chapter 2 an historical overview of nursing

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Chapter 2

An HistoricalOverview of Nursing

Marilyn Klainberg

PURPOSE

• To familiarize the reader with the impact of historical events on nursing• To present social factors that have influenced the development of nursing • To explore political and economic factors influencing nursing today• To introduce nurses and other leaders in health care who have had an impact on nursing

OUTLINE

The Impact of Nursing on the Evolution ofHealth Care

Introduction: Ancient Cultures Before ChristThe Crusades (A.D. 1095–1291)The Renaissance

The 18th CenturyThe 19th Century

John SnowNursing Leaders of the 19th Century

The 20th and 21st CenturiesNursing Education in the United StatesLicensureThe Great Depression Nurses in Wars Fought by the United

States Nursing Leaders of the 20th Century

Today

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22 Chapter 2: An Historical Overview of Nursing

The Impact of Nursing on theEvolution of Health Care

This chapter provides a brief historical overviewof health care and identifies nurse leaders whohave influenced the events that changed orimproved the healthcare system within theframework of specific historical events. Addi-tional nurse leaders who have more recentlyinfluenced the healthcare system are identifiedand presented throughout this book.

It is important to be familiar with the effortsof those who have gone before us, because theyhave a special meaning to our future. It has beensaid that “those who cannot remember the pastare condemned to repeat it” (Santayana, 1953).Much of the early history of and informationabout nursing health care is based on informa-tion about ancient cultures that has been gath-ered by anthropologists and documented byhistorians (Spector, 2004).

Introduction: Ancient CulturesBefore Christ Care of the sick is not new. People have cared fortheir sick throughout recorded history, and weassume, before that. The term to nurse comesfrom the Middle English words nurice and norice,which are contractions of nourice, from OldFrench that was originally derived from Latinnutricia (Klainberg, Holzemer, Leonard, &Arnold, 1998). This term means “a person whonourishes” and often referred to a wet nurse. (Awet nurse is a woman who breastfeeds infants forthose who are unable to do so.) (Klainberg, etal., 1998).

Although we often assume that life in ancientand earlier cultures may have been a basis forwhat we consider nursing today, care of the sick

at that time was clearly very different because ofthe needs of and the lifestyles in society and theimpact of science and technology. Back then, pal-liative care was primarily provided for the sick.

Life in ancient cultures (and in some non-Western cultures today) was nomadic and wasbuilt around finding food and maintainingwarmth. Health practices were varied and basedupon ingenuity, prior experiences, and the envi-ronment. People used plants and herbs to heal,and they harbored the notion that evil spirits andmagic affected well-being. Early people viewedillness and death as part of the natural phenom-ena of life, and of course there were variations ofpractices among cultures (Spector, 2004).

Persons designated to care for the sick—usuallymen—passed information verbally through thegenerations. Some of the information we knowabout these ancient cultures and their forms ofhealth care comes from the work of anthropolo-gists, and some comes from information that hasbeen handed down from generation to generation.

As people’s lives and environments becamemore developed, irrigation and waste were thefirst issues related to treating disease. Priests,spiritual guides, or “medicine men” were thehealthcare providers for their communities.During these times, the sick became their re-sponsibility (Kalisch & Kalisch, 1978). Sicknesswas often attributed to evil spirits or somethingthat had been done to offend the priests or gods.Health care was often the result of trial and error,because science and technology as we know themtoday were not available. If a person ate some-thing that made him ill, that person was told notto eat it again; if an herb made someone feel wellor seemed to improve health, then that herbwould be used for its assumed curative powers.

As early as 3000 B.C., the Egyptian health-care system was the first to maintain medical

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The Impact of Nursing on the Evolution of Health Care 23

records. The Egyptians were also the first to clas-sify drugs and develop a planned system to main-tain the health of their society. Rules regardingfood safety and cleanliness were first attributed tothe Egyptians and are still maintained today bymany of the Muslim and Jewish faiths.

Babylonia was the second oldest society tomaintain medical records (Donahue, 1996).During this time, the Persians, Italians, Chinese,and Indians also developed rudimentary andearly attempts at the provision of health care.Greek society put an emphasis on personalhealth more than community health and be-lieved that personal health was influenced by theenvironment. The Romans recognized the im-portance of the regulation of medical practiceand created punishment for medical negligence.

During the Middle Ages, A.D. 500 to 1500,Christianity attempted to bring forth the notionof personal responsibility for self, as well as forothers, and this was reflected in the care of thesick. Religious communities established care forthe sick poor in hospes, places that could offernurturance and palliative care and from whichthe terms hospital and hospice derive (Nutting &Dock, 1935).

From A.D. 50 to 800, these hospes, or hospi-tals, were usually near a church or a monastery.Men were the caregivers during this time, andwomen were permitted to be midwives or wetnurses and were considered witches if theyattempted to usurp the role of the male health-care provider (Ehrenreich & English, 1973).

The Crusades (A.D. 1095–1291)War has always had an impact on the health careof society and on nursing. Woven throughoutthe history of humans and throughout thischapter are the impact and legacy of war uponhealth.

During the time of the Crusades, monksoften tended to the sick. It was during this timethat the Church established military nursingorders, such as the Knights Hospitalers (theKnights of Saint John of Jerusalem), made upexclusively of men who provided care for pil-grims and travelers who were in need of care(Beyond the French Riviera, 2007). Their famewas widespread, and it even influenced somecrusaders to lay down their weapons and join theKnights of St. John in their work to provide forthe poor, the pilgrims, and travelers (Nutting &Dock, 1935).

The RenaissanceThroughout the Renaissance period, from 1500to 1700, growing interest in science and tech-nology led to some advances in medicine andpublic health. In 1601, the Church of Englandmandated the Elizabethan Poor Law, which cre-ated overseers for the poor, blind, orphans, andlame (Bloy, 2002). Poverty was considered a wayof life for some. The rich paid for nurses to takecare of their sick at home. The Poor Law wasintended to provide a place where the poor sickand orphaned would be cared for.

