Historical Perspectives of Nursing and Concepts of Nursing

Definitions of Nursing.

What Is Nursing? Staff Nurses Working in Hospitals: Who Are They, What Do They Do, and What Challenges Do They Face?


Nursing is a healthcare profession focused on the care of individuals, families, and communities so they may attain, maintain, or recover optimal health and quality of life from conception to death.

Nurses work in a large variety of specialties where they work independently and as part of a team to assess, plan, implement and evaluate care. Nursing Science is a field of knowledge based on the contributions of nursing scientist through peer-reviewed scholarly journals and evidenced-based practice.

History of nursing

In fifth century BC, Hippocrates was one of the first people in the world to study healthcare, earning him the title of "the father of modern medicine".[1][2] Western European concepts of nursing were first practiced by male Catholic monks who provided for the sick and ill during the Dark Ages of Europe.

During 17th century Europe, nursing care was provided by men and women serving punishment. It was often associated with prostitutes and other female criminals serving time. They had a reputation for being drunk and obnoxious, a view amplified by the doctors of the time to make themselves seem more important and able. It was not until Florence Nightingale, a well-educated woman from a wealthy class family, became a nurse and improved it drastically that people began to accept nursing as a respectable profession. Other aspects also helped in the acceptance of nursing. In 1853 Theodore Fliedner set up a hospital where the nurses he employed had to be of good nature. Many people were impressed with this facility, and because of it, the British Institute of Nursing Sisters was set up.

Prior to the foundation of modern nursing, nuns and the military often provided nursing-like services.[3] The religious and military roots of modern nursing remain in evidence today in many countries, for example in the United Kingdom, senior female nurses are known as sisters. It was during time of war that a significant development in nursing history arose when English nurse Florence Nightingale, working to improve conditions of soldiers in the Crimean War, laid the foundation stone of professional nursing with the principles summarised in the book Notes on Nursing. Other important nurses in the development of the profession include: Mary Seacole, who also worked as a nurse in the Crimea; Agnes Elizabeth Jones and Linda Richards, who established quality nursing schools in the USA and Japan, and Linda Richards who was officially America's first professionally trained nurse, graduating in 1873 from the New England Hospital for Women and Children in Boston.

New Zealand was the first country to regulate nurses nationally, with adoption of the Nurses Registration Act on the 12 September 1901. It was here in New Zealand that Ellen Dougherty became the first registered nurse. North Carolina was the first state in the United States to pass a nursing licensure law in 1903.

Nurses in the United States Army actually started during the Revolutionary War when a general suggested to George Washington that the he needed female nurses "to attend the sick and obey the matron's orders. In July 1775, a plan was submitted to the Second Continental Congress that provided one nurse for every ten patients and provided that a matron be allotted to every hundred sick or wounded".

Nurses have experienced difficulty with the hierarchy in medicine that has resulted in an impression that nurses' primary purpose is to follow the direction of physicians.[5] This tendency is certainly not observed in Nightingale's Notes on Nursing, where the physicians are mentioned relatively infrequently, and often in critical tones—particularly relating to bedside manner.

The modern era has seen the development of nursing degrees and nursing has numerous journals to broaden the knowledge base of the profession. Nurses are often in key management roles within health services and hold research posts at universities.


World War II

United States

As Campbell (1984) shows, the nursing profession was transformed by World War Two. The profession contained a basic tension between the tender loving care provided sick people, on the one hand, and the well-trained efficient specialists on the other was a historic tension in the nursing profession that was partially resolved by the war. The military wanted well-trained efficient specialists. All the services used enlisted men to handle the routine care of sick patients are wounded patients, and use their nurses as officers who were trained specialists. In military units, male doctors supervised female nurses, and both were officers, while the women in practice supervised large numbers of enlisted men. Although enlisted medic could become an officer, it was not easy, and none could become a nurse. Indeed there were no male nurses in the American military until years later. Army and Navy nursing was highly attractive and a larger proportion of nurses volunteered for service higher than any other occupation in American society. The nation responded by a dramatic increase in the numbers and functions of nurses, and a moderate modest increase in their pay scales, with the expansion powered by the training of 200,000 nurses aides by the Red Cross, and the creation of a temporary new government agency, the Cadet Nurse Corps, which enrolled 170,000 young women in speeding up training programs in the nation's 1200 nursing schools. About 5% five percent of the Cadet nurses, and Army nurses were black, but the Navy refused to accept black nurses until it was forced to admit a handful by the White House near the end of the war. The black Army nurses were used in all-black units, handle and to handle medical services for prisoners of war.[7][8]

