Lesson 1, Topic 1
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Changes in Nursing during the Twentieth Century

May 1, 2021

Changes in Nursing during the Twentieth Century

Like the superintendents, who operated at the national level, the graduates of the training schools also attempted to establish standards and, in their case, established the Alumnae Association for the actual practice of nursing at the local level.


At the beginning of the twentieth century, more than 400 schools of nursing were found in the United States, with variations in the curricula and program lengths and differences between the competencies of program graduates. In 1903, North Carolina, New Jersey, New York, and Virginia became the first states to mandate licensure (the granting of permission by the overseeing authority to engage in practice or activity that would otherwise be illegal) as a criterion for entry to professional practice. The nursing organizations recognized

the need to amend their purpose and redirect their focus. As part of the reorganization that followed, in 1911, the American Society of Superintendents of Training Schools became the National League for Nursing Education (NLNE, n.d.). The years that followed the organization developed and released their first nursing curriculum plan.

World War I

In 1917, the United States’ entry into World War I brought an increased demand for nurses. The newly formed Army and Navy Nurse Corps sought nurses who certifiably demonstrated “good moral character and professional qualifications.” The available supply of nurses could not meet the demand, so once again, untrained women volunteered their services. Nursing leaders, concerned that these untrained personnel would be caring without adequate training for wounded and ailing soldiers, moved quickly to establish the Army School of Nursing. At the height of their service, more than 20,000 women are estimated to have served in the Nurse Corps (Army Heritage Center Foundation, n.d.).

After the war, most of the women who had served as military nurses returned to their homes and their previous jobs and careers. The image attached to professional nurses still posed a problem for most women, and few had the desire to remain in nursing as civilians. Furthermore, they were disenchanted because nurses’ training still focused heavily on “service to the patient” rather than on a comprehensive professional education, which was far removed from what the Nightingale Plan had proposed for aspiring nurses.

World War II

Twenty-five years later, World War II escalated the demand for trained nurses once again. The number of patient casualties and level of acuity skyrocketed. Early in the war, the Cadet Nurse Corps was established to provide an abbreviated training program designed to meet the needs of the war effort. In addition, federally subsidized programs in nursing were developed and implemented to offer women and, for the first time, men an education and a career in nursing while serving their country in the war.

After the war, many of the nurses trained by these programs remained in military service. Prestige, pay, and the opportunity for advancement were much greater in military service than for civilian nurses. In the major hospitals, particularly in urban areas, civilian nurses received low pay and worked long shifts in atrocious conditions. These conditions were hardly likely to attract those who became nurses as a result of the war and who, ironically, enjoyed a certain lifestyle that war invariably provides. The aftereffects of World War I, the Great Depression, and World War II led to an increased nursing shortage.

Further, state boards of nursing, which had licensure responsibility, came under increasing pressure to mandate requirements for nurses. State-administered licensing examinations no longer seemed adequate for the country’s needs. The parochial state examinations were in no way standardized and allowed persons with a wide spectrum of competence to enter nursing. National norms of competence were sorely needed.

Contemporary Nursing

The focus of health care from care of the sick to an ever-expanding profit-driven industry resulted in a change in its culture and characteristics. Growth and diversity of services became the major emphasis as the industry became increasingly lucrative. Contemporary nursing was born as the demand for nurses increased at a rate greater than could be met. This demand was accompanied by a growth in specialized inpatient services and an intensive growth in community-based services such as occupational and home health nursing. Advanced practice nursing roles, including nurse anesthetists, nurse practitioners, and midwives, have surged in recent decades.

The future of nursing as a profession has remained a source of deliberation. In 1903, Isabel Hampton Robb and Adelaide Nutting published a position paper recommending the baccalaureate degree level as the minimum acceptable preparation for entry into the profession. The associate degree was recommended as the minimum for technical nursing practice. Decades later in 1965, the American Nurses Association (ANA) took a position recommending that nursing education take place in institutions of learning within the general system of education, much as Robb and Nutting had proposed. Since that time there has been a change in the settings for nursing education. Although many early nursing programs were managed by hospitals, in the mid-1960s, hospitals began moving away from operating schools of nursing. Today both registered nursing and licensed practical nursing programs are primarily conducted in technical schools, colleges, and universities. Licensed practical nurse (LPN) and licensed vocational nurse (LVN) programs may also be administered by high schools in some parts of the country. The shift toward colleges and universities provides the student nurse a broader educational base with an emphasis on not only skill development but the integration of nursing theory and related general education courses (Box 1-1). More recently, the Institute of Medicine (IOM) has generated conversation with their publication, The Future of Nursing: Focus on Nursing Education. The document presents the coming challenges to the health care and the nursing professions. The IOM has taken the position of promoting the need for changes in the nursing workforce, with a goal for 80% of working nurses to be

Box 1-1 The Patient Care Partnership: Understanding Expectations, Rights, and Responsibilities

When you need hospital care, your doctor and the nurses and other professionals at our hospital are committed to working with you and your family to meet your health care needs. Our dedicated doctors and staff serve the community in all its ethnic, religious, and economic diversity. Our goal is for you and your family to have the same care and attention we would want for our families and ourselves.
The sections below explain some of the basics of how you can expect to be treated during your hospital stay. They also cover what we will need from you to care for you better. If you have questions at any time, please ask them. Unasked or unanswered questions can add to the stress of being in the hospital. Your comfort and confidence in your care are very important to us.