It was under this law that provisions for thepoor to receive care in either hospitals or alms-houses became available. Because many of thepoor were very ill when they arrived at hospitals,and little more than palliative care could be pro-vided for them, they often died in the hospitals.Therefore, to most people the idea of being hos-pitalized had negative connotations, and hospi-tals were considered places where people weresent to die.

Those who were sick but rich continued to becared for at home by private duty nurses, whowere privately reimbursed. Often nurses whotook care of the sick in their homes were also

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expected to do other jobs within the household,including housekeeping, cleaning, and cooking.

The 18th Century

The industrial revolution began in the late 18thcentury in England (1760) and continued intothe early 19th century. It was a time of techno-logical advancement throughout the world. Earlytechnology influenced the economy. Because ofthe evolution of technology, factories emergedthat had the ability to manufacture and producespecific products in volume rather than goodsacquired from farming, manual labor, or crafts-persons. The use of machinery and the develop-ment of factories quickly spread throughout theworld.

As factories evolved, people left rural andfarming communities for cities to find employ-ment. During this time, many people migratedto cities that were unprepared for a populationincrease; in turn, many of the new residentsfound themselves living in overcrowded, unsan-itary housing and working in dangerous condi-tions for long hours. There was little protectionfor the worker—no sick pay or leave and poorworking conditions.

Later, as science made society more aware of therelationships between hygiene and health, effortswere made to improve the poor and unsanitaryconditions of overcrowding by providing placesfor people to take hot baths and sanitariums forthe ill. Although there were persons interested inimproving health care and who attempted to findways to meet these challenges, plagues remaineda major source of sickness and death.

It was not until the 18th century that anyformal interventions were made by the govern-ment toward providing health care for the com-munity. The 18th century was a turbulent time.

In 1776, the United States declared indepen-dence from Britain, and in 1789 the FrenchRevolution began. The 18th century was also atime of scientific innovation. Benjamin Franklininvented eyeglasses that addressed both near-and farsightedness, Leeuwenhoek improved themicroscope invented earlier by Galileo so thatbody cells and bacteria could be identified, andthe functioning of the heart was described.These changes began to influence how peoplelived. It was during this time that the role of thenurse began to be acknowledged and schools ofnursing were established.

The 19th Century

Change is often a result of challenges in the com-munity and the world. The 19th century was alsoa time for innovation and reform. Throughouthistory those who we consider healthcare leadershave changed or influenced the well-being of acommunity or society. Those transformationsmay have been influenced by need or have re-sulted from changes in or outside of a system. Theidentification of a leader is often dependent uponhow the leader creates or deals with change basedupon the needs of a society. Dr. John Snow, aphysician, is an example of how one person cansignificantly influence the well-being of an entirecommunity by identifying and acting upon aneed for change.

John SnowIn the 19th century, John Snow intervened andwas able to contain a major outbreak of cholera inLondon. Although he was not a nurse, I mentionDr. Snow here because his role in controlling amajor outbreak of cholera with little sophisti-cated equipment or knowledge of bacteriologywas critical. Snow and his assistants calculated

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The 19th Century 25

the actual number of deaths from cholera bygoing door to door and collecting informationfrom residents about the status of health withintheir households. They collected informationabout who provided water to the homes in thevarious districts in London. Snow discovered thatthe areas supplied by the Southwark andVauxhall Water Company had 114 deaths per100,000, while those supplied by the LambethCompany had few deaths from cholera.

After a tedious investigation, Snow was con-vinced that the source of the epidemic was con-taminated water. He knew the water from theSouthwark and Vauxhall Water Company wasfrom the lower Thames, which was closer toLondon. London was a big city and greatlyinhabited. Without sewage disposal as we knowit today, waste was disposed directly into theThames. Lambeth Company water was from anarea north of London, which was less inhabitedand therefore an uncontaminated area of theThames. Because there was no indoor plumbingat that time, water was drawn for whole com-munities from a local pump. The pump in theSouthwark and Vauxhall Water supply was fromthe local Thames, which was contaminated.

Upon determining this, Snow removed thehandle from the pump for the water that wassupplied by the Southwark and Vauxhall Com-pany. This required the community to drawwater from another source, one that was not con-taminated. That simple act stopped the out-break of cholera in London (Klainberg, et al.,1998). The pump without the handle remainsin London as a tribute to John Snow’s work.

Nursing Leaders of the 19thCenturyThe following nurses made changes in the prac-tice of nursing in small or great ways and wereamong the nurse leaders of the 19th century.

Florence Nightingale (1820–1910)

It was during the 19th century that FlorenceNightingale forever changed the practice ofnursing. Nightingale was often referred to as“the Lady with the Lamp,” which was how shewas described in a poem by Henry WadsworthLongfellow in 1857. She has also been called apioneer of modern nursing.

Florence Nightingale was a philanthropistfrom a wealthy English family who lived duringa time when well-bred women from the upperclass were not usually involved in caring for thesick. Despite convention, Nightingale wanted tostudy the care and treatment of diseases andafflictions, so she enrolled in a 3-month programto study nursing under the direction of PastorFliedner and his wife Erika at Kaiserwerth Ger-many (Kelly & Joel, 1996). Upon graduationfrom the program, Nightingale became involvedin creating the organization called “Establish-ment for Gentle Women During Illness.” Ulti-mately, she was appointed to the leadershipposition of this organization, because she wasknowledgeable as a result of prior experience inthe administration of hospitals and she had anexpertise in nursing. As her work in nursing wasacknowledged, she was consulted in the organi-zation of training nurses; however, her efforts inthe Crimean War intervened.

Florence Nightingale became involved in theCrimean War (1853–1856) after hearing aboutthe squalid conditions of soldiers who had beeninjured. She organized other nurses who joinedher in bringing aid, comfort, and supplies toinjured soldiers. When she arrived in the Crimeawhat she saw was beyond her expectations. Shefound injured soldiers in neglected and filthyconditions with dirty rags covering theirwounds. She brought clean sheets, bandages, andsimply soap and water to cleanse the wounds ofthe soldiers, who were dying of infections caused

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by the squalid conditions. Because of FlorenceNightingale and the women volunteers she led,the death rate from infections for wounded sol-diers was almost obliterated.

