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Evolution Of Nursing

Evolution Of Nursing
Masoud khodaveisi
Contemporary Nursing Issues,
Trends, & Management, 2014
Barbara Cherry, Susan R. Jacob
CHAPTER 1 The Evolution of
Professional Nursing, Page 1
Evolution Of Nursing
 Nursing is a dynamic profession that has evolved into a
theory, research, and evidence-based practice.
 From its unorganized and variably defined beginnings, to a
profession based on the framework of competence,
autonomy, determination, and human caring has
• The challenges and opportunities have paralleled the path
of world history and have brought about significant
changes in the profession.
Evolution Of Nursing
 From the men who opened the path, to the women who
brought dignity and respect to their philosophy of caring,
to the pioneers who brought unity to the profession
plagued by a history of racism, sexism, and sometimes
disgrace, nursing has become recognized as critical to the
health of the nation.
 Despite myriad challenges, the practice of nursing has been
distinguished and qualified by the intellect, skill,
commitment, and contribution of countless sisters,
deaconesses, and individuals, such as Seacole, Dix, Barton,
Wald, Breckenridge, and Nightingale.
Evolution Of Nursing
The nursing profession has the capacity to effect
far reaching changes in the health care system.
Close proximity to patients and scientific
understanding of care across the health care
continuum from health promotion to disease
prevention to coordination of care give nurses the
unique ability to lead in the improvement and
redesign of the health care system.
Evolution Of Nursing
Research has linked nursing care to the safety of
Nurses will continue to increase knowledge,
manage technology, and maintain ethical
standards to provide high-quality, patientcentered, safe care to individuals, families,
communities, and populations throughout the
Evolution Of Nursing
Nurses are crucial in preventing medication
errors, reducing infection rates, and facilitating
patients‟ transition from hospital to home.
Significant nursing contributions to creating a
quality, patient-centered health care system that is
accessible, equitable, evidence based, and
sustainable will require transforming the work
environment, scope of practice, education, and
numbers of nurses.
Evolution Of Nursing
Through periods of war, socioeconomic change,
and health care reform, nurses have played a vital
role in initiating change to improve the health care
Nurses have provided the integrity to maintain the
quality of care in all health care settings.
Evolution Of Nursing
 The evolution of the practice from the treatment of disease
to health promotion and disease prevention has led the way
in determining the type of providers needed to care for
patients in the future.
 This evolution will continue to provide the foundation for
the scope of practice, educational curricula, scholarship,
and research necessary for nurses to lead and manage the
health care environment of the future.
Important Events In The Evolution Of Nursing
 1751 The Pennsylvania Hospital is the first hospital
established in America.
 1798 The U.S. Marine Hospital Service comes into being
by an act of Congress on July 16. It is renamed the
U.S. Public Health Service in 1912.
 1840 Two women, Mary Williams and Frances Rose, who
founded Nursing Sisters of the Holy Cross, are listed as
nurses in the City of Baltimore Directory.
 1851
Kaiserswerth to train as a nurse.
Important Events In The Evolution Of Nursing
 1854 During the Crimean War, Florence Nightingale
transforms the image of nursing.
 1861 The outbreak of the Civil War causes women to
volunteer as nurses.
 1872 Another school of nursing opens in the United States:
the New England Hospital for Women and Children in
Boston, Massachusetts.
Important Events In The Evolution Of Nursing
 1873 Linda Richards is responsible for designing a written
patient record and physician‟s order system the first in a
 1879 Mary Mahoney, the first trained nurse, graduates
from the New England Hospital for Women and Children
in Boston, Massachusetts.
 1882 The American Red Cross is established by Clara
 1886 The Visiting Nurse Association (VNA) is started in
Philadelphia; Spelman College, Atlanta, Georgia,
establishes the first diploma nursing program for
Important Events
 1893 Lillian Wald and Mary Brewster establish the Henry
Street Visiting Nurse Service in New York.
 1896 The Nurses‟ Associated Alumnae of the United
States and Canada is established.
