The Origins of Nursing (The Nature of Nursing) Part 2

Nursing in the United States

Nursing in the colonial United States was primarily a family matter, with mothers caring for their own families or neighbors helping each other. Throughout the 19 th and 20th centuries, historical and nursing developments interacted to build the foundation of modern nursing practice. The establishment and growth of a system of nursing education is the most important development that has shaped today’s nursing. Box 1-1 lists important milestones in the development of nursing in both the United States and Canada.

The First Nursing Schools

The influence of Florence Nightingale and the Kaiserswerth school extended to the United States when Pastor Fliedner came to Pittsburgh, Pennsylvania, with four nurse-deaconesses. In 1849, he became involved with the Pittsburgh Infirmary, the first Protestant hospital in the United States. Today it is called Passavant Hospital. The four deaconesses trained other nurses and started the movement to educate American nurses. The Pittsburgh Infirmary was the first real school of nursing in the United States, although limited training existed in other hospitals in New York and Pennsylvania before 1849.

In 1873, three nursing programs based on the Nightingale plan were formally established: Bellevue Hospital School of Nursing in New York; Connecticut Training School in New Haven; and Boston Training School at Massachusetts General Hospital.

Notable American Nurses

With the onset of the Civil War (1861-1865), the public need for nurses became more evident. In 1861, the Union Army appointed Dorothea Lynde Dix (1802-1887) Superintendent of Female Nurses. Her job was to recruit volunteer nurses to treat men injured in the war. Dix is especially remembered for her campaign against the inhumane treatment of the mentally ill. One of Dix’s volunteers was Louisa May Alcott (author of Little Women). Another was Clara Barton (1821-1912), who in 1881 founded the organization now known as the American Red Cross.

Melinda Ann (Linda) Richards (1841-1930) was the first trained nurse in the United States. She graduated in the early 1870s and organized the school of nursing at Massachusetts General Hospital, then called the Boston Training School.

BOX 1-1.

Milestones in Modern Nursing in the United States and Canada

Comprehensive views of the history of nursing are available from the web sites of the American Association of the History of Nursing, Inc., Brownson’s Nursing Notes, the American Nurses Association, and many other Internet sites.


Pittsburgh Infirmary begins training nurses in America.


The Household Nursing Association School of Attendant Nursing in Boston and


Dorothea Dix is appointed Superintendent of Female Nurses of the Union

the National League for Nursing Education are founded.


Army in the American Civil War:

Women’s Hospital (Philadelphia), Bellevue Hospital School of Nursing (New York), ConnecticutTraining School (New Haven), and Boston Training School are founded.


Ethyl Johns establishes the first baccalaureate program in the British Empire in Vancouver, BC; Minneapolis Vocational School establishes the first vocational school-based PN program.


Melinda Richards becomes the first trained nurse in the United States.


Arizona establishes a nursing program for Native American women.

Howard University (Washington, DC) established an 18-month program for black students. The school was transferred to Freedman Hospital the next year.


New York becomes the first state to mandate licensure of practical nurses.

Graduate School of Midwifery is established in Kentucky.



Mary Eliza Mahoney is the first black graduate nurse in the United States.


ANA establishes “Male Nurses’ Section”; six states offer option for PN licensure.


Clara Barton founds the American branch of the Red Cross.


Association of Practical Nurse Schools is founded in Chicago (later NAPNES).


The New York YMCA founds the Ballard School of Practical Nursing.


U.S. Office of Education establishes national curriculum for practical nurses.


Lillian Wald and Mary Brewster found the first Visiting Nurse Service.


President Franklin Roosevelt signs bill for the U.S. Cadet Nurse Corps (operates


Isabel Robb and Lavinia Dock found the American Society of Superintendents of Training Schools of Nursing (later, Education Committee of National League for Nursing).


until 1945).

University of Minnesota establishes experimental four-quarter practical nursing program in collegiate setting (operates until 1967); U.S. Office of Education publishes


Nurses’ Associated Alumnae of the United States and Canada organizes (later, part of American Nurses Association [ANA]).

Practical Nursing, an Analysis of the Practical Nurse Occupation with Suggestions for Organization ofTraining Programs.


International Council of Nurses (ICN) organizes.


Lillian Kuster founds National Federation of LPNs (NFLPN); U.S. Air Force Nurse


Isabel Robb founds the American Journal of Nursing.


Corps organizes.

National practical nursing curriculum

early 1900s

Mary Breckinridge establishes a nurse-midwife school.

develops; LPN licensure becomes available in many states; all states now use the State


Congress establishes the U.S. Army Nurse Corps.

