Chapter 1 NURSING: HISTORICAL, PRESENT AND FUTURE PERSPECTIVES
To understand contemporary issues in nursing the student nurse needs to understand how nursing has evolved in Australia and New Zealand. This chapter includes a discussion of the history of nursing, factors influencing nursing practice, the role of the nurse in contemporary health care and professional nursing organisations. This chapter will help the student to understand and appreciate the influences of the past, present and future on modern nursing.
Nurses these days don’t look like nurses anymore. In my days we had our starched uniform with aprons, caps with colour-coded stripes to denote our status, black tights and shoes. These days most nurses wear casual slacks and blouses. They certainly look comfortable and practical but I was proud of my uniform and what it meant.
Nursing is an art and a science with a unique body of knowledge that draws from the social, the behavioural and the physical sciences. Nursing is a unique profession because it addresses responses of individuals and families to health promotion, health maintenance and health problems. There are many philosophies and definitions of nursing. Florence Nightingale defined nursing over 100 years ago as ‘the act of utilising the environment of the patient to assist him in his recovery’. Nightingale considered a clean, well-ventilated and quiet environment essential for recovery. Often considered the first nurse theorist, Nightingale raised the status of nursing through education. Nurses were no longer untrained housekeepers but people educated in the care of the sick (Berman et al 2008).
Virginia Henderson was one of the first modern nurses to define nursing. The definition she posed in 1966 was adopted by the International Council of Nurses (ICN) in 1973 and still holds wide appeal to the nursing profession. Henderson defined nursing as:
assisting the individual, sick or well, in the performance of those activities contributing to health, its recovery, promoting quality of life or to a peaceful death that the client would perform unaided if he or she had the necessary strength, will or knowledge.
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 the 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.
In nursing, a combination of technical skill, clinical experience and theoretical knowledge is required. Historically there has been a tendency for nursing education to focus on the mastery of nursing skills. However, nursing practice is far more complex than technical skills alone. Nursing expertise is required for interpreting clinical situations and for complex decision making. It is the basis for the advancement of nursing practice and the development of nursing science. When providing nursing care, the nurse makes clinical judgments about the care needed for clients based on fact, experience and standards of care. Knowledge, expertise and lifelong learning are gained through the continual process of critical thinking (Crisp & Taylor 2005) (see Chapter 18).
The recipients of nursing are sometimes called consumers, patients or clients. A consumer is defined as an individual, a group of people or a community that uses a service or commodity. Individuals who use health care products or services are consumers of health care. A patient is a person who is waiting for or undergoing medical treatment and care. Usually, people become patients when they seek assistance because of illness or for surgery. Some nurses believe that the term ‘patient’ implies passive acceptance of the decisions and care of health professionals, and nurses are now increasingly using the term ‘client’ to refer to recipients of health care. A client is a person who engages the advice or services of another who is qualified to provide this service. The health status of a client is the responsibility of the individual in collaboration with health professionals (Berman et al 2008).
Historical accounts of nursing reflect the dynamic and evolving nature of the profession. The word ‘nurse’ is derived from a Latin word meaning to nourish or cherish, and, as birth, illness, injury and death are common to all human beings, there has always been a need for someone to take on the task of caring for others. In earlier times superstition and witchcraft formed the basis of the treatment of illness, and for many centuries it was believed that sickness was a punishment for wrongdoing and that the signs of illness were evidence of the presence of evil spirits. Treatment was prescribed by witch doctors and priests and, although much of it was barbaric and caused more suffering than the illness, many old herbal remedies are still used in a modified form today. Until well into the 18th century those who suffered a mental illness were considered to be possessed by the devil and were treated with extreme cruelty.
Some of the earliest organised nursing was performed by men who staffed the hospitals founded by military religious orders during the crusades; for example, the Knights of St John of Jerusalem, the Teutonic Knights and the Knights of St Lazarus. During the 12th and 13th centuries several secular orders were active in caring for the sick, whose members included men and women. Some of the orders were the Ursulines, the Poor Clares, the Beguines and the Benedictines. Also at this time a religious order, called the Augustinian Sisters of the Hôtel Dieu, was founded in Paris, which is the world’s oldest order of nuns devoted purely to nursing.
