CHAPTER ONE: HISTORY OF NURSINGNursing is a constantly evolving profession. If nurses are to survive the ebb and flow created by politics, social structures, the economy and technology, they must evolve as well. For a nurse to limit his or her vision of a nurse’s role is to cut oneself off from the many opportunities created by the changes that occur in the whole world picture. The scope of nursing is immense, and as anyone who has been in the profession greater than ten years can attest to, the changes are constant. By a study of the history of nursing one can perhaps gain some comfort from seeing that it has been a profession in constant flux for hundreds of years and that it will more than likely continue to do so. Though change creates feelings of stress and anxiety, the outcome is generally one of greater advancement of the profession, as well as increased opportunities for nurses. Hospital nursing has been the calling for most nurses in the last half century. But it has not always been so. Now, as hospital opportunities wane and other areas of health care beckon, it is interesting to note where we’ve come from. We tend to think of Florence Nightingale as the mother of nursing, yet certainly individuals who cared for the sick existed long before she intervened. In early civilizations the sick were cared for at home by a female family member. It appears the first hospitals came into being around 750 B.C. and can be credited to the genius of Roman progress, while they pioneered in areas of sanitation including aqueducts, sewage systems and baths. These hospitals were detached buildings where valuable slaves from Roman estates were cared for. In addition, convalescent camps were created to treat sick and injured soldiers (Kelly 1991). The care of the sick outside the home would have been delegated to men at this time, since the status of women was so low. They were not allowed any kind of education or involvement with the community. Women were completely confined to their homes and family duties (Kelly 1991). In the first five centuries of Christianity, care of the sick was turned over to the church. Deacons and sometimes deaconesses were responsible for this care. Even so, not all deaconesses were ordained by the church fathers, who resisted giving too much recognition or freedom to women. Widows over 60 years of age, and sometimes virgins, were allowed to give care to the sick. Monastic orders in the Middle Ages, A.D. 500 to 1500, were responsible for care of the sick. These orders were composed of monks and nuns and were more concerned with the religious welfare of patients than physical ailments. Nursing orders proliferated during this time of the Crusades, the military expeditions undertaken in the eleventh, twelfth and thirteenth centuries by Christians to recover the Holy Land from the Moslems. From all over Europe men, women and children marched to do battle in Jerusalem. Few were prepared for the arduous mission, thus hospitals arose as need increased. The nursing orders had names such as; The Order of St. Benedict, The Kings Hospitallers and The Hospital Brothers of St. Anthony, and performed specifically dedicated functions, such as caring for only lepers, or those wounded on the battlefield, or those afflicted with an ailment called St. Anthony’s Fire. In many cases, men comprised much of the “nursing” staff because attitudes toward women often limited them to the care of women only. By the end of the Middle Ages many hospitals existed all over Europe, particularly in the larger cities such as Paris and Rome and in England. Nursing care at this time was quite basic, limited to bathing, feeding, giving medicines, making beds and assisting patients with necessary activities. The Renaissance in the fourteenth century saw a separation of hospital and church. Huge strides were made in the area of science during this period and care of the sick became much more skilled. The Reformation of the sixteenth century again brought about changes in care of the sick. This was a religious movement which led to the formation of Protestant churches as individuals revolted against the supremacy of the pope and the Catholic Church. Many monasteries closed, which meant that those who had been largely responsible for care of the sick disbanded, creating a huge void in health care. From this point on, male nurses almost totally disappeared from the scene and nursing became what we are accustomed to today, primarily female dominated. Those women hired to perform nursing duties were deaconesses and other elderly women. Young women were still to devote their lives to family. By the end of the eighteenth century, nursing was becoming recognized as an important service. Diderot included a comment about nursing in his Encyclopedia, a formidable book of knowledge for its time. Though not a particularly dignified or flattering description of nursing, the book, nonetheless, acknowledge its importance. He is quoted as saying that nursing “is as important for humanity as its functions are low and repugnant” (Kelly 1991). It is doubtful this commentary would draw many to nursing schools in this day and age. The first nursing textbook was published in Vienna in the early eighteenth century, another indication of the recognition of nursing as a vocation needful of specific information, skills and guidelines. The Industrialization of Europe during the mid-nineteenth century, the Victorian Era, again saw a change