When Nightingale returned home to London,she was honored as a national heroine. She re-mained committed to establishing a program totrain nurses. In 1860, Nightingale established atraining program for nurses at St. Thomas’s Hos-pital in London, where the Florence NightingaleMuseum is presently housed.

Shortly thereafter, Nightingale took to her beduntil her death in 1910. It was believed that shewas ill resulting from a weakened conditionattributed to her work during the Crimean War.She wrote extensively from her sickbed, andmany feel her writings remain significant andinfluential in nursing today. Her most wellknown book, Notes on Nursing, is still revered. Shemade nursing a profession for respectable women.Up until that time, nursing was not consideredappropriate for women, and men played a majorrole in nursing. Nightingale died in her sleep atage 90. Every year during the week in which shewas born, nurses in the United States celebrateNational Nurses week in her honor.

Mary Seacole (1805–1861)

Mary Jane Grant Seacole was born in Kingston,Jamaica, to a Jamaican mother who was a nurseand a Scottish father who was a career soldier.Not formally trained as a nurse, she learned hernursing skills from her mother (Carnegie, 1995).As a nurse, she traveled to Cuba and Panama andworked during cholera and yellow fever epi-demics. In 1836, Mary married Edwin Seacole,who subsequently died in 1844.

In 1854, after learning about the war in theCrimea, Seacole asked the war office of the Britishgovernment to send her to the Crimea as an army

nurse. She was refused even an interview becauseof her race and ethnicity (Carnegie, 1995). Sea-cole, determined to help the war effort, fundedher own trip to the Crimea, bringing supplieswith her. She soon established a hospital andrespite home for wounded and fatigued soldiersin Balaclava. She worked as a volunteer and didnot receive army recognition or rank in theBritish Army. She was known as “Mother Sea-cole” on the battlefield, because she nursed thewounded. Unlike Florence Nightingale, MarySeacole received little fame or notoriety for herwork or her role in the Crimean War. After thewar, she returned to England destitute and inpoor health. Her plight was publicized by news-papers, and eventually she was recognized inEngland and Jamaica for her work in the Crimea.

Clara Barton (1812–1912)

Clara Barton, born in Massachusetts, was a NewEngland school teacher (Donahue, 1996). Des-pite not having formal training as a nurse, shevolunteered as a nurse during the AmericanCivil War. She was instrumental in organizingand acquiring needed supplies for the troopsduring the Civil War, often using her ownfinancial resources. She was referred to by thesoldiers she cared for as the “little lone lady inblack silk” (Donahue, 1996).

Following the Civil War, she remained activein attempting to locate missing men who werein the army and helped to establish the firstnational cemetery for soldiers killed in war(Donahue, 1996). Exhausted following the war,she went to Europe to recover. There she learnedabout the International Red Cross. Clara Bartonis best known for her role in establishing theAmerican Red Cross in the United States.Barton was able to convince Congress to affili-ate with the International Red Cross. This affil-

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iation created the ability for the Red Cross tofunction during times of peace.

Mary Mahoney (1845–1926)

Mary Mahoney, the first African American reg-istered nurse educated in the United States, wasborn in Boston. In 1879, at age 34, MaryMahoney graduated from the New EnglandHospital for Women and Children. She was thefirst black woman to graduate from a profes-sional school of nursing (Carnegie, 1995).Schools in the United States at that time eitherlimited the admission of black women toschools of nursing or did not permit admissionat all. Her graduation had a tremendous impactupon the future of all black nurses.

As a nurse leader, she recognized the need fornurses to work together to improve their role inthe nursing profession, and she became a mem-ber of the American Nurses Association (ANA).She was the cofounder of the National Asso-ciation of Colored Graduate Nurses (NACGN)and helped make it possible for black nurses notonly to be recognized but officially received bythe president of the United States, Warren G.Harding. She left a legacy behind for all blacknurses. She was named to the Nursing Hall ofFame posthumously, and in 1972, the UnitedStates Congress honored Mary Mahoney for herdedication to nursing.

Mary Adelaide Nutting (1858–1948)

Mary Adelaide Nutting, a suffragette and nursehistorian, was well known as an advocate ofhigher education for nurses. Born in Canada, shewas a member of the first graduating class ofnurses at Johns Hopkins University in 1891 andwas to become the school’s second superintend-ent of nursing. She was instrumental in creatingchanges to improve the education of the nursing

students at John’s Hopkins Hospital by expand-ing the program from two to three years, allow-ing for greater time in the classroom, and bydecreasing the number of hours the studentswere required to work in the hospital. (Hospitalsfrequently had students working long hours atthe hospital in addition to their student require-ments.) She realized that students needed timeto study to become good nurses (Pipkin, 2001).

Subsequently, Nutting established the firsthigher education program for nurses as theDepartment of Nursing and Health, TeachersCollege, Columbia University, New York, andwas appointed the chairperson from 1919 to1925. She was the first woman to hold a profes-sorship at Columbia University.

During World War I, because of the shortageof nurses, Nutting was called upon to chair theNursing Committee for the Counsel of NationalDefense. It was the charge of this committee tofind ways to recruit and train women as nursesfor the United States Army. Nutting was alsoinstrumental in the development and creationof the American Journal of Nursing.

Lavinia Dock (1858–1956)

Lavinia Dock was a graduate of the BellevueTraining School for nurses in 1888. She was anurse leader who helped change and advance theprofession of nursing. She used her nursingskills during the yellow fever epidemic inJacksonville, Florida, and provided care at theJohnstown flood in 1890. Ultimately, sheworked with Isabel Hampton Robb at St. JohnsUniversity. Like Nutting, Lavinia Dock was asuffragette, working for women’s rights. Dockwas an activist, interested in changing society.Dock worked with the New York Women’sTrade Union League and walked picket lines forthe Shirtwaist strike in 1913. She spoke at an

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ANA convention urging nurses to support aunion movement for nurses. In 1896, she joinedLillian Wald at the Henry Street Settlement,where they worked together for 20 years.

