During the Middle Ages, warfare, famine, and plagues persisted in Europe and the Middle East. Hospitals existed for military personnel, and wealthy patients were cared for at home. People became concerned about providing care to the poor and less-well-off members of society. Table 2-1 highlights some of the efforts to address the issue.

Rathbone, a Quaker, merchant, and philanthropist, is considered the originator of district nursing (Brainard, 1985; Gardner, 1936; Monteiro, 1985). Rathbone was a visitor for the District Provident Society in Liverpool, England, and went to the homes of members of his district every week. He believed that personal contacts with the poor could assist people out of poverty and that financial relief alone was insufficient. He persuaded the Liverpool Relief Society to adopt a system whereby the town was divided into districts and subdivided into sections; after a paid relief worker had assessed the situation initially, the “case” was turned over to the friendly visitor in the district for ongoing assistance.

The first organized lay visitors to “sick poor” persons in America were members of the Ladies’ Benevolent Society of Charleston, South Carolina, founded in 1813 (Brainard, 1985). The society’s formation was a response to the poverty and suffering brought about by a yellow fever epidemic and the trade embargoes during the War of 1812. The society adopted principles that did not appear in England until 40 years later. Membership transcended church and color lines, and patients’ religious beliefs were not interfered with. Although substantial amounts of food, clothing, fuel, bedding, and soap were distributed, money was not given out. The circumstances of “sick poor” persons were investigated, and attempts were made to furnish work for unemployed persons. Charleston was divided into districts that corresponded to election wards. Ladies visited for 3 months. The society existed until the Civil War. In 1881, it resumed its work, and a trained nurse was employed in 1903.

In 1839, the Nurse Society in Philadelphia assigned lady visitors by districts. Responsible women were assigned to act as nurses under the direction of physicians and lady visitors (Brainard, 1985). Although these nurses are considered “the first to systematically care for the poor in their homes” in the United States, they were not trained. Neither did they visit multiple homes; rather, they stayed with one patient until discharged by the physician.

Visiting nursing by trained nurses in the United States began in the industrialized cities of the Northeast almost 20 years after its inception in Liverpool (Waters, 1912). In 1877, the Women’s Branch of the New York City Mission sent trained nurses into the homes of poor persons; 2 years later, the Society for Ethical Culture placed one nurse in a city dispensary for the purpose of home visiting. Both assigned nurses by districts (Brainard, 1985).

It is not known whether the New York City Mission spontaneously generated the idea of visiting nurses or whether members of their board had visited London (Brainard, 1985). Frances Root, a graduate of the first class of nurses educated at Bellevue Hospital, was the first trained visiting nurse in the United States in 1877. During the next year, the number of nurses expanded to five, and the salary of each was provided by a charitable lady. The philosophy of the New York City Mission focused on fulfilling a religious call, providing material relief, and caring for the ill. There was little focus on instruction in hygiene, sanitation, or prevention.

Felix Adler, founder of the Society for Ethical Culture, was influenced by the New York City Mission, but he wanted nurses to provide care in a nonsectarian way. The nurses employed by the Society for Ethical Culture received their patient assignments from physicians in dispensaries; each nurse visited in the district served by a dispensary. Teaching of cleanliness and proper feeding of infants and children were included as aspects of preventive care.

In 1893, Lillian Wald (age 26 years) and Mary Brewster organized the Nurses’ Settlement in New York City, also known as the Henry Street Settlement (Figure 2-1). An 1891 graduate of the New York Hospital Training School for Nurses, Wald cared for neglected children for a year at the New York Juvenile Asylum (Kraus, 1980). She entered the Women’s Medical College and was asked to teach home nursing to a group of immigrant women. When she went to the home of a young girl who requested aid for her sick mother, Wald had an experience that changed the direction of her life. She left the medical college and recruited Brewster, a nursing school classmate, to live on the East Side, a poverty-stricken neighborhood of Jewish immigrants. Mrs. Solomon Loeb, the wife of a wealthy banker, agreed to support the two nurses and provided $60 per month for each nurse and money for emergencies. During the summer of 1893, they lived in the College Settlement (started in 1889).

Settlements were part of a movement among university-educated young adults to reside in communities, to study the communities’ problems through relationships with residents, and to reform the squalid conditions of urban workers (Kraus, 1980). Crowded tenements had insufficient ventilation and no toilets or baths. Fire escapes were also crowded with sleeping people. A police census in 1900 identified more than 2900 persons living in an area smaller than two football fields—approximately 1724 persons per acre (Kraus, 1980, p. 180). In this environment, Wald was committed to providing nursing services to “sick poor” persons. By 1900, there were 15 nurses; by 1909, there were 47 nurses on call; and by 1914, there were 82 affiliated nurses (Kraus, 1980). In 1913, the Henry Street Settlement reached 22,168 persons, or 1048 more than all persons admitted that year to Mount Sinai Hospital, New York Hospital, and Presbyterian Hospital combined (Kraus, 1980, p. 176).

Alleviation of human suffering and illness was profound. The beneficial results in terms of creative nursing practice and the inception of new modes of health care delivery are still with us today.

