Roman mythological figures included the goddess Fortuna, who was usually recognized as being responsible for one’s fate and who also served as Jupiter’s nurse (Dolan, 1969). Even before Greek and Roman times, ancient Egyptian physicians and nurses assembled voluminous pharmacopoeia with more than 700 remedies for numerous health problems. Great emphasis was placed on the use of animal parts in concoctions that were generally drunk or applied to the body. The physician prescribed and provided the treatments and usually had an assistant who provided the nursing care (Kalisch and Kalisch, 1986). Some ancient medicine was based on driving out the evil spirit rather than curing or treating the malady. The treatments were often very foul and frequently included fecal material. By now you may be thinking of the saying, “The treatment was successful, but the patient died.”

Advancement of medical knowledge halted abruptly after the Roman Empire was conquered and the Dark Ages began. Any medical and health care knowledge that survived these dark times did so only through the efforts of Jewish physicians who were able to translate the Greek and Roman works (Kalisch and Kalisch, 1986). One bright spot was in Salerno, where a school of medicine and health was established for physicians and women to assist in childbirth. In fact, a midwife named Trotula wrote what may be considered the first nursing textbook on the cure of diseases of women (Dalton, 1900). Generally, nursing was performed by designated priestesses and was associated with some type of temple worship. Little information has survived about this early period. Historians have assumed that Hippocrates was assisted by women, but there is little information to support that. From these roots, nursing began to develop as a recognized and valued service to society (Jamieson and Sewall, 1949).

Women sympathetic to the Christian cause of aiding the poor were encouraged in this work by the bishops and deacons. Eventually, the deacons relinquished this work to women and established the position of deaconess for that purpose. To maintain a pure heart, these women were required by the Church to be either virgins or widows. The stipulation for widows, however, was that they had to have been married only once (Jamieson and Sewall, 1949). The deaconesses carried nursing forward as they ministered to the sick and injured in their homes. Phoebe, a friend of Paul’s and the very first deaconess in the young Christian church, has been called the first visiting nurse (Dana, 1936).

Treatments continued to be a mixture of scientific fact, home remedies, and magic. Eventually, an order of widows evolved that was composed of women who were free from home responsibilities and thus able to commit fully to working among the poor. The widows, although not ordained, continued to do the same work as the deaconesses. This was soon followed by the creation of the Order of Virgins as the Church began placing greater value on purity of body. Although deaconess orders were abolished in the Mediterranean countries, they thrived in other European countries. The traditional commitment to care for the poor and sick became invaluable in a society that generally had neither the time nor the inclination to aid them. Eventually, these women became known as nuns (from non nuptae, meaning “not married”).

This was a time of tremendous upheaval in the world. Wars, invasions, and battles were constant, and as a result of these encounters, the number of widows was significant. Society during this time did not have the sophistication or the means to deal with the dependents of the soldiers killed in battle. As a means of survival, women joined the nuns as a form of protection from starvation and poverty. This was a dark and dreary time in which superstition, witchcraft, and folklore were predominant influences. Because of the need for physical protection, convents were built to shelter these women (Jamieson and Sewall, 1949). The convents became havens to which women could withdraw from ignorance and evil and be nurtured in traditional Christian beliefs (Donahue, 1985). The deaconesses, widows, and virgins continued to minister to and nurse the ill within the safety of the convent.

The Holy Wars furthered the development of nursing in a rather interesting way. Because many Christian crusaders became ill while in Jerusalem, a hospital known as the Hospital of St. John was built to accommodate them. Those who fought in these Holy Wars had taken oaths of chivalry, justice, and piety and were known as knights. Often the knights were accompanied into battle by men trained in the healing arts. These male nurses cared for wounded or otherwise stricken knights. They usually wore a red cross emblazoned on their tunics so that in the heat of battle they could be easily identified and avoid injury or death (Bullough and Bullough, 1978).

The Hospital of St. John gave excellent nursing care. Many of the nurses who survived stayed to work with the hospital organizers. As the battles in the Holy Land continued, the nurses and knights organized a fighting force with a code of rules and a uniform consisting of a black robe with a white Maltese cross, the symbol of poverty, humility, and chastity. They ventured out to rescue the sick and wounded and transport them to the hospital for care; thus they became known as the Hospitalers (Kalisch and Kalisch, 1986). Male nurses dominated these orders. Other orders that emulated the Hospitalers developed in Europe, and more hospitals were opened based on the Hospital of St. John model (Donahue, 1985).