The public image of the nurses was highly favorable during the war, as the simplified by such Hollywood films as "Cry 'Havoc'" which made the selfless nurses heroes under enemy fire. Some nurses were captured by the Japanese,[9] but in practice they were kept out of harm's way, with the great majority stationed on the homefront. However 77 were stationed in the jungles of the Pacific, where their uniform consisted of "khaki slacks, mud, shirts, mud, field shoes, mud, and fatigues." The 20,000 nurses in Europe were safely behind the lines. They had two missions one provide technical nursing services to military hospitals and second to train and the male Army medics and male pharmacy mates in the Navy. These men handled frontline nursing care, and also staffed homefront hospitals, where the nurses directly supervised them. The medical services were large operations, with over 600,000 soldiers, and ten enlisted men for every nurse. Nearly all the doctors were men, with women doctors allowed only to examine the WAC. Forward medical units, were emergency surgery was undertaken, was done without the benefit of nurses. Well behind the battlefield, the nurses worked in evacuation hospitals, primarily in the role of supervising the medics and the Navy’s pharmacy mates. The closer to the front, the more flexible and autonomous was the nurse’s’ role. The women wanted to be much closer to the front, but they had too weak a voice to counter the Pentagon’s highly protective attitude.

Down to 1942, the American Red Cross controlled access to the military. The Red Cross was controlled by civilian men, professional experts and social work and fundraising. The new leaders emerging from the war had learned command skills, maneuvering in complex bureaucracies, the taste of equal pay an officer status, and autonomy within military medical system. New technical skills validated their demands for an autonomy as they learned and employed in crisis situations the latest trauma and medical techniques and technologies. The military nurses returned home as the nation’s experts in blood transfusion and the application of new drugs like penicillin. When the nurses returned home they used the previously powerless American Nurses Association to take control of the nursing profession.



Military nursing had only a small role for women in Britain, where 10,500 nurses enrolled in Queen Alexandra's Imperial Military Nursi  ng Service (QAIMNS) and the Princess Mary's Royal Air Force Nursing Service. These services dated to 1902 and 1918, and enjoyed royal sponsorship. There also were VAD nurses who had been enrolled by the Red Cross.[12]



Germany had a very large and well organized nursing service, with three main organizations, one for Catholics, one for Protestants, and the DRK (Red Cross). In 1934 the Nazis set up their own nursing unit, the Brown nurses, and absorb one of the smaller groups, bringing it up to 40,000 members. It set up kindergartens, hoping to seize control of the minds of the younger Germans, in competition with the other nursing organizations. Civilian psychiatric nurses who were Nazi party members participated in the killings of invalids, although the process was shrouded in euphemisms and denials.

Military nursing was primarily handled by the DRK, which came under partial Nazi control. Frontline medical services were provided by male medics and doctors. Red Cross nurses served widely within the military medical services, staffing the hospitals that perforce were close to the front lines and at risk of bombing attacks. Two dozen were awarded the highly prestigious Iron Cross for heroism under fire. They are among the 470,000 German women who served with the military.[14]



Although nursing practice varies both through its various specialities and countries, these nursing organizations offer the following definitions:

Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles.

International Council of Nurses

The use of clinical judgement in the provision of care to enable people to improve, maintain, or recover health, to cope with health problems, and to achieve the best possible quality of life, whatever their disease or disability, until death.

Royal College of Nursing UK

Nursing is the protection, promotion, and optimization of health and abilities; prevention of illness and injury; alleviation of suffering through the diagnosis and treatment of human responses; and advocacy in health care for individuals, families, communities, and populations.

American Nurses Association

The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge.

