Nursing care: evolution of a profession

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Nursing is a parental instinct. This innate emotion to provide care transcends beyond human species. Word ‘nurse’ has its origin in latin ‘nutrire‘ to suckle. Maternal and child care is an ancient nursing task. Various cultures describe wet-nurses – who would take care of children and even breast-feed them. Ancient nursing was more of an apprenticeship to a physician. Mostly, family members of the sick would perform this task. Destitute still required others to care for them. While, caring for ones own was easy, caring for others and unknown required devotion and discipline.

Nursing as a religious duty

Many religions promote caring for others as a virtue. In christianity, deacons and deaconesses adopted this role. They were helpers to the priests, nuns, monks and patron saints. Deaconess was a lady in ministry of the church. Supervised by nuns, she was often delegated to conduct childbirth. Thus, she was an early nurse who cared for the sick and destitute. By 1000 AD, clergy had established various hospitals, entirely served by nuns. Phoebe, Fabiola, Paula, and Marcella are some of the named deaconesses who provided care in these early days. These hospitals also had their patron saints, who were portrayed as having magical healing powers.

Priests often identified eligible women from the community, to take care of the orphanages. Isabel Zendel was one such young girl in Spain. At a young age of 19, she was identified by a local parish to supervise an orphanage. Thereafter, in 1803 she was to take care of 22 orphans (inoculated with cow-pox) on-board expedition ship Santa-Maria. She was also only woman in this mission. (Read a previous small-pox blog) Today she is celebrated as first nurse aboard an overseas humanitarian mission

Revival of Deaconess system

Theodor Fliedner and his wife Friedreike Munster in 1836 established a deaconess motherhouse in Kaiserswerth, Germany. It was a training school for young women that also ensured employment. Curriculum included childbirth, nursing, marriage, social service and housework. Over next three decades, its alumni set up similar schools across Europe. Notable among them was Florence nightingale who trained here in 1850. Thereafter, nightingale briefly worked in England, before leaving for her famous mission in Crimea. Alumni from Kaiserswerth established many similar establishments across Europe. By 1890, there were more than 5000 deaconesses in Europe.

Crimean war and learnings

Florence nightingale laid foundations of modern nursing. After her training at Kaiserswerth, she was superintendent of Institute of sick gentlewomen in England. In 1854, during Crimean war, British army requested some nurses to be posted to take care of the injured and sick solders. Nuns from France and Russia were already taking care of their battered armies. British soldiers fared worse as they had no such system.

Florence nightingale and 38 others were dispatched to the war-zone. Their efforts made a huge difference in delivery of care. They not only made military hospital more clean, and ventilated but also developed a system of care. Florence also knew how to present her findings. She used graphical representation of data (learned from her father) to show a reduction in mortality from 44% to 7%.

Florence Nightingale and dawn of modern nursing

On return from the war theatre, Florence was a celebrity. She was remembered by fellow soldiers as a “lady with a lamp” as she would take night-rounds of her patients. This system of nursing was incorporated in the ‘nightingale schools’ that were to follow.

In next two years, she received sufficient donations to set up first training school for nurses. Thus, she established nightingale school of nursing in St Thomas hospital in 1860. Nursing became a secular profession. Today, we owe first nursing uniforms, nursing pledge, and spread of nursing education to her efforts. Inspired by her efforts and system, many nursing schools were established across the world during her lifetime. Decorated by an order of merit in 1907, Florence Nightingale lived till age of 90.

Establishment of Modern nursing in India

Indian subcontinent has an informal system of traditional midwives (or dais) since ages. Even today we find these untrained birth attendants in most villages. In 1664, East India Company established first hospitals in fort St George Madras. Religious women from England staffed this hospital as nurses. Most early hospitals set up by the company and later British were christian missionary hospitals. Based on Nightingale’s model, first nursing school in India was at St Stephen’s hospital in Delhi in 1867, followed by at Madras General hospital in 1871. Most hospitals in 19th and 20th century had a nursing school for midwifery courses.

From nurse volunteers to trained nurses

During American civil war (1861-1865) many women volunteered as nurses. Driven by altruism, and nationalism they were to become leaders of nursing in America. One of these volunteers was Clara Barton, who in 1881 established American Red Cross. This volunteer workforce reduced war-casualties. Another volunteer nurse was Dorothia Dix who went on to work for the care of mentally ill.

While, nurse volunteers provided care for the wounded soldiers, there were hardly any civilian nurses. Nursing care in American hospitals was often given by convicts, drunkards, and those forced by law into social service. First Nightingale schools were established in America in 1872-3. Laywomen, rather than physicians established these schools. Linda Richards, Isabel Hompton, and Sophia Palmer were first trained American nurses.

