The advent of professional nursing is a fairly recent phenomenon in history. This is a remarkable achievement in human civilization, since the profession of nursing defies natural instinct. It is perfectly natural to care for one’s own kin in times of sickness or when they have become too frail to care for themselves due to age or physical or mental challenges. It is anything but natural to do so for those outside one’s very own family and clan. What is natural instead is to instinctively shun suffering and wailing. It is also only natural to dissociate oneself from failing life, from dying, and death, as is so powerfully expressed by Velma Wallis in her novel Two Old Women.1 The altruism we encounter in our health-care system whenever we visit a doctor’s office or a hospital or when we decide to join “the largest of the health-care professions” (Lynaugh and Brush 1996, 73) by becoming a nurse is—again—anything but normal.2 And, honestly, who really wants always to face the wretchedness and misery of human life in hospitals and nursing homes, in insane asylums and hospices, in neglected family homes and struggling communities? Who can really want to endure these conditions at the expense of constantly suppressing one’s own feelings and emotions? It is important for all persons in the profession—as it is for all of society—consciously to acknowledge this. Otherwise a proper understanding of the particular challenge of nursing will not be gained.3
The occupational prestige that nursing has today is also of very recent origin. The task of assisting strangers too sick to manage their private daily routines themselves—eating, drinking, and bodily cleanliness—and to keep them company always has required robust personalities. It asks for people strong nerved enough to handle the sometimes quite disgusting care of wounds and to attend to the hygiene of the private parts.4 Until about a century ago, nursing was practiced only in private homes. Families unable to provide care for their sick hired persons somehow skilled in nursing and compensated for these services in kind with food, drink, lodging, and—only occasionally—cash. The nursing appointment often lasted only days or weeks, but also could be extended provided the means for remuneration were there. One frequently in-demand nursing service was, of course, the care for pregnant and nursing women, but once the child was born and the mother strong and well, once the patient recovered or died, the nurse’s employment and income ceased until she was called for assistance elsewhere (see Reverby 1987). The nursing attendants of old, thus, depended heavily on neighborhood and physicians’ referrals. Both their reputation and their income were determined by success and public acceptance.
Literary characters, for instance Mrs. Sarah Gamp and Mrs. Betsey Prig in Charles Dickens’s 1844 novel Martin Chuzzlewit, represent average nurses in the pre-Nightingale days quite faithfully. In a preface to the novel written years later and obviously in response to particular criticisms, Dickens explicitly remarked: “I have taken every available opportunity of showing the want of sanitary improvements in the neglected dwellings of the poor. Mrs. Sarah Gamp was… a fair representation of the hired attendant on the poor in sickness.… Mrs. Betsey Prig was a fair specimen of a Hospital Nurse” (Dickens 1987, Preface, XV; see also Metz 2001, 268–283 and Summers 1989). It is highly instructive that in 1888 one of the very first issues of the British Nursing Record, a journal founded to herald groundbreaking changes in nursing and nursing education, used the image of Mrs. Gamp as the stereotype to illustrate the disgusting and dark past of a profession which by then had become somewhat reputable due to concern for cleanliness and nobility.5
What brought about change in the nineteenth century? First of all, it was the Deaconess movement, which formed in 1836 in Kaiserswerth (near Düsseldorf, Germany) under the leadership of Pastor Theodor Fliedner (1800–1864) and his wife Friederike (1800–1842). The Fliedners ran an educational institution for training young women as “Protestant attendants” for “deserving” poor, orphaned children, and the sick. These women were soon called “Deaconesses,”6 indicating Fliedner’s conscious attempt to revive an ancient Christian ministry of solidarity with the needy and poor in order to cope with the enormous social challenges of his day caused by the Industrial Revolution. Another of his goals was to help unmarried women find a respectable career, so the Deaconesses, who all lived in celibacy, wore the dress and bonnet of married women of the day, the bonnet which later became the nurse’s cap (Dolan 1968, 264–265; Ellis and Hartley 2008, 155–156; Kalisch and Kalisch 1995, 79–84).
The Deaconesses lived in a “Motherhouse,” an order-like community with a spiritual regimen, and were supervised by an aristocratic spinster. The students received basic education in the arts and sciences as well as in housekeeping and also in medicine, the latter being taught by a licensed physician. Once consecrated “Deaconesses” they went out to work in hospitals, families, and in parishes but continued to live in the “Motherhouse” which not only guided their work and provided them with a nominal allowance, but also fostered their lifelong spiritual discipline and devotion.7 All these elements together—decorum, education, medical training, spiritual nurture, frugal lifestyle, personal commitment, and competent leadership by people of high social standing—were instrumental in raising the occupational prestige of the profession, and since Kaiserswerth Deaconesses were also taking up work in other parts of the world, mainly the Near East8 and the US,9 the idea spread beyond local confines. Florence Nightingale visited Kaiserswerth twice;10 the second time she participated in a three-month educational course, as she did later also in Paris (1853) with the Sisters of Charity. While she held Kaiserswerth in high esteem as her “spiritual home,” she judged that the nursing of the sick there was not on par with like institutions of the day in London or Paris (Donahue 1996, 200; Bostridge 2008, 145–146).