in the type of individual who was to nurse the sick. Graciousness and elegance were the life-style of the time. A woman’s mission in life was to carry out the traditions and duties of family. This is not so different from the thousands of years preceding, however, the Victorian Era brought in more rigid moral and behavioral standards. The image of woman was feminine, elegant, dainty and fragile. She was not to be affronted with the baseness of life. Certainly this would include caring for the sick. The common women worked mostly as servants for the more affluent. And men, women and children worked under inhumane conditions in factories. Thus, the care of the sick was relegated to the outcast women, the unsavory types, such as prisoners and prostitutes. Once cared for by devotees of the church, patients now received the unskilled and most probably uncompassionate attention of those with nowhere else to go. Health conditions during this time were deplorable, with epidemics such as cholera wiping out entire cities. Many children were orphaned as a result and abandoned in almshouses. The times were ripe for reform, and many scientific advancements did occur during this time, such as Louis Pasteur’s formulation of the germ theory of disease, and Robert Koch’s identification of the tubercle bacillus which resulted in reductions in loss of life from tuberculosis. Wilhelm Rontgen discovered x-rays in 1895, which led to the later discovery by Pierre and Marie Curie of radium in 1898. While science and medicine were changing and advancing rapidly, the benefit of such milestones could only be marginal while patients were cared for in deplorable conditions and by unskilled workers. Enter Florence Nightingale, a revolutionary woman of her time. Called the founder of modern nursing, Florence nightingale was an extremely controversial woman of the Victorian Age. Yet because of her high standing in society, her connections with powerful men, the decision makers of the time and her well developed education, she was able to affect the most profound impact on the care of the sick than any other single individual. She developed a new system of nursing education and health care, and also improved the social welfare systems of the time. Her accomplishments include the following:
A caring and compassionate woman, she was no less aggressive and driven as an administrator and planner who literally forced change in the intolerable social conditions of the sick and poor of that time (Kelly 1991). This was an age when women were totally dominated by men. It was undesirable for a woman to have any kind of education, to show intelligence or interest in anything other than household concerns. Nightingale, encouraged by her wealthy and well educated family, acquired an education far superior to even most men of the time. Portraits and descriptions of her show a slender, attractive and fun-loving individual, whose patients also referred to her as attractive, warm and light-hearted. Sneering at the popular view of nursing at the time, she wrote the following:
Nightingale sought to change the image of nurses at a time, who were workhouse inmates and well-known for their drunkenness and thievery. A Nightingale nurse was scrupulous in her moral behavior and appearance, education and skilled, completely dedicated to her profession and obedient to the system for which she worked. One of her greatest accomplishments came from her contribution to battlefield hospitals during the Crimean War. In 1854 Nightingale was appointed by the government to lead a group of nurses to the Crimea in order to provide care that had been virtually non-existent and under deplorable conditions. She reduced a death rate of sixty (60) percent for hospitalized soldiers to one (1) percent by the end of the war. In addition to improving health care to soldiers, she also began a program of social welfare among the soldiers, which included among other benefits, the provision of sick pay (Kelly 1991). Despite all her power, influence, and independence, history reveals her insistence on the physician’s authority overall; she deferred to physicians and insisted upon the same from her nurses. She may well be the originator of the “doctor-nurse game” we experience today. It is also interesting to note that, while she so obviously improved the welfare of the sick, complementing the efforts of physicians to keep their patients alive, she was deeply resented by many doctors. Many felt that it was a waste to educate nurses and did not seem to understand that nursing was anything more than the performance of menial tasks of which anyone could be trained to do. One physician remarked, “A nurse is a confidential servant, but still only a servant. ….She should be middle-aged when she begins nursing and if somewhat tamed by marriage and the troubles of a family, so much the better” (Kelly 1991). In 1860, Nightingale established a training school for nurses. This was a one year program which included studies unheard of up to this time for nurses, in subjects such as chemistry and physiology. The education included information on hygiene, sanitation and nutrition. She was an advocate of preventive care, and at age 74 established what she termed “Health Nursing”, the forerunner of Public Health. When asked to supply nurses for particular positions, she outlined to the employer the specific details of their housing conditions, holidays, salaries and retirement benefits. Not