Nursing process – a historical essay. Professional organizations of nurses.
Nursing is an art and a science by which people are assisted in learning to care for themselves whenever possible and cared for by others when they are unable to meet their oweeds. Nursing has evolved from an unstructured method of caring for the ill to a scientific profession. The result has been movement from the mystical beliefs of primitive times to a “high-tech, high-touch” era. Nursing combines art and science. Using scientific knowledge in a humane manner, nursing combines critical thinking skills with caring behaviors. Nursing requires a delicate balance of promoting clients’ independence and dependence. Nursing focuses not on illness but rather on the client’s response to illness. Nursing promotes health and helps clients move to a higher level of wellness. This aspect of nursing also includes assisting a client with a terminal illness to maintain comfort and dignity in the final stage of life. This chapter traces the evolution of nursing by exploring its rich heritage. Social forces that have affected the development of nursing are examined.
HISTORICAL OVERVIEW To understand the present status of nursing, it is necessary to have a base of historical knowledge about the profession. By studying nursing history, the nurse is better able to understand such issues as autonomy (being self-directed), unity within the profession, supply and demand, salary, education, and current practice.
History is a study of the past that includes events, situations, and individuals (Figure 1-1).
By learning from historical role models, nurses can enhance their abilities to create positive change in the present and set a course for the future. The study of nursing history offers another advantage—learning where the profession has been and its advancements.
Empowerment is the process of enabling others to do for themselves. Only wheurses are empowered are they truly autonomous. Autonomy has historically been difficult for nurses to achieve. Empowerment and autonomy go together and are necessary for nursing to bring about positive changes in health care today (Figure 1-2).
Power is not authority— authority is power. Learning from the past is the major reason for studying history. Ignoring nursing’s history can be detrimental to the future of the profession. By applying the lessons gained from a historical review, nurses will indeed be a vital force in the new millennium.
Evolution of Nursing Nursing has evolved with the development of civilization of mankind. Refer to Table 1-1 and the following for a discussion of nursing from early civilizations to the present era of advanced nursing practice and health care reform.
Early Civilizations The evolution of nursing dates back to 4000 BC, to primitive societies in which mother-nurses worked with priests. In 2000 BC, the use of wet nurses is recorded in Babylonia and
Ancient
Roman Empire Hospitals were first established in the Eastern Roman Empire (
Middle Ages Hospitals in large Byzantine cities were staffed primarily by paid male assistants and male nurses. During the medieval era, these hospitals were established primarily as almshouses, with care of the sick being secondary. Medical practices in
Renaissance During the Renaissance (AD 1400–1550), interest in the arts and sciences emerged. This was also the time of many geographic explorations by Europeans. As a result, the world literally expanded. Because of renewed interest in science, universities were established, but no formal nursing schools were founded. Because of social status and customs, women were not encouraged to leave their homes; they continued to fulfill the traditional role of nurturer/caregiver in the home.
Enlightenment and Industrial Revolution The Industrial Revolution introduced technology that led to a proliferation of factories. Conditions for the factory workers were deplorable. Long hours, grueling work, and unsafe conditions prevailed in the workplace. The health status of laborers received little, if any, attention. Medical schools were founded, including the Royal College of Surgeons in
Religious Influences The strong influence of religions on the development of nursing started in
The implementation of her principles in the areas of nursing practice and environmental modifications resulted in reduced morbidity and mortality rates during the war. Nightingale forged the future of nursing education as a result of her experiences in training nurses to care for British soldiers. She established the Nightingale Training School of Nurses at
Some of Nightingale’s novel beliefs about nursing education were:
• A holistic framework inclusive of illness and health
• The need for a theoretical basis for nursing practice
• A liberal education as a foundation for nursing practice
• The importance of creating an environment that promotes healing
• The need for a body of nursing knowledge that was distinct from medical knowledge (Nightingale, 1969)
Nightingale introduced many other concepts that, though unique in her time, are still used today. She advocated:
(1) having a systematic method of assessing clients;
(2) individualizing care on the basis of the client’s needs and preferences; and
(3) maintaining confidentiality.
Nightingale also recognized the influence of environmental factors on health. She advocated that nurses provide clean surroundings with fresh air and light to improve the quality of care (Nightingale, 1969). Nightingale believed that nurses should be formally educated and should function as client advocates.