Virginia Avenel Henderson


Nursing as a profession

The authority for the practice of nursing is based upon a social contract that delineates professional rights and responsibilities as well as mechanisms for public accountability. In almost all countries, nursing practice is defined and governed by law, and entrance to the profession is regulated at the national or state level.

The aim of the nursing community worldwide is for its professionals to ensure quality care for all, while maintaining their credentials, code of ethics, standards, and competencies, and continuing their education.[15] There are a number of educational paths to becoming a professional nurse, which vary greatly worldwide, but all involve extensive study of nursing theory and practice, and training in clinical skills.

Nurses care for individuals of all ages and cultural backgrounds who are healthy and ill in a holistic manner based on the individual's physical, emotional, psychological, intellectual, social, and spiritual needs. The profession combines physical science, social science, nursing theory, and technology in caring for those individuals.

In order to work in the nursing profession, all nurses hold one or more credentials depending on their scope of practice and education. A Licensed practical nurse (LPN) (also referred to as a Licensed vocational nurse, Registered practical nurse, Enrolled nurse, and State enrolled nurse) works independently or with a Registered nurse. The most significant differentiation between an LPN and RN is found in the requirements for entry to practice, which determines entitlement for their scope of practice, for example in Canada an RN requires a bachelors degree and a LPN requires a 2 year diploma. A Registered nurse (RN) provides scientific, psychological, and technological knowledge in the care of patients and families in many health care settings. Registered nurses may also earn additional credentials or degrees.

RNs may also pursue different roles as advanced practice registered nurses.

Nurses may follow their personal and professional interests by working with any group of people, in any setting, at any time. Some nurses follow the traditional role of working in a hospital setting.

Around the world, nurses have been traditionally female. Despite equal opportunity legislation nursing has continued to be a female dominated profession.[19] For instance, in Canada and America the male-to-female ratio of nurses is approximately 1:19. This ratio is represented around the world. Notable exceptions include: Francophone Africa, which includes the countries of Benin, Burkino Faso, Cameroon, Chad, Congo, Ivory Coast, the Democratic Republic of Congo, Djibouti, Guinea, Gabon, Mali, Mauritania, Niger, Rwanda, Senegal, and Togo, which all have more male than female nurses. In Europe, in countries such as Spain, Portugal, Czechoslovakia, and Italy, over 20% of nurses are male.


Regulation of practice

The practice of nursing is governed by laws that define a scope of practice, generally mandated by the legislature of the country or area within which the nurse practices. Nurses are held legally responsible and accountable for their practice. The standard of care is that of the "prudent nurse."


Nursing theory and process

Nursing practice is the actual provision of nursing care. In providing care, nurses implement the nursing care plan using the nursing process. This is based around a specific nursing theory which is selected based on the care setting and population served. In providing nursing care, the nurse uses both nursing theory and best practice derived from nursing research.

In general terms, the nursing process is the method used to assess and diagnose needs, plan outcomes and interventions, implement interventions, and evaluate the outcomes of the care provided. Like other disciplines, the profession has developed different theories derived from sometimes diverse philosophical beliefs and paradigms or worldviews to help nurses direct their activities to accomplish specific goals.


Nursing worldwide

Throughout the world nurses are known to be caring individuals that people look for as someone to advocate for the sick and provide empathy towards the needy.


United Kingdom

To practice lawfully as a registered nurse in the United Kingdom, the practitioner must hold a current and valid registration with the Nursing and Midwifery Council. The title "Registered Nurse" can only be granted to those holding such registration. This protected title is laid down in the Nurses, Midwives and Health Visitors Act, 1997.


First level Nurses

First level nurses make up the bulk of the registered nurses in the UK. They were previously known by titles such as RGN (registered general nurse), RSCN (registered sick children's nurse), RMN (registered mental nurse) , RNMH (registered nurse (for the) mentally handicapped).

The titles used now are similar and with slight differences i.e. RNA (registered nurse adult), RNC (registered nurse child), RNMH (registered nurse mental health), RNLD (registered nurse learning disabilities).

