Introduction to Nursing (OER): Chapter 1

To fully appreciate nursing as both a science and art, this chapter reviews nursing history and describes how nurse pioneers shaped the profession. Originally, health care was provided by priests, monks, knights, nuns, family members, lay midwives. Contemporary nursing practice was developed by meeting the needs of various populations: wartime injuries, public health issues, sanitation, infection prevention, and maternal and infant mortality. 

The duties and responsibilities of nurses have evolved. In the 19^th century, nurses were required to care for patients, maintain personal integrity, provide housekeeping duties, and work from 7:00 am to 9:00 pm (Archives of New Zealand, n.d.). The following quote is from a certificate awarded to Elizabeth Bregg at Wellington Hospital in New Zealand during that period (Archives of New Zealand, n.d.).

“You are required to be sober, honest, truthful, trustworthy, punctual, quiet and orderly, cleanly and
neat, patient, cheerful, and kindly. You are expected to become skillful – 

1. In the dressing of blisters, burns, sores, wounds; in applying fomentations, poultices, and 
dressings.
2. In the administration of enemas and the use of the catheter for women.
3. In the management of helpless patients, i.e., moving, changing, personal cleanliness of, 
feeding, keeping warm or cool, preventing and dressing bed sores.
4. In bandaging, making bandages and rollers, and lining splints.
5. To be competent to cook gruel, arrowroot, puddings, and drinks for the sick.
6. To understand ventilation or keeping the ward fresh by night as well as by day. You are to 
be careful that great cleanliness is observed in all the utensils, those used for the secretions 
as well as those required for cooking.
7. To make strict observation of the sick in the following particulars:
The state of excretions, expectorations, pulse, skin, appetite; intelligence, as delirium or stupor; 
breathing, sleep, state of wounds, eruptions; effect of diet or of stimulants and of medicines. 
To “take” the temperature and respiration.
8. And to learn the management of convalescence.”

Originally, nurses were not allowed to marry and were cloistered in dormitories on hospital grounds where they lived strictly disciplined lives (Weatherford, 2010). Students served as free labor, scrubbing floors, doing laundry, and other menial tasks.  Later, nursing education was transformed by strong leaders who introduced the nurse uniform and cap which became a respected symbol of high academic standards (Weatherford, 2010). Despite reforms in education, nurses and students continued to work long hours six days per week (Hurst, 2009). 

Florence Nightingale

Image source: CreativeCommons.com

Florence Nightingale was born on May 12, 1820, into a wealthy family who did not appreciate her desire to care for the sick and injured. She pursed her calling despite the negative social stigma attached to nursing. She enrolled as a nursing student at the German Institute of Protestant Deaconesses in 1850 and became a trailblazing figure who transformed 19^th-century healthcare policies. After graduation, she returned to London and improved hospital hygiene practices and sanitation, which decreased the cholera death rate. In 1853 18,000 soldiers were in foreign hospitals during the Crimean War and were neglected and living in unsanitary conditions. The English government asked Nightingale to organize a corps of nurses and within three days, she recruited three dozen nurses and sailed for Constantinople. The military hospital sat on a large cesspool that contaminated the water and building. Using statistics, she discovered that the high rate of death was from infectious diseases rather than combat injuries. Nightingale and her nurses scrubbed floors, walls, beds, linens, and utensils.  She spent every waking moment caring for the soldiers and became known as “the lady with the lamp” who made constant rounds (Selanders, 2019).

Due to her efforts, the death rate was reduced by two thirds within six months. In the summer of 1856, Queen Victoria gave her an engraved brooch which became known as the Nightingale Jewell. She used her gift of $250,000 from the Queen to develop the Nightingale Training School for Nurses at St. Thomas Hospital in London (Biography.com, 2019a).

Despite these successes, Nightingale contracted Brucellosis and was homebound by the age of 38. However, she continued to improve healthcare around the world through her writings. She elevated nursing from a lowly occupation to an honorable profession and became known a the first practicing nurse epidemiologist and an expert statistician. Her coxcomb pie charts on mortality rates influenced the direction of medical epidemiology around the world. In 1857, she published her Crimean War research which established the Royal Commission for the Health of the Army. In 1859, she published Notes on Hospitals which addressed administration issues. She served as a consultant in the United States Civil War on field hospital management and consulted with the Indian government on sanitation practices. 1907 she received the Order of Merit from King Edward and in 1908 was the first woman to receive the Freedom Medal of London. In 1910 King George sent a celebratory message on her 90^th birthday (Biography.com, 2019a).