Trained nurses and their associations

In late 19th century hospitals realised that a nursing school provided them with available Human Resources. Almost all hospitals vied to have them, and established their own nursing schools. In early years, there was not only a variation in teaching standards, but we also had two types of nurses. We had trained nurses, who came from these nursing schools. We also had various other nurses, who were more informally trained. Groups of trained nurses decided to have their associations. In 1887, we had British nursing association, and in 1890s we had first American nursing associations. In India, Trained nursing association (TNAI) was formed in 1908-11.

Nurses associations pushed for better working conditions, a mandatory registration and standards for nursing education. Nursing associations introduced the concept of eight-hour shifts and round the clock coverage in hospitals. Mandatory registration and licences to practice were introduced in 1940s. National nursing councils were conceptualised and with these nursing was now an established profession.

Nursing education and registration comes of age

Early in 20th century, various countries established standards for nursing education. Countries were also standardising their nursing education systems. Nursing examination was standardised by nursing associations. Between 1907-10 Indian mission hospitals had set up examination boards for nursing education. Next step was to standardise nursing education and registrations.

In 1920, British parliament established General nursing council for England and Wales. Around the same time, registration of nurses was initiated in US. Initially registration was optional, and those registered would suffix “R.N.” after their name. Beginning 1940s, registration was made mandatory in United States.

In the India started first bachelor in nursing program in Delhi and Vellore in 1946. Next year in 1947, government established Indian nursing council (INC). In last 75 years nursing curriculum in India has progressed from ANM (Auxiliary nursing midwifery), GNM (General nursing midwifery), BSc (Nursing) to Masters and doctoral courses.

Nurses in war-zones

Second World War was quite destructive. In addition to red-cross volunteers, militaries also had their own system of nurses and doctors. Nurse volunteers worked under supervision of trained nurses. For the first time, many countries employed nurses within armed forces. This improved care for the military personnel, and also income and stature for the nurses.

Nursing care in mid 20th century

By mid 20th century, hospital-care became more specialised. We had discovered newer therapies, intravenous medication, complex life-support measures, and monitoring modalities. Gradually nursing care also became more complex. We had nursing specialities within and outside the hospital.

These changes in the profession, also affected nursing uniforms. Dresses from nightingale schools had a long cap, clock, and a jacket over a grey dress. By 1970s nursing care demanded more efficiency, and the uniforms became simpler – white dress and a cap.

Nursing uniforms evolve with the times

Depiction of nurses in postage stamp has changed over a period of time. Early nursing uniforms carried a religious aura. Later cap replaced an elaborate headgear. Over next few years, caps also became smaller and more symbolic. Caps would have ribbons or bands, to indicate hierarchy in nursing cadres. As scrubs were adopted as a standard dress by most nurses as well as doctors, caps were shed.

Nursing uniforms has also changed in colour. In early 1900s, white colour was universally adopted. This signified cleanliness, sanitary contritions and purity. White was also a colour of the priests. However, white was difficult to maintain. It would become stained and dirty. Slowly the colour changed to green (inside the operation theatres), to light or dark blue. Different colours were used to identify nursing hierarchy.

Nursing uniforms have also changed with popular fashion. Attires have not only become gender neutral, but also neutral to occupation and hierarchy.

Emergency care and nurses

Today nurses are engaged in a variety of out of hospital healthcare roles. A nurse or a paramedic is an essential part of out-of-hospital acute care. Postage stamps depict nurses engaged in patient evacuation, transport and delivery to a hospital.

Primary care and public health nursing

While in hospitals and even in emergency rooms, physicians exhibit a dominant role. On the other hand in the community, and especially in physician deficient settings, nurses have a dominant role. One of the earliest engagement was in organisation of district nursing services. These primary care services were first established in late 19th century.

World Health Organization was established in 1948. Devastation of Second World War, and in order to provide a universal health-care, primary care has become quite important. Nursing services in primary care include basic maternal and child care, vaccination, geriatric care and care for the disabled.

Today nurses also manage various outreach facilities and services. Professionally trained nurses provide hospice and home based geriatric care.

A complementary and equal role

In many parts of the world, nursing is not subservient to physician based systems. Some health systems allow nurse-practitioners to provide basic medicinal prescriptions. This task-shifting aims to improve efficiency of the health systems.

Healthcare is a teamwork. Within hospitals, nursing and medical cadres are complimentary, along with pharmacists, technicians, physiotherapists, and counsellors. Nursing personnel are numerically largest, commiserate with their direct care-delivery roles.