Main article: State Enrolled Nurse

Second level nurse training is no longer provided, however they are still legally able to practice in the United Kingdom as a nurse. Many have now either retired or undertaken conversion courses to become first level nurses. They are entitled to refer to themselves as Registered Nurses as their registration is on the Nursing & Midwifery Council register of nurses.

They split into several major groups:

·                     Nurse practitioners - These nurses obtain a minimum of a Master of Science in Nursing or a doctoral degree. They often perform roles similar to those of physicians and physician assistants, they can prescribe medications as independent or supplementary prescribers. Most NP's have referral and admission rights to hospital specialities. They commonly work in primary care (e.g. GP surgeries), A&E departments, or pediatrics although they are increasingly being seen in other areas of practice. The title "nurse practitioner" is legally protected, except in the State of Tennessee. * Specialist community public health nurses - traditionally district nurses and health visitors, this group of research and publication activities.

·                     Lecturer-practitioners - these nurses work both in the NHS, and in universities. They typically work for 2–3 days per week in each setting. In university, they train pre-registration student nurses (see below), and often teach on specialist courses for post-registration nurses * Lecturers - these nurses are not employed by the NHS. Instead they work full time in universities, both teaching and performing research.



Many nurses who have worked in clinical settings for a long time choose to leave clinical nursing and join the ranks of the NHS management. This used to be seen as a natural career progression for those who had reached ward management positions, however with the advent of specialist nursing roles (see above), this has become a less attractive option.

Nonetheless, many nurses fill positions in the senior management structure of NHS organisations, some even as board members. Others choose to stay a little closer to their clinical roots by becoming clinical nurse managers or modern matrons.


Nurse education


In order to become a registered nurse, and work as such in the NHS, one must complete a program recognized by the Nursing and Midwifery Council. Currently, this involves completing a degree or diploma, available from a range of universities offering these courses, in the chosen branch specialty (see below), leading to both an academic award and professional registration as a 1st level registered nurse. Such a course is a 50/50 split of learning in university (i.e. through lectures, essays and examinations) and in practice (i.e. supervised patient care within a hospital or community setting).

These courses are three (occasionally four) years' long. The first year is known as the common foundation program (CFP), and teaches the basic knowledge and skills required of all nurses. The remainder of the program consists of training specific to the student's chosen branch of nursing. These are:

·                     Adult nursing.

·                     Child nursing.

·                     Mental health nursing.

·                     Learning disabilities nursing.

As of 2013, the Nursing and Midwifery Council will require all new nurses qualifying in England to hold a degree qualification.

Midwifery training is similar in length and structure, but is sufficiently different that it is not considered a branch of nursing. There are shortened (18 month) programmes to allow nurses already qualified in the adult branch to hold dual registration as a nurse and a midwife. Shortened courses lasting 2 years also exist for graduates of other disciplines to train as nurses. This is achieved by more intense study and a shortening of the common foundation program.

Student nurses currently receive a bursary from the government to support them during their nurse training. Diploma students in England receive a non-means-tested bursary of around £6000 per year (with additional allowances for mature students or those with dependent children), whereas degree students have their bursary means tested (and so often receive less). Degree students are, however, eligible for a proportion of the government's student loan, unlike diploma students. In Scotland, however, all student nurses regardless of which course they are undertaking, receive the same bursary in line with the English diploma amount. In Wales only the Degree level course is offered and all nursing students therefore receive a non-means-tested bursary.

Before Project 2000, nurse education was the responsibility of hospitals and was not based in universities; hence many nurses who qualified prior to these reforms do not hold an academic award.



After the point of initial registration, there is an expectation that all qualified nurses will continue to update their skills and knowledge. The Nursing and Midwifery Council insists on a minimum of 35 hours of education every three years, as part of its post registration education and practice (PREP) requirements.

There are also opportunities for many nurses to gain additional clinical skills after qualification. Cannulation, venepuncture, intravenous drug therapy and male catheterisation are the most common, although there are many others (such as advanced life support) which some nurses will undertake.

