EVOLUTION OF THE NURSE

12 May

It was often said that every woman is a nurse. After nursing adopted the Nightingale model, it could be said that ‘‘every nurse is a woman.’’ (A man who performed similar hospital work was typically called an orderly.) Nursing, whether in the sickroom or in the hospital ward, was considered part of woman’s natural role. While accepting many aspects of the traditional division between male and female roles, Flor- ence Nightingale (1820–1910) and other nursing reformers attempted to transform nursing from another form of unskilled drudgery into a pro- fession suitable for educated, middle-class women. Before Nightingale was called to nursing, religious women—nursing sisters—were involved in the development of nursing and the establishment of hospitals. Nevertheless, by the nineteenth century, hospitals were generally infa- mous for their miserable conditions and the incompetence of their nurs- ing staff. Thus, although Nightingale did not invent nursing, she was certainly a key figure in reforming the image and training of the modern nurse. Without excessive exaggeration, Nightingale often said that the benefits of medicine were uncertain, but the value of good nursing care was beyond dispute. Well-trained Nightingale nurses emphasized obsessive cleanliness in hospitals wards, even before surgeons adopted antisepsis and asepsis. Although the work carried out by nurses has changed in many ways since the Nightingale era, studies conducted in the 1990s confirmed Nightingale’s dictum. Patients treated at hospitals with a higher proportion of registered nurses suffered lower rates of complications and were released sooner than patients in hospitals with relatively low numbers of registered nurses. Longer hospital stays were associated with higher rates of complications like urinary infections, pneumonia, gastrointestinal bleeding, shock, cardiac arrest, and deaths that might have been prevented by rapid intervention.

The American Nurses Association has long insisted that maintaining appropriate levels of registered nurses is critical to insuring good patient care. In 1921, when American hospital administrators celebrated the first National Hospital Day, they acknowledged the coevolution of the modern hospital and the trained nurse by selecting May 12, Florence Nightingale’s birthday, for the festivities. In the United States, efforts to establish nursing schools were inspired by Nightingale and the experi- ences of the Civil War. Long before hospitals assumed a significant role in the education of doctors, hospital administrators found it rewarding to establish schools for the training of nurses. The number of nurse training schools in the United States grew rapidly after the first such schools were founded in the 1870s. By 1930, over two thousand hospi- tals were staffing their wards and selling the services of their own stu- dent nurses. As the number of nursing schools expanded, competition for the limited number of hospital positions and private duty assign- ments diminished the professional expectations of all trained nurses. Following the Nightingale model, early nursing reformers hoped to recruit from a select pool of ‘‘lady pupils’’ who would see nursing as a special calling. As the number of hospital nursing schools expanded, however, selectivity declined and nurses were seen as merely useful, reliable workers, who were expected to remain subordinate and deferen- tial to doctors. While attempting to create a standardized curriculum for nursing schools, nursing leaders also struggled to establish a pro- fessional identity for trained nurses. Well aware of the fact that the term ‘‘nurse’’ was used indiscriminately, nursing associations worked for licens- ing laws that would differentiate between trained and untrained nurses. By World War II, nursing practice had essentially established its modern form as graduate nurses replaced student nurses in hospital wards. Mary Adelaide Nutting (1858–1948) and Lavinia Lloyd Dock (1858–1956), nursing reformers and educators, insisted that the primary obligation of the nurse was the patient, not the doctor and urged nurses to control their own profession. As advocates of the Progressive world- view, Dock and Nutting saw their work as part of women’s mission to achieve social reform and progress. In addition to teaching and writing, Dock expressed her commitment to social reforms and public health concerns through her work in the settlement house movement. Dock worked as a public health nurse with her colleague Lillian Wald (1867–1940), the founder of the Henry Street Settlement, in New York City. Convinced that books and journals written by and for nurses were essential elements in the battle for professional autonomy, Dock and Nutting spent many years gathering material for their four-volume His- tory of Nursing (1907–1912). Recent studies indicate that nurses are still working towards Dock’s goal of the control of nursing by nurses. Following the model of Nightingale’s district nursing experiments, during the 1880s charitable organizations throughout the United States sponsored visiting nursing organizations. Nurses cared for the sick poor, providing help in bathing, dressing, feeding, and cleaning the home, as well as giving medicines, taking vital signs, teaching family members how to care for the patient and avoid contagion. Nurses in major cities also attempted to Americanize the immigrant families they visited. Some nurses and social reformers believed their work would also help reform the social conditions that led to illness, filth, and poverty. During the early twentieth century, the expanding public health movement offered trained nurses a field with the promise of more professional autonomy than routine hospital work or private duty nurs- ing. Public health nurses were involved in visiting nurse services, settle- ment houses, school nursing, child welfare, anti-venereal disease campaigns, factory dispensaries, first aid stations, preventive medicine, and health education. By having an approved protocol and standing orders from a doctor, the nurse avoided legal problems and enjoyed considerable autonomy. The National Organization for Public Health Nursing was founded in 1912, but most local governments did not respond to the idea that nursing services were essential aspects of public health work. Visiting nurse associations were, however, profoundly impacted by changes in the medical system as the role of hospitals expanded. After World War II, the organization of health services underwent changes that once again thwarted the professional aspi- rations of the nurse. Eventually, hospitals, official government agencies, and physicians found ways to take over work previously done by volun- tary social service agencies and public health nurses.

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