Physicians and hospital administrators saw women as a source of inexpensive or free nursing labor who could further their economic goals. Many women entered nursing and provided student labor for hospitals in exchange for receiving apprenticeship training to become nurses. Many of these women came from the working class and had limited opportunities for education and meaningful work. After they were trained for nursing in hospital schools, many found themselves without employment as new student recruits filled available staff positions. Nurses were exploited both as students and as experienced workers. They were treated as submissive, obedient, and humble women who were “trained” in correct procedures and techniques. Ideally, they fulfilled their responsibilities to physicians without question. Nurses’ positive desire to help people in need, coupled with their relative lack of educational preparation and social or political power, led to an extended period in history when nursing was practiced primarily under the control and direction of medicine (Evans, Pereira, & Parker, 2009; Group & Roberts, 2001; Lovell, 1980; Malka, 2007).

Despite strong leaders who followed the Nightingale tradition and who viewed nursing knowledge as unique, nursing knowledge has not always been regarded as distinct from medicine. The control of nursing education and practice was transferred from the profession to hospital administrators and physicians during the early 1900s, when most of the Nightingale-modeled schools in the United States were brought under the control of hospitals (Ashley, 1976). Strong efforts to move nursing to institutions of higher learning were not enough. In a manner that was consistent with the social history of women, nursing was viewed and increasingly treated as a role that supported and supplemented medicine and certainly not as one that required a unique knowledge base (Hughes, 1980, 1990). Although training was acceptable and even necessary, true education for women and nurses was discouraged, discouraging, and limited. Indeed, education was counterproductive for women who, as nurses, were expected to follow orders and serve the needs and interests of physicians when it came to providing care (Melosh, 1982; Reverby, 1987a, 1987b).

Economic independence for women in the United States was not possible until the mid-1900s. Even a woman who earned an income was not able to have a bank account, own property, or conduct financial transactions in her own name. Normal schools were established for the training of teachers and nursing schools were available for training nurses, but, to obtain long-term security, women were required to conform to the role of wife or daughter. Throughout the early part of the 20th century, nursing practice was based on rules, principles, and traditions that were passed along through limited apprenticeship forms of education. Nursing practice also included an ever-increasing array of delegated medical tasks that were acquired as medical knowledge expanded; these tasks were performed by nurses as extensions of physicians. Higher education for nurses was not available. What evolved as nursing knowledge was wisdom that came from years of experience. Nursing was viewed primarily as a nurturing and technical art that required apprenticeship learning and innate personality traits that were congruent with that art (Hughes, 1990). Tradition as a basis for nursing practice was perpetuated by the nature of apprenticeship education (Ashley, 1976). Nursing students were presumed to learn at random through long hours of experience (with limited exposure to lectures or books) and to accept without question the prescriptions of practical techniques. The novice nurse acquired knowledge of what was right and wrong in practice by observing more experienced practitioners and by memorizing facts about the performance of nursing tasks. Nurse recruits also learned what sort of person a nurse should be through the imposition of rigid rules that regulated most aspects of behavior, including sleeping, eating, socializing, and dress, both inside and outside the hospital walls. Rules were strictly enforced with severe penalties for those who strayed outside of the rules’ boundaries.

Despite social impediments to the development of nursing knowledge, nursing philosophy and ideology remained committed to the idea that nursing requires a knowledge base for practice that is distinct from that of medicine (Abdellah, 1969; Hall, 1964; Henderson, 1964, 1966; Rogers, 1970). This commitment grew from the consistent recognition that, although the goals of nursing and medicine were related, the central goals and functions of nursing required knowledge not provided by medicine or by any other single discipline outside of nursing.

Although social circumstances limited the possibilities for nursing education, early nursing leaders sustained ideals that reflected Nightingale’s model of education and practice. Because most nursing service was provided as free labor by students in hospitals, those who graduated secured jobs as independent practitioners who were engaged by families to assist with the care of the sick in homes and hospitals. Many nurse leaders were active in confronting a wide range of community-based social and health issues of the time, including temperance, freedom for enslaved people, the right of the disenfranchised to vote, and the control of venereal disease. These experiences cultivated and required a broad view of nursing knowledge and a desire to change the future of nursing. These were women for whom technical training was not enough. Despite that training, they saw nursing as independent and vital and as having a firm knowledge base.