Lillian Wald (1867–1940)

Another nurse to bring about change duringthis era was Lillian Wald. Wald, a nurse andsocial worker born to a middle-class Jewish fam-ily in Rochester, New York, is most famous forher influence in initiating the Visiting NurseService of New York. She initially worked as anurse at an orphanage. During that time, shewas asked to volunteer to teach home classes forwomen at the Henry Street Settlement on theLower East Side of New York, a place that edu-cated mostly immigrant poor. At one of thoseclasses, a young child approached Wald andasked her to come to the tenement where thechild’s family was living to help care for her sickmother. Wald found the place to be in a verypoor state and the mother, who had recentlydelivered a baby, in a bed of blood-soiled cloth-ing (Visiting Nurse Service of New York, 2007).Wald cared for the woman, cleaned her bed androom, and comforted the family.

This event changed Lillian Wald’s life andhealth care forever. Not long thereafter, LillianWald began to care for sick residents of theLower East Side and soon decided to devote herlife to this cause. In 1893, along with anothernurse, Mary Brewster, Lillian Wald founded theHenry Street Settlement Visiting Nurse Service,which would become the Visiting Nurse Serviceof New York. By 1910, the notion of the visit-ing nurse was supported and endorsed by healthdepartments, the Public Health Service, andschools. The idea of keeping people healthy andnot spreading disease had taken hold.

The 20th and 21st Centuries

At the end of the 19th century and the be-ginning of the 20th century, issues related tosanitation in relationship to the health of com-munities were the primary concern of healthcareplanners and providers. During the 20th cen-tury, the discovery of new and more potentantibiotics and other scientific breakthroughschanged forever how the healthcare system dealtwith infection.

Toward the mid-20th century, a shift in pri-ority from the health of the community to thehealth and well-being of the individual oc-curred, and toward the end of the 20th centuryanother shift toward care of the patient in thecommunity occurred. Technological innova-tions improved and advanced how healthcareproviders approached disease. The impact ofhealth insurance also addressed and changedhow healthcare providers address the well-being of the individual and the community.Furthermore, the cost of health care began toincrease continually, and ethical issues aroseregarding who should receive treatment basedon their age or socioeconomic status; these is-sues continue today.

The world during these times has grownsmaller with advances in transportation and thespeed at which people can travel around theworld. Although many of the recent technolog-ical advances have improved health and affectedsociety positively, some, such as the rapidity inwhich people can travel the world, have in-creased the possibility of transmitting conta-gious diseases. The future of health care is fluidand not only depends on the advances made intechnology but the economy and social issuesthroughout the world.

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Nursing Education in theUnited StatesNursing education has been determined not onlyby the evolution of technology and advances inscience, but by the needs and development ofsociety. Initially, nursing education programswere informally part of hospitals and preparedyoung women to provide palliative care topatients. Courses could be completed in as fewas six months. These programs trained studentsto provide food and a clean environment.

Hospital-based diploma schools of nursingwere the first form of nursing education in theUnited States. These programs restricted theiradmission to white women. The first programto admit one black and one Jewish woman ineach class was established at the New EnglandHospital for Women and Children in Boston,Massachusetts in 1863. It was not until 1872that formal training schools for nurses wereestablished and students graduating from theseprograms were given a diploma upon gradua-tion (Carnegie, 1995).

The history of baccalaureate education cannotbe discussed without mentioning the impact ofthe Flexner Report on nursing education. In1910, Abraham Flexner, a social worker, wrote apaper identifying a profession. This report waspart of work established by the Carnegie Foun-dation addressing medical professionalism (Klain-berg, et al., 1998). Since its publication, therehave been many others who have built upon theFlexner Report, adapting what stipulates a pro-fession. The impact of this report affected manyprofessions, particularly nursing. The amendedguidelines of a profession include the following:

• Professional preparation (as opposed toan occupation)

• Preparation that takes place in an insti-tution of higher learning, such as a col-lege (community college or 4-yearbaccalaureate) or a university

• A specific and unique body of knowledge• An affiliation with a professional orga-

nization• Ethical codes • Licensing• A service orientation• Specific educational guidelines

Diploma programs have, for the most part,been replaced by associate degree or baccalaure-ate programs, but there are still some diplomaschools of nursing, which are nursing educationprograms provided by hospitals. Most nursingeducation programs that exist today are either incommunity colleges, which provide an associate’sdegree in science, or are baccalaureate programsfrom which students graduate with a bachelor ofscience degree. Students who graduate from anyof these programs can take the National CouncilLicensure Examination (NCLEX) examinationsto become registered nurses.

Graduate education beyond a baccalaureateeducation includes a variety of advanced practiceroles. Master’s degrees fulfill a variety of areas,such as clinical nurse specialist, nurse practi-tioner, certified nurse midwife, certified regis-tered nurse anesthetist, informatics specialist,and doctorate (Doctor of Philosophy [PhD],Doctor of Education [EdD], Doctor of NursingScience [DNS, DNSc], Doctor of Nursing [ND],and Doctor of Nursing Practice [DNP]).

The notion of clinical specialization grew asthe nursing profession grew and as a result of theneeds of society. It began early in the 20th cen-tury when nurses acquired specialties through

The 20th and 21st Centuries 29

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hospital-based courses, and it became morecomplex after World War II (Mezey, McGivern,& Sullivan-Marx, 1999). In 1964, the NurseTraining Act was enacted, which provided fund-ing to support the education of advanced prac-tice nurses. It was not until 1965 that the firstnurse practitioner program was created. Therewas some initial resistance to the notion of thenurse practitioner, but by the 1980s this focusbecame a part of master’s programs. Until then,many nurse practitioners could acquire theiradvanced practice certification following grad-uation by taking an accreditation examination.

LicensureIn 1901, the first conference of the InternationalCouncil of Nurses (ICN) met in New York Stateand passed a resolution stating that all nursesshould be licensed by examination (Kalisch &Kalisch, 1978). Although licensure of nurseswas met by strong opposition in most states,North Carolina was the first state nursing asso-ciation to put this forward to its legislature(Kalisch & Kalisch, 1978). Subsequently, a billwas approved requiring nurses to pass an exam-ination to practice as nurses in North Carolina,regardless of where they were trained.

