Throughout the pages of recorded history, nursing has been integrated into every facet of life. A legacy of human caring was initiated when, according to the Book of Exodus, two midwives, Shiphrah and Puah, rescued the baby Moses and hid him to save his life. This legacy of caring has progressed throughout the years, responding to psychologic, social, environmental, and physiologic needs of society. Nurses of the past and present have struggled for recognition as knowledgeable professionals. The evolution of this struggle is reflected in political, cultural, environmental, and economic events that have sculptured our nation and world history (Snodgrass, 1999).

In the beginning men were recognized as health healers. Women challenged the status quo and transformed nursing from the mystical phenomenon to a respected profession (Snodgrass, 1999). The work of Florence Nightingale and Mary Seacole played a major role in bringing about changes in nursing. Using the concept of role modeling, these women demonstrated the value of their worth through their work in fighting for the cause of health and healing. During the twentieth century nurses made tremendous advancements in the areas of education, practice, research, and technology. Nursing as a science progressed through education, clinical practice, development of theory, and rigorous research. Today nurses continue to be challenged to expand their roles and explore new areas of practice and leadership. This chapter will describe the evolution of nursing from prehistoric times through 2000. Box 1-1 summarizes some of the important events in the evolution of nursing.


The practice of nursing in the prehistoric period was strongly guided by health beliefs. Nursing and medical practice were delineated by beliefs of magic, religion, and superstition. Individuals who were ill were considered to be cursed by evil spirits and evil gods that entered the human body and caused suffering and death if not cast out. These beliefs dictated the behavior of primitive people who sought to scare away the evil gods and spirits. Members of tribes participated in rituals, wore masks, and engaged in demonstrative dances to rid the sick of demonic possession of one's body. Sacrifices and offerings that sometimes included human sacrifices were made to rid the body of evil gods, demons, and spirits. Many tribes used special herbs, roots, and vegetables to cast out the "curse" of illness.



Ancient Egyptians are noted for their accomplishments at such an early period. They were the first to use the concept of suture in repairing wounds. They also were the first to be recorded as developing community planning that resulted in a decrease in public health problems. One of the main public health problems was the spread of disease through the consumption of water because the water resources were sometimes contaminated. Specific laws on cleanliness, food use and preservation, drinking, exercise, and sexual relations were developed. Health beliefs of Egyptians determined preventive measures taken and personal health behaviors practiced. These health behaviors were usually carried out to accommodate the gods. Some behaviors were also done to expressively appease the spirits of the dead (Ellis and Hartley, 2001). The Egyptians invented the development of the calendar and writing that denoted the initiation of recorded history. The oldest records date back before Christ in sixteenth century BC Egypt. A document containing almost 1000 natural pharmacologic remedies was written to assist in the care and management of disease (Ellis and Hartley, 2001). As in the case of Shiphrah and Puah, the midwives who saved the baby Moses, nurses were used by kings and other aristocrats to deliver babies and care for the young, the elderly, and those who were sick. Other documentation regarding nurses in Egypt is scant.


Dating from 2000 to 1200 BC, the earliest cultures of India were Hindu. The sacred books of the Hindu, Vedas, were used to guide health care practices. The Vedas included herbs, spices, displays of magic, and charms. These ingredients were used to rid the body of demons and cure illness. The Indians documented information concerning prenatal care and childhood illnesses. Public hospitals were constructed from 274 to 236 BC and were staffed by male nurses with qualifications and duties similar to those of the twentieth-century practical nurse. The Hindu physicians performed major and minor surgeries, including limb amputations, cesarean deliveries, and wound suturing. Women were primarily responsible for caring for the home and family, and they did not work outside the home. (Ellis and Hartley, 2001; Walton, Barondess, and Locke, 1994).


The teachings of Confucius (551-479 BC) had a powerful impact on the customs and practices of the people of ancient China. One tradition that exemplified their belief about health and illness was the yin and yang philosophy. The yin represents the feminine forces, which were negative and passive. The yang represents the masculine forces, which were positive and active.

