Once defined as religious vocation or womanly duty, nursing today emphasizes specialized education to support the work of health care. It remains a predominantly female profession despite an increase in male nursing students: in 1992 only 4% of nurses were male; in 1993, 12% of new graduates were men. Nurses teach preventive care and maintain health, assist medical treatment, aid rehabilitation, and attend the dying. Two-thirds of all nurses work in hospitals with others in public health agencies, nursing homes, offices, schools, and industries. Nurses are also educators, supervisors, administrators, and independent practitioners.
In the mid-19th century most nursing care was done at home as part of women’s unpaid domestic duties. Hospital patients, mostly destitute, were attended by women in religious orders or laywomen trained informally on the job. In the last half of the century changing social conditions supported the development of a more sophisticated system of health care, one that created a place for the “trained nurse.” In the United States the Civil War and the Spanish-American War both necessitated coordination of medical and nursing resources. The quickening pace of industrial work in the United States?accompanied by the world’s highest rate of injury on the job?strained existing hospital resources. Urban growth brought new working-class and immigrant populations into cities, where poverty, overcrowding, and poor urban sanitation created formidable new health problems. For middle-class families traditional unpaid nursing was replaced by a reliance on women paid to nurse the sick. By the end of the 19th century anesthesia and antisepsis had increased the efficacy of medical care, and surgical intervention and hospitalization both became safer.
Reform-minded women organized to respond to wartime conditions and growing urban populations. During the Civil War, Dorothea Dix sought respectable and plain-looking women to attend sick and wounded soldiers, striving to overcome the association of nurses with camp-followers. After the war women organized investigations of hospital care and established training programs for nurses, responding to Florence Nightingale’s reforms of English nursing. In 1873 three schools of nursing opened, at Bellevue Hospital in New York City, Massachusetts General Hospital in Boston, and New Haven Hospital in Connecticut. The first school of nursing for black women opened in 1891, at Provident Hospital in Chicago. Meanwhile, urban reformers concerned about the sick poor began to hire trained nurses to replace the charitable services of genteel laywomen. In 1877 the Women’s Branch of the New York City Mission became the first organization to send out trained nurses for home visiting. In 1893, Lillian Wald and Mary Brewster established a nurses’ settlement house on New York City’s Lower East Side.
The rapid expansion of hospitals spurred the growth of nurses’ training schools. Under the prevailing system of apprenticeship training, students performed most of the work of the hospital. In exchange they received training on the job, some classroom education, room, board, and a small stipend. While Nightingale had developed nursing schools as autonomous institutions with independent control over their budgets, U.S. nurses’ training became closely tied to hospital economics. In 1873, when the first three nursing schools were founded, there were fewer than 200 hospitals in the United States. By the late 1920s there were about 7,500, and over 2,000 had schools of nursing. Few hospitals employed their own graduates, and most nurses worked in private duty, hired by families to attend individual patients at home or in hospitals.
New associations attested to nurses’ growing self-consciousness and self-organization. In 1893 the American Society of Superintendents of Training Schools (ASSTS), composed of superintendents of the larger U.S. and Canadian schools, organized to try to regulate the burgeoning hospital training programs. In 1896 the Nurses’ Associated Alumnae (NAA) formed, focusing its efforts on education reform and state registration campaigns to enforce minimum standards of preparation. In 1900, NAA began to publish The American Journal of Nursing; in 1911, when the group split into Canadian and U.S. sections, the U.S. division was renamed the American Nurses’ Association (ANA), which remains the largest professional association in nursing. The National Association of Colored Graduate Nurses was organized in 1908 to defend and represent the small minority of black nurses. Many state chapters refused membership to these nurses, who were then excluded from the national ANA. Public health nurses banded together in the National Organization for Public Health Nursing, founded in 1912.