The altruistic spirit of nursing was also seen in the craftsmen’s guilds. Although their primary purpose was to provide training and jobs through the practice of apprenticeship, the guilds provided care and aid for their members when they became old and could no longer work at their trade. The guilds also assisted members and their families in times of illness and injury. The apprenticeship system—in which experience is gained on the job but no formal education is provided—once served as a model for the training of nurses (Donahue, 1985). This system is no longer used and is now considered to have been detrimental to the evolution of nursing.

What nursing gained during this period of history was status. The altruistic ideal of providing care as a service performed out of humility and love became the foundation for nursing. The recognition of the value of hospitals grew; all across Europe, cities were building their own hospitals. A general resurgence in the demand for trained doctors and nurses contributed to the building of medical schools and the development of university programs in the art and science of healing.

Revolts—not the kind that led to battles, but revolts of a social nature—were common. There were battles too; however, the social revolts had a more direct impact on nursing. The revolution of the spirit, more commonly known as the Renaissance, ushered in new concepts of the world: the discovery of the laws of nature by Newton, the exploration of unknown lands, and the growth of secular interests (humanism) over spiritual ones. In this era emerged several outstanding humanists who were to become saints (Donahue, 1985). Interestingly, in depictions of these saints, they are shown as needing nursing care or as giving care to a wounded or injured person.

In Europe, the Protestant Reformation began primarily as a religious reform movement, but ended with revolt within the Church. Many hospitals in Protestant countries were forced to close, and those loyal to the Church that operated them were driven out of the country, resulting in a significant shortage of nurses (mostly nuns) to care for the ill and injured. The poor and ill were considered a burden to society, and those hospitals that remained operational in the Protestant countries became known as “pest houses.” To fill the need for nurses, women (many of whom were alcoholics and former prostitutes) were recruited. Generally, during this period, a nurse was a woman serving time in a hospital rather than a prison (Donahue, 1985; Jamieson and Sewall, 1949).

The industrial and intellectual revolutions that followed the Reformation all had significant impacts on nursing. During the Industrial Revolution, as production of much-needed goods was streamlined through industrial innovation, craftsmen left the rural life to work in factories. The intellectual contributions of scientists, many of whom were physicians, combined with the inventions of the microscope, thermometer, and pendulum clock, advanced our knowledge and understanding of the world. The invention of the printing press allowed for easier sharing of information, which further contributed to experimentation. Finally, a disease that was feared worldwide was conquered when Edward Jenner (1749-1823) proved the effectiveness of the smallpox vaccination.

Throughout these revolutions, however, the maternal and infant death rates continued to be high. In fact, before his pioneering work in antisepsis in obstetrics, Ignaz Phillipp Semmelweis (1818-1865) observed that patients giving birth in hospitals under the care of educated physicians had significantly higher death rates than women giving birth at home or in clinics with the assistance of midwives.

Despite all the knowledge gained during this time of revolution, society was generally callous toward the plight of children. Children were abandoned without apparent remorse, and infanticide was practiced by poor families desperate to reduce the number of mouths to feed. These families had no reliable form of birth control except abstinence. Because it was common practice for the woman hired as a wet nurse to sleep with the infant, many infants were inadvertently suffocated. Donahue (1985) reported that, during this period, 75% of all children baptized were dead before they reached the age of 5 years. Because of the persistence of these sad conditions, children’s and foundlings’ hospitals were established. Eventually, laws were enacted to aid these unfortunate victims (Donahue, 1985).

Existing health care conditions for the ill and injured continued to contribute to high mortality rates. Some sources reported hospital mortality rates as high as 90%. Conditions in the armies were no better. In any military action, mortality rates were high. Reports from the battlefront during the Crimean War suggested that battles were postponed because there were too few able-bodied soldiers to fight. Dysentery and typhoid were the military’s nemeses. If a soldier was wounded, infection invariably resulted. Hospitals generally offered no guarantee of survival. In any event, these occurrences had a serious effect on military strategies. If men are ill or injured, battles cannot be won.