As nurses developed community-based practices, their work and writings reflected the multiple patterns of knowing in which their efforts were grounded. There is substantial evidence that graduate nurses during the early part of the 20th century had ethical and moral commitments that contributed substantively to improving health conditions in hospitals, homes, and communities. Not only did they develop health knowledge as they practiced, but they were politically committed to finding ways to distribute this knowledge to the people who needed it (Wheeler, 1985). Consistently throughout the early 20th century, nursing leaders in the United States worked together nationally and internationally in strong connecting networks and called for a social and political ethic that would restore the control of nursing practice to nurses and that would promote the health and welfare of citizens.

Margaret Sanger, Lillian Wald, Lavinia Dock, Susie Walking Bear Yellowtail, Mabel Staupers, and Adah Thoms are among those nurses who were challenged by specific needs in society and set about to change problematic practices that affected health care. They observed the circumstances of people in their work environment, identified health-related needs, and worked with others to meet those needs. They acted to improve health care practices by integrating ethical commitment with scientific knowledge.

For example, Sanger developed knowledge about reproduction and birth control. She fought against great odds to distribute birth control information to women who were desperate to obtain it, and she established a foundation for family planning programs that remains viable today in the form of Planned Parenthood (Sanger, 1971). Wald became concerned about child care and family health in the context of extremely poor conditions of sanitation in the crowded immigrant tenements of New York City. She established the Henry Street Settlement in New York City, which is still operating today. On the basis of concepts of community health nursing and social welfare programs, Wald developed stations from which safe milk was distributed to families with young children, and she also established centers for educating mothers about the care of their families (Silverstein, 1985; Wald, 1971). Dock was an ardent suffragist and pacifist who worked for much of her professional life with Wald at the Henry Street Settlement. She campaigned actively for changes in labor laws that would benefit women and children. Twenty years of her life were devoted to gaining the vote for women in the United States; she reasoned that, if women could vote, the oppressive laws that affected them could be changed (Christy, 1969).

Many influential nurses among minority groups in the United States also took equally significant actions to improve the health and well-being of their people, but they are far less known. Susie Walking Bear Yellowtail was a midwife who traveled throughout North American Indian reservations to assess the health, social, and educational problems of Native Americans, and she then recommend solutions (American Nurses Association, 2009b). She was instrumental in ending the abuses of women (e.g., involuntary sterilization) that were occurring within the Indian Health Care System (Scozzari, 2008). Mabel Staupers worked for improved access to equitable health care services for African American citizens (American Nurses Association, 2009a). Her research into the health care needs of individuals in Harlem led to the founding of the first facility in Harlem for treating tuberculosis in African Americans. Adah Belle Thoms was among the first nursing leaders to recognize public health as a new field of nursing. In 1917, she added a course on the subject to New York’s Lincoln School for Nurses curriculum (American Nurses Association, 2008). She also founded the Blue Circle Nurses, a group of African American nurses who worked with local communities and who provided instruction regarding sanitation, diet, and appropriate clothing. Adah Thoms also organized a campaign to encourage members of the National Association of Colored Graduate Nurses to vote after the passage of the 19th amendment, which gave women the right to vote (Thoms, 1929/1985).

Effie Taylor acknowledged the existence of social inequities in a speech given at the opening session of a national nursing organization meeting. Taylor noted that the “nations of the world are sick mentally and socially and need to be enabled to live better, think better and act better.” (1934, p. 474).

How injustices are created is embedded in an eloquent quote from Lavinia Dock (1902-1903), who noted the following in an early issue of American Journal of Nursing:

Kinloch, a Scottish physician and Chief of the Department of Health in Scotland, echoes Dock when he notes that “were our efforts unified . . . we need not be concerned with signs and symptoms, but with proper nurture, replacing the need for treatment” (1932, p. 714). Another cause of social injustices was “anxiety over material necessities,” as mentioned in a 1913 physician’s address to graduates of the El Reno Sanitarium. Such anxiety “precludes living the ideal, full, free and independent effective life” (Young, 1913, p. 266). Although this physician was addressing graduating nurses, the precept would likely have applied to others as well.