Nightingale’s most well-known book, Notes on Nursing: What it is and What it is Not (Nightingale, 1859) shaped contemporary nursing and much of its content remains relevant today. She stated that a nurse’s role “is to put the patient in the best condition for nature to act upon him” (Nightingale, p. 133, 1859). “If a patient is cold, if a patient is feverish, if a patient is faint, if he is sick after taking food, if he has a bedsore, it is generally the fault not of the disease but of the nursing” (Nightingale, p. 8. 1859). However, she recognized that environmental factors such as architecture, sanitation, and administration could render quality nursing care impossible. She also emphasized that the art of nursing should include careful therapeutic communication (Nightingale, 1860).

This video by a well-known nurse, Barbara Dossey, brings Nightingale’s insights to modern-day nursing: https://www.youtube.com/watch?v=mRAoD0-loWM. Miss Nightingale died on August 13, 1910, having lived 90 years.  Before her death, she refused a national funeral and was buried in her family plot in Hampshire England. For more information on this phenomenal nurse, and a look at her home, go to http://www.florencenightingale.org/.   

The English nurse Florence Nightingale was an innovator in displaying statistical data through graphs. In 1858 she devised the typed depicted here, which she named Coxcomb. Like pie charts, the Coxcomb indicates frequency by relative area, but it differs in its use of fixed angles and variable radii.

Image source: Encyclopedia Britannica  https://www.britannica.com/biography/Florence-Nightingale/media/415020/70822

Clara Barton

Image Source: National Women’s History https://www.womenshistory.org/education-resources/biographies/clara-barton

Clara Barton was born on December 25, 1821, and became interested in nursing while helping her brother after a severe head injury. She became a teacher at the age of 15 and opened a free public school in New Jersey. In the 1850's she moved to Washington, D.C. and worked as a clerk in the United States Patent Office. During the Civil War, she distributed supplies for the Union Army but was not content. She became an independent nurse and saw combat in Fredericksburg, VA. She cleansed wounds, comforted dying soldiers, and became known as the ‘Angel of the Battlefield’ (Michals, 2015).

She worked with the International Red Cross in Switzerland during the Franco-Prussian War. Upon return to the U.S., after ten years of lobbying, she founded The American Red Cross in 1881. As its first President, she guided the first relief work for victims of natural disasters such as floods and served in that capacity until 1904. She was an autocratic leader who took no salary and often used her own funds to finance relief efforts. She died on April 12, 1912 (Biography.com, 2019b).

Lavinia Dock

Image source: Wikipedia

Born on February 26, 1858, Lavinia Lloyd Dock was financially independent. She was inspired by an article to become a nurse and graduated from the Training School for Nurses in 1886 at Belview Hospital in New York. In 1889 she worked with Clara Barton in the Johnstown, Pennsylvania flood. In 1890, she published Materia Medica for Nurses as the first standard nursing textbook. She was appointed by Isabel Hampton Robb as Assistant Superintendent of Nurses at the new Johns Hopkins Hospital. In 1893 she organized the American Society of Superintendent Training Schools and the Nurses Association Alumni which is now known as the American Nurses Association (American Association for the History of Nursing [AAHN], n.d.a; Sklar, 2000).

In 1896 she joined other nurses at the Henry Street Settlement on the lower East Side of New York City and learned much about critical thinking while caring for a large immigrant population.  She developed a strong empathy for oppressed classes and worked for 20 years to transform public health delivery. In 1899 Dock and Ethyl Gordon Fenwick founded the International Council of Nurses. In 1907 she wrote The History of Nursing with Adelaide Nutting. In the same year, her political allegiance shifted from nursing to suffrage when she joined the Equality League of Self-Supporting Women (Sklar, 2000). 

