Nursing, profession that

assumes responsibility for the continuous care of the sick, the injured, the disabled, and
the dying. Nursing is also responsible for encouraging the health of individuals,
families, and communities in medical and community settings. Nurses are actively
involved in health care research, management, policy deliberations, and patient
advocacy. Nurses with postbaccalaureate preparation assume independent responsibility
for providing primary health care and specialty services to individuals, families, and
communities.

hypertension
Nurse using a sphygmomanometer to check a patient's blood pressure.
James Gathany/Centers for Disease Control and Prevention (CDC) (Image ID: 7872)

Professional nurses work both independently and in collaboration with other health care
professionals such as physicians. Professional nurses supervise the work of nurses who
have limited licenses, such as licensed practical nurses (LPNs) in the United States and
enrolled nurses (ENs) in Australia. Professional nurses also oversee the work of nursing
assistants in various settings.

Nursing is the largest, the most diverse, and one of the most respected of all the health
care professions. There are more than 2.9 million registered nurses in the United States
alone, and many more millions worldwide. While true demographic representation
remains an elusive goal, nursing does have a higher proportional representation of racial
and ethnic minorities than other health care professions. In some countries, however,
men still remain significantly underrepresented.

The demand for nursing remains high, and projections suggest that such demand will
substantively increase. Advances in health care technology, rising expectations of
people seeking care, and reorganization of health care systems require a greater number
of highly educated professionals. Demographic changes, such as large aging populations
in many countries of the world, also fuel this demand.

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History of nursing
Although the origins of nursing predate the mid-19th century, the history of professional
nursing traditionally begins with Florence Nightingale. Nightingale, the well-educated
daughter of wealthy British parents, defied social conventions and decided to become a
nurse. The nursing of strangers, either in hospitals or in their homes, was not then seen
as a respectable career for well-bred ladies, who, if they wished to nurse, were expected
to do so only for sick family and intimate friends. In a radical departure from these
views, Nightingale believed that well-educated women, using scientific principles and
informed education about healthy lifestyles, could dramatically improve the care of sick
patients. Moreover, she believed that nursing provided an ideal independent calling full
of intellectual and social freedom for women, who at that time had few other career
options.

In 1854 Nightingale had the opportunity to test her beliefs during Britain’s Crimean
War. Newspaper stories reporting that sick and wounded Russian soldiers nursed by
religious orders fared much better than British soldiers inflamed public opinion. In
response, the British government asked Nightingale to take a small group of nurses to
the military hospital at Scutari (modern-day Üsküdar, Turk.). Within days of their
arrival, Nightingale and her nurses had reorganized the barracks hospital in accordance
with 19th-century science: walls were scrubbed for sanitation, windows opened for
ventilation, nourishing food prepared and served, and medications and treatments
efficiently administered. Within weeks death rates plummeted, and soldiers were no
longer sickened by infectious diseases arising from poor sanitary conditions. Within
months a grateful public knew of the work of the “Lady with the Lamp,” who made
nightly rounds comforting the sick and wounded. By the end of the 19th century, the
entire Western world shared Nightingale’s belief in the worth of educated nurses.
Florence Nightingale at the Barrack Hospital
Florence Nightingale at the Barrack Hospital in Scutari (Üsküdar), writing letters for
wounded soldiers of the Crimean War, 1855.
© Photos.com/Thinkstock

Nightingale’s achievements overshadowed other ways to nurse the sick. For centuries,
most nursing of the sick had taken place at home and had been the responsibility of
families, friends, and respected community members with reputations as effective
healers. During epidemics, such as cholera, typhus, and smallpox, men took on active
nursing roles. For example, Stephen Girard, a wealthy French-born banker, won the
hearts of citizens of his adopted city of Philadelphia for his courageous and
compassionate nursing of the victims of the 1793 yellow fever epidemic.

Stephen Girard, lithograph by A. Newsam after a portrait by B. Otis

Courtesy of the Library of Congress, Washington, D.C.

As urbanization and industrialization spread, those without families to care for them
found themselves in hospitals where the quality of nursing care varied enormously.
Some patients received excellent care. Women from religious nursing orders were
particularly known for the quality of the nursing care they provided in the hospitals they
established. Other hospitals depended on recovering patients or hired men and women
for the nursing care of patients. Sometimes this care was excellent; other times it was
deplorable, and the unreliability of hospital-based nursing care became a particular
problem by the late 19th century, when changes in medical practices and treatments
required competent nurses. The convergence of hospitals’ needs, physicians’ wishes,
and women’s desire for meaningful work led to a new health care professional: the
trained nurse.

