Role Development in Professional Nursing Practice, Fifth Edition drives comprehension through various strategies that meet the learning needs of students while also generating enthusiasm about the topic. This interactive approach addresses different learning styles, making this the ideal text to ensure mastery of key concepts

The Pedagogy

Role Development in Professional Nursing Practice, Fifth Edition drives comprehension through various strategies that meet the learning needs of students while also generating enthusiasm about the topic. This interactive approach addresses different learning styles, making this the ideal text to ensure mastery of key concepts. The pedagogical aids that appear in most chapters include the following:

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Library of Congress Cataloging-in-Publication Data

Names: Masters, Kathleen, editor. Title: Role development in professional nursing practice / [edited by]

Kathleen Masters. Description: Fifth edition. | Burlington, Massachusetts : Jones & Bartlett

Learning, 2018. | Includes bibliographical references and index. Identifiers: LCCN 2018023086 | eISBN 9781284152920 Subjects: | MESH: Nursing–trends | Nursing–standards | Professional

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Dedication

This book is dedicated to my Heavenly Father and to my loving family: my husband, Eddie, and my two daughters, Rebecca and Rachel. Words cannot express my appreciation for their ongoing encouragement and

support throughout my career.

1

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CONTENTS

Preface Contributors

UNIT I: FOUNDATIONS OF PROFESSIONAL NURSING PRACTICE

A History of Health Care and Nursing Karen Saucier Lundy and Kathleen Masters

Classical Era Middle Ages The Renaissance The Dark Period of Nursing The Industrial Revolution And Then There Was Nightingale . . . Continued Development of Professional Nursing in the United Kingdom The Development of Professional Nursing in Canada The Development of Professional Nursing in Australia Early Nursing Education and Organization in the United States

2

3

4

5

The Evolution of Nursing in the United States: The First Century of Professional Nursing The New Century International Council of Nurses Conclusion References

Frameworks for Professional Nursing Practice Kathleen Masters

Overview of Selected Nursing Theories Overview of Selected Nonnursing Theories Relationship of Theory to Professional Nursing Practice Conclusion References

Philosophy of Nursing Mary W. Stewart

Philosophy Early Philosophy Paradigms Beliefs Values Developing a Personal Philosophy of Nursing Conclusion References

Competencies for Professional Nursing Practice Jill Rushing and Kathleen Masters

Overview Nurse of the Future: Nursing Core Competencies Critical Thinking, Clinical Judgment, and Clinical Reasoning in Nursing Practice Conclusion References

Education and Socialization to the Professional Nursing Role Kathleen Masters and Melanie Gilmore

8

6

7

Professional Nursing Roles and Values The Socialization (or Formation) Process Facilitating the Transition to Professional Practice Conclusion References

Advancing and Managing Your Professional Nursing Career Mary Louise Coyne and Cynthia Chatham

Nursing: A Job or a Career? Trends That Affect Nursing Career Decisions Showcasing Your Professional Self Mentoring Education and Lifelong Learning Professional Engagement Expectations for Your Performance Taking Care of Self Conclusion References

Social Context and the Future of Professional Nursing Mary W. Stewart, Katherine E. Nugent, and Kathleen Masters

Nursing’s Social Contract with Society Public Image of Nursing The Gender Gap Changing Demographics and Cultural Competence Access to Health Care Societal Trends Trends in Nursing Conclusion References

UNIT II PROFESSIONAL NURSING PRACTICE AND THE MANAGEMENT OF PATIENT CARE

Safety and Quality Improvement in Professional Nursing Practice Kathleen Masters

10

9

11

Patient Safety Quality Improvement in Health Care Quality Improvement Measurement and Process The Role of the Nurse in Quality Improvement Conclusion References

Evidence-Based Professional Nursing Practice Kathleen Masters

Evidence-Based Practice: What Is It? Barriers to Evidence-Based Practice Promoting Evidence-Based Practice Searching for Evidence Evaluating the Evidence Implementation Models for Evidence-Based Practice Conclusion References

Patient Education and Patient-Centered Care in Professional Nursing Practice Kathleen Masters

Dimensions of Patient-Centered Care Communication as a Strategy to Support Patient-Centered Care Patient Education as a Strategy to Support Patient-Centered Care Evaluation of Patient-Centered Care Conclusion References

Informatics in Professional Nursing Practice Kathleen Masters and Cathy K. Hughes

Informatics: What Is It? The Effect of Legislation on Health Informatics Nursing Informatics Competencies Basic Computer Competencies Information Literacy Information Management Current and Future Trends

13

12

14

15

Conclusion References

Leadership and Systems-Based Professional Nursing Practice Kathleen Masters and Sharon Vincent

Healthcare Delivery System Nursing Leadership in a Complex Healthcare System Nursing Models of Patient Care Roles of the Professional Nurse Conclusion References

Teamwork, Collaboration, and Communication in Professional Nursing Practice Kathleen Masters

Interprofessional Teams and Healthcare Quality and Safety Interprofessional Collaborative Practice Domains Interprofessional Team Performance and Communication Conclusion References

Ethics in Professional Nursing Practice Janie B. Butts and Karen L. Rich

Ethics Ethical Theories and Approaches Professional Ethics and Codes Ethical Analysis and Decision Making in Nursing Relationships in Professional Practice Moral Rights and Autonomy Social Justice Death and End-of-Life Care Conclusion References

Law and Professional Nursing Practice Kathleen Driscoll and Kathleen Masters

The Sources of Law

Classification and Enforcement of the Law Nursing Scope and Standards Malpractice and Negligence Nursing Licensure Professional Accountability Conclusion References

Appendix A Provisions of Code of Ethics for Nurses Appendix B The ICN Code of Ethics for Nurses Glossary Index

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PREFACE

Although the process of professional development is a lifelong journey, it is a journey that begins in earnest during the time of initial academic preparation. The goal of this book is to provide nursing students with a road map to help guide them along their journey as professional nurses.

This book is organized into two units. The chapters in the first unit focus on the foundational concepts that are essential to the development of the individual professional nurse. The chapters in Unit II address issues related to professional nursing practice and the management of patient care, specifically in the context of quality and safety. In the Fifth Edition, the chapter content is conceptualized, when applicable, around nursing competencies, professional standards, and recommendations from national groups, such as Institute of Medicine reports. All chapters have been updated, several chapters have been expanded, and two new chapters have been added in this edition. The chapters included in Unit I provide the student nurse with a basic foundation in such areas as nursing history, theory, philosophy, socialization into the nursing role, professional development, the social context of nursing, and professional nursing competencies. The social context of nursing chapter has been

expanded to incorporate not only societal trends but also trends in nursing practice and education that are changing the future landscape of the profession. The chapters in Unit II are more directly related to patient care management and, as stated previously, are presented in the context of quality and safety. Chapter topics include the role of the nurse in patient safety and quality improvement, evidence-based nursing practice, the role of the nurse in patient education and patient-centered care, informatics in nursing practice, the role of the nurse related to teamwork and collaboration, systems-based practice and leadership, ethics in nursing practice, and the law as it relates to patient care and nursing. Unit II chapters have undergone revision, with a refocus of the content on recommended nursing and healthcare competencies as well as recommendations from faculty using the text in the classroom.