Upon this scene entered Florence Nightingale.

First, let us discuss the legend. Published works about Florence Nightingale before the 1960s generally presented the legend. Most authors agreed that she was beautiful, intelligent, wealthy, socially successful, and educated. She certainly had an ability to influence people and used every Victorian secret to accomplish her desires. Although Nightingale believed it improper to accept payment for her services, she did demand financial support for materials, goods, and staff to accomplish her programs and goals. Some historians believe that it was through Nightingale’s influence that Jean Henri Dunant, a Swiss gentleman, provided the aid to the wounded that lay the foundation for the organization of the International Red Cross (Bullough et al, 1990; Dodge, 1989; Dossey, 2000).

Regardless of what actually happened between Dunant and her, Nightingale’s interest and ambition lay in becoming a nurse. Her family was in an uproar over this decision. As described by Dossey (2000), Florence (or “Flo” as her family and friends called her) began her journey as a mystic when she was 16 years old. Her experience of a sudden, inner “knowing” took place under two majestic cedars at Lebanon in Embley (England), one of her sacred spots for contemplation. She claimed to receive the following in her awakening moment: “That a quest there is, and an end, is the single secret spoken.” Energized by her contact with the Divine Reality or Consciousness, Florence “worked very hard among the poor people” with “a strong feeling of religion” for the next 3 months (Dossey, 2000, p 33) (Critical Thinking Box 6-1, Figure 6-1, and Box 6-1).

Nightingale’s parents felt that hospitals were terrible places to go and that nurses were, in most cases, the dregs of society. Hospitals were certainly not places for women of proper social upbringing. Although she was forbidden to do so, Nightingale studied nursing (in secret). After a fortuitous meeting, a relationship developed between Nightingale and Sidney and Elizabeth Herbert, an influential couple who were interested in hospital reform. Impressed with Nightingale’s analytical mind and her ability to apply nursing knowledge to the critical situation in the hospitals (Bullough and Bullough, 1978; Bullough et al, 1990), they encouraged her to study nursing at Kaiserswerth School, run by Lutheran deaconesses (Dolan, 1969). Her family, of course, was very unhappy. In fact, Dodge (1989) reported that the event precipitated a family crisis because they threatened to withdraw financial support.

Nightingale accepted a position as administrator of a nursing home for women, the Institution for the Care of Sick Gentlewomen in Distressed Circumstances. She hired her own chaperone and went to work at reforming the way things were done. Nightingale’s interest in hospital reform was insatiable. She visited hospitals and took copious notes on nursing care, treatments, and procedures. She sent reports on hospital conditions to Sidney Herbert, the British Secretary of War. Secretary Herbert then assigned her other hospitals to review. The reviews always included recommendations for improving nursing care. From this early background of experiences, Nightingale was now ready for her greatest mission—the Crimean War. The legend was on the way (Bullough et al, 1990).

In 1854, soldiers were dying, more from common diseases than from bullets. Bullough and colleagues (1990) reported that the Crimean War was a series of mistakes. No plan was made for supplying the troops, no plan was in place to maintain the environment in camps, and no provisions were available to care for the injured after the battle. When Herbert appointed Nightingale as head of a group of nurses to go to Crimea, she had already developed a plan of action. In fact, some historians believe that she was already planning to go in an unofficial capacity. The announcement caused a sensation, and when Nightingale began a rigorous selection process for accepting nurses, many volunteered, but few were chosen. She cleaned up the kitchens, the wards, the patients, and the mess. From there, the legend grew.

She was clever; after demonstrating the effectiveness of her methods, she withdrew her services. Naturally, all that she had accomplished was done under the scrutiny, skepticism, suspicion, and anger of the physicians. Without the services of the nurses, the abominable conditions quickly returned, and finally the physicians begged her to do whatever she wished—just help! Nightingale responded to the pleading. The actual number of soldiers who benefited from the care of her nurses was immeasurable.