Hospitals established their own training schools for nurses. In exchange for lectures and
clinical instructions, students provided the hospital with two or three years of skilled
free nursing care. This hospital-based educational model had significant long-term
implications. It bound the education of nurses to hospitals rather than colleges, a tie that
was not definitively broken until the latter half of the 20th century. The hospital-based
training model also reinforced segregation in society and in the health care system. For
instance, African American student nurses were barred from almost all American
hospitals and training schools. They could seek training only in schools established by
African American hospitals. Most of all, the hospital-based training model strengthened
the cultural stereotyping of nursing as women’s work. Only a few hospitals provided
training to maintain men’s traditional roles within nursing.

Still, nurses transformed hospitals. In addition to the skilled, compassionate care they
gave to patients, they established an orderly, routine, and systemized environment
within which patients healed. They administered increasingly complicated treatments
and medication regimes. They maintained the aseptic and infection-control protocols
that allowed more complex and invasive surgeries to proceed. In addition, they
experimented with different models of nursing interventions that humanized
increasingly technical and impersonal medical procedures.

Outside hospitals, trained nurses quickly became critical in the fight against infectious
diseases. In the early 20th century, the newly discovered “germ theory” of disease (the
knowledge that many illnesses were caused by bacteria) caused considerable alarm in
countries around the world. Teaching methods of preventing the spread of diseases,
such as tuberculosis, pneumonia, and influenza, became the domain of the visiting
nurses in the United States and the district nurses in the United Kingdom and Europe.
These nurses cared for infected patients in the patients’ homes and taught families and
communities the measures necessary to prevent spreading the infection. They were
particularly committed to working with poor and immigrant communities, which often
had little access to other health care services. The work of these nurses contributed to a
dramatic decline in the mortality and morbidity rates from infectious diseases for
children and adults.
tuberculosis vaccination
A child receiving a UNICEF-funded tuberculosis vaccine at a school in Bulacan
province, Philippines, c. 1952.
© UNICEF/ICEF-2539

tuberculosis
American Red Cross poster promoting a Christmas seal campaign to raise money to
fight tuberculosis, c. 1919.
Library of Congress, Washington, D.C. (LC-DIG-ppmsca-43170)

At the same time, independent contractors called private-duty nurses cared for sick
individuals in their homes. These nurses performed important clinical work and
supported families who had the financial resources to afford care, but the unregulated
health care labour market left them vulnerable to competition from both untrained
nurses and each year’s class of newly graduated trained nurses. Very soon, the supply of
private-duty nurses was greater than the demand from families. At the turn of the 20th
century, nurses in industrialized countries began to establish professional associations to
set standards that differentiated the work of trained nurses from both assistive-nursing
personnel and untrained nurses. More important, they successfully sought licensing
protection for the practice of registered nursing. Later on, nurses in some countries
turned to collective bargaining and labour organizations to assist them in asserting their
and their patients’ rights to improve conditions and make quality nursing care possible.
By the mid-1930s the increasing technological and clinical demands of patient care, the
escalating needs of patients for intensive nursing, and the resulting movement of such
care out of homes and into hospitals demanded hospital staffs of trained rather than
student nurses. By the mid-1950s hospitals were the largest single employer of
registered nurses. This trend continues, although as changes in health care systems have
reemphasized care at home, a proportionately greater number of nurses work in
outpatient clinics, home care, public health, and other community-based health care
organizations.

Other important changes in nursing occurred during the latter half of the 20th century.
The profession grew more diverse. For example, in the United States, the National
Organization of Coloured Graduate Nurses (NOCGN) capitalized on the acute shortage
of nurses during World War II and successfully pushed for the desegregation of both the
military nursing corps and the nursing associations. The American Nurses Association
(ANA) desegregated in 1949, one of the first national professional associations to do so.
As a result, in 1951, feeling its goals fulfilled, the NOCGN dissolved. But by the late
1960s some African American nurses felt that the ANA had neither the time nor the
resources to adequately address all their concerns. The National Black Nurses
Association (NBNA) formed in 1971 as a parallel organization to the ANA.