The Fifth Edition incorporates the revised Nurse of the Future: Nursing Core Competencies: Registered Nurse throughout each chapter. The 10 essential competencies that are intended to guide nursing curricula and practice emanate from the central core of the model that represents nursing knowledge (Massachusetts Department of Higher Education, 2016) and are based on the American Association of Colleges of Nursing (AACN) Essentials of Baccalaureate Education for Professional Nursing Practice, National League for Nursing Council of Associate Degree Nursing competencies, Institute of Medicine recommendations, Quality and Safety Education for Nurses (QSEN) competencies, and American Nurses Association standards, as well as other professional organization standards and recommendations. The 10 competencies included in the model are patient-centered care, professionalism, informatics and technology, evidence-based practice, leadership, systems-based practice, safety, communication, teamwork and collaboration, and quality improvement. Essential knowledge, skills, and attitudes (KSAs) reflecting cognitive, psychomotor, and affective learning domains are specified for each competency. The KSAs identified in the model reflect the expectations for initial nursing practice following the completion of a prelicensure professional nursing education program (Massachusetts Department of Higher Education, 2016).

This new edition has competency boxes throughout the chapters that link examples of the KSAs appropriate to the chapter content to Nurse of the Future: Nursing Core Competencies required of entry-level

professional nurses. The competency model is explained in detail in Chapter 4 and is available in its entirety online at http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

The Fifth Edition also includes applicable AACN essentials incorporated as key outcomes throughout each chapter to assist faculty with the alignment of curricular content with criteria required by accreditors. The key outcomes also demonstrate for students the link between expectations included in the competency model, the expectations embodied in the essentials document, and the chapter content. A discussion of the AACN (2008) Essentials of Baccalaureate Education for Professional Nursing Practice is also included in Chapter 4.

This new edition continues to use case studies, congruent with Benner, Sutphen, Leonard, and Day’s (2010) Carnegie Report recommendations that nursing educators teach for “situated cognition” using narrative strategies to lead to “situated action,” thus increasing the clinical connection in our teaching or that we teach for “clinical salience.” In addition, critical thinking questions are included throughout each chapter to promote student reflection on the chapter concepts. Classroom activities are also provided based on chapter content. Additional resources not connected to this text, but applicable to the content herein, include a toolkit focused on the nursing core competencies available at http://www.mass.edu/nahi/documents/NursingCoreCompetenciesToolkit- March2016.pdf and teaching activities related to nursing competencies available on the QSEN website at http://qsen.org/teaching-strategies/.

Although the topics included in this textbook are not inclusive of all that could be discussed in relationship to the broad theme of role development in professional nursing practice, it is my prayer that the subjects herein make a contribution to the profession of nursing by providing the student with a solid foundation and a desire to grow as a professional nurse throughout the journey that we call a professional nursing career. Let the journey begin.

—Kathleen Masters

References American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved

from http://www.aacnnursing.org/Education-Resources/AACN- Essentials

Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass.

Massachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. Retrieved from http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Editor Kathleen Masters, DNS, RN Professor and Dean University of Southern Mississippi College of Nursing Hattiesburg, Mississippi

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CONTRIBUTORS

Janie B. Butts, PhD, RN Professor University of Southern Mississippi College of Nursing Hattiesburg, Mississippi

Cynthia Chatham, DSN, RN Associate Professor University of Southern Mississippi College of Nursing Long Beach, Mississippi

Mary Louise Coyne, DNSc, RN Professor University of Southern Mississippi College of Nursing Long Beach, Mississippi

Kathleen Driscoll, JD, MS, RN University of Cincinnati College of Nursing Cincinnati, Ohio

Melanie Gilmore, PhD, RN Associate Professor (Retired) University of Southern Mississippi

College of Nursing Hattiesburg, Mississippi

Cathy K. Hughes, DNP, RN Teaching Assistant Professor University of Southern Mississippi College of Nursing Hattiesburg, Mississippi

Karen Saucier Lundy, PhD, RN, FAAN Professor Emeritus University of Southern Mississippi College of Nursing Hattiesburg, Mississippi

Katherine E. Nugent, PhD, RN Professor and Dean (Retired) University of Southern Mississippi College of Nursing Hattiesburg, Mississippi

Karen L. Rich, PhD, RN Associate Professor University of Southern Mississippi College of Nursing Long Beach, Mississippi

Jill Rushing, MSN, RN Director of BSN Program University of Southern Mississippi College of Nursing Hattiesburg, Mississippi

Mary W. Stewart, PhD, RN Director of PhD Program University of Mississippi Medical Center School of Nursing Jackson, Mississippi

Sharon Vincent, DNP, RN, CNOR University of North Carolina College of Nursing Charlotte, North Carolina

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UNIT I

Foundations of Professional Nursing Practice

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CHAPTER 1

A History of Health Care and Nursing1 Karen Saucier Lundy and Kathleen Masters

Learning Objectives

After completing this chapter, the student should be able to:

1. Identify social, political, and economic influences on the development of professional nursing practice.

2. Identify important leaders and events that have significantly affected the development of professional nursing practice.

Key Terms and Concepts

Greek era Roman era Deaconesses Florence Nightingale Reformation Chadwick Report Shattuck Report William Rathbone Ethel Fenwick Jeanne Mance Mary Agnes Snively Goldmark Report Brown Report Isabel Hampton Robb American Nurses Association (ANA) Lavinia Lloyd Dock American Journal of Nursing (AJN) Margaret Sanger Lillian Wald Jane A. Delano Annie Goodrich Mary Brewster Henry Street Settlement Elizabeth Tyler Jessie Sleet Scales

Dorothea Lynde Dix Clara Barton Frontier Nursing Service Mary Breckinridge Mary D. Osborne Frances Payne Bolton International Council of Nurses (ICN)

Although no specialized nurse role per se developed in early civilizations, human cultures recognized the need for nursing care. The truly sick person was weak and helpless and could not fulfill the duties that were normally expected of a member of the community. In such cases, someone had to watch over the patient, nurse him or her, and provide care. In most societies, this nurse role was filled by a family member, usually female. As in most cultures, the childbearing woman had special needs that often resulted in a specialized role for the caregiver. Every society since the dawn of time had someone to nurse and take care of the mother and infant around the childbearing events. In whatever form the nurse took, the role was associated with compassion, health promotion, and kindness (Bullough & Bullough, 1978).

Classical Era More than 4,000 years ago, Egyptian physicians and nurses used an abundant pharmacologic repertoire to cure the ill and injured. The Ebers Papyrus lists more than 700 remedies for ailments ranging from snakebites to puerperal fever (Kalisch & Kalisch, 1986). Healing appeared in the Egyptian culture as the successful result of a contest between invisible beings of good and evil (Shryock, 1959). Around 1000 B.C., the Egyptians constructed elaborate drainage systems, developed pharmaceutical herbs and preparations, and embalmed the dead. The Hebrews formulated an elaborate hygiene code that dealt with laws governing both personal and community hygiene, such as contagion, disinfection, and sanitation through the preparation of food and water. The Jewish contribution to health is greater in sanitation than in their concept of disease. Garbage and excreta were disposed of outside the city or camp, infectious diseases were quarantined, spitting was outlawed as unhygienic, and bodily cleanliness became a prerequisite for moral purity. Although many of the Hebrew ideas about hygiene were Egyptian in origin, the Hebrews were the first to codify them and link them with spiritual godliness (Bullough & Bullough, 1978).