only was she an educator and administrator, apparently she was an unofficial union leader as well. She believed that women should be paid as highly as men and that if they were not adequately compensated, intelligent, independent women would not be attracted to nursing. Sound familiar? Nightingale was insistent that nurses were to perform nursing duties, which did not include such things as cleaning, laundering and fetching. Her comment on this was, “if you want a charwoman, hire one” (Kelly 1991). A devotee of higher learning, she felt strongly about continuing education for nurses, seeing nursing as a progressive art. “A woman who thinks of herself, ‘Now I am a full nurse, a skilled nurse. I have learnt all there is to be learned,’ take my word for it, she does not know what a nurse is, and she will never know: she has gone back already” (Kelly 1991). She herself is credited with being the first nurse researcher, and published many books and articles. While Nightingale exuberantly fought for the rights of nurses, she was equally zealous in her expectations of her charges. When requests were made for Nightingale nurses for particular appointments, she hand-picked her staff and only assigned those of the most scrupulous characteristics. Her expectations would be a challenge for most of us today, but it must be remembered that she strove to dramatically turn around an unsavory image of nursing as well as the deplorable conditions of the health care system. If she were heavy-handed in her requirements, it might well be the only method to have made such a dramatic shift at that time. Following is an excerpt from an article by Florence Nightingale on “Nurses, Training of and Nursing the Sick”.
Nightingale’s influence even extended to the United States, where she consulted with the Union on hospital organization. While she was active in changing the face of nursing in England, other notable women were exerting their influence in the United States. The shift in health care in the United States began during the Civil War. Prior to this no organized system of care for the sick and wounded existed. Louisa May Alcott, Georgeanna Woolsey, Mary Ann Bickerdyke and even Walt Whitman are some of those who worked at organizing hospitals during the war. Even during such a great time of need as the war, nurses were not welcomed or appreciated by the physicians. Woolsey wrote that the surgeons treated the nurses without even common courtesy, and attempted to force them away by making life unbearable. Though there were some qualified doctors at the battlefield, apparently many were incompetent, drunk much of the time and often refused to attend the wounded. Bickerdyke managed to have many of these physicians dismissed as result of her friendships with Generals Grand and Sherman. The Civil War opened up nursing to a large number of women, particularly the well-bred ladies, who might otherwise never have entered the field. These women, Georgeanna Woolsey among them, were instrumental in leading the movement towards establishing training schools for nurses in the U.S. Remember that during the Victorian Age it was considered base and unlady-like for a woman to be educated or to work outside the home. This attitude, along with the barriers put up by physicians; make it a truly amazing accomplishment that nursing and nursing schools became established at all. In 1871, the editor of Godey’s Lady’s Book, the most popular woman’s magazine of the time, wrote an article which is surprisingly progressive and modern for the time. The following is an excerpt from “Lady Nurses”:
Fortunately, more physicians began to support the idea of trained nurses. At a meeting of the American Medical Association in 1869, it was stated that it was “just as necessary to have well-trained nurses as to have intelligent and skillful physicians (Kelly 1991)”. In 1872 a training school for nurses was established at the New England Hospital for Women and Children, which was staffed by women physicians. This was a one year program which consisted primarily of students providing nursing care to patients from 5:30 A.M. to 9:00 P.M., with an occasional lecture. Students had a free afternoon every second week from 2:00 to 5:00 P.M. The first student graduated from this rigid program was Melinda Ann (Linda) Richards, who has been referred to as America’s first trained nurse, and later became a key figure in nursing education. By 1873, three more schools were established using the Nightingale model. One of these was the Bellevue Training School in New York City, where much of our present-day nursing practice was first implemented. These milestones include interdisciplinary rounds, where nurses gave report using nursing care plans; patient record-keeping and writing of orders; and the first nursing uniform was borne, initiated by a stylish aristocrat named Euphemia Van Rensselaer. These schools became quite successful and popular which resulted in their rapid proliferation, from 15 in 1880 to 1,105 in 1909 (Kelly 1991). These were hospital-based diploma schools which took advantage of the students who provided virtually free labor. The only graduate nurses in the hospital were the superintendent and one or two supervisors. Most of the graduate nurses found private duty positions in the homes of the affluent, since so few positions actually existed in hospitals for graduate nurses. Hospitals employed only a few supervisors, and students comprised