 1898 Namahyoke Curtis, an untrained nurse, is assigned
by the War Department as a contract nurse in the SpanishAmerican War.
 1899 The International Council of Nurses (ICN) is
 1900 The first issue of the American Journal of Nursing
is published.
Important Events
 1901 The Army Nurse Corps is established under the
Army Reorganization Act.
 1902 School of nursing is established in New York City by
Linda Rogers.
 1903 The first nurse practice acts are passed, and North
Carolina is the first state to implement registration of
 1908 The National Association of Colored Graduate
Nurses is founded; it is dissolved in 1951.
Important Events
 1909 Ludie Andrews sues the Georgia State Board of
Nurse Examiners to secure nurses the right to take the
state board examination and become licensed; she wins in
 1911 The American
 1912 The U.S. Public Health Service and the National
League for Nursing (NLN) are established.
 1918 Eighteen black nurses are admitted to the Army
Nurse Corps after the armistice is signed ending World
War I.
Important Events
 1919 Public Health Nursing is written by Mary S.
Gardner. A public health nursing program is started at the
University of Michigan.
 1921 The Sheppard-Towner Act is passed providing
federal aid for maternal and child health care.
 1922 Sigma Theta Tau is founded (becomes the
International Honor Society of Nursing in 1985).
 1923 The Goldmark Report criticizes the inadequacies
of hospital-based nursing schools and recommends
increased educational standards.
Important Events
 1924 The U.S. Indian Bureau Nursing Service is founded
by Elinor Gregg.
 1925 The Frontier Nursing Service is founded by Mary
 1935 The Social Security Act is passed.
 1937 Federal appropriations for cancer, venereal diseases,
tuberculosis, and mental health begin.
 1939 World War II begins.
 1941 The U.S. Army establishes a quota of 56 nurses for
admission to the Army Nurse Corps. The Nurse Training
Act is passed.
Important Events
 1943 An amendment to the Nurse Training bill is passed that
bars racial bias.
 1945 The U.S. Navy drops the color bar and admits four
African-American nurses.
 1946 Nurses are classified as professionals by the U.S. Civil
Service Commission. The Hospital Survey and Construction
Act (Hill-Burton) is passed.
 1948 The Brown Report discusses the future of nursing.
 1948 Estelle Osborne is the first nurse elected to the board of
the ANA. The ANA votes individual membership to all
African-American nurses excluded from any state association.
Important Events
 1949 M. Elizabeth Carnegie is the first nurse to be elected
to the board of a state association (Florida).
 1950 The Code for Professional Nurses is published by
the ANA.
 1952 National nursing organizations are reorganized from
six to two: ANA and NLN.
 1954 The Supreme Court decision Brown v. Board of
Education asserts that “separate educational facilities
are inherently unequal.”
Important Events
 1965 The Social Security Amendment includes Medicare
and Medicaid.
 1971 The National Black Nurses Association is organized.
 1973 The ANA forms the American Academy of Nursing.
 1974 The American Assembly of Men in Nursing is
 1978 Barbara Nichols is the first nurse elected president of
the ANA. M. Elizabeth Carnegie, a nurse, is elected
president of the American Academy of Nursing.
Important Events
 1979 Brigadier General Hazel Johnson Brown is the first
chief of the Army Nurse Corps.
 1985 Vernice Ferguson, a nurse, is elected president of
Sigma Theta Tau International.
 1986 The Association of Black Nursing Faculty is founded
by Dr. Sally Tucker Allen.
 1990 Congress proclaims March 10 as Harriet Tubman
Day in the United States, honoring her as a brave freedom
fighter and nurse during the Civil War.
 1990 The Blood borne Pathogen Standard is established by
Important Events
 1991 Healthy People 2000 is published.
 1993 The National Center for Nursing Research is
upgraded to the National Institute of Nursing Research
within the National Institutes of Health.
 1994 NCLEX-RN®, a computerized
examination, is introduced.
