American Nursing: An Introduction to the Past
Professional nursing holds a unique place in the American health care system. As members of the largest health care profession, the nation’s 3.1 million nurses work in diverse settings and fields and are frontline providers of health care services. While most nurses work in acute-care settings such as hospitals, nurses’ expertise and skills extend well beyond hospital walls. Working independently and with other health care professionals, nurses promote the health of individuals, families, and communities. Millions of Americans turn to nurses for delivery of primary health care services, health care education. and health advice and counseling. Nurses are critical links in maintaining a cutting-edge health care system.Nursing continues to be an indispensable service to the American public.
While many may think of a nurse as someone who takes care of hospitalized patients, nurses also fill a wide variety of positions in health care in many varied settings, working both collaboratively and independently with other health care professionals. For example, most Americans are familiar with home care nurses who provide a plethora of nursing and health care services to patients in their homes. School nurses have a long history of providing health services to school children from kindergarten through high school. Nurses play a major role in delivering care to those residing in long-term-care facilities such as nursing homes. Workers with job-related health concerns often seek out nurses employed by business and industry. Many people visit a nurse practitioner as their primary caregiver. Expectant mothers often prefer nurse midwives as their health care providers during pregnancy and childbirth. And each day, in operating rooms across the country, nurse anesthetists insure that patients undergoing surgery receive safe anesthesia care. Today, schools of nursing compete for the brightest applicants, and nursing is highly regarded as an excellent career choice for both women and men.
Most people think of the nursing profession as beginning with the work of Florence Nightingale, an upper class British woman who captured the public imagination when she led a group of female nurses to the Crimea in October of 1854 to deliver nursing service to British soldiers. Upon her return to England, Nightingale successfully established nurse education programs in a number of British hospitals. These schools were organized around a specific set of ideas about how nurses should be educated, developed by Nightingale often referred to as the “Nightingale Principles.” Actually, while Nightingale’s work was ground-breaking in that she confirmed that a corps of educated women, informed about health and the ways to promote it, could improve the care of patients based on a set of particular principles, she was the not the first to put these principles into action.
Nursing and Hospital Care in the United States
Throughout history most sick care took place in the home and was the responsibility of family, friends, and neighbors with knowledge of healing practices. In the United States, family-centered sickness care remained traditional until the nineteenth century. Sick care delivered by other than family and close acquaintances was generally limited to epidemics and plagues that periodically swept through towns and cities. By the beginning of the nineteenth century, however, urbanization and industrialization changed the way in which—and in many cases the place in which—sick individuals received care. Hospitals began to proliferate to serve those who were without the resources to provide their own care, and as hospitals increased in numbers so did the demand for caregivers who would be able to deliver thoughtful care to the patients in them. Early nineteenth-century hospitals were built mainly in more populated sections of the country, generally in large cities. Nursing care in these institutions differed enormously. In hospitals operated by religious nursing orders, patients received high quality care. But, in other institutions, nursing care was more variable, ranging from good in some hospitals, to haphazard and poor in others.
The Beginnings of Nurse Education
Recognizing the importance of good nursing care to a patient’s well-being, some physicians initiated courses for those interested in nursing. In 1798 Valentine Seaman, a New York physician, organized an early course of lectures for nurses who cared for maternity patients. An early nineteenth-century program, the Nurse Society of Philadelphia (also referred to as the Nurse Charity of Philadelphia) trained women in caring for mothers during childbirth and postpartum period. Its founder, Dr. Joseph Warrington, a strong advocate of providing instruction for women interested in pursuing nursing as an occupation, authored a 1839 book entitled The Nurse’s Guide Containing a Series of Instruction to Females who wish to Engage in the Important Business of Nursing Mother and Child in the Lying-In Chamber . This publication, which each Nurse Society nurse received, represents an early example of a nursing practice text. Between 1839 and 1850 the Nurse Society employed about fifty nurses, establishing an early practice of engaging nurses for care of patients in the home.
The outbreak of the Civil War created an immediate need for capable nurses to care for the enormous number of sick and wounded. About 20,000 women and men served as nurses in both the North and the South. The commendable service rendered by Civil War nurses provided a rationale for future experiments in setting up training programs for nursing. One such program was initiated in Pennsylvania where the Women’s Hospital of Philadelphia offered a six months nurse training course, which graduated its first class in 1869. Similar courses, such as that offered by the New England Hospital for Women and Children were begun in other locales.
Professional Nurse Education Begins
The year 1873 was a watershed year in American professional nursing history. In that year, three nurse educational programs—the New York Training School at Bellevue Hospital, the Connecticut Training School at the State Hospital (later renamed New Haven Hospital) and the Boston Training School at Massachusetts General Hospital—began operations. These three programs, all based on ideas advanced by Florence Nightingale, are generally acknowledged to be the forerunners of organized, professional nurse education in the United States.