Many nurses who qualified with a diploma choose to upgrade their qualification to a degree by studying part time. Many nurses prefer this option to gaining a degree initially, as there is often an opportunity to study in a specialist field as a part of this upgrading. Financially, in England, it is also much more lucrative, as diploma students get the full bursary during their initial training, and employers often pay for the degree course as well as the nurse's salary.

In order to become specialist nurses (such as nurse consultants, nurse practitioners etc.) or nurse educators, some nurses undertake further training above bachelors degree level. Masters degrees exist in various healthcare related topics, and some nurses choose to study for PhDs or other higher academic awards. District nurses and health visitors are also considered specialist nurses, and in order to become such they must undertake specialist training (often in the form of a top up degree (see above) or post graduate diploma).

All newly qualifying district nurses and Health Visitors are trained to prescribe from the Nurse Prescribers' Formulary, a list of medications and dressings typically useful to those carrying out these roles. Many of these (and other) nurses will also undertake training in independent and supplementary prescribing, which allows them (as of May 1, 2006) to prescribe almost any drug in the British National Formulary. This has been the cause of a great deal of debate in both medical and nursing circles.




Canadian nursing dates all the way back to 1639 in Quebec with the Augustine nuns.[32] These nuns were trying to open up a mission that cared for the spiritual and physical needs of patients. The establishment of this mission created the first nursing apprenticeship training in North America. In the nineteenth century there were some Catholic orders of nursing that were trying to spread their message across Canada. Most nurses were female and only had an occasional consultation with a physician. Towards the end of the nineteenth century hospital care and medical services had been improved and expanded. Much of this was due to Florence Nightingale who was training women in English Canada. In 1874 the first formal nursing training program was started at the General and Marine Hospital in St. Catharines in Ontario. Many programs popped up in hospitals across Canada after this one was established. Graduates and teachers from these programs began to fight for licensing legislation, nursing journals, university training for nurses, and for professional organizations for nurses.

The first instance of Canadian nurses and the military was in 1885 with the Northwest Rebellion. Some nurses came out to aid the wounded. In 1901 Canadian nurses were officially part of the Royal Canadian Army Medical Corps. Georgina Fane Pope and Margaret Clothilde Macdonald were the first nurses officially recognized as military nurses.[32] Nursing continued to expand and develop. In the early twentieth century more nursing programs were developed for public health nursing and disease prevention. More changes occurred after World War II. The health care system expanded and medicare was introduced. Currently there are 260,000 nurses in Canada but they face the same difficulties as most countries. Nurses are becoming more scarce and the population is aging which requires more nursing care.



All Canadian nurses and prospective nurses are heavily encouraged by the Canadian Nurses Association to continue their education to receive a Baccalaureate degree. They believe that this is the best degree to work towards because it results in better patient outcomes. In addition to helping patients, nurses that have a Baccalaureate degree will be less likely to make small errors because they have a higher level of education. A Baccalaureate degree also gives a nurse a more critical opinion which gives he or she more of an edge in the field. This ultimately saves the hospital money because they deal with less problematic incidents. All Canadian provinces except for the Yukon and Quebec require that all nurses must have a Baccalaureate degree. The basic length of time that it takes to obtain a Baccalaureate degree is four years. However, Canada does have a condensed program that is two years long.

There are nineteen specialties that a nurse could choose from if he or she wanted to narrow down his or her field. According to the Canadian Nurses Association some of those specialties are Cardiovascular Nursing, Community Health Nursing, Critical Care Nursing, Emergency Nursing, Gerontology Nursing, Medical-Surgical Nursing, Neuroscience Nursing, Oncology Nursing, Orthopedic Nursing, Psychiatric/Mental Health Nursing, and Rehabilitation Nursing. Each specialty requires its own test and competencies. Many tests are offered online through the Canadian Nurses Association.




Nursing was not an established part of Japan's healthcare system until 1899 with the Midwives Ordinance.[32] From there the Registered Nurse Ordinance came into play in 1915. This established a legal substantiation to registered nurses all over Japan. A new law geared towards nurses was created during World War II. This law was titled the Public Health Nurse, Midwife and Nurse Law and it was established in 1948.[32] It established educational requirements, standards and licensure. There has been a continued effort to improve nursing in Japan. In 1992 the Nursing Human Resource Law was passed.[32] This law created the development of new university programs for nurses. Those programs were designed to raise the education level of the nurses so that they could be better suited for taking care of the public.


