Chapter 1
The Evolution of
Professional Nursing
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Prehistoric Period
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Health beliefs
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All natural phenomena, including illnesses, were the
work of the gods
Health practices
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Engaged in acts intended to deter evil gods and
demons
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Early Civilization
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Egypt
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Health beliefs and practices
• Valued personal health; preventive measures taken to
appease the gods
• Developed specific laws on cleanliness, food use and
preservation, drinking, exercise, and sexual relations, and a
pharmacopeia with more than 700 natural remedies
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Nursing
• Little information available
• Women were hired by privileged families to care for the sick
and to assist with childbirth; Shiphrah and Puah were
midwives who saved the baby Moses.
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Early Civilization
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Palestine
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Health beliefs and practices
• Developed the Mosaic Code, one of the first organized
methods of disease control and prevention
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Nursing
• Little information available
• Nursing and medical care were provided in the home by
male Hebrew priests and women (usually widows or
maidens) who focused on both physical and spiritual
healing and comfort.
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Early Civilization
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Greece
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Health beliefs
• Believed that the gods and goddesses of Greek mythology
controlled health and illness
• Temples built to honor Asclepius, the god of medicine, were
designated to care for the sick.
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Medical science
• Asclepius carried a staff intertwined with serpents, representing
wisdom and immortality; staff was the model for medical
Caduceus
• Hippocrates is considered the “father of medicine.”
• Hippocrates was the first to attribute disease to natural causes
rather than supernatural causes and curses of the gods.
• Scientific approach; patient-centered approach
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Early Civilization
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India
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Health beliefs and practices
• Vedas (2000-1200 BC), sacred Hindu books, were the source of
information about health practices.
• Focused on the use of magic, charms, herbs, and spices to cure
disease and remove demons
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Medical science
• Developed procedures to perform major and minor surgical
operations
• Recorded extensive information about childhood diseases,
prenatal care, and conditions of the urinary and nervous systems
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Nursing
• Hindu physicians performed major and minor surgeries, including
limb amputations, cesarean deliveries, and suturing wounds
• Women did not work outside the home.
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Early Civilization
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China
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Health beliefs
• Teachings of Confucius (531-479 BC) had a powerful impact
on health practices.
• Believed in the yin and yang philosophy; an imbalance
between the two would result in ill health
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Health practices
• Used treatments, including acupuncture, hydrotherapy,
massage, and exercise, to promote health and harmony
• Used drug therapy to manage disease conditions and
recorded more than 1000 drugs
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Early Civilization
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Rome
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Adapted health and medical practices from the
countries conquered and the physicians enslaved
(27 BC-476 AD)
 Established the first military hospital in Europe in
Rome
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The Renaissance and the
Reformation Period
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Major advancements in medicine: pharmacology,
chemistry, and medical knowledge
“Dark ages” of nursing
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Religious orders became almost extinct as a result of
dissension between Roman Catholic Christians and
Protestant sects
 Nursing no longer appealed to women of high social
status; hospital care was regulated to common women,
prisoners, thieves, and drunks.
 Nursing became an undesirable job with poor pay, long
hours, and strenuous work that was considered menial.
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Middle Ages
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Women used herbs and new methods of healing.
Men used purging, leeching, and mercury.
The Roman Catholic Church became a central figure in
health care.
Wives of emperors and other women became nurses.
Most changes in health care were based on charity and
the sanctity of human life.
Women cared for the sick in their homes.
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The Renaissance and the
Reformation Period
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Social conditions
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Famine, plague, filth, and crime ravaged Europe.
Nursing orders were established out of great
concern for social welfare.
• Sisters of Charity—recruited young women for nurse
training, developed educational programs, and cared for
abandoned children
• St. Vincent de Paul—established the Hospital for the
Foundling to care for orphaned and abandoned children
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The Colonial American Period
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Mexico
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First colonists in Mexico were members of Catholic
religious orders.
Hospital of the Immaculate—first hospital in North
America, built in 1524 in Mexico City; first medical
school, built at the University of Mexico
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The Colonial American Period
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Colonial America
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Health care was sadly deficient; life expectancy was
low; plagues such as yellow fever and smallpox
were a constant threat.
Physicians were poorly trained and used crude
methods of treatment such as bleeding and
purgatives.
Through the efforts of Benjamin Franklin,
Pennsylvania Hospital was the first hospital built in
the United States in 1751.
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Florence Nightingale
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Early nursing career
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Family opposed her interest in nursing at first, then
she was permitted to pursue nurse training.
1851—attended a 3-month nurse training program at
the Institute of Deaconesses at Kaiserwerth,
Germany
1854—began training at the Harley Street Nursing
Home; served as the superintendent of nurses at
King’s College Hospital in London
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Florence Nightingale
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Crimean War
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1854—accepted an assignment to lead a group of 38 nurses
who were sisters and nuns from various Catholic and Anglican
orders to the Crimea to work at the Barracks Hospital in Scutari
Despite deplorable conditions, the army doctors at first refused
her assistance.
Eventually, the doctors, in desperation, called for her help.