Disease and disability in the Mesopotamian area were considered a great curse, a divine punishment for grievous acts against the gods. Experiencing illness as punishment for a sin linked the sick person to anything even remotely deviant. Not only was the person suffering from the illness but also he or she also was branded by society as having deserved it. Those who obeyed God’s law lived in health and happiness, and those who transgressed the law were punished with illness and suffering. The sick person then had to make atonement for the sins, enlist

a priest or other spiritual healer to lift the curse, or live with the illness to its ultimate outcome (Bullough & Bullough, 1978). Nursing care by a family member or relative would be needed, regardless of the outcome of the sin, curse, disease-atonement-recovery, or death cycle. This logic became the basis for explanation of why some people “get sick and some don’t” for many centuries and still persists to some degree in most cultures today.

The Greeks and Health In Greek mythology, the god of medicine, Asclepias, cured disease. One of his daughters, Hygieia, from whom we derive the word hygiene, was the goddess of preventive health and protected humans from disease. Panacea, Asclepias’ other daughter, was known as the all-healing “universal remedy,” and today her name is used to describe any ultimate cure-all in medicine. She was known as the “light” of the day, and her name was invoked and shrines built to her during times of epidemics (Brooke, 1997).

During the Greek era, Hippocrates of Cos emphasized the rational treatment of sickness as a natural rather than a god-inflicted phenomenon. Hippocrates (460–370 B.C.) is considered the father of medicine because of his arrangements of the oral and written remedies and diseases, which had long been secrets held by priests and religious healers, into a textbook of medicine that was used for centuries (Bullough & Bullough, 1978).

In Greek society, health was considered to result from a balance between mind and body. Hippocrates wrote a most important book, Air, Water, and Places, which detailed the relationship between humans and the environment. This is considered a milestone in the eventual development of the science of epidemiology as the first such treatise on

the connectedness of the web of life. This topic of the relationship between humans and their environment did not recur until the development of bacteriology in the late 1800s (Rosen, 1958).

Perhaps the idea that most damaged the practice and scientific theory of medicine and health for centuries was the doctrine of the four humors, first spoken of by Empedocles of Acragas (493–433 B.C.). Empedocles was a philosopher and a physician, and as a result, he synthesized his cosmologic ideas with his medical theory. He believed that the same four elements that made up the universe were found in humans and in all animate beings (Bullough & Bullough, 1978). Empedocles believed that man [sic] was a microcosm, a small world within the macrocosm, or external environment. The four humors of the body (blood, bile, phlegm, and black bile) corresponded to the four elements of the larger world (fire, air, water, and earth) (Kalisch & Kalisch, 1986). Depending on the prevailing humor, a person was sanguine, choleric, phlegmatic, or melancholic. Because of this strongly held and persistent belief in the connection between the balance of the four humors and health status, treatment was aimed at restoring the appropriate balance of the four humors through the control of their corresponding elements. Through manipulating the two sets of opposite qualities—hot and cold, wet and dry—balance was the goal of the intervention. Fire was hot and dry, air was hot and wet, water was cold and wet, and earth was cold and dry. For example, if a person had a fever, cold compresses would be prescribed; for a chill the person would be warmed. Such doctrine gave rise to faulty and ineffective treatment of disease that influenced medical education for many years (Taylor, 1922).

Plato, in The Republic, details the importance of recreation, a balanced mind and body, nutrition, and exercise. A distinction was made among gender, class, and health as early as the Greek era; only males of

the aristocracy could afford the luxury of maintaining a healthful lifestyle (Rosen, 1958).

In The Iliad, a poem about the attempts to capture Troy and rescue Helen from her lover, Paris, 140 different wounds are described. The mortality rate averaged 77.6%, the highest as a result of sword and spear thrusts and the lowest from superficial arrow wounds. There was considerable need for nursing care, and Achilles, Patroclus, and other princes often acted as nurses to the injured. The early stages of Greek medicine reflected the influences of Egyptian, Babylonian, and Hebrew medicine. Therefore, good medical and nursing techniques were used to treat these war wounds: The arrow was drawn or cut out, the wound washed, soothing herbs applied, and the wound bandaged. However, in sickness in which no wound occurred, an evil spirit was considered the cause. The Greeks applied rational causes and cures to external injuries, whereas internal ailments continued to be linked to spiritual maladies (Bullough & Bullough, 1978).

Roman Era During the rise and the fall of the Roman era (31 B.C.–A.D. 476), Greek culture continued to be a strong influence. The Romans easily adopted Greek culture and expanded the Greeks’ accomplishments, especially in the fields of engineering, law, and government. For Romans, the government had an obligation to protect its citizens not only from outside aggression, such as warring neighbors, but also from inside the civilization, in the form of health laws. According to Bullough and Bullough (1978), Rome was essentially a “Greek cultural colony” (p. 20).

Galen of Pergamum (A.D. 129–199), often known as the greatest Greek physician after Hippocrates, left for Rome after studying medicine in Greece and Egypt and gained great fame as a medical practitioner,

lecturer, and experimenter. In his lifetime, medicine evolved into a science; he submitted traditional healing practices to experimentation and was possibly the greatest medical researcher before the 1600s (Bullough & Bullough, 1978). He was considered the last of the great physicians of antiquity (Kalisch & Kalisch, 1986).

The Greek physicians and healers certainly made the most contributions to medicine, but the Romans surpassed the Greeks in promoting the evolution of nursing. Roman armies developed the notion of a mobile war nursing unit because their battles took them far from home where they could be cared for by wives and family. This portable hospital was a series of tents arranged in corridors; as battles wore on, these tents gave way to buildings that became permanent convalescent camps at the battle sites (Rosen, 1958). Many of these early military hospitals have been excavated by archaeologists along the banks of the Rhine and Danube rivers. They had wards, recreation areas, baths, pharmacies, and even rooms for officers who needed a “rest cure” (Bullough & Bullough, 1978). Coexisting were the Greek dispensary forms of temples, or the iatreia, which started out as a type of physician waiting room. These eventually developed into a primitive type of hospital, places for surgical clients to stay until they could be taken home by their families. Although nurses during the Roman era were usually family members, servants, or slaves, nursing had strengthened its position in medical care and emerged during the Roman era as a separate and distinct specialty.

The Romans developed massive aqueducts, bathhouses, and sewer systems during this era. At the height of the Roman Empire, Rome provided 40 gallons of water per person per day to its 1 million inhabitants, which is comparable to our rates of consumption today (Rosen, 1958).

Middle Ages Many of the advancements of the Greco-Roman era were reversed during the Middle Ages (A.D. 476–1453) after the decline of the Roman Empire. The Middle Ages, or the medieval era, served as a transition between ancient and modern civilizations. Once again, myth, magic, and religion were explanations and cures for illness and health problems. The medieval world was the result of a fusion of three streams of thought, actions, and ways of life—Greco-Roman, Germanic, and Christian (Donahue, 1985). Nursing was most influenced by Christianity with the beginning of deaconesses, or female servants, doing the work of God by ministering to the needs of others. Deacons in the early Christian churches were apparently available only to care for men, whereas deaconesses cared for the needs of women. The role of deaconesses in the church was considered a forward step in the development of nursing and in the 1800s would strongly influence the young Florence Nightingale. During this era, Roman military hospitals were replaced by civilian ones. In early Christianity, the Diakonia, a kind of combination outpatient and welfare office, was managed by deacons and deaconesses and served as the equivalent of a hospital. Jesus served as the example of charity and compassion for the poor and marginal of society.