Nightingale’s great success prompted her to begin developing schools of nursing based on her knowledge of what was effective nursing. Eventually, many schools in Europe and America used the Nightingale model for nursing education. The program was generally 1 year in length, and classes were small. Many women wanted to become nurses; however, only 15 to 20 applicants were accepted for each class. The goals of her programs included training hospital nurses, training nurses to train others, and training nurses to work in the district with the sick poor (Dolan, 1969). Nightingale had changed society’s view of the nurse to one of dignity and value and worthy of respect. As a tribute to Nightingale, Lystra Gretter, an instructor of nursing at the old Harper Hospital in Detroit, Michigan, composed “The Nightingale Pledge,” which was first used by its graduating class in the spring of 1893. It is an adaptation of the Hippocratic Oath taken by physicians (Box 6-2).

In any legend, the truth is often mixed with myth. The stories surrounding Florence Nightingale are many. What is interesting is that, before the 1970s, authors tended to deify Nightingale or establish her as a saintly person. These myths make for interesting reading. Early nurse historians also contributed to these myths by their interpretations of Nightingale’s work. But myths have a purpose. They can be used to explain world views of groups of people or professions at a given time, and they provide explanations for practice beliefs or natural phenomena. Myths tend to maintain a degree of accuracy when the truth is lost. The trick is to separate myth from fact and story from legend and to draw conclusions regarding the occurrences. This is no easy task when one studies Florence Nightingale. Therefore, it is important to read a variety of studies across several time periods before drawing conclusions about the legend and the lady.

In summary, Florence Nightingale had certain characteristics that assisted her in becoming successful during the strict Victorian times in which she lived. She was extremely well educated for her time. She had traveled throughout the world and had the advantage of personal wealth and a gift for establishing relationships with persons of influence and philanthropic spirit. Most portraits depict her as an attractive woman with pleasant features. Contemporary historians agree she had tremendous compassion for all who suffered. She was very strong-willed, a characteristic that carried her through the period of the Crimean War. She had the ability to analyze data and draw relevant conclusions, on which she based her recommendations. Her students of nursing received better preparation than most physicians. She was 36 at the end of the war, and when she returned home, she became a virtual recluse until she died at age 90. She did have some physical ailments: Crimean fever, sciatica, rheumatism, and dilation of the heart, each of which could have crippling side effects and contributed to her becoming bedridden (Bullough et al, 1990). According to Dossey (2000), “In 1995, D.A.B. Young, a former scientist at the Wellcome Foundation in London, proposed that the Crimean fever was actually Mediterranean fever, otherwise known as Malta fever; this disease is included under the generic name brucellosis” (p 426). Because of the widespread Crimean fever that the soldiers encountered, it is thought that Nightingale was most likely exposed to this disease through ingesting contaminated food, such as meat or raw milk, cheese, or butter. It seems a logical assumption that Nightingale’s 32-year history of debilitating, chronic symptoms is compatible with a diagnosis of chronic brucellosis. In any event, the legend and the lady had a significant effect on American nursing as we know it today (Bullough and Bullough, 1978; Bullough et al, 1990; Dodge, 1989; Dolan, 1969; Dossey, 2000).

In colonial times, nursing responsibilities were shared by all able-bodied persons; however, when there was a choice, women were preferred as nurses. Early colonial historians described care for the ill and house chores as the responsibilities of nurses. Although most women of this era were considered dainty (Bradford, 1898), nurses were usually depicted as willing to do hard work. Some colonies organized nursing services that sought out the sick and provided comfort to those who were ill with smallpox and other diseases (Bullough and Bullough, 1978). There were few trained nurses, however, and most of the individuals who delivered nursing care in the five largest hospitals were men (Dolan, 1969). Eventually, women were hired at the command of George Washington to serve meals and care for the wounded and ill. The era ended with the enactment of the first legislation to improve health and medical treatment and to provide for formal education for society as a whole (Dolan, 1969).

Most women were considered fragile and dainty. They were often ill. It has been suggested that some women used illnesses and frailty as a form of birth control to prevent the numerous pregnancies that most women experienced. Some historians concluded that it was through their weaknesses that women gained control and attention. If the wife was ill or frail, maids or servants were hired, but if the wife were healthy, the husband would expect more from her. The Victorian wife was expected to “be good.” She was esteemed by her husband but had limited power within the confines of the home and society. She was expected to be hard-working and able to maintain harmony while at the same time being submissive to the demands of her husband. Generally, this fostered dependence on the dominant male figure—the Victorian husband (Rybczynski, 1986).