Board Test Pool Examination for licensure; several organizations combine to create


The states of North Carolina, New York, New Jersey, and Virginia pass nursing licensure laws.


National League for Nursing (NLN). NAPNES publishes Journal of Practical Nursing; National Association of Colored


Canadian Nurse first publishes (in both French and English).

Graduate Nurses dissolves, and ANA admits these nurses.


Thompson Practical Nursing School is founded in Brattleboro, Vermont; Mary A.


First 2-year associate degree program for educating RNs opens in the United States (Teachers College of Columbia University). National Student Nurses’ Association (NSNA) is founded.

Nutting and Isabel Robb establish the first college-based nursing program (Teacher’s College of Columbia University [New York]).



American Red Cross starts home nursing classes; Congress establishes the Navy Nurse Corps; National Association of Colored Graduate Nurses is founded.


Nearly 300 practical nursing programs exist; U.S. Army gives first male nurse rank equal to female nurses; male nurses are allowed to join Nurse Corps.


University of Minnesota becomes the first school to continuously educate nurses at the university level.



All states now have laws to license practical nurses.

U.S. Department of Health, Education, and



Mississippi becomes the first state to license practical nurses.

Welfare publishes Guides for Developing Curricula for Education of Practical Nurses by


Smith-Hughes Vocational Education Act passes, enabling federal funding for practical nursing education


Dorothea Orem.

NLN begins offering accreditation for PN programs.


NLN accredits the first PN program—the Chicago Public School Practical Nursing Program.


First computerized examination, NCLEX, is given for nursing licensure.

National certification in long-term care



National Black Nurses’ Association is founded; Lucille Kinlein is first nurse to function as independent practitioner:


becomes available to LPN/LVNs.

In recognition of the ongoing nursing shortage the Nurse Reinvestment Act was


Textbook of Basic Nursing, 2nd edition, is first to delineate behavioral/learning objectives for students; ANA begins certifying nurses in specialty practice.


signed August 1, 2002 to further recruitment and retention of nurses including the use of Career Ladders.

From 2006 to 2016, the estimated employ


Health Occupations Students of America (HOSA) is founded in Oklahoma.

ment of LPN/LVNs is expected to grow faster than the average for all occupations


NLN publishes entry-level competencies of graduates of PN/VN programs.


or about 14%.

Textbook of Basic Nursing celebrates its


Congress establishes Medicare reimbursement on basis of Diagnosis-Related Groups (DRGs).

10th edition having been a staple of LPN/ LVN nursing education for nearly 50 years.


American Medical Association (AMA) proposes 9-month program for Registered Care Technologists, which is prevented by major opposition from nursing.

Isabel Hampton Robb (1860-1910) was the founder of the school of nursing at Johns Hopkins University. She is credited with founding two national nursing organizations, one in 1911, which eventually emerged as the American Nurses Association (originally called the Alumnae Association). She and Lavinia Lloyd Dock (1858-1956) founded the American Society of Superintendents of Training Schools of Nursing in 1894, which in 1903 evolved into the Education Committee of the National League for Nursing.Robb also founded the American Journal of Nursing. She introduced charting and nurse licensure to improve continuity of care. She also initiated the idea of graduate nursing study in the late 1800s.

Lillian Wald (1867-1940) is considered the founder of American public health nursing. She is best known for founding the Henry Street Settlement Visiting Nurse Society (VNS) in New York City in 1893. The Henry Street Settlement was a neighborhood nursing service that became a model for similar programs in the United States and other countries. Wald also convinced New York City schools to have a nurse on duty during school hours. She persuaded President Theodore Roosevelt to create a Federal Children’s Bureau and insisted that nursing education occur in institutions of higher learning.

Mary E. Mahoney (1845-1926) promoted fair treatment of African Americans in healthcare. She was the first African American graduate nurse, and promoted integration and better working conditions for minority healthcare workers in Boston.

Mary Breckinridge (1881-1965) was a pioneer as a visiting nurse-midwife to the mountain people of Kentucky in the early 1900s, often making her rounds on horseback. She also started one of the first midwifery schools in the United States.

Collegiate Nursing Education

In 1907, Mary Adelaide Nutting (1858-1947) and Isabel Robb were instrumental in establishing the first college-based nursing program at Teachers College of Columbia University. Nutting thus became the first nurse to be on a university staff. She was also instrumental in founding the International Council of Nurses.

In 1909, the University of Minnesota established the first continuous program to educate nurses at the university level, with an enrollment of four students. Isabel Robb strongly influenced the organization of this program, which is considered the beginning of nursing as a profession. This program, however, did not lead to a bachelor’s degree until 1919, when several other schools had also initiated college-and university-based nursing programs.