The Chinese believed that an imbalance between these two forces would result in illness, whereas balance between the yin and yang represented good health (Giger and Davidhizar, 1999). The ancient Chinese used a variety of treatments believed to promote health and harmony, including acupuncture. Acupuncture involves insertion of hot and cold needles into the skin and underlying tissues to manage or cure illnesses such as pain, stroke, or breathing difficulty and ultimately to affect the balance of yin and yang. Hydrotherapy, massage, and exercise were used as preventive health measures (Giger and Davidhizar, 1999). The Chinese also used drug therapy to manage disease conditions and recorded more than 1000 drugs derived from animals, vegetables, and minerals (Walton, Barondess, and Locke, 1994).


The Roman Empire (27 BC-476 AD), a military dictatorship, adapted medical practices from the countries they conquered and the physicians they enslaved. The first military hospital in Europe was established in Rome. The physicians were enslaved and forced to provide details about their medical practice. Both male and female attendants assisted in the care of the sick. Galen was a famous Greek physician who worked in Rome and made important contributions to the practice of medicine by expanding his knowledge in anatomy, physiology, pathology, and medical therapeutics (Walton, Barondess, and Locke, 1994).


The Middles Ages (476 BC-1450 AD) followed the demise of the Roman Empire (Walton, Barondess, and Locke, 1994). Women used herbs and new methods of healing, whereas men continued to use purging, leeching, and mercury. This period also saw the Roman Catholic Church become a central figure in the organization and management of health care. Most of the changes in health care were based on the Christian concepts of charity and the sanctity of human life. Wives of emperors and other women considered noble became nurses. These women devoted themselves to caring for the sick, often carrying a basket of food and medicine as they journeyed from house to house (Bahr and Johnson, 1995). Widowers and unmarried women became nuns and deaconesses. Two of these deaconesses, Dorcas and Phoebe, are mentioned in the Bible as outstanding for the care they provided to the sick (Freedman, 1995).

During the Middle Ages physicians spent most of their time translating medical essays; they actually provided little medical care. Poorly trained barbers who lacked any formal medical education performed surgery and medical treatments that were considered "bloody" or "messy." Nurses also provided some medical care, although in most hospitals and monasteries female nurses who were not midwives were forbidden to witness childbirth, help with gynecologic examinations, or even diaper male infants (Kalish and Kalish, 1986). In addition, they were not permitted to have contact with male patients, administer enemas, or care for a man with a venereal disease. Nurse midwives provided the bulk of obstetric care within the community (Ellis and Hartley, 2001).

During the Crusades, which lasted for almost 200 years from 1096 to 1291, military nursing orders known as templars and hospitalers were founded. Monks and Christian knights provided nursing care and also defended the hospitals during battle, wearing a suit of armor under their religious habits. The habits were distinguished by the Maltese cross to identify the monks and knights as Christian warriors. The same cross was used years later on a badge designed for the first school of nursing and became a forerunner for the design of nursing pins (Ellis and Hartley, 2001).


The Renaissance and Reformation periods (1500-1700), also known as the rebirth of Europe, followed the Middle Ages. Major advancements were made in pharmacology, chemistry, and medical knowledge including anatomy, physiology, and surgery.

During this period, as a result of religious dissention between Roman Catholic Christians and the Protestant sects, many monasteries closed, and religious orders were dissolved. Roman Catholics and Protestants dissolved many of their religious facilities known for meeting the health care needs of the people. Contrary to the Catholic teaching, the Protestant church believed that women's duties involved childbearing and caring for the home, not working outside the home. Women of nobility no longer desired to work in hospitals. Individuals who worked as nurses were female prisoners, prostitutes, and those of undesirable character. Nursing was no longer the respected profession it had once been. This period was referred to as the "Dark Ages of Nursing" (Ellis and Hartley, 2001). During the sixteenth and seventeenth centuries, famine, plague, filth, and horrible crimes ravaged Europe. King Henry VII eliminated the organized monastic relief programs that aided the orphans, poor, and other displaced people. It became common to encounter homeless men, women, and children begging in the streets. Beggars were beaten, branded, and chained to the galleys of boats as punishment for their disgraceful behavior (Ellis and Hartley, 1988).

