– Through the efforts of Benjamin Franklin, Pennsylvania Hospital was the first hospital built in the United States in 1751
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Florence Nightingale
• Early nursing career– Family opposed her interest in nursing at first,
then she was permitted to pursue nurse training– 1851 - Attended a 3-month nurse-training
program at the Institute of Deaconesses at Kaiserwerth, Germany
– 1854 - Began training at the Harley Street Nursing Home; served as the superintendent of nurses at King’s College Hospital in London
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Florence Nightingale
• Crimean War– 1854 - Accepted an assignment to lead a group of 38
nurses who were sisters and nuns from various Catholic and Anglican orders to the Crimea to work at the Barracks Hospital in Scutari
– Despite deplorable conditions, the army doctors at first refused her assistance
– Eventually the doctors, in desperation, called for her help
– Purchased medical supplies, food, and linen; set up a kitchen; instituted laundry services; initiated social services; spent up to 20 hours each day providing nursing care
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• The Lady With the Lamp
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Florence Nightingale
• Major accomplishments– Demonstrated the value of aseptic techniques and
infection control procedures– Honored for her contributions to nursing research– Demonstrated the value of political activism to affect
health care reform– Established the first nursing school in England– Honored as the founder of professional nursing services,
initiated social services, spent up to 20 hours each day providing nursing care
– Introduced principles of asepsis and infection control, a system for transcribing doctor’s orders, and a system to maintain patient records
– Kept careful statistics - documented a decrease in the death rate of soldiers from 42% to 2% as a result of health care reforms that emphasized sanitary conditions
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Mary Seacole
• Jamaican nurse who played a major role in the Crimean War– Denied the opportunity to join Nightingale’s nursing
brigade because she was black– Opened a lodging house with her own money to care
for sick and wounded soldiers– Contributed to the control of the cholera epidemic
with extensive knowledge in tropical medicine
• Honored by the Jamaican government and the British Commonwealth with a medal for saving the lives of countless sick and wounded soldiers
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• Mary Seacole
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Nursing in the United States
• The Civil War Period– The Civil War or the War between the States(1861-
1865)– No army nurses and no organized medical corps
when the war began– Dorothea Dix - Appointed to organize military
hospitals, provide trained nurses, and disperse supplies; she received no official status and no salary for this position
– 6 million people hospitalized during the war - 425,000 for war casualties; vast majority for disease epidemics
– 181 African-American nurses, both men and women, served from 1863 to 1864. Caucasian nurses made $12.00 per month; African-American nurses made $10.00
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• Nurses Pictured With Civil War Soldiers
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• Field Hospitals with MDs and Nurses
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Nursing in the United States
– African-American nurses made important contributions• Harriet Tubman cared for wounded soldiers and conducted an
“underground railroad” to lead slaves to freedom• Sojourner Truth, known for her abolitionist efforts as well as her nursing
efforts, was an advocate of clean and sanitary conditions so patients could heal
• Susie King Taylor, though hired in the laundry, worked full-time as a nurse on the battlefront with no pay or pension; not considered an official Union Army nurse
– Volunteer nurses who made important contributions• Clara Barton operated a war relief program; credited with founding the
American Red Cross• Louisa May Alcott authored detailed accounts of the experiences
encountered by nurses during the war for a newspaper publication entitled “Hospital Sketches”
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Nursing in the United States
– Number of nurse training schools increased after the war• Offered little classroom education• On-the-job training occurred in the hospital wards• Students were used as supplemental hospital staff
– 1890 - Establishment of African-American hospitals and nursing schools gained momentum• John D. Rockefeller established the first school of
nursing for African-American women at the Atlanta Baptist Seminary, now known as Spelman College
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Nursing in the United States
• 1900 to World War I– Advances in the nursing profession• By 1910 most states passed legislation requiring nurse
registration before entering practice• Required entry level for nursing students was
upgraded to high school graduate• Nurse training programs improved to include a more
comprehensive course of study
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Nursing in the United States
– Lillian Wald developed a viable practice for public health nursing (The Henry Street Settlement) located in the Lower East Side of New York City• Purpose was to provide well-baby care, health education,
disease prevention, and treatment of minor illnesses• Nursing practice at the Henry Street Settlement formed the
basis for public health nursing in the United States– Developed the first nursing service for occupational health
(Metropolitan Life Insurance Company)• Prevention of disease in workers to promote productivity• Sliding-scale fee
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Lillian Wald
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Nursing in the United States
• World War I and the 1920s– Advances in medical care and public health• Improved hospital care and surgical techniques• Discoveries in pharmacology - insulin and the precursor to
penicillin• Environmental conditions improved; serious epidemics of
the previous century became nonexistent
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Nursing in the United States
– Advances in nursing• Nurses served honorably during WWI• Nurse anesthetists made their first appearance as part of
front-line surgical teams• U.S. Public Health Service sought the assistance of a nurse to
establish nursing services at military outposts• American Red Cross, founded by Clara Barton in 1882,
became more active in urban settings as well as rural communities
• Mary Breckenridge established the Frontier Nursing Service (FNS) in 1925 in rural Kentucky to assist disadvantaged women and children; documented the impact of nursing services on improving the health of communities; well known for midwifery services
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Nursing in the United States
– Legislation• Sheppard-Towner Act - first legislation to assist special
populations and provided public health nurses with resources to promote health and well-being of women, infants, and children