Nursing and the Civil War
These women performed various duties, including the implementation of sanitary conditions in field hospitals. Dorothea Dix, a
The Women’s Movement In 1848, the Women’s Rights Convention in
Nursing Pioneers Moderursing was forged by the contributions of many outstanding nurses through the years. The establishment of public health nursing, the provision of rural health care services, and the advancement of nursing education occurred as a result of the works of nurse pioneers, who are discussed below. Note that the term trained nurse was used historically as the predecessor of registered nurse.
Lillian Wald Lillian Wald (Figure 1-5)
spent her life providing nursing care to the indigent population. In 1893, as the first community health nurse, she founded public health nursing with the establishment of the Henry Street Settlement Service (Figure 1-6) in
Wald was a tireless reformer who:
• Improved housing conditions in tenement districts
• Supported education for the mentally challenged
• Advocated passage of more lenient immigration regulations
• Initiated change of child labor laws and founded the Children’s Bureau of the
Department of Labor In addition to initiating public health nursing, Wald also established a school of nursing.
Isabel Hampton Robb Isabel Hampton Robb (Figure 1-7)
was responsible for founding several nursing organizations, namely the Superintendents’ Society in 1893 and the Nurses’ Associated Alumnae of the
During the Civil War, women were instrumental in the effort to minimize the risk of spreading contagious diseases among wounded soldiers. (Photo courtesy of Corbis-Bettmann)
Jane Delano
During World War I, Jane Delano, a graduate of Bellevue School of Nursing and former American Nurses Association president, took one of the first stances that created a division among nursing leaders (Figure 1-8). In 1912, physicians wanted the Red Cross to put untrained nursing aides at their sides to assist with war casualties. Physicians, not nurses, would train the aides in caring for the sick.
Annie Goodrich
Annie Goodrich (Figure 1-9) was influential iational and international nursing issues. During World War I, the supply of civiliaurses was greatly depleted because of the Army’s need for trained nurses. Goodrich pushed for the establishment of an Army training school for nurses, which she envisioned as a model for other schools of nursing. She then was appointed dean of the Army School of Nursing. As an advocate of college-based educational nursing programs, Goodrich became the first dean of Yale University School of Nursing.
Lavinia Dock An influential leader in Americaursing education was Lavinia Dock, who graduated from
Nursing Leaders Americaursing’s history is rich with many outstanding leaders. Following is a discussion of some other nursing pioneers in
Mary Breckinridge In 1925, Mary Breckinridge introduced a system for delivering health care to rural
Martha Franklin Martha Franklin was one of the first people to advocate racial equality iursing. She was the only African American graduate of her class at Women’s
Amelia Greenwald Amelia Greenwald was a pioneer in public health nursing on the international scene. In 1908, she entered the
Mamie Hale In 1942, Mamie Hale was hired by the Arkansas Health Department to upgrade the educational programs for midwives (Figure 1-10).
Hale, a graduate of Tuskegee School of Nurse-Midwifery, gained the support of granny midwives, public health nurses, and obstetricians. Through education, Hale decreased superstition and illiteracy of those functioning as midwives. Hale’s efforts resulted in improved mortality rates for both mothers and infants.
Mary Mahoney
was a noted nursing leader who encouraged a respect for cultural diversity. Today, the ANA bestows the Mary Mahoney Award in recognition of individuals who make significant contributions toward improving relationships among multicultural groups.
Harriet Neuton Phillips Harriet Neuton Phillips was the first known graduate of the Women’s
Linda Richards In 1873, the first diploma from an American training school for nurses was awarded to Linda Richards. Richards founded or reorganized 10 hospital-based training schools for nurses. She introduced the practice of keeping nurses’ notes and physicians’ orders as part of medical records. Also, Richards began the practice of nurses wearing uniforms. As the first Superintendent of Nurses at
Margaret Sanger In 1912, Margaret Sanger, a nurse living in
Sanger fought to revise legislation that prohibited dissemination of information about contraception. Sanger was not afraid of controversy and spent one month in jail for distributing information on birth control. As a true activist, Sanger made birth control an issue and fought for the rights of poor women. She understood the relationship between poverty, overpopulation, and high infant and maternal mortality rates. Sanger founded the American Birth Control League and was the first president of the International Planned Parenthood Federation.