New York State passed a more stringent billshortly thereafter that required nurses to pass anursing examination and also to graduate froma school of nursing approved by the Regents ofthe State University in New York State (Kalisch& Kalisch, 1978). Since then, there have beenmany changes in the methods of testing nursesfor licensure. Today, the National CouncilLicensure Examinations (NCLEX) examinationsare given online in the United States and insome other countries. All nurses graduatingfrom established and credentialed nursing pro-

grams and successfully passing the NCLEXexamination may practice nursing in the state inwhich they have applied to take the examina-tion. Many states offer reciprocity.

The Great DepressionThe Great Depression followed the stock marketcrash of 1929. The crash, also referred to as BlackThursday, was one of the most devastating stockmarket crashes in American history. The economicimpact created a shift in employment and approx-imately 30% of the population became unem-ployed. This affected the economic well-being ofthe entire nation, creating large numbers of home-less people. Many people did not have money topurchase food or health care, and the Depressionprofoundly influenced how nursing was practiced.

Until that point, most nurses worked in pri-vate homes caring for patients who could affordtheir services. Hospitals mostly utilized stu-dents to care for the ill. Students provided cheaplabor, but when they graduated they could notfind jobs in hospitals, so most sought employ-ment in patients’ homes where they cared forthe sick or elderly who could afford private care.Hospitals replaced graduating students withnew students. After the crash and the Depres-sion, many nurses working in homes lost theirjobs, because many families could no longerafford their services. Hospitals found they couldhire trained nurses for very little, because thenurses were in need of jobs, and they could behired for either low wages or in exchange forroom and board (Hott & Garey, 1988). Hos-pitals began to use trained nurses instead of stu-dents to provide care for their patients. Studentscontinued to have a role in hospitals after that,but they no longer provided primary care forpatients independently.

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Nurses in Wars Fought by theUnited States During and following the American Revolution,men served as corpsmen, providing nursing carefor soldiers. Following the Civil War and beforethe Spanish American War in 1898, nurses inthe United States Army were also men. Thesemen were known as hospital corpsmen. Theywere trained at differing caregiving levels.However, there were not enough hospital corps-men, and a need for trained nurses was evident.

In 1898, the United States Congress appro-priated funds for the employment of trainednurses and for the development of the ArmyNurse Corps (McGee & Hughes, n.d.). Therewere no restrictions on whether the nurses shouldbe male or female. Those who applied to betrained as nurses were mostly women, and thesewomen performed well in their role as nurses.Following this, there was little objection towomen in the Army Nurse Corps. The contribu-tion of the female nurses during the Spanish-American War and during the yellow feveroutbreak positively advanced their role in theArmy Nurse Corps. Female nurses along withmale nurses have served in every American warsince. Army Nurse Corps did not become a partof the Army Medical Department until 1901.

World War I (1914–1918)

The United States entered World War I in1917. Before entering World War I, the UnitedStates established the Bureau of War RiskInsurance in 1914. The Bureau of War RiskInsurance was originally intended to insureships and cargo but was amended in 1917 tomeet the needs of the returning veterans. Thiswas to become the Veteran’s Bureau.

During World War I, the number of nurses inthe military grew from about 4000 to 20,000,serving both overseas and domestically. ArmyNurses served in the United States, France,Hawaii, Puerto Rico, and the Philippines.Nurses also provided care on transport ships car-rying wounded home across the Atlantic.

In 1917, because of its outstanding record ofcaring for merchant seamen and controlling dis-ease, and despite the uncertainty of its role, thePublic Health Service (PHS) was made part ofthe military by President Woodrow Wilson(Mullan, 1989). The Public Health Service, inaddition to being concerned with issues relatedto the war, was dealing with other health issues,particularly venereal disease among soldiers andthe Spanish flu, which killed 50,000 Americansby 1919 (Mullan, 1989). As the war generatedveterans in need of health services, the PHS wasfurthermore asked to be responsible for return-ing soldiers and to oversee the Marine Hospitalsystem, which was called upon to provide carefor returning soldiers (Mullan, 1989).

World War II

The United States entered World War II afterbeing attacked at Pearl Harbor on December 7,1941. At that time, the number of nurses in theArmy could not meet the demand and needs ofthe military. Initially, this was a dilemma forcivilian nurses who were torn between joiningthe military or continuing to work in their civil-ian jobs (Kalisch & Kalisch, 1978). To helpencourage nurses to join the military and to pre-vent hospitals from being depleted of nurses, theNational Council for War Service establishedguidelines for the recruitment of nurses (Kalisch& Kalisch, 1978). Other issues that preventednurses from enlisting were the low salary nurses


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who joined the military at the beginning of thewar received compared to men and that nursesreceived no official rank or benefits.

In May 1942, with the fall of Corregidor inthe Philippines, 54 Army nurses became Japaneseprisoners of war (Norman, 1999). During theircaptivity, they suffered greatly but continued tocare for patients in internment hospitals. Underequally poor conditions, other brave nurses caredfor patients under German shellfire in Europe.

In 1943, Frances Bolton introduced a bill toCongress to provide military rank for the nursesto correct the inequity between males in themilitary and military nurses (who were mostlyfemale). In 1944, Congress enacted a law that

provided military nurses with a temporary offi-cer’s rank for the duration of the war. Also in1944, the military was desperately in need ofnurses, and under the Bolton Act, the UnitedStates Public Health Service created the UnitedStates (U.S.) Cadet Nurse Corps to create anaccelerated program to educate nurses. Onehundred twenty-five nurses were admitted dur-ing the first two months and 125,000 duringthe next two years (Kalisch & Kalisch, 1978).The U.S. Cadet Nurse Corps program wasphased out in 1948, three years after the end ofthe war. See Box 2–1 to read about how inter-national events influenced one woman to jointhe U.S. Cadet Nurse Corps.