the staff. In the private duty positions nurses could earn a salary ranging from $10 a week to a very rare $20. Other working women at the time earned $4 to $6 a week. Though nurses earned more, they were also available as a servant to the family on a 24 hour basis, and were lucky to have any time off at all (Kelly 1991). Choices for women at this time were terribly limited. Higher educations for women meant learning to type or teach and these skills were seldom taught in universities. Women were rarely admitted to colleges or universities. Consequently, the hospital-based nurse training programs received hundreds to thousands of applications a year. Though ultimately, attrition was about 75%, once students had a taste of the difficult and unpleasant living and working conditions (Kelly 1991). Students were poorly housed, overworked and apparently even under-fed. Particularly disturbing is the fact that they were completely unprotected from life-threatening illness. Apparently it was not uncommon for 80% of a graduating class to have a positive tuberculin test. Nursing students were true martyrs, and this seemed to be the expectation. At this time it was very rare for a man to be admitted to a training program, and apparently very few applied. When men were accepted, they received a shorter training program and were called “attendants” rather than nurses. Meanwhile, despite the growing popularity of training schools and hospital exploitation of nursing students, much of the medical community continued to feel threatened and voice their objections. The following is taken from a medical journal article by a disgruntled physician:
However, not to paint a completely negative picture of the influence of the medical community on nursing, there were some physicians who voiced support of the idea of nursing as a profession rather than a trade. Dr. Richard Cabot made a statement in 1901 regarding suggested reforms for nursing schools:
The two decades surrounding the turn of the century saw a flurry of activity around the advancements in nursing and the expansion of the nurse’s role into many other areas besides simply the bedside. Nurses in need of jobs became creative, turning social need into their professional advantage. These nurses pioneered in areas unheard of at the time, at a time when women were given little credibility, and the role of a trained nurse still controversial. Their fortitude and creativity should provide encouragement to nurses in the 1990’s. Community Health Nursing, or Public Health Nursing, was begun in 1893 by Lillian Wald who moved with colleague, Mary Brewster, to an immigrant neighborhood in the Lower East Side of New York City to serve the poor community. They not only tended to the health needs of their clients, but sought to integrate the other social services available to totally meet the needs of the poor. Lillian Wald worked to establish nurses in schools. She convinced the school board of the efficacy of such a service, and by 1903 the board began to appoint nurses to the schools. Prevention was emphasized, thus keeping attendance up while reducing illness. Industrial nursing found its inception at the Vermont marble Company in Proctor, Vermont in 1895. A nurse was hired to provide “district nursing” service to employees of the company. Again, prevention and teaching “habits for healthy living” were emphasized (Kelly 1991). The Spanish-American War at the end of the century once again made evident the need for nurses to care for sick and injured soldiers. While the attitude of military authorities and physicians remained hostile towards nurses caring for military personnel, a group of influential women, some of whom were nurses, lobbied through a bill, which led to the establishment of the Army Nurse Corps in 1901. In 1908, a Navy Nurse Corps was also established. Other advances in nursing practice include the setting of nursing standards. Improving curricula, writing text-books, starting two enduring professional organizations (The American Nurses’ Association and The American Red Cross) and a nursing journal (The American Journal of Nursing), establishing a teacher training program in a university and initiating nursing licensure (Kelly 1991). Before nursing licensure became a law, there were still many thousands of untrained nurses competing for positions with graduate nurses (15,000 untrained nurses in New York at the time, as opposed to 2,500 who were trained). (Kelly 1991) Nurses were able to receive certificates from correspondence courses or even by purchasing a certificate stating they were trained nurses. The nurses who fought for strict criteria for licensure met opposition, not only from physicians who did not support the idea of trained nurses, but also from hospitals and others who were able to employ these non-graduate nurses for far less than the graduates. In 1903, North Carolina, followed by New Jersey and then New York became the first states to register nurses by the new standards under law, and the term Registered Nurse was borne. This law was pushed through by dedicated women at a time when women could not even vote! This ushered in changes in training program curriculums, most expanding to three years, and a more humane program for the student. The hours students served in hospitals was reduced, and even further protected under labor laws passed in 1911, restricting women to eight hours of work per day. Ten years after these first