It was Florence Nightingale’s (1820–1910) ability for keen observation, her talent to see matters in context, her systematic approach to nursing by painstaking record keeping—besides her commitment to practical nursing itself and her tireless advocacy in both writing and student formation for skilled nursing work—that made her the founder of professional nursing.11 In her Notes on Nursing, she programmatically turned the task of attending the sick from a charitable, well-intended waiting upon suffering people into a pro-active initiative to ease pain and respond to the immediate needs of the ill. In addition to practicing these skills, she urged nurses to create an atmosphere conducive to patients’ recovery by paying attention to overall environmental details, such as the room’s ventilation, cleanliness, lighting, and quiet (Nightingale 1860; also see McDonald 2004, 17–19). And she was plain spoken, too. Her Notes on Hospitals opens with the blunt and pointed remark: “It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm” (1863, Preface, iii).
Nightingale’s “Nurses Training School” founded at St. Thomas Hospital, London, in 1860—though not the first of its kind12—served as the model for numerous similar institutions around the world. The first such institution in the United States did not open until 1873 when three opened in rapid succession: the first at Bellevue Hospital in New York, the second as the independent Connecticut Training School in New Haven, and, finally, the Boston Training School for Nurses (see Bostridge 2008).13 The training the students received in these schools, which by the turn of the twentieth century numbered no less than 432 (Donahue 1996, 273–280; quote 324), was akin to that offered at Kaiserswerth. The nursing students were initially trained not just for work in hospitals but also for work in families, with the poor, and as teachers for youngsters.
Still, the occupational prestige of nursing, which had to do not only with competence and skill in actual nursing but also—and much the more so—with the social background of the average nurses, was poor. “Let it cease to be a disgrace to be called a nurse;” the English physician and advocate for quality nursing Edward Henry Sieveking (1816–1904) wrote in The Englishwoman’s Magazine in 1852, “…let the terms of nurse and gin-drinker no longer be convertible; let us banish the Mrs. Gamps to the utmost of our power; and substitute for them clean, intelligent, well-spoken, Christian attendants upon the sick” (quoted in Summers 1989, 365). Efforts to raise public prestige were also pursued on the American continent. The influential editor of the then very popular Godey’s Lady’s Book, Sarah J. Hale (1788–1879) of Philadelphia, in 1871 published an article in her periodical entitled “Lady Nurses” (Sherbrooke 1985). A champion of women’s education, Ms. Hale opened her article tellingly: “Much has been… said of the benefits that would follow if the calling of sick nurse were elevated to a profession which an educated lady might adopt without a sense of degradation, either on her own part or in the estimation of others”; and further: “The ‘graduate nurse’ would in general estimation be as much above the ordinary nurse of the present day as the professional surgeon… is above the barber-surgeon of the last century.” However, the profession’s struggle for proper recognition and prestige was far from over, despite the fact that around those years the public image of nursing received a powerful boost from a very different quarter. In this time of armed conflict and war, nursing wounded soldiers became a patriotic virtue: “Become a nurse: Your country needs you!”
Florence Nightingale was well known for her service in the barracks hospitals on the battlefields of the Crimean War (1853–1856). And years before the first formal training schools were opened in the US, numerous volunteers—both male and female—served as nurses in the Civil War (1861–1865).14 Henry Dunant (1828–1910) founded the Red Cross in 1863, partly because of the trauma he suffered witnessing the carnage of the battle of Solferino (1859). The new organization counted the senior Swiss army general Henri Dufour (1787–1875) among its five constitutive committee members (Bossier 1985, Moorehead 1998, Dunant 1986). The two world wars of the twentieth century (World War I, 1914–1918; World War II 1939–1945) and multiple other armed conflicts occurring thereafter—Korea (1950–1953), Vietnam (1959–1975) and the Gulf War (1990–1991)—also contributed to shaping the profession.