Communicable diseases were rampant during the Middle Ages, primarily because of the walled cities that emerged in response to the paranoia and isolation of the populations. Infection was next to impossible to control. Physicians had little to offer, deferring to the church for management of disease. Nursing roles were carried out primarily by religious orders. The oldest hospital (other than military hospitals in the

Roman era) in Europe was most likely the Hôtel-Dieu in Lyon, France, founded about 542 by Childebert I, king of Paris. The Hôtel-Dieu in Paris was founded around 652 by Saint Landry, bishop of Paris. During the Middle Ages, charitable institutions, hospitals, and medical schools increased in number, with the religious leaders as caregivers. The word hospital, which is derived from the Latin word hospitalis, meaning service of guests, was most likely more of a shelter for travelers and other pilgrims as well as the occasional person who needed extra care (Kalisch & Kalisch, 1986). Early European hospitals were more like hospices or homes for the aged, sick pilgrims, or orphans. Nurses in these early hospitals were religious deaconesses who chose to care for others in a life of servitude and spiritual sacrifice.

Black Death During the Middle Ages, a series of horrible epidemics, including the Black Death or bubonic plague, ravaged the civilized world (Diamond, 1997). In the 1300s, Europe, Asia, and Africa saw nearly half their populations lost to the bubonic plague. Worldwide, more than 60 million deaths were attributed to this horrible plague. In some parts of Europe, only one-fourth of the population survived, with some places having too few survivors alive to bury the dead. Families abandoned sick children, and the sick were often left to die alone (Cartwright, 1972).

Nurses and physicians were powerless to avert the disease. Black spots and tumors on the skin appeared, and petechiae and hemorrhages gave the skin a darkened appearance. There was also acute inflammation of the lungs, burning sensations, unquenchable thirst, and inflammation of the entire body. Hardly anyone afflicted survived the third day of the attack. So great was the fear of contagion that ships carrying bodies of infected persons were set to sail without a crew to drift from

port to port through the North, Black, and Mediterranean seas with their dead passengers (Cohen, 1989).

Medieval people knew that this disease was in some way communicable, but they were unsure of the mode of transmission (Diamond, 1997); hence the avoidance of victims and a reliance on isolation techniques. During this time, the practice of quarantine in city ports was developed as a preventive measure that is still used today (Bullough & Bullough, 1978; Kalisch & Kalisch, 1986).

The Renaissance During the rebirth of Europe, political, social, and economic advances occurred along with a tremendous revival of learning. Donahue (1985) contends that the Renaissance has been “viewed as both a blessing and a curse” (p. 188). There was a renewed interest in the arts and sciences, which helped advance medical science (Boorstin, 1985; Bullough & Bullough, 1978). Columbus and other explorers discovered new worlds, and belief in a sun-centered rather than an Earth-centered universe was promoted by Copernicus (1473–1543). Sir Isaac Newton’s (1642–1727) theory of gravity changed the world forever. Gunpowder was introduced, and social and religious upheavals resulted in the American and French revolutions at the end of the 1700s. In the arts and sciences, Leonardo da Vinci, known as one of the greatest geniuses of all time, made a number of anatomic drawings based on dissection experiences. These drawings have become classics in the progression of knowledge about the human anatomy. Many artists of this time left an indelible mark and continue to exert influence today, including Michelangelo, Raphael, and Titian (Donahue, 1985).

The Reformation Religious changes during the Renaissance influenced nursing perhaps more than any other aspect of society. Particularly important was the rise of Protestantism as a result of the reform movements of Martin Luther (1483–1546) in Germany and John Calvin (1509–1564) in France and Switzerland. Although the various sects were numerous in the Protestant movement, the agreement among the leaders was almost unanimous on the abolition of the monastic or cloistered career. The effects on nursing

were drastic: Monastic-affiliated institutions, including hospitals and schools, were closed, and orders of nuns, including nurses, were dissolved. Even in countries where Catholicism flourished, royal leaders seized monasteries frequently.

Religious leaders, such as Martin Luther, who led the Reformation in 1517, were well aware of the lack of adequate nursing care as a result of these sweeping changes. Luther advocated that each town establish something akin to a “community chest” to raise funds for hospitals and nurse visitors for the poor (Dietz & Lehozky, 1963). Thus, the closures of the monasteries eventually resulted in the creation of public hospitals where laywomen performed nursing care. It was difficult to find laywomen who were willing to work in these hospitals to care for the sick, so judges began giving prostitutes, publically intoxicated women, and poverty- stricken women the option of going to jail, going to the poorhouse, or working in the public hospital. Unlike the sick wards in monasteries, which were generally considered to be clean and well managed, the public hospitals were filthy, disorganized buildings where people went to die while being cared for by laywomen who were not trained, motivated, or qualified to care for the sick (Sitzman & Judd, 2014a).

In England, where there had been at least 450 charitable foundations before the Reformation, only a few survived the reign of Henry VIII, who closed most of the monastic hospitals (Donahue, 1985). Eventually, Henry VIII’s son, Edward VI, who reigned from 1547 to 1553, endowed some hospitals, namely, St. Bartholomew’s Hospital and St. Thomas’ Hospital, which would eventually house the Nightingale School of Nursing later in the 1800s (Bullough & Bullough, 1978).

The Dark Period of Nursing The last half of the period between 1500 and 1860 is widely regarded as the “dark period of nursing” because nursing conditions were at their worst (Donahue, 1985). Education for girls, which had been provided by the nuns in religious schools, was lost. Because of the elimination of hospitals and schools, there was no one to pass on knowledge about caring for the sick. As a result, the hospitals were managed and staffed by municipal authorities; women entering nursing service often came from illiterate classes, and even then, there were too few to serve (Dietz & Lehozky, 1963). The lay attendants who filled the nursing role were illiterate, rough, inconsiderate, and often immoral and alcoholic. Intelligent women and men could not be persuaded to accept such a degraded and low-status position in the offensive municipal hospitals of London. Nursing slipped back into a role of servitude as menial, low- status work. According to Donahue (1985), when a woman could no longer make it as a gambler, prostitute, or thief, she might become a nurse. Eventually, women serving jail sentences for such crimes as prostitution and stealing were ordered to care for the sick in the hospitals instead of serving their sentences in the city jail (Dietz & Lehozky, 1963). The nurses of this era took bribes from clients, became inappropriately involved with them, and survived the best way they could, often at the expense of their assigned clients.

Nursing had, during this era, virtually no social standing or organization. Even Catholic sisters of the religious orders throughout Europe “came to a complete standstill” professionally because of the intolerance of society (Donahue, 1985, p. 231). Charles Dickens, in Martin Chuzzlewit (1844), created the enduring characters of Sairey

Gamp and Betsy Prig. Sairey Gamp was a visiting nurse based on an actual hired attendant whom Dickens had met in a friend’s home. Sairey Gamp was hired to care for sick family members but was instead cruel to her clients, stole from them, and ate their rations; she was an alcoholic and has been immortalized forever as a reminder of the world in which Florence Nightingale came of age (Donahue, 1985). The first hospital in the Americas, the Hospital de la Purísima Concepción, was founded some time before 1524 by Hernando Cortez, the conqueror of Mexico. The first hospital in the continental United States was erected in Manhattan in 1658 for the care of sick soldiers and slaves. In 1717, a hospital for infectious diseases was built in Boston; the first hospital established by a private gift was the Charity Hospital in New Orleans. A sailor, Jean Louis, donated the endowment for the hospital’s founding (Bullough & Bullough, 1978).