World War II: poster

U.S. Army Nurse Corps poster from World War II reading “More nurses are needed!
All women can help—learn how you can aid in army hospitals.”
National Library of Medicine, Bethesda, Md.

Nursing’s educational structure also changed. Dependence on hospital-based training

schools declined, and those schools were replaced with collegiate programs either in
community or technical colleges or in universities. In addition, more systematic and
widespread programs of graduate education began to emerge. These programs prepare
nurses not only for roles in management and education but also for roles as clinical
specialists and nurse practitioners. Nurses no longer had to seek doctoral degrees in
fields other than nursing. By the 1970s nurses were establishing their own doctoral
programs, emphasizing the nursing knowledge and science and research needed to
address pressing nursing care and care-delivery issues.

During the second half of the 20th century, nurses responded to rising numbers of sick
patients with innovative reorganizations of their patterns of care. For example, critical
care units in hospitals began when nurses started grouping their most critically ill
patients together to provide more effective use of modern technology. In addition,
experiments with models of progressive patient care and primary nursing reemphasized
the responsibility of one nurse for one patient in spite of the often-overwhelming
bureaucratic demands by hospitals on nurses’ time.

The nursing profession also has been strengthened by its increasing emphasis on
national and international work in developing countries and by its advocacy of healthy
and safe environments. The international scope of nursing is supported by the World
Health Organization (WHO), which recognizes nursing as the backbone of most health
care systems around the world.

The practice of nursing

Scope of nursing practice
According to the International Council of Nurses (ICN), the scope of nursing practice
“encompasses autonomous and collaborative care of individuals of all ages, families,
groups, and communities, sick or well and in all settings.” National nursing associations
further clarify the scope of nursing practice by establishing particular practice standards
and codes of ethics. National and state agencies also regulate the scope of nursing
practice. Together, these bodies set forth legal parameters and guidelines for the practice
of nurses as clinicians, educators, administrators, or researchers.

Education for nursing practice

Nurses enter practice as generalists. They care for individuals and families of all ages in
homes, hospitals, schools, long-term-care facilities, outpatient clinics, and medical
offices. Many countries require three to four years of education at the university level
for generalist practice, although variations exist. For example, in the United States,
nurses can enter generalist practice through a two-year program in a community college
or a four-year program in a college or university.

Preparation for specialization in nursing or advanced nursing practice usually occurs at

the master’s level. A college or university degree in nursing is required for entrance to
most master’s programs. These programs emphasize the assessment and management of
illnesses, pharmacology, health education, and supervised practice in specialty fields,
such as pediatrics, mental health, women’s health, community health, or geriatrics.
Research preparation in nursing takes place at the doctoral level. Coursework
emphasizes nursing knowledge and science and research methods. An original and
substantive research study is required for completion of the doctoral degree.

Forms of general nursing practice

Hospital-based nursing practice
Hospital nursing is perhaps the most familiar of all forms of nursing practice. Within
hospitals, however, there are many different types of practices. Some nurses care for
patients with illnesses such as diabetes or heart failure, whereas others care for patients
before, during, and after surgery or in pediatric, psychiatric, or childbirth units. Nurses
work in technologically sophisticated critical care units, such as intensive care or
cardiac care units. They work in emergency departments, operating rooms, and recovery
rooms, as well as in outpatient clinics. The skilled care and comfort nurses provide
patients and families are only a part of their work. They are also responsible for
teaching individuals and families ways to manage illnesses or injuries during recovery
at home. When necessary, they teach patients ways to cope with chronic conditions.
Most hospital-based nurses are generalists. Those with advanced nursing degrees
provide clinical oversight and consultation, work in management, and conduct patient-
care research.

Forms of general nursing practice

Hospital-based nursing practice
Hospital nursing is perhaps the most familiar of all forms of nursing practice. Within
hospitals, however, there are many different types of practices. Some nurses care for
patients with illnesses such as diabetes or heart failure, whereas others care for patients
before, during, and after surgery or in pediatric, psychiatric, or childbirth units. Nurses
work in technologically sophisticated critical care units, such as intensive care or
cardiac care units. They work in emergency departments, operating rooms, and recovery
rooms, as well as in outpatient clinics. The skilled care and comfort nurses provide
patients and families are only a part of their work. They are also responsible for
teaching individuals and families ways to manage illnesses or injuries during recovery
at home. When necessary, they teach patients ways to cope with chronic conditions.
Most hospital-based nurses are generalists. Those with advanced nursing degrees
provide clinical oversight and consultation, work in management, and conduct patient-
care research.
nurse; doctor; MRI
A nurse (right) and doctor preparing a hospital patient for an MRI.
© Epstock/Dreamstime.com