three states passed licensing laws, 38 additional states had done the same. However, this still did not preclude non-licensed nurses from calling themselves “nurse” and obtaining work. The first mandatory law in regards to licensure was passed in New York in 1938, and implemented in 1944. In the early 20th century, Public health Nursing began to expand as awareness of social needs heightened. By 1916, public health nurses were functioning as welfare workers, sanitarians, housing inspectors and health teachers. Margaret Higgins Sanger established the first birth control clinic in America after witnessing the chronic, unwanted pregnancies of her patients on the Lower East Side of New York, and women dying from self-abortion tactics. She believed in the free dissemination of birth control information, for which she was arrested and spent 30 days in the workhouse. Despite this, she continued to fight for her cause. Anesthesia is another area that opened up for nurses. Apparently as early as 1877 the Mayo brothers trained two nursing sisters to assume this duty at the Mayo Clinic. In 1909, a course for nurse anesthetists was established in Oregon. In the period following World War I a nursing shortage occurred. This is partly due to an image problem that existed at the time, and is felt to continue to haunt nursing. By many, nursing was viewed as arduous, low paying work. Also, nursing education was suffering due to lack of funds. And still, despite licensure requirements, individuals could obtain a certificate from an unregistered program and compete in the job market for lower pay alongside licensed nurses. They could not legally call themselves registered nurses, but they could still apply for jobs as nurses, and often usurped the registered nurses in these because they would work for less. The stock market crash of 1929 brought unemployment to as many as 10,000 graduate nurses. In the American Journal of Nursing it was common to see notices warning nurses not to come to specific areas in search of work. Hospitals continued to exploit students as cheap labor, and the affluent families who at one time hired private duty nurses could no longer afford such a luxury. Help came when the Roosevelt Administration allocated funds for visiting nurses to the indigent under the Federal Emergency Relief Administration. Ten thousand nurses found jobs in public hospitals, clinics, public health agencies and other health services. Though there were men graduating from nursing programs, generally exclusively male in attendance, they were discriminated against until after World War II. It was felt by the powerful influences in and out of nursing that men did not fit the image of nursing. Since the image of nursing was largely one of maternal nurturance or angel of mercy, a man’s masculinity was questioned if he entered the field. And it is interesting that, while female nurses in the armed forces were granted full commissioned status in 1947, it was not until 1954 that male nurses were admitted to full rank as officers and this in the male dominated military. World War II again saw great demand for nurses, with the usual postwar nurse shortage. At this time it was found that only one of six Army nurses planned to return to her civilian job (Kelly 1992). Nurses found the pay and working conditions in the service superior to civilian nursing jobs. One survey showed that only 12% of nurses queried stated they would make nursing a career (Kelly 1991). Most preferred to work part-time after marriage or retire from the field entirely. Nurses still were not paid well. In 1946, staff nurses were making about $36 for a 48 hour work week (Kelly 1991). This was even less than typists or seamstresses, and naturally far less than men. To accommodate this shortage, the hiring of nurses aides and practical nurses (LPN or LVN) became a popular solution. Nurses with little or no education would work under the supervision of a physician or RN, and would save the hospital money. Many physicians still believed it was unnecessary to hire educated nurses to care for the sick, and saw this as an adequate solution. This is how the concept of team nursing was started, with patient care being delegated to nonprofessionals, and the RN Team Leader relegated to the increasing amounts of paper-work and medication rounds. By 1952, a shocking 56% of nursing personnel in hospitals consisted of nonprofessionals (Kelly 1991). The postwar nursing shortage may also have been due to the difficulties nursing programs experienced at this time, and the subsequent negative image of nursing as a career. Standards had fallen in the diploma programs; teachers were inadequately prepared and students were still being required to provide nursing care in the host hospitals. Often two-thirds of the hours of care were delivered by students (Kelly 1991). Though some baccalaureate programs existed, curriculums were not standardized and it was difficult to determine which offered a good education. Most nurses at this time were still being trained in 3-year hospital-based diploma programs. The first enduring baccalaureate program in nursing was founded in 1909 by Dr. Richard Olding Beard at the University of Minnesota. Students took specialized university courses, but also worked a 56-hour week in the hospital, and after three years were still awarded a diploma rather than a degree. Soon other colleges and universities adopted this idea, developing a five-year