Nursing today is very different from nursing in the past, and it is expected to change

even further in the twenty-first century.

HISTORICAL PERSPECTIVES
Nursing has changed dramatically as a result of social demands and influences. An
examination of nursing's origins shows the profession's ongoing fight for autonomy and
professionalization. A renewed interest in nursing history has resulted in an increasing
body of related literature in recent decades. Only a few facets of incidents that have
affected nursing practice are highlighted in this section. Recurring themes of women’s
roles and status, religious (Christian) values, war, societal attitudes, and visionary
nursing leadership have influenced nursing practice in the past. Many of these factors
still exert their influence today.

Women’s Roles
Traditional female roles of wife, mother, daughter, and sister have always included the
care and nurturing of other family members. From the beginning of time, women have
cared for infants and children; thus, nursing could be said to have its roots in “the
home.” Additionally, women, who in general occupied a subservient and dependent
role, were called on to care for others in the community who were ill. Generally, the
care provided was related to physical maintenance and comfort. Thus, the traditional
nursing role has always entailed humanistic caring, nurturing, comforting, and
supporting.

Religion
Religion has also played a significant role in the development of nursing.
Although many of the world’s religions encourage benevolence, it
was the Christian value of “love thy neighbor as thyself ” and Christ’s
parable of the Good Samaritan that had a significant impact on the
development of Western nursing. During the third and fourth centuries,
several wealthy matrons of the Roman Empire, such as Fabiola,
converted to Christianity and used their wealth to provide houses of and the homeless.
Women were not, however, the sole providers of
nursing services.
The Crusades saw the formation of several orders of knights,
including the Knights of Saint John of Jerusalem (also known as
the Knights Hospitalers), the Teutonic Knights, and the Knights of
Saint Lazarus (Figure 1–1 •). These brothers in arms provided nursing
care to their sick and injured comrades. These orders also built
hospitals, the organization and management of which set a standard
for the administration of hospitals throughout Europe at that time.
The Knights of Saint Lazarus dedicated themselves to the care of
people with leprosy, syphilis, and chronic skin conditions.
During medieval times, there were many religious orders of men
in nursing. For example, the Alexian Brothers organized care for
victims of the Black Plague in the 14th century in Germany. In the
19th century, they followed the same traditions as women’s religious
nursing orders and established hospitals and provided nursing care.
The deaconess groups, which had their origins in the Roman
Empire of the third and fourth centuries, were suppressed during
the Middle Ages by the Western churches. However, these groups of
nursing providers resurfaced occasionally throughout the centuries,
most notably in 1836 when Theodor Fliedner reinstituted the Order
of Deaconesses and opened a small hospital and training school in
Kaiserswerth, Germany. Florence Nightingale received her “training”
in nursing at the Kaiserswerth School.
Early religious values, such as self-denial, spiritual calling, and devotion
to duty and hard work, have dominated nursing throughout its
history. Nurses’ commitment to these values often resulted in exploitation
and few monetary rewards. For some time, nurses themselves believed
it was inappropriate to expect economic gain from their “calling.”