Marion Faber, a registered nurse, noted that it is “effects of the environment that cause deformation of the personality” (1927, p. 1048), whereas Joseph Mountin, a physician and then an assistant surgeon general of the United States, stated that the “hospital hierarchy tries to provide social service according to the rules of private competitive enterprise” and this “requires a financial sleight of hand to keep the institution going” (1943, p. 34). According to William Kilpatrick, a doctorally prepared educator, these hierarchies resulted in a “factory system that reduces individuals to a non-entity amid the bigness of the organization” (1921-1922, p. 791)

Concerns about increasing levels of education at the time led two doctorally prepared academic educators to suggest that “vested interest will preclude the development of professionalism (in nursing) as hospitals will not be able to adjust to the loss of student work hours” (Bixler & Bixler, 1945, p. 732). Isabel Stewart, a nurse and faculty member at Columbia University, wrote that custom and training are the great authorities and are rigid and static (1921-1922). Stewart further noted that “authority becomes entrenched and does not allow for change in the individual” (1921-1922, p. 908). Allen Gregg, a physician and Director of Medical Sciences at the Rockefeller Foundation, attributed injustices to “envy and malice and hate and violence” (1940, p. 738)

Paul Johnson (1928), a doctorally prepared individual, stated the following in an address to the Massachusetts State League of Nursing Education:

Katherine McClure, a nurse professor, noted the need to “improve the environment and conditions of the persons she nurses without remaking them to suit ourselves” (1951, pp. 221-222), whereas nurse Janet Geister wrote that “the real wisdom of human life is compounded out of the experiences of ordinary men” (1937, p. 261). These nurses apparently recognized the importance of acting in relation to the needs of others while understanding that effective change must come from a grassroots position.

Bixler and Bixler (1945) stated that nurses’ social attitudes should reflect the conception that “every citizen is entitled to health care” (p. 733), whereas Taylor (1934) wrote that nurses must have a “broad sense of justice” (p. 475), should “not know color or creed” (p. 473), and “be for the poor as well as the rich” (p. 473). Kilpatrick (1921-1922) further addressed how to undo social injustices by stating that nurses should “seek the development and expression of each in relation to all, and cause others to grow” (p. 795), whereas Stewart (1921-1922) stated that “knowledge, culture, individual development, freedom, health and expertness are used in service of the social group,” emphasizing that “education has a social purpose and nursing is no exception.” (p. 908)

Noted anthropologist Margaret Mead, in an address to a convention of the American Nurses Association, stated that “nursing stands between those who are vulnerable and the community that may forget them, not care for them” (1956, p. 1002). Genevieve Noble, a graduate nursing student, understood that nurses must notice injustice when she stated that the “nurse cannot be indifferent to the welfare and happiness of the undernourished child in the street or the maid working in her corridor” (1940, p. 161). Esther Lucille Brown, a researcher for the Russell Sage Foundation who was the author of reports about nursing, recognized that “nursing must create alliances with problems outside the privileged home and hospital, and should be concerned with those who have chronic disease, are aged and physically handicapped” (Goostray & Brown, 1954, p. 720). Finally, Elizabeth Porter, who was president of the American Nurses Association, summarized many of the social conditions that create social injustices and inequities (i.e., the focus of emancipatory knowing). Porter (1953) noted that “hunger, poverty, injustice and disease are the enemies of peace,” and she also noted the following:

For Porter (1953), necessary actions included “supporting humanitarian programs on a worldwide scale” (p. 948), taking responsibility to change the “conditions in which men live and the conditioning of their mind” (p. 948), and “putting the good of the world and community before the selfish interest of individuals or specialized groups” (p. 949).

To summarize, the early nursing literature addresses the importance of emancipatory knowing by recognizing the fact that social injustices existed in addition to the conditions that created them. This literature is replete with directives for nursing actions required to rectify societal injustices and conditions that privilege one group over another. Injustices were not hidden or mystified. Rather—and perhaps concurrent with the expansion of nursing into community-based practices—the necessity to recognize social inequalities and to take strong measures to rectify them was emphasized.

Before the 1950s, ethics was primarily represented as virtues possessed by the nurse. Nurses were expected to be moral individuals, who, it follows, do the right thing. Virtue and responsibility were paramount for nurses. Duty and responsibility included protection, truth telling, and imparting specialized knowledge (Conrad, 1947; De Witt, 1901; Warnshius, 1926). An editorial in the American Journal of Nursing noted that “the doctor is responsible for the general conduct of the case, but the nurse is responsible for the honest performance of her own duties” (De Witt, 1901, p. 15). This editorial further noted that “born qualities added to training” were critical for ethical conduct (p. 15). Duty often was expressed in religious admonitions to love, live right, and have faith; it was seen as a sacred obligation, as illustrated by a lay author who wrote that “a good nurse will die before admitting she is even tired [for] loyal service is one of the articles of the profession’s religion” (Drake, 1934, pp. 137-138). Moral fitness for nursing was important, and moral examinations were recommended. Agnes Riddles (1928), a nurse, stated that “women [nurses] should hold their position only after a moral examination as well as a technical one” (p. 29). Riddles listed a variety of moral infractions attributable to nurses of the time, including a lack of consideration for the patient, the neglecting of aseptic precautions, disrespecting human life, and lack of proper experience with assembling needed nursing materials.