Community health nursing practice

Community health nursing incorporates varying titles to describe the work of nurses in
community settings. Over the past centuries and in different parts of the world,
community health nurses were called district nurses, visiting nurses, public health
nurses, home-care nurses, and community health nurses. Today community health
nursing and public health nursing are the most common titles used by nurses whose
practices focus on promoting and protecting the health of populations. Knowledge from
nursing, social, and public health sciences informs community health nursing practices.
In many countries, ensuring that needed health services are provided to the most
vulnerable and disadvantaged groups is central to community health nursing practice. In
the United States, community health nurses work in a variety of settings, including state
and local health departments, school health programs, migrant health clinics,
neighbourhood health centres, senior centres, occupational health programs, nursing
centres, and home care programs. Care at home is often seen as a preferred alternative
for caring for the sick. Today home-care nurses provide very sophisticated, complex
care in patients’ homes. Globally, home care is being examined as a solution to the
needs of the growing numbers of elderly requiring care.

Mental health nursing practice

Mental health (or psychiatric) nursing practice concentrates on the care of those with
emotional or stress-related concerns. Nurses practice in inpatient units of hospitals or in
outpatient mental health clinics, and they work with individuals, groups, and families.
Advanced-practice mental health nurses also provide psychotherapy to individuals,
groups, and families in private practice, consult with community organizations to
provide mental health support, and work with other nurses in both inpatient and
outpatient settings to meet the emotional needs of patients and families struggling with
physical illnesses or injuries.

The care of children

The care of children, often referred to as pediatric nursing, focuses on the care of
infants, children, and adolescents. The care of families, the most important support in
childrens’ lives, is also a critically important component of the care of children.
Pediatric nurses work to ensure that the normal developmental needs of children and
families are met even as they work to treat the symptoms of serious illnesses or injuries.
These nurses also work to promote the health of children through immunization
programs, child abuse interventions, nutritional and physical activity education, and
health-screening initiatives. Both generalist and specialist pediatric nurses work in
hospitals, outpatient clinics, schools, day-care centres, and almost anywhere else
children are to be found.

vaccine
A nurse immunizing a patient with an intramuscular vaccination.
James Gathany/Centers for Disease Control and Prevention (CDC) (Image ID: 9424)

The care of women

The care of women, especially of childbearing and childrearing women (often called
maternal-child nursing), has long been a particular nursing concern. As early as the
1920s, nurses worked with national and local governments, private charities, and other
concerned professionals to ensure that mothers and children received proper nutrition,
social support, and medical care. Later, nurses began working with national and
international agencies to guarantee rights to adequate health care, respect for human
rights, protection against violence, access to quality reproductive health services, and
nutritional and educational support. Generalist and specialist nurses caring for women
work on obstetrical and gynecological units in hospitals and in a variety of outpatient
clinics, medical offices, and policy boards. Many have particular expertise in such areas
as osteoporosis, breast-feeding support, domestic violence, and mental health issues of
women.

Geriatric nursing practice

Geriatric nursing is one of the fastest-growing areas of nursing practice. This growth
matches demographic need. For example, projections in the United States suggest that
longer life expectancies and the impact of the “baby boom” generation will result in a
significant increase in the number of individuals over age 65. In 2005 individuals over
65 accounted for about 13 percent of the total population; however, they are expected to
account for almost 20 percent of the total population by 2030. Moreover, those over 65
use more health care and nursing services than any other demographic group. Most
schools of nursing incorporate specific content on geriatric nursing in their curricula.
Increasingly, all generalist nurses are prepared to care for elderly patients in a variety of
settings including hospitals, outpatient clinics, medical offices, nursing homes,
rehabilitation facilities, assisted living facilities, and individuals’ own homes.
Specialists concentrate on more specific aspects of elder care, including maintaining
function and quality of life, delivering mental health services, providing environmental
support, managing medications, reducing the risks for problems such as falling,
confusion, skin breakdown, and infections, and attending to the ethical issues associated
with frailty and vulnerability.