Box 2–1 How I Became a Nurse

Jacqueline Rose Hott

There are specific days anyone over the age of50 always remembers: the day Kennedy wasshot, November 22, 1963, and the attack onthe Twin Towers, September 11, 2001. Wecan remember where we were and what wewere doing when we heard about thesenational tragedies. Long before these events,though, came the day the Japanese attackedPearl Harbor, on December 7, 1941. For me,a 16-year-old freshman at New Jersey Collegefor Women (NJC) in New Brunswick, NewJersey, that Sunday morning in Decemberwill always stand out as a life-shaping expe-rience. It was the day that brought me intonursing as a career.

I was not one of those women who hadalways wanted to be a nurse. I wanted to be areporter, so I was an English major. I had

been editor of my high school newspaper andsenior yearbook; I had a column in the col-lege newspaper. Always interested in humanbehavior, I also studied psychology as myminor. I knew nothing about nursing, exceptthat my physician at home in Jersey City hadmarried a nurse who worked at Bellevue andwho occasionally helped him in his office.

Unlike me, my older sister wanted to bea nurse so that she could leave home; how-ever, my parents would not give permissionbecause she was not yet 17. My family triedto dissuade my sister by saying, “Nurses justcarry bedpans. Is that what you want to do?”She got married instead.

I was struggling at NJC, not with studiesor grades (after all, I had been my high schoolvaledictorian), but with the cost of living on

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campus. I had scholarships to pay tuition,but to help my blue-collar family pay for therest I was working jobs as a waitress in thecollege cafeteria, an aide in the AlumnaeHouse, and a teacher in a religious school onSundays. The attack on Pearl Harbor createda public relations bonanza of informationabout nursing and made me see that nursingcould be a way to solve my economic prob-lems in seeking an education.

I don’t remember when I first saw theposter about joining the U.S. Cadet NurseCorps: “Enlist in a Proud Profession.” Theatmosphere on our brother campus, RutgersUniversity, was heavy with the draft loomingover its men. At NJC, we had special exer-cises to prepare ourselves physically for com-bat threats. I still don’t know what triggeredmy change besides the public relations in-formation from the U.S. Cadet Nurse Corpsin pamphlets and posters that encouragedwomen to join the war effort. The educa-tional bonus in becoming a nurse was con-tinuing my baccalaureate education for free!As a sophomore student in the next semester,I would be able to transfer enough credits sothat after graduation from a school of nurs-ing in 33 months, I would have a bachelor’sdegree in nursing science (BSN), a profession,and no debt. Indeed, my next college wouldhave free room, board, and tuition and giveme a stipend of $15 a month. (Would someeconomist figure that out in today’s prices?)And I would be serving my country! Now, ifI would look good in that uniform . . . (I did!)

Deciding which college I would transferto was not too difficult. I wanted a programthat would accept my college credits, and

NJC recommended two: Cornell Universityand Bellevue School of Nursing. The onlything I knew about Cornell was the song “FarAbove Cayuga’s Waters” and that it was along distance from home in Jersey City.Otherwise, my doctor’s wife had gone toBellevue, it was famous for psychiatry, and itwas just across the Hudson from home if Ineeded chicken soup. So, I became a cadetnurse at Bellevue.

Leaving NJC was hard. I was honored bythe school as a Distinguished Alumnus afterit became Douglass College. Surely, the rootsof leadership for this woman started in a col-lege for women and were nurtured and devel-oped at Bellevue and later at New YorkUniversity’s graduate programs in nursing.

I started at Bellevue in September 1943 inone of the largest admitting nursing classesBellevue had ever had. We had college grad-uates, baccalaureate students, new high schoolgraduates, married and divorced women,blacks, Asians, Catholics, and Jews, althoughmost students were white, Anglo-SaxonProtestants. Our faculty were all WASPs untilwe reached senior year in psychology.

Rigidity of rules and doing things theBellevue way (the only way?) were the norm.Great chauvinistic pride in being a Bellevuenurse was instilled early. The goal was to bethe best nurse, to give the best patient care.If we had problems, they were challengesand we were creative problem solvers. Wewere Bellevue nurses; we overcame. As U.S.Cadet Nurse Corps nurses, we were beingprepared for combat; whether the combatwas lack of equipment, personnel, or time,we persevered.

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By the end of World War II, 215 nurses haddied in service to the United States. Their ser-vice was important to the war effort duringWorld War II, and they were not unlike thecourageous nurses who served in the KoreanWar, the Vietnam War, and Desert Storm andwho today serve in Iraq.

Nursing Leaders of the 20thCentury

Mary Breckinridge (1881–1965)

In 1925, the Frontier Nursing Service was be-gun in Kentucky by Mary Breckinridge, anurse, who remained its director until her deathin 1965. This service provided care for the sickpoor in rural communities. Nurses traveled byfoot or by horse to reach patients who wouldotherwise not receive the care of a healthcareprovider. Nurses cared for rural and isolatedfamilies and individuals who were ill or who hadbeen injured and also delivered babies.

During World War I, while serving as a vol-unteer nurse in France, Breckinridge met aBritish nurse who was also a midwife. When shestarted the Frontier Nursing Service, she real-ized that the frontier nurses would need thisskill and sent nurses to England to study mid-wifery. With the outbreak of World War II in

Europe, Breckinridge was no longer able to sendAmerican nurses to Britain. Realizing the im-portance of midwifery to Frontier Nursing Ser-vice nursing practice, Breckenridge began theFrontier Graduate School of Midwifery. Thename of the school changed to the Frontier Schoolof Midwifery and Family Nursing (FSMFN)(Kelly & Joel, 1996).

Margaret Sanger (1878–1966)

Margaret Sanger worked as a nurse with poorwomen on the Lower East Side in New YorkCity. Through this work, she became aware ofthe impact of unplanned and unwelcome preg-nancies upon these women. She was alreadyfamiliar with this on a personal level, becauseshe was one of 11 children and saw how multi-ple pregnancies caused her own mother’s healthto suffer. She believed women should have birthcontrol available to them.

