Lesson 1, Topic 1
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Nursing Education in the Nineteenth Century

May 1, 2021

Nursing Education in the Nineteenth Century

The hospitals of the early nineteenth century were vastly different than those of today. Hospitals, or pesthouses as they were called, were dirty, overcrowded facilities filled with patients. The care delivered was limited in scope. The providers of care were typically untrained. Poor hygienic practices were used. These factors resulted in high infection and mortality rates. Hospitals of this era were places to contract diseases rather than be cured of them. Interest in care of the sick and disabled was limited. Training programs for health care providers were scarce, which led to recruitment of care providers with questionable qualifications. Women of “proper upbringing” did not work outside of the home. The ranks of workers loosely referred to as nurses were filled with women who drank heavily, engaged in prostitution, and were inmates in jails and prisons. Although religious orders did train and educate a small number of nurses, they were unable to meet the health care needs of communities.

Under the guidance of Theodor Fliedner, a German pastor in Kaiserswerth, Germany, the Lutheran Order of Deaconesses established the first school of nursing in the mid-1800s. The reputation of the school soon spread throughout Europe. It reached a young woman in England, Florence Nightingale, whose interest in nursing spurred her to overcome the opposition of her family, her friends, and the social class to which she belonged.

Florence Nightingale (1820–1910)

Florence Nightingale (Figure 1-1), a strong-minded, intelligent, and determined young woman, joined the Kaiserswerth program in 1851 at age 31 years and became the superintendent of a charity hospital for ill governesses in 1853. The quality of patient care improved, but the governing board of the hospital was not always pleased with the changes and innovations

she made and the guidance she gave her uneducated nurses.

In the following year, concerned by the news of the number of casualties and deaths among soldiers in the Crimean War, and the atrocious conditions suffered by the wounded, Nightingale sent the secretary of war, a long-standing friend, a letter offering her services; ironically, it crossed with his request for her to lead a group of nurses to Scutari, Turkey, to care for the wounded. Within a week of receiving the secretary’s letter, she and 38 other nurses were on their way.

With use of the principles she learned at Kaisers­werth, Florence Nightingale began to provide care to the wounded soldiers. Her nursing skills, dedication, and leadership turned the tide at the Barrack Hospital. Sanitary conditions, nonexistent before her arrival, were established. The hospital units were cleaned, and clothes were washed regularly. The mortality rate dropped significantly. The changes did not end with the physical environment of the hospital. Through Nightingale’s patience, dedication, and empathic treatment of the soldiers, a psychological change took place as well. The soldiers grew to respect her and looked forward to her presence on the wards. They looked for her smile and took strength from her personality. When she made her rounds late at night through the rows of the injured and sick, she carried a lamp to light her way. Soon she was known as the “Lady with the Lamp.” The small lamp became her trademark and continues to be the symbol of the nursing profession around the world (Figure 1-2).

The standards of nursing care Florence Nightingale established gained the respect of the medical community and led to improved care for the sick and a much improved image of nursing in general. She is credited as the first nursing theorist. The need for educated and

trained nurses had become painfully evident, and the time was right for a shift in the approach to nursing education (Ellis, 2008).

Nursing From Occupation to Profession

In 1860, Florence Nightingale began the reformation of nursing from occupation to profession by establishing the nursing school at Saint Thomas Hospital in London. With a reputation as a progressive medical facility, it was the ideal place to promote the new standards of nursing in which she so strongly believed.

The nursing program operated separately from the hospital. It was financially independent to ensure that the major emphasis of its activity was placed squarely on the education of nursing students (Figure 1-3).

Students had to pass strict procedures for admission, and a residence was provided for them. The nurses’ training lasted 1 year and included both formal instruction and practical experience. Complete records were kept on each student’s progress. This practice was known as the “Nightingale Plan,” which became the model for nursing education in the twentieth century. After the students graduated, records were also kept on their place of employment. The “register” that resulted was the beginning of a movement to exercise control over the nursing graduate and to establish a standard for the practicing nurse.

Students admitted into the nursing program at Saint Thomas had to provide excellent character references, show a strong commitment to a career in nursing, and demonstrate that they were intellectually capable of passing the course of study before them. The new “Nightingale nurses” improved patient care by such measures as good hygiene and sanitation, patient observation, accurate record keeping, nutritional improvements, and the introduction and use of new medical equipment. The demand for their services was overwhelming.

Development of Nursing Education in the United States

At the same time Florence Nightingale was active in Europe, circumstances in the United States were creating similar patient care problems. Both the American Revolution and the Civil War were characterized by severe casualties, disease, infected wounds, and archaic medical care. As in the Crimean War, nurses were scarce, and those who were available were poorly trained to handle the horrors of war.

In 1849, the same Pastor Theodore Fliedner of Germany who had established Nightingale’s alma mater traveled to the United States with four of his highly trained nurse deaconesses. He was instrumental in the establishment of the first Protestant hospital on American shores. Located in Pittsburgh, it was called the Pittsburgh Infirmary and is still in existence today under the name Passavant Hospital. While Fliedner was busy with the hospital, his deaconesses began the first formal education of nurses in the United States.

As hospitals in the large cities grew to meet the demands for health care, a shortage of nurses developed. Most early nursing programs were supported by these large hospitals. In 1869, the American Medical Association recommended that every large hospital should establish and support its own school of nursing to meet the need for patient care. Schools of nursing would be established by the turn of the century, all modeled after the Nightingale Plan.

In May 1873, the Bellevue Hospital School of Nursing in New York established itself as the foremost proponent of the Nightingale Plan in America.