 1996 The Commission on Collegiate Nursing Education is
established as an agency devoted exclusively to the
accreditation of baccalaureate and graduate-degree
nursing programs.
Important Events
 1999 Beverly Malone, the second president of the ANA, is
named Deputy Assistant Secretary for Health, Department
of Health and Human Services, Office of Public Health and
 1999 The IOM releases its landmark report: To Err Is
Human: Building a Safer Health System.
 2000 M. Elizabeth Carnegie is inducted into the ANA Hall
of Fame. The American Nurses Credentialing Center gives
its first psychiatric mental health nurse practitioner
examination. Healthy People 2010 is published.
Important Events
 The AACN reports a faculty vacancy rate of 7.4%
among the 220 nursing schools that responded to a
survey. According to the AACN, the average age of fulltime faculty is older than 50 years of age; the average age
of doctorally prepared professors is 55.9 years of age.
 2001 Beverly Malone is appointed General Secretary,
Royal College of Nursing, London. The Health Care
Financing Administration (HCFA) becomes the Centers
for Medicare & Medicaid Services (CMS).
Important Events
 2002 Johnson and Johnson Health Care Systems, Inc.
launches The Future of Nursing, a national publicity
campaign to address the nursing shortage.
 2002 To address the nursing shortage, the Nurse Reinvestment
Act is signed into law by President George W. Bush.
 2002 Significant funding is obtained for geriatric nursing
 2003 The American Nurses Foundation launches an
“Investment in Nursing” campaign to deal with the nursing
 2003 The IOM report Keeping Patients Safe: Transforming the
Work Environment of Nurses is released.
Important Events
 2003 The AACN White Paper on the Role of the Clinical
Nurse Leader is published.
 2005 The CCNE decides that only programs that offer
practice doctoral degrees with the Doctor of Nursing
Practice (DNP) title will be eligible for CCNE
 2005 The NLN offers and certifies the first national
certification for nurse educators; the initials CNE may be
placed behind the names of those certified.
 2006 The AACN approves essentials of doctoral education
for advanced nursing practice (DNP).
Important Events
 2007 The Commission on Nurse Certification, an
autonomous arm of the AACN, begins certifying clinical
nurse leaders (CNLs).
 2008 The Commission on Collegiate Nursing Education
begins accrediting DNP programs.
 2010 The Patient Protection and Affordable Care Act
(Public Law 111-152) is passed.
 2010 The Health Care and Education Affordability
Reconciliation Act is passed.
 2011 The IOM Report The future of nursing: leading
change, advancing health is released.
Nursing education in Iran
Nursing education in Iran: Past, present, and
The history of modern nursing education
in Iran
Rasoul Tabari Khomeiran a, Cecil Deans
History Of Modern Nursing Education In Iran
• The development of nursing in Iran has been
influenced by historical, religious, cultural and
economic variables.
• As with many other developing countries, such as
China, Taiwan and Lebanon, modern nursing was
introduced to Iran by Western missionaries.
Along with their religious duties, the missionaries
initiated medical services for local residents and
trained a small number of Iranian women in the
care of sick people in hospitals.
History Of Modern Nursing Education In Iran
 In 1916, eleven years after the introduction of the first nursing school
in the Middle East in Lebanon, an American missionary established
Iran‟s first nursing school, in Tabriz, which offered a program that
largely met the local hospital‟s needs and focused on the practical
aspects of nursing.
 The graduates from the Tabriz school contributed significantly to the
distribution of ideas emanating from the American model of nursing.
 It remained the only nursing program in Iran until 1935 when the
government established four new nursing schools: in Mashhad, Shiraz,
Rasht and Tehran.
 The graduates of these schools were called „doctor assistants‟, in
recognition of the then-accepted view of nurses as handmaidens, and
doctors as holding a superior place in the community.
History Of Modern Nursing Education In Iran
 Over the years, under the influence of British trained
nurses, Iranian‟s nursing education system underwent a
gradual shift from the American nursing model to the
British nursing model.