The History of Practical Nursing Education

Practical nursing, also called vocational nursing, has existed for many years. Women often cared for others and called themselves practical nurses. Not until the 1890s, however, was formal education in practical nursing available.

Pioneer Schools

Curricula in all of the early practical nursing schools included child care, cooking, and light housekeeping, in addition to care of the sick at home. Hospital care was not necessarily included.

Ballard School. In 1892, the Young Women’s Christian Association (YWCA) opened the first practical nursing school in the United States in Brooklyn, New York. Later, it was named the Ballard School because Lucinda Ballard provided the funding. Practical nursing (attendant nursing) was one of several courses offered to women. This program was a 3-month course to train women in simple nursing care, emphasizing care of infants and children, older adults, and the disabled in their own homes. The Ballard School closed in 1949 because of YWCA reorganization.

Thompson Practical Nursing School. Thomas Thompson, a wealthy man who lived in Vermont during the Civil War, learned that women were making shirts for the army at only a dollar a dozen. In his will, he left money to help them. Richard Bradley, his executor, was a public-spirited man and determined that the local citizens needed nursing service. In 1907, he used some of Thompson’s money to establish the Thompson Practical Nursing School in Brattleboro, Vermont. This school still exists today.

Household Nursing School. In Boston, a group of women wanted to provide nursing care in the home for people who were sick. They called on Bradley for advice, and he encouraged them to follow Brattleboro’s example. In 1918, the Household Nursing Association School of Attendant Nursing opened. The school was later renamed the Shepard-Gill School of Practical Nursing in honor of Katherine Shepard Dodge, the first director, and Helen Z. Gill, her associate and successor. This school operated until 1984.

In all, 36 practical nursing schools opened during the first half of the 20th century in the United States. Between 1948 and 1954, 260 additional programs had opened. Today, more than 1,500 practical nursing programs exist in the United States. There is a growing need for licensed practical nurses/licensed vocational nurses (LPNs/LVNs) in multiple healthcare settings. Many LPN/LVNs chose to continue their nursing education and become RNs via utilization of resources, such as career ladder programs, which accept LPN/LVN curricula for RN programs.

American Red Cross Training

In 1908, the American Red Cross began offering home nursing education to teach lay women appropriate nursing care for illnesses within their own families. Jane Delano (1862-1919) was an Army nurse who was instrumental in this movement.

Practical Nursing in Vocational and Community Colleges

In the early part of the 20th century, nursing schools—training both practical nurses and registered nurses—were traditionally located in or affiliated with hospitals. In 1917, the U.S. Congress passed the Smith-Hughes Act, the funds from which gave impetus to vocational-technical and public education. In 1919, the first vocational school-based nursing program opened in Minneapolis at Minneapolis Vocational High School. Today, the majority of practical nursing and associate’s-degree nursing programs are located in vocational education settings or in community colleges.

Other Milestones in Practical Nursing Education

The Association of Practical Nurse Schools was founded in 1941. It was later renamed the National Association of Practical Nurse Education and Service.

In 1914, Mississippi became the first state to designate licensed practical nurses (LPNs). By 1955, all states had laws to license practical nurses. The first state to have mandatory licensure for LPNs to practice was New York.

During World War II, people realized that nurses needed a consistent curriculum. In 1942, the U.S. Office of Education planned and advocated the first practical nursing curriculum for the entire country.

In 1966, the Chicago Public School system’s program was the first practical nursing program to be accredited by the National League for Nursing (NLN).

Nursing During Wartime

Nursing during wartime has long been important. From Florence Nightingale in the Crimea to the American Civil War, Spanish-American War, Korea, Vietnam, and continuing to the wars of the 21st century, nurses have always played a vital role.

World War I marked the first emergency training of nurses. The Army School of Nursing was established; Annie W. Goodrich (1876-1955) wrote the curriculum. Hundreds of women were trained in this abbreviated program; however, nearly all of them left nursing and returned to homemaking after the war’s end in 1918.

The U.S. Cadet Nurse Corps was established during World War II, with Lucile Petry Leone (1902-1999) as Director. More than 14,000 volunteer nurses graduated in about 2 years. Originally, the plan was to draft nurses into the Army. A major opponent to this idea was Katherine J. Densford (1890-1978), Director of the School of Nursing at the University of Minnesota. She promised to train expanded numbers of nurses in a short time, if the government abandoned the nurse draft. Because of Densford’s efforts, the student population at Minnesota multiplied by five in a matter of weeks; more than 1,200 cadets graduated from that school alone.