The success of these first three so-called “Nightingale schools” led to a proliferation of similar nursing schools, or as they were most commonly called, nurse training programs. By 1900, somewhere between 400 to 800 schools of nursing were in operation in the country. These programs followed a fairly typical pattern. The school was either affiliated with or owned by a hospital that provided the students with the clinical experience considered necessary for the education of a nurse. Students received two to three years of training. While in the program students carried out the majority of patient care activities offered in the hospital, receiving only a modicum of classroom education in the form of lectures on patient care and related subjects. At the end of the educational program, students received a diploma and were eligible to seek work as a trained nurse.
These early nurse education programs were, in reality, little more than apprenticeship programs that used student nurses for their labor. Despite their significant shortcomings, however, they proved very popular with both hospitals and students and created a pattern of hospital-based nurse education that persisted until the mid-twentieth century. And, while many disparaged the exploitative nature of the nurse education system, the presence of trained nurses with their emphasis on cleanliness, orderliness and close observation of patients successfully transformed hospitals into scientific institutions of caring. Further, the popularity of the schools, as evidenced by their high student admission rates and the large numbers of nurses they graduated, testified to the profession’s appeal as an excellent occupation in which to carve out a career. Schools of nursing did improve over time. Better oversight of nursing educational programs by state licensing boards as well as the increasingly complex demands of patient care led the schools to increase the amount of theoretical instruction and decrease the amount of direct work performed by students.
The Profession of Nursing Organizes
As the number of nurses grew in the late nineteenth century, nursing took on the rudimentary characteristics of a profession. In the 1890s, nurses organized two major professional associations: the American Society of Superintendents of Training Schools for Nurses, later renamed the National League of Nursing Education, and the Associated Alumnae of the United States, later renamed the American Nurses Association. Other major organizations, such as the National Association of Colored Graduate Nurses and the National Organization for Public Health Nursing formed in the early twentieth century. State nurses associations also organized and were instrumental in passing state nurse registration acts which regulated and provided a licensing system for nursing practice. The successful passage of nurse registration acts, considered a significant legislative accomplishment at a time when women held little political power, also provided nurses with their modern legal title, registered professional nurses (RN).
These changes improved and reformed many aspects of the nurse training system, but problems remained. Reflecting the social and legal status of African Americans at the time, American professional nursing maintained strict racial segregation until the mid-twentieth century. African American individuals wanting to become nurses had to train in a separate educational system and faced a divided employment field in which white and black nurses did not participate equally. Nursing also remained a predominantly female profession. While a few schools admitted men, most schools refused them admission.
Challenges for Nursing
Employment conditions for nurses also presented challenges. In the early part of the twentieth century, hospitals employed only a few graduate nurses, mainly in supervisory positions. They relied instead on student nurses for the majority of the bedside care provided to patients. Most nurses, once they graduated from their educational program, entered the field of private duty nursing. Private duty nurses were employed by individual patients primarily in their homes. As institutions became the more normative site for delivery of sick care, private duty nurses moved with their patients into the hospital, delivering care to hospitalized individuals who could afford to pay for their own nurse. But for nurses, private duty often did not provide regular and dependable employment; nurses were hired on an ad hoc basis by patients and were oftentimes without a regular source of income. The cost of private duty was also quite high, limiting the number of patients employing private duty nurses. It was not until the mid-twentieth century that hospitals hired nurses as regular staff on a permanent basis, providing full professional nursing services to all hospitalized patients.
Despite the many difficulties within the profession, nursing continued to grow as an occupational field and became recognized as an essential health care service by the early twentieth century. Nurses fanned out into diverse fields delivering services to many people outside of hospitals. For example, Lillian Wald founded the Henry Street Settlement House in 1893, which provided nursing and other social services to impoverished populations on the Lower East Side of New York City. Replication of Wald’s work in other parts of the country led to the growth of the field of public health nursing, opening up new employment opportunities for nurses and expanding the type of services provided by nurses.
The onset of World War I created a critical demand for the special skills of nurses. About 23,000 American nurses served in the military, delivering care to the armed forces both in the United States and at the war front,. The success of military nurses in providing essential care during the war insured their participation in succeeding conflicts. At home, nurses continued to provide essential service to the civilian population.
The special skills possessed by nurses were easily transferred to different fields of health care. For example, nurses were educated to administer anesthesia during surgery, leading to the specialty field of nurse anesthetists. By the early twentieth century it was quite common to find nurse anesthetists delivering anesthesia in many of the nation’s hospitals. By the 1920s, in some parts of the country, nurse-midwives delivered babies, in many cases to the most impoverished populations.
