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History of Nursing

Nursing is old; the nursing profession is not. Care of the sick has always been done, mostly by women, mostly unpaid, mostly invisible. What happened in the nineteenth and twentieth centuries was the conversion of that work into an occupation with training, credentials, wages, a licence, and a claim to knowledge of its own. Almost every argument the profession still has — about degrees, about autonomy, about staffing, about who counts as a nurse — is a continuation of that conversion.

Before the profession

Organized nursing in Europe was largely a religious function. Monastic and later Catholic nursing orders staffed hospitals for centuries, and their model — vocation, obedience, self-denial, service without wages — left marks on the occupation that outlasted the orders themselves. Military nursing developed alongside it, likewise structured by hierarchy and duty.

Starting the story in Europe is itself a distortion. Rufaida Al-Aslamia was running a care tent in seventh-century Medina with a team of women she had trained herself, and the Islamic bimaristans were operating with paid staff, wards separated by condition and outpatient departments while European care was still confined to monasteries.

The Reformation dissolved much of that infrastructure in Protestant countries without replacing it, and by the early nineteenth century hospital nursing in Britain had a reputation somewhere between menial labour and disrepute. This is the situation Nightingale's generation set out to change, and the reason their reforms emphasized respectability so heavily.

Nightingale

Florence Nightingale took a party of nurses to the British military hospitals at Scutari during the Crimean War in 1854. She became famous for it, and the fame has obscured what she actually accomplished.

The familiar claim that she cut the death rate at Scutari from roughly forty percent to two percent is not straightforwardly true, and Nightingale knew it. Mortality at Scutari peaked in February 1855 and fell sharply afterwards, but the fall coincided with the arrival of a Sanitary Commission that repaired the sewers and improved ventilation. Nightingale's own later analysis concluded that the deaths were overwhelmingly from preventable disease driven by sanitary conditions — a conclusion that reflects badly on the hospital she was running. Historians continue to argue over how much of the improvement to attribute to her. Her statistics comparing Scutari with the hospitals at the front are the least quoted and most interesting part of the record.

What is not in dispute is the second half of her career. Notes on Nursing appeared in 1859, before any school existed to use it. The Nightingale Training School opened at St Thomas' Hospital on 9 July 1860, the first institution designed to educate nurses as professionals. And her use of statistics to argue for sanitary reform made her one of the most effective public health advocates of the century. Her intellectual contribution — that nursing's object is the patient's environment and condition rather than the disease — is treated under nursing theory.

The other nurse of that war has taken much longer to be counted. Mary Seacole, a Jamaican woman with more practical experience of epidemic disease than almost anyone in the British Empire, applied to Nightingale's recruiters and to four government departments, was refused by all of them, paid her own passage, and treated soldiers on the Crimean battlefield at her own expense until she went bankrupt.

America: war, then schools

The American Civil War produced a generation of nurses without producing a profession. Dorothea Dix organized the Union's army nurses as the first woman to hold a federal executive appointment; Clara Barton worked at the front and afterwards founded the American Red Cross; Mary Ann Bickerdyke set up some three hundred field hospitals with Sherman's backing; Walt Whitman and Louisa May Alcott both spent time in the Washington hospitals and wrote the best surviving accounts of the work. On the Confederate side Sally Tompkins ran the hospital with the lowest death rate of the war. None of them were trained, because there was nowhere to train.

Two of the war's nurses were Black women whose service the government never paid for and the profession did not record for a century: Susie King Taylor, who nursed a Union regiment for four years and three months, and Harriet Tubman, who treated dysentery and smallpox in the Sea Islands camps and later ran a hospital ward at Fort Monroe.

That changed in 1873, when three schools opened on the Nightingale model — at Bellevue Hospital in New York, the Connecticut Training School in New Haven, and the Boston Training School at Massachusetts General. In the same year Linda Richards graduated from the New England Hospital for Women and Children in Boston, the first American to complete a formal nurse training programme. In 1879 Mary Eliza Mahoney graduated from the same school, the first Black woman in the United States to do so.

The training school system spread rapidly for a reason that had little to do with education: student nurses staffed the hospital for free. Schools were attached to hospitals, students worked long shifts as the primary labour force, and instruction fitted around the work. The arrangement was economically irresistible and educationally indefensible, and it defined American nursing for fifty years.

Isabel Hampton Robb attacked it from inside at Johns Hopkins from 1889 — three-year course, eight-hour day, and the student wage abolished on the argument that a paid student is an employee. Adelaide Nutting, who succeeded her, made the case with data, counting the hours to show how little of a student's time was instruction. Between them Robb, Nutting and Lavinia Dock also built the institutions the profession still runs on: the bodies that became the American Nurses Association and the National League for Nursing, the American Journal of Nursing, and the first histories of the field.

Not every advance came from the schools. In 1898 Anna Caroline Maxwell took trained nurses into a typhoid-ridden army camp at Chickamauga and the death rate fell far enough to settle an argument: Congress created a permanent Army Nurse Corps three years later. In the same decade Alice Magaw was administering thousands of anesthetics at the Mayo brothers' hospital and publishing her outcomes in the medical press, which is how nurse anesthesia acquired an evidence base before anesthesiology existed as a medical specialty.