Out of great concern for social welfare, several nursing groups, such as the Order of the Visitation of St. Mary, St. Vincent de Paul, and the Sisters of Charity, were organized to give time, service, and money to the poor and sick. The Sisters of Charity recruited young women for training in nursing, developed educational programs, and cared for abandoned children. In 1640 St. Vincent de Paul established The Hospital for the Foundling to care for the many orphaned and abandoned children (Ellis and Hartley, 1988).


The first hospital and the first medical school were founded in North America. The hospital was the Hospital of the Immaculate built in Mexico City. The first medical school was built at the University of Mexico. In the American colonies, individuals with infectious diseases were isolated in almshouses or pest houses (Kalisch and Kalisch, 1986). Procedures such as purgatives and bleeding were widely used, leading to low life expectancy. Plagues such as yellow fever and smallpox caused thousands of deaths. Benjamin Franklin who was outspoken regarding the care of the sick insisted that a hospital be built to care for the sick. He believed that the community should be responsible for the management and treatment of those who were ill. Through his efforts the first hospital was built in the United States in Philadelphia in 1751. This hospital was called Pennsylvania Hospital (Oermann, 1997). Staff in this and other early hospitals were often untrained, and the public feared that poor patients were used for training purposes. Individuals of wealth did not go to hospitals because they were seen as places to care for the "unfortunate" people (Ellis and Hartley, 1988).


Florence Nightingale was born in Florence, Italy on May 12, 1820. The Nightingale family was wealthy, well traveled, and well educated. Nightingale was a highly intelligent, talented, and attractive woman. From an early age she demonstrated a deep concern for the poor and suffering. At the age of 25 she became interested in training as a nurse. However, her family, who strongly opposed a nursing career, preferred that she marry and take her place in society (Kelly and Joel, 1996). In 1851 her parents finally permitted her to pursue nurse's training. Nightingale attended a 3-month nursing training program at the Institution of Deaconesses at Kaiserswerth, Germany. In 1854 she began training nurses at the Harley Street Nursing Home and also served as superintendent of nurses at King's College Hospital in London (Kalisch and Kalisch, 1995).

The outbreak of the Crimean War marked a turning point in Nightingale's career. In October 1854 Sidney Herbert, British Secretary of War and an old friend of the Nightingale family, wrote to Nightingale begging her to lead a group of nurses to the Crimea to work at one of the military hospitals under government authority and expense (Dolan, 1978). Nightingale accepted his offer and assembled 38 nurses who were sisters and nuns from different Catholic and Anglican orders (Kelly and Joel, 1996).

Despite the distressing conditions at the Barracks Hospital, the army doctors and surgeons at first refused Nightingale's assistance (Kelly and Joel, 1996). However within 1 week, with scurvy, starvation, dysentery, and more fighting erupting, the doctors in desperation called her to help. Nightingale immediately purchased medical supplies, food, linen, and hospital equipment using her own money and that of the Times Relief Fund. Within 10 days she had set up a kitchen for special diets and had rented a house that she converted into a laundry (Kalisch and Kalisch, 1995). The wives of soldiers were hired to manage and operate the laundry service. She assigned soldiers to make repairs and clean up the building. Weeks later she initiated social services, reading classes, and even established coffeehouses for soldiers to enjoy music and recreation (Kelly and Joel, 1996).

Nightingale worked long, hard hours to care for these soldiers. She spent up to 20 hours each day caring for wounds, comforting soldiers, assisting in surgery, directing staff, and keeping records. Nightingale introduced principles of asepsis and infection control, a system for transcribing doctor's orders, and a procedure to maintain patient records. By the end of the Crimean War, Nightingale had trained as many as 125 nurses to care for the wounded and ill soldiers (Dolan, 1978).

Nightingale is credited for using public health principles and statistical methods to advocate improved health conditions for British soldiers. Through carefully kept statistics, Nightingale was able to document that the soldiers' death rate decreased from 42% to 2% as a result of health care reforms that emphasized sanitary conditions. Because of her remarkable work in using statistics to demonstrate cause and effect and improve the health of British sol diers, Nightingale is honored for her contributions to nursing research (Nies and McEwen, 2001).