Purchased medical supplies, food, and linen; set up a kitchen;
instituted laundry services; initiated social services; spent up to
20 hours each day providing nursing care
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Florence Nightingale
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Major accomplishments
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Demonstrated the value of aseptic techniques and infection
control procedures
Honored for her contributions to nursing research
Demonstrated the value of political activism to affect health
care reform
Established the first nursing school in England
Honored as the founder of professional nursing services,
initiated social services, spent up to 20 hours each day
providing nursing care
Introduced principles of asepsis and infection control, a system
for transcribing doctor’s orders, and a system to maintain
patient records
Kept careful statistics—documented a decrease in the death
rate of soldiers from 42% to 2% as a result of health care
reforms that emphasized sanitary conditions
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Mary Seacole
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Jamaican nurse who played a major role in the
Crimean War
Was denied the opportunity to join Nightingale’s nursing
brigade because she was black
 Opened a lodging house with her own money to care for
sick and wounded soldiers
 Contributed to control of the cholera epidemic through
extensive knowledge in tropical medicine
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Honored by the Jamaican government and the
British Commonwealth with a medal for saving the
lives of countless sick and wounded soldiers
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Nursing in the United States
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The Civil War period
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The Civil War or the War Between the States(1861-1865)
No army nurses and no organized medical corps when
the war began
Dorothea Dix—appointed to organize military hospitals,
provide trained nurses, and disperse supplies; she
received no official status and no salary for this position
6 million people hospitalized during the war—425,000 for
war casualties; vast majority for disease epidemics
181 African-American nurses, both men and women,
served from 1863 to 1864. Caucasian nurses made
$12.00 per month; African-American nurses made $10.00
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Nursing in the United States
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African-American nurses made important contributions.
• Harriet Tubman cared for wounded soldiers and conducted an
“underground railroad” to lead slaves to freedom.
• Sojourner Truth, known for her abolitionist efforts, as well as her
nursing efforts, was an advocate of clean and sanitary conditions
so patients could heal.
• Susie King Taylor, although hired in the laundry, worked full time
as a nurse on the battlefront with no pay or pension; not
considered an official Union Army nurse
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Volunteer nurses who made important contributions
• Clara Barton operated a war relief program; credited with founding
the American Red Cross
• Louisa May Alcott authored detailed accounts of the experiences
encountered by nurses during the war for a newspaper publication
entitled Hospital Sketches.
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Nursing in the United States
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Number of nurse training schools increased after the war
• Offered little classroom education
• On-the-job training occurred in the hospital wards.
• Students were used as supplemental hospital staff.
 1890—Establishment of African-American hospitals and
nursing schools gained momentum.
• John D. Rockefeller established the first school of nursing
for African-American women at the Atlanta Baptist
Seminary, now known as Spelman College.
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Nursing in the United States
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1900 to World War I
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Advances in the nursing profession
• By 1910, most states passed legislation requiring nurse
registration before entering practice.
• Required entry level for nursing students was upgraded to
high school graduate.
• Nurse training programs were improved to include a more
comprehensive course of study.
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Nursing in the United States
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Lillian Wald developed a viable practice for public health
nursing (The Henry Street Settlement) located in the Lower
East Side of New York City.
• Purpose was to provide well baby care, health education,
disease prevention, and treatment of minor illnesses.
• Nursing practice at the Henry Street Settlement formed the
basis for public health nursing in the United States.
Developed the first nursing service for occupational health
(Metropolitan Life Insurance Company)
• Prevention of disease in workers to promote productivity
• Sliding scale fee
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Nursing in the United States
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World War I and the 1920s
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Advances in medical care and public health
• Improved hospital care and surgical techniques
• Discoveries in pharmacology—insulin and the precursor to
penicillin
• Environmental conditions improved; serious epidemics of
the previous century became nonexistent.
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Nursing in the United States
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Advances in nursing
• Nurses served honorably during WWI
• Nurse anesthetists made their first appearance as part of frontline surgical teams.
• U.S. Public Health Service sought the assistance of a nurse to
establish nursing services at military outposts.
• American Red Cross, founded by Clara Barton in 1882,
became more active in urban settings and rural communities.
• Mary Breckenridge established the Frontier Nursing Service
(FNS) in 1925 in rural Kentucky to assist disadvantaged
women and children; documented the impact of nursing
services on improving the health of communities; well known
for midwifery services
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Nursing in the United States
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Legislation
• Sheppard-Towner Act—first legislation to assist special
populations and provide public health nurses with resources
to promote the health and well-being of women, infants, and
children
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The Great Depression (1930-1940)
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Social issues
• American economy was disintegrated with more than 6
million people unemployed.
• Nurses also were forced to join the ranks of the
unemployed.
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Nursing in the United States
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Legislation
• “New Deal” enacted to rescue the country and provide for
medical care and other services for the large numbers of
indigent people
• Social Security Act of 1935 affected health care and
provided avenues for public health nursing.
