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 149^th in job satisfaction, while their licensed practical colleagues (LPNs) come in at 184^th (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.

AUTHOR'S NOTE

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 cresset@valpo.edu.

WORKS CITED