Nightingale also demonstrated the value of political activism to effect health care reform by writing letters of criticism accompanied by constructive recommendations to British army leaders. Nightingale's ability to overthrow the British army management method that had allowed the deplorable conditions to exist in the army hospitals was considered one of her greatest achievements (Nies and McEwen, 2001).

In 1855, after visiting the frontlines and hospitals in Balaclava, Nightingale contracted "Crimean Fever" and was taken to the Castle Hospital. There she received intensive care from the doctors and nurses she trained. She remained in poor condition for several weeks. Soldiers wept when they heard of her illness and near death. She eventually recovered, but the illness had taken its toll on her overall health.

In 1860 Nightingale established the first nursing school in England. By 1873 graduates of Nightingale's nurse training program in England migrated to the United States, where they became supervisors in the first of the hospital-based (diploma) nursing schools: Massachusetts General Hospital in Boston, Bellevue Hospital in New York, and the New Haven Hospital in Connecticut.

Florence Nightingale's work, from the Crimean War to the establishment of formal nursing education programs, was a catapult for the reorganization and advancement of professional nursing. Until her death in August 1910, Nightingale demonstrated the powerful impact that well-educated, creative, skilled, and competent individuals have in the provision of health care. She is honored as the founder of professional nursing (Kalisch and Kalisch, 1995).


Mary Seacole was ajamaican nurse who learned the art of caring and healing from her mother. In her native land of Jamaica, British West Indies, she was nicknamed "Doctress" because of her administration of care to the sick in a lodging house in Kingston (Carnegie, 1995). Seacole learned of the Crimean War and wrote to the British government requesting to join Nightingale's group of nurses. However, she was denied the right to join because she was black. She was concerned about this denial, because many of the British soldiers had lived in Jamaica and she had provided health care to them.

Seacole had served in Cuba and Panama during the yellow fever and cholera epidemics. She had also conducted forensic studies on an infant who died of cholera in Panama. She felt that her experience would be valuable in treating disease in the Crimean War. Therefore she sailed to England at her own expense. She provided a letter of introduction to Nightingale, which was blocked because she was black, even though she was trained by British army doctors (Carnegie, 1995).

After several efforts failed to allow her to join the group, Seacole, who was not a woman of wealth, purchased her own supplies and traveled over 3000 miles to the Crimea. She built and opened a lodging house. On the bottom floor was a restaurant, and on the top floor an area arranged like a hospital to nurse sick soldiers (Carnegie, 1995).

When Seacole finally met Nightingale, the response was still the same: "no vacancies" (Carnegie, 1995). Being denied enlistment did not deter Seacole; she remained faithful and nursed the sick throughout the Crimean War. Her efforts did not go unnoticed by the English people. Long after the war the government finally bestowed a medal on her for her efforts and the services she provided to the sick and injured soldiers.


The Civil War Period

The Civil War, or the War Between the States (1861 to 1865), was a period of time in which the health care conditions in the United States of America were similar to those of the time of Nightingale and Seacole. There were numerous epidemics such as syphilis, gonorrhea, malaria, smallpox, and typhoid (Oermann, 1997).

The Civil War was initiated by the attack on Fort Sumter, South Carolina, April 17,1861. During this period of time there were no nurses who were formally trained to care for the sick. However, thousands of men and women from the South and North volunteered to care for the wounded. Hospitals were set up in the field, and there were hospital transports (Carnegie, 1995).

The Secretary of War Simon Cameron appointed a schoolteacher by the name of Dorothea Lynde Dix to organize military hospitals and provide medical supplies to the Union army soldiers. Dix received no official status and no salary for this position.