 During this time, the influence of British nursing practice
on the Iranian nursing profession was profound and far
 As with their colleagues in western countries, the nurses
who trained under this system were influenced by Florence
Nightingale who had had a major impact upon nursing
History Of Modern Nursing Education In Iran
 The Islamic revolution and its subsequent „„Cultural Revolution‟‟
brought about many changes in the higher education system.
 The nursing education scheme, largely based upon the British
system, was replaced by a reconstructed academic system, and
nursing curricula were revised.
 At the time, some nursing schools were affiliated to the Ministry of
Culture & Higher Education [MCHE] (now the Ministry of
Science, Research & Technology [MSRT]), while some were
affiliated to the Ministry of Health (MoH).
 During this period, there was an increased demand for practical
nurses due to the Iran–Iraq war and an acute shortage in skilled
nurses across the country.
History Of Modern Nursing Education In Iran
 In order to meet this demand and generate a rapid
increase in the nursing workforce over a short period, the
three-year nursing programs were replaced with a twoyear basic nursing program.
 The graduates of the two-year basic program were then
able to take a competitive nationwide examination to
determine their eligibility to enroll in an additional twoyear program leading to a baccalaureate degree in nursing.
History Of Modern Nursing Education In Iran
Those nurses who had been educated under the
earlier three-year programs were offered an
additional one-year program that would qualify
them for a baccalaureate degree.
In 1987, the temporary subsidence of high demand
for nurses meant the two-year programs were
abrogated, and the basic nursing program was
consolidated to create a four-year nursing
History Of Modern Nursing Education In Iran
 As mentioned earlier, the Islamic revolution had a major impact
on Iran‟s higher education sector, including nursing education.
 One significant change was the integration of religious beliefs
within the nursing education program to fulfill the spiritual
needs of the community the applicants planned to serve.
 Another major change came from the recommendation that
nursing care may be improved when it is delivered by nurses of
the same sex as the patient, and, despite the fact that nursing
was traditionally perceived in Iran as a female profession, this
recommendation resulted in changes to the distribution gender
of applicants, with increasing numbers of males motivated to
select nursing as their career.
History Of Modern Nursing Education In Iran
 In the past two decades, the growth and development of
nursing schools has been determined and influenced by
various pieces of government legislation.
 In response to the need created by rapid post-war
development to supply an adequate workforce for the
health care sector, the medical section of the MCHE was
incorporated into the MoH in 1985.
 As a result of the nationwide restructuring of higher
education, the medical education section, alongside
treatment affairs, undergone supervision of a new
established authority called Ministry of Health & Medical
Education (MoHME).
History Of Modern Nursing Education In Iran
 In that year, all nursing schools affiliated to the former
MoH (non-university-affiliated schools) and schools
affiliated to the former MCHE were integrated into the
 These changes led to a significant increase in medical
education placements and subsequently the number of
student admissions.
 These changes, which enhanced the establishment of
higher education institutes all over the country, were
largely accomplished by ongoing appeals from political
parties and resulted in a considerable increase in the
number of nursing schools in Iran.
History Of Modern Nursing Education In Iran
 From the late 1980s, budget considerations together with
an over-supply of nursing graduates forced the MoHME
and government to revise policies regarding the admission
of nursing students.
 A comprehensive evaluation of the viability of nursing
programs resulted in the closure of a number of smaller
nursing schools.
 Simultaneously, a number of other nursing schools were
urged to close their part-time programs and decrease the
number of students admitted to full-time programs.
 These measures resulted in a considerable decrease in the
total number of nursing student admissions over last
The Iranian nursing education system
 Due to the large number of general applicants for the
limited number of university places in Iran, applicants to
all courses including medical and medical-related courses
such as nurse education programs are required to have
passed the competitive National Higher Education
Entrance Examination (NHEEE).
 Although there is no passing score for the NHEEE,
applicants who attain high rankings have a higher
probability in gaining entry to university and their desired
course of study.