Shirley Titus Shirley Titus received a diploma from St. Luke’s Hospital School of Nursing in
Adah Belle Thoms Adah Belle Thoms was a crusader for improved relationships among persons of all races. In the early 1900s, she became acting director of nursing of the
NURSING IN THE 20TH CENTURY The beginning of the 20th century brought about changes that have influenced contemporary nursing. Several landmark reports about medical and nursing education, as well as some contemporary reports, are discussed below. The establishment of visiting nurse associations and their use of protocols are discussed.
Flexner Report In 1910, supported by a Carnegie grant, Abraham Flexner visited the 155 medical schools in the
Early Insurance Plans At the turn of the 20th century, there were more than 4000 hospitals and 1000 schools of nursing. During this time, the concepts of third-party payments and prepaid health insurance were instituted. Third-party payments refer to situations in which someone other than the recipient of health care (usually an insurance company) pays for the health care services provided. Prepaid medical plans were started in
Blue Cross and Blue Shield The Depression provided the main impetus for the growth of insurance plans. In addition, the American philosophy of health care for all contributed to the growth of insurance plans. In 1920, American hospitals offered a prepaid hospital plan that led to the “Baylor Plan,” which eventually became the prototype of Blue Cross. Blue Cross was the result of a joint venture between hospitals, physicians, and the general public. The American Hospital Association pioneered the development of an insurance company to provide benefits to subscribers who were hospitalized. Blue Shield was developed by the American Medical Association to provide reimbursement for medical services provided to subscribers. In 1933, the American Hospital Association endorsed Blue Cross, and in 1938 the American Medical Association endorsed Blue Shield. The federal government became more involved in health care delivery in 1935 with the passage of the Social Security Act, which provided for (among other things) benefits for the elderly, child welfare, and federal funding for training of health care personnel. During World War II, the
Visiting Nurses Associations In 1901, at the suggestion of Lillian Wald, the Metropolitan Life Insurance Company, which provided visiting nursing services to its policyholders, entered into an agreement with the
Settlement. Wald worked with Metropolitan to expand the services of the Henry Street Settlement to other cities; thus, one form of managed care began. Nurses providing care in the home environment experienced greater autonomy of practice than hospital- based nurses (Figure 1-13).
This led to conflicts with some physicians about the scope of medical practice versus nursing practice parameters. Some physicians thought nurses were taking over their practice, whereas other physicians encouraged nurses to do whatever was necessary to care for the sick at home. In
Landmark Reports in Nursing Education During the first half of the 20th century, a number of reports were issued concerning nursing education and practice. Three of them, the Goldmark, the Brown, and the
Goldmark Report In 1918, Adelaide Nutting (relentless in her efforts to document the need for nursing education reform) approached the Rockefeller Foundation for support. Funding was provided, and, in 1919, the Committee for the Study of Nursing Education was established to investigate the training of public health nurses. E. A. Winslow, professor of public health,
Brown Report In 1948, Esther Lucille Brown, a social anthropologist, published Nursing for the Future and Nursing Reconsidered: A Study for Change. Several recommendations were put forth in this study, including the need for nurses to demonstrate greater professional competence by moving nursing education from the hospital to the university setting. Although published 20 years after the Goldmark report, the Brown report identified many of the same problems in diploma education—nursing students were still being used for service by the hospitals and inadequate resources and authoritarianism in hospitals still prevailed iursing education. Brown recognized that nursing education in the university setting would provide the proper intellectual climate for the professional. Visionary nurse educators were securing necessary learning resources: libraries, laboratories, and clinical facilities. Professional endeavors such as research and publication were being implemented by nurse leaders.
Other Health Care Initiatives In the 1960s, health care services were provided to the elderly and the indigent with the federal government’s inception of Medicare and Medicaid. This era also saw passage of the Nurse Training Act (1964), which provided federal funds to expand enrollments in schools of nursing. Federal funds were used to construct nursing schools, and student loans and scholarships were made available to nursing students.
Selected Legislation The Health Maintenance Organization Act of 1973 provided an alternative to the private health insurance industry.
Health maintenance organizations (HMOs) are prepaid health plans that provide primary health care services for a predetermined fee. (See Chapter 7 for further discussion.) Because the fee is set in advance of services being rendered, HMOs provide cost-effective services.