Nurses served during the Civil War under primitive working conditions. Often maintaining sanitary conditions was not possible. It is recorded that more than six million patients were admitted to hospitals, with approximately one-half million surgical cases. However, approximately 2000 individuals served as nurses (Fitzpatrick, 1997; Kalisch and Kalisch, 1995). This was far less than the number needed to provide adequate care. According to the records that were kept at three hospitals, 181 African-American nurses, both men and women, served between July 16, 1863, and June 14, 1864. Caucasian nurses made $12 per month; African- American nurses made $10 per month (Carnegie, 1995). Three African-American nurses made important contributions to nursing efforts during the Civil War:

Harriet Tubman, Sojourner Truth, and Susie King Taylor. Harriet Tubman served as a nurse in the Sea Islands off the coast of South Carolina. She cared for the sick and was known as the "Conductor of the Underground Railroad." It is also reported that she was the first woman to lead American troops into battle (Carnegie, 1995). Sojourner Truth, known for her abolitionist efforts as well as her nursing efforts, was an advocate of clean and sanitary conditions for patients so they could heal. Susie King Taylor, though hired in the laundry, worked as a nurse due to the growing number of wounded who needed assistance. Having learned to read and write, which was against the law for African-Americans, she also taught many of her comrades in Company E to read and write (Carnegie, 1995).

Many other volunteer nurses made important contributions during the Civil War. Clara Barton served on the front line during the Civil War and operated a war relief program to provide supplies to the battlefields and hospitals. Barton also set up a postwar service to find missing soldiers and is credited with founding the American Red Cross (Oermann, 1997). Louisa May Alcott, who served as a nurse for 6 weeks until stopped by ill health, authored detailed accounts of the experiences encountered by nurses during the war for a newspaper publication entitled Hospital Sketches (Kalisch and Kalisch, 1995).

When the Civil War ended, the number of nurse training schools increased. These early nursing programs offered little or no classroom education, and on-the-job training occurred in the hospital wards. The students learned routine patient care duties, worked long hours 6 days per week, and were used as supplemental hospital staff. After graduation most of the nurses practiced as private duty nurses or hospital staff (Lindeman and McAthie, 1990). The first nursing textbook, published in 1876, was used by the New York Training School for Nurses at Bellevue Hospital. It was entitled A Manual of Nursing (Kalisch and Kalisch, 1995).

During the 1890s the nationwide establishment of African-American hospitals and nursing schools gained momentum as African-American musicians, educators, and community leaders became alarmed at the high rates of African-American morbidity and mortality. Because of segregation and discrimination, African-Americans had to establish their own health care institutions to provide African-American patients with access to quality health care and to provide African-American men and women with opportunities to enter the nursing profession. In 1886 John D. Rockefeller funded the establishment of the first school of nursing for African-American women at the Atlanta Baptist Seminary—now known as Spelman College (Salzman, Smith, and West, 1996).

1900 to World War I

In the 1900s states began to require nurses to become registered before entering practice. By 1910 most states had upgraded education requirements to high school, upgraded training, and required registration before practice (Deloughery, 1991; Donahue, 1999).

Lillian Wald, a pioneer in public health nursing, is best known for the development and establishment of a viable practice for public health nurses in the twentieth century. The main location for this practice was the Henry Street Settlement House, located in the Lower East Side of New York City. Its purpose was to provide well-baby care, health education, disease prevention, and treatment of patients with minor illnesses. Nursing practice based at the Henry Street Settlement House formed the basis of public health nursing for the entire country. Instead of relying on patients visiting the clinic, public health nurses made their way to the various tenements located around Henry Street (Stanhope and Lancaster, 2000; Snodgrass, 1999).

Lillian Wald also developed the first nursing service for occupational health. Ms. Wald believed that prevention of disease among workers would improve productivity. She was able to convince the Metropolitan Life Insurance Company of these ideas. As a result, nursing agencies such as those in place at the Henry Street Settlement House provided skilled nursing services to employees. Another innovation that emerged from this program was the sliding fee scale. Patients were billed according to their income or ability to pay. This innovative nursing service existed for 44 years before it was dissolved by the Metropolitan Life Insurance Company (Stanhope and Lancaster, 2000).

In 1911 Wald chaired a committee formed by members of the Associated Alumnae of Training Schools for Nurses, later to become the American Nurses Association (ANA), and the Society of Superintendents of Training Schools for Nurses, the precursor of the National League for Nursing (NLN). The purpose of the committee was to develop standards for nursing services performed outside of a hospital environment. The committee determined that a new organization was needed to meet the needs of community health nurses. The result of the committee's recommendation was the formation of the National Organization for Public Health Nursing, whose goals were to establish educational and practice standards for community health nursing (Stanhope and Lancaster, 2000).