 Generally, the highest ranked students select the more
socially prestigious courses, such as medicine, dentistry or
The Iranian nursing education system
Lower ranking students have limited choice and
often select courses, including nursing, most often
without any particular motivation or interest.
The rationale for selecting a university course,
even one that is not a first preference, is that it
attracts a grant to study in university which is
perceived by the general public as prestigious and
a significant social advantage;
however, in some disciplines with a clinical
component, there may be some negative
The Iranian nursing education system
 In Iran, the government regulates nursing and other health
discipline education through a series of education plans.
 The nursing education plan, approved by MoHME‟s Nursing
Council, sets a national standard for nursing education for the
whole country.
 The plan includes the aims, scope and contents of nursing
education in all education programs, and all nursing schools must
consider the plan when implementing nurse education activities.
 Each nursing school, however, has a right to develop its own
curriculum guidelines based upon the national nursing education
 These guidelines include a description of learning and teaching
methods, types of assessment, evaluation and examination
The Iranian nursing education system
 Nurse education programs are offered through two
different cost systems. The first is through the state sector
MSUs, which are affiliated to and supervised by MoHME.
 The state sector system provides an equal opportunity to
everyone, irrespective of wealth and income level, to study
at an Iranian university. In the state sector MSUs, nursing
education (and all other higher education) is free of charge
for students, although they must pay for their books and
other study expenses.
 In addition, many students attending MSUs are entitled to
grants through a loan from the welfare bureau of
MoHME, with repayments required once the graduate is
The Iranian nursing education system
The second cost system is offered through the nongovernment nationwide Azad University (AU) in
more than sixty nursing schools is available in
large and small cities all over the country.
Although there is no exact number available for
student enrolments in the AU nursing programs, it
estimated that these student enrolments exceed
those in the state sector nursing schools.
The Iranian nursing education system
 In Iran, students can study nursing across all higher
education levels from bachelor to doctoral.
 However, unlike some western countries, Iran does not
differentiate by rank within licensed nursing personnel,
and Registered Nurse (RN) is the only professionally
recognized rank. Upon successful completion of nurse
education programs, graduates are automatically granted
the status of RN, which is the minimum legal and
educational requirement for professional nursing practice.
 As RNs are trained as generalists rather than specialists,
they are eligible to practice in any ward of the hospital.
The Iranian nursing education system
Although continued education programs are
offered to nurses, and they are evaluated by their
managers on an annual basis, currently there is no
renewal system for RNs.
Consequently, almost every nurse‟s registration
status continues automatically, unless the nurse
engages in actions that require disciplinary
The Iranian nursing education system
Two other categories of health workers are
employed alongside and assisting RNs: Komak
Behyar (associated nurse assistant) and Behyar
(nurse assistant).
These health workers complete their unique
training programs in the non-higher education
Komak Behyar: associated nurse assistant
The Komak Behyar, in terms of organizational
structure, is the most junior member of the health
care delivery team in direct contact with patients.
Following a short-time, vocational training
hospital-based course, which varies in length
between two months and six months and is
conducted by RNs,
the Komak Behyar is employed generally to satisfy
the patients‟ needs by performing basic nursing
Behyar: nurse assistant
The Behyar, to a large extent, is equivalent to the
assistant nurse in other countries.
The Behyar is able to provide primary nursing
care independently and is engaged in more
advanced nursing care under RN supervision.
There are two types of Behyar training programs.
One enrolls high school graduates through an
exclusive competitive examination held by
MoHME and has a one-year curriculum.
Behyar: nurse assistant
The other admits high school first-year students
and has a three-year curriculum.
Graduates of Behyari programs are awarded a
tertiary diploma.
In some wards, such as outpatient clinics, and in
some less developed areas of the country, the
Behyar are the primary nursing workforce relied
upon to provide nursing care.
Baccalaureate programs
 In Iran, the baccalaureate program is the basic nursing
program at the academic level and the only avenue leading
to registration as a professionally registered nurse.
 The goal of this program is to produce competent nurses
with the necessary theoretical knowledge and technical
skill to provide high quality general nursing care.