During the 16th century, Henry VIII ordered the dissolution of the English monasteries and the confiscation of their property and enormous wealth. This meant that large numbers of sick and destitute people previously cared for by the religious orders were left to die. Workhouses were built to house the poor, many of who were sick. They lived in appalling conditions and were required to work in return for the accommodation provided. Finally, conditions in the city of London became so dreadful that Henry VIII was forced to allow hospitals such as St Bartholomew’s, St Thomas’s and St Mary’s to be re-founded, and others to be established, after many petitions from the people of London. The hospitals were badly staffed by untrained workers, many of who were of very poor character. Patients were housed in dreary, grossly overcrowded wards.
The period from the beginning of the 18th century to the middle of the 19th century has been termed the ‘Dark Ages’ of nursing, during which the care of the sick and the status of the nurse reached the lowest level imaginable. The squalid conditions in hospitals and the undesirable character of those attending the sick were publicised by people such as the prison reformers, John Howard and Elizabeth Fry, and the writer, Charles Dickens, who in Martin Chuzzlewit created the unsavoury characters Sairy Gamp and Betsy Prig to typify the nurses of the time — criminals and women of low moral standards, uneducated and who lived and worked in appalling conditions.
In 1836, with the help of his wife a Lutheran clergyman named Theodor Fliedner established an institution called Kaiserwerth, situated near Dusseldorf in Germany. There they trained carefully selected women as deaconesses, and Kaiserwerth became famous for the high standard of training and the quality of care given to the sick. It became the centre of nurse training and received many trainees from overseas countries, some of who set up similar institutions in their own countries.
Modern nursing has evolved as a result of the influence that Kaiserwerth had on people like Elizabeth Fry, who founded the Protestant Sisters of Charity in an attempt to ensure that the sick were cared for by women of good reputation, such as Agnes Jones. Jones revolutionised conditions in the workhouses and established a school of nursing to train nurses in the care of sick people in the workhouses, and Florence Nightingale, the founder of modern nursing.
Florence Nightingale was born in 1820 during a trip made by her English parents to the Italian city of Florence, after which she was named. Her parents were wealthy and cultured and Florence received an extensive education far beyond the standard usually received by the young women of her time. She travelled widely and led the full social life common to one in her place in society but, despite this, felt unhappy and dissatisfied. She was interested in nursing but this met with strong opposition from her family and it was not until she was over 30 years of age that she was able to realise her ambition. In 1850 she spent 2 weeks at Kaiserwerth and visited again in 1851, when she was appointed as Superintendent of the ‘Establishment for Gentlewomen During Illness’.
Florence Nightingale first achieved fame when, in 1854, she was asked to take a party of 38 nurses to Scutari in the Crimea. On arrival the nurses met with fierce opposition from the medical officers, who would not allow them to care for the sick and injured soldiers. Nightingale devoted her energies to improving the filthy conditions by introducing the principles of personal and communal hygiene, obtaining medical supplies, organising a good food supply, and generally establishing sanitary conditions, such as hand washing, and the importance of fresh air. Within 2–3 weeks opposition had been overcome and the nurses were invited to take over the care of the sick. To the soldiers, Nightingale became an idol and, as she brought ease and comfort to the very sick by the light of the lamp she carried at night, she became known as the ‘Lady of the Lamp’.
After the Crimean War the English public raised almost £50 000 as a mark of appreciation of Nightingale’s work. She used the money to establish a School of Nursing at St Thomas’s Hospital in London. The first probationer nurses were admitted to the Nightingale School in June 1860 and given 1 year of training followed by 2 years of experience in the hospital. Many of these nurses became Matrons of the large hospitals in London and elsewhere. By the time Florence Nightingale died in 1910 at the age of 90, remarkable progress had been made in nursing service and education of the nurse.