During the 1600s and 1700s, colonial hospitals with little resemblance to modern hospitals were often used to house the poor and downtrodden. Hospitals called “pesthouses” were created to care for clients with contagious diseases; their primary purpose was to protect the public at large rather than to treat and care for the clients. Contagious diseases were rampant during the early years of the American colonies, often being spread by the large number of immigrants who brought these diseases with them on their long journey to America. Medicine was not as developed as in Europe, and nursing remained in the hands of the uneducated. By 1720, average life expectancy at birth was only around 35 years. Plagues were a constant nightmare, with outbreaks of smallpox and yellow fever. In 1751, the first true hospital in the new colonies, Pennsylvania Hospital, was erected in Philadelphia on the recommendation of Benjamin Franklin (Kalisch & Kalisch, 1986).

By today’s standards, hospitals in the 1800s were disgraceful, dirty, unventilated, and contaminated by infections; to be a client in a hospital

actually increased one’s risk of dying. As in England, nursing was considered an inferior occupation. After the sweeping changes of the Reformation, educated religious health workers were replaced with lay people who were “down and outers,” in prison or had no option left but to work with the sick (Kalisch & Kalisch, 1986).

The Industrial Revolution During the mid-1700s in England, capitalism emerged as an economic system based on profit. This emerging system resulted in mass production, as contrasted with the previous system of individual workers and craftsmen. In the simplest terms, the Industrial Revolution was the application of machine power to processes formerly done by hand. Machinery was invented during this era and ultimately standardized quality; individual craftsmen were forced to give up their crafts and lands and become factory laborers for the capitalist owners. All types of industries were affected; this new-found efficiency produced profit for owners of the means of production. Because of this, the era of invention flourished, factories grew, and people moved in record numbers to work in the cities. Urban areas grew, tenement housing projects emerged, and overcrowding in cities seriously threatened individuals’ well-being (Donahue, 1985).

Workers were forced to go to the machines, not the other way around. Such relocations meant giving up not only farming but also a way of life that had existed for centuries. The emphasis on profit over people led to child labor, frequent layoffs, and long workdays filled with stressful, tedious, unfamiliar work. Labor unions did not exist, and neither was there any legal protection against exploitation of workers, including children (Donahue, 1985). All these rapid changes and often threatening conditions created the world of Charles Dickens, where, as in his book Oliver Twist, children worked as adults without question.

According to Donahue (1985), urban life, trade, and industrialization contributed to these overwhelming health hazards, and the situation was confounded by the lack of an adequate means of social control. Reforms

were desperately needed, and the social reform movement emerged in response to the unhealthy by-products of the Industrial Revolution. It was in this world of the 1800s that such reformers as John Stuart Mill (1806– 1873) emerged. Although the Industrial Revolution began in England, it quickly spread to the rest of Europe and to the United States (Bullough & Bullough, 1978). The reform movement is critical to understanding the emerging health concerns that were later addressed by Florence Nightingale. Mill championed popular education, the emancipation of women, trade unions, and religious toleration. Other reform issues of the era included the abolition of slavery and, most important for nursing, more humane care of the sick, the poor, and the wounded (Bullough & Bullough, 1978). There was a renewed energy in the religious community with the reemergence of new religious orders in the Catholic Church that provided service to the sick and disenfranchised.

Epidemics had ravaged Europe for centuries, but they became even more serious with urbanization. Industrialization brought people to cities, where they worked in close quarters (as compared with the isolation of the farm) and contributed to the social decay of the second half of the 1800s. Sanitation was poor or nonexistent, sewage disposal from the growing population was lacking, cities were filthy, public laws were weak or nonexistent, and congestion of the cities inevitably brought pests in the form of rats, lice, and bedbugs, which transmitted many pathogens. Communicable diseases continued to plague the population, especially those who lived in these unsanitary environments. For example, during the mid-1700s, typhus and typhoid fever claimed twice as many lives each year as did the Battle of Waterloo (Hanlon & Pickett, 1984). Through foreign trade and immigration, infectious diseases were spread to all of Europe and eventually to the growing United States.

The Chadwick Report Edwin Chadwick became a major figure in the development of the field of public health in Great Britain by drawing attention to the cost of the unsanitary conditions that shortened the life span of the laboring class and threatened the wealth of Britain. Although the first sanitation legislation, which established a National Vaccination Board, was passed in 1837, Chadwick found in his classic study, Report on an Inquiry into the Sanitary Conditions of the Labouring Population of Great Britain, that death rates were high in large industrial cities, such as Liverpool. A more startling finding, from what is often referred to simply as the Chadwick Report, was that more than half the children of labor-class workers died by age 5, indicating poor living conditions that affected the health of the most vulnerable. Laborers lived only half as long as the upper classes.

One consequence of the report was the establishment in 1848 of the first board of health, the General Board of Health for England (Richardson, 1887). More legislation followed that initiated social reform in the areas of child welfare, elder care, the sick, mentally ill persons, factory health, and education. Soon sewers and fireplugs, based on an available water supply, appeared as indicators that the public health linkages from the Chadwick Report had an effect.

The Shattuck Report In the United States during the 1800s, waves of epidemics of yellow fever, smallpox, cholera, typhoid fever, and typhus continued to plague the population as in England and the rest of the world. As cities continued to grow in the industrialized young nation, poor workers crowded into larger cities and suffered from illnesses caused by the unsanitary living conditions (Hanlon & Pickett, 1984). Similar to Chadwick’s classic study in England, Lemuel Shattuck, a Boston bookseller and publisher who had

an interest in public health, organized the American Statistical Society in 1839 and issued a census of Boston in 1845. Shattuck’s census revealed high infant mortality rates and high overall population mortality rates. In 1850, in his Report of the Massachusetts Sanitary Commission, Shattuck not only outlined his findings on the unsanitary conditions but also made recommendations for public health reform that included the bookkeeping of population statistics and development of a monitoring system that would provide information to the public about environmental, food, and drug safety and infectious disease control (Rosen, 1958). He also called for services for well-child care, school-age children’s health, immunizations, mental health, health education for all, and health planning. The Shattuck Report was revolutionary in its scope and vision for public health, but it was virtually ignored during Shattuck’s lifetime. Nineteen years later, in 1869, the first state board of health was formed (Kalisch & Kalisch, 1986).

And Then There Was Nightingale . . . Florence Nightingale (Figure 1-1) was named one of the 100 most influential persons of the last millennium by Life magazine (“The 100 People Who Made the Millennium,” 1997). She was one of only eight women identified as such. Of those eight women, including Joan of Arc, Helen Keller, and Elizabeth I, Nightingale was identified as a true “angel of mercy,” having reformed military health care in the Crimean War and used her political savvy to forever change the way society views the health of the vulnerable, the poor, and the forgotten. She is probably one of the most written about women in history (Bullough & Bullough, 1978). Florence Nightingale has become synonymous with modern nursing.

Figure 1-1 Engraving From 1873 featuring the English reformer and founder of modern nursing, Florence Nightingale.

