History and Evolution

of Nursing

Trends and Changes

Early History
Ancient writings in Greece, Rome, Egypt and India
refer to persons dedicated to caring for the sick, injured,
making herbal remedies, and midwives for new mothers

Nurses are mostly household servants, part of the

military or members of religious orders.

12th century the Knights of St. Thomas a group of

vowed Englishmen with the purpose of tending to the
sick, wounded and burying fallen crusade soldiers
Plague Doctors
Separate occupation from the
surgeon-barber and town
physician

Hired to care for people inflicted

with bubonic plague (black
death) and dispose of the bodies

Kept quarantined from the rest of

the town and village
Contract for a plague doctor: Pavia, Italy 1479
 Clause 1.  The community of Pavia and its council shall provide the sum of
30 florins per month to Master Giovanni de Ventura.
 Clause 4.  The community of Pavia and its council shall provide Dr. Ventura
with an adequate house in an adequate location, completely furnished.  
 Clause 5.  The community of Pavia and its council shall continue to pay
Master Giovanni Ventura for a period of two months after the termination
of his employment.
 Clause 6.  The said Master Giovanni shall not be bound or held under
obligation except only in attending the plague patients. Giovanni must treat
all patients and visit infected places as it shall be found to be necessary.
 Clause 9.  The said Master Giovanni shall not be able to ask a fee from
anyone, unless the plague victim himself or his relatives shall freely offer it.
 Clause 14.  Said Master Giovanni would have and should be obliged to do
his best and visit the plague patients twice or three times or more times per
day, as it will be found necessary.
 (http://web.mac.com/mloret/iWeb/apeuro06/Plague%20Doctor.html)
The Reformation
Diminished role of nursing
care provided by religious
orders as convents and
monasteries were closed in
countries hostile to the
Catholic Church
(www.angelfire.com/fl/EeirensFaerieTales/NursingDeclineH
istory, 2010)

•Early application of science in explanation of health and disease

• Illustrations of human anatomy
• Rudimentary explanations from vivisections
 Victorian Era
Attending to the ill in poor houses
and sanatoriums was done by
prostitutes and prisoners

Sairey Gamp (Charles Dickens’

novel Martin Chuzzlewitt) the
unpleasant domestic nurse . (Dickens,
1843)

Mrs. Beeton's Book of Household

Management, 1861, places nurses
in the chapter ‘domestic servants’
(www.victorianlondon.org/professionsandtrades, 2010)
Contemporary Events
 1796: Jenner inoculates people with cow pox to prevent
small pox – trend towards science of vaccines
 1858: Publication of Gray’s Anatomy: Descriptive and
Surgical
 1860s: Louis Pasteur proves broth does not spontaneously
spoil without microorganisms
 Beginning of the germ theory
 1856-1863: Bro. Gregor Mendel charted genetic
patterns in pea plants (work rediscovered in 1930s)
 1867: Joseph Lister performed surgery using carbolic acid
for antiseptic surgery
 1901: Landsteiner categorized blood types for successful
transfusions
 Florence Nightingale
Considered the founder of modern nursing,
applied statistics, epidemiology, hospital
administration and sanitary engineering, plus
was a social reformer
Highly-educated and from a wealthy family
Went from goodwill hospital visitor to nurse
Trained in hospital at Kaiserwerth Germany and
with Sisters of Charity in Paris
• 1860, Opened college level St. Thomas school of nursing in
London
• Wanted nurses to be upper-class and educated women
who cared for the sick and wounded for altruistic reasons
Nightingale’s Work
• In 1859, wrote Notes on nursing: What it is and
what it is not, the first textbook and nursing theory

• A social reformer who petitioned politicians for better

conditions for the poor and soldiers, and more career
opportunities for women

• Organized district nursing in London in partnership

with businessman and MP William Rathbone
Nightingale in the Crimean War
With 38 women volunteers,
Nightingale travelled to
Turkey in 1854 to help the
sick and wounded English
soldiers in camps
Her statistics proved more
soldiers died from
preventable infections than
from battle injuries •An example of one of her pie charts,
Improved the camp’s she visually depicted more soldiers
sanitation and lowered dying from infections then from
the mortality rate from battle injuries.
infections 42% to 2% (www.uh.edu/engines/epi1712.htm, 2010)
Her Nursing Practice
The body heals itself, disease is the body’s way of
repairing itself after exposure to poison or decay
Nurses should be proper women who are single,
chaste, and live without alcohol, tobacco and dancing
Nursing is to create an environment where healing
can occur
Fresh air, clean water, removal of waste, moderate
room temperatures
Exposure to pollutants perpetuates illness
Create an atmosphere of rest and protect patient
from worry
Her writings
Nightingale did not write about human anatomy or microorganisms

in her book. She wrote about maintaining a clean and healing
environment. The chapters to Notes on Nursing are as follows:

Preface Bed and Bedding

Ventilation and Light
Warming Cleanliness of Rooms And
Health of Houses Walls
Petty Management Personal Cleanliness
Noise Chattering Hopes And
Variety Advices
Taking Food Observation of the Sick
What Food? Conclusion
Appendix
Notes on Nursing
 Notes on Nursing was not a comprehensive guide
for trained nurses, but was written to help any
women provide better care for sick persons at
home
• ‘The following notes are by no means intended as a . . .
manual to teach nurses to nurse. They are meant simply to give
hints for thought to women who have personal charge of the
health of others. Every woman . . . in England has, at one time
or another of her life, charge of the personal health of somebody,
whether child or invalid,--in other words, every woman is a
nurse’
(Nightingale, Notes on Nursing, Preface, 1859)
Select Quotes
Air: ‘The very first canon of nursing, the first and the last
thing upon which a nurse's attention must be fixed, the
first essential to a patient, without which all the rest you
can do for him is as nothing, with which I had almost said
you may leave all the rest alone, is this: TO KEEP THE
AIR HE BREATHES AS PURE AS THE EXTERNAL
AIR, WITHOUT CHILLING HIM.
(Nightingale, Notes on Nursing, Ch 1, 1859)

• Every nurse ought to be careful to wash her hands very

frequently during the day.
(Nightingale, Notes on Nursing, Ch 11, 1859)
Select Quotes
 Light: Second only to their need of fresh air is their need of
light; that, after a close room, what hurts them most is a dark
room. And that it is not only light but direct sun-light they
want.
(Nightingale, Notes on Nursing, Ch. 9, 1859)

 Music: Wind instruments, including the human voice, and

stringed instruments, capable of continuous sound, have
generally a beneficent effect--while the piano-forte, with such
instruments as have no continuity of sound, has just the
reverse. The finest piano-forte playing will damage the sick,
while an air . . . will sensibly soothe them.
(Nightingale, Notes on Nursing, Ch.4, 1859)
Nursing in the Civil War Era
No organized nursing profession prior to the 1860s
in the United States
Confederate and Union armies during the Civil War
recruited nurses to treat injured soldiers
First use of shrapnel to injure multiple people at once
More people needed to treat the injured
Gangrene infections
Catholic Sisters formed and staffed make-shift tent
hospitals
Efficient, clean and devoted to their patients
Men and women volunteers
Sojourner Truth, Harriet Tubman and Walt Whitman
Dorothea Dix (1802-1887)
Originally a school teacher
who in 1841 became a
reformer for treatment of
the mentally ill
Within 10 years visited
>300 jails and >500
almshouses
Advocated for mentally ill
•By 1880, <1% of prison
persons to be removed from
jails/almshouses and be
population were the
placed in public hospitals mentally ill

•Union’s superintendent for

nurses during the Civil War
 Clara Barton 1821 - 1912
Teacher and U.S. patent office clerk
prior to volunteering for the War
While travelling in Switzerland she
read the works of Henry Dunant
about treating all war wounded
She founded the American Red
Cross in 1881 (biggest single
charity in the U.S. today) to aid
victims of disasters
“Angel of the Battlefield” 
• Collected and distributed Also championed prison reform,
women’s voting, education and
supplies for Civil War
civil rights movements
soldiers  (www.redcross.org/museum/history/claraBarton.asp,
•Formed a tent hospital 2011)
•Direct care for wounded
Formation of Education
1873: three nursing schools opened in NY, CT, and
MA
Based on the St. Thomas model
Segregated, limited opportunities for Black and Jewish
Americans
Three nursing schools for men (often to work in mental
health institutions by 1898. Little changed for men until
after 1950s)
At the turn of the century majority of nurses were
trained in hospital apprentice programs
Professional Organizations
Establishment of Official Groups
Formation of the National League of Nurses (1893)
 American Nurses Association (1896)
 International Council of Nurses (1899)
 National Association of Colored Graduate Nurses
(1908)