The history of nursing in Australia is inextricably linked to our penal past. In the establishment of the original English colony at Sydney Cove, little attention was paid to the provision of care for the ill and infirm. When Sydney Hospital was opened in 1811, most nurses were convict women, with some convict men also performing nursing duties. They were provided with their keep but no wages in exchange for their labour. The nurses were frequently described as being of poor character, with drunkenness while on duty common. The first Australian lunatic asylum was opened at Tarban Creek, in Gladesville NSW, in 1811. Untrained mental attendants staffed the institution. Large numbers of disturbed people were primarily restrained as a means of control. The staff were custodians and there was virtually no emphasis on treatment.
The first trained nurses, five Irish Sisters of Charity, arrived in Sydney in 1838. The Nightingale influence was experienced in 1868, when Lucy Osburn and her four Nightingale nurses arrived. Gradually, the Nightingale principles for the care of the physically ill were adopted. Nurses were trained in practical skills such as the application of dressings, leeching and administering enemas. Of equal importance were the character traits of punctuality, cleanliness, sexual purity and, above all, obedience. A large proportion of nursing work was akin to housekeeping, dominated by domestic tasks. However, it was acknowledged that diligence and compassion were desirable characteristics in those who cared for the sick.
As scientific advances were made the recognition of the need for nursing training grew. By 1900 most of the larger Australian hospitals had three-year training programs for student nurses, with lectures delivered by medical staff. Unfortunately, because of the long hours of work, student nurses were frequently too tired to concentrate during such classes. During the 20th century the move towards professionalism would emerge and with it would come considerable conflict between the view of nursing as a vocation, which should be inherently subordinate to medicine, and the view of nursing as a profession, different from, but of equal status with, medicine.
In 1867 an Act of Parliament was passed that made it mandatory that persons showing signs of mental impairment must be sent to a lunatic asylum rather than a prison. By 1900 the mentally ill were separated from the developmentally disabled. Nursing in the mental asylum continued to be predominantly delivered by male attendants. The care continued to be custodial but medical staff provided some lectures to the attendants. The idea of employing female attendants began to receive serious consideration around this period.
The increase in training for nurses was accompanied by heightened agitation for the registration of nurses. South Australia was the first State to pass the relevant legislation in 1920. Western Australia followed in 1922, New South Wales and Victoria in 1924. The emerging sense of professionalism among nurses led to a greater focus on industrial issues. The Australian Nursing Federation held its first meeting in 1924 and through this forum the quest for greater professional recognition, increased wages and improved working conditions began — a quest that continues today (Crisp & Taylor 2005).
In 1984 the Federal Government announced full support for the transfer of nursing education into the tertiary sector. This occurred over the subsequent decade. The type of tertiary education the nurse receives will determine the level at which the nurse practises. Within Australia, there are broadly two levels of nurse. The Registered Nurse (RN) (in Victoria the term Registered Nurse Division 1 is used) is licensed to practise nursing without supervision in the fields in which they are registered. RNs are regarded as responsible and accountable for all decisions and actions taken in relation to client care. Registration requires the completion of an undergraduate degree in the higher-education or university sector. The course is generally of 3 years’ duration but some programs extend over three-and-a-half or 4 years.
The Enrolled Nurse (EN) is a second-level nurse — in Victoria, the term Registered Nurse Division 2 is used. The exact nature of the scope of practice of the EN varies across states and territories, but duties are usually conducted under the direction and supervision of the RN. Entry onto the roll, or register, requires the completion of a certificate, advanced certificate or diploma (depending upon which state or territory the qualification is undertaken in), generally through the Technical and Further Education (TAFE) system or a private registered training organisation (RTO). The duration of these programs varies from 12 months to 2 years.
Australian state and territory governments provide financial assistance to educate ENs through programs that provide both on- and off-the-job education. EN trainees are employed by health care agencies for a period of approximately 2 years. During this time a trainee participates in a mixture of off-the-job education coordinated by an RTO, and on-the-job (workplace) experiences to develop the required competencies for enrolment with their respective state/territory nurses’ board. First-level Registered Nurses provide clinical supervision and support for the trainees. RTOs and health care agencies enter written agreements specifying the responsibilities of all parties for the duration of the traineeship.