© traveler1116/E+/Getty Images

Born on May 12, 1820, in her namesake city, Florence, Italy, Florence Nightingale was the second child in the wealthy English family of William

and Frances Nightingale. As a young child, Florence displayed incredible curiosity and intellectual abilities not common to female children of the Victorian age. She mastered the fundamentals of Greek and Latin, and she studied history, art, mathematics, and philosophy. To her family’s dismay, she believed that God had called her to be a nurse. Nightingale was keenly aware of the suffering that industrialization created; she became obsessed with the plight of the miserable and suffering people. Conditions of general starvation accompanied the Industrial Revolution, prisons and workhouses overflowed, and persons in all sections of British life were displaced. She wrote in the spring of 1842, “My mind is absorbed with the sufferings of man; it besets me behind and before. . . . All that the poets sing of the glories of this world seem to me untrue. All the people that I see are eaten up with care or poverty or disease” (Woodham-Smith, 1951, p. 31).

Nightingale’s entire life would be haunted by this conflict between the opulent life of gaiety that she enjoyed and the misery of the world, which she was unable to alleviate. She was, in essence, an “alien spirit in the rich and aristocratic social sphere of Victorian England” (Palmer, 1977, p. 14). Nightingale remained unmarried, and at the age of 25, she expressed a desire to be trained as a nurse in an English hospital. Her parents emphatically denied her request, and for the next 7 years, she made repeated attempts to change their minds and allow her to enter nurse training. She wrote, “I crave for some regular occupation, for something worth doing instead of frittering my time away on useless trifles” (Woodham-Smith, 1951, p. 162). During this time, she continued her education through the study of math and science and spent 5 years collecting data about public health and hospitals (Dietz & Lehozky, 1963). During a tour of Egypt in 1849 with family and friends, Nightingale spent her 30th year in Alexandria with the Sisters of Charity of St. Vincent de Paul, where her conviction to study nursing was only reinforced (Tooley,

1910). While in Egypt, Nightingale studied Egyptian, Platonic, and Hermetic philosophy; Christian scripture; and the works of poets, mystics, and missionaries in her efforts to understand the nature of God and her “calling” as it fit into the divine plan (Calabria, 1996; Dossey, 2000).

The next spring, Nightingale traveled unaccompanied to the Kaiserwerth Institute in Germany and stayed there for 2 weeks, vowing to return to train as a nurse. In June 1851, Nightingale took her future into her own hands and announced to her family that she planned to return to Kaiserwerth and study nursing. According to Dietz and Lehozky (1963, p. 42), her mother had “hysterics” and scene followed scene. Her father “retreated into the shadows,” and her sister, Parthe, expressed that the family name was forever disgraced (Cook, 1913). In 1851, at the age of 31, Nightingale was finally permitted to go to Kaiserwerth, and she studied there for 3 months with Pastor Fliedner. Her family insisted that she tell no one outside the family of her whereabouts, and her mother forbade her to write any letters from Kaiserwerth. While there, Nightingale learned about the care of the sick and the importance of discipline and commitment of oneself to God (Donahue, 1985). She returned to England and cared for her then ailing father, from whom she finally gained some support for her intent to become a nurse—her lifelong dream.

In 1852, Nightingale wrote the essay “Cassandra,” which stands today as a classic feminist treatise against the idleness of Victorian women. Through her voluminous journal writings, Nightingale reveals her inner struggle throughout her adulthood with what was expected of a woman and what she could accomplish with her life. The life expected of an aristocratic woman in her day was one she grew to loathe, and she expressed this detestation throughout her writings (Nightingale, 1979). In “Cassandra,” Nightingale put her thoughts to paper, and many scholars believe that her eventual intent was to extend the essay to a novel. She wrote in “Cassandra,” “Why have women passion, intellect, moral activity

—these three—in a place in society where no one of the three can be exercised?” (Nightingale, 1979, p. 37). Although uncertain about the meaning of the name Cassandra, many scholars believe that it came from the Greek goddess Cassandra, who was cursed by Apollo and doomed to see and speak the truth but never to be believed. Nightingale saw the conventional life of women as a waste of time and abilities. After receiving a generous yearly endowment from her father, Nightingale moved to London and worked briefly as the superintendent of the Establishment for Gentlewomen During Illness hospital, finally realizing her dream of working as a nurse (Cook, 1913).

The Crimean Experience: “I Can Stand Out the War with Any Man” Nightingale’s opportunity for greatness came when she was offered the position of superintendent of the female nursing establishment of the English General Hospitals in Turkey by the secretary of war, Sir Sidney Herbert. Soon after the outbreak of the Crimean War, stories of the inadequate care and lack of medical resources for the soldiers became widely known throughout England (Woodham-Smith, 1951). The country was appalled at the conditions so vividly portrayed in the London Times. Pressure increased on Sir Sidney to react. He knew of one woman who was capable of bringing order out of the chaos and wrote a letter to Nightingale on October 15, 1854, as a plea for her service. Nightingale accepted the challenge and set sail with 38 self-proclaimed nurses with varied training and experiences, of whom 24 were Catholic and Anglican nuns. Their journey to the Crimea took a month, and on November 4, 1854, the brave nurses arrived at Istanbul and were taken to Scutari the same day. Faced with 3,000 to 4,000 wounded men in a hospital designed to accommodate 1,700, the nurses went to work (Kalisch &

Kalisch, 1986). They found 4 miles of beds 18 inches apart. Most soldiers were lying naked with no bedding or blanket. There were no kitchen or laundry facilities. The little light present took the form of candles in beer bottles. The hospital was literally floating on an open sewage lagoon filled with rats and other vermin (Donahue, 1985).

By taking the newly arrived medical equipment and setting up kitchens, laundries, recreation rooms, reading rooms, and a canteen, Nightingale and her team of nurses proceeded to clean the barracks of lice and filth. Nightingale was in her element. She set out not only to provide humane health care for the soldiers but also to essentially overhaul the administrative structure of the military health services (Williams, 1961).

Florence Nightingale and Sanitation Although Nightingale never accepted the germ theory, she demanded clean dressings; clean bedding; well-cooked, edible, and appealing food; proper sanitation; and fresh air. After the other nurses were asleep, Nightingale made her famous solitary rounds with a lamp or lantern to check on the soldiers. Nightingale had a lifelong pattern of sleeping few hours, spending many nights writing, developing elaborate plans, and evaluating implemented changes. She seldom believed in the “hopeless” soldier, only one who needed extra attention. Nightingale was convinced that most of the maladies that the soldiers suffered and died from were preventable (Williams, 1961).

Before Nightingale’s arrival and her radical and well-documented interventions based on sound public health principles, the mortality rate from the Crimean War was estimated to be from 42% to 73%. Nightingale is credited with reducing that rate to 2% within 6 months of her arrival at Scutari. She did this through careful, scientific epidemiologic research

(Dietz & Lehozky, 1963). Upon arriving at Scutari, Nightingale’s first act was to order 200 scrubbing brushes. The death rate fell dramatically once Nightingale discovered that the hospital was built literally over an open sewage lagoon (Andrews, 2003).

According to Palmer (1982), Nightingale possessed the qualities of a good researcher: insatiable curiosity, command of her subject, familiarity with methods of inquiry, a good background of statistics, and the ability to discriminate and abstract. She used these skills to maintain detailed and copious notes and to codify observations. Nightingale relied on statistics and attention to detail to back up her conclusions about sanitation, management of care, and disease causation. Her now-famous “cox combs” are a hallmark of military health services management by which she diagrammed deaths in the army from wounds and from other diseases and compared them with deaths that occurred in similar populations in England (Palmer, 1977).