Early discussions for professional standards and

training
Address lack of uniformity and inadequate curriculums
in nursing schools
Consider a state registration of nurses
Emergence of Public Health Nurses
Nightingale created ‘district nursing’ in London where
a nurse was assigned to overall health of a
neighborhood
Lillian Wald – Working in poverty stricken
neighborhoods in NYC, she formed the outreach clinic
The Henry Street Settlement (1893)
health education, lifestyle education, infant/children
checkups, home visits, sanitation improvements
Racial equality, all services were integrated
Founding member of the NAACP
Jessie Scales and Elizabeth Tyler established The
Stillman House in the African-American districts of
NYC alongside Ms. Wald
Women’s Health – early 1900s
Mary Breckinridge – midwife who
founded Frontier Nursing Service
to extend healthcare to women and
infants in poverty stricken areas of
the rural Appalachian Mountains
Meticulous record keeper and
patient educator
Lower infant mortality rate than
today’s national average
•Margaret Sanger – Advocated for the rights over
contraception and reproductive control
- Founder of Planned Parenthood
- Supported the eugenics movement
Contemporary Events
World War I – Militaries internationally mobilized nurses to
provide care wounded soldiers
1920: U.S. Congress approved nurses as ranked military
Spanish Influenza Pandemic (1918) – H1N1 virus infected
over 30% of the world’s population (1.86B) and killed over
50 million (may be as high as 100 million)
In 1928 Alexander Fleming incidentally discovered bacteria
did not grow around penicillium notum mold, further work
put Penicillin antibiotics into mass production by 1948
During the Great Depression and WWII President Roosevelt
designated funds in SSA & CWA for public health projects
Dr. Jonas Salk polio vaccine was made public in 1955
Professional and Societal Evolutions
1940s – proliferation of hospitals led to staffing
shortages and strained working conditions
Hospitals start to become the biggest employer of nurses
1947: Nurses gain status as commissioned officers in
the U.S. military
Segregation ended in corps
men allowed as military nurses in 1954
1950s – formation of associates degree as abbreviated
education from community colleges to increase supply
of practicing nurses
1950-1960s - formation of nursing process, theories,
nurse specialties and graduate degrees
 (Young and Patterson, 2007)
Contemporary Events
1965 – President Johnson and Congress pass Medicare
and Medicaid to fund healthcare for the elderly and
poor
Remains single largest funder of hospitals and nursing
homes
1971 – Pres. Nixon approves presence of for-profit
managed healthcare business model
1980s to present –
emergence of technology and specialized technicians and
professionals
Increasing cost and decreasing access to healthcare
Slow infusion of men and minorities into nursing
Proliferation in lifestyle related illnesses in population
Contemporary Issues in Nursing
Uneven allocation of funding for patient care
Mismatch of employment availability comes in
waves
Projected long-term shortage
Stable career myth
Prevalent view of nurses as skilled labor in servant
role and not as independent professionals
Blurred professional boundaries, roles and images
Don’t let Hollywood inform the public on nurse’s
image and role. It’s wrong almost every time.
Finding the nursing presence in technology
dominant interventions
Nursing as a Profession
Profession vs. Occupation
Job, career, or occupation signify a person’s
primary work for income
Profession - a vocation to espouse the knowledge,
principles and duty of a chosen identity with a
designated purpose of work
Nursing and nurses contain features of both
Distinct education pathways for entry
Various attitudes in practicing nurses
Diverse and dynamic roles
Role and capabilities tied to employer
Features of a Profession
Abraham Flexner, Richard Hall and committees and
provided definitions of professionalism.
All professions include themes of:
A sense of service to the public good
Specialized theories begat intellectual and practical
knowledge
Control over own practice and code of conduct

Internal Barriers ?
External Barriers ?
Breakthroughs ?
Nursing’s Professional Standards
Nursing’s Social Policy Statement: summarizes the
relationship between the nursing profession and society
Obligation to recipients

Scope and Standards of Practice: Outlines the

expectations of a member’s practice
Establish competencies and requirements of care

Code of Ethics: Guides the profession’s and members’

decisions toward greater principles and duties
Features of the Nursing Profession
Lucie Kelly PhD. RN listed 8 characteristics of the nursing
profession
1. Services are vital to humanity
2. Special body of knowledge
3. Practitioners are accountable for own work and decisions
4. Practitioners are educated at institutions of higher
learning
5. Practitioners are relatively independent, autonomous
6.Practitioners are motivated by service to others and
consider their work as an important part of their lives
7. Presence of code of conduct and ethics guides decisions
of practitioners
8. Organization encourages high standards
References
Chitty, K. and Black, B. (2011). Professional nursing: Concepts and
challenges (6th ed). Maryland Heights, MO: Saunders
Dickens, C. (1843) Martin Chuzzlewitt. London: Oxford
European History (2010). Retreived online homepage.mac.
Com/mloret/apeuro/Personal48
Nightingale, F. (1859) Notes on nursing: What it is and what it is not.
New York: Appleton
American Red Cross (2011) Retrieved online from
www.redcross.org/museum/history/claraBarton.asp
Tomey, A & Alligood, M (2006). Nursing theorists and their work. St.
Louis: Mosby
Victorian History (2010). Retrieved online www.victorianlondon.org
Young, L. and Paterson, B. (2007). Teaching nursing: Developing a
student-centered learning environment. Philadelphia, PA: Lippincott