In 1916, Margaret Sanger opened a familyplanning and birth control clinic in New YorkCity. Nine days after she opened the center, itwas raided by the police and Sanger served 30days in prison. This was one of her many arrestsover the years that resulted from her efforts toprovide education about contraception to wo-men. In 1930, Sanger successfully opened a fam-ily planning clinic in Harlem, New York, with

Looking back from more than 60 yearslater, I realize that my classmates wereremarkably capable women, some just teen-agers like me, others mature and seasoned. Aspart of our contract with the U.S. CadetNurse Corps, we promised to continue innursing for three years after graduation in1946. I am still proudly keeping that prom-

ise as an independent clinical nurse practi-tioner in adult psychiatric nursing. TheCadet Nurse Corps poster is on the wall ofmy den. It still inspires me. When I left thedeanship at Adelphi University School ofNursing, I left my U.S. Cadet Nurse Corpspurse in the display closet as a memento. Ihope that it will continue to inspire others.

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support of the community, but it wasn’t until1939 that the American Medical Association offi-cially recognized birth control as an integral partof medical practice. Shortly thereafter, the BirthControl Federation of America emerged. In 1942,the Birth Control Federation of America changedits name to Planned Parenthood Federation ofAmerica (PPFA) (Planned Parenthood, 2008).The conflict over birth control did not end there.Threats of bombing Planned Parenthood clinicscontinued late into the 20th century.

Virginia Henderson (1897–1996)

Virginia Henderson attended the Army Schoolof Nursing in Washington, DC, and graduatedin 1921. She went on to Teachers College, Col-umbia University, graduating with a master’sdegree in nursing education. In 1955, withBertha Harmer, Henderson coauthored Textbookof the Principles and the Practice of Nursing, a fun-damental textbook. Her book and subsequentwritings redefined the practice of nursing. Hen-derson emphasized in the book that the goal ofthe healthcare provider is to help people becomeas independent as possible (Harmer & Hen-derson, 1955). She described the nurse’s role asthreefold: “substitutive (doing for the person),supplementary (helping the person), or complemen-tary (working to help the patient)” (Harmer &Henderson, 1955).

Henderson believed that “the unique func-tion of the nurse is to assist the individual, sickor well, in the performance of those activitiescontributing to health or its recovery (or topeaceful death) that he would perform unaidedif he had the necessary strength, will or knowl-edge and to do this in such a way as to help himgain independence as rapidly as possible” (Har-mer & Henderson, 1955). Henderson was one ofthe first nurses to point out that nursing does not

consist of merely following physicians’ orders.Virginia Henderson remained an active contrib-utor to nursing and continued to lecture togroups of nurses about her philosophy untilshortly before her death in 1996 at age 99.

Mildred Montag (1908–2004)

Orphaned at an early age, Mildred Montag wasraised by her aunt and uncle on a farm. Sheattended Hamline University, in St. Paul, Min-nesota, and graduated in 1930 as a history major.She then decided to become a nurse and attendedthe University of Minnesota, in Minneapolis,and graduated in 1933 with a bachelor of science(BS) degree in nursing. She went on to attendColumbia University, Teachers College, in NewYork, majoring in nursing education, and grad-uated in 1938 with a master of art (MA) degreein nursing education.

The United States’ entry into World War IIresulted in an urgent need for more nurses toserve in the military. In 1942, Dr. Montag wasasked by Adelphi College (presently AdelphiUniversity), under a grant from the United StatesPublic Health Service, to determine whetherlocal hospitals would cooperate in establishing aschool of nursing at Adelphi College. In January1943, the School of Nursing at Adelphi College,the first program for nursing on Long Island, wasestablished and Dr. Montag was named the direc-tor. The first 25 students were admitted underthe Nurse Training Act of 1943, also known asthe Bolton Act. Montag remained director of theAdelphi College School of Nursing from 1943 to1948. As founder and director of the program,Dr. Montag is credited with developing the nurs-ing program and making it an integral part ofAdelphi College.

In 1950, Mildred Montag graduated with adoctorate from Teachers College and her doctoral

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dissertation changed how we educate nurses inthe United States. At that time, most of theschools of nursing were 3-year diploma programsowned and operated by hospitals (Kalisch &Kalisch, 1978). In her doctoral dissertation,Montag proposed creating a 2-year program toprepare technical nurses to assist the professionalnurse, whom she envisioned as having a bac-calaureate degree. Dr. Montag’s goal was to alle-viate the critical shortage of nurses by decreasingthe length of the education process from a min-imum of three years to two years and to providea sound educational base for nursing instructionby placing the program in community/juniorcolleges.

In 1958, as a result of her dissertation, the W. K. Kellogg Foundation funded the imple-mentation of the project at seven pilot sites infour states (Haase, 1990). Associate degree edu-cation for nursing began as part of this experi-mental project at Teachers College, ColumbiaUniversity, based on Montag’s dissertation. Inaddition to creating a program that decreasedthe time to become a nurse, benefits of the asso-ciate’s degree in nursing (ADN) program in-cluded reasonable cost and proximity of ADNprograms to the community, access for diversepopulations, the inclusion of adult learners,males, and married students. Seven communitycolleges were included in this 5-year nursingresearch project to evaluate the impact of anassociate’ degree education for nurses, and Dr.Montag was named the director of the project(Kalisch & Kalisch, 1978). Dr. Montag was theauthor of many publications and the recipient ofmany awards related to the development of theADN program. She remained actively involvedin nursing and particularly in Adelphi UniversitySchool of Nursing (formerly Adelphi College)until her death at age 95.

Hildegard E. Peplau (1909–1999)

Dr. Hildegard E. Peplau, born in Pennsylvania in1909, is known for her work and great strides inpsychiatric nursing. She helped to create changein the collective way nurses and patients thoughtabout their roles in the patient–healthcareprovider relationship (Peplau, O’Toole, & Welt,1989). Her groundbreaking work helped nursesto use their interpersonal skills therapeutically.She emphasized the nurse–patient relationship asthe foundation of nursing practice. Peplau devel-oped an interpersonal model emphasizing theneed for a partnership between nurse and patient,and her theories were considered by many to berevolutionary. She opposed patients passively re-ceiving treatment, as well as nurses passively act-ing out doctors’ orders.