Charlotte Aikins (1915), presumably a nurse educator, outlined an entire curriculum for teaching ethics in Trained Nurse and Hospital Review. The curriculum included knowledge of “the customs and laws of the hospital world which she (student) must be admonished to accept meekly” (p. 136) and “personal virtues of importance such as reticence, tact, and discretion in order that she may do no harm” (p. 136). “Health, carriage, voice, manner, habits and general deportment” (p. 136) also were important. During the junior year, ethics would cover “handling of supplies and appliances, avoiding accidents, use of good surgical technique, wise use of recreation and holidays, and the necessity of a good conscience” (p. 137). Another early nurse mentioned the need to keep preconceptions and prejudices to a minimum as a part of ethical conduct (Oettinger, 1939).

Paul Johnson (1928), in an address to a statewide gathering of nurses, asked the following: “What should ethics teach?” (p. 1084). He differentiated ethics and morality. Ethics, according to Johnson, is the “science of right conduct” (p. 1085). Ethics investigates “boldly” what this is by “questioning moral tradition, examining moral facts, and searching out moral values” (p. 1085). Ethics requires “careful investigation, open-minded judgment, the practice of reasonableness and intelligent doubting” (p. 1085). Ethical sensitivity—rather than the rules approach of “laying down exact rules for conduct” (p. 1084) —was important to cultivate. Such an attitude questions the establishment of rules as the basis for biomedical ethics and validates a relational perspective for ethical conduct. Johnson’s early article also challenges virtue ethics, which is a position that relies on a good person to do the right thing by differentiating ethics and morality.

Early authors imparted a variety of goals for ethical knowledge and knowing, including the protection of patients’ privacy and rights, advocacy, and the minimization of patients’ discomfort and inconvenience. Broader goals also were mentioned, such as increasing tolerance and respect by respecting the worth, autonomy, and dignity of individuals; assisting with the development of the individual; strengthening society and the Self; developing economic security; and promoting peace.

The importance of the person of the nurse is evident in that the prevailing ethics of the time called for a virtuous person. However, qualities of a person beyond virtue also are found in the early literature. Margaret Conrad (1947), writing about the nature of expert nursing care, recognized the necessity for a well-balanced, integrated personality to contribute to the care of others. Allen Gregg (1940), a physician, in an address to three national nurse meetings, asked nurses to “seek honestly and earnestly to find what really matters to us and what beliefs and convictions we hold” (p. 738). Gregg also redefined virtue as “the inner life as well as the outer in consistency of behavior with one’s own thoughts and feelings” (p. 740) and further stated that “motives and conduct must harmonize” (p. 740). Motives must be sound or there is “no virtue in the great sense, no independence, and no self-confidence” (p. 741). The fundamental importance of personal knowledge is acknowledged in that “only when a person is something to herself can she become anything to anybody else” (p. 741). Gregg’s article, which was written during the postwar period, recognized that science could not provide personal knowledge because “the social wisdom of man does not derive from chemistry and physics and mechanical skill. Decency does not visit our common dwelling place without invitation” (p. 739).

Genevieve Noble (1940), writing as a student in “The Spirit of Nursing,” emphasized the need for an inherent inner self-discipline rather than an imposed discipline for adequate nursing care. Katherine Oettinger (1939) gave equal importance to personal knowing and empirics by stating that “the personality of the nurse is quite as important as the distinctive facts she learns” (p. 1224).