program consisting of two years of college and three years in a diploma school. This became a rather common program through the 1940’s. Curriculums varied dramatically from one program to another. The Brown report in 1948 indicated that nursing education was far from professional. Shortly after this, the National League for Nursing (NLN) began the process of accreditation for nursing programs. Those schools that met the rigid standards were placed on a published list so that potential students could better choose a reputable program. This resulted in the eventual closure of the non-accredited schools which did not meet the high standards of the NLN. Still, baccalaureate and diploma programs excluded many potential students from applying. They would not accept male and black students, and they insisted on unmarried applicants, with a rigid paternalistic approach to the guardianship of student’s lives while in the program. Married students and men were still being excluded from many programs into the late 1960’s. With the proliferation of community colleges after World War II, these individuals found opportunities in the Associate Degree (AD) programs being offered at the community college level. These programs, as well as the practical nurse programs, became the most popular avenue for nursing education of that time. This eventually helped to loosen the rigid control over nursing student’s lives in both diploma and baccalaureate programs. In 1965, the ANA issued its Position Paper on Education for Nursing, stating that the education of nurses should take place in institutions of higher learning. Since then, the gradual closure of hospital-based diploma programs has taken place. This was the beginning of positive change in the education and practice of nursing, the recognition of the professional nurse and the struggle for nursing autonomy (Kelly 1991). CURRENT ISSUES Throughout history, nursing has experienced constant change as a result of the political, social and economic climate. The 1980’s and 1990’s present such a picture again. In the 1980’s nursing school enrollment dropped dramatically as a new generation of women experienced expanded opportunities in other career arenas, nursing salaries were not competitive with salaries in other areas, especially business and high technology. The image of nursing was still not a positive one. Turnover was high and burn-out common. More and more career opportunities began to open up for nurses in areas other than acute care hospitals. Nurses found they received greater satisfaction and recognition in these other areas and what resulted was a nursing shortage even those outside the area of health care referred to as a crisis. The New York Times, Time Magazine and the Wall Street Journal ran headlines on the nationwide nursing shortage. There seemed to be no end in sight, and commissions on both private and governmental levels were formed to study the problem and find solutions. This became a very creative time in nursing, and nurses found they could virtually write their own ticket in hospitals, working out a schedule, salary and benefit package to meet individual needs. Salaries were improved; nurses were offered a full 40-hour salary for simply working every weekend; health insurance benefits were offered at 20 hours per week; sign-on bonuses were used to entice nurses back into hospitals; day care offered; educational opportunities were made available and any number of other attractive perks began to draw nurses back into acute care. Then what happened? In the late 1980’s health care began to suffer from restrictions in coverage for Medicare and other insurance carriers. This reduced the number of days of hospitalization a patient could receive, and minimalized the types of procedures which could be covered. Over time, hospitals began to experience greater and greater reductions in census, as well as receiving less than adequate reimbursement for care. Nursing structure had returned to primary nursing, with the elimination of non-licenses and non-RN staff. Thus, all those employed in hospitals to care for the patient at the bedside were relatively highly paid. Budget cuts have been seen across the country, with massive lay-offs of nursing and other allied health personnel in an attempt to keep hospitals operating at a minimal cost. Whether a victim of hospital budget cuts, or simply in the market for an interesting career change, be assured that a nursing education and experience acquired in any aspect of the profession are transferable to other career areas. There are valuable skills, aptitudes, personality characteristics and work ethic attitudes that go along with a nurse’s profile. Given what we have seen of nursing in history, we can only assume that the course of nursing will change again in time, shifts in health care will naturally occur and nursing demand will once again change, or divert into other areas. Nursing, despite the economy and the bleak picture in acute care hospitals, is still a versatile and viable career option, one that can be lucrative, can be prestigious, and can be creative, flexible, glamorous, challenging and rewarding. Though a nurse may wear a business suit rather than a uniform, or walk the halls of a courthouse rather than a hospital ward, he or she is still a nurse and can have a great impact on the quality of patient care. The following chapter will prove just how far nursing has come. Enjoy the adventure! |