War
Throughout history, wars have accentuated the need for nurses. During
the Crimean War (1854–1856), the inadequacy of care given to soldiers led to a public
outcry in Great Britain. The role Florence Nightingale
played in addressing this problem is well known. She was asked
by Sir Sidney Herbert of the British War Department to recruit a contingent
of female nurses to provide care to the sick and injured in the
Crimea. Nightingale and her nurses transformed the military hospitals
by setting up sanitation practices, such as hand washing and washing
clothing regularly. Nightingale is credited with performing miracles;
the mortality rate in the Barrack Hospital in Turkey, for example, was
reduced from 42% to 2% in 6 months (Donahue, 2011, p. 118).
During the American Civil War (1861–1865), several nurses
emerged who were notable for their contributions to a country torn by
internal strife. Harriet Tubman and Sojourner Truth (Figures 1–2
and 1–3 •) provided care and safety to slaves fleeing to the North on the
Underground Railroad. Mother Biekerdyke and Clara Barton searched
the battlefields and gave care to injured and dying soldiers. Noted authors Walt
Whitman and Louisa May Alcott volunteered as nurses
to give care to injured soldiers in military hospitals. Another female
leader who provided nursing care during the Civil War was Dorothea
Dix (Figure 1–4 •). She became the Union’s superintendent of female
nurses responsible for recruiting nurses and supervising the nursing
care of all women nurses working in the army hospitals.
The arrival of World War I resulted in American, British, and
French women rushing to volunteer their nursing services. These
nurses endured harsh environments and treated injuries not seen
before. A monument entitled “The Spirit of Nursing” stands in
Arlington
National Cemetery (Figure 1–5 •). It honors the nurses
who served in the U.S. armed services in World War I, many of whom
are buried in Section 21, which is also called the “Nurses Section”
(
Arlington National Cemetery, n.d.). Progress in health care occurred
during World War I, particularly in the field of surgery. For example,
advancements were made in the use of anesthetic agents, infection
control, blood typing, and prosthetics.
World War II casualties created an acute shortage of caregivers,
and the Cadet Nurse Corps was established in response to a marked
shortage of nurses (Figure 1–6 •). Also at that time, auxiliary health
care workers became prominent. “Practical” nurses, aides, and technicians
provided much of the actual nursing care under the instruction
and supervision of better prepared nurses. Medical specialties
also arose at that time to meet the needs of hospitalized clients.
During the Vietnam War, approximately 11,000 American
military women stationed in Vietnam were nurses. Most of them
volunteered to go to Vietnam right after they graduated from nursing
school, making them the youngest group of medical personnel
ever to serve in wartime (Vietnam Women’s Memorial Foundation,
n.d.). Near the Vietnam Veterans Memorial (“The Wall”) stands the
Vietnam
Women’s Memorial (Figure 1–7 •). Before the mid-1800s, nursing was without
organization, education,
or social status; the prevailing attitude was that a woman’s place
was in the home and that no respectable woman should have a career.
The role for the Victorian middle-class woman was that of wife
and mother, and any education she obtained was for the purpose of
making her a pleasant companion to her husband and a responsible
mother to her children. Nurses in hospitals during this period were
poorly educated; some were even incarcerated criminals. Society’s attitudes
about nursing during this period are reflected in the writings
of Charles Dickens. In his book Martin Chuzzlewit (1896), Dickens
reflected his attitude toward nurses through his character Sairy
Gamp (Figure 1–8 •). She “cared” for the sick by neglecting them,
stealing from them, and physically abusing them (Donahue, 2011,
p. 112). This literary portrayal of nurses greatly influenced the negative
image and attitude toward nurses up to contemporary times.
In contrast, the guardian angel or angel of mercy image arose in the
latter part of the 19th century, largely because of the work of Florence
Nightingale during the Crimean War. After Nightingale brought respectability
to the nursing profession, nurses were viewed as noble,
compassionate, moral, religious, dedicated, and self-sacrificing.
Another image arising in the early 19th century that has affected
subsequent generations of nurses and the public and other professionals
working with nurses is the image of doctor’s handmaiden. This
image evolved when women had yet to obtain the right to vote, when
family structures were largely paternalistic, and when the medical
profession portrayed increasing use of scientific knowledge that, at
that time, was viewed as a male domain. Since that time, several images
of nursing have been portrayed. The heroine portrayal evolved
from nurses’ acts of bravery in World War II and their contributions
in fighting poliomyelitis—in particular, the work of the Australian
nurse Elizabeth Kenney. Other images in the late 1900s include the
nurse as sex object, surrogate mother, and tyrannical mother.
During the past few decades, the nursing profession has
taken steps to improve the image of the nurse. In the early 1990s,
the Tri-
Council for Nursing (the American Association of Colleges
of Nursing, the American Nurses Association [ANA], the
American
Organization of Nurse Executives, and the National League for Nursing [NLN]) initiated
a national effort, titled “Nurses
of America,” to improve the image of nursing. Launched in 2002,
the Johnson & Johnson corporation continues their “Campaign for
Nursing’s Future” to promote nursing as a positive career choice.
Through various outreach programs, this campaign increases exposure
to the nursing profession, raises awareness about its challenges
(e.g., nursing shortage), and encourages people of all ages to
consider a career in nursing.