Nightingale was first and foremost an administrator: She believed in a hierarchical administrative structure with ultimate control lodged in one person to whom all subordinates and offices reported. Within a matter of weeks of her arrival in the Crimea, Nightingale was the acknowledged administrator and organizer of a mammoth humanitarian effort. From her Crimean experience on, Nightingale involved herself primarily in organizational activities and health planning administration. Palmer contends that Nightingale “perceived the Crimean venture, which was set up as an experiment, as a golden opportunity to demonstrate the efficacy of female nursing” (Palmer, 1982, p. 4). Although Nightingale faced initial resistance from the unconvinced and oppositional medical officers and surgeons, she boldly defied convention and remained steadfastly focused on her mission to create a sanitary and highly structured environment for her “children”—the British soldiers who dedicated their lives to the defense of Great Britain. Because of her insistence on absolute authority

regarding nursing and the hospital environment, Nightingale was known to send nurses home to England from the Crimea for suspicious alcohol use and character weakness.

It was through this success at Scutari that she began a long career of influence on the public’s health through social activism and reform, health policy, and the reformation of career nursing. Using her well-publicized successful “experiment” and supportive evidence from the Crimea, Nightingale effectively argued the case for the reform and creation of military health care that would serve as the model for people in uniform to the present (D’Antonio, 2002). Nightingale’s ideas about proper hospital architecture and administration influenced a generation of medical doctors and the entire world, in both military and civilian service. Her work in Notes on Hospitals, published in 1860, provided the template for the organization of military health care in the Union Army when the U.S. Civil War erupted in 1861. Her vision for health care of soldiers and the responsibility of the governments that send them to war continues today; her influence can be seen throughout the previous century and into this century as health care for the women and men who serve their country is a vital part of the well-being not only of the soldiers but also of society in general (D’Antonio, 2002).

Returning Home a Heroine: The Political Reformer When Nightingale returned to London, she found that her efforts to provide comfort and health to the British soldier succeeded in making heroes of both herself and the soldiers (Woodham-Smith, 1951). Both had suffered from negative stereotypes: The soldier was often portrayed as a drunken oaf with little ambition or honor, and the nurse as a tipsy, self-serving, illiterate, promiscuous loser. After the Crimean War and the

efforts of Nightingale and her nurses, both returned with honor and dignity, never again downtrodden and disrespected.

After her return from the Crimea, Florence Nightingale never made a public appearance, never attended a public function, and never issued a public statement (Bullough & Bullough, 1978). She single-handedly raised nursing from, as she put it, “the sink it was” into a respected and noble profession (Palmer, 1977). As an avid scholar and student of the Greek writer Plato, Nightingale believed that she had a moral obligation to work primarily for the good of the community. Because she believed that education formed character, she insisted that nursing must go beyond care for the sick; the mission of the trained nurse must include social reform to promote the good. This dual mission of nursing— caregiver and political reformer—has shaped the profession as we know it today. LeVasseur (1998) contends that Nightingale’s insistence on nursing’s involvement in a larger political ideal is the historic foundation of the field and distinguishes us from other scientific disciplines, such as medicine.

How did Nightingale accomplish this? She effected change through her wide command of acquaintances: Queen Victoria was a significant admirer of her intellect and ability to effect change, and Nightingale used her position as national heroine to get the attention of elected officials in Parliament. She was tireless and had an amazing capacity for work. She used people. Her brother-in-law, Sir Harry Verney, was a member of Parliament and often delivered her “messages” in the form of legislation. When she wanted the public incited, she turned to the press, writing letters to the London Times and having others of influence write articles. She was not above threats to “go public” by certain dates if an elected official refused to establish a commission or appoint a committee. And when those commissions were formed, Nightingale was ready with her list of selected people for appointment (Palmer, 1982).

Nightingale and Military Reforms The first real test of Nightingale’s military reforms came in the United States during the Civil War. Nightingale was asked by the Union to advise on the organization of hospitals and care of the sick and wounded. She sent recommendations back to the United States based on her experiences and analysis in the Crimea, and her advisement and influence gained wide publicity. Following her recommendations, the Union set up a sanitary commission and provided for regular inspection of camps. She expressed a desire to help with the Confederate military also but, unfortunately, had no channel of communication with them (Bullough & Bullough, 1978).

The Nightingale School of Nursing at St. Thomas: The Birth of Professional Nursing The British public honored Nightingale by endowing 50,000 pounds sterling in her name upon her return to England from the Crimea. The money had been raised from the soldiers under her care and donations from the public. This Nightingale Fund eventually was used to create the Nightingale School of Nursing at St. Thomas, which was to be the beginning of professional nursing (Donahue, 1985). Nightingale, at the age of 40, decided that St. Thomas’ Hospital was the place for her training school for nurses. While the negotiations for the school went forward, she spent her time writing Notes on Nursing: What It Is and What It Is Not (Nightingale, 1860). The small book of 77 pages, written for the British mother, was an instant success. An expanded library edition was written for nurses and used as the textbook for the students at St. Thomas. The book has since been translated into many languages, although it is believed that Nightingale refused all royalties earned from

the publication of the book (Cook, 1913; Tooley, 1910). The nursing students chosen for the new training school were handpicked; they had to be of good moral character, sober, and honest. Nightingale believed that the strong emphasis on morals was critical to gaining respect for the new “Nightingale nurse,” with no possible ties to the disgraceful association of past nurses. Nursing students were monitored throughout their 1-year program both on and off the hospital grounds; their activities were carefully watched for character weaknesses, and discipline was severe and swift for violators. Accounts from Nightingale’s journals and notes reveal instant dismissal of nursing students for such behaviors as “flirtation, using the eyes unpleasantly, and being in the company of unsavory persons.” Nightingale contended that “the future of nursing depends on how these young women behave themselves” (Smith, 1934, p. 234). She knew that the experiment at St. Thomas to educate nurses and raise nursing to a moral and professional calling was a drastic departure from the past images of nurses and would take extraordinary women of high moral character and intelligence. Nightingale knew every nursing student, or probationer, personally, often having the students at her house for weekend visits. She devised a system of daily journal keeping for the probationers; Nightingale herself read the journals monthly to evaluate their character and work habits. Every nursing student admitted to St. Thomas had to submit an acceptable “letter of good character,” and Nightingale herself placed graduate nurses in approved nursing positions.

One of the most important features of the Nightingale School was its relative autonomy. Both the school and the hospital nursing service were organized under the head matron. This was especially significant because it meant that nursing service began independently of the medical staff in selecting, retaining, and disciplining students and nurses (Bullough & Bullough, 1978). Nightingale was opposed to the use of a

standardized government examination and the movement for licensure of trained nurses. She believed that schools of nursing would lose control of educational standards with the advent of national licensure, most notably those related to moral character. Nightingale led a staunch opposition to the movement by the British Nurses’ Association (BNA) for licensure of trained nurses, one the BNA believed critical to protecting the public’s safety by ensuring the qualification of nurses by licensure exam. Nightingale was convinced that qualifying a nurse by examination tested only the acquisition of technical skills, not the equally important evaluation of character (Nutting & Dock, 1907; Woodham-Smith, 1951).