What to Expect during Your Hospital Stay

•High-quality hospital care. Our first priority is to provide you the care you need, when you need it, with skill, compassion, and respect. Tell your caregivers if you have concerns about your care or if you have pain. You have the right to know the identity of doctors, nurses, and others involved in your care, and when they are students, residents, or other trainees.
•A clean and safe environment. Our hospital works hard to keep you safe. We use special policies and procedures to avoid mistakes in your care and keep you free from abuse or neglect. If anything unexpected or significant occurs during your hospital stay, you will be told what happened, and any resulting changes in your care will be discussed with you.
•Involvement in your care. You and your doctor often make decisions about your care before you go to the hospital. Other times, especially in emergencies, those decisions are made during your hospital stay. When decision making takes place, it should include the following:
1.Discussing your medical condition and information about medically appropriate treatment choices. To make informed decisions with your doctor, you need to understand the following:
•The benefits and risks of each treatment.
•Whether your treatment is experimental or part of a research study.
•What you can reasonably expect from your treatment and any long-term effects it might have on your quality of life.
•What you and your family will need to do after you leave the hospital.
•The financial consequences of using uncovered services or out-of-network providers.
Please tell your caregivers if you need more information about treatment choices.
2.Discussing your treatment plan. When you enter the hospital, you sign a general consent to treatment. In some cases, such as surgery or experimental treatment, you may be asked to confirm in writing that you understand what is planned and agree to it. This process protects your right to consent to or refuse a treatment. Your doctor will explain the medical consequences of refusing recommended treatment. It also protects your right to decide if you want to participate in a research study.
3.Getting information from you. Your caregivers need complete and correct information about your health and coverage so that they can make good decisions about your care. That includes the following:
•Past illnesses, surgeries, or hospital stays.
•Past allergic reactions.
•Any medications or dietary supplements (such as vitamins and herbs) that you are taking.
•Any network or admission requirements under your health plan.
4.Understanding your health care goals and values. You may have health care goals and values or spiritual beliefs that are important to your well-being. They will be taken into account as much as possible throughout your hospital stay. Make sure your doctor, your family, and your care team know your wishes.
5.Understanding who should make decisions when you cannot. If you have signed a health care power of attorney that states who should speak for you if you become unable to make health care decisions for yourself, or a “living will” or “advance directive” that states your wishes about end-of-life care, give copies to your doctor, your family, and your care team. If you or your family need help making difficult decisions, counselors, chaplains, and others are available to help.
6.Protection of your privacy. We respect the confidentiality of your relationship with your doctor and other caregivers, and the sensitive information about your health and health care that are part of that relationship. State and federal laws and hospital operating policies protect the privacy of your medical information. You will receive a Notice of Privacy Practices that describes the ways that we use, disclose, and safeguard patient information and that explains how you can obtain a copy of information from our records about your care.
7.Preparing you and your family for when you leave the hospital. Your doctor works with hospital staff and professionals in your community. You and your family also play an important role in your care. The success of your treatment often depends on your efforts to follow medication, diet, and therapy plans. Your family may need to help care for you at home. You can expect us to help you identify sources of follow-up care and to let you know if our hospital has a financial interest in any referrals. As long as you agree that we can share information about your care with them, we will coordinate our activities with your caregivers outside the hospital. You can also expect to receive information and, where possible, training about the self-care you will need when you go home.
8.Help with your bill and filing insurance claims. Our staff will file claims for you with health care insurers or other programs such as Medicare and Medicaid. They will also help your doctor with needed documentation. Hospital bills and insurance coverage are often confusing. If you have questions about your bill, contact our business office. If you need help understanding your insurance coverage or health plan, start with your insurance company or health benefits manager. If you do not have health coverage, we will try to help you and your family find financial help or make other arrangements. We need your help with collecting needed information and other requirements to obtain coverage or assistance.
While you are here, you will receive more detailed notices about some of the rights you have as a hospital patient and how to exercise them. We are always interested in improving. If you have questions, comments, or concerns, please contact: _______________.

From American Hospital Association: The patient care partnership: Understanding expectations, rights, and responsibilities, Chicago, 2003, AHA. Reprinted with permission from the American Hospital Association.