During the 1920s and 1930s, hospitals continued to expand adding more and more patient beds and delivering care that was rapidly becoming more complex. Nurses were the most essential ingredient in insuring that patients received competent care delivered in a safe manner. Hospitals continued to rely heavily on student nurses for patient care, but a trend emerged in which hospitals hired more nurses who had completed their education and graduated. These nurses, initially called “general duty nurses” but later referred to as “staff nurses,” assumed greater and greater importance in insuring that the nation’s hospitals operated efficiently. By the 1950s, staff nursing was nursing’s main occupational field.
Mid-twentieth Century Nursing
When the United States entered World War II, nurses duplicated the excellent work they had performed in World War I, taking critical positions in the armed services and insuring that the military received appropriate care. About 78,000 nurses served in World War II, their contributions acknowledged as essential to victory. The post-World-War-II era posed new challenges for the profession. While the modern intensive health care system that emerged after the war demanded larger numbers of nurses to handle the increasingly complex and technical care needs of patients, there seemed to be fewer young women (the major population from which nursing drew its recruits) willing to choose nursing as a career. Nursing’s image took on an heroic cast during the war, but the reality for most nurses, was that the work was incredibly demanding with few financial rewards and poor working conditions. Nursing failed to keep up economically with other occupations. Severe shortages of nurses characterized the immediate post
war period, threatening the delivery of health services to the public.
At the same time, internal debates within the profession over the type of work in which nurses should engage and the proper way to educate a nurse divided nurses into different camps. Some educators and other health care
analysts promoted removing nursing education from its base within hospital training schools and placing it in institutions of higher education. By 1960, approximately 172 college-based nursing education programs awarded Bachelors of Science in Nursing degrees. These experts believed baccalaureate educated nurses would be better prepared to care for the complex needs of late-twentieth-century patients and would be able to take on more advanced roles in the delivery of health care. Proponents of the traditional hospital-based diploma programs disagreed, arguing that nurses trained in hospital programs excelled at delivering bedside care, the major area in which nurses worked. Before the debate was settled one way or the other, a new nurse educational program centered in two-year community colleges emerged. Community-college-based programs (also known as Associate Degree programs) seemed to offer the best of both worlds. Education took place in institutions of higher education, and the demands of patient care did not intrude on the learning process as often occurred in diploma programs. Graduates of community college programs seemed well suited to assume employment as hospital bedside nurses. Further, the ability of community college programs to graduate large numbers of nurses offered potential respite from repeated nurse shortages.
The community college movement achieved only partial success. Community college programs did graduate many new nurses and often at a lower cost than traditional diploma programs. But, as the needs of late-twentieth-century patients became increasingly more complex, research studies indicated that being treated by nurses prepared at the baccalaureate level improved patient outcomes.
The Modern Practice of Nursing
Despite disagreements among nurses about the appropriate type and place of nursing educational programs, the profession itself flourished in the late twentieth century. In the mid-twentieth century nursing abandoned its objectionable system of racial and gender segregation, opening up equal educational, professional, and employment opportunities to all nurses. Beginning in the 1960s, new types of nurses, who specialized in different hospital settings such as intensive care units, and nurse practitioners who were trained to deliver a variety of primary care services began to appear on the health care scene. The emergence of these “advanced practice nurses” enabled hospitals and other health care facilities to deliver more efficient, less costly, and safer health care services. Today, nurse practitioners, clinical nurse specialists, and other specialty-area nurses are well established and carry out a significant portion of health care activities
Nursing education also thrived in the latter half of the twentieth century. Significant federal financial support for educating nurses, which became available beginning in the 1960s, permitted the revamping and modernizing of many nursing educational programs. Significantly, increased funding for nursing research permitted nursing to develop a sounder scientific basis for its practice. Nurse researchers today carry out cutting-edge studies that shed light on the ways and means of solving many health care problems and improving nursing services.
As the twenty-first century continues, the profession of nursing faces many challenges. periodic shortages of nurses continue to occur, and a lasting solution to maintaining an adequate supply of nurses remains elusive. As the baby boom generation ages, larger numbers of older Americans may strain the health care system and require increased amounts of nursing care. The demands of twenty-first-century health care services will continue to test the nursing profession’s ability to maintain high caliber care that meets contemporary societal needs.
Historically, the nursing profession has consistently demonstrated its ability to adapt to changing and varied health care needs. It remains an exceedingly popular and highly respected profession that attracts large numbers of new recruits to its ranks. There is little doubt that nursing will continue to maintain its status as an extremely important profession, serving the health needs of the nation.
Jean C. Whelan (1949-2017) was Adjunct Assistant Professor of Nursing, University of Pennsylvania School of Nursing.