Taking Health Care to the Community: Nightingale and Wellness Early efforts to distinguish hospital from community health nursing are evidence of Nightingale’s views on “health nursing,” which she distinguished from “sick nursing.” She wrote two influential papers, one in 1893, “Sick-Nursing and Health-Nursing” (Nightingale, 1893), which was read in the United States at the Chicago Exposition, and the second, “Health Teaching in Towns and Villages” in 1894 (Monteiro, 1985). Both papers praised the success of prevention-based nursing practice. Winslow (1946) acknowledged Nightingale’s influence in the United States by being one of the first in the field of public health to recognize the importance of taking responsibility for one’s health. According to Palmer (1982), Nightingale was a leader in the wellness movement long before the concept was identified. Nightingale saw the nurse as the key figure in establishing a healthy society. She saw a logical extension of nursing in acute hospital settings to the community. Clearly, through her Notes on Nursing, she visualized the nurse as “the nation’s first bulwark in health maintenance, the promotion of wellness, and the prevention of

disease” (Palmer, 1982, p. 6). William Rathbone, a wealthy ship owner and philanthropist, is

credited with the establishment of the first visiting nurse service, which eventually evolved into district nursing in the community. He was so impressed with the private duty nursing care that his sick wife had received at home that he set out to develop a “district nursing service” in Liverpool, England. At his own expense, in 1859, he developed a corps of nurses trained to care for the sick poor in their homes (Bullough & Bullough, 1978). He divided the community into 16 districts; each was assigned a nurse and a social worker that provided nursing and health education. His experiment in district nursing was so successful that he was unable to find enough nurses to work in the districts. Rathbone contacted Nightingale for assistance. Her recommendation was to train more nurses, and she advised Rathbone to approach the Royal Liverpool Infirmary with a proposal for opening another training school for nurses (Rathbone, 1890; Tooley, 1910). The infirmary agreed to Rathbone’s proposal, and district nursing soon spread throughout England as successful health nursing in the community for the sick poor through voluntary agencies (Rosen, 1958). Ever the visionary, Nightingale contended that the goal is to care for the sick in their own homes (Attewell, 1996). A similar service, health visiting, began in Manchester, England, in 1862 by the Manchester and Salford Sanitary Association. The purpose of placing health visitors in the home was to provide health information and instruction to families. Eventually, health visitors evolved to provide preventive health education and district nurses to care for the sick at home (Bullough & Bullough, 1978).

Although Nightingale is best known for her reform of hospitals and the military, she was a great believer in the future of health care, which she anticipated should be preventive in nature and would more than likely take place in the home and community. Her accomplishments in the field

of “sanitary nursing” extended beyond the walls of the hospital to include workhouse reform and community sanitation reform. In 1864, Nightingale and William Rathbone once again worked together to lead the reform of the Liverpool Workhouse Infirmary, where more than 1,200 sick paupers were crowded into unsanitary and unsafe conditions. Under the British Poor Laws, the most desperately poor of the large cities were gathered into large workhouses. When sick, they were sent to the workhouse infirmary. Trained nursing care was all but nonexistent. Through legislative pressure and a well-designed public campaign describing the horrors of the workhouse infirmary, reform of the workhouse system was accomplished by 1867. Although not as complete as Nightingale had wanted, nurses were in place and being paid a salary (Seymer, 1954).

The Legacy of Nightingale A great deal has been written about Nightingale—an almost mythic figure in history. She truly was a beloved legend throughout Great Britain by the time she left the Crimea in July 1856, 4 months after the war. Longfellow immortalized this “Lady with the Lamp” in his poem “Santa Filomena” (Longfellow, 1857). However, when Nightingale returned to London after the Crimean War, she remained haunted by her experiences related to the soldiers dying of preventable diseases. She was troubled by nightmares and had difficulty sleeping in the years that followed (Woodham-Smith, 1983). Nightingale became a prolific writer and a staunch defender of the causes of the British soldier, sanitation in England and India, and trained nursing.

As a woman, she was not able to hold an official government post, nor could she vote. Historians have had varied opinions about the exact nature of the disability that kept her homebound for the remainder of her life. Recent scholars have speculated that she experienced posttraumatic

stress disorder (PTSD) from her experiences in the Crimea; there is also considerable evidence that she suffered from the painful disease brucellosis (Barker, 1989; Young, 1995). She exerted incredible influence through friends and acquaintances, directing from her sick room sanitation and poor law reform. Her mission to “cleanse” spread from the military to the British Empire; her fight for improved sanitation both at home and in India consumed her energies for the remainder of her life (Vicinus & Nergaard, 1990).

According to Monteiro (1985), two recurrent themes are found throughout Nightingale’s writings about disease prevention and wellness outside the hospital. The most persistent theme is that nurses must be trained differently and instructed specifically in district and instructive nursing. She consistently wrote that the “health nurse” must be trained in the nature of poverty and its influence on health, something she referred to as the “pauperization” of the poor. She also believed that above all, health nurses must be good teachers about hygiene and helping families learn to better care for themselves (Nightingale, 1893). She insisted that untrained, “good intended women” could not substitute for nursing care in the home. Nightingale pushed for an extensive orientation and additional training, including prior hospital experience, before one was hired as a district nurse. She outlined the qualifications in her paper “On Trained Nursing for the Sick Poor,” in which she called for a month’s “trial” in district nursing, a year’s training in hospital nursing, and 3 to 6 months training in district nursing (Monteiro, 1985).

The second theme that emerged from her writings was the focus on the role of the nurse. She clearly distinguished the role of the health nurse in promoting what we today call self-care. In the past, philanthropic visitors in the form of Christian charity would visit the homes of the poor and offer them relief (Monteiro, 1985). Nightingale believed that such activities did little to teach the poor to care for themselves and further

“pauperized” them—dependent and vulnerable—keeping them unhealthy, prone to disease, and reliant on others to keep them healthy. The nurse then must help the families at home manage a healthy environment for themselves, and Nightingale saw a trained nurse as being the only person who could pull off such a feat.

By 1901, Nightingale lived in a world without sight or sound, leaving her unable to write. Over the next 5 years, Nightingale lost her ability to communicate and most days existed in a state of unconsciousness. In November 1907, Nightingale was honored with the Order of Merit by King Edward VII, the first time it was ever given to a woman. After 50 years, in May 1910, the Nightingale Training School of Nursing at St. Thomas celebrated its jubilee. There were now more than a thousand training schools for nurses in the United States alone (Cook, 1913; Tooley, 1910).

Nightingale died in her sleep around noon on August 13, 1910 and was buried quietly and without pomp near the family’s home at Embley, her coffin carried by six sergeants of the British Army. Only a small cross marks her grave at her request: “FN. Born 1820. Died 1910.” (Brown, 1988). The family refused a national funeral and burial at Westminster Abbey out of respect for Nightingale’s last wishes. She had lived for 90 years and 3 months.

Continued Development of Professional Nursing in the United Kingdom Although Florence Nightingale opposed registration, based on the belief that the essential qualities of a nurse could not be taught, examined, or regulated, registration in the United Kingdom began in the 1880s. The Hospitals Association maintained a voluntary registry that was an administrative list. In an effort to protect the public led by Ethel Fenwick, the BNA was formed in 1887 with its charter granted in 1893 to unite British nurses and to provide registration as evidence of systematic training. Finally, in 1919, nurse registration became law. It took 30 years and the tireless efforts of Ethel Fenwick, who was supported by other nursing leaders, such as Isla Stewart, Lucy Osbourne, and Mary Cochrane, to achieve mandated registration (Royal British Nurses’ Association, n.d.).