The ANA and the NLN are still leading nursing organizations today. The ANA has focused primarily on professional aspects of nursing, and the NLN was the only accrediting body for nursing schools until 1996 when the Commission for Collegiate Nursing Education (CCNE), an autonomous arm of the American Association of Colleges of Nursing (AACN) was established as an agency devoted exclusively to the accreditation of baccalaureate and graduate degree nursing programs (Stanhope and Lancaster, 2000).

World War I and the 1920s

During the early 1900s the world was moving rapidly toward global conflict. Germany was arming, and the rest of Europe was trying to ignore the threat. Prosperous was the word used to describe the U.S. economy. Women were granted the right to vote and were moving into the work force on a regular basis.

Advancements in medical care and public health were being made. The primary site for medical care moved from the home to the hospital, and surgical and diagnostic techniques were improved. Pneumonia management was the focus of scientific study. Insulin was discovered in 1922, and in 1928 Alexander Fleming discovered the precursor of penicillin that eventually would be used to successfully treat patients with pneumonia and other infections (Kalisch and Kalisch, 1995).

Environmental conditions improved, and the serious epidemics of the previous century became nonexistent. Lillian Wald, in her book The House on Henry Street, linked poor environmental and social conditions to prevalent illnesses and poverty. Wald used this information to lead the fight for better sanitation and housing conditions (Stanhope and Lancaster, 2000).

With the outbreak of World War I (WWI) in 1914, nurses were desperately needed to care for the soldiers who were injured or who suffered from the many illnesses that were a result of trench warfare (Stanhope and Lancaster, 2000). The war offered nurses a chance to advance into new fields of specialization. For example, nurse anesthetists made their first appearance as part of the surgical teams at the front line. More than 20,000 United States-trained nurses served in WWI (Oermann, 1997).

Because many nurses volunteered to provide services during the war, the community health nursing movement in the United States stalled. However, the American Red Cross, founded by Clara Barton in 1882, assisted in efforts to continue public health nursing. The Red Cross nurses originally focused on the rural communities that were not able to access health care services. As the war continued, the Red Cross nurses also moved into urban areas to provide health care services.

During WWI the U.S. Public Health Service, founded in 1798 to provide health care services to merchant seamen, was charged with the responsibility to provide health services at the military posts located within the United States. A nurse, loaned by The National Organization for Public Health Nursing, established nursing services at U.S. military outposts. The responsibilities of the U.S. Public Health Service continued to grow; eventually it was composed of physicians, nurses, and other allied health professionals who provided indigent care and practiced in community health programs (Stanhope and Lancaster, 2000).

Further changes were in store for nursing during WWI. In 1918 the Vassar Camp School for Nurses was established. Its purpose was to provide an intensive, 2-year nurses training program for college graduates. Graduates of the program were given an army reserve commission and would be activated during times of war to meet increased nursing needs. Sponsored by the American Red Cross and the Council of National Defense, the school graduated 435 nurses. The Vassar Camp School for Nurses was a short-lived enterprise. When peace was declared in 1919, the program was permanently disbanded (Stanhope and Lancaster, 2000; Snodgrass, 1999).

In 1921 the federal government recognized the need to improve the health of women and children and passed the Sheppard-Towner Act, one of the first pieces of federal legislation passed to provide funds to assist in the care of special populations (Oermann, 1997). This funding provided public health nurses with resources to promote the health and well-being of women, infants, and children.

Following on these improvements, the Frontier Nursing Service (FNS) was established in 1925 by Mary Breckenridge of Kentucky. Born into a wealthy family, Breckenridge learned the value of providing care to others from her grandmother. Breckenridge began her career in New York's St. Luke's Hospital School of Nursing. After serving as a nurse during WWI, she returned to Columbia University to learn more about community health nursing. Armed with her new knowledge and a passion to assist disadvantaged women and children, Breckenridge returned to Kentucky and the rural Appalachian Mountains (Oermann, 1997; Stanhope and Lancaster, 2000).

Oddsei - What are the odds of anything.