World War II also marked the first time that men as well as women were actively recruited into nursing. Male nurses were not given equal rank to female nurses in the Armed Forces, however, until 1954. By the war’s end in 1945, the world had changed. Many cadet nurses remained in the field, especially in the military. This employment gave many women a measure of independence that they had not previously known. After this time, emphasis was placed on improved graduate education for nurses. Nurses also began to assume a broader, more responsible role—a trend that continues today.

Current Nursing Trends

As you will note from your reading and from studying Box 1-1, nursing evolved rapidly in the 20th century. Many factors influenced trends that are expected to continue in the 21st century. The responsibilities of the nurse have increased as a direct result of these trends. This topic has been written with these trends in mind:

Higher client acuity in hospital and long-term settings: Because of limitations on payment for healthcare, hospital stays are markedly shorter than they were a few years ago. Clients in all healthcare facilities are more acutely ill than in years past. Long-term care facilities also find clients with highly acute conditions because of the growth of home care for those with more manageable conditions. Such developments require nurses working in all care areas to have higher levels of skill, additional education, and more specialization.

Shift to community-based care: Most clients now receive healthcare outside acute care settings. For example, much surgery is now done on an outpatient basis; many clients receive care for chronic or long-term conditions at home; and community clinics provide primary healthcare for many clients. Thus, today’s nursing is delivered in a much wider range of settings than in the past.

Technology: Nurses, clients, and family members often must learn to operate highly sophisticated equipment to manage conditions in the home. This equipment makes accuracy in diagnosis and treatment possible. The teaching role of nursing is emphasized to a greater extent.

Social factors: Many clients are homeless, unemployed, or underemployed. Many people have no health insurance. Devastating diseases, such as acquired immunodeficiency syndrome (AIDS) or tuberculosis, are becoming more prevalent. These factors create a need for more healthcare in the public sector.

Lifestyle factors and greater life expectancy: Today’s society and the healthcare industry emphasize prevention of disease, healthy lifestyles, and wellness programs. Many people are living much longer and are more active and healthy into their later years than in past generations. Greater life expectancy is causing huge growth in the areas of extended, long-term, and home care. This growth will require many more nurses to work in such fields.

Changes in nursing education: Today’s nursing programs emphasize education over service to clinical sites; they identify specific objectives (outcomes) for students.

Autonomy: The women’s movement has influenced nurses, many of whom are women, to be more assertive and independent. Today’s nursing role is a collaboration with others in the healthcare field. Primary care, previously delivered only by physicians, is now being delivered by advanced practice nurses as well.


An insignia is a distinguishing badge of authority or honor. The symbolism dates back to the 16 th century in Europe, when only a nobleman could wear a coat of arms. Later this privilege was expanded to include members of guilds (craftsmen). Certain types of training schools, including religious nursing orders, were also given the privilege. Until recently, female nurses wore nursing caps and all nurses were awarded a school pin at graduation. Some schools also had distinguishing capes. The “Nightingale lamp,” “Lamp of Nursing,” or “Lamp of Learning” remains a standard of nursing insignia (see Fig. 1-3).

Nursing Uniforms

Even though nurses in today’s healthcare facilities usually do not wear traditional white uniforms or nursing caps, looking professional is important. Clients usually feel more comfortable when nurses are easily identifiable and distinguishable from other staff. For example, a nametag is required whenever you give nursing care, no matter where you are employed.

The Nursing School Pin

You may receive a nursing pin at graduation that symbolizes your school of nursing. Early nursing symbols were usually religious in nature. Today, many nursing school pins bear some religious symbol, such as a cross (based on the Maltese Cross) or a Star of David, even though the school may not be directly affiliated with a religious organization. The Nightingale lamp is also a common component of the nursing pin.

Key Concept Remember that as you embark on your nursing career; you continue nursing’s history and heritage.


•    Medicine men and women and religious orders cared for the sick in early times.

•    Florence Nightingale contributed a great deal to the development of contemporary nursing.

•    Establishment of nursing schools in the United States began in the late 19 th century.

•    The first practical nursing school in the United States opened in 1892 in New York.

•    Nursing during the First and Second World Wars contributed to the profession’s and to women’s evolving roles in society.

•    Many current societal and healthcare trends are influencing the nursing profession, including higher levels of client acuity in hospital settings, more community-based care, technological advances, changing lifestyles, greater life expectancy, changing nursing education, and more nursing autonomy.

• Nursing insignia, such as those found on nursing school pins, often symbolize nursing’s history and heritage.

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