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Nursing in the United States
• Main purposes of the Social Security Act
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National age-old insurance system
Federal grants to states for maternal and child welfare
services
Vocational rehabilitation services for the handicapped
Medical care for crippled children and blind people to
strengthen public health services
A Federal-State unemployment system
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Nursing in the United States
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World War II
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Legislation
• Programs enacted to expand nursing education and
increase the number of nurses in all military branches
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Advances in nursing
• Nursing became an essential part of the military advance.
• Nurses recognized as an integral part of the military and
attained officer rank
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Nursing in the United States
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Post World War II (1945-1950)
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Social issues
• Unemployment dropped to all-time lows
• Women were encouraged to return to childbearing and
marriage rather than to continue employment outside the
home.
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Advances in nursing
• Demonstrated value to the armed services during the
Korean War
• Emerged as a true profession with minimum national
standards for nursing education established
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Nursing in the United States
• By 1950, all states had adopted the State Board Test Pool.
• Number of nursing baccalaureate programs grew.
• Associate degree programs developed in community and
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junior colleges
Legislation
• Nurse Training Act of 1943—first instance of federal funding
to support nurse training
• Hill-Burton Act—provided funding to construct hospitals;
created a hospital construction boom that increased the
demand for professional nurses
• African-American nurses were barred from membership in
the ANA because of segregation laws; all barriers were
dropped in the early 1960s.
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Nursing in the United States
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Nursing in the 1960s
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Legislation had a major and lasting impact on nursing
and health care.
• Community Mental Health Centers Act of 1963
• Medicaid, Title XIX of the Social Security Act, 1965
• Medicare, Title XVIII of the Social Security Act, 1965
Impact of Medicare reimbursement on nursing
• Hospital occupancy increased, resulting in an increased
need for hospital nurses.
• Nursing embraced the hospital setting as the usual practice
site.
• Home health movement was initiated.
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Nursing in the United States
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Nursing in the 1970s
Influenced by the women’s movement, nurses demanded
fairer wages and better working conditions.
 Hospitals continued to be the focus of nursing education
and practice.
 Nurses were instrumental in developing community
programs, including hospice programs, birthing centers,
and adult day care centers.
 Nurse practitioners began to be recognized as viable,
cost-effective providers of comprehensive health
services.
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Nursing in the United States
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Nursing in the 1980s
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Types of patients needing health care changed.
• Increasing numbers of homeless and indigent
• Emergence of acquired immunodeficiency syndrome (AIDS)
Spiraling health care costs became an issue.
• Diagnosis-related group (DRGs) system for reimbursement was
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instituted.
Hospitals were forced to enhance efficiencies and reduce patients’
length of stay.
Case management emerged as a new area of nursing
specialization.
Outpatient and ambulatory services grew.
Enrollment in managed care plans and health maintenance
organizations grew.
Advanced nurse practitioners increased in popularity.
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Nursing in the United States
• Nursing practice began to move from the hospital setting to
community settings.
• Disease prevention and health promotion gained importance.
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Medical care continued to advance.
• Organ transplantation
• Resuscitation and support of premature infants
• Medical specialties flourished.
• Medical technology flourished.
Inadequate funding for public health programs became an
issue.
Scholars suggested that nursing research needed to be
focused on substantive information to guide practice.
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Nursing in the United States
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Nursing in the 1990s
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Growing concerns about the health of the nation
• Healthy People 2000 initiative
• Increasing focus on health promotion and disease prevention
activities
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Influence of the AIDS epidemic
• New procedures for infection control were required.
• Universal Precautions were mandated.
Exposure to hazardous materials
• Workplace chemicals and radioactive substances created health
risks.
• Employee training was instituted across all industries.
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Nursing in the United States
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Managed care movement
• Focus moved from acute care to prevention and primary care.
• Emphasis on outpatient, ambulatory, and home services
• Massive downsizing of hospital nursing staff and increase in
unlicensed assistive personnel
• Increasing demand for community health nurses and advanced
practice nurses
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Changing nursing requirements for the 1990s and beyond
• Focus on health risk assessments based on family and
environmental issues
• Focus on health promotion and disease prevention
• Promote counseling and health education
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Nursing in the United States
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Nursing in the 21st century
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Challenges facing professional nurses
• Changing duties and responsibilities
• Severe nursing shortage
• Patient safety, accountability, and quality of care
Core competencies required by professional nurses
• Critical thinking
• Communication
• Assessment
• Leadership
• Technical Skills
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Nursing in the United States
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Knowledge required by professional nurses
• Health promotion/disease prevention
• Information technology
• Health systems
• Public policy
Consumer issues in health care
• Access
• Quality
• Cost
• Accountability
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Nursing in the United States
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Changes in society
• Aging population
• Intercultural population
• Consumer health value
• Need for a well-trained work force
• AACN (2004) reports 8.1% faculty vacancy rate; average age of
full time faculty older than 54.3 years of age
• Nurse Reinvestment Act signed into bill August 2002 to provide
funds for nursing education, recruitment, and retention
• 2.9 million nurses make up the largest health care profession.
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Nursing in the United States
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Opportunities for professional nurses
• Opportunities to increase knowledge
• Evidence-based practice
• United efforts to shape health care; influence policy
• United efforts to address the nursing shortage
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