Registration

North Carolina passed the first nurse registration law in 1903. It protected the title "registered nurse" and said nothing about what a nurse could do. New Jersey, New York, and Virginia followed within the year, and by 1923 every state then in the Union had one. New York wrote the first statutory definition of nursing practice in 1938. See nurse practice acts and boards of nursing.

The principle underneath those laws had been fought over in Britain for thirty years first. Ethel Gordon Fenwick argued from 1887 that nursing needed a legal register and an examinable standard; Nightingale opposed her, holding that the qualities that make a nurse cannot be examined. Fenwick won with the Nurses Registration Act of 1919, and holds British registration number one.

The reports that moved education

Two investigations broke the training school model.

Josephine Goldmark's 1923 report for a Rockefeller Foundation committee examined more than seventy schools and stated the obvious plainly: hospitals were staffed by students, and patient care took priority over teaching them. It recommended affiliation with universities and national accreditation.

The Foundation then funded a working example. Annie Goodrich became founding dean of the Yale School of Nursing in 1923 — the first nursing school anywhere with its own dean, its own budget, its own faculty and its own degree, owned by no hospital.

Esther Lucille Brown's Nursing for the Future in 1948 went further and recommended that nursing education move into colleges outright.

Neither report was implemented quickly, but together they set the direction. In 1952 Mildred Montag proposed a two-year associate degree programme based in community colleges, intended to prepare a technical nurse — a distinct, subordinate role — in half the time. It succeeded far beyond its design and in a way she had not intended: because the graduates passed the same licensing examination, states licensed them as registered nurses rather than as technicians, and no separate role was ever created. The associate degree became a dominant route to the licence and remains one, which is why the same licence today is reachable by three different educational paths. See levels of nursing.

Segregation and its undoing

Black nurses were excluded from most training schools, most hospitals, and the American Nurses Association itself for the first half of the twentieth century. The National Association of Colored Graduate Nurses was founded in New York in August 1908 in response — by Martha Minerva Franklin, who had written to every Black nurse she could locate to find out how general the exclusion was, with Adah Belle Thoms and Mahoney.

Thoms forced the first breach in 1918, when the Army finally accepted a handful of Black nurses during the influenza pandemic. Estelle Massey Osborne used a federal wartime post in the 1940s to open some twenty nursing schools to Black students for the first time.

Under Mabel Keaton Staupers the organization campaigned successfully to open the segregated military nursing corps during the Second World War, then did something unusual: having achieved integration of the national association, its members voted it out of existence in 1951 and merged into the American Nurses Association.

Twenty years of individual membership showed the limits of that. Black nurses were members and were not in the leadership, and in 1971 a new generation including Betty Smith Williams founded the National Black Nurses Association. It took until 1979 for Hazel Johnson-Brown — refused a nursing school place in Pennsylvania as a girl because she was Black — to become chief of the Army Nurse Corps and the Army's first Black woman general.

The wars

Both world wars converted nursing shortages into federal policy.

The First World War settled the question of status. American military nurses had no rank of any kind, which left them without authority, protection or pension. Julia Stimson, who directed nursing for the American Expeditionary Forces, won them relative rank in 1920 and became the first woman major in the United States Army; Lenah Higbee had run the Navy Nurse Corps through the war and the 1918 pandemic and was the first woman awarded the Navy Cross.

The most consequential intervention was the Bolton Act, which became law on 1 July 1943 and created the United States Cadet Nurse Corps. The programme paid for nursing education in exchange for a pledge of service in military or essential civilian nursing until at least six months after the war ended. Over five years it enrolled 169,443 students and produced 124,065 graduates — the largest federally funded nursing education programme in American history, and a demonstration that the shortage was solvable when the government chose to pay for solving it.

Military service also drove nursing's professional standing. Rank, commissions, and veterans' education benefits after the war brought many nurses into universities who would not otherwise have gone. Edith Shain belongs to that generation.

Expansion of the role

Mary Breckinridge had shown in rural Kentucky from 1925 that nurse-midwives operating a decentralized system could transform maternal and infant outcomes in a place physicians did not serve. Lillian Wald had shown the same thing in the New York tenements a generation earlier, and invented the term public health nurse for it. The lesson was applied more broadly forty years later.

In 1965 Loretta Ford, a nurse, and Henry Silver, a physician, founded the first nurse practitioner programme at the University of Colorado, focused initially on the care of well children. The model spread into a full advanced practice tier, now the fastest-growing part of the profession.

The same year, the American Nurses Association issued its position that the bachelor's degree should be the minimum preparation for professional nursing. Sixty years later it has still not been enacted as a licensure requirement anywhere, though the labour market has largely delivered it.

The profession also gained an intellectual apparatus in this period — Virginia Henderson's definition, Hildegard Peplau's psychiatric nursing, Ida Jean Orlando's deliberative process, Martha Rogers's insistence that nursing was a science with its own subject matter, and the federal research institute Faye Glenn Abdellah helped establish from inside the Public Health Service. See nursing theory.

The recent argument

The through-line from the training schools to the present is the question of who pays for adequate nursing and what happens when nobody does. California legislated minimum staffing ratios in 1999; three more states have followed. The pandemic that began in 2020 produced the sharpest workforce disruption since the war, and the research linking staffing to patient survival is now the profession's most powerful political instrument. See nurse staffing and patient outcomes.

Sources

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