While armed conflicts increased the overall reputation of nursing services, they also left their mark on nursing itself in, for instance, the uniforms, the hierarchical structure, and the organization of practical nursing, especially in hospitals, and, of course, in the often very annoying way in which nurses—and physicians alike—have the patients under their command (Ellis and Hartley 208, 134–140). The impact of war and armed conflict on nursing was so crucial that it could be said that “Nursing is warfare, and the nurses are soldiers” (Malka 2007, 13). and also: “War is the father of modern nursing” (Nickels 1985).
As for the occupational prestige of the nursing profession today, a Harris poll of “Most Prestigious Occupations” conducted in August 2009 is highly instructive. It found that nurses rank fourth (after firefighters, scientists, and medical doctors) with a 56 percent approval rating in the public eye. This ranking placed nurses above teachers (sixth), clergy (eighth), members of Congress (twelfth), and well ahead of bankers whose profession ranked nineteenth (in a list of twenty-three) and who scored a public approval rating of only 16 percent! (The Harris Poll, 4 August 2009). However, regarding actual job satisfaction things look somewhat different. According to a study of two-hundred professions summarized in the Wall Street Journal in January 2009, Registered Nurses (RNs) rank 149th in job satisfaction, while their licensed practical colleagues (LPNs) come in at 184th (Needleman 2009; also see Careercast 2009).
A lot has changed, indeed, since the days of Ms. Sarah Gamp and the early days of professional nursing. The once famous nurse’s cap has vanished, as can be seen by comparing the cover of the first edition of Kalisch & Kalisch The Advance of American Nursing of 1978, which depicted nurses in traditional dresses and caps, with the third edition of 1995, which presents a nurse dressed on one side of her body in a lab coat with a stethoscope around her neck and on the other side in a business suit and carrying a briefcase. Also telling is the poster for 2009’s “Nursing Week” which shows that what once was the responsibility of an identifiable individual is now handled by a team of highly specialized professionals.
Both nurses’ education and their social standing have changed dramatically, as have their places of work. Formal nursing training in the US was established in the second half of the nineteenth century as a hospital-based education. Surprisingly, until well into the twentieth century, only a fraction of trained nurses actually went on to work in hospitals. Lynaugh and Brush point out that “Three-quarters of all graduate nurses in the 1920s and early 1930s were concentrated in the private duty market, working either in patients’ homes or as ‘specials’ for patients requiring hospitalization. These graduate nurses were paid by the patients they cared for, usually on a daily or weekly basis. It was student nurses who were the mainstay workforce for hospitals; graduate nurses’ work was not intrinsically linked to the hospital ward until the 1940s” (Lynaugh and Brush 1996, 1; see also Rosenberg 1987; Long and Golden 1989). However, private graduate nurses were, up until the late 1960s, frequently contracted to care for hospital patients needing unusual attention or post-operative supervision. Only after the Medicare/Medicaid legislation of 1965, did hospitals become the all defining focus for most graduate nurses. Under the Regional Medical Programs, nurses received government-funded special training for intensive or critical-care units which opened in significant numbers of hospitals at that time, thus offering specialized nursing careers which have increased ever since.15
The year 1965 also marks the beginning of a new kind of nursing education emerging alongside hospital run nursing schools scattered all over the country.16 With the introduction of the Medicare/Medicaid programs paid for by public funds, health-care and hospital access were opened to the elderly (i.e., those over sixty-five) and the poor, leading to a heightened demand for nurses. To meet this need, the federal government supported two initiatives that caused a drift away from classical training sites (see Kalisch and Kalisch 1995, 432–434, 446–452; Lynaugh and Brush 1996 12–14; 42–46): associate degree programs through community colleges (in existence since 1952 but now receiving more attention, see Lynaugh and Brush 1996, 49; Lenburg 1975) and new incentives toward obtaining a baccalaureate degree in four-year colleges. These changes recognize the ever rising mental and intellectual challenges of nursing work in the complex reality of the hospital world today where the demands of patients and their families have to be reconciled with the demands of evidence-based case management and the expectations and interests of other stakeholders in the health-care delivery system, be they medical institutions, professional organizations, licensing bodies, or hospital corporations trying to break even or make profits (Lynaugh and Brush 1996, 73).
Mindful of the impressive changes and the remarkable developments that have taken place within the nursing profession, one wonders why many of those in the profession continue to stress the need to enhance the image of nursing, as, for instance, Carol Huston does in her book Professional Issues in Nursing published as recently as 2006. Huston states that “[m]ore efforts must be made to improve the public’s image of nursing” because the nursing profession, she asserts, has been “unable to effectively change public perceptions regarding professional nursing roles and behaviors” (99). The Harris poll referred to above indicates that public perceptions of the nursing profession are better than Huston realizes, but Huston’s call is indicative of the concerns that continue to exist inside the profession (71).