Primary health care refers to the client’s point of entry into the health care system and includes assessment, diagnosis, treatment, coordination of care, preventive services, and education. (See Chapter 3 for further discussion.) The National Commission for Manpower study, released in 1977, resulted in amendments to the House of Representatives 2504 of Title XVIII of the Social Security Act that provided payment for rural health clinic services. Through the efforts of Anne Zimmerman, former President of the ANA, the bill was amended to substitute the term primary care providers for physician extenders and, therefore, allowed nurse practitioners to be paid directly for their services. This was a major success for nursing. The Rural Health Clinic Service Act of 1977 covered services rendered by nurse practitioners and nurse-midwives. The Omnibus Budget Reconciliation Act of 1980 mandated payment for nurse-midwife services to needy recipients. Nursing became an integral part in meeting the needs of vulnerable populations.
Education and Practice: Contemporary Reports During the 1980s, several important studies were commissioned to examine the areas of nursing education and practice.
National Commission on Nursing The National Commission on Nursing was created in 1980 by the American Hospital Association (AHA), the Hospital Research and Education Trust, and the American Hospital Supply Corporation to study nursing education and related issues in hospital management, nursing practice, and nursing education.
The commission’s conclusions addressed the need for:
• Adequate clinical education for students
• Baccalaureate education and educational mobility
• Involvement of nurses in collaborative institutional and clinical decision making
• Improved working conditions, specifically, salaries, flexible scheduling, and differentiated practice
As a result of the commission’s study, attention was given to the need for physicians and nurses to enter into collaborative practice.
Secretary’s Commission on Nursing Although the IOM study indicated that there were sufficient numbers of staff nurses, based on supply and demand, hospitals continued to report severe shortages. As a response to hospitals’ recruitment and retention challenges, Health and Human Services Secretary Otis R. Brown, MD, established the Secretary’s Commission on Nursing, which made the following recommendations related to nursing practice:
• Nurse compensation
• Health care financing
• Nurse decision making
• Development, use, and maintenance of nursing resources (Secretary’s Commission on Nursing, 1988)
This commission recognized that the federal government alone could not correct the problems facing nursing and health care but rather that the concerted efforts of health care organizations were needed for the implementation of the report’s recommendations.
SOCIAL FORCES AFFECTING NURSING From the earliest recordings of nursing, 4000 BC through the Christian era, women were allowed to perform the nurse role only in the home. Nursing’s links with the church caused nursing to be viewed as a “service,” not a profession such as medicine. The Crimean and Civil Wars had a significant impact oursing’s future by focusing on women as nurse providers and on the need for nurse training.
During the 20th century, the evolution of medical education as an established profession had far advanced that of nursing. The Flexner report carved the destiny for physicians. The Goldmark and Brown reports created havoc for nurses as they debated the issue of nursing education in the university setting.
The Depression and World War II brought social reform and created health and medical insurance that strengthened the organized power base of both physician and hospital. Nursing—almost exclusively a female profession—had little power and, therefore, did not exert much influence on the social forces at play. The greatest advances for nurses were seen in the realm of public health and preventive health care.
As physicians were released from military service after World War II, the era of specialized medicine began. Physicians used their veterans’ educational entitlement benefits to take residency training in one or more specialty areas. By 1966, more than 70% of the physicians in practice were specialists.
The 1960s was a decade of growth and change. As technologic advances increased the scope of practice of medicine and nursing, other social forces were at play: access to health care services enhanced by Medicare and Medicaid; physician and nurse shortages; the feminist movement; the inception of nurse practitioners; and a focus on health maintenance.
The economic recession of the 1970s saw health care costs escalating along with unemployment. Professional autonomy was being debated, nursing theories were being developed, and nursing education was being integrated into the university setting. Nurses were becoming more politically astute in that they were working through professional organizations to affect health care legislation.
During the 1980s, nursing became more specialized and autonomous. The rapid technologic advances in medicine required more specialization iursing. Nurse practitioners were being more widely accepted by the general public and other health care providers. Expanded roles of nurses were developing in response to greater demands for nursing services. One factor that led to an increased need for nursing was the proliferation of HMOs in early 1980s.