• The Great Depression (1930-1940)– Social issues
• American economy disintegrated with over 6 million people unemployed
• Nurses also were forced to join the ranks of the unemployed
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Nursing in the United States
– Legislation• “New Deal” enacted to rescue the country and
provided for medical care and other services for the large numbers of indigent people• Social Security Act of 1935 affected health care and
provided avenues for public health nursing
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Nursing in the United States
• Main purposes of the Social Security Act– National age-old insurance system– Federal grants to states for maternal and child welfare services– Vocational rehabilitation services for the handicapped– Medical care for crippled children and blind people strengthen
public health services– A Federal-state unemployment system
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Nursing in the United States
• World War II– Legislation• Programs enacted to expand nursing education and
increase the number of nurses in all military branches
– Advances in nursing• Nursing became an essential part of the military
advance• Nurses recognized as an integral part of the military
and attained officer rank
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Nursing in the United States
• Post World War II (1945-1950)– Social issues
• Unemployment dropped to all-time lows• Women were encouraged to return to childbearing and
marriage rather than continue employment outside the home
– Advances in nursing• Demonstrated value to the armed services during the
Korean War• Emerged as a true profession with minimum national
standards for nursing education established
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Nursing in the United States
• By 1950 all states had adopted the State Board Test Pool• Number of nursing baccalaureate programs grew• Associate-degree programs developed in community and junior
colleges– Legislation– Nurse Training Act of 1943: first instance of federal
funding to support nurse training• Hill-Burton Act: provided funding to construct hospitals; created
a hospital construction boom that increased the demand for professional nurses
• African-American nurses were barred from membership in the ANA due to segregation laws; all barriers were dropped in the early 1960s
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Nursing in the United States
• Nursing in the 1960s– Legislation had a major and lasting impact on nursing
and health care• Community Mental Health Centers Act of 1963• Medicaid, Title XIX of the Social Security Act, 1965• Medicare, Title XVIII of the Social Security Act, 1965
– Impact of Medicare reimbursement on nursing• Hospital occupancy increased resulting in an increased need
for hospital nurses• Nursing embraced the hospital setting as the usual practice
site• Home health movement was initiated
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Nursing in the United States
• Nursing in the 1970s– Influenced by the women’s movement, nurses
demanded fairer wages and better working conditions– Hospitals continued to be the focus of nursing
education and practice– Nurses were instrumental in developing community
programs including hospice programs, birthing centers, and adult day care centers
– Nurse practitioners began to be recognized as viable, cost-effective providers of comprehensive health services
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Nursing in the United States
• Nursing in the 1980s– Types of patients needing health care changed
• Increasing numbers of homeless and indigent• Emergence of acquired immune deficiency syndrome (AIDS)
– Spiraling health care costs became an issue• Diagnosis-related group (DRGs) system for reimbursement was
instituted• Hospitals were forced to increase efficiencies and reduce
patients’ length of stay• Case management emerged as a new area of nursing
specialization• Outpatient and ambulatory services grew• Enrollment in manage care plans and health maintenance
organizations grew• Advanced nurse practitioners increased in popularity
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Nursing in the United States
• Nursing practice began to move from the hospital setting to community settings
• Disease prevention and health promotion gained importance
– Medical care continued to advance• Organ transplantation• Resuscitation and support of premature infants• Medical specialties flourished• Medical technology flourished
– Inadequate funding for public health programs became an issue
– Scholars suggested that nursing research needed to be focused on substantive information to guide practice
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Nursing in the United States
• Nursing in the 1990s– Growing concerns about the health of the nation
• Healthy People 2000 initiative• Increasing focus on health promotion and disease prevention
activities– Influence of the AIDS epidemic
• New procedures for infection control were required• Universal Precautions were mandated
– Exposure to hazardous materials• Workplace chemicals and radioactive substances created health
risks• Employee training was instituted across all industries
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Nursing in the United States
– Managed care movement• Focus moved from acute care to prevention and primary care• Emphasis on outpatient, ambulatory, and home services• Massive downsizing of hospital nursing staff and increase in
unlicensed assistive personnel• Increasing demand for community health nurses and advanced
practice nurses
– Changing nursing requirements for the 1990s and beyond• Focus on health risk assessments based on family and
environmental issues• Focus on health promotion and disease prevention• Promote counseling and health education
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Nursing in the United States
• Nursing in the 21st century– Challenges facing professional nurses
• Changing duties and responsibilities• Nursing shortage• Public concern over patient safety and quality of care
– Core competencies required by professional nurses• Critical thinking• Communication• Assessment• Leadership• Technical Skills
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Nursing in the United States
– Knowledge required by professional nurses• Health promotion/disease prevention• Information technology• Health systems• Public policy
– Consumer issues in health care• Access• Quality• Cost• Accountability
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Nursing in the United States
– Changes in society• Aging population• Intercultural population• Consumer health value• Need for a well trained work force• AACN (2000) reports 7.4% faculty vacancy rate; average full time
faculty over 50 years of age; average age of doctorally prepared faculty 55.9
• Nurse Reinvestment Act signed into bill August 2002 to provide funds for nursing education, recruitment, and retention
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Nursing in the United States
– Opportunities for professional nurses (2.6 million members)• Evidence-based practice• United efforts to shape health care• United efforts to address the nursing shortage