In 1886, inspired by district nursing in England, ladies in Boston and Philadelphia founded associations for the sole purpose of trained nurses providing care to “sick poor” persons in their homes (Brainard, 1985; Gardner, 1936). The Women’s Education Association, encouraged by members Abbie Howes and Phoebe Adams, supported the Instructive District Nursing Association of Boston, so named to emphasize the importance of education in nursing work (Brainard, 1985).

The association adopted principles for working with the poor. For example, nurses were not to give money to patients or interfere with patients’ religious beliefs and political opinions (Brainard, 1985). To prevent cross-infection, caring for patients with contagious diseases was limited. Instruction on hygiene, self-care, and prevention was as important as care of the ill. Nurses reported to a single physician, who directed patient care. As the association expanded, professional nursing supervisors were employed, and nurses were expected to help community residents with fund-raising activities to support the association’s work. By 1920, more than 36,000 patients were seen by association nurses each year; of these, 23% were maternity cases.

In Philadelphia, the District Nurse Society, later named the Visiting Nurse Society of Philadelphia, was established with the sponsorship of Mrs. Williams Jinks and other ladies. Like the Boston association, the Philadelphia society had a twofold mission: to care for the sick and to “teach cleanliness and proper care of the sick” (Brainard, 1985, p. 219).

The society employed nurses and attendants and added supervisory nurses in the first year. Fees of $0.50 to $1 were charged for each nurse visit, although services were provided free to those unable to pay. Initially only for poor persons, visiting nurse services expanded around 1918 to include others in need of nursing care. Nurses provided home visits or were available for care of longer duration at an hourly fee ($1.24 to $1.75 per hour) (Brainard, 1985, p. 224).

In the United States, such care was generally known by the term visiting nursing rather than by the English term district nursing (Brainard, 1985). The term visiting nursing was probably adopted because not all nurses were assigned to districts. Many types of organizations employed visiting nurses, including nursing associations, churches, hospitals, industries, and charity organizations. During the 1890 s, the number of visiting nursing associations dramatically increased, especially in northeastern and midwestern cities.

In 1909, Ysabella Waters, a nurse with the Henry Street Settlement, undertook a national survey of organizations that employed trained nurses as visiting nurses. Waters reported a dramatic increase in visiting nursing associations since 1890. She noted that nurses served both the poor and those of greater economic means. A visiting nurse no longer worked primarily with one physician but could accept requests for services from all physicians. Website Resource 2Adepicts rules for nurses that were included in Waters’s book; these rules incorporate the principles that first appeared in district nursing.

The demand for even more visiting nursing services led nursing leaders to consider the issue of standards for practice. There was concern that untrained nurses would be hired to meet the expanding demand and that nursing might revert to pre-Nightingale practices. In 1911, Ella Crandall, professor in the Department of Public Health and Nursing at Teachers College in New York, initiated correspondence with other nursing leaders to solicit their opinions about an “organization to protect the standards of visiting nursing” (Brainard, 1985, p. 326).

A joint committee appointed by the American Nurses Association (ANA) and the Society of Superintendents of Training Schools and chaired by Lillian Wald met to consider the issue. They sent letters to more than 1000 organizations in the United States that employed visiting nurses, inviting each to send a representative to a special meeting at the next ANA meeting in June 1912. Eighty replies were received, and 69 organizations agreed to send a delegate (Brainard, 1985; Fitzpatrick, 1975).

The report of the joint committee was accepted. A National Visiting Nurse Association was formed as a member of the ANA, and recommended standards for organizations that employed visiting nurses were accepted (Brainard, 1985; Fitzpatrick, 1975).

The name of the association was debated at length because there had not been any agreement within the joint committee. A majority had favored National Visiting Nurse Association, but Crandall led a vocal minority advocating incorporation of Wald’s term public health nursing (Brainard, 1985; Fitzpatrick, 1975). The reasons for selecting visiting nursing included the fact that it was the term commonly recognized by the public. Public health nursing was a broader term, which encompassed all nurses “doing work for social betterment” and was not limited to those who primarily did home visiting to provide bedside care (Brainard, 1985, p. 332). Public health nursing was general enough to include nurses in schools, tuberculosis programs, hospital dispensaries, factories, settlements, and child welfare organizations, in addition to those providing bedside care through home visiting. Crandall argued that the public health movement would expand and that adoption of the term public health nursing provided a generic label under which new forms of practice could evolve. The organization was finally named National Organization for Public Health Nursing (NOPHN). The word for was consciously selected to allow the participation of nonnurses in promoting the work of public health nursing (Brainard, 1985; Fitzpatrick, 1975). In 1952, the NOPHN merged with the National League for Nursing (NLN), which continues today.

Descriptive epidemiological studies laid the groundwork for sanitary reforms in England and the United States (Duffy, 1990). In 1842, Edwin Chadwick published a report on the unsanitary conditions among poor persons in the cities in Great Britain. Lemuel Shattuck founded the American Statistical Society in 1839 and identified high death rates among workers in Boston. His Report of the Sanitary Commission of Massachusetts in 1850 called for government to improve sanitary and social conditions to reduce incidences of disease and death. In 1854, the English physician John Snow demonstrated that the cases of cholera in an outbreak were linked to water from the same well. The germ theory of disease was only emerging. Table 2-3 lists other public health accomplishments in the United States.

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