Great things have been achieved and great strides have been made, yet there remains unease among nurses regarding their profession’s reputation and role and the education that leads to the professional practice of nursing.
Christoffer H. Grundmann is John R. Eckrich University Professor in Religion and the Healing Arts at Valparaiso University.
This essay is an abridged version of the first section of the Rae M. Huegli Lecture, delivered by the author on 9 October 2009 to the College of Nursing, Valparaiso University. This selection focuses on the historical development of the profession of nursing. The text of the complete lecture can be obtained by contacting The Cresset offices at email@example.com.
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1. Another novel, this time set within the context of Japanese culture, is Gail Tsukiyama’s The Samuarai’s Garden. For Japanese cultural attitudes toward sickness, especially leprosy see: Ninomiya 1996 and Sato and Narita 2003.
2. The debate on altruism in animals by socio-biologists and in evolutionary biology has yet to prove that there really is such a quality. What we know about unselfish behavior so far relates to comparatively small cohorts only and to relatively close-knit kinship relations in humans and non-human animals. For some of the more recent literature in English on this topic see: Dugatkin 2006, Fletcher and Doebeli 2006, Lehmann and Keller 2006, Okasha 2005, Rosenberg, A. 1992, Wilson and Dugatkin 1992, and Uyenoyama and Feldman 1992.
3. Canadian born Sir William Osler (1849–1919), the first professor of medicine at the newly established Johns Hopkins Hospital (1889) and later Regius Professor of Medicine at Oxford, UK, when addressing the 1891 graduating class of nurses at Johns Hopkins made a similar observation saying: “Nursing as an art to be cultivated, as a profession to be followed, is modern; nursing as a practice originated in the dim past, when some mother among the cave-dwellers cooled the forehead of her sick child with water from the brook, or first yielded to the prompting to leave a well-covered bone and a handful of meal by the side of a wounded man left in the hurried flight before an enemy” (Osler 1932, 156).
4. For further study of this topic see: Holmes, Perron, and O’Byrne 2006, Alavi 2005, and Miller 2004.
5. On this publication see Lorentzon 2004. On the comparison in question see Summers 1989.
6. Pastor Fliedner did not name the trainees “Deaconesses” at first due to a charge by the then Prussian King Friedrich Wilhelm III (1770–1840) who objected that women were to become bearers of a title of a Church ministry who do work in non-Church ministries (Greschat 1998).
7. For the impact of the Deaconess movement on the British Isles in those days see Stanley 1854 and Bostridge 2008, 96–103.
8. Kaiserswerth Deaconesses began working in Jerusalem, Palestine in 1851, in Smyrna (Izmir), in the then Ottoman Empire, now Turkey, in 1853, in Constantinople and Alexandria, Egypt, in 1857, and in Beirut, Lebanon in 1860.
9. Deaconesses took up work in Pittsburgh, Pennsylvania in 1849. Pastor Fliedner himself accompanied the first group of four to their new place of work among the immigrants.
10. The visits took place in 1850 and 1851 according to the archive at Kaiserswerth. These years conflict, however, with the statement by Patricia Donahue (1996, 200) who gives 1847 as the year of these visits; see also Bostridge 2008, 142–160.
11. The telling title of the 1999 report of the Joint Commission on Accreditation of Healthcare Organizations reads: Florence Nightingale: Measuring Hospital Care Outcomes.
12. The St. John’s House in London was founded in 1840. And the Quaker Elizabeth G. Fry (1780–1845) not only was engaged in campaigning for prison reforms but also founded the Institute for Nursing Sisters (Society of Protestant Sisters of Charity), who received nursing training in St. John’s House (see Summers 1989, 372–373; Donahue 1996, 187–191; Bostridge 2008, 97–99).
13. For the history of early schools for nursing in the US and Canada see Kalisch & Kalisch 1995, 57–84.
14. Famous names to be mentioned here are Dorothea Lynde Dix, Clara Barton, Louisa May Alcott, Mother Bickerdyke (Mary Ann Ball), Hariet Tubman, Sojourner Truth, and Walt Whitman, the poet and outstanding male nurse of his day. For a more detailed list of some of these names see Ellis and Hartley 2008, 136 (for a more extensive treatment see Donahue 1996, 242–264; Kalisch and Kalisch 1995, 38–56).
15. By 1969 at least 50% of general hospitals in the US had some kind of such a unit. (Lynaugh and Brush, 1996, 35, see also 3, 41, 52ff). But until about that time the general rule was: “If a patient was critically ill, the family would try to hire a private duty nurse if they could find and afford one” (ibid. 33).
16. There were a total of 1,100 of these according to Lynaugh and Brush 1996, 11.