Types of Nurses

Japan only recognizes four types of nursing and they are Public Health Nursing, Midwifery, Registered Nursing and Assistant Nursing.


Public Health Nursing

This type of nursing is designed to help the public and is also driven by the public's needs. The goals of public health nurses are to monitor the spread of disease, keep vigilant watch for environmental hazards, educate the community on how to care for and treat themselves, and train for community disasters.



Nurses that are involved with midwifery are independent of any organization. A midwife takes care of a pregnant woman during labor and postpartum. They assist with things like breastfeeding and caring for the child.


Assistant Nursing

Individuals who are assistant nurses follow orders from a registered nurse. They report back to the licensed nurse about a patient's condition. Assistant nurses are always supervised by a licensed registered nurse.


Nursing Education

In 1952 Japan established the first nursing university in the country. An Associate Degree was the only level of certification for years. Soon people began to want nursing degrees at a higher level of education. Soon the Bachelors Degree in Nursing (BSN) was established. Currently Japan offers doctorate level degrees of nursing in a good number of its universities.

There are three ways that an individual could become a registered nurse in Japan. After obtaining a high school degree the person could go to a nursing university for four years and earn a Bachelor degree, go to a junior nursing college for three years or go to a nursing school for three years. Regardless of where the individual attends school they must take the national exam. Those who attended a nursing university have a bit of an advantage over those who went to a nursing school. They can take the national exam to be a registered nurse, public health nurse or midwife. In the cases of become a midwife or a public health nurse, the student must take a one year course in their desired field after attending a nursing university and passing the national exam to become a registered nurse. The nursing universities are the best route for someone who wants to become a nurse in Japan. They offer a wider range of general education classes and they also allow for a more rigid teaching style of nursing. These nursing universities train their students to be able to make critical and educated decisions when they are out in the field. Physicians are the ones who are teaching the potential nurses because there are not enough available nurses to teach students. This increases the dominance that physicians have over nurses.

Students that attend a nursing college or just a nursing school receive the same degree that one would who graduated from a nursing university, but they do not have the same educational background. The classes offered at nursing colleges and nursing schools are focused on more practical aspects of nursing. These institutions do not offer many general education classes, so students who attend these schools will solely be focusing on their nursing educations while they are in school. Students who attend a nursing college or school do have the opportunity to become a midwife or a public health nurse. They have to go through a training institute for their desired field after graduating from the nursing school or college. Japanese nurses never have to renew their licenses. Once they have passed their exam, they have their license for life.


United States

The scope of practice of registered nurses is the extent to and limits of which an RN may practice. In the United States, these limits are determined by a set of laws known as the Nurse Practice Act of the state or territory in which an RN is licensed. Each state has its own laws, rules, and regulations governing nursing care. Usually the making of such rules and regulations is delegated to a state board of nursing, which performs day-to-day administration of these rules, qualifies candidates for licensure, licenses nurses and nursing assistants, and makes decisions on nursing issues. It should be noted that in some states the terms "nurse" or "nursing" may only be used in conjunction with the practice of a Registered Nurse (RN) or licensed practical or vocational nurse (LPN/LVN).

The scope of practice for a registered nurse is wider than for an LPN/LVN because of the level and content of education as well as what the Nurse Practice Act says about the respective roles of each.

In the hospital setting, registered nurses are often assigned a role in which they delegate tasks to LPNs and unlicensed assistive personnel.

RNs are not limited to employment as bedside nurses. Registered nurses are employed by physicians, attorneys, insurance companies, governmental agencies, community/public health agencies, private industry, school districts, ambulatory surgery centers, among others. Some registered nurses are independent consultants who work for themselves, while others work for large manufacturers or chemical companies. Research Nurses conduct or assist in the conduct of research or evaluation (outcome and process) in many areas such as biology, psychology, human development, and health care systems. The average salary for a staff RN in the United States in 2007 was over $60,000.

Oddsei - What are the odds of anything.