During the 1990s, nurses were actively assuming more responsibilities for the delivery of health care. Evolving technology mandated nurses to continue to advance their knowledge base and skills. The aging of the population called for more nursing involvement with the elderly. Nurses, as individuals and as members of professional organizations, were involved in shaping policies for health care reform. Nursing was a stronger advocate for vulnerable populations: the elderly; those living in poverty; the homeless; and those with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS).
Healthy People Initiatives Healthy People initiatives has become the nation’s health agenda. This initiative began with a report entitled Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention in 1979. The report described the Healthy People as the nation’s health agenda to guide policy on public health initiatives for health promotion and disease prevention activities during the decade 1980–1990. Five goals were identified to decrease the mortality rates for four distinct age groups (infants, children ages 1–14 years, adolescents and young adults up to age 34, adults ages 25–65) and to reduce the average number of days of illness among those over age 65 (U.S. Public Health Service, 1979). Also identified in the report were 15 strategies to achieve the goals; these strategies were studied by panels of experts and resulted in quantifiable objectives to implement the 15 strategies by governmental bodies and private sector agencies at the national, state, local, and community levels (U.S. Public Health Service, 1979). Achievement of the 226 objectives was measured and reported at 2-year increments by the
The outcomes from the 1979 Healthy People initiative led to the development of the Healthy People 2000 Objectives. Coordinated by the U.S. Public Health Service, this program identified the following goals to be achieved from 1990 to 2000: increase the span of healthy life; reduce health disparities; and promote access to preventive services for all Americans (U.S. Department of Health and Human Services, 1991). The original 15 strategies were expanded to include 22 priority areas, and the total number of objectives was increased to 319. The objectives were classified into three major categories: health promotion; health protection; and preventive services.
The first draft of Healthy People 2010 initiatives appeared in the September 1997 issue of the Federal Register. Early work focused on identifying the 2000 objectives to be continued into the 2010 agenda. The Healthy People Consortium, an alliance that includes more that 350 national organizations and 270 state public health, mental health, substance abuse, and environmental agencies, launched in January 2000 the following Healthy People 2010 goals and objectives.
• Major goals 1. Increase quality and years of healthy life. 2. Eliminate health disparities.
• Enabling goals 1. Promote healthy behaviors. 2. Promote healthy and safe communities. 3. Improve systems for personal and public health. 4. Prevent and reduce diseases and disorders.
An additional 26 focus areas, objectives, and developmental objectives were identified to support the achievement of the major and enabling goals.
Success of the Healthy People program requires the cooperative efforts of all health care disciplines to pool their resources and services in order to provide accessible, quality health care and preventive services for all Americans regardless of nationality, ethnicity, and economic status (
Alternative Methods of Health Care Delivery As it has evolved over time, nursing is still focused on caring. Rapid technologic advances, the changing climate of financing health care, and the explosion of alternative delivery methods present challenges to nurses. How are nurses responding to these challenges?
• By shaping health care policies
• By collaborating with other health care providers
• By continuing to advance nursing education Nursing in the new millennium will be vastly different from what it has been. Collaborative health care services and innovative settings for the delivery of health care are currently being developed by nurses.
Costs and Quality Controls During the 1970s, the cost-control systems of various federal government health programs were inadequate because of the rapid escalation of health care expenditures. Consequently, the Tax Equity Fiscal Responsibility Act (TEFRA) of 1982 was created in response to the $287 billion spent on health care in 1981. While the federal government, with TEFRA and prospective payment legislation, tried to control costs, there was also a heightened concern with the quality of health care. Business and industry embraced quality control systems in the 1940s and 1950s. However, the health care industry failed to see the need for these types of controls until the 1980s. The Joint Commission on the Accreditation of Healthcare Organizations’ (JCAHO) agenda for change in the late 1980s emphasized monitoring quality for outcomes rather than process, thus advocating change from a static quality assurance system to dynamic quality improvement. The JCAHO (1996) views quality of care as an ongoing process that continuously looks for ways to improve the care provided. See Chapter 25 for a discussion of the issue of quality management in nursing and health care.
Health Care Reform Health care access and costs were the focus of attention in the 1990s with an ever-increasing number (over 60 million) of Americans being uninsured or underinsured. Children remain at risk for having their health care neglected; one in five American children is not insured. Nursing as a profession has made great strides in effecting federal and state health care legislation (Figure 1-14).
