Nursing as a Profession
Eight Characteristics of a Profession
Development of Theoretical Basis for Practice
Florence Nightingale is identified as the Hippocrates of modern nursing. While the most beloved story of Miss Nightingale is about her work in the Crimean War, her real contribution was through the meticulous record-keeping (statistical data) and contribution to sanitary science, the reform of military health care in Britain, and her contribution to nursing education. She was the first nursing researcher beginning the process of developing nursing's body of knowledge
Florence Nightingale wrote extensively about nursing. She developed a model for nursing education that has guided nursing education throughout the 20th century. Nurses were to be in charge of nursing education. Her training program emphasized education, not service. It required classroom instruction as well as clinical instruction. She published her Notes on Nursing (1859) as a model for nursing practice in which she advocated that nurses should not only know how to carry out a physician’s orders, but why it is being done, and to use the “trained power of one’s own impressions made by one’s own senses, so that these should tell the nurse how the patient is.” According to Nightingale this educated "power of observation" is the “sine qua non of being a nurse.” Her model for nursing practice is regarded as the first theoretical model of nursing practice.
Development of Nursing Education in Institutions of Higher Education
Florence Nightingale had traveled and systematically studied hospitals in Germany, Greece, and Egypt. Eventually she enrolled in nursing education at the famous Kaiserwerth hospital in Germany and completed the training program there.
Florence Nightingale established a nursing education program in 1860 that became a model for nursing education. It was based on professional nursing standards of care. Her nursing school trained hospital nurses, instructed nurses in the training of others, and trained home care nurses to visit and care for the people in poverty who were sick. The length of the program was one year of classroom and clinical instruction, followed by two years on the staff of the hospital. Nightingale’s school established nursing as a place for educated women, thus raised nursing from degradation and disgrace to the rank of a respectable occupation for women.
Social forces in the United States turned nursing education in a different direction. Around the beginning of the 20 th century hospitals proliferated, often established by physicians and with a motivation for profit. The need for nursing services in these hospitals led to the establishment of a plethoria of nursing schools to supply a labor force for the hospital. There was no regulation of the hospitals much less the nursing schools; therefore there was wide variability in the structure and quality of nursing education. Nursing education became primarily an apprenticeship in which nursing students provided service to the hospital basically in exchange for room and board. In the majority of schools more service than education was taking place.
At the same time the seeds of nursing as a profession were beginning to sprout. The conditions in hospitals during the Civil War had made it apparent that nurses needed to be trained. Three nursing schools emerged in the United States in the 1870s. 1) The Bellevue Hospital Training School was established based on the model of Florence Nightingale and the early graduates became leaders in nursing: Isabel Adams Hampton Robb, and Lavinia Lloyd Dock. 2) The Connecticut Training School was one of the first to obtain University affiliation. With an endowment of $1,000,000 from the Rockfeller Foundation it eventually became the Yale University School of Nursing. 3) The third, the Boston Training School, was opened at the Massachusetts General Hospital of Boston. Nursing education proved its worth and by 1900 there were 432 nursing school in the United States.
Development of Self Regulation of Practice
Licensure and Registration
In 1860 a physician, Sir Henry W. Acland, published the first words advocating that nurses should be centrally registered, follow a recognized curriculum of study, and meet a minimum standard of proficiency. Florence Nightingale was opposed to licensure on the basis that it implied that the graduate of a nursing program was a finished product. However, as nursing programs proliferated, each developed their own standards (or lack of standards) and the need for uniform standards of education and practice became apparent. The first licensure laws in the United States came in 1903. A national examination was proposed in 1942 and by 1950 the same examination was given by all states.
Licensure/Registration is not the mechanism by which the profession of nursing controls nursing practice. It is--to the extent that nurses are on the board of nurse examiners. However, the authority for the Board is the Nurse Practice Act that is written by individual state legislatures for the purpose of protecting the public. Because Nurse Practice Acts are written by state legislatures, the acts vary from state to state.
The regulation of nursing practice by the profession (control of nursing by nurses) of nursing comes through professional organizations. The organization of nursing as a profession began almost as early as the advent of training for nurses. Early nursing leaders recognized that the voice of many single individuals could never be as great as the collective voice of those same individuals. The first organizations were the alumnae of such schools as Bellevue Hospital in New York, Illinois Training School of Cook County Hospital in Chicago, Johns Hopkins Hospital in Baltimore, Massachusetts General Hospital in Boston, and Boston City Hospital.
National League for Nursing
At the World’s Fair in Chicago in 1893, there was a congress on charities, corrections, and philanthropy, with a subsection on nursing. Isabel Hampton Robb was the chairwoman of the subsection on nursing which was the first time nurses had meet together as an united body. Following the meeting she formed the American Society of Superintendents of Training Schools for Nurses. This organization in effect became an accreditation agency for nursing schools in the United States and Canada. In 1912 this society became the National League for Nursing Education, later to be renamed the National League for Nursing. At the same World's Fair meeting Lavinia L. Dock also spoke a on the relationship of training schools to hospitals. The national league for nursing includes both nurses and nonnurse members--note the "for" in the name.
American Nurses’ Association
The American Nurses Association had its origins in the federation of alumnae associations, known as the Nurses Associated Alumnae of the United States and Canada. The original purpose of the organization was to develop a code of ethics, elevate the standards of nursing education, and promote the interest of the profession. Isabel Adams Hampton Robb was the first president of the organization. The ANA is the political voice of nursing in the United States. Its membership includes individual nurses, state associations, and other nursing organizations.
Three Women—one dream
Isabel Hampton Robb was not yet 30 years old when she organized the John Hopkins Training School for Nurses. She was an advocate for reducing the long hours of nursing students and improving the education in the school of nursing. (Kalish and Kalish, p. 131) She wrote the first major textbook in nursing, Nursing: Its Principles and Practices for hospitals and private use (1893) W.B. Saunders.
Lavinia Dock campaigned for better working conditions for nurses and was not opposed to labor unions to achieve this goal. She said nurses should stand together solidly and resist the dictation of the medical profession. (Kalish and Kalish, 1995, p 208). Lavinia Dock was a radical feminist and an active advocate for women’s suffrage. She believed that male domination in the health field was the major problem confronting the nursing profession. She held various positions as an assistant to Isabel Hampton Robb, as superintendent of the Illinois Training School in Chicago, and working with Lillian Wald at the Henry Street Settlement. Her accomplishments included publication of a book on venereal disease.
Mary Adelaide Nutting was a nursing leader who was greatly influenced by Isabel Hampton Robb beginning as a student in the first graduating class of Johns Hopkins. She became Robb’s successor at Johns Hopkins. She translated Robb’s dream of an 8-hour day and a three-year course into reality. She also developed preparatory or preliminary courses for nursing students and began the practice of having students pay tuition. She was named Professor of Nursing Education at Teacher’s College, Columbia, becoming the first professor of nursing in the world. She was an advocate for academic preparation for nurses, stating that “Surely we will not be satisfied in perpetuating methods and traditions. Surely we shall wish to be more and more occupied with creating them.” (1925)
Nursing Literature—the body of knowledge
The first nursing journal, Nightingale, was published in 1886. Several other journals followed. The Associated Alumnae established a professional journal as a means of communication among nurses; The American Journal of Nursing was first published in 1900 and became the official journal of the American Nurses Association.