 The centralized four-year baccalaureate program
produces graduates who are generalist nurses and
constitutes the backbone of the nurse education system in
Baccalaureate programs
 As with all other university-based programs, high school
graduates are admitted to these programs on the basis of
their ranking in the competitive NHEEE.
 Currently, there are approximately 100 baccalaureate
nursing programs (each with at least 130 credits) offered in
MSUs and AU courses across the country.
Baccalaureate programs
 The learning environment for students engaged in
baccalaureate programs is shared between classroom,
hospital, community and other educational settings.
 The percentage of classroom time in the total program
is about 40%;
 hospital time (including working in community based
health-care delivery settings) is about 54%;
 and miscellaneous educational activities (including
laboratory settings activities) occupy less than 6% of
the program.
Master programs
 The first Master of Nursing program in Iran was
established in 1988.
 By 2004, the number of these programs, which are mainly
affiliated with major MSUs in metropolitan cities, has
increased to fourteen.
 The aim of the Master of Nursing program is to prepare
competent nurses who are able to act as nurse educators,
conduct clinical research and manage health care delivery
 Enrolment in a Master of Nursing program requires the
applicant to hold a Bachelor of Nursing degree and to have
successfully completed the MoHME-developed annual
competitive examination.
Master programs
The exam consists of key nursing areas, including
adult medical–surgical, obstetric-gynecological,
pediatrics, community health nursing, as well as
measurement of the applicant‟s ability to read and
comprehend nursing professional literature in the
English language.
Master programs
In Iran, the Master of Nursing is a three-year
classroom and clinical program containing about
43 compulsory and optional credits in total.
The focus of classroom teaching centres upon
student participation in student and faculty-led
seminars and roundtable discussions.
Master of Nursing degrees are available in two
Master programs
Each field has four different specialties, including
medical/surgical nursing, mental health nursing,
paediatric nursing and community health nursing.
Master of Nursing curricula focus mainly on
educational units rather than practical units, and
include core basic, clinical and functional courses.
Master programs
 Employment in an academic setting, in comparison to
clinical setting, has more financial benefits in Iran;
therefore, many Master of Nursing graduates prefer to
pursue careers in the academe rather than service sector,
in contrast to western countries (Emerson and Records,
 Master of Nursing graduates comprise the majority of
nursing school faculties, and many new graduates work in
clinical areas only because the academic positions have
been filled by ex-graduates.
 Despite this trend, many nursing managers allege that the
current focus on educational courses in Master of Nursing
programs rarely prepares a person to be a good clinician.
Doctoral programs
 The framework and foundation of the first doctoral
nursing program in Iran was laid out in 1995 at Tabriz
University of Medical Sciences.
 In the eleven years since that first PhD program officially
began, the number of programs has grown to seven.
 These programs are 4.5 years in length and consist of 52
credits, including 20 credits for dissertation.
Doctoral programs
 The programs present somewhat of a blend of the US and
UK models, in that they require course work fewer than
American programs and have a focus on the students‟
research throughout the program.
 The students accepted into the doctoral programs are
Master of Nursing graduates who have been successful in
both an annual competitive nationwide examination
(developed by MoHME) and an interview with a panel of
nursing experts.
Doctoral programs
 The purpose of the doctoral program is to prepare
graduates for a lifetime of intellectual inquiry and creative
scholarship and research, and to further the extension of
nursing knowledge in Iran.
 Graduates from the programs are expected to be
knowledgeable professionals who are able to provide
invaluable insights into nursing issues, thereby improving
the nursing care status in the health care system.
Doctoral programs
Currently, around twentyfive nurses have
completed the PhD program the majority of whom
have eventually assumed faculty roles in
baccalaureate and masters‟ programs across the
Because the field of nursing suffers from an acute
shortage of doctorally prepared faculty, there has
been a growth in the number of doctoral
programs in Iran, and metropolitan MSUs are
now seeking approval from the High Council of
Higher Education Planning (HCHEP) and
MoHME to establish PhD programs.