Let us examine nursing during this same time, especially within the hospital organization. Nurses generally were women who wanted to avoid the drudgery of a Victorian marriage. They were required to be single to make a complete commitment to their vocation. Schooled in submission, women were expected to be equally accommodating within the hospital organization. A good nurse worked for harmony within the hospital. She was expected to be hard-working and submissive. The doctor and the hospital administrator were frequently the same person, usually a man who expected position and power to go hand in hand. Patients were admitted only if they had income and could afford to pay for the services. It was the physician who generated income, and good nurses were expected to help him continue to maintain power. Because the system rewarded people for being ill, there was little incentive to be healthy. Social values contributed to dependence on the health care system. From this milieu came the reformers (Bullough and Bullough, 1978; Davis, 1961; Kalisch and Kalisch, 1986; Stewart, 1950).

The Victorian era, although a time of repression for women, was also a time of reform. A list of important names in nursing reform includes M. Adelaide Nutting, Minnie Goodnow, Lavinia L. Dock, Annie W. Goodrich, Isabel Hampton Robb, Lilian D. Wald, Isabel M. Stewart, and Sophia Palmer, among others (Jamieson and Sewall, 1949; Kalisch and Kalisch, 1986). These women, who had in common a comfortable upper middle-class background, intelligence, and education, also had in common a desire to reach beyond the constraints that society imposed on them. As society began to realize the important role that nurses played in treating the ill and injured, it also began to understand the need for training programs that would educate better nurses. Reformers focused on establishing standards for nursing education and practice. Among their accomplishments were the organization of the American Nurses Association and the creation of its journal, the American Journal of Nursing, and the enactment of legislation to require the licensure of prepared nurses. This protected the public from inadequate care given by people who were not trained to nurse (Christy, 1971; Dock, 1900).

As mentioned previously, Florence Nightingale acquired the nickname “Lady with the Lamp” while caring for soldiers during the Crimean War. Throughout the night, she would carry her lamp while checking on each soldier. For many historical scholars, this image of Nightingale more accurately represents Longfellow’s poetic imagination in his 1857 Santa Filomena than the historical record (Grypma, 2010). Here is a link to this famous poem: www.theatlantic.com/past/docs/unbound/poetry/nov1857/filomena.htm.

The nurse’s cap design evolved from the traditional garb of the early deaconesses or nuns who were some of the earliest nurses to care for the sick. More recently, the cap’s original use was to keep a female nurse’s hair neatly in place and present a professional appearance. There were two types of cap styles: one was a long nurse’s cap, which covered most of the nurse’s head; the other was a short nurse’s cap, which sat on top of the head. The design of the cap identified the nurse’s alma mater, which differentiated graduates from their respective nursing programs. Typically, a black band sewn on the cap signified a senior level student or graduate status, and sometimes identified the head nurse on a clinical unit. The origin of the black or navy band is unknown; some historical scholars believed the black band was a sign of mourning for Florence Nightingale. By the late 1970s, the hat had disappeared almost completely, as have “capping” ceremonies when the new student passed a probationary period of the program to receive their nursing cap. Also, the rapid growth of the number of men in nursing also necessitated a unisex uniform.

The nursing pin is a 1000-year-old symbol of service to others (Rode, 1989). The Maltese cross worn by the knights and nurses during the Crusades is considered the origin of the nursing pin. The most recent ancestor of the pin is the hospital badge that has been worn to identify the nurse since its inception more than 100 years ago. The nursing pin was given by the hospital school of nursing to the graduating students to identify them as nurses who were educated to serve the health needs of society. As schools of nursing flourished, each designed their own unique pin to represent their unique philosophy and beliefs. The pin is still worn as part of the nurse’s uniforms today.

The oldest form of educational preparation leading to licensure as an RN in the United States is the diploma program. Education in diploma schools emphasized the skills needed to care for the acutely ill patient. Graduates received a diploma in nursing, not an academic degree. From 1872 until the mid-1960s, the hospital diploma program was the dominant nursing program. Currently, there are approximately 59 diploma programs accredited by the National League for Nursing (NLN); this represents the smallest percentage of all basic RN programs (NLNAC, 2007). Perhaps one of the reasons for this decline was that the courses offered by hospitals frequently did not earn college credit. Although most diploma programs are associated with institutions of higher learning, where the graduates receive some college credit, they still may not receive college credit for the nursing courses.