In 1911, she opposed state regulation of prostitution and advocated for the treatment of sexually transmitted diseases. In 1917, she moved to Washington, DC and helped to establish the National Women’s Party and picketed the White House for which she was jailed three times. In 1921 she advocated for the Equal Rights Amendment and in 1947 was honored for her achievements by the international council of nurses. Dock died on April 17, 1956. (AAHN, n.d.a) 

Lillian Wald

Image Source: Wikipedia

Lillian Wald was born on March 10, 1867, to a privileged family of Jewish descent. She is considered one of the most influential and respected social reformers of the 20^th century. As a gifted student, she applied to Vassar at the age of 16 but was refused due to her young age. She graduated from the New York Hospital School of Nursing in Manhattan in 1891. She later attended the Women's Medical College to become a physician where she accepted an opportunity to organize classes in-home nursing for immigrants on the Lower East Side of New York City. There she witnessed poor sanitation and living conditions. She left medical school to establish and live within the Nurses' Settlement which became known as the Henry Street Settlement. During this time, she established the first American public-school nursing program. In 1910, the Teachers College at Columbia University established a department of nursing and health where she was appointed as the first professor of nursing. Due to her efforts, most nursing education takes place in academic settings with hospital-based clinical experience (Henry Street Settlement, n.d.; Virginia Commonwealth University, n.d.).

In 1893 she stared the Visiting Nurses Service. Nursing care was provided along with social services and education on many subjects. In 1905 the group included 18 district centers and 4,500 patients. By 1913, the Henry Street Settlement had expanded to seven buildings and two satellite centers. There were 3,000 members and 92 nurses who made over 200,000 visits per year. Referrals came from physicians, individuals, and charitable organizations. Health education classes were offered, and the Boys and Girls Clubs of American were started. Wald coined the term, Public Health Nursing and placed nurses in public schools (Henry Street Settlement, n.d.; Encyclopedia Britannia.com, n.d.).

During World War 1, Wald formed the American Union Against Militarism to combat the war. She and others lead a march of 1,000 women in New York to protest the war. She was a member of the Women’s Peace Party and later created the Women’s International League for Peace and Freedom. She worked with Margaret Sanger on the right for women to have birth control and served in the American Red Cross. She also lobbied for safe industrial workplaces (Encyclopedia Britannia.com, n.d.). Wald authored The House on Henry Street and Windows on Henry Street. 

She received the Lincoln Medallion as an outstanding citizen of New York and was named one of the twelve greatest living American women by the New York Times. In summary, Wald was known as a courageous national leader who campaigned for social reform, public health, and human rights. She influenced and helped to establish the National Association for the Advancement of Colored People, the United States Children’s Bureau, the National Child Labor Commission, and the National Women’s Trade Union and League (Virginia Commonwealth University, n.d.). Wald died on September 1, 1940, at the age of 73. 

Isabel Hampton Robb

 Image Source: Medical Archives of the Johns Hopkins Medical Institutions

Isabel Hampton Robb was born on August 26, 1859, in Ontario, Canada. She graduated from the Belview Training Hospital for Nursing in 1883 and worked at St. Paul’s House in Rome, Italy which served American and European travelers. In 1886, she was appointed Superintendent for the Illinois Training School for Nurses at Cook County Hospital in Chicago. There she implemented a grading scale for nurses to prove competencies in nursing practice.  She also developed the curriculum for Lakeside Hospital which became Case Western and was the first to include teachings of Florence Nightingale (AAHN, n.d.b; Case Western Reserve University, n.d.).

She became the first Superintendent at Johns Hopkins School of Nursing in 1889. In 1893 she published Nursing: It’s Principles and Practices which guided nursing curricula over three years. This text included economics, proper hygiene, protocols for bacteriological notes, and proper bed-making and standardized nursing education in the United States and abroad (Medical Archives of the Johns Hopkins Medical Institutions [MAJHM], n.d.).   

Hampton and Dock founded the American Society of Superintendents of Training Schools for Nurses in the United States and Canada which later became the National League for Nursing (Medical Archives of the Johns Hopkins Medical Institutions, n.d.).  In 1896 she became the first president of the American Nurses Association formerly known as the American Nurses Association Alumni (MAJHM, n.d.).