Nursing Leaders
Florence Nightingale, Clara Barton, Linda Richards, Mary Mahoney,
Lillian Wald, Lavinia Dock, Margaret Sanger, and Mary
Breckinridge
are among the leaders who have made notable contributions
both to nursing’s history and to women’s history. These
women were all politically astute pioneers. Their skills at influencing
others and bringing about change remain models for political nurse
activists today. Contemporary
nursing leaders, such as Virginia
Henderson, who created a modern worldwide definition of nursing,
and Martha Rogers,
a catalyst for theory development, are discussed
in Chapter 3 .
NIGHTINGALE (1820–1910)
The contributions of Florence Nightingale to nursing are well
documented. Her achievements in improving the standards for the
care of war casualties in the Crimea earned her the title “Lady with
the Lamp.” Her efforts in reforming hospitals and in producing and
implementing public health policies also made her an accomplished
political nurse: She was the first nurse to exert political pressure on
government. Through her contributions to nursing education—perhaps
her greatest achievement—she is also recognized as nursing’s
first scientist-theorist for her work Notes on Nursing: What It Is, and
What It Is Not (1860/1969).
Nightingale (Figure 1–9 •) was born to a wealthy and intellectual
family. She believed she was “called by God to help others . . .
[and] to improve the well-being of mankind” (Schuyler, 1992, p. 4).
She was determined to become a nurse in spite of opposition from
her family and the restrictive societal code for affluent young English
women. As a well-traveled young woman of the day, she visited
Kaiserswerth
in 1847, where she received 3 months’ training in nursing. In 1853 she studied in Paris
with the Sisters of Charity, after which
she returned to England to assume the position of superintendent of
a charity hospital for ill governesses.
When she returned to England from the Crimea, a grateful
English
public gave Nightingale an honorarium of £4,500. She later
used this money to develop the Nightingale Training School for
Nurses, which opened in 1860. The school served as a model for
other training schools. Its graduates traveled to other countries to
manage hospitals and institute nurse-training programs.
Despite poor health that left her an invalid, Florence Nightingale
worked tirelessly until her death at age 90. As a passionate statistician,
she conducted extensive research and analysis (Florence Nightingale
International Foundation, 2014). Nightingale is often referred to as
the first nurse researcher. For example, her record keeping proved
that her interventions dramatically reduced mortality rates among
soldiers during the Crimean War.
Nightingale’s vision of nursing changed society’s view of nursing.
She believed in personalized and holistic client care. Her vision
also included public health and health promotion roles for nurses.
It is easy to see how Florence Nightingale still serves as a model for
nurses today.
BARTON (1821–1912)
Clara Barton (Figure 1–10 •) was a schoolteacher who volunteered
as a nurse during the American Civil War. Her responsibility was to
organize the nursing services. Barton is noted for her role in establishing
the American Red Cross, which linked with the International Red
Cross when the U.S. Congress ratified the Treaty of Geneva (
Geneva
Convention). It was Barton who persuaded Congress in 1882 to ratify
this treaty so that the Red Cross could perform humanitarian efforts
in time of peace.
RICHARDS (1841–1930)
Linda Richards (Figure 1–11 •) was America’s first trained nurse.
She graduated from the New England Hospital for Women and
Children in 1873. Richards is known for introducing nurse’s notes
and doctor’s orders. She also initiated the practice of nurses wearing
uniforms (ANA, 2013b). She is credited for her pioneering work in
psychiatric and industrial nursing. MAHONEY (1845–1926)
Mary Mahoney (Figure 1–12 •) was the first African American
professional nurse. She graduated from the New England Hospital
for Women and Children in 1879. She constantly worked for the acceptance
of African Americans in nursing and for the promotion of
equal opportunities (Donahue, 2011, p. 144). The ANA (2013c) gives
a Mary Mahoney Award biennially in recognition of significant contributions
in interracial relationships.
WALD (1867–1940)
Lillian Wald (Figure 1–13 •) is considered the founder of public
health nursing. Wald and Mary Brewster were the first to offer
trained nursing services to the poor in the New York slums. Their
home among the poor on the upper floor of a tenement, called the
Henry Street Settlement and Visiting Nurse Service, provided nursing
services, social services, and organized educational and cultural
activities. Soon after the founding of the Henry Street Settlement,
school nursing was established as an adjunct to visiting nursing.
DOCK (1858–1956)
Lavinia L. Dock (Figure 1–14 •) was a feminist, prolific writer,
political activist, suffragette, and friend of Wald. She participated in protest movements
for women’s rights that resulted in the 1920
passage of the 19th Amendment to the U.S. Constitution, which
granted women the right to vote. In addition, Dock campaigned for
legislation to allow nurses rather than physicians to control their profession.
In 1893, Dock, with the assistance of Mary Adelaide Nutting
and Isabel Hampton Robb, founded the American Society of Superintendents
of Training Schools for Nurses of the United States, a precursor
to the current National League for Nursing.
SANGER (1879–1966)
Margaret Higgins Sanger (Figure 1–15 •), a public health
nurse in New York, has had a lasting impact on women’s health
care. Imprisoned for opening the first birth control information
clinic in America, she is considered the founder of Planned Parenthood.
Her experience with the large number of unwanted pregnancies
among the working poor was instrumental in addressing this
problem. BRECKINRIDGE (1881–1965)
After World War I, Mary Breckinridge (Figure 1–16 •), a notable
pioneer nurse, established the Frontier Nursing Service (FNS). In
1918, she worked with the American Committee for Devastated
France, distributing food, clothing, and supplies to rural villages
and taking care of sick children. In 1921, Breckinridge returned to
the United States with plans to provide health care to the people
of rural America. In 1925, Breckinridge and two other nurses began
the FNS in Leslie County, Kentucky. Within this organization,
Breckinridge started one of the first midwifery training schools in
the United States.