In 1951, Mildred Montag published her doctoral dissertation, The Education of Nursing Technicians, which proposed education for the RN in the community college. Dr. Montag suggested that the associate degree program be a terminal degree to prepare nurses for immediate employment. According to Dr. Montag, there was a need for a new type of nurse, the “nurse technician,” whose role would be broader than that of a practical nurse but narrower than that of the professional nurse. The technical nurse was to function at the “bedside.” The duties of the technical nurse, according to Dr. Montag, would include (1) giving general nursing care with supervision, (2) assisting in the planning of nursing care for patients, and (3) assisting in the evaluation of the nursing care given (Montag, 1951).

In 1952, an advisory committee was established by the American Association of Junior Colleges. Along with the National League for Nursing (NLN), this committee was to conduct cooperative research on nursing education in the community college. The goals of this Cooperative Research Project were threefold: (1) to describe the development of the associate degree nursing program, (2) to evaluate the associate degree graduates, and (3) to determine the future implications of the associate degree on nursing. The original project was directed by Dr. Montag at Teachers College of Columbia University and included seven junior colleges and one hospital from each of the six regions of the United States.

In the proposed technical nursing curriculum, there was to be a balance between general education and nursing courses. Unlike the diploma programs, the emphasis was to be on education, not service. At the end of 2 years, the student was to be awarded an associate’s degree in nursing and would be eligible to take the state board examinations for RN licensure.

The early baccalaureate nursing programs were usually 5 years in length and consisted of the basic 3-year diploma program with an additional 2 years of liberal arts. In 1919, there were eight baccalaureate programs. In a 2006-2007 survey conducted by the American Association of Colleges of Nursing (AACN) found that total enrollment in all nursing programs leading to the baccalaureate degree, both entry-level and RN degree completion programs, was 180,127—up from 163,706 in 2005 (AACN, 2008).

Until the 1960s, the master’s degree in nursing was viewed as a terminal degree. The goal of graduate education was to prepare nurses for teaching, administration, and supervisory positions. In the early 1970s, the emphasis shifted to developing clinical skills, and the roles of clinical specialists and nurse practitioners emerged. By the late 1970s, the focus again shifted back to teaching, administration, and supervisory positions (McCloskey and Grace, 2001).

In response to health care reform, the number of master’s programs has increased. Enrollments in master’s degree programs rose 18.1% (8337 students) bringing the total student population to 56,028. In research-focused doctoral programs, enrollments increased by 6.3% (231 students) with the total student population at 3927 (AACN, 2008).

As a student, you study nursing texts that explain theories, skills, principles, and the care of patients. Every text has at least one introductory chapter that describes nursing and its significance. By examining many of these introductory chapters of nursing texts, you can generate a rather extensive list of roles (Anglin, 1991). From this list of roles, six major categories can be determined (Table 6-1). The most traditional role for nurses is that of caregiver. The nurse as teacher is often referred to when discussing patient care or nursing education. The role of advocate has been very controversial since 1900. Nurses were also expected to be managers ever since the first formal education or training program was instituted. Another interesting role for the nurse is that of colleague. The final role is that of expert.

TABLE 6-1

What Nurses Do

CAREGIVER	TEACHER	ADVOCATE	MANAGER	COLLEAGUE	EXPERT
Care provider Comforter Handmaiden Healer Helper Nurturer Practitioner Rehabilitator Support agent Only gold members can continue reading. Log In or Register to continue Share this: Click to share on Twitter (Opens in new window) Click to share on Facebook (Opens in new window) Related Related posts: Using Nursing Research in Practice Image of Nursing: Influences of the Present Nursing Theory Ethical Issues Stay updated, free articles. Join our Telegram channel Join Tags: Nursing Today Revised Reprint Transitions and Trends Jan 10, 2017 | Posted by admin in NURSING | Comments Off on Historical Perspectives: Influences on the Present Full access? Get Clinical Tree Get Clinical Tree app for offline access Get Clinical Tree app for offline access