The expanding health-care system reshaped nursing between 1910 and 1945. Some nurses found refuge from an overcrowded private-duty market in the public health movement, whether in tax-supported efforts sponsored by the 1921 Sheppard-Towner Act, a federal initiative to fund maternity and infant care, or in privately funded projects like Mary Breckinridge’s Frontier Nursing Service, founded in 1925 to bring health care to isolated rural populations. Public health provided nurses with innovative roles and autonomy; but as the agenda of public health expanded, its funding contracted.
Responding to pressure from nursing organizations, increased demands for services, and the growing complexity of care, hospitals began to hire graduate nurses to staff their wards in the 1930s and 1940s. In World War II nurses supervised male corpsmen and, for the first time, won the recognition of regular military rank. The U.S. Cadet Nurse Corps recruited thousands of young women into nursing.
Nursing since 1945
War and postwar shortages moved nursing toward a greater division of labor and specialization. Formal programs were developed for the so-called auxiliary nurses who assisted registered nurses (RNs) on the wards, and they were licensed as practical nurses (LPNs), working under the supervision of RNs. As hospitals and medical care grew more specialized, services like intensive care, cardiac care, burn units, and dialysis spawned new nursing specialties. Nursing leaders, long committed to college education for nurses, intensified the campaign to raise standards and to remove nursing education from the control of the hospitals. The Brown report, a 1948 assessment of the present and future of nursing, recommended college degrees as the minimum credential for professional nurses. The proposed standards caused bitter conflict in nursing ranks, and at first college education made slow inroads.
From the late 1930s to the late 1970s nurses faced a curious dilemma. Hospital expansion supported a continuing demand for nurses, and the field gained some authority from the prestige of medicine and from a shortage of nurses. Yet nurses continued to suffer the disadvantages of female workers in a sex-segregated workforce. Their incomes lagged dramatically behind those of men with equivalent education, and nurses also earned less than women in comparable “female” jobs such as social work or teaching. On the job many hospital-based nurses felt the tension of increased responsibilities, without commensurate authority over working conditions or decisions about patient care.
In the late 1930s unionization began to gain some support from nurses critical of an overly passive and cautious ANA. In response in 1946 the ANA set national standards for minimum salaries and working conditions and helped local associations to use those standards in negotiations with hospitals. Unionization gained momentum in the 1960s and 1970s. The ANA changed its no-strike policy in 1968, and in 1974 the Taft-Hartley Act’s prohibition of collective bargaining in voluntary hospitals was revoked.
Nurses have also responded to the frustrations of hospital work with revised and expanded forms of nursing practice. The theory and practice of primary care has emphasized the need for continuity, and one nurse may now coordinate all the aspects of care for an individual patient, reducing the fragmentation of institutional care. Nurses have also tried to establish career ladders that affirm the value of bedside nursing: the nurse-clinician can advance in salary and authority without leaving her patients for supervisory positions, the traditional route upward in nursing. Nurse-practitioners and nurse-midwives have tried to carve out independent domains, challenging medical practice laws and reimbursement patterns that constrain autonomous nursing practice.
Into the 1990s, nurses have struggled to define their places in a health-care system characterized by escalating costs, disproportionate investment in critical care, and political impasse over the federal government’s role as provider of comprehensive health care. In some cases cost-containment efforts by the federal government and insurance providers resulted in layoffs and work speedups for hospital nurses. As patients were discharged “quicker and sicker,” nurses faced new challenges in community agencies called to assist patients convalescing at home. Cost pressures have also created potential opportunities for nurse specialists to assume some of the work of assessment and management formerly reserved for physicians. This practice has gained a wider acceptance with the increased influence of managed care health plans that lower costs by emphasizing health maintenance and controlling access to expensive specialists.
Most registered nurses in the United States graduate from 2-year associate degree programs, which accounted for 64% of new graduates in 1993. Another 28% were educated in 4- or 5-year baccalaureate programs, with hospital schools graduating about 12% of new nurses. Licensed practical nurses most often prepare in vocational schools or junior colleges, with some attending programs in hospitals, secondary schools, or government agencies. Nurses’ aides and orderlies, who assist RNs and LPNs, train on the job.