In 1899 Robb helped to establish the American Journal of Nursing and developed a course in hospital economics at Teachers College at Columbia University. Robb, Hampton, Dock, and Nutting were the first professors to teach the course. In 1900 she authored Nursing Ethics and in 1907 Educational Standards for Nurses. She died in 1910 in a tragic streetcar accident (MAJHM, n.d.). She was later inducted into the American Nurses Association Hall of Fame (American Nurses Association, n.d.).

Image Source: Wikipedia. The first nursing class of Johns Hopkins Hospital.

Mary Mahoney

Image Source: Wikipedia

Mary Mahoney was born on May 7, 1845. She began working as an untrained practical nurse at the New England Hospital for Women and Children. She served as a cook, a janitor, and washerwoman until she became the first black woman to graduate from the hospital's nurse training program. She was also one of the three students to graduate from a class of 40 where sixteen-hour days were considered the norm (Hurst, 2009). She was one of the first black members of the Nurses Association Alumni of the United States and Canada and the National Association of Colored Graduate Nurses. She worked as a private duty nurse for prominent Boston families and in 1900 she served as the Superintendent of Howard Orphan Asylum for Black Children in New York (Biography.com, n.d.).

Mahoney is credited as one of the first women to register to vote in Boston. She died on January 4, 1926. She was inducted into the Nursing Hall of Fame in 1976 and was added to the National Women’s Hall of Fame in 1993 (Hurst, 2009).

Mary Adelaide Nutting

Image Source: Wikipedia    

Mary Adelaide Nutting was born on November 1, 1858, in Quebec, Canada. She was a student in the first class of Johns Hopkins Hospital School of Nursing. After graduation, she became a head nurse and was later promoted to Assistant Superintendent. In 1894 she promoted to Superintendent and Principal of the School of Nursing by Isabel Hampton Robb. She worked to transform nursing education where students worked 60-100 hours per week. She changed priorities, removed stipends, expanded curriculum from two to three years, and provided scholarships for needy students (Encyclopedia Britannia, 2019).

While at Johns Hopkins Hospital School of Nursing, Nutting created multiple courses including hospital economics where she taught part-time until 1907. She also developed a six-month preparation course in hygiene, elementary practical nursing, anatomy, physiology, and pharmacology to prepare students for hospital ward work and established the professional library at Johns Hopkins. She was the first nursing professor at Columbia and served as the head of the nursing department until retiring in 1925. Her course in hospital admin, nursing education, public health brought the college international recognition (MAJHM, n.d.).

In 1900 she helped to establish the American Journal of Nursing.  In 1934 she became the honorary president of the Florence Nightingale International Foundation. In 1944 she was the first recipient of the National League for Nursing award titled the Mary Adelaide Nutting Medal.  Before her death on October 3, 1948, she authored several books including The Education and Professional Position of Nurses which reported her research on U.S. schools of nursing (Encyclopedia Britannia, 2019).

Mildred Montag

Image Source: Teachers College Columbia University

Mildred Montag was born on August 10, 1908, and died on January 21, 2004. She received a baccalaureate in nursing from the University of Minnesota and a Master of Nursing and Ph.D. from Teachers College Columbia University. She held numerous prestigious tenured positions at St. Luke’s Hospital School of Nursing and Adelphi University (Teachers College Columbia University, 2004).

Her influence on nursing education in the United States and abroad was primarily due to her focus on elevating nursing as a profession. To address the serious nursing shortage caused by World War II, she redefined nursing education by moving programs into community and junior colleges. Before her work, 85% of the nursing curriculum was designed by physicians and hospitals. This evolutionary step moved students into an academic model, which spread across the nation. In 1958 the William W. Kellogg foundation financed pilot programs in seven community colleges across four states. By 1994 there were 868 Associate Degree Nursing programs (Harker, 2017).

The transformation of nursing education included specific sequences: course work, clinical laboratories, and academic preparation. Her work impacted the delivery of nursing care and licensure at various levels of preparation. Her goal was to ensure that patient care be given by well-educated nursing professionals (Harker, 2017). 

Other pioneers

Other less known nurses influenced contemporary nursing. Linda Richards was America’s first trained nurse, graduating from the New England Hospital for Women and Children (AAHN, n.d.c). She introduced narrative notes for physicians and nurses to improve clinical communication. Harriet Tubman provided independent nursing care (non-trained) during the Civil War to freed slaves as they journeyed north (Larson, n.d.).