The 1990s were filled with challenges as nurses were held accountable for quality nursing care amidst cutbacks in staffing patterns. Some of these challenges were settled by legislative outcomes such as determining nurse client ratios in skilled nursing facilities and prohibiting acute care hospitals from assigning unlicensed personnel to perform nursing functions, in lieu of a registered nurse. Nurses worked in collaboration with other health care professionals in providing community-based services and in developing evidencebased practice among diverse health care settings. “Evidence-based practice is the application of the best available empirical evidence, including recent research findings to clinical practice in order to aid clinical decision- making” (Taylor-Piliae, p. 30, 1998).
THE FUTURE OF NURSING History is being made daily for nurses and other health care providers as the citizens of this country decide which way to move with health care reform initiatives. Pressing issues for nursing include developing evidence-based practice that can be uniformly adopted in diverse nursing care settings; monitoring safe practice in a restructured health care environment; and designing systems that will enhance collaborative planning, and implement actions and policies to address the changes occurring in the nursing labor market. Nurses can make the most of this time of transformation, which is driven by societal needs. Nurses and nursing students need to stay abreast of current issues and be active with local nursing leaders to communicate nursing’s position(s) on health care reform and alternative health care delivery models. Nurses are being recognized as autonomous professionals and are involved in administrative and clinical decision making (Figure 1-15).
Only wheurses are empowered are they truly autonomous.
K E Y C ONCEPTS
• Nursing is an art and a science in which people are assisted in learning to care for themselves whenever possible and cared for when they are unable to meet their oweeds.
• Nurses will understand such issues as autonomy, unity within the profession, supply and demand, salary, education, and current practice and the empowerment of the profession by studying nursing’s history.
• Nursing’s early history was heavily influenced by religious organizations and the need for nurses to care for soldiers during wartime. Florence Nightingale forged the future of nursing practice and education as a result of her experiences in training nurses to care for soldiers.
• Nursing’s early American leaders, professional organizations, and landmark reports have influenced the infrastructure of current nursing practice.
• Influential nursing leaders, such as Lillian Wald, Jane Delano, Isabel Hampton Robb, Annie Goodrich, Adelaide Nutting, and Lavinia Dock, were instrumental in the advancement of nursing education and practice.
• Other nursing pioneers, such as Amelia Greenwald, Mary Breckenridge, Mamie Hale, Mary Mahoney, Linda Richards, and Margaret Sanger, made important contributions to both nursing education and the fields of rural, public health, maternity, and multicultural nursing.
• In 1923, the Goldmark report concluded that, for nursing to be on equal footing with other disciplines, nursing education should occur in the university setting.
• The Brown report (1948) addressed the need for nurses to demonstrate greater professional competence by moving nursing education to the university setting.
• The Health Maintenance Organization Act of 1973 provided an alternative to the private health insurance industry.
• Contemporary reports issued by the National Commission on Nursing, the Institute of Medicine, and the Secretary’s Commission on Nursing focused on the areas of nursing education, practice, and nursing’s role in health care financing policies.
• Developments such as alternative methods of health care delivery, evidence-based practice, and the efforts devoted to health care reform have led to diversified nursing roles.
• As the nursing profession continues to evolve and respond to the challenges within the health care system, nurses will remain responsive to societal needs.
C R I T I C A L T H I N K I N G AC T I V I T I E S
1. What does the phrase “using their own history” mean to nurses? After studying this chapter, list some major lessons nurses can derive from history.
2. Examine the history of your nursing school. Are the early leaders honored for their contributions?
3. Identify some contemporary nursing leaders. What are their contributions to the nursing profession?
4. Choose the correct answer. The major recommendation of both the Goldmark and Brown reports was to: a. recruit more people into the nursing profession.
b. compensate nurses with higher salaries and more comprehensive benefits.
c. place nursing education within institutions of higher learning.
d. increase the amount of clinical practice iursing education programs.
5. List some key legislative measures that have affected nurse’s role in the delivery of health care in the
WEB RESOURC E S
Agency for Healthcare Research and Quality http://www.ahrq.gov American Association for the History of Nursing http://www.aahn.org
Healthy People 2010 [email protected]
National Council of State Board of Nursing http://www.ncsbn.org