CLINICAL INTEREST BOX 1.1 Major milestones in Australia’s nursing history
|1811||Sydney Hospital opened, Tarban Creek Asylum opened|
|1838||Five Irish Sisters of Charity arrived in New South Wales|
|1848||Opening of Yarra Bend Asylum in the Port Phillip district (later to be known as Melbourne) to enable the transfer of mentally ill prisoners from gaol|
|1867||Legislation was passed to ensure that mentally ill persons were sent to an asylum rather than gaol|
|1868||Arrival of Lucy Osburn and four Nightingale nurses. Beginning of the Nightingale influence in Australia|
|1885||Introduction of district nursing into Australia, based on the model developed in England|
|1899–1902||The Boer War years. Hundreds of female nurses volunteered but met with prejudice against female nurses in the military. A small number served in South Africa|
|1900||Completion of the separation of the mentally-ill and the mentally-retarded for the purposes of treatment and care|
|1901||Introduction of nursing registration in South Australia|
|1910||The formation of the Victorian Bush Nursing Association. Followed a year later by the NSW Association|
|1914–1918||2692 Australian nurses served in World War I, 2000 served outside Australia|
|1922||Introduction of nursing registration in Western Australia|
|1924||Introduction of nursing registration in New South Wales and Victoria|
|1924||First meeting of the Australian Nursing Federation held|
|1939–1945||One third of Australia’s trained nurses volunteered for service overseas|
|1949||Formation of the College of Nursing Australia (now known as Royal College of Nursing, Australia)|
|1974||First pre-registration tertiary-based course began in Victoria. Formation of the Congress of Mental Health Nurses (now known as the Australian and New Zealand College of Mental Health Nurses)|
|1978||Release of the document “Goals in Nursing Education” was a joint policy statement of the College of Nursing Australia, The Royal Australian Nursing Federation, the Florence Nightingale Committee and the New South Wales College of Nursing|
|1979||The Royal Australian Nursing Federation joined the Australian Council of Trade Unions|
|1980||Formation of the National Florence Nightingale Memorial Committee, to provide postgraduate courses for nurses|
|1981||The first International Council of Nursing Conference in Australia|
|1984||The federal government announced full support for the transfer of nursing education into the tertiary sector.|
|The anti-strike clause was removed from the constitution of the RANF|
|1985||The first nurses’ strike in Australia occurred in Victoria|
|1989||The first pre-registration programs for psychiatric nursing and intellectual disability nursing commenced in the tertiary sector in Victoria|
|1992||The Australian Nursing and Midwifery Council (ANMC) Inc forms to ensure a national approach to the regulation and practice of nursing|
|1993||Transfer of basic nursing education to the tertiary sector is complete across Australia. Registered Nurses can now study at graduate diploma, Masters degree and PhD level|
|1996||National Enrolled Nurse Association (NENA) was formed to:|
|2000||Establishment of the ANMC national competency standards for the Registered Nurse|
|2001||Memorandum of Cooperation signed, linking the ANMC and the Nursing Council of New Zealand to work closely together on nurse regulatory issues of common interest|
|2002||Development of a code of ethics for nursing in Australia under the auspices of the ANMC, Australian Nursing Federation and Royal College of Nursing Australia|
|2002||Establishment of the ANMC national competency standards for the EN|
|2003||Establishment of nursing and nursing education taskforce to drive major nursing education and workforce reforms in Australia|
|2003||Development of a code of conduct for nurses in Australia, which states a declared position in relation to the standards of behaviour that can be expected of each nurse|
|2003||The ANMC and the Nursing Council of New Zealand launched its ground-breaking research project, which will see the development of Competency Standards For Nurse Practitioners in Australia and New Zealand|
|2006||The ANMC released Competency Standards for Nurse Practitioners|
|2006||COAG agreed to the Productivity Commission’s recommendation for national registration standards for health professionals|
|2007||ANMC released ‘A national framework for the development of decision-making tools for nursing and midwifery practice’|
(Crisp & Taylor 2005; the Australian Nursing and Midwifery Council Inc [www.anmc.org.au]; and the Australian Nursing Federation (1999) The ANF celebrates 75 years. Australian Nursing Journal 6(8): 14–21 [anf.org.au/nena])