During World War II, Hildegard Peplau wasa member of the Army Nurse Corps. Followingthe war, she returned to school, and in 1947, shereceived a degree in psychiatric nursing fromTeachers College, Columbia University, NewYork, and went on to receive a doctor of educa-tion degree in curriculum development fromColumbia University in 1953.

Ruth Lubic Watson (1931–Present)

Ruth Lubic Watson is a nurse–midwife and, in1993, was the first nurse ever named a MacArthurFellow by the John D. and Catherine T. Mac-Arthur Foundation. Dr. Watson served as thedirector of the Maternity Center Association,which began in 1917. In 1975, she founded thefirst freestanding birthing center on the UpperWest Side in New York City. In 1983, Watsonbecame the president of the National Associationof Childbearing Centers, which brought birthingcenters to impoverished areas in the Bronx, NewYork, and Washington, D.C., to provide care tounderserved communities.

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Today 37

The New York City Family Health andBirthing Center on the Upper West Side nolonger exists, but Dr. Watson continues to beactively involved in the center in the Bronx andin Washington, D.C. Among many prestigiousawards Dr. Watson has received, she wasawarded the Institute of Medicine (IOM) Lein-hard Award in 2001 for the advances she hasmade in personal health of others. Dr. Watsoncontinues to speak to professional groups to pro-mote the cause and efforts of the professionalnurse–midwife.

M. Elizabeth Carnegie (1916–2008)

M. Elizabeth Carnegie was a nurse historian andthe author of several publications of greatimportance to the history of nursing, includingThe Path We Tread. Her work to advance blackand minority nurses has improved the status ofnursing for all nurses.

Aware of the nursing shortage in the militaryduring World War II, Carnegie applied to theNavy and was rejected. The Army took AfricanAmerican nurses, but during this time said theycould not recruit and take any more black nursesbecause they could not house them with whitenurses. In an interview, she stated, “During theshortage of nurses during World War II, Iapplied to the Navy and just got a letter sayingthey were not taking colored nurses; the Army’sexcuse was they couldn’t house black and whitenurses together, could not have them in thesame bunks” (Hott & Garey, 1988). Carnegieand other African American nurses protestedthis with a campaign in the newspapers. Event-ually, the Army did take African Americannurses to meet the needs of the Armed Forces(Carnegie, 1995).

Dr. Carnegie was employed by the AmericanJournal of Nursing from 1953, and upon her

retirement in 1978, she became the editoremeritus of Nursing Research. Her groundbreak-ing book The Path We Tread: Blacks in NursingWorldwide 1854–1994 is in its third edition.Dr. Carnegie initiated the nursing program atHampton University in Virginia, was the pres-ident of the American Academy of Nursing,and was the dean of the School of Nursing atFlorida A&M University. She has been a dis-tinguished visiting professor at many univer-sities. Up until her death in February 2008,Dr. Carnegie was an independent consultantand received countless awards and honorarydegrees from universities throughout the coun-try. Most recently, she received a lifetimeachievement award from Adelphi Universityand the Alpha Omega Chapter, Sigma ThetaTau International.

Today

Today we think of our healthcare system asmore sophisticated than that of previous gen-erations because it is based on technology andscience. However, in some ways it is not unlikethe past because it is dynamic and changing.For example, today men are more prevalent innursing than they have been in previous years,and this is because of changes in society andthe evolving image of the nurse. Much of thecare nurses provide for individuals and com-munities is based on the needs of society and isdriven not only by need and tradition, but bychanges in society brought on by environmen-tal changes.

Today, as in years past, we find that manycultures and individuals maintain relation-ships with the persons to whom they give thepower to lead them to wellness, such as nurses,

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physicians, or designated persons in the com-munity. For many, these individuals serve asgatekeepers for their care. There are many com-munities that, either because of religious orother beliefs, require the healthcare provider tofirst deal with the designated gatekeeper toprovide care for individuals or communities andmust be considered and included when creatinga plan of care.

Now, in the 21st century, there is an empha-sis on the health of the individual within thecommunity. Several factors have created thisshift: the influence of insurance on the status ofhealth and care; a decrease in resources, includ-ing fewer hospitals and fewer professional nurses;an aging population; early retirement; a shift tosecond careers; a struggling economy; and anemphasis on prevention, safety, and self-care.

Summary

This chapter provides a brief historical overviewof health care. The nurse leaders identified influ-enced events that changed or improved thehealthcare system. These nurse leaders played animportant part in shaping nursing as we knowit today. Some names, such as Florence Night-ingale, are familiar and associated with nursing;the others recognized in this chapter played animportant role in changing the profession.Many other nurses not mentioned in this chap-ter have made their mark on nursing and helda vision that affects the future of nursing.Although understanding our past and the his-tory of nursing is important to our future, you,the reader, are the future of nursing and will alsoleave your footprint on the profession.

QUESTIONS

1. Mary Mahoney was the first a. African American registered nurseb. nurse to fight in the Civil Warc. to graduate from a baccalaureate nursing programd. person to welcome Florence Nightingale to the Crimea

2. Mildred Montag’s goal in creating the 2-year nursing program was toa. prepare registered nurses to replace baccalaureate nursingb. prepare technical nurses to assist the professional nursec. lessen the burden created by the nursing shortaged. get evidence to complete her dissertation

3. Florence Nightingale was known as thea. nurse who changed nursing foreverb. nurse responsible for the end of the Crimean Warc. Lady with the Lampd. mother of nursing

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4. Dr. Hildegard E. Peplau is known for her work and great strides ina. medical surgical nursingb. nursing educationc. psychiatric nursingd. caring for the sick poor

5. The first Frontier Nursing Service was beguna. by Florence Nightingale to help the sick poor in Wyoming b. by Elizabeth Carnegie in Washington, D.C.c. by Mary Breckinridge in Kentucky d. with help from Hildegard E. Peplau

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chapter 2 an historical overview of nursing

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