Important personal characteristics included an acceptance of the Self that is grounded in self-knowledge and confidence. Personal integrity, honesty, enthusiasm, versatility, courageousness, stability, and emotional diversity were important features of personal knowledge. Such knowledge is created by engagement with life, finding out what really matters, and reflecting on it. Nursing practice requires a depth of personal knowing that acknowledges the validity of feelings, an openness to freely discussing feelings, and an examination of reciprocal emotions in dialogue and relation. A nurse of high personal character displays an inner and outer harmony and commands the respect of his or her Self and of others. As Oettinger (1939) put it, such a nurse is “free from conscript minds giving conscript thoughts” and is “free to change the status quo” (p. 1244). In summary, a whole host of personal attributes that go beyond virtuous behavior, including self-discipline, knowledge of the Self, and an openness to the processes of reflection to create actions with integrity are basic to good nursing care.

A sense that nursing has an artistic component is clearly evident in the early periodical literature. L. F. Simpson (1914), another physician who was speaking to nurses, stated that “real nursing is an art; and a real nurse is an artist” (p. 133). Conrad (1947) stated that the art of nursing included such things as “knowing what the patient wants before she is asked” (p. 162). It arises from “combining instinct, knowledge and experience” (p. 162). According to Conrad, art depends on imagination and resourcefulness and requires “true perspective” (pp. 162-163). Furthermore, art requires practice, and some nurses “never acquire it” (Simpson p. 135). Experience was seen as important to the development of aesthetic knowing. Austin Drake (1934), a layperson, put it in the following way:

Art in the more traditional sense was recognized as important to the art/act of nursing. In 1923, Lois Mossman, an assistant professor of education, acknowledged that “science cannot explain what happens when we respond to beauty of form or motion but the response is pleasurable and influences what we are doing” (p. 318). Mossman asked novice nurses to “experience beauty, to see it in the commonplace, to learn of books, poems, pictures, and music that interpret beauty and draw from them to fit the needs of those we serve” (p. 319). According to Mossman, “Life is rhythmical and lights must be set off by the shadows” (p. 319).

Edward Garesche (1927), a Roman Catholic priest, eloquently expressed the elusiveness of assessing our art and the importance of distinguishing it from empirics. He stated: “The service of the learned professions does not bear measuring while it is being rendered” (p. 901).

In summary, the early literature represents aesthetics as a combination of knowledge, experience, intuition, and understanding. Aesthetic knowing was creative and intuitive and consisted of exquisite judgments made without conscious awareness but rather that were sensed intuitively by unexplained insight and hunches. Aesthetic knowledge was gained through appreciation of the arts and by subjective sensitivity to individual differences. Aesthetic knowing was also gained by personal imitation of those who possessed the art. Aesthetic knowing required speculation, imagination, and the superimposition of impressions on facts. The practitioner who had a sincere intentionality and the ability to carry out sophisticated assessment could act artfully. It was through the interpretation of interaction that each succeeding interaction became more meaningful.

Before the “era of science” in the mid-1950s, there was clear recognition of scientific knowledge as a source of power. A physician who addressed the annual meeting of the Michigan Nurses Association acknowledged that scientific knowledge had increased and asked nurses to acknowledge its power and value for producing knowledge. The physician cautioned against quackery and portrayed science as a source of legitimate criteria for the selection of information provided to patients (Warnshius, 1926). Despite the value of science, this physician also emphasized the importance of a central focus on the welfare of the patient.

Empirics was commonly represented as the knowledge of the underlying principles and techniques associated with nursing. According to Margaret Conrad (1947), a baccalaureate-prepared professor of nursing, this required an understanding of the laws of nature and the principles of physics, chemistry, physiology, and psychology. In other early articles, the procedural and technical aspects of nursing were emphasized, including bed making; food tray handling and feeding; carrying out personal hygienic measures, such as bed baths and oral hygiene; and managing delegated medical procedures, such as drains, catheterizations, enemas, alcohol baths, vital signs, and medication administration (Brigh, 1944; Mountin, 1943).

Muriel Burgess (1941), a nursing student, outlined the “facts of care,” which included diagnosis; social factors, such as heredity, environment, and education; and medical factors, such as history of family, history of the present illness, symptom onset, physical examination, and laboratory and radiography findings. She further noted that the plan should include the progress of the patient and make use of graphs whenever possible. The treatments prescribed and the continuing plan for care were also important.

Genevieve and Roy Bixler (1945), two doctorally prepared educators, addressed the development of empirics and wrote “the elements of science should be defined and organized, gathered from every science contributing to nursing and arranged in the most convenient order for thought” (p. 730). Bixler and Bixler stated that scientific compartmentalizations were artificial, arbitrary, and to be avoided by nursing science. Nursing science existed apart from practice, but its use in the service of professional practice represented a “new synthesis” (p. 731). Science, they asserted, needed to be integrated as an art.

Formal observation was also established as a valued technique and a skill that was critical for the development of nursing empirics. A 1947 editorial in the American Journal of Nursing emphasized the need for nurses to develop keen observation skills because “the lack of descriptions or records of nursing care based on actual experience is appalling” (p. 655). Written observations could form the basis for a complete patient study to provide an interpretive picture of present-day nursing (“Changes in nursing practice,” 1947). In a speech at a student nurse convention, Blanche Pfefferkorn (1933), who was identified only as a registered nurse, stated that empiric knowledge came from questionnaires, detached observation, and field studies. According to Pfefferkorn, a scientific attitude was important. Scientific knowledge included “facts that were organized into a form or structure that were not dynamic and reports of field studies” (p. 260). Regardless of the source, scientific knowledge served as a skeleton and answered questions about “what”; good science represented the “what” of nursing very well. Pfefferkorn noted that the nurse needed to know “how”—not just “what”—and stated that field studies could “enliven fact gathering by providing knowledge of how” (p. 260). Agnes Meade (1936), a nurse who wrote an article entitled “Training the Senses in Clinical Observation,” cautioned about the following pitfall of scientific bias: “A distinguishing feature of scientific observation is that the observer knows what is being sought, and to a certain extent what is likely to be found” (p. 540).

In summary, in the early literature, the nature and importance of science for nursing were clearly reflected. Early authors envisioned ways for empiric knowledge to be created and displayed. Although scientific-empiric knowledge could come from disciplines outside of nursing, there was a recognition of the unique nature of nursing science. Principles, facts gleaned from observation, and procedural guides for action were important forms of empirics that were necessary for completing the routine hygienic care of patients as well as delegated medical tasks. Despite the recognition of the value of empirics, the idea that science alone is an inadequate practice guide appears frequently. A physician addressing a graduating class of diploma nurses told them that “the profession of nursing is an art depending upon science. In nursing the art must always predominate though underlying science is important” (Worcester, 1902, p. 908).

Although theories from other disciplines have been useful, nurses also have exercised caution rather than arbitrarily applying these theories. In some instances, the theories of other disciplines do not take into consideration significant factors that influence a nursing situation. For example, some theories of learning that are applicable to classroom learning do not adequately reflect the process of learning when an individual is faced with illness, and they do not deal with the ethical issues that a nurse might face when disclosing sensitive information to a patient. Although borrowed theories may be useful, their usefulness cannot be assumed until they are examined from the perspective of nursing in nursing situations (Barnum, 1998; Walker & Avant, 2004). The trend of using theories from related disciplines may have been an outgrowth of predoctoral and postdoctoral fellowship funding for nurses that began in the mid-1950s. This funding nurtured a cadre of nurse scientists who studied research approaches in fields related to but outside of nursing. After these nurses were educated, they would return to nursing and conduct research, thereby contributing to nursing’s knowledge base.

There was considerable debate about whether the writings of leaders such as Callista Roy, Betty Neuman, Imogene King, and Dorothea Orem and others were to be called “models,” “theories,” or “philosophies.” This debate reflected an underlying acknowledgment that empiric knowledge alone was an inadequate metatheory for practice. How to name these theory-like constructions: theories, conceptual models, theoretic frameworks, conceptual frameworks? This remains a debatable subject, and various terminologies can be found in the contemporary theoretic literature. We have chosen to refer to these broad theory-like structures as conceptual frameworks or theoretic frameworks, and their authors we call theorists. Regardless of labels, nursing practice consistent with these (and other) conceptual frameworks was taught in educational institutions, integrated into practice, and used to guide research. The use of conceptual frameworks cultivated a tacit recognition of the significance of multiple patterns of nursing knowledge. As nurses began to integrate these ideas into practice settings, the actual and potential relationships between nursing’s conceptual frameworks and nursing practice became clearer. Practicing nurses found a new sense of purpose and direction that was consistent with the basic values of nursing, and they also achieved a sense of the increasing effectiveness as a result of systematic and thoughtful forms of nursing practice. Transferring these ideals of practice into the health care setting also served to illuminate the difficulties of finding nursing opportunities in the increasingly competitive health care system. Table 2-1 is a historical